Rodrigo Gomes da Silva

The impact of early nutrition on metabolic response and postoperative ileus

Purpose of review Early nutrition has been evaluated and used as a possible strategy to decrease the negative impact of the metabolic response to injury and postoperative ileus. The metabolic response to injury, be it surgical or traumatic, is a physiological mechanism that, according to the magnitude and duration of the event, can impact on the patients morbidity and survival. The adequate initial approach is a determinant factor that might influence its outcome. Simultaneously, gastrointestinal tract motility is transiently impaired, leading to the so-called postoperative ileus. The latter not only causes patient discomfort, but is also related to abdominal complications and worsening of the nutritional status, as well as increased length of hospital stay and costs. Recent findings Multimodal surgical strategies such as preoperative intake of a carbohydrate drink, together with patient education of the postoperative care plan, efficacious analgesia and early nutrition have been described to significantly decrease the stress response and improve the ileus. Therefore, these strategies accelerate rehabilitation and, as a consequence, decrease complications and length of hospital stay and its related costs. Summary Understanding perioperative pathophysiology and implementing care regimes through a multimodal approach in order to reduce the stress of the operation and the related postoperative ileus are major challenges. These factors will certainly impact on patient outcomes.Purpose of reviewEarly nutrition has been evaluated and used as a possible strategy to decrease the negative impact of the metabolic response to injury and postoperative ileus. The metabolic response to injury, be it surgical or traumatic, is a physiological mechanism that, according to the magnitude and duration of the event, can impact on the patients morbidity and survival. The adequate initial approach is a determinant factor that might influence its outcome. Simultaneously, gastrointestinal tract motility is transiently impaired, leading to the so-called postoperative ileus. The latter not only causes patient discomfort, but is also related to abdominal complications and worsening of the nutritional status, as well as increased length of hospital stay and costs. Recent findingsMultimodal surgical strategies such as preoperative intake of a carbohydrate drink, together with patient education of the postoperative care plan, efficacious analgesia and early nutrition have been described to significantly decrease the stress response and improve the ileus. Therefore, these strategies accelerate rehabilitation and, as a consequence, decrease complications and length of hospital stay and its related costs. SummaryUnderstanding perioperative pathophysiology and implementing care regimes through a multimodal approach in order to reduce the stress of the operation and the related postoperative ileus are major challenges. These factors will certainly impact on patient outcomes.

Stapled hemorrhoidectomy: present status

AIM To evaluate cost-effectiveness of stapled hemorrhoidectomy comparing its results with conventional technique. SOURCE OF DATA We retrospectively analyzed the MEDLINE data basis from 2000 to 2004 studying randomized clinical trials which compared pain intensity, recovery period, return to work and occurrence of anal incontinence, in addition to postoperative complications and costs evaluation between stapled and conventional hemorrhoidectomy during different periods of follow-up. CONCLUSIONS Stapled hemorrhoidectomy provides lesser postoperative pain and earlier return to work than conventional hemorrhoidectomy. However, its efficacy could not be determined, since rigorous prospective and randomized clinical trials with long-term follow-up periods and large size samples are not available at this time.

Paradigmas e evidências da nutrição peri-operatória

Understanding perioperative pathophysiology and implementing care regimes, through a multimodal approach, to reduce the organic response to stress after surgery and the related postoperative ileus, are major challenges. Multimodal surgical strategies such as pre-operative intake of a carbohydrate drink, instead of the usually recommended 2- to 6-hour period of nothing-bymouth, together with patients education of the postoperative care plan, plus efficacious analgesia and early postoperative nutrition, among others, have been described to significantly impact on the previous variables. Therefore, these strategies accelerate rehabilitation and, as a consequence, decrease complications and hospital length of stay and, its related costs.

Resultados do registro de cirurgias colorretais videolaparoscópicas realizadas no Estado de Minas Gerais - Brasil de 1996 a 2009

INTRODUCAO: A partir de 1991, a videolaparoscopia comecou a ser considerada no tratamento de doencas colorretais. O aprimoramento da tecnica cirurgica associado aos beneficios encontrados em diversos estudos publicados levou a modificacoes nas perspectivas da videolaparoscopia. A partir da publicacao do estudo COST as resseccoes oncologicas laparoscopicas foram reconhecidas como alternativa viavel, com resultados semelhantes a cirurgia convencional. PACIENTES E METODOS: Realizou-se pesquisa atraves de formulario especifico e consulta a prontuarios dos principais servicos de coloproctologia de Belo Horizonte. Avaliando-se sexo, idade, indicacao cirurgica, procedimento realizado, tecnica laparoscopica, complicacoes, conversao, estadiamento e recidiva (no caso de neoplasias). RESULTADOS: Foram levantados dados sobre 503 cirurgias colorretais laparoscopicas: 347 (68,9%) em mulheres e 156 (31,1%) homens. A tecnica cirurgica foi totalmente laparoscopica em 137 casos, video-assistida 245 casos. O procedimento mais realizado foi a retossigmoidectomia (41,1%), seguido pela colectomia direita (12,5%), colectomia esquerda (6,9%). Doencas benignas foram responsaveis por 259 (51,5%) casos, destes as principais indicacoes cirurgicas foram endometriose 126 (48,6%), polipos 40 (15,4%), doenca diverticular 30 (11,6%). Das 240 cirurgias realizadas por doencas malignas as mais frequentes foram retossigmoidectomia 102 (42,5%), colectomia direita 46 (19,1%), colectomia esquerda 18 (7,5%), amputacao abdominoperineal 18 (7,5%). Houve 54 conversoes (10.7%) dos casos, 12,9% (31/240) nos casos de neoplasias, 8,5% (22/259) nos de doencas benignas. Complicacoes sistemicas ou cirurgicas ocorreram em 31 (6,1%) e 56 (11,1%) casos, respectivamente. Foram registrados onze (2,18%) obitos nos primeiros 30 dias apos a cirurgia. CONCLUSAO: O estudo atual foi o primeiro levantamento da implantacao de cirurgias colorretais laparoscopicas realizado de forma multicentrica em Minas Gerais. Os dados levantados sao consistentes com registros nacionais de videocirurgia colorretal, mostrando a eficiencia do metodo de aprendizado com realizacao de cirurgias com tutor. Alem disso, que pequena parte das cirurgias colorretais sao realizadas por via laparoscopica no estado, restritos apenas a centros especializados, sobrecarregando esses servicos e limitando o acesso para a populacao.

Effect of spleen surgeries on Escherichia coli distribution on the mononuclear phagocytic system

OBJECTIVE To avoid asplenic state, many approaches preserving the spleen have been proposed in the literature: splenorraphy, partial splenectomy with or without preservation of hilar vessels and splenic tissue auto-implants. Subtotal splenectomy, preserving the upper spleen pole nourished only by splenogastric vessels is an alternative when the splenic pedicle must be ligated. The purpose of this study was to evaluate the influence of partial, subtotal and total splenectomies on the distribution of Escherichia coli in the mononuclear phagocytic system. METHOD Thirty-two rats divided into four groups were studied: sham operation (total spleen preservation), partial splenectomy, subtotal splenectomy and total splenectomy. Five weeks after surgeries, an aliquot of E. coli marked with tecnetium-99m was injected intravenously. The animals were killed 20min later and the spleen, lungs and liver were removed in order to determine the distribution of labeled bacteria. RESULTS The amount of E. coli in the splenic tissue was greater in the intact spleen group than in the partial or subtotal splenectomy groups. Phagocytosis through the spleen did not differ between the partial and subtotal splenectomy groups. The amount of bacteria in the lungs was greater in the partial than in the subtotal splenectomy group. The distribution of labeled bacteria was greater in the liver of animals submitted to subtotal splenectomy than in the other groups. CONCLUSION The upper splenic pole, supplied only by splenogastric vessels, has the ability to remove live bacteria from the blood stream, showing that effective blood clearance occurs even without vascularization through the splenic pedicle. Thus, the distribution of E. coli through the mononuclear phagocytic system shows different behavior depending on the type of splenectomy to which the animals are submitted.

Randomized Clinical Trial Impact of Oral Administration of Saccharomyces boulardii on Gene Expression of Intestinal Cytokines in Patients Undergoing Colon Resection

BACKGROUND When intestinal microbiota is imbalanced, a patient becomes more vulnerable to infectious complications; intervention with beneficial probiotics may help lower risk for infection. The aim of this study was to measure levels of inflammatory cytokine messenger RNA (mRNA) in surgical samples of intestinal mucosal tissues from patients who were given the probiotic Saccharomyces boulardii before undergoing colon surgery. METHODS Thirty-three patients undergoing colon resection were randomly assigned to receive at least 7-day preoperative probiotic treatment (n = 15) or conventional (n = 18) treatment. Probiotic treatment consisted of oral lyophilized S boulardii Cytokine mRNA levels (interleukin [IL]-10, IL-1β, IL-23A, tumor necrosis factor [TNF]-α, IL-12B, interferon-γ [INF-γ], and IL-17A) were measured in samples obtained during the operation. Postoperative infections were also assessed. RESULTS Patients who received probiotics had significantly lower mucosal IL-1β, IL-10, and IL-23A mRNA levels than the control group (P = .001, P = .04, and P = .03, respectively). However, mRNA expression of other cytokines did not differ between the 2 groups (P > .05). The incidence of postoperative infectious complications was 13.3% and 38.8% in probiotic and control groups, respectively (P > .05). There was no perioperative mortality in either group. The mean total length of hospital stay was similar between the groups (P > .05). CONCLUSIONS Probiotic treatment with S boulardii downregulates both pro- and anti-inflammatory cytokines in the intestinal colonic mucosa with no statistical impact on postoperative infection rates.

Multiple symmetric lipomatosis.

Background: Multiple symmetric lipomatosis (MSL) is a relatively uncommon entity of unknown etiology characterized by symmetrically subcutaneous accumulation of nonencapsulated adipose tissue. Approximately 200 to 300 cases have been published. Objectives: The aims of this article are to report the case of a 58-year-old Brazilian patient with MSL and provide a comprehensive overview of the current concepts concerning this disease. Methods: Our search yielded 28 articles on MSL, including case reports and reviews of the literature. Results: MSL predominantly affects Mediterranean males with a history of chronic alcohol abuse. It is usually asymptomatic and may be associated with diabetes mellitus, hyperlipidemia, hyperuricemia, macrocytic anemia, and oral cancer. Surgical resection is the best treatment option. Conclusion: The case reported is a classic presentation of MSL; however, it is particularly uncommon owing to the association with immune thrombocytopenic purpura. This association has been described only once in the medical literature.

Impacto do uso da solução reveladora de linfonodos no estadiamento do câncer colorretal

INTRODUCTION: Accurate pathological study of colorectal cancer (CRC) specimens is of paramount importance to prognosis and indication of adjuvant therapies. Despite the minimum of 12 lymph nodes has been considered adequate to correctly establish the stage of disease, a bigger harvest of lymph nodes would increase the number of metastatic lymph nodes obtained. AIMS: To evaluate the harvest of lymph nodes from mesocolic fat before and after the introduction of routine use of a revealing solution of lymph nodes. Methods: We evaluated a total of 706 pathological reports of CRC, 582 without use of revealing solution and 124 with use of this solution. RESULTS: most of patients were females (57.6%) with mean age of 61.36 years. Sixty per cent of tumors were located distally to splenic flexure. The average of lymph nodes obtained was 16.73 and 28.97 before and after use of revealing solution, respectively (p < 0,001). Percentage of specimens with eleven or less lymph nodes (Nx) decreased significantly after use of revealing solution (32.7 to 3.2%; p < 0,0001). In opposite, there was a significative increase in number of cases sorted as pN0, pN1, pN2 e pN3 after use of revealing solution. CONCLUSION: The use of revealing solution of lymph nodes causes great impact in the pathological study of CRC and its routine use is strongly recommended in the surgical pathology services.

Late postoperative follow-up of patients undergoing subtotal splenectomy

PURPOSE Over the past 21 years, we have performed more than 200 subtotal splenectomies, in which the upper splenic pole vascularized only by the gastrosplenic pole vascularized only by the gastrosplenic vessels is preserved, to treat different pathologic conditions. A meticulous follow-up of the postoperative results of this procedure is of fundamental importance. METHODS All patients undergoing subtotal splenectomy were invited to be reviewed. A total of 86 patients who had undergone surgery 1 to 20 years ago were gathered; the surgical procedure was performed for one of the following conditions: portal hypertension due to schistosomiasis (n = 43), trauma (n = 31), Gauchers disease (n = 4), myeloid hepatosplenomegaly due to myelofibrosis (n = 3), splenomegalic retarded growth and sexual development (n = 2), severe pain due to splenic ischemia (n = 2) and pancreatic cystadenoma (n = 1). Patients underwent a hematologic exam, an immunologic assessment, abdominal ultrasonography, computed tomography, scintigraphy and endoscopy. RESULTS Increased white blood cell count and platelets were the only hematological abnormalities. No immunologic deficit was found. Esophageal varices were still present in patients who underwent surgery because of portal hypertension although without rebleeding. The ultrasound, tomography and scintigraphy exams confirmed the presence of functional splenic remnants without significant size alteration. CONCLUSIONS Subtotal splenectomy seems to be a safe procedure that can be useful in treating conditions involving the spleen. The functions of the splenic remnants are preserved during long periods of time.

Câncer colorretal: resultados da avaliação patológica padronizada de 521 casos operados no Hospital das Clínicas da UFMG

INTRODUCTION: The incidence and mortality of colorectal cancer (CRC) have shown, worldwide, an upward trend, particularly in developed countries and urban areas of developing countries. The study of tumors pathological characteristics is important for staging and the definition of the proper therapy to be used. The aim of this study is to evaluate the pathologic features of surgical specimens of colorectal resections due CRC at Hospital das Clinicas, Universidade Federal de Minas Gerais. RESULTS: We evaluated 521 surgical specimens of colorectal resections. The mean age of patients was 62.47 (± 14.67) years, 302 (58%) were female. Tumors of the left colon were more common (340 [65.3%]). There was a predominance of adenocarcinoma (457 [87.7%]), ulcero-infiltrative (176 [33.8%]), moderately differentiated (396 [76%]), pT3 (316 [60.7%]) and pN0 (213 [40.9%]). The average number of dissected lymphonodes per surgical specimen was 22.13 (± 14.27). CONCLUSIONS: Data from our series of CRC did not differ from what was reported in the literature. In summary, the CRC was more common in women than in men, affecting most frequently the left colon, and the predominant type was moderately differentiated adenocarcinoma, pT3 and pN0