Orlando de Castro e Silva

Aspectos básicos da lesão de isquemia e reperfusão e do pré-condicionamento isquêmico

A isquemia tem papel fundamental em muitas situacoes clinicas perioperatorias . Apesar da revascularizacao sanguinea a um orgao isquemico seja essencial para prevenir a irreversibilidade da lesao celular, a reperfusao pode agravar as lesoes produzidas na fase isquemica isolada. Assim, o dano celular induzido apos reperfusao de um orgao isquemico e denominado de lesao de isquemia-reperfusao (I/R). Aspectos basicos da lesao I/R, sao revisados neste artigo.

Liver cirrhosis and hepatic stellate cells

The cirrhosis represents the final stage of several chronic hepatic diseases and it is characterized by the presence of fibrosis and morphologic conversion from the normal hepatic architecture into structurally abnormal nodules. In the evolution of the disease there is loss of the normal vascular relationship and portal hypertension. There are also regenerative hepatocellular alterations that become more prominent with the progression of the disease. The liver transplantation continues to be the only therapeutic option in cases of disease in terminal phase. The hepatic stellate cells (HSC) are perisinusoidal cells that store vitamin A and produce growth factors, citocins, prostaglandins and other bioactive substances. They can suffer an activation process that convert them to cells with a phenotype similar to myofibroblasts. When activated, they present increased capacity of proliferation, mobility, contractility and synthesis of collagen and other components of extracellular matrix. They possess cytoplasmic processes adhered to sinusoids and can affect the sinusoidal blood flow. HSC are important in pathogenesis of fibrosis and portal hypertension.A cirrose representa o estagio final de diversas doencas hepaticas cronicas e e caracterizada pela presenca de fibrose e conversao da arquitetura hepatica normal em nodulos estruturalmente anormais. Na evolucao da doenca ocorre perda da relacao vascular normal e hipertensao portal. Ha tambem alteracoes regenerativas hepatocelulares que se tornam mais proeminentes com a progressao da doenca. O transplante hepatico permanece como a unica opcao terapeutica nos casos de doenca em fase terminal. As celulas estreladas hepaticas (CEH) sao celulas perisinusoidais que armazenam vitamina A e produzem fatores de crescimento, citocinas, prostaglandinas e outras substâncias bioativas. Podem sofrer um processo de ativacao para um fenotipo semelhante a miofibroblastos. Quando ativadas apresentam maior capacidade de proliferacao, motilidade, contractilidade, sintese de colageno e componentes da matriz extracelular. Possuem processos citoplasmaticos aderidos aos sinusoides e podem afetar o fluxo sanguineo sinusoidal. As CEH sao importantes na patogenese da fibrose e hipertensao portal.

Liver transplantation: expectation with MELD score for liver allocation in Brazil

Liver transplantation represents the most effective therapy for patients suffering from chronic end-stage liver disease. Until very recently, in Brazil, liver allocation was based on the Child-Turcotte-Pugh score and the waiting list followed a chronological criterion. In February 2002 the Model for End-stage Liver Disease (MELD) score was adopted for the allocation of donor livers in the US. After that change, an increased number of patients with more severe liver disease was observed, although there was no difference in 1-year patient and graft survival. A reduction in waiting-list mortality was also observed. In Brazil, the MELD score was adopted on May 31st, 2006. Good results are expected regarding the new criterion for allocation.

Nonalcoholic fatty liver disease and obesity

PURPOSE The aim of this review is to update concepts of the nonalcoholic fatty liver disease (NAFLD) and to establish a relationship between this condition and obesity. METHODS By means of a comprehensive literature review where special attention was devoted to articles published in the last 5 years, NAFLD is discussed in view of new concepts, diagnosis, staging, and treatment. RESULTS NAFLD is emerging as one of the main causes of chronic liver disease and it is believed to be the hepatic component of the metabolic syndrome, whose central features include obesity, hyperinsulinemia, peripheral insulin resistance, diabetes, dyslipidemia, and hypertension. The surgical treatment of morbid obesity is one of the options available for the treatment of NAFLD. CONCLUSION Nonalcoholic fatty liver disease is strongly related with obesity.

New photonic technologies for the treatment and diagnosis of hepatic diseases: an overview of the experimental work performed in collaboration, between Physics Institute of São Carlos and Ribeirão Preto Faculty of Medicine of the University of São Paulo

Recent advances in optical techniques have created a great range of possibilities for diagnosis and therapeutics in liver related diseases. With the uses of efficient light sources like lasers and LEDs (Light Emitting Diodes) it is possible to employ the light-tissue interaction to promote hepatic tissue regeneration after partial hepatectomy, to detect hepatocarcinoma and steatosis by utilizing optical fluorescence, to evaluate the metabolism of the liver during hepatic transplantation as well as to treat liver tumors. We present here an overview of the technique presently in development at the Ribeirâo Preto Faculty of Medicine-USP in cooperation with the Physics Institute of São Carlos-USP. The results obtained so far have been the subject of a list of publications and are here presented as an overview. A new perspective for modern application of optical techniques in different medical practices related to the liver is presented.

Transplante de fígado: resultados de aprendizagem de pacientes que aguardam a cirurgia

This study aims to describe the learning results of the implementation of teaching strategies involving patients who will be submitted to liver transplantation. One of these strategies is to give the patients a manual with orientations and the subsequent application of a questionnaire related to the content of the manual. Authors analyzed 13 patients who were waiting for liver transplantation. With respect to the answers regarding the questionnaire, an average of 83.8% of correct responses was given and only one patient got all the questions right. During the correction and the time to clarify their doubts, authors concluded that the opportunity of reading the manual and applying the questionnaire allowed patients and families to get a better understanding about the surgerys most important aspects.O objetivo deste estudo e descrever os resultados de aprendizagem da experiencia de implementacao de estrategias de ensino com os pacientes que serao submetidos a transplante de figado. Uma delas e a entrega de um manual de orientacao aos pacientes que entram no programa, com posterior aplicacao de questionario relacionado ao conteudo do manual. Analisou-se 13 pacientes em lista de espera para transplante de figado, todos ocupando as primeiras posicoes no cadastro tecnico. Em relacao as respostas obtidas dos questionarios aplicados, a media de acertos foi de 80,6%, sendo que apenas um paciente acertou todas as questoes. Durante a correcao e esclarecimento das duvidas, concluiu-se que a leitura do manual de orientacao e a aplicacao do questionario proporcionam esclarecimento melhor dos pacientes e de seus familiares em relacao aos aspectos mais importantes da cirurgia.

The use of perioperative serial blood lactate levels, the APACHE II and the postoperative MELD as predictors of early mortality after liver transplantation

PURPOSE To evaluate the accuracy of different parameters in predicting early (one-month) mortality of patients submitted to orthotopic liver transplantation (OLT). METHODS This is a retrospective study of forty-four patients (38 males and 10 females, mean age of 52.2 ± 8.9 years) admitted to the Intensive Care Unit of a tertiary hospital. Serial lactate blood levels, APACHE II, MELD post-OLT, creatinine, bilirubin and INR parameters were analyzed by receiver-operator characteristic (ROC) curves as evidenced by the area under the curve (AUC). The level of significance was set at 0.05. RESULTS The mortality of OLT patients within one month was 17.3%. Differences in blood lactate levels became statistically significant between survivors and nonsurvivors at the end of the surgery (p<0.05). The AUC was 0.726 (95%CI = 0.593-0.835) for APACHE II (p = 0.02); 0.770 (95%CI = 0.596-0.849) for blood lactate levels (L7-L8) (p = 0.03); 0.814 (95%CI = 0.690-0.904) for MELD post-OLT (p < 0.01); 0.550 (95%CI = 0.414-0.651) for creatinine (p = 0.64); 0.705 (95%CI = 0.571-0.818) for bilirubin (p = 0.05) and 0.774 (95%CI = 0.654-0.873) for INR (p = 0.02). CONCLUSION Among the studied parameters, MELD post-OLT was more effective in predicting early mortality after OLT.

Routine abdominal drains after Roux-en-Y gastric bypass: a prospective evaluation of the inflammatory response

BACKGROUND Despite the extensive published data regarding the use of drains in surgery, it is still controversial. Most bariatric surgeons use drains as routinely. However, drains have sometimes have been shown to be unhelpful and even to increase the anastomotic leak rates. The purpose of the present study was to evaluate the peritoneal inflammatory response in the presence of a drain left in place until the seventh postoperative day after bariatric surgery. METHODS All patients who underwent open Roux-en-Y gastric bypass from February 2007 to August 2008 were prospectively evaluated. A 24F Blake drain was left in place for 7 days. The peritoneal effluent from the drain was collected for the determination of cytokine levels and for microbiologic analysis. RESULTS A total of 107 obese patients were studied. A marked increase in the levels of tumor necrosis factor-α and interleukin-1β was observed by the seventh postoperative day, even in patients without any abdominal complications. Bacterial contamination of the peritoneal effluent was also demonstrated. CONCLUSION The results of our study have shown that at 7 days after surgery, a marked peritoneal inflammatory response and bacterial contamination are present. These findings could have resulted from the use of the drain for 7 postoperative days.

The effect of laser on remanescent liver tissue after 90% hepatectomy in rats

PURPOSE To evaluate the effect of laser beam on reminiscent liver after partial hepatectomy 90%. METHODS Wistar rats, (N=42), were divided into six groups with seven specimens each. The partial hepatectomy (HP) was performed in all animals through exeresis of approximately 90% of the liver parenchyma. The animals from groups HP and Laser application, HPL24, HPL48 and HPL72 undertook laser irradiation carried out through application (dose of 22.5 J/cm2) in five different sites in the reminiscent liver. The rats were then sacrificed 24, 48 and 72 hours after HP procedure, for the liver regeneration analysis,using the Proliferating Cell Nuclear Antigen (PCNA),and for dosage of serum aminotransferases. RESULTS Were demonstrated an increase of the serum levels of alanine aminotransferase for the group of 24 hours and a decrease for the group of 72 hours exposed to laser. The index of marked cells had a considerable more improvement for the group of 72 hours exposed in laser compared to other groups. CONCLUSION Laser did not cause hepatic injuries additional to the partial hepatectomy and perhaps led to a benefit by stimulating the proliferative activity.

Doação de órgãos para transplantes no Brasil: o que está faltando? O que pode ser feito?

The fundamental problem in the modern practice of organ transplantation is the striking disparity between the number of patients potentially treatable with the donation of viable grafts and the same impressive organ shortage, particularly in our country. What is missing in order to solve this problem is a way to solve it effectively? We must make the whole transplant process effective, bringing hope to many sick people waiting possible curative therapy, the replacement of an organ for terminal illnesses. The transplant is an effective therapeutic indication in irreversible kidney, heart, liver, lungs and pancreas diseases. The patients in terminal states of renal function and endocrine pancreas have therapeutic alternative to transplantation, dialysis and administration of exogenous insulin, respectively. In terminal states of the heart, liver or lung have the sole option to replace the diseased organ. As a cause of bankruptcy are very common diseases in our population such as diabetes, hypertension, alcoholic liver disease and viral hepatitis1,3,5. Given this scenario it is observed in Brazil, on one hand, the large number of patients waiting for a transplant, and other, donations and recovery of organs below the needs of large waiting list. Additionally, it is important to emphasize that the effectiveness of organ transplantation is directly related to the donation process and in our country, in cases of liver transplantation, almost totally dependent on the deceased organs donor . It is noteworthy that by the end of third quarter of 2010, 1059 of liver transplants performed in Brazil, only 7% were living donors4. It appears, therefore, crucial to deceased donor liver transplantation in adults as for children, by the shortage of deceased donors with low age, live donors appears as the best alternative option3. In Brazil, two types of solid organ transplants were better developed: kidney and liver. After a difficult initial phase 60s and 80s with the establishment and standardization of surgical techniques, new immunosuppressive drugs, clinical management of learning and adaptation of logistics throughout the transplant process, in 90s the rate of growth of these two modes did well. Others was also evolved as the heart, pancreas, kidney, pancreas, lungs and intestine3,4. Brazil, with its continental size and presenting external causes as the main predictor of mortality in young adults2 during the 2000s showed no increase in the number of transplants, particularly kidney (18.2 per million population pmp in 2005 to 24.4 pmp in 2010) and liver (5.2 pmp in 2005 to 7.4 pmp in 2010). Currently, with the country population of 190 million people and possessing high potential transplant recipients, more than half the states do not do transplants in general, particularly the liver. They are states of the Midwest, Northern and most of the Northeast4. Interestingly, transplant groups were installed in our country following the same route of colonization, from east to west-central. Nevertheless, the states of the federation who do, their implementation is not distributed equally and there is great heterogeneity of numbers of procedures per million people. This is due to the absence of national policy with regard to both the donation of organs as well as encouraging the formation of transplantation teams, which most often are formed by individual effort of persons. The state of Sao Paulo holds more than half of liver transplants done in the country (17.8 pmp), while Brazil as a whole, reached the 2010 mark of 7.4 pmp, ranging from 2.4 (Bahia ) to 17.8 pmp (Sao Paulo); additionally, various federal states do not perform the procedure. The state of São Paulo reached levels very similar to the vast majority of U.S. states (U.S. is 17.9 pmp). Spain, with well-organized political organ donation and transplantation, achieved more than 35 liver transplants pmp, per year, above the national brazilian average1,3,4. In a country the size of Brazil, this small increase in the number is due to limiting factors, such as donation not approved by family and bad conditions of maintenance of the donor in hospital. When analyzing separately the state of Sao Paulo, the number of potential donors is 63