Ten years of IRCAD, Barretos, SP, Brazil

Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.

STUDY OF PALM OIL AND GLUTAMINE AS FUNCTIONAL FOODS ON PEPTIDE TYROSINE TYROSINE AND GLUCAGON-LIKE PEPTIDE 1 IN OBESE PATIENTS FOLLOWING UP ON THE AMBULATORY HEALTH SERVICES OF A PUBLIC HOSPITAL

Incretin-based therapies are an alternative for the treatment of type 2 diabetes and weight reduction. In this respect, functional foods such as palm oil and glutamine are dietary strategies for the stimulation of intestinal peptides. Objective: The aim of this study was to evaluate whether the palm oil capsules of ileal release (LI) and of glutamine (LI) result in increased secretion of glucagon-like peptide-1 (GLP-1) and Peptide tyrosine tyrosine (PYY). Method: Nineteen obese patients follow-up of the Ambulatory Health Services, received nutritional guidance and supplementation with ileal release capsules containing palm oil and glutamine. Result: Prospective analysis showed an increase in median GLP-1 levels between T0 (before treatment) and T2 (after 2 months of treatment) from 21.9 pmol/liter (2-93) to 25.7 pmol/liter (3-92.5) (p= 0.564). The baseline of peptide YY increased between T0 68.5 pg / mL (46.5 to 150) to 71 pg / mL (46-181) in T2 (p= 0.909). The significant level established for all analyses was 5% (p <0.05). Conclusion: The daily intake of palm oil capsules (LI) and of glutamine (LI) by a period of 2 months did not influence the secretion of GLP-1 and PYY in obese patients. However, weight maintenance was observed during the evaluated period. Further studies are needed for inferences in this population, to determine if functional foods such as palm oil and glutamine are associated with other specific health benefits.

Pre- and postoperative respiratory muscle strength, body mass index and fasting glucose profile of patients with type 2 diabetes mellitus submitted to metabolic surgery / Perfil de pacientes com diabetes mellitus tipo 2 quanto a força muscular respiratória, o índice de massa corpórea e a glicemia em jejum avaliados no pré e no pós-operatório de cirurgia metabólica

Abstract Introduction: The lung is considered a target organ in diabetes mellitus as a consequence of alterations secondary to chronic hyperglycemia that compromise respiratory muscle strength. Metabolic surgery for improving diabetes mellitus has beneficial effects on weight loss and glucose metabolism. Objective: The objective of this study was to evaluate the respiratory muscle strength, assessed by MIP and MEP, body mass index (BMI) and fasting glucose profile of patients with type 2 diabetes mellitus before and after metabolic surgery without gastric resection. Method: Seventeen patients with type 2 diabetes mellitus participated in the study. The participants had a mean age of 44.8 ± 11.81 years. Results: The results showed a significant decrease of MEP values ​​in the immediate postoperative period when compared to the preoperative period (p=0.001), while no significant results were obtained for MIP. Regarding BMI and fasting glucose, significant weight loss and a significant reduction in fasting glucose levels were observed in the late postoperative period (p=0.006 and p=0.007, respectively). Conclusion: The MIP and MEP were reestablished and satisfactory results were obtained for BMI and fasting glucose in the late postoperative period. Further studies are needed to monitor patients in the pre- and postoperative period of metabolic surgery, identifying complications and acting on the care and recovery of these patients.

Resumo Introdução: O pulmão é considerado um dos órgãos-alvo do diabetes mellitus, como consequência das alterações secundárias à hiperglicemia crônica, comprometendo a força muscular respiratória. A cirurgia metabólica para a melhora do diabetes mellitus exerce efeitos benéficos na perda de peso e no metabolismo da glicose. Objetivo: O objetivo deste estudo foi avaliar o perfil da força muscular respiratória, avaliada por PImáx e PEmáx, o índice de massa corporal (IMC) e a glicemia em jejum de pacientes com diabetes mellitus tipo 2 antes e após a cirurgia metabólica sem ressecção gástrica. Método: Dezessete pacientes com diabetes mellitus tipo 2 participaram do estudo. Os participantes tinham idade média de 44,8±11,81 anos. Resultados: Os resultados mostraram uma diminuição significativa dos valores da PEmáx no pós-operatório imediato, quando comparado ao pré-operatório (p = 0,001), enquanto não foram obtidos resultados significativos para a PImáx. Em relação ao IMC e à glicemia em jejum, observou-se perda significativa de peso e redução significativa dos níveis de glicemia de jejum no pós-operatório tardio (p = 0,006; p= 0,007, respectivamente). Conclusão: A PImáx e a PEmáx foram restabelecidas e resultados satisfatórios foram obtidos para IMC e glicemia de jejum no pós-operatório tardio. Mais estudos são necessários para monitorar pacientes no pré e pós-operatório de cirurgia metabólica, identificando complicações e atuando no cuidado e recuperação desses pacientes.

Eficácia do treinamento muscular inspiratório pré-operatório utilizando o Threshold IMT em pacientes submetidos à cirurgia esofágica: um ensaio clínico randomizado / Effectiveness of preoperative inspiratory muscle training using the Threshold IMT in patients undergoing esophageal surgery: a randomized clinical trial

INTRODUÇÃO: O treinamento muscular inspiratório (TMI) no pré-operatório pode evitar complicações pulmonares no pós-operatório (CPPO) em pacientes submetidos a esofagectomia. OBJETIVO: Avaliar a eficácia do TMI que foi realizado no período pré-operatório e seus benefícios no período pós-operatório, através da avaliação da pressão inspiratória máxima (PImáx), da pressão expiratória máxima (PEmáx), da ventilação voluntária máxima (VVM) e do pico de fluxo expiratório (PFE) e os benefícios do mesmo no pós-operatório. MATERIAIS E MÉTODOS: Foi realizado um ensaio clínico, randomizado, que foi realizado pela disciplina de Cirurgia do Aparelho Digestivo do Hospital das Clínicas da Universidade Federal do Triângulo Mineiro. Foram incluídos 26 pacientes em: Grupo Controle (GC: n=12) e Grupo Intervenção (GI: n=14). O GI realizou TMI por no mínimo 2 semanas. As avaliações foram realizadas no pré e pós-operatório. RESULTADOS: Houve aumento da PImáx (p=0,006), da PEmáx (p=0,005) e do VVM (0,042) no GI, após o TMI realizado no pré-operatório em relação ao GC. Na avaliação do PFE não foi observada aumento após o TMI no GI em relação ao GC (p=0,63). Na alta hospitalar houve queda das variáveis avaliadas em ambos os grupos e no 30°PO ocorreu recuperação em relação aos valores iniciais. Quanto a ocorrência de CPPO não houve diferença significativa entre os grupos. CONCLUSÃO: O TMI realizado em nosso estudo melhorou a força muscular inspiratória, expiratória e a função ventilatória no préoperatório, porém não resultou em melhor evolução no pós-operatório de pacientes submetidos a esofagectomia.

INTRODUCTION: Preoperative inspiratory muscle training (IMT) can prevent postoperative pulmonary complications in patients undergoing esophagectomy. OBJECTIVE: To evaluate the effectiveness of preoperative IMT and its postoperative benefits by assessing maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), maximal voluntary ventilation (MVV), and peak expiratory flow (PEF). MATERIALS AND METHODS: A randomized clinical trial was conducted by the Digestive Tract Surgery Service, University Hospital of the Federal University of Triângulo Mineiro. Twenty-six patients were included: control group (CG, n=12) and intervention group (IG, n=14). Patients of IG underwent IMT for at least 2 weeks. Assessments were performed before and after surgery. RESULTS: There was an increase of MIP (p=0.006), MEP (p=0.005) and MVV (0.042) in IG after preoperative IMT compared to CG. Evaluation of PEF revealed no increase in IG after IMT compared to CG (p=0.63). A decrease in the variables analyzed was observed in both group at discharge and the variables had returned to baseline values on postoperative day 30. There was no significant difference in the frequency of postoperative pulmonary complications between groups. CONCLUSION: The IMT applied in our study improved preoperative inspiratory and expiratory muscle strength and ventilatory function but did not result in better postoperative evolution of patients undergoing esophagectomy.

Comparative evaluation of magnetic resonance cholangiopancreatography and perioperative cholangiography in patients with suspect choledocholithiasis / Avaliação comparativa da colangiopancreatografia por ressonância magnética e da colangiografia peroperatória na suspeita de coledocolitíase

ABSTRACT Background: Cholelithiasis is a highly prevalent condition, and choledocholitiasis is a high morbidity complication and requires accurate methods for its diagnosis. Aim: To evaluate the population of patients with suspected choledocholitiasis and check the statistical value of magnetic resonance cholangiopancreatography, ultrasonography, the laboratory and the clinic of these patients comparing them to the results obtained by perioperative cholangiography. Methods: This is a retrospective cohort study, which were evaluated 76 patients with cholelithiasis and suspected choledocholithiasis. Results: It was observed that the presence of dilatation of the biliary tract or choledocholithiasis in the ultrasonography was four and eight times increased risk of perioperative cholangiography for positive choledocholithiasis, respectively. For each unit increased in serum alkaline phosphatase was 0.3% increased the risk of perioperative cholangiography for positive choledocholithiasis. In the presence of dilatation of the bile ducts in the ultrasonography was four times greater risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. In the presence of pancreatitis these patients had five times higher risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. On the positive magnetic resonance cholangiopancreatography presence to choledocholithiasis was 104 times greater of positive perioperative cholangiography for choledocholithiasis. Conclusions: The magnetic resonance cholangiopancreatography is a method with good accuracy for propedeutic follow-up for the diagnosis of choledocholithiasis, consistent with the results obtained from the perioperative cholangiography; however, it is less invasive, with less risk to the patient and promote decreased surgical time when compared with perioperative cholangiography.

RESUMO Racional: A colelitíase é afecção de alta prevalência, sendo a coledocolitíase complicação de elevada morbidade e que necessita de métodos acurados para seu diagnóstico. Objetivo: Avaliar o perfil populacional de pacientes com suspeita de coledocolitíase e verificar o valor estatístico da colangiopancreatografia por ressonância magnética, da ultrassonografia, dos exames laboratoriais e da clínica desses pacientes e compará-los aos resultados obtidos pela colangiografia peroperatória. Métodos: Trata-se de estudo longitudinal, de coorte, retrospectivo, no qual foram avaliados 76 pacientes com diagnóstico de colelitíase e suspeita de coledocolitíase. Resultados: Observou-se que na presença de dilatação das vias biliares ou coledocolitíase na ultrassonografia havia risco quatro e oito vezes maior, respectivamente, de colangiografia peroperatória positiva para coledocolitíase. Para cada unidade de aumento na fosfatase alcalina sérica houve aumento em 0,3% no risco de colangiografia peroperatória positiva para coledocolitíase. Na presença de dilatação das vias biliares na ultrassonografia ou clínica de pancreatite havia risco quatro e cinco vezes maior, respectivamente, de colangiopancreatografia por ressonância magnética positiva para coledocolitíase. Na presença de colangiopancreatografia por ressonância magnética positiva para coledocolitíase o risco foi 104 vezes maior de colangiografia peroperatória positiva para coledocolitíase. Conclusão: A colangiopancreatografia por ressonância magnética para seguimento propedêutico tem boa acurácia para o diagnóstico de coledocolitíase, e concordante com os resultados obtidos na colangiografia peroperatória. O método é menos invasivo, com menores riscos ao paciente e com diminuição do tempo cirúrgico dispendido para realização da colangiografia peroperatória.

Preservation of the vagus nerves in subtotal esophagectomy without thoracotomy

Abstract Purpose: To evaluate the outcome of transhiatal esophagectomy without thoracotomy and with preservation of the vagal trunks for the treatment of advanced megaesophagus. Methods: Between March 2006 and September 2017, it was performed 136 transhiatal esophagectomies without thoracotomy by laparoscopy, with preservation of the vagus nerves. All patients were evaluated pre and postoperatively for respiratory and nutritional aspects Post operatively, some surgical aspects were evaluated like radiology and endoscopy of the digestive tract. Results: Follow-up for 7 months to 12 years by clinical, radiologic, endoscopic and pH monitoring revealed satisfactory and encouraging outcomes of the procedure. Conclusion: The laparoscopic transhiatal esophagectomy is a feasible and safe technique with good postoperative outcomes.

Combination of preoperative pulmonary and nutritional preparation for esophagectomy

Abstract Purpose: To compare pulmonary and nutritional parameters before and after inspiratory muscle training (IMT) and enteral feeding support in patients with esophageal disease undergoing preoperative outpatient follow-up. Methods: Thirty patients with a mean age of 55.83 years, 16 men and 14 women, were included. Pulmonary assessment consisted of the measurement of MIP, MEP, and spirometry. Anthropometric measurements and laboratory tests were performed for nutritional assessment. After preoperative evaluation, inspiratory muscle training and enteral nutrition support were started. A p<0.05 was considered statistically significant. Results: After an outpatient follow-up period of 4 weeks, a significant increase in MIP (-62.20 ± 25.78 to -81.53 ± 23.09), MEP (73.4 ± 31.95 to 90.33 ± 28.39), and FVC (94.86 ± 16.77 to 98.56 ± 17.44) was observed. Regarding the anthropometric variables, a significant increase was also observed in BMI (20.18 ± 5.04 to 20.40 ± 4.69), arm circumference (23.38 ± 3.28 to 25.08 ± 4.55), arm muscle circumference (21.48 ± 3.00 to 22.07 ± 3.36), and triceps skinfold thickness (5.62 ± 2.68 to 8.33 ± 6.59). Conclusion: Pulmonary and nutritional preparation can improve respiratory muscle strength, FVC and anthropometric parameters. However, further studies are needed to confirm the effectiveness of this preoperative preparation.

Prevalence of bacteriobilia in patients undergoing elective colecystectomy / Prevalência de bacteriobilia em pacientes submetidos à colecistectomia eletiva

ABSTRACT Background: Cholelithiasis is one of the diseases with greater surgical indication. Currently, laparoscopic cholecystectomy is the gold standard in the treatment of cholelithiasis. Aim: To analyze the culture of bile from patients with cholelithiasis, mainly in the occurrence of brown and mixed stones. Methods: Was carried out a prospective study with 246 cases with biliary lithiasis who underwent elective laparoscopic cholecystectomy. Bile culture was performed in all. During anesthetic induction the patients received a single dose of intravenous cefazolin 1 g. At the end of the surgery, the gallbladder was punctured, its contents extracted and immediately placed in a sterile 20 ml propylene flask and promptly sent to bacterioscopy with Maconkey and blood agars. Incubation at 37° C for 24 h was carried out. A protocol was elaborated to include the main factors potentially related to cholelithiasis and the possible presence of associated bacterial infection. Results: Of the 246 patients, 201 had negative bile culture and 45 positive. Of the 45 patients with bacteriobilia, 34 had growth of a single type of bacterium in bile culture and 11 more than one. Conclusions: It was observed a relationship between bacteriobilia and age, suggesting that age is a risk factor for bacteriobilia. The use of antibiotic prophylaxis in the elderly is therefore recommended.

RESUMO Racional: A colecistolitíase é uma das doenças que têm maior indicação cirúrgica. Atualmente a colecistectomia laparoscópica é o padrão-ouro no seu tratamento. Objetivo: Analisar a cultura da bile de pacientes portadores de colecistolitíase, principalmente na ocorrência de cálculos com pigmentos marrons e mistos. Métodos: Foi realizado estudo prospectivo de 246 casos de pacientes portadores de litíase biliar, submetidos à colecistectomia laparoscópica eletiva, sendo realizada cultura da bile. Durante a indução anestésica os pacientes receberam dose única de cefazolina 1 g, intravenosa. No final da operação foi puncionada a vesícula biliar, extraído seu conteúdo e imediata colocação em frasco estéril de propileno de 20 ml e prontamente encaminhado para bacterioscopia com semeadura do material coletado em ágar sangue e de Maconkey com posterior incubação em estufa de cultura a 37° C durante 24 h. Foi elaborado um protocolo capaz de englobar os principais fatores potencialmente relacionados à colecistolitíase e a possível presença de infecção bacteriana associada. Resultados: Dos 246 participantes, 201 tiveram cultura de bile negativa e 45 positiva. Dos 45 pacientes com bacteriobilia, 34 tiveram crescimento de um único tipo de bactéria e 11 mais de uma. Conclusões: Foi observada relação entre bacteriobilia e a idade, sugerindo que a idade é fator de risco para bacteriobilia. Recomenda-se assim o emprego de antibioticoprofilaxia nos idosos.

Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy / Análise comparativa da função pulmonar em mulheres submetidas à colecistectomia laparoscópica convencional e por portal único

ABSTRACT Objective: to evaluate the pulmonary function of women submitted to conventional and single-port laparoscopic cholecystectomy. Methods: forty women with symptomatic cholelithiasis, aged 18 to 70 years, participated in the study. We divided the patients into two groups: 21 patients underwent conventional laparoscopic cholecystectomy, and 19, single-port laparoscopic cholecystectomy. We assessed pulmonary function through forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and the FEV1/FVC ratio, measured before and 24 hours after the procedure. Results: in both groups, FVC and FEV1 were lower in the postoperative period than those obtained in the preoperative period, with a greater reduction in the group undergoing conventional laparoscopic cholecystectomy. Regarding the FEV1/FVC (%) values, there was no statistically significant difference in any of the groups or times analyzed. Conclusion: there was a greater decline in FVC and FEV1 in the postoperative group of patients submitted to conventional laparoscopic cholecystectomy.

RESUMO Objetivo: avaliar a função pulmonar, através da capacidade vital forçada (CVF) e volume expiratório forçado no primeiro segundo (VEF1), e a relação VEF1/CVF% de mulheres submetidas à colecistectomia laparoscópica convencional e por portal único, antes e 24 horas depois do procedimento. Métodos: quarenta mulheres com colelitíase sintomática, com idades entre 18 e 70 anos, participaram do estudo. As pacientes foram distribuídas em dois grupos: 21 pacientes foram submetidas à colecistectomia laparoscópica convencional e 19 à colecistectomia laparoscópica por portal único. Resultados: nos dois grupos submetidos aos procedimentos cirúrgicos os valores espirométricos da CVF e da VEF1 no pós-operatório foram inferiores aos valores obtidos no pré-operatório, com redução maior no grupo submetido à colecistectomia laparoscópica convencional. Quanto aos valores da VEF1/CVF (%) não houve diferença estatisticamente significativa em nenhum dos grupos ou tempos analisados. Conclusão: houve maior declínio na CVF e no VEF1 no pós-operatório do grupo de pacientes submetidas à colecistectomia laparoscópica convencional.

Pulmonary function evaluation in type 2 diabetes mellitus patients submitted to metabolic surgery / Avaliação da função pulmonar em pacientes com diabetes mellitus tipo 2 submetidos à cirurgia metabólica

Abstract Introduction: Diabetes Mellitus (DM) is a multifactorial metabolic disorder. As considered a public health problem needing additional treatment options. Objective: This prospective study aimed at evaluating pulmonary function through spirometry, before and after metabolic surgery without gastric resection in type 2 DM patients. Methods: Sample was composed by 17 type 2 DM females. They were analyzed in pre (24 hours before surgical procedure), immediate post-operative period POST1 (24 hours after surgical procedure) and in the late postoperative period POST2 (two years after surgical procedure). Besides statistical analysis, it was evaluated the following spirometric parameters: forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and the FEV1 / FVC ratio (%). Results: Spirometric parameters showed a value increase when compared PRE and POS2 values, except for FVC and FEV1, which was not statistically significant. Conclusion: Type 2 DM women submitted to metabolic surgery without gastric resection showed spirometric value increased after two-year surgical procedure, when compared to preoperative period values. It is important additional studies about pulmonary function, diabetic patients and metabolic surgery without gastric resection.

Resumo Introdução: O Diabetes Mellitus (DM) é uma desordem metabólica multifatorial. Considerado um problema de saúde pública necessita de opções de tratamento adicionais. Objetivo: Este estudo prospectivo avaliou a função pulmonar, através da espirometria, antes e após a cirurgia metabólica sem ressecção gástrica em pacientes com diabetes mellitus tipo 2. Métodos: A amostra foi composta por 17 mulheres com diabetes mellitus tipo 2. Elas foram avaliadas no PRE (24 horas antes da cirurgia), pós-operatório imediato POST1 (24 horas após a cirurgia) e no pós-operatório tardio POST2 (dois anos após a cirurgia). Além da análise estatística, foram avaliados os seguintes parâmetros expirométricos: capacidade vital forçada (CVF), volume expiratório forçado no primeiro segundo (VEF1) e relação VEF1/CVF (%). Resultados: os parâmetros expirométricos aumentaram quando comparados aos valores PRE e POS2, exceto para CVF e VEF1, os quais não foram estatisticamente significativos. Conclusão: Mulheres diabéticas tipo 2 que realizaram cirurgia metabólica sem ressecção gástrica aumentaram o valor expirométrico após dois anos do procedimento cirúrgico, quando comparadas aos valores no pré-operatório. Estudos adicionais são importantes sobre a função pulmonar, diabetes e cirurgia metabólica sem ressecção gástrica.

Evaluation of the effectiveness of preoperative outpatient pulmonary preparation in patients undergoing esophageal surgery / Avaliação da efetividade do preparo pulmonar ambulatorial no período pré-operatório de cirurgia do esôfago / Evaluación de la efectividad del preparo pulmonar ambulatorial en el período pre-operatorio de cirugía del esôfago

Abstract Introduction: Preoperative inspiratory muscle training (IMT) can minimize the occurrence of complications after esophagectomy. Objective: To evaluate the effects of preoperative IMT in patients undergoing esophageal surgery by determining respiratory muscle strength (PImax and PEmax), pulmonary function (FEV1, FVC, FEV1/FVC) and functional capacity by the 6-minute walk test (6MWT). Methods: Twenty-two patients were randomized into two groups: a control group (CG; n = 10) and an intervention group (IG; n = 12). Only IG performed IMT for a minimum period of 2 weeks. The assessments were conducted pre- and post-surgery. Results: An increase of PImax was observed in IG, but not in CG, in the second preoperative assessment (p = 0.014). Assessment on postoperative day 1 showed a reduction in maximal respiratory pressures in the two groups, but the reduction was more marked in IG (p < 0.05). Partial recovery of the variables evaluated was observed at discharge in the two groups. These variables had fully returned to initial values on postoperative day 30. The distance walked in the 6MWT was greater in IG, but the difference was not significant (p = 0.166). There was no difference in the frequency of pulmonary complications between groups. Conclusion: Preoperative IMT performed in our study improved inspiratory muscle strength but did not influence the postoperative pulmonary function or functional capacity of patients undergoing esophagectomy.

Resumo Introdução: O treinamento muscular inspiratório (TMI), realizado no pré-operatório, pode minimizar a ocorrência de complicações após esofagectomia. Objetivo: Avaliar os efeitos do TMI realizado no pré-operatório da cirurgia do esôfago através da força muscular respiratória (PImáx e PEmáx), da função pulmonar (VEF1, CFV, VEF1/CVF) e da capacidade funcional através do teste de caminhada de 6 minutos (TC6'). Métodos: 22 pacientes foram randomizados em: Grupo Controle (GC; n = 10) e Grupo Intervenção (GI; n = 12). Somente o GI realizou TMI por no mínimo 2 semanas. As avaliações foram realizadas no pré e pós-operatório. Resultados: Houve aumento da PImáx no GI na 2° PRÉ (p = 0,014), enquanto no GC não houve alteração. Na avaliação do 1°PO os dois grupos apresentaram redução das pressões respiratórias máximas, porém a redução foi mais acentuada no GI (p < 0,05). Na alta hospitalar ocorreu recuperação parcial das variáveis avaliadas em ambos os grupos e no 30°PO ocorreu recuperação plena em relação aos valores iniciais. Em relação ao TC6' houve um aumento da distância percorrida no GI, mas não foi significante (p = 0,166). Não houve diferença na ocorrência de CP entre os grupos. Conclusão: O TMI realizado em nosso estudo melhorou a força muscular inspiratória, mas não influenciou a função pulmonar e a capacidade funcional pós-operatória de pacientes submetidos a esofagectomia.

Resumen Introducción: El entrenamiento muscular inspiratorio (TMI), realizado en el preoperatorio, puede minimizar la ocurrencia de complicaciones después de la esofagectomía. Objetivo: Evaluar los efectos del TMI realizado en el preoperatorio de la cirugía del esófago a través de la fuerza muscular respiratoria (PImáx y PEmáx), de la función pulmonar (VEF1, CFV, VEF1 / CVF) y de la capacidad funcional a través del test de caminata de 6 minutos (TC6'). Métodos: 22 pacientes fueron randomizados en: Grupo Control (GC, n = 10) y Grupo Intervención (GI; n = 12). Sólo el GI realizó TMI por lo menos 2 semanas. Las evaluaciones se realizaron en el pre y postoperatorio. Resultados: Hubo aumento de la PImáx en el GI en el 2°PRÉ (p = 0,014), mientras que en el GC no hubo alteración. En la evaluación del 1°PO los dos grupos presentaron reducción de las presiones respiratorias máximas, pero la reducción fue más acentuada en el GI (p < 0,05). En el alta hospitalaria ocurrió recuperación parcial de las variables evaluadas en ambos grupos y en el 30°PO ocurrió recuperación plena en relación a los valores iniciales. En relación al TC6'hubo un aumento de la distancia recorrida en el GI, pero no fue significativo (p = 0,166). No hubo diferencia en la ocurrencia de CP entre los grupos. Conclusión: El TMI realizado en nuestro estudio mejoró la fuerza muscular inspiratoria, pero no influenció la función pulmonar y la capacidad funcional postoperatoria de pacientes sometidos a esofagectomía.

Comparative study of respiratory muscle strength in women undergoing conventional and single-port laparoscopic cholecystectomy

Abstract Purpose: To evaluate respiratory muscle strength (PImax and PEmax) before and 24 and 48 h after conventional and single-port laparoscopic cholecystectomy. Methods: Forty women with symptomatic cholelithiasis (18 to 70 years) participated in the study. The patients were divided into two groups: 21 patients undergoing conventional laparoscopic cholecystectomy and 19 patients undergoing single-port laparoscopic cholecystectomy. Differences were considered to be significant when p<0.05. Results: The results showed a greater decline in PImax after 24 h in the group submitted to conventional laparoscopic cholecystectomy, with a significant difference between groups (p=0.0308). Conclusion: Recovery of the parameters studied was more satisfactory and respiratory muscle strength was less compromised in the group submitted to single-port laparoscopic cholecystectomy.

Comparative study of pain in women submitted to conventional laparoscopic cholecystectomy versus single-port laparoscopic cholecystectomy

Abstract Purpose: To evaluate postoperative pain in patients submitted to conventional laparoscopic cholecystectomy with four ports versus single-port laparoscopic cholecystectomy with only one port. Methods: Twenty-one patients were included in the conventional laparoscopic cholecystectomy group and 19 other patients in the single-port laparoscopic cholecystectomy group. A VAS was used for the assessment of postoperative pain at three time points. Differences were considered statistically significant when p<0.05. Results: Intergroup analysis showed no significant difference in VAS scores between the conventional laparoscopic cholecystectomy and single-port laparoscopic cholecystectomy groups at any of the time points studied. Conclusion: This study found no significant difference in postoperative pain between the two groups.

Metástase gástrica de melanoma maligno / Gastric metastasis of malignant melanoma

O melanoma maligno corresponde a 5% de todas as neoplasias da pele. Apresenta elevada agressividade local e tendência à disseminação através de metástases. O aparelho digestivo não é sítio secundário comum de melanoma, e o estômago é raramente comprometido. Relatamos caso de paciente do sexo masculino, 64 anos, com quadro de astenia progressiva, anemia, episódio de síncope e história de exérese de melanoma maligno nível IV de Clark em asa nasal há 6 anos, com esvaziamento de cadeia linfonodal cervical ipsilateral. Durante a investigação, foi encontrada massa gástrica, sendo submetido à gastrectomia total com reconstrução em Y de Roux, com melhora substancial dos sintomas. O exame anatomopatológico da massa gástrica confirma o resultado de metástase de melanoma maligno pela biópsia endoscópica pré-operatória. O paciente segue em acompanhamento ambulatorial sem manifestações de novas metástases até o momento. (AU)

Malignant melanoma accounts for 5% of all skin cancers. It has high local aggressiveness and tendency to spread through metastases. The digestive tract is not common secondary site of melanoma, and the stomach is rarely compromised. We report the case of a male patient, 64, with progressive asthenia, anemia, syncope and previously excision of malignant melanoma Clark level IV in nasal wing for 6 years with ipsilateral cervical lymph node emptying. During the investigation we found gastric mass and underwent total gastrectomy and Roux-en-Y with substantial improvement in symptoms. The anatomopathological examination of the gastric mass confirms the result of malignant melanoma metastasis by the preoperative endoscopic biopsy. The patient is in outpatient treatment without signs of new metastases so far. (AU)

Comparative analysis of immunological profiles in women undergoing conventional and single-port laparoscopic cholecystectomy / Perfil imunológico de mulheres submetidas à colecistectomia laparoscópica convencional e por portal único

ABSTRACT Background: Surgical trauma triggers an important postoperative stress response characterized by significantly elevated levels of cytokines, an event that can favor the emergence of immune disorders which lead to disturbances in the patient's body defense. The magnitude of postoperative stress is related to the degree of surgical trauma. Aim: To evaluate the expression of pro-inflammatory (TNF-α, IFN-γ, IL-1β, and IL-17) and anti-inflammatory (IL-4) cytokines in patients submitted to conventional and single-port laparoscopic cholecystectomy before and 24 h after surgery. Methods: Forty women with symptomatic cholelithiasis, ranging in age from 18 to 70 years, participated in the study. The patients were divided into two groups: 21 submitted to conventional laparoscopic cholecystectomy and 19 to single-port laparoscopic cholecystectomy. Results: Evaluation of the immune response showed no significant difference in IFN-γ and IL-1β levels between the groups or time points analyzed. With respect to TNF-α and IL-4, serum levels below the detection limit (10 pg/ml) were observed in the two groups and at the time points analyzed. Significantly higher postoperative expression of IL-17A was detected in patients submitted to single-port laparoscopic cholecystectomy when compared to preoperative levels (p=0.0094). Conclusions: Significant postoperative expression of IL-17 was observed in the group submitted to single-port laparoscopic cholecystectomy when compared to preoperative levels, indicating that surgical stress in this group was higher compared to the conventional laparoscopic cholecystectomy.

RESUMO Racional: O trauma cirúrgico induz resposta de estresse pós-operatório significativo, evidenciado pelos níveis elevados de citocinas, podendo favorecer o surgimento de distúrbios imunológicos. A magnitude de estresse está relacionada ao grau do trauma cirúrgico. Objetivos: Avaliar a expressão das citocinas pró-inflamatórias (TNF-α, IFN-γ, IL-1β, IL-17) e da anti-inflamatória (IL-4) no pré e pós-operatório de pacientes submetidas à colecistectomia laparoscópica por dois métodos: convencional e por portal único. Métodos: Quarenta mulheres com colecistolitíase sintomática foram operadas, sendo 21 por procedimento laparoscópico convencional e 19 por portal único. As citocinas TNF-α, IFN-γ, IL-1β, IL-4, e IL-17 presentes no plasma foram quantificadas pelo método de ELISA em dois momentos: no pré-operatório e após 24 h da operação. Resultados: A avaliação da resposta imune não mostrou diferença estatisticamente significante das citocinas IFN-γ e IL-1β na comparação entre os grupos e tempos analisados. Em relação às citocinas TNF-α e IL-4 os níveis séricos estavam abaixo dos níveis de detecção (10 pg/ml) em ambos os grupos e tempos analisados. Observou-se que as operadas por portal único apresentaram expressão significativa da IL-17A do período pré para o pós-operatório (p=0,0094). Conclusões: A expressão aumentada da IL-17A no pós-operatório do grupo de portal único pode indicar que o estresse cirúrgico foi maior em comparação ao da colecistectomia laparoscópica convencional.

Late evaluation of patients operated for gastroesophageal reflux disease by nissen fundoplication / Avaliação tardia de pacientes operados por doença do refluxo gastroesofágico pela técnica de nissen

ABSTRACT Background: Surgical treatment of GERD by Nissen fundoplication is effective and safe, providing good results in the control of the disease. However, some authors have questioned the efficacy of this procedure and few studies on the long-term outcomes are available in the literature, especially in Brazil. Aim: To evaluate patients operated for gastro-esophageal reflux disease, for at least 10 years, by Nissen fundoplication. Methods: Thirty-two patients were interviewed and underwent upper digestive endoscopy, esophageal manometry, 24 h pH monitoring and barium esophagogram, before and after Nissen fundoplication. Results: Most patients were asymptomatic, satisfied with the result of surgery (87.5%) 10 years after operation, due to better symptom control compared with preoperative and, would do it again (84.38%). However, 62.5% were in use of some type of anti-reflux drugs. The manometry revealed lower esophageal sphincter with a mean pressure of 11.7 cm H2O and an average length of 2.85 cm. The average DeMeester index in pH monitoring was 11.47. The endoscopy revealed that most patients had a normal result (58.06%) or mild esophagitis (35.48%). Barium swallow revealed mild esophageal dilatation in 25,80% and hiatal hernia in 12.9% of cases. Conclusion: After at least a decade, most patients were satisfied with the operation, asymptomatic or had milder symptoms of GERD, being better and with easier control, compared to the preoperative period. Nevertheless, a considerable percentage still employed anti-reflux medications.

RESUMO Racional: O tratamento cirúrgico para DRGE empregando a fundoplicatura à Nissen é eficaz e seguro, oferecendo bons resultados no controle da doença. Entretanto, alguns autores têm questionado quanto a sua eficácia, e poucos estudos com avaliação tardia destes doentes são encontrados na literatura, sobretudo no Brasil. Objetivo: Avaliar pacientes operados por doença do refluxo gastroesofágico há pelo menos 10 anos, pela técnica de Nissen. Métodos: Trinta e dois pacientes foram entrevistados e submetidos à endoscopia digestiva alta, manometria esofágica, pHmetria prolongada de 24h e esofagograma baritado, antes e após a fundoplicatura à Nissen. Resultados: A maioria estava assintomático 10 anos após a operação e satisfeitos com o resultado dela (87,5%) e a fariam novamente (84,38%), devido melhor controle sintomático com medicação, em comparação com o período pré-operatório. Entretanto, 62,5% empregavam algum tipo de medicação anti-refluxo. Quanto aos exames, a manometria revelou extensão média de 2,85 cm de esfíncter esofágico inferior, com pressão média de 11,7 cm de H2O. O índice médio de DeMeester na pHmetria foi de 11,47. Na endoscopia a maior parte dos pacientes apresentou exame normal (58,06%), ou esofagite leve (35,48%). O esofagograma revelou discreta dilatação esofágica em 25,80% e hérnia hiatal em 12,9% dos casos. Conclusão: Após no mínimo uma década, a maioria dos doentes estava satisfeita com a operação, assintomática ou apresentava sintomatologia mais branda da DRGE que era de melhor e mais fácil controle, comparado ao período pré-operatório. Porcentagem não desprezível ainda empregava medicações para refluxo.

IMMUNOLOGICAL EVALUATION OF PATIENTS WITH TYPE 2 DIABETES MELLITUS SUBMITTED TO METABOLIC SURGERY / AVALIAÇÃO IMUNOLÓGICA DE PACIENTES COM DIABETE MELITO TIPO 2 SUBMETIDOS À CIRURGIA METABÓLICA

Background: Immunological and inflammatory mechanisms play a key role in the development and progression of type 2 diabetes mellitus. Aim: To raise the hypothesis that alterations in immunological parameters occur after duodenojejunal bypass surgery combined with ileal interposition without gastrectomy, and influences the insulin metabolism of betacells. Methods: Seventeen patients with type 2 diabetes mellitus under clinical management were submitted to surgery and blood samples were collected before and six months after surgery for evaluation of the serum profile of proinflammatory (IFN-γ, TNF-α, IL-17A) and anti-inflammatory cytokines (IL-4, IL-10). In addition, anthropometric measures, glucose levels and insulin use were evaluated in each patient. Results: No changes in the expression pattern of proinflammatory cytokines were observed before and after surgery. In contrast, there was a significant decrease in IL-10 expression, which coincided with a reduction in the daily insulin dose, glycemic index, and BMI of the patients. Early presentation of food to the ileum may have induced the production of incretins such as GLP-1 and PYY which, together with glycemic control, contributed to weight loss, diabetes remission and the consequent good surgical prognosis of these patients. In addition, the control of metabolic syndrome was responsible for the reduction of IL-10 expression in these patients. Conclusion: These findings suggest the presence of low-grade inflammation in these patients during the postoperative period, certainly as a result of adequate glycemic control and absence of obesity, contributing to a good outcome of surgery.

Racional: Mecanismos imunológicos e inflamatórios desempenham papel-chave no desenvolvimento e progressão do diabete melito tipo 2. Objetivo: Levantar a hipótese de que alterações nos parâmetros imunológicos ocorrem após operação duodenojejunal combinada com interposição ileal sem gastrectomia, e influenciam o metabolismo da insulina das células beta. Métodos: Dezessete pacientes com diabete melito tipo 2 sob manejo clínico foram submetidos à cirurgia e amostras de sangue foram coletadas antes e seis meses após para avaliação do perfil de sorológico de citocinas pró-inflamatórias (IFN-γ, TNF-α, IL-17A) e anti-inflamatórias(IL-4, IL-10). Além disso, parâmetros antropométricos, glicemia e uso de insulina foram avaliados em cada paciente. Resultados: Não ocorreram alterações no padrão de expressão de citocinas pró-inflamatórias observadas antes e depois da operação. Em contraste, houve diminuição significativa na expressão de IL-10, que coincide com redução da dose diária de insulina, com o controle glicêmico e redução do IMC dos pacientes. Apresentação precoce de alimentos para o íleo pode ter induzido a produção das incretinas tais como GLP-1 e PYY, que, juntamente com o controle da glicemia, contribuíram para a perda de peso, remissão do diabete e o bom prognóstico consequente cirúrgico. Além disso, o controle de síndrome metabólica foi responsável pela redução da expressão de IL-10 nestes doentes. Conclusão: Baixo grau de inflamação estava presente nesses pacientes no pós-operatório, certamente pelo adequado controle glicêmico e ausência de obesidade, o que contribuiu para bom resultado cirúrgico.

Histological and endoscopic features of the stomachs of patients with Chagas disease in the era of Helicobacter pylori

Introduction Most studies that have evaluated the stomachs of patients with Chagas disease were performed before the discovery of Helicobacter pylori and used no control groups. This study compared the gastric features of chagasic and non-chagasic patients and assessed whether gastritis could be associated with Chagas disease. Methods Gastric biopsy samples were taken from patients who underwent endoscopy for histological analysis according to the Updated Sydney System. H. pylori infection was assessed by histology, 16S ribosomal ribonucleic acid (rRNA) polymerase chain reaction (PCR), serology and the 13C-urea breath test. Patients were considered H. pylori-negative when all of these diagnostic tests were negative. Clinical and socio-demographic data were obtained by reviewing medical records and using a questionnaire. Results The prevalence of H. pylori infection (70.3% versus 71.7%) and chronic gastritis (92.2% versus 85%) was similar in the chagasic and non-chagasic groups, respectively; such as peptic ulcer, atrophy and intestinal metaplasia. Gastritis was associated with H. pylori infection independent of Chagas disease in a log-binomial regression model. However, the chagasic H. pylori-negative patients showed a significantly higher grade of mononuclear (in the corpus) and polymorphonuclear ...

Effect of the ingestion of the palm oil and glutamine in serum levels of GLP-1, PYY and glycemia in diabetes mellitus type 2 patients submitted to metabolic surgery / Efeito do óleo de palma e da glutamina nos níveis séricos de GLP-1, PYY e da glicemia em portadores de diabete melito tipo 2 submetidos à cirurgia metabólica

BACKGROUND: Incretins are hormones produced by the intestine and can stimulate the secretion of insulin, helping to diminish the post-prandial glycemia. The administration of an emulsion of palm oil can help in the maintenance of the weight, and can increase circulating incretins levels. Glutamine increases the concentration of incretins in diabetic people. Both can help in metabolic syndrome. AIM: To analyze the effects of ingestion of palm oil and glutamine in glycemia and in incretins in patients with diabetes submitted to surgical duodenojejunal exclusion with ileal interposition without gastrectomy. METHODS: Eleven diabetic type 2 patients were included and were operated. They were called to laboratory follow-up without eating anything between eight and 12 hours. They had there blood collected after the stimulus of the palm oil and glutamine taken in different days. For the hormonal doses were used ELISA kits. RESULTS: The glycemia showed a meaningful fall between the fast and two hours after the stimulus of the palm oil (p=0,018). With the glutamine the GLP-1 showed an increase between the fast and one hour (p=0,32), the PYY showed an important increase between the fast and one hour after the stimulus (p=0,06), the glycemia showed a meaningful fall after two hours of the administration of the stimulus (p=0,03). CONCLUSION: Palm oil and glutamine can influence intestinal peptides and glucose .

RACIONAL: A administração de óleo de palma auxilia na manutenção do peso e aumenta níveis de incretinas circulantes. A glutamina aumenta a concentração de incretinas em indivíduos diabéticos. Assim, eles podem influenciar no tratamento da síndrome metabólica. OBJETIVO: Analisar os efeitos da ingestão de óleo de palma e glutamina na glicemia e incretinas em pacientes diabéticos que foram submetidos à operação de exclusão duodenojejunal com interposição ileal sem gastrectomia. MÉTODOS: Participaram 11 pacientes, portadores de diabete melito tipo 2, que foram operados com exclusão duodenojejunal com interposição ileal sem gastrectomia. Foram convocados para comparecer ao laboratório em jejum de oito a 12 horas e submetidos ao procedimento de coleta de sangue após os estímulos de óleo de palma e glutamina via oral em dias distintos. Para as dosagens hormonais foram utilizados kits de ELISA. RESULTADOS: A glicemia apresentou queda significativa entre o jejum e duas horas após o estímulo de óleo de palma (p=0,018). Com a glutamina, o GLP-1 apresentou aumento entre o jejum e uma hora (p=0,32); o PYY apresentou aumento entre o jejum e uma hora após o estímulo (p=0,06); a glicemia apresentou queda significativa após duas horas da administração do estímulo (p=0,03). CONCLUSÃO: O óleo de palma e a glutamina podem influenciar os peptídeos intestinais e na glicemia .

Intraoperative cholangiography during elective laparoscopic cholecystectomy: selective or routine use?

PURPOSE: To investigate clinical, laboratory and ultrasonographic parameters in patients with and without preoperative criteria for intraoperative cholangiography (IOC) during laparoscopic cholecystectomy in order to define predictive factors of choledocolithiasis. METHODS: As a criterion for inclusion in the study the patients should present chronic calculous cholecystitis in the presence or absence of any recent clinical, laboratory of ultrasonographic finding suggesting choledocolithiasis, who were therefore submitted to cholangiography during surgery. RESULTS: A total of 243 laparoscopic cholecystectomies with IOC were performed on patients with chronic calculous cholecystitis with or without a preoperative formal indication for contrast examination. Choledocolithiasis was detected in 33 (13.58%) of the 243 patients studied. The incidence of previously unsuspected choledocolithiasis was only one case (1.0%) among 100 patients without an indication for this exam. However, 32 (22.37%) cases of choledocolithiasis were observed among the 143 patients with a preoperative indication for IOC. CONCLUSION: The use of selective cholangiography is safe for the diagnosis of choledocolithiasis. Only 22.37% of the cholangiography results were positive in cases of suspected choledocolithiasis.