Olímpia Alves Teixeira Lima

Fatores de risco para as complicações após apendicectomias em adultos

BACKGROUND: Risk factors for adverse outcomes after the surgical treatment of appendicitis in adults are poorly defined. Accurate presurgical assessment of the risk of preoperative complications and mortality is important in planning surgical therapy. METHODS: All patients undergoing surgical intervention for appendicitis from January 2003 and January 2004 were selected for study. Independent variables examined included 11 putative preoperative risk factors and 4 intraoperative process measures. Dependents variables were complications. Stepwise logistic regression analysis was used for construct models predicting complications. RESULTS: There was a high risk in female (OR=1,97, 95%, IC-1,19-3,13), in appendix with perforation (OR=4,67 95%, IC-2,43-8,94), appendix without perforation (OR=3,32, 95%, IC-1,72-6,38), drainage (OR=17,54, 95%,IC-4,83-63,77) and ASA II (OR=1,53, 95%, IC 2,52-15,89). CONCLUSION: Four factors, in the logistic regression analysis, predicted a high risk of complications after the surgical treatment of appendicitis: female, necrosis with or without ruptured appendix, drainage and ASA Class II.

Giant hepatic adenoma associated with anabolic-androgenic steroid abuse: case report

Hepatic adenoma (HA) is an uncommon primary benign neoplasm of hepatocellular origin that most frequently affects young women. It has generally been associated with use of oral contraceptives. Glycogen storage disease has also been associated with development of HA and in such cases, it is also more likely to be multiple and to undergo malignant transformation. HA may be also found in association with other conditions such as diabetes mellitus, pregnancy, Fanconi anemia, Hurler disease, familial adenomatous polyposis and tyrosinemia3,5,6,9,13. More rarely, HA has been associated with abusive use of anabolic-androgenic steroids (AAS), mainly among bodybuilders 8,11,12. Most of these tumors are detected incidentally by means of imaging examinations such as ultrasound or other scanning techniques. Others because of hepatomegaly, right upper quadrant discomfort, pain, compression of neighboring organs, or intraperitoneal hemorrhage. The diagnosis is sometimes established only during intraoperative exploration3,5,6,9,13. Tumor rupture is frequently observed in bulky tumors, and this occurrence presents high mortality9,13. HA has also been associated with malignant transformation. This association has also been observed in large tumors6,9. The preferred treatment is surgical resection by means of guided hepatectomy or enucleation. This is the approach of choice for symptomatic patients or even for large tumors > 5 cm13. Today, the laparoscopic approach has become the gold standard because it provides low morbidity, fast recovery and cosmetic advantages1,4,7. However, for treating large lesions, especially when they are close to major vascular structures, an open approach is safer4,7.

Hepatectomia direita ampliada com ressecção parcial da veia cava para metástase colorretal: relato de caso

Introduction: Hepatectomy has been standard treatment for metastases from colorectal origin (CR). Metastases with inferior vena cava (IVC) involvement may require combined resection of the liver and IVC. This approach may present high surgical risk, Both profuse bleeding and gas embolism are letal intraoperative complications. Case: The authors present a case of single hepatic CR metastasis that was treated by means extended right hepatectomy with partial inferior vena cava resection and primary reconstruction. Patient present good postoperative course without neoplasm recurrence (one year follow-up period). Conclusion: Resection of VCI and combined reconstruction with hepatectomy may be satisfactorily done in selected cases. Lack of alternative treatments associated poor prognosis of untreated cases has justified this aggressive conduct. Therefore, this approach should be realized by hepatic surgery expertise team.

Extrahepatic biliary cystadenocarcinoma mimicking Klatskin tumor

Cistadenocarcinoma biliar (BCAC) é uma rara neoplasia maligna cística. Alguns autores pensam ser ela a conversão de cistoadenoma biliar de longa evolução. Na maioria dos casos ocorre no parênquima (cistadenocarcinoma intra-hepático); por vezes, pode ser observado com origem biliar extrahepática3,4,6,7,8,10,11. Cistadenocarcinoma biliar extrahepático (EBCAC) geralmente conduz icterícia associada com massa palpável1,2,5,6,9. No passado o diagnóstico era feito por meio de colangiopancreatografia retrógrada endoscópica. No entanto, tomografia computadorizada ou ressonância magnética ainda são preferidos por serem não invasivos1,2,3,4,5,6,7,8,9,10. Às vezes, EBCAC tem dificuldades no diagnóstico diferencial com colangiocarcinoma, principalmente quando ocorre no hilo hepático.6 O tratamento cirúrgico proporciona bom prognóstico; no entanto, ressecção em bloco do trato biliar com hepatectomia pode ser necessária para obter margens livres3,6,10. Até o momento não foi encontrado qualquer caso relatado no Brasil, nem operação bem sucedida usando ressecção biliar em bloco com hepatectomia para tratá-lo.

LAPAROSCOPIC DISTAL PANCREATECTOMY WITH SPLEEN PRESERVATION

ABSTRACT Background: Laparoscopic distal pancreatectomy has been the choice for resection of distal pancreas lesions due many advantages over open approach. Spleen preservation technique seems minimizes infectious complications in long-term outcome. Aim: To present the results of laparoscopic distal pancreatectomies with spleen preservation by Kimura´s technique (preservation of spleen blood vessels) performed by single surgical team. Methods: Retrospective case series aiming to evaluate both short and long-term outcomes of laparoscopic distal pancreatectomies with spleen preservation. Results: A total of 54 laparoscopic distal pancreatectomies were performed, in which 26 were laparoscopic distal pancreatectomies with spleen preservation by Kimura´s technique. Mean age was 47.9 years-old (21-75) where 61.5% were female. Mean BMI was 28.5 kg/m² (18-38.8). Mean diameter of lesion was 4.3 cm (1.8-7.5). Mean operative time was 144.1 min (90-200). Intraoperative bleeding was 119.2 ml (50-600). Conversion to laparotomy 3% (n=1). Postoperative morbidity was 11.5%. Postoperative mortality was null. Mean of hospital stay was 4.8 days (2-14). Mean time of follow-up period was 19.7 months (2-60). There was no neoplasm recurrence or mortality on evaluated period. There was no infectious complication. Conclusion: Laparoscopic distal pancreatectomy with spleen and splenic vessels preservation is feasible, safe, and effective procedure. This technique presented both low morbidity and null mortality on this sample. There were neither infectious complications nor neoplasm recurrence on long-term follow-up period.

CRITICAL EVALUATION OF LONG-TERM RESULTS OF MALIGNANT HEPATIC TUMORS TREATED BY MEANS CURATIVE LAPAROSCOPIC HEPATECTOMY

ABSTRACT Background: Laparoscopic hepatectomy has presented great importance for treating malignant hepatic lesions. Aim: To evaluate its impact in relation to overall survival or disease free of the patients operated due different hepatic malignant tumors. Methods: Thirty-four laparoscopic hepatectomies were performed in 31 patients with malignant neoplasm. Patients were distributed as: Group 1 - colorectal metastases (n=14); Group 2 - hepatocellular carcinoma (n=8); and Group 3 - non-colorectal metastases and intrahepatic cholangiocarcinoma (n=9). The conversion rate, morbidity, mortality and tumor recurrence were also evaluated. Results: Conversion to open surgery was 6%; morbidity 22%; postoperative mortality 3%. There was tumor recurrence in 11 cases. Medians of overall survival and disease free survival were respectively 60 and 46 m; however, there was no difference among studied groups (p>0,05). Conclusion: Long-term outcomes of laparoscopic hepatectomy for treating hepatic malignant tumors are satisfactory. There is no statistical difference in relation of both overall and disease free survival among different groups of hepatic neoplasms.