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

Background: Intrahepatic cholangiocarcinoma (iCCA) was considered a contraindication for liver transplantation. However, recent studies have shown that highly selected cases of patients with a good response to neoadjuvant therapy may achieve acceptable survival rates when following liver transplantation.

Aims: To present two cases of patients with iCCA, without extrahepatic disease, who underwent living donor liver transplantation after receiving neoadjuvant chemotherapy.

Methods: Two cases of patients with histopathological diagnosis of locally advanced iCCA, ineligible for resection and without evidence of extrahepatic disease, are presented.

Results: These patients underwent at least nine sessions of neoadjuvant chemotherapy, including Gemcitabine and Cisplatin, with or without the addition of immunobiological agents, resulting in a radiological tumor response. They subsequently underwent living donor liver transplantation. The average follow-up time was 15 months, with no clinical or radiological signs of disease.

Conclusions: In well-selected patients without extrahepatic disease, living donor liver transplantation represents a potential therapeutic option for iCCA.

Background: Colon cancer is the third most common malignancy in Colombia, only exceeded by prostate and breast cancers. It is the second most common cancer among females and the third most common among males. The epidemiology of this disease has changed in Colombia, and its peak incidence has now surpassed that of gastric cancer.

Aims: We aimed to determine the association between hospital surgical volume and mortality in patients with colon cancer undergoing surgical resection in Colombia.

Methods: This was a national retrospective cohort study based on administrative data and included adult patients undergoing surgical resection for colon cancer who were enrolled in Colombia's contributory health system between 2012 and 2017. We defined exposure as the hospital's surgical volume where the colon cancer surgery was performed. We classified the patients as exposed to a high surgical volume (above the 90th percentile of the provider distribution) and a low surgical volume (under the 90th percentile). The main outcomes were 30-day and 1-year mortality. Multivariate Poisson regressions were used to identify the association between exposure and mortality rates.

Results: The study included 4,647 patients, of which 4,188 underwent surgery at hospitals with a colectomy volume lower than 33 per year and 459 underwent surgery at institutions with volumes equal to or higher than 33 per year. In the multivariate analysis, after adjusting for observable variables, a lower risk of 30-day mortality was found in patients who underwent surgery at high surgical volume institutions (relative risk - RR 0.57, 95% confidence interval - 95%CI 0.033-0.97). No differences were found in the one-year mortality.

Conclusion: The high surgical volume of a hospital is associated with a 30-day mortality in colon cancer, as described in other studies, but the 1-year mortality did not show this association. Prospective studies are required to establish a causal relationship.

Background: Many free radicals result in an inflammatory process due to complications caused by gallstones. These free radicals are inactivated by various reactions and participate in different reactions. Molecules are oxidants and antioxidants that take an active role in almost every event that takes place in the body.

Aims: To analyse the changes in total antioxidant level (TAL) and total oxidant level (TOL) in the follow-up of patients hospitalized for cholelithiasis or its complications, showing the active oxidative stress, and to test the usability of these parameters in the evaluation of treatment success.

Methods: Forty-five patients took part in the study. Blood samples were taken twice, previous to surgery and 6 hours after surgery. Tissue samples were also obtained from patients who were operated. Then, the samples were sent to a laboratory to measure the total oxidant and antioxidant status of patients.

Results: The median for the TAL_before (pre-operation or hospitalization in non-operational) variable was 2.40 (interquartile range - IQR=0.50), and the median for the TAL_after variable was 2.20 (IQR=0.33). The median of the tissue-derived TAL variable was 0.32 (IQR=0.13), and the median of the TOL variable was 0.43 (IQR=0.52). The median value of the TAL_before variable for men was 2.50 (IQR=0.50), while the median value for the TAL_before variable for women was 2.30 (IQR=0.50). TAL_before variable values did not show a statistically significant difference according to gender (Z=1.446; p=0.154, p>0.05). Similarly, the median values of TOL_before variable by gender were similar (Z=0.614; p=0.545, p>0.05).

Conclusions: Cholelithiasis and its complications cause many inflammatory responses, ending with free radical formation. During follow-up, its level decreases due to consumption or success of the treatment.

Background: Pancreas divisum is an anatomical abnormality where the junction of the main and accessory pancreatic duct fails to occur and the smaller-caliber duct acts as dominant, resulting in overload during the drainage of the organ's secretion through the minor duodenal papilla.

Aims: To report a case of recurrent acute pancreatitis due to symptomatic pancreas divisum who underwent pancreatoduodenectomy.

Case report: A 21-year-old male patient presented with intermittent painful crises, located in the upper abdomen, with radiation to the back, associated with nausea and vomiting, for the past three years. Magnetic resonance imaging and endoscopic retrograde cholangiopancreatography revealed pancreas divisum, subsequently confirmed by endoscopic ultrasound. An attempt was made through endoscopic intervention but failed to catheterize the minor papilla; therefore, a pancreaticoduodenectomy was indicated. The organ was identified as hard and atrophied, with moderate peripancreatic inflammation. The histopathological findings also identified a focal well-differentiated G1-type neuroendocrine tumor measuring 0.4 cm.

Conclusions: In patients with pancreas divisum, rare cases may progress to recurrent acute pancreatitis. Pancreaticoduodenectomy is an option in symptomatic patients who had no success with endoscopic treatment.

Obesity is recognized as a significant risk factor for various types of cancer. Although the incidence of some types of cancer across various primary sites is decreasing due to specific prevention measures (screening programs, smoking cessation), the incidence of neoplasms in the young population shows a significant increase associated with obesity. There is sufficient evidence to say that bariatric surgery has been shown to significantly lower the risk of developing obesity-associated cancers, which are linked to metabolic dysregulation, chronic low-grade systemic inflammation, and hormonal alterations such as elevated levels of insulin and sex hormones.

Mixed neuroendocrine-non-neuroendocrine tumors (MiNEN) are a rare type of tumor formed by two components, a non-neuroendocrine component that is most often an adenocarcinoma and a neuroendocrine tumor, and each of these components must represent at least 30% of the tumor. The origin of this tumor on the ampulla of Vater or periampullary region is more infrequent. Usually, the lesions are highly aggressive and quickly metastasizing, and their biological behavior is dictated by the high grade of the neuroendocrine component. This is the first report of a patient with ampullary MiNEN treated employing a robotic pancreaticoduodenectomy. Although being submitted to aggressive treatment with complete surgical resection followed by systemic therapy, the patient developed early recurrence with hepatic metastatic disease, demonstrating the hostile nature of these tumors.

Background: There is recent evidence showing that obesity is associated with gastroesophageal reflux disease and esophageal dysmotility, although symptoms are not always present.

Aims: This is a prospective study based on high-resolution manometry findings in bariatric surgery candidates and their correlation with postoperative dysphagia.

Methods: Manometric evaluation was performed on candidates for bariatric surgery from 2022 to 2024. The examination was conducted according to the protocol of the fourth version of the Chicago Classification, including different positions and provocative maneuvers to confirm the diagnosis of dysmotility. Patients were followed for 90 days after surgery to verify the occurrence of dysphagia or difficulty adapting to the diet.

Results: High-resolution manometry was performed on 46 candidates for bariatric surgery with a mean body mass index of 46.5 kg/m2. Esophagogastric junction outflow obstruction was diagnosed in 16 (34.8%) patients, and ineffective esophageal motility was diagnosed in 8 (17.4%) patients. None of the subjects reported symptoms during the preoperative period. Out of the 46 individuals initially included, 44 underwent bariatric surgery, 23 (52.3%) underwent Roux-en-Y gastric bypass, and 21 (47.7%) underwent sleeve gastrectomy. One patient with esophagogastric junction outflow obstruction reported dysphagia after Roux-en-Y bypass, but symptoms spontaneously resolved during the 90-day follow-up period.

Conclusions: Although patients with severe obesity have a high prevalence of esophageal motility disorders, no clinical repercussions were observed after bariatric surgery during the study period.

Background: Obesity is a multifactorial disease affecting a significant portion of the population. Bariatric surgery emerges as a prominent approach in this context, representing an effective treatment both in the short and long term. The costs associated with bariatric surgery vary depending on the characteristics of the patients, current hospital practices, and available funding sources.

Aims: To analyze the costs of minimally invasive bariatric surgery for the treatment of obesity in a tertiary federal public hospital.

Methods: An observational and descriptive study aimed at assessing the costs associated with laparoscopic vertical gastrectomy (GV) and Roux-en-Y gastric bypass (RYGB) in a federal public tertiary service from 2018 to 2021. Data were obtained through the management of medical-hospital expenses related to surgical and anesthetic supplies, as well as the amount reimbursed by the funding source to the hospital.

Results: Over the analyzed period, a total of 177 minimally invasive bariatric surgeries were performed. In terms of the charges, since 2018, the hospital has been receiving an amount of R$ 6,145.00 for the "bariatric surgery by videolaparoscopy" procedure, which includes RYGB, and R$ 4,095.00 for "vertical gastrectomy." Regarding the average hospital cost of surgical supplies, RYGB incurred a total of R$ 9,907.54, while GV incurred a total of R$ 9,315.84. The average total cost of RYGB was R$ 10,799.23, and, for GV, it was R$ 10,207.53. These figures indicate that the hospital incurred a loss of approximately R$ 4,654.23 for performing RYGB and R$ 6,112.53 for GV.

Conclusion: Despite the increasing number of eligible patients for surgical treatment of obesity and the consequent quantitative growth of these procedures funded by the Brazilian Unified Health System (SUS), the costs exceed the reimbursement from the funding source in federal public hospitals. There is a need for a precise assessment of financing in the fight against obesity.

Background: The relationship between thrombosis and cancer is based on evidence that cancer promotes prothrombotic changes in the host hemostatic system. The activation of blood coagulation is closely linked to tumor growth and dissemination.

Aims: To evaluate whether quantifications of plasma circulation tumor deoxyribonucleic acid (DNA) and thrombin-antithrombin complex could act as predictors for thrombotic events and death in patients with gastric or colorectal adenocarcinomas, while also evaluating the Karnofsky Performance Status.

Methods: Eighty-two patients were included in the study and divided into three groups: controls (n=20), gastric adenocarcinomas (n=21), and colorectal adenocarcinomas (n=41). In order to calculate the Karnofsky index, information was collected to measure the patient's ability to perform common daily tasks. The following serum measurements were conducted: complete blood count, platelet count, extracellular deoxyribonucleic acid, and thrombin-antithrombin complex.

Results: Ten patients (16%) experienced thrombosis during treatment. Patients with thrombin-antithrombin complex levels greater than 0.53 had a five-times higher risk of thrombosis. Lower Karnofsky Performance Status was also a risk factor for the event in this population. Neither thrombin-antithrombin complex nor plasma circulation tumor DNA were predictors of death after multivariate adjustment. Thus, Karnofsky index signaled a better overall survival prognosis for colorectal and gastric adenocarcinoma patients.

Conclusions: Thrombin-antithrombin complex acts as a marker for thrombosis in patients with colorectal and gastric adenocarcinomas. We recommend prophylactic anticoagulation when the Karnofsky value is low and/or the thrombin-antithrombin complex concentration is greater than 0.53 ng/ml.