Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery最新文献

Complete removal of metastatic disease and maintenance of an adequate liver remnant remains the only treatment option with curative intent concerning colorectal liver metastases. Surgery impacts on the long-term prognosis and complications adversely affect oncological results. The actual morbidity involving this scenario is debatable and estimated to be ranging from 15% to 50%. Postoperative complications eventually lead to an increase in both mortality rates and tumor recurrence. Biliary fistula and liver failure are the leading complications following liver resection to metastatic colorectal cancer. Prophylactic drainage does not prevent fistulas or hemorrhage. Drainage along with endoscopic intervention and/or surgery may be necessary for grade B and C fistulas. Liver failure is a potentially lethal complication with few therapeutic options. Patient selection and preoperative care are crucial for its prevention.

In patients with synchronic liver colorectal metastasis, resection of the primary tumor and liver metastases is the only potentially curative strategy. In such cases, there is no consensus on whether resection of the primary tumor and metastases should be performed simultaneously or whether a staged approach should be performed (resection of the primary tumor and after, hepatectomy, or hepatectomy first). Patients with no bowel occlusion and with extensive liver disease are advised neoadjuvant oncological therapy. Similarly, various strategies such as portal vein embolization, liver deprivation, two-staged hepatectomy, and associating liver partition and portal vein ligation are available for patients who do not have a sufficient future liver remnant (generally 30-40% of the total). Therefore, a multidisciplinary approach is required for the treatment of these patients.

Background: Preoperative hospitalization with the purpose to obtain more effective weight loss provides intensive care for patients who have a higher body mass index (BMI) and associated diseases that involve a greater risk of peri- and postoperative complications. It is a therapeutic strategy that can make it possible to overcome obstacles related to the difficulty of adhering to obesity treatment.

Aims: To analyze the implementation of a preoperative hospitalization strategy for weight loss in patients eligible for bariatric surgery.

Methods: Retrospective study that included 194 patients with a BMI=50 kg/m2. They were grouped according to preoperative preparation strategies: inpatient (n=32) and outpatient (n=162), who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2010 and 2020. The groups were compared regarding preoperative weight loss before and after the strategies and postoperative up to two years after surgery.

Results: Most patients were female and there were significant differences in age group (an average of 42.94 years in the preoperative hospitalization strategy group and 37.73 in the outpatient strategy group). The mean BMI in the hospitalized group was 63.01±8.72 kg/m2, and in the outpatient group it was 54.95±4.31 kg/m2. There was a significant difference only between initial and preoperative weight in the hospitalized group. Furthermore, the difference between initial weight and last recorded weight up to two years after surgery was significant in each group. The occurrence of associated diseases was higher in the outpatient group.

Conclusions: Patients following the preoperative hospitalization strategy experienced significant weight loss before surgery.

Background: Pancreatic neuroendocrine tumors (PNETs) are uncommon and heterogeneous neoplasms, often exhibiting indolent biological behavior. Their incidence is rising, largely due to the widespread use of high-resolution imaging techniques, particularly influencing the diagnosis of sporadic non-functioning tumors, which account for up to 80% of cases. While surgical resection remains the only curative option, the impact of factors such as tumor grade, size, and type on prognosis and recurrence is still unclear.

Aims: To investigate prognostic risk factors and outcomes in patients with sporadic PNETs treated surgically.

Methods: A retrospective analysis was conducted on patients with sporadic PNETs who underwent pancreatic resection. Data were collected from medical records.

Results: A total of 113 patients were included: 32 with non-functioning tumors (NF-PNETs), 70 with insulinomas, and 11 with other functioning tumors (OF-PNETs). Patients with insulinoma were significantly younger, had a higher BMI, lower prevalence of comorbidities and ASA scores, and underwent significantly more pancreatic enucleations compared to patients with OF-PNET and NF-PNET. The insulinoma group had more grade I tumors, smaller tumor diameter, lower TNM staging, and lower disease recurrence rates. In univariate analysis, age, tumor type, tumor size, and TNM staging were identified as potential risk factors for tumor recurrence. In multivariate analysis, only the NF-PNET type was identified as an independent prognostic factor for disease recurrence.

Conclusions: NF-PNETs are an independent prognostic risk factor for disease recurrence. This finding supports the need for closer follow-up of patients with small tumors who are selected for conservative management.

The development of surgical techniques, chemotherapy, biological agents, and multidisciplinary approaches have made patients with unresectable colorectal liver metastases eligible for surgery. Many strategies have been developed to allow patients for surgical resection (percutaneous portal vein embolization, liver venous deprivation, parenchyma-sparing liver surgery, reverse strategy, associating liver partition and portal vein ligation for staged hepatectomy, and liver transplantation), the only form of disease control and curative treatment.

Background: Hepatocellular carcinoma (HCC) encompasses rare variants like chromophobe hepatocellular carcinoma (CHCC) characterized by distinct histological features and molecular profiles.

Case report: A 56-year-old male with chronic hepatitis C, presenting pain in the right hypochondrium. Imaging revealed a solitary liver lesion, subsequently resected and histologically diagnosed as HCC. Macroscopic examination found a 4×4 cm encapsulated liver nodule with necrotic areas, surrounded by numerous smaller satellite nodules in Segment 6. The liver was in micronodular cirrhosis. Histologically, the tumor had focal trabecular or pseudoglandular patterns within a vascularized stroma. The cells were large, with clear to eosinophilic cytoplasm and hyperchromatic and pleomorphic nuclei with focal anaplastic features. No vascular invasion was noted in adjacent cirrhotic liver tissue.

Results: The final diagnosis was CHCC. Due to its rarity and overlapping characteristics with other hepatic tumors, CHCC poses diagnostic challenges. Accurate diagnosis necessitates thorough histopathological assessment and molecular testing. The identification of the alternative lengthening of telomeres phenotype may distinguish CHCC from conventional HCC and hold potential implications for targeted therapeutic approaches.

Conclusions: Recognition of HCC variants is critical for effective management and underscores the need for continued research into its clinical behavior and therapeutic responses.

Background: Laparoscopic cholecystectomy is considered safe; however, it is not free from complications, such as bile duct injuries, bleeding, and infection of the surgical site.

Aims: The aim of this study was to determine the effectiveness of two prediction tools, the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) calculator and the surgical Apgar, in predicting post-cholecystectomy complications.

Methods: A cross-sectional, analytical, and comparative study was conducted on patients over 18 years old diagnosed with acute cholecystitis who underwent open or laparoscopic cholecystectomy at the Regional Teaching Hospital of Trujillo between 2015 and 2019. A chi-square test was used for bivariate analysis, and the receiver operating characteristic (ROC) curve analysis was employed to determine the discriminative capacity of the ACS-NSQIP and surgical Apgar calculators in predicting severe complications.

Results: A total of 227 patients were included in the study. The analysis revealed that the mean age of patients who experienced severe complications was 75.32±4.58 years. Additionally, 52.6% of these patients were male. Regarding the prediction analysis based on the ROC curve, the ACS-NSQIP calculator showed an area under the curve of 0.895 (95%CI 0.819-0.971; p=0.01), whereas the surgical Apgar calculator showed an area under the curve of 0.611 (95%CI 0.488-0.735; p=0.11).

Conclusions: The obtained results indicate that the ACS-NSQIP calculator is effective in predicting severe complications in patients undergoing cholecystectomy due to acute cholecystitis. These findings may have important implications for clinical practice and medical decision-making, focusing on the appropriate use of prediction tools to improve outcomes in this type of surgical procedure.

Background: Multimodal protocols such as Acceleration of Total Postoperative Recovery and Enhanced Recovery After Surgery propose a set of pre- and post-operative care to accelerate the recovery of surgical patients. However, in clinical practice, simple care such as early refeeding and use of drains are often neglected by multidisciplinary teams.

Aims: Investigate whether early postoperative refeeding determines benefits in colorectal oncological surgery; whether the patients' clinical conditions preoperatively and the use of a nasogastric tube and abdominal drain delay their recovery.

Methods: Retrospective cohort carried out at the Cascavel Uopeccan Cancer Hospital, including adult cancer patients (age ≥18 years), from the Unified Health System (SUS), who underwent colorectal surgeries from January 2018 to December 2021.

Results: 275 patients were evaluated. Of these, 199 (75.4%) were refed early. Late refeeding (odds ratio - OR=2.1; p=0.024), the use of nasogastric tube (OR=2.72; p=0.038) and intra-abdominal drain (OR=1.95; p=0.054) increased the chance of infectious complication. Multivariate analysis showed that receiving a late postoperative diet is an independent risk factor for infectious complications. Late refeeding (p=0.006) after the operation and the placement of an intra-abdominal drain (p=0.007) are independent risk factors for remaining hospitalized for more than five days postoperatively.

Conclusions: Refeeding early in the postoperative period reduces the risk of infectious complications. Using abdominal drains and refeeding late (>48h) for cancer patients undergoing colorectal surgery are risk factors for hospital stays longer than five days.

Background: Cholangiocarcinoma (CCA) is a rare neoplasm, with high mortality, originating in the bile ducts. Its incidence is higher in Eastern countries due to the endemic prevalence of liver parasites. Factors such as metabolic syndrome, smoking, and pro-inflammatory conditions are also linked to the disease. Clinical features include asthenia, abdominal pain, cholestasis, and increased serum levels of CEA and CA19-9.

Aims: The aim of this study was to evaluate CCA prevalence, survival, and potential prognostic and therapeutic implications in a patient cohort and assess correlations with clinical laboratory data and possible associated risk factors.

Methods: This is a retrospective study of the clinical and histological data of patients diagnosed with CCA at Santa Casa de Misericórdia in Porto Alegre, Brazil, between 2016 and 2021.

Results: There was a 56% prevalence of CCA in women, with intrahepatic localization in 55.4% of cases and unifocality in 85.6% of patients. The mean age of the patients was 63 years (26-89 years), with a mean tumor size of 5.5 cm. The median survival time was 7 months (0 to >50). CA19-9 was altered in 81% of patients, whereas GOT/GPT was altered in 62.5% and gamma-glutamyl transferase/alkaline phosphatase/bilirubin in 69.1% of patients. Mortality was higher among patients with extrahepatic CCA.

Conclusion: Risk factors such as smoking, cholecystectomy, cirrhosis, intrahepatic lithiasis, and transplantation should be considered individually by the attending physician for radiological monitoring and incidental discovery of the neoplasm. Lack of timely identification by the attending physician can delay diagnosis, increasing mortality.