Uirá Fernandes Teixeira

AMBULATORY LAPAROSCOPIC CHOLECYSTECTOMY IS SAFE AND COST-EFFECTIVE: a Brazilian single center experience

BACKGROUND - Laparoscopic cholecystectomy is the treatment of choice for gallstone disease, and has been perfomed as an outpatient surgery in many Institutions over the last few years. OBJECTIVE - This is a retrospective study of a single center in Brazil, that aims to analyze the outcomes of 200 cases of ambulatory laparoscopic cholecystectomy performed by the same Hepato-Pancreato-Biliary team, evaluating the safety and cost-effectiveness of the method. METHODS - Two hundred consecutive patients who underwent elective laparoscopic cholecystectomy were retrospectively analyzed; some of them underwent additional procedures, as liver biopsies and abdominal hernias repair. RESULTS - From a total of 200 cases, the outpatient surgery protocol could not be carried out in 22 (11%). Twenty one (95.5%) patients remained hospitalized for 1 day and 1 (4.5%) patient remained hospitalized for 2 days. From the 178 patients who underwent ambulatory laparoscopic cholecystectomy, 3 (1.7 %) patients returned to the emergency room before the review appointment. Hospital cost was on average 35% lower for the ambulatory group. CONCLUSION - With appropriate selection criteria, ambulatory laparoscopic cholecystectomy is feasible, safe and effective; readmission rate is low, as well as complications related to the method. Cost savings and patient satisfaction support its adoption. Other studies are necessary to recommend this procedure as standard practice in Brazil.

A rare case of multiple skin metastases from squamous cell carcinoma of the esophagus

Summary Background: Esophageal cancer is an aggressive disease that generally has a poor prognosis. Patients affected by the disease usually present with signs and symptoms related to local growth of the tumor, gastrointestinal bleeding and nutritional impairment. Skin metastases are rare events, associated with advanced stage and poor survival. Case Report: We report the case of a 51-year-old man who presented poor general status, dysphagia, weight loss and skin lesions disseminated throughout the body. Endoscopic examination revealed the presence of esophageal squamous cell carcinoma, and biopsies of skin lesions showed metastasis of this cancer to the esophagus. Conclusions: We believe that any suspicious lesion that presents together with a history of gastrointestinal malignancy should be biopsied, since it can change the staging and prognosis of patients.

Early Drain Amylase Value Predicts the Occurrence of Pancreatic Fistula After Pancreaticoduodenectomy.

To the Editor: We read with special interest the article by Ven Fong et al published on August 2015. We believe that this study is a cornerstone in pancreatic surgery, bringing a new concept that can greatly contribute to postoperative care in patients undergoing pancreaticoduodenectomy (PD). Surgical resection remains the treatment of choice for patients with periampullary tumors, representing the only chance to obtain long-term survival. Nowadays, with improvements in surgical expertise, anesthesia and postoperative care, this procedure can be accomplished with a mortality rate of less than 5%. Pancreatic fistula (PF), especially that one of clinical relevance, is a major complication after PD, affecting up to one-third of patients. Early prediction of its occurrence is of considerable interest; its exclusion in the early postoperative days enables the treatment of patients under fast-track protocol, which includes mobilization and removal of abdominal drains, rapid evolution of oral feeding, shorter length of hospital stay, and cost savings. This idea is important because the occurrence of PF changes the surveillance of patients, carrying a high percentage of major complications (bleeding, abdominal abscess, need for invasive procedures, or reoperation), often requiring interruption of enteral nutrition, maintenance of drains, use of antibiotics, and close monitoring of 7

Primitive Neuroectodermal Tumor of the Pancreas: A Case Report and Review of the Literature.

Primitive neuroectodermal tumors (PNETs) are presented as rare malignant neoplasms. In unusual cases, those neoplasms may arise in solid organs containing neuroendocrine cells, such as the pancreas. Herein the case of a 28-year-old patient that underwent gastroduodenopancreatectomy after the diagnosis of a huge mass (PNET) located in both head and body of the pancreas is reported. This is the 19th case of pancreatic PNET reported in literature.

Síndrome de Mirizzi em associação com níveis séricos de CA 19-9 superiores a 20.000U/ml: é possível?

Mulher de 83 anos foi atendida com historia de ictericia progressiva, coluria, hipocolia, prurido, dor em abdome superior e emagrecimento. Ao exame fisico apresentava-se icterica com discreta dor a palpacao do hipocondrio direito, sem evidencia de massas palpaveis. Os exames laboratoriais da admissao foram: bilirrubina total=26, bilirrubina direta=15,8, gama glutamil-transferase=829, fosfatase alcalina=518, transaminase glutâmico-oxalacetica=115, transaminase glutâmico-piruvica=92, hemoglobina=12,7, tempo de protrombina=89%, antigeno carboidrato 19-9=24.480. Destes, destaca-se o CA 19-9 de 24.480 U/mL. Tomografia computadorizada de abdome evidenciou dilatacao importante das vias biliares intra e extra-hepaticas e do segmento proximal do ducto hepatico comum (Figura 1). Observou-se tambem aparente compressao do hepatocoledoco pela vesicula biliar que se encontrava moderadamente distendida, com paredes espessadas, e provavel imagem de calculo na sua regiao infundibular medindo cerca de 2,0 cm. Ressalte-se que a possibilidade de neoplasia em via biliar nao podia ser afastada.A paciente em foi submetida a laparotomia exploradora, na qual foi evidenciado processo inflamatorio intenso no triângulo de Calot, com presenca de fistula entre a vesicula biliar - que apresentava-se escleroatrofica -, e o hepatocoledoco. Iniciou-se pela abertura da vesicula, onde foi identificado calculo unico de 2,3 cm no infundibulo, realizada biopsia da parede do coledoco e exploracao da via biliar a procura de outros calculos, que nao foram encontrados. Realizou-se coledocostomia com colocacao de dreno de Kehr e colangiografia de controle pelo dreno. Observou-se passagem do contraste para o duodeno e ausencia de lesoes ou calculos. A biopsia hepatica revelou reacao portal de padrao biliar com septos porta-porta, sugestivo de obstrucao de grandes ductos. Biopsias do coledoco/ducto hepatico/vesicula biliar nao revelaram malignidade, sendo compativeis com inflamacao aguda e cronica e edema, confirmando o diagnostico de sindrome de Mirizzi.A paciente evoluiu bem no pos-operatorio. Colangiografia no 9o dia foi normal. Houve normalizacao dos marcadores de colestase e decrescimo significativo do nivel serico do Ca 19-9 para 355,9 U/mL. No seguimento de tres anos, a paciente permanecia viva em bom estado geral sem evidencia de doenca maligna e com niveis sericos de CA 19-9 dentro da normalidade.

A case of oncogenic osteomalacia owing to inguinal tumor

Abstract The oncogenic hypophosphatemic osteomalacia is a very incapacitating disease and the mortality rate, mainly due to metabolic disorder, depends on the early diagnosis, since the surgery is curative. The major difficulty is to consider this kind of disease in patients with complex clinical presentation. Moreover, medical centers have to provide a good diagnostic infrastructure because these tumors, in most cases, are small and do not have an obvious site. This case report is about a man with a rapid loss of strength and muscle mass, which had his diagnosis in a late, culminating in significant deformities and organic dysfunctions with clinical repercussions. However, the fast diagnosis with appropriate tests determined the stop point of the evolution of disease and marked the beginning of metabolic recovery. This case reinforces the global problem health care infrastructure and the access to diagnostic equipment, demonstrating the impact on the patient’s health of our service.

Oncogenic hypophosphatemic osteomalacia: From the first signal of disease to the first signal of healthy

Highlights • Oncogenic hypophosphatemic osteomalacia is an uncommon paraneoplastic syndrome. Neoplasia with high morbimortality if not detected early.• A free margin excision is necessary to stop deformity evolution.

Apocrine sweat gland adenocarcinoma: A rare case report and review

Highlights • Apocrine Sweet Gland Adenocarcinoma is a very uncommon cancer that can cause structural deformities by metabolic disorder (paraneoplastic syndrome).• That’s the first case related on Brazil.• This case contributes to the best choice of the exams required for detection of this rare cancer (there is no consensus in the literature by the limited number of cases).

Use of Left Gastric Vein as an Alternative for Portal Flow Reconstruction in Liver Transplantation

Portal vein thrombosis is observed in up to 10% of liver transplant candidates, hindering execution of the procedure. A dilated gastric vein is an alternative to portal vein reconstruction and decompression of splanchnic bed. We present two cases of patients with portal cavernoma and dilated left gastric vein draining splanchnic bed who underwent liver transplantation. The vein was dissected and sectioned near the cardia; the proximal segment was ligated with suture and the distal segment was anastomosed to the donor portal vein. Gastroportal anastomosis is an excellent option for portal reconstruction in the presence of thrombosis or hypoplasia. It allows an adequate splanchnic drainage and direction of hepatotrophic factors to the graft.

ASSOCIATION BETWEEN MURINE DOUBLE MINUTE 2 - T309G polymorphism and recurrence of hepatocellular carcinoma after surgical treatment

BACKGROUND Discovery and incorporation of biomarker panels to cancer studies enabled the understanding of genetic variation and its interference in carcinogenesis at molecular level. The potential association between single nucleotide polymorphism (SNP) 309 and increased development of tumors, such as hepatocellular carcinoma, has been subject to several studies. This is the first study on this association conducted in Brazil. METHODS 62 cases of cirrhotic patients with hepatocellular carcinoma surgically treated by partial hepatectomy (HPT) or by liver transplantation (LTX) from 2000 to 2009 at Santa Casa Hospital Complex, in the city of Porto Alegre, were retrospectively analyzed. Tumor samples from surgical specimen were collected and prepared for study in paraffin blocks. RESULTS Overall survival was 26.7 months in the HPT group and 62.4 months in the LTX group (P <0.01). Overall tumor recurrence was 66.7% in the HPT group (10/15) and 17% in the LTX group (8/47) (X²=13.602, P <0.01). Alpha-fetoprotein levels >200ng/mL, microvascular invasion and histological grade were associated with tumor recurrence (P <0.01). Recurrence rates in each surgical group and analysis of factors associated with tumor recurrence, when stratified for each genotypic pattern, were both not statistically significant. CONCLUSION G/G genotype was not associated with tumor recurrence after surgical treatment and it did not show any correlation with other prognostic factors.