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

Background: Knowledge of the cystic artery and its variations is essential to perform safe cholecystectomies. The cystic artery originates from the right hepatic artery, passing posterior to the common hepatic duct, anterior to the cystic duct, and branching into two branches at the neck of the gallbladder. However, variations in position, size, and relationship with adjacent structures are common.

Aims: This article presents a literature review regarding cystic artery variations and their frequency during cholecystectomies.

Methods: The articles selected for this review were chosen from the PubMed and SciELO databases. The standardized descriptors used were anatomic variation and cholecystectomy. These were chosen using the "Medical Subject Headings" and combined with the Boolean operator AND and the non-standard descriptor cystic artery.

Results: It was found in 54.5% of the studies that the anatomical pattern of the cystic artery was the most frequent type. A different origin from the standard was cited in 63.6% of the articles. Double irrigation of the gallbladder was found in 59.1%. In 36.4%, the cystic artery was anterior to the common hepatic duct or the cystic duct. Cystic arteries outside Calot's triangle were found in 36.4%. Short cystic arteries were found in 13.6%. The absence or non-identification of the artery was reported in 9.1%.

Conclusions: Variations of the cystic artery are common and are frequently reported. One aspect of a safe cholecystectomy is anatomical knowledge and its possible variations. Thus, surgeons must be familiar with this point in order to reduce vascular and biliary injuries.

Background: Surgery is associated with a high risk for morbidity and mortality, particularly when performed in critical patients requiring intensive care unit (ICU) admission.

Aim: The aim of this study was to investigate risk factors associated with adverse outcomes in a large cohort of patients admitted to a single-center ICU after abdominal surgery.

Methods: All patients admitted to a surgical ICU for postoperative care, from January 2016 to December 2022, were retrospectively evaluated. Data concerning demographics and clinical and perioperative variables were compared to in-hospital mortality.

Results: A total of 1,717 patients (1,096 women, mean age: 61±17 years) were evaluated. Most of the patients underwent colorectal (n=499), pancreatic (n=148), biliary tract (n=147), and gastric surgeries (n=145); liver resection (n=131); and several gynecological or obstetric procedures (n=250). Only 52.3% of these surgical procedures were elective. The mean Charlson Comorbidity Index (CCI) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were 4.4±2.8 and 10.1±5.6, respectively. Mortality was observed in 158 (9.2%) patients. Age (70.4±14.3 vs. 60.6±17.1 years in survivors, p=0.002), CCI (6.1±2.5 vs. 4.3±2.8 in survivors, p=0.005), type of surgery (13.6% in emergent/urgent vs. 5.5% in elective surgeries, p<0.001), and APACHE II score (16.7±8.4 vs. 9.4±4.7 in survivors, p<0.0001) were associated with mortality on univariate analysis, but only CCI, type of surgery, and APACHE II score were independently correlated with a higher risk of death on multivariate analysis.

Conclusions: Mortality after abdominal surgery in patients requiring postoperative ICU support is less than 10% nowadays, and it is independently associated with urgent or emergent surgeries, disease severity, and comorbidity.

Background: Pancreaticoduodenectomy (PD) is a major intervention in digestive surgery. Although its mortality is currently low in experienced centers, morbidity remains high, dominated by a pancreatic fistula.

Aims: The aim of this study was to analyze the risk factors for postoperative pancreatic fistula (POPF) after PD.

Methods: A retrospective study was conducted at the General Surgery Department of Habib Thameur University Hospital in Tunis for 12 years (2010-2021). All patients who underwent PD were included regardless of indications.

Results: Our series comprised 50 patients, consisting of 27 men and 23 women. The rate of a pancreatic fistula was 32% (16 patients) with an average time of onset of 5 days (1-12 days). It was observed as a biochemical leak (grade A) in 1 patient (2%), pancreatic fistula grade B in 5 patients (10%), and pancreatic fistula grade C in 10 patients (20%). Pancreatic fistula was responsible for 10% of postoperative mortality (five patients). Univariate analysis showed a statistically significant correlation between POPF and the following factors: diameter of the main pancreatic duct ≤3 mm (p=0.036, p<0.05), soft texture of the pancreas (p=0.025, p<0.05), pancreaticojejunostomy by two semi-overlapping sutures (p=0.049, p<0.05), and fasting blood glucose level ≤8 mmol/l (p=0.025, p<0.05). Multivariate analysis showed that soft pancreatic texture was the only independent risk factor for POPF (p=0.02, p<0.05).

Conclusion: The soft texture of the pancreas is the only independent risk factor for POPF. Prospective randomized studies are still needed to accurately determine the true risk factors for a pancreatic fistula after PD.

Background: The coronavirus disease 2019 (COVID-19) greatly impacted patients undergoing bariatric surgery due to prolonged quarantine and lockdown measures.

Aims: The aim of this study was to qualitatively investigate the impact of the COVID-19 quarantine and lockdown measures on the mental and emotional health of post-bariatric surgery women.

Methods: A qualitative study was carried out, with individual interviews conducted via video calls using a video-communication service (Google Meet®). The moderator guide inquired about three pre-established topics based on the literature: mental and emotional health, social relationship, and the use of health technology.

Results: A total of 12 women participated in this study, with an average age of 43±9.83 years, a body mass of 82.33±13.83 kg, a height of 1.62±0.06 m, a body mass index of 26.32±2.97 kg/m2, and post-surgery time of 12.83±4.37 months. The interviews had an average duration of 50.71±7.26 min. Our results suggested a negative impact of the COVID-19 pandemic on aspects of mental and emotional health, such as increased anxiety, depressive symptoms, fear, stress, and anguish, which were somehow diminished in patients who were closer to family members. Bariatric surgery was mentioned as a positive aspect by the patients for coping with clinical risk conditions.

Conclusions: The study showed a negative impact of the COVID-19 pandemic on aspects of mental and emotional health mostly due to lockdown measures, which led to social isolation and an increased burden with household chores.

Background: Biliary fistula is one of the most common complications after liver resection and is associated with significant morbidity and mortality. One of the methods used to evaluate biliary fistulas is the White test, which consists of injecting a lipid emulsion into the bile duct. However, no standard technique for performing the White test has been published.

Aims: The aim of this study was to standardize the technique for performing the White test in patients undergoing hepatectomies, with and without previous cholecystectomy, and to assess the preliminary results.

Methods: Patients over 18 years of age who were submitted to open hepatectomy were included in the study. The primary outcome was the rate of biliary fistula. Secondary outcomes were the incidence of acute pancreatitis and overall morbidity, measured by the Clavien-Dindo classification.

Results: The standard technique for the White test was performed on 17 patients. In total, three patients had previous cholecystectomy, and two had low insertion of the cystic duct, requiring cannulation of the hepatocholedochal duct. None of the patients developed clinically significant biliary leaks. Acute pancreatitis did not occur in any patient. One patient developed pneumonia requiring mechanical ventilation (Clavien-Dindo IV). All others had minor or no complications.

Conclusions: The standardized technique for performing the White test suggests an appropriate strategy to maximize the detection of intraoperative biliary leaks.

Background: Microscopic analysis of tumor budding (TB) may be an essential predictive tool for regional lymph node metastases in colorectal cancer, especially among patients in intermediate stages, who exhibit considerable prognostic variability.

Aims: The aim of this study was to assess the predictive power of BT regarding the presence of lymph node metastases and its association with other characteristics related to colorectal carcinoma progression.

Methods: This is a cross-sectional, retrospective study with a quantitative approach, focusing on the review of medical records and histopathological reports of patients who underwent oncologic surgery for colorectal cancer.

Results: A total of 153 patient records were examined, with a predominance of the 61-70 age group and a male majority (50.98%). Adenocarcinoma not otherwise specified was the most common histological type (60.78%), with the majority exhibiting moderate differentiation (87.58%). From the total sample, 97 cases (63.39%) exhibited TB, with 51.55% classified as a high budding score. Invasion of adipose tissue/subserosa was the most prevalent, occurring in 46.41% of cases. Regional lymph node metastases and angiolymphatic invasion were observed in 66 and 101 patients, respectively. Cross-tabulation analysis showed a statistically significant association between TB and lymph node metastasis (p<0.05).

Conclusions: The relationship between TB and lymph node metastasis highlights the significance of this histological factor in the risk stratification and prognosis of patients with colorectal cancer, complementing TNM staging. Therefore, the assessment of tumor budding is crucial in histopathological reports, potentially influencing additional therapeutic decisions.

Deaths related to colorectal cancer are generally associated with its metastases that affect the liver (50%) through the hematogenous route. Approximately 20-25% of these patients already have synchronous metastases in the liver at the time of primary tumor diagnosis. In others, liver metastases will occur during the course of the disease and are called metachronous. Metachronous metastases are believed to have a better prognosis; however, 20-25% of metastatic cases can be resected during the course of the disease. There is a lack of consensus on the diagnostic time interval for metastases to be considered metachronous in the consulted literature. Surgical treatment of metastases and lymph nodes is indicated, and extrahepatic neoplastic disease must be carefully evaluated. Liver transplantation can benefit the patient, should be evaluated, and is indicated in some special situations.

Background: Colonoscopy is a widely used endoscopic procedure to investigate diseases of the colon and rectum. Colonoscopy procedure has difficulties for the patient and endoscopist.

Aims: To investigate whether the use of an abdominal corset can make the colonoscopy procedure easier and faster.

Methods: This is a prospective randomised controlled study. Patients over 18 years of age who underwent elective colonoscopy in our clinic were evaluated. Patients were divided into two groups according to the use of the corset. Variables were compared between the groups.

Results: A total of 204 patients were included in the study. Corsets were used in 97 patients and not used in 107 patients. The need for manual compression was found to be decreased in the corset use group. There was no effect of corset use on cecal intubation time in the general population. It was found that cecal intubation time decreased with corset use in patients with body mass index - BMI<30 and male gender.

Conclusions: The need for manual compression can be reduced by the use of an abdominal corset during colonoscopy. The use of an abdominal corset may make the colonoscopy procedure faster and easier for the endoscopist and the patient.

Background: Research indicates that patients undergoing bariatric surgery face a six to seven times higher risk of developing alcohol use disorder (AUD) compared with the population of obese individuals not undergoing surgical intervention. Studies suggest that problematic alcohol consumption encompassing depression escalates gradually after surgery.

Aims: The purpose of this study was to evaluate the impact of bariatric surgery on the incidence of AUD and depression during the postoperative period.

Methods: Prospective study that evaluated 68 patients who underwent either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). The presence of AUD and depression was assessed both pre- and post-operatively. AUD assessment utilized the AUD identification test-C score, whereas depression assessment employed the Beck Depression Inventory (BDI).

Results: The average age of the sample was 42.81±9.28 years, with 85.3% being female. The mean follow-up was 16.54±7.41 months. In the preoperative assessment, 92.6% of the sample fell into the low-risk category for AUD. No significant difference was observed between the RYGB and SG groups. Postoperatively, 89.7% of the sample was classified as low risk for AUD, with no significant differences compared with the preoperative assessment. Regarding depression, there was no significant difference between pre- and post-operative periods for all patients. However, a notable trend toward a reduction in "severe depression" was observed in the postoperative period for patients undergoing SG (pre: 14.0% vs. post: 7.0%, p=0.013).

Conclusions: There is no significant difference in the presence of AUD and depression between pre- and post-operative assessments in patients who have undergone bariatric surgery.

Background: Differences in skin color have socioeconomic and health implications; however, gaps persist in understanding health-related quality of life (HRQoL) perception.

Aims: To examine whether skin color differences influence HRQoL in obese patients undergoing Roux-en-Y gastric bypass surgery.

Methods: Cross-sectional study with participants of both genders, aged 18 to 60, and three to six months postoperatively. Data were collected from October 2018 to July 2019 at a bariatric clinic in Salvador, Bahia. Skin color, Moorehead-Ardelt II Quality of Life Questionnaire (MAQOL-II) scores, anthropometric measurements, socioeconomic status, physical activity, and body image perceptions were recorded.

Results: Of 196 patients, 67.35% were Black. "Self-esteem" in MAQOL-II demonstrated the most significant post-surgical improvement, with 62.8% reporting "much better" outcomes. Adjusted residuals associated "much better" and "unchanged" responses with skin color. The overall MAQOL-II score indicated lower HRQoL scores (M=1.65; standard deviation - SD=0.98) for individuals with black skin compared to those with white skin. Analyzing questionnaire responses, both racial groups exhibited equal percentages (45.3%) reporting "much better" and "better" post-surgery progress. However, no statistically significant differences in HRQoL were observed when comparing skin color.

Conclusions: Skin color appears not to significantly impact the HRQoL of obese patients undergoing Roux-en-Y gastric bypass.