Pedro Eder Portari Filho

Comparative study of the different degrees of risk of gastrointestinal stromal tumor

OBJECTIVE To evaluate the applicability of the main categories of risk and morphological factors in the prognosis of gastrointestinal stromal tumors. METHODS we retrospectively studied fifty-four cases of GIST, assessing the main prognostic factors of this neoplasis: risk levels, topography, size, mitotic index, necrosis, histological subtype and immunophenotype. We also verified their association and the reduction of overall survival. RESULTS Univariate analysis showed that tumors with mitoses number greater than 5 per 50CGA (high-power fields), the presence of necrosis and a high risk for both the systems proposed by Fletcher and Miettinen had a significant association with reduced survival (p = 0.00001, 0.0056, 0.03 and 0.009, respectively). The remaining analyzed factors (size, histological subtype, topography and immunophenotype) had no such association. Multivariate analysis (Jacard index) showed that the Miettinen degree of risk was the one that best correlated with prognosis. CONCLUSION the risk criteria of Fletcher and Miettinen are important in assessing the prognosis of patients with gastrointestinal stromal tumors, especially the latter, which adds to the mitotic index and the presence of tumor necrosis.

Prevenção e tratamento de náuseas e vômitos no período pós-operatório

Postoperative nausea and vomiting are common and can be prevented. Complications of this condition cause higher rates of morbidity and mortality. A review of literature was carried out on MEDLINE, with focus on controlled clinical trials. Pathophysiology is complex, with many afferent and efferent pathways, and its comprehension facilitate the choice of medication. Risk factors are presented, with a stratified score of chance to develop postoperative nausea and vomiting. An algorithm for identification of higher risk patients was elaborated and classified the level of prevention/treatment recommended to avoid excessive use of drugs and their side effects. Postoperative nausea and vomiting must be prevented, because of the involved complications and discomfort for patients. A systematic approach with analysis of preoperative risk factors and prescription of medication can be effective for prevention.

ORGANIC INFLAMMATORY RESPONSE TO REDUCED PREOPERATIVE FASTING TIME, WITH A CARBOHYDRATE AND PROTEIN ENRICHED SOLUTION; A RANDOMIZED TRIAL.

BACKGROUND this study aims to assess the organic inflammatory response of the video laparoscopic cholecystectomy, with abbreviation of the preoperative fasting to 2h using a carbohydrate and protein enriched solution. METHODS this is a randomized, prospective study with patients divided into the following 2 groups: group A, conventional fasting and group B, 2h abbreviated fasting with oral ingestion of a carbohydrate and protein solution. Serum glucose, insulin, interleukin 1, and TNF-α were mesasured before ingestion of the solution, during induction of anesthesia, and 4 h after the end of surgery. RESULTS thirty-eight patients completed the study without presenting pulmonary complications associated with bronchoaspiration. The postoperative HOMA-IR variance was greater in group A (p = 0.001). CONCLUSION the abbreviation of preoperative fasting for 2 h, using carbohydrate and protein enriched solutions, is safe, reduces insulin resistance, and does not increase the risk of bronchoaspiration.

ACERTO guidelines of perioperative nutritional interventions in elective general surgery

OBJECTIVE to present recommendations based on the ACERTO Project (Acceleration of Total Post-Operative Recovery) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures. METHODS review of relevant literature from 2006 to 2016, based on a search conducted in the main databases, with the purpose of answering guiding questions previously formulated by specialists, within each theme of this guideline. We preferably used randomized controlled trials, systematic reviews and meta-analyzes but also selected some cohort studies. We contextualized each recommendation-guiding question to determine the quality of the evidence and the strength of this recommendation (GRADE). This material was sent to authors using an open online questionnaire. After receiving the answers, we formalized the consensus for each recommendation of this guideline. RESULTS the level of evidence and the degree of recommendation for each item is presented in text form, followed by a summary of the evidence found. CONCLUSION this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons, the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery. The prescription of these recommendations can accelerate the postoperative recovery of patients submitted to elective general surgery, with decrease in morbidity, length of stay and rehospitalization, and consequently, of costs.

Esofagectomia vídeo-tóraco-laparoscópica com tempo torácico em posição pronada

OBJECTIVE to analyze the National Cancer Institute Abdominopelvic Division (INCA / MS/HC I) initial experience with thoraco-laparoscopic esophagectomy with thoracic stage in prone position. METHODS we studied 19 consecutive thoraco-laparoscopic esophagectomies from may 2012 to august 2014, including ten patients with squamous cells carcinoma (five of the middle third and five of the lower third) and nine cases of gastroesophageal junction adenocarcinoma (six Siewert I and three Siewert II). All procedures were initiated by the prone thoracic stage. RESULTS There were minimal blood loss, optimal mediastinal visualization, oncological radicality and no conversions. Surgical morbidity was 42 %, most being minor complications (58% Clavien I or II), with few related to the technique. The most common complication was cervical anastomotic leak (37%), with a low anastomotic stricture rate (two stenosis: 10.53%). We had one (5.3%) surgical related death, due to a gastric tube`s mediastinal leak, treated by open reoperation and neck diversion. The median Intensive Care Unit stay and hospital stay were two and 12 days, respectively. The mean thoracoscopic stage duration was 77 min. Thirteen patients received neoadjuvant treatment (five squamous cells carcinoma and eight gastroesophageal adenocarcinomas). The average lymph node sample had 16.4 lymph nodes per patient and 22.67 when separately analyzing patients without neoadjuvant treatment. CONCLUSION the thoraco-laparoscopic approach was a safe technique in the surgical treatment of esophageal cancer, with a good lymph node sampling.