Brazilian consensus on incidental gallbladder carcinoma / Consenso brasileiro de carcinoma incidental de vesícula biliar

ABSTRACT Background: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. Aim: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. Methods: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. Results: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. Conclusions: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

RESUMO Racional: Carcinoma incidental da vesícula biliar é definido como uma neoplasia descoberta por exame histológico após colecistectomia videolaparoscópica. É potencialmente uma doença curável. Entretanto algumas questões relacionadas ao seu manuseio permanecem controversas e uma estratégia definida está associada com melhor prognóstico. Objetivo: Desenvolver o primeiro consenso baseado em evidências para o manuseio de pacientes com carcinoma incidental da vesícula biliar no Brasil. Métodos: Dezesseis questões foram selecionadas e para responder as questões e 36 membros das sociedades brasileiras e internacionais foram incluídos. As recomendações foram baseadas em evidências da literatura atual. Um relatório final foi enviado para os membros do painel para avaliação de concordância. Resultados: Avaliação intraoperatória da peça cirúrgica, uso de bolsas para retirar a peça cirúrgica e exame histopatológico de rotina, foram recomendados. Avaliação pré-operatória completa é necessária e deve ser realizada assim que o estadiamento final esteja disponível. Avaliação da margem do ducto cístico e biópsia de rotina do linfonodo 16b1 são recomendadas. Quimioterapia deve ser considerada e quimioradioterapia indicada se a margem cirúrgica microscópica seja positiva. Os portais devem ser ressecados excepcionalmente. O estadiamento laparoscópico antes da operação é recomendado, mas o tratamento radical por abordagem minimamente invasiva deve ser realizado apenas em centros especializados em cirurgia hepatopancreatobiliar minimamente invasiva. A extensão da ressecção hepática é aceitável até que seja alcançada a ressecção R0. A linfadenectomia padrão é indicada para tumores iguais ou superiores a T2, mas a ressecção da via biliar não é recomendada de rotina. Conclusões: Recomendações seguras foram preparadas para carcinoma incidental da vesícula biliar, destacando os mais frequentes tópicos do trabalho diário do cirurgião do aparelho digestivo e hepatopancreatobiliar.

Liver resection for non-oriental hepatolithiasis / Ressecção hepática no tratamento da hepatolitíase não oriental

ABSTRACT Background: Primary intrahepatic lithiasis is defined when the stones are formed in the liver and associated with local dilatation and biliary stricture. Liver resection is the ideal procedure. Aim: To evaluate the results of liver resection in the treatment of non-oriental intrahepatic lithiasis. Methods: Fifty-one patients with symptomatic benign non-oriental hepatolithiasis underwent surgical resection in six institutions in Brazil. Demography data, clinical symptoms, classification, diagnosis, management and postoperative course were analyzed. Results: Of the 51 patients, 28 were male (54.9%), with a mean age of 49.3 years. History of cholangitis was observed in 15 (29.4%). The types of intrahepatic lithiasis were type I in 39 (76.5%) and type IIb in 12 (23.5%), with additional type Ea in six (11.8%). Liver function test were normal in 42 patients (82.4%). Segmental atrophy was observed in 12 (23.5%). Treatments included left lateral sectionectomy in 24 (47.1%), left hepatectomy in 14 (27.5%) and right hepatectomy in eight (15.7%), with associated hepaticojejunostomy in four (7.8%). Laparoscopic liver resection was performed in eight (15.7%). Postoperative complications were observed in 20 (39.2%) with no mortality. Conclusion: Liver resection in patients with hepatolithiasis is the ideal procedure as it removes stones, stricture, atrophic parenchyma, and minimizes the risk of cholangiocarcinoma.

RESUMO Racional: Litíase intra-hepática primária é definida quando os cálculos são formados dentro do fígado, podendo estar associada à dilatação local e estenosa da via biliar. A ressecção hepática é considerada o procedimento ideal. Objetivo: Avaliar os resultados da ressecção hepática no tratamento da litíase intra-hepática não oriental. Métodos: Cinquenta e um pacientes com hepatolitíase benigna não oriental sintomática foram submetidos à ressecção hepática em seis instituições no Brazil. Os dados demográficos, sintomas clínicos, classificação, diagnóstico, tratamento e evolução pós-operatória foram analisados. Resultados: Dos 51 pacientes havia 28 homens (54,9%), e a idade média era de 49,3 anos. História de colangite foi observada em 15 pacientes (29,4%). Os tipos de litíase observados foram tipo I em 39 (76,5%) e tipo IIb em 12 (23,5%), com o tipo adicional Ea em seis pacientes (11,8%). Os testes de função hepática estavam normais em 42 (82,4%) e atrofia segmentar foi observada em 12 (23,5%). O tratamento incluiu setorectomia lateral esquerda em 24 (47,1%), hepatectomia esquerda em 14 (27,5%) e hepatectomia direita em oito pacientes (15,7%). A hepaticojejunostomia esteve associada ao procedimento inicial em quatro (7,8%). Hepatectomia por videolaparoscopia foi realizada em oito (15,7%). Complicações pós-operatórias foram observadas em 20 pacientes (39,2%) e não houve mortalidade. Conclusão: Ressecção hepática na hepatolitíase é o procedimento ideal, pois remove os cálculos, a estenose, o parênquima atrofiado e minimiza os riscos para colangiocarcinoma.

Quimioterapia Aerossolizada e Pressurizada Intraperitoneal (PIPAC) por monoportal: aplicação alternativa no controle das metástases peritoneais / Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) through a single port: alternative delivery for the control of peritoneal metastases

RESUMO A carcinomatose peritoneal é a evolução natural das neoplasias gastrointestinais, ginecológicas e primárias do peritônio. Nos últimos anos, a carcinomatose passou a ser considerada uma doença confinada ao peritônio, e não mais uma doença disseminada. Desta forma, a associação de citorredução cirúrgica associada à quimioterapia intraperitoneal se tornou o ponto chave no controle das metástases peritoneais. Tradicionalmente, a quimioterapia intraperitoneal é aplicada utilizando soluções líquidas. Uma nova modalidade de infusão da quimioterapia na cavidade abdominal surge como uma alternativa ao método tradicional. A chamada PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy) transforma a solução terapêutica líquida em um spray aerossolizado, potencializando a distribuição e penetração da quimioterapia intraperitoneal. Este relato tem por objetivo descrever essa nova técnica cirúrgica inovadora, realizada pela primeira vez por um monoportal no Brasil, alterando a forma descrita originalmente para a aplicação da PIPAC.

ABSTRACT Peritoneal carcinomatosis is the natural course of gastrointestinal, gynecologic, and primary peritoneal neoplasms. In recent years, our understanding of carcinomatosis has changed; it is no longer considered a disseminated condition, but rather a disease confined to the peritoneum. Thus, the combination of cytoreductive surgery and intraperitoneal chemotherapy has become the cornerstone of control of peritoneal metastases. Traditionally, intraperitoneal chemotherapy is delivered in the form of liquid solutions. However, a new mode of chemotherapy delivery to the abdominal cavity has arisen as an alternative to the conventional method. In Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC), the liquid solution is aerosolized into a spray, potentiating the distribution and penetration of the chemotherapeutic agent intraperitoneally. The present study aims to describe a novel form of this innovative surgical technique performed for the first time in Brazil, in a modification of the technique originally described for PIPAC: delivery through a single-port device.

A prototype single-port device for pressurized intraperitoneal aerosol chemotherapy. Technical feasibility and local drug distribution

Abstract Purpose: To evaluate the technical feasibility and homogeneity of drug distribution of pressurized intraperitoneal aerosol chemotherapy (PIPAC) based on a novel process of intraperitoneal drug application (multidirectional aerosolization). Methods: This was an in vivo experimental study in pigs. A single-port device was manufactured at the smallest diameter possible for multidirectional aerosolization of the chemotherapeutic drug under positive intraperitoneal pressure. Four domestic pigs were used in the study, one control animal that received multidirectional microjets of 9 mL/sec for 30 min and three animals that received multidirectional aerosolization (pig 02: 9 mL/sec for 30 min; pigs 03 and 04: 3 mL/sec for 15 min). Aerosolized silver nitrate solution was applied for anatomopathological evaluation of intraperitoneal drug distribution. Results: Injection time was able to maintain the pneumoperitoneum pressure below 20 mmHg. The rate of moderate silver nitrate staining was 45.4% for pig 01, 36.3% for pig 02, 36.3% for pig 03, and 72.7% for pig 04. Conclusions: Intra-abdominal drug distribution had a broad pattern, especially in animals exposed to the drug for 30 min. Our sample of only four animals was not large enough to demonstrate an association between aerosolization and a higher silver nitrate concentration in the stained abdominal regions.

Oxidative stress in human aorta of patients with advanced aortoiliac occlusive disease

Abstract Introduction: Oxidative stress seems to be a role in the atherosclerosis process, but research in human beings is scarce. Objective: To evaluate the role of oxidative stress on human aortas of patients submitted to surgical treatment for advanced aortoiliac occlusive disease. Methods: Twenty-six patients were divided into three groups: control group (n=10) formed by cadaveric organ donors; severe aortoiliac stenosis group (patients with severe aortoiliac stenosis; n=9); and total aortoiliac occlusion group (patients with chronic total aortoiliac occlusion; n=7). We evaluated the reactive oxygen species concentration, nicotinamide adenine dinucleotide phosphate-oxidase, superoxide dismutase and catalase activities as well as nitrite levels in samples of aortas harvested during aortofemoral bypass for treatment of advanced aortoiliac occlusive disease. Results: We observed a higher level of reactive oxygen species in total aortoiliac occlusion group (48.3±9.56 pmol/mg protein) when compared to severe aortoiliac stenosis (33.5±7.4 pmol/mg protein) and control (4.91±0.8 pmol/mg protein) groups (P<0.05). Nicotinamide adenine dinucleotide phosphate oxidase activity was also higher in total aortoiliac occlusion group when compared to the control group (3.81±1.7 versus 1.05±0.31 µmol/min.mg protein; P<0.05). Furthermore, superoxide dismutase and catalase activities were significantly higher in the severe aortoiliac stenosis and total aortoiliac occlusion groups when compared to the control cases (P<0.05). Nitrite concentration was smaller in the severe aortoiliac stenosis group in comparing to the other groups. Conclusion: Our results indicated an increase of reactive oxygen species levels and nicotinamide adenine dinucleotide phosphate-oxidase activity in human aortic samples of patients with advanced aortoiliac occlusive disease. The increase of antioxidant enzymes activities may be due to a compensative phenomenon to reactive oxygen species production mediated by nicotinamide adenine dinucleotide phosphate oxidase. This preliminary study offers us a more comprehensive knowledge about the role of oxidative stress in advanced aortoiliac occlusive disease in human beings.

Brazilian consensus for multimodal treatment of colorectal liver metastases. module 3: controversies and unresectable metastases / Consenso brasileiro de tratamento multidisciplinar de metástase hepática de origem colorretal módulo 3: controvérsias e metástases irressecáveis

ABSTRACT In the last module of this consensus, controversial topics were discussed. Management of the disease after progression during first line chemotherapy was the first discussion. Next, the benefits of liver resection in the presence of extra-hepatic disease were debated, as soon as, the best sequence of treatment. Conversion chemotherapy in the presence of unresectable liver disease was also discussed in this module. Lastly, the approach to the unresectable disease was also discussed, focusing in the best chemotherapy regimens and hole of chemo-embolization.

RESUMO Neste último módulo do consenso, abordou-se alguns temas controversos. O primeiro tópico discutido foi o manejo da doença após progressão na primeira linha de quimioterapia, com foco em se ainda haveria indicação cirúrgica neste cenário. A seguir, o painel debruçou-se sobre as situações de ressecção da doença hepática na presença de doença extra-hepática, assim como, qual a melhor sequência de tratamento. O tratamento de conversão para doença inicialmente irressecável também foi abordado neste módulo, incluindo as importantes definições de quando se pode esperar que a doença se torne ressecável e quais esquemas terapêuticos seriam mais efetivos à luz dos conhecimentos atuais sobre a biologia tumoral e taxas de resposta objetiva. Por último, o tratamento da doença não passível de ressecção foi discutida, focando-se nos melhores esquemas a serem empregados e seu sequenciamento, bem como o papel da quimioembolização no manejo destes pacientes.

Oxidative stress in carotid arteries of patients submitted to carotid endarterectomy. The role of aging process

ABSTRACT PURPOSE: To evaluated the role of oxidative stress on aging process in patients submitted to carotid endarterectomy. METHODS: Twenty patients were divided into two groups: older group (≥ 70 years old); and the younger group (< 70 years old). We evaluated the reactive oxygen species (ROS) concentration, nicotinamide adenine dinucleotide phosphate (NADPH)-oxidase, superoxide dismutase (SOD) and catalase (CAT) activities as so as nitrite levels in fragments of carotid arteries harvested during carotid endarterectomy for treatment of high grade carotid stenosis. RESULTS: We observed a higher levels of ROS and NADPH oxidase activity in the older group (p<0.05). Furthermore, the nitrite concentration was lower in the older group (14.55 ± 5.61 x 10-3 versus 26.42 ± 8.14 x 10-3 µM; p=0.0123). However, the activities of antioxidant enzymes (CAT and SOD) were similar in both the groups. CONCLUSIONS : Arterial aging is associated with increased concentrations of oxygen species and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity as so as nitrite reduction in human carotid artery specimens. Maybe therapies that block NADPH oxidase activity and enhance nitrite stores would be a good strategy to reduce the effect of oxidative stress in arterial aging.

I brazilian consensus on multimodal treatment of colorectal liver metastases. module 2: approach to resectable metastases / I consenso brasileiro de tratamento multidisciplinar de metástase hepática colorretais módulo 2: manejo das metástases ressecáveis

Background : Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients. Aim : In the second module of this consensus, management of resectable liver metastases was discussed. Method : Concept of synchronous and metachronous metastases was determined, and both scenarius were discussed separately according its prognostic and therapeutic peculiarities. Results : Special attention was given to the missing metastases due to systemic preoperative treatment response, with emphasis in strategies to avoid its reccurrence and how to manage disappeared lesions. Conclusion : Were presented validated ressectional strategies, to be taken into account in clinical practice.

Racional: As metástases hepáticas de câncer colorretal são evento frequente e potencialmente fatal na evolução dos pacientes. Objetivo : No segundo módulo desse consenso, foi discutido o manejo de metástases hepáticas ressecáveis. Método : Foi definido o conceito de metástases síncrônicas e metacrônicas, e ambos os cenários foram discutidos separadamente de acordo com as suas peculiaridades prognósticas e terapêuticas. Resultados : Foi dada especial atenção às missing metástases em resposta ao tratamento pré-operatório sistêmico, com ênfase em estratégias para evitar sua recorrência e como gerenciar as lesões desaparecidas. Conclusão : Foram apresentadas e validadas estratégias de ressecção em várias circunstâncias, para serem aplicadas na prática clínica.

FIRST BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 1: PRE-TREATMENT EVALUATION / I CONSENSO BRASILEIRO DE TRATAMENTO MULTIDISCIPLINAR DE METÁSTASE HEPÁTICA COLORRETAIS. MÓDULO 1: AVALIAÇÃO PRÉ-TRATAMENTO

Background : Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients with these tumors. Aim : In this module, was contextualized the clinical situations and parameterized epidemiological data and results of the various treatment modalities established. Method: Was realized deep discussion on detecting and staging metastatic colorectal cancer, as well as employment of imaging methods in the evaluation of response to instituted systemic therapy. Results : The next step was based on the definition of which patients would have their metastases considered resectable and how to expand the amount of patients elegible for modalities with curative intent. Conclusion : Were presented clinical, pathological and molecular prognostic factors, validated to be taken into account in clinical practice.

Racional : As metástases hepáticas de câncer colorretal são evento frequente e potencialmente fatal na evolução de pacientes com estas neoplasias. Objetivo : Neste módulo procurou-se contextualizar esta situação clínica, bem como parametrizar dados epidemiológicos e de resultados das diversas modalidades de tratamento estabelecidas. Método : Foi realizada discussão sobre como detectar e estadiar o câncer colorretal metastático, bem como o emprego dos métodos de imagem na avaliação de resposta ao tratamento sistêmico instituído. Resultado : Fundamentou na definição de quais pacientes teriam suas metástases consideradas ressecáveis e de como se poderia ampliar a gama de pacientes submetidos às modalidades de tratamento ditas de intuito curativo. Conclusão : Foram apresentados os fatores prognósticos clínicos, patológicos e moleculares com validação para serem levados em consideração na prática clínica.

The association between preoperative chemotherapy and the prevalence of hepatic steatosis in hepatectomy for metastatic colorectal cancer / Associação da quimioterapia pré-operatória e a prevalência de esteatose hepática em hepatectomias por metástase de câncer colorretal

BACKGROUND: Some studies have suggested that preoperative chemotherapy for hepatic colorectal metastases may cause hepatic injury and increase perioperative morbidity and mortality. AIM: To evaluate the prevalence of hepatic steatosis in patients undergoing preoperative chemotherapy for metastatic colorectal cancer. METHODS: Observational retrospective cohort study in which 166 patients underwent 185 hepatectomies for metastatic colorectal cancer with or without associated preoperative chemotherapy from 2004 to 2011. The data were obtained from a review of the medical records and an analysis of the anatomopathological report on the non-tumor portion of the surgical specimen. The study sample was divided into two groups: those who were exposed and those who were unexposed to chemotherapy. RESULTS: From the hepatectomies, 136 cases (73.5%) underwent preoperative chemotherapy, with most (62.5%) using a regimen of 5-fluorouracil + leucovorin. A 40% greater risk of cell damage was detected in 62% of the exposed group. The predominant histological pattern of the cell damage was steatosis, which was detected in 51% of the exposed cases. Exposure to chemotherapy increased the risk of steatosis by 2.2 fold. However, when the risk factors were controlled, only the presence of risk of hepatopathy was associated with steatosis, with a relative risk of 4 (2.7-5.9). CONCLUSION: Patients exposed to chemotherapy have 2.2 times the risk of developing hepatic steatosis, and its occurrence is associated with the presence of predisposing factors such as diabetes mellitus and hepatopathy. .

RACIONAL: Alguns estudos sugerem que a quimioterapia pré-operatória para metástases hepáticas do câncer colorretal pode causar dano celular e aumentar morbidade e mortalidade. OBJETIVO: Analisar a prevalência de esteatose hepática em fígados de pacientes expostos à quimioterapia pré-operatória por metástase de câncer colorretal. MÉTODOS: O delineamento do estudo foi observacional de coorte retrospectivo, no qual 166 pacientes foram submetidos a 185 hepactectomias por metástase de câncer colorretal, com e sem quimioterapia pré-operatória, no período de 2004 a 2011. Os dados foram extraídos da revisão dos prontuários e da análise do laudo anatomopatológico da parte não tumoral da peça cirúrgica. A amostra foi dividida em grupo exposto e não-exposto à quimioterapia. Os dados foram analisados por programa estatístico Stata 11.2, e aplicado o teste exato de Fischer para análise bivariada, e a regressão de Poisson, para análise multivariada; valores p< 0,05 foram considerados como significativos. RESULTADOS: Das hepatectomias, 136 casos (73,5%) receberam quimioterapia pré-operatória, e o regime mais utilizado (62,5%) foi 5-fluorouracila+leucovorin. No grupo exposto, a lesão hepatocelular esteve presente em 62% dos casos e correspondeu a risco de 40% em relação ao grupo não-exposto. O padrão histológico da lesão hepatocelular predominante foi a esteatose, em 51% de casos do grupo exposto. A exposição à quimioterapia aumentou em 2,2 vezes a possibilidade de esteatose. Entretanto, quando foram controlados os fatores de risco, somente a hepatopatia prévia esteve associada à presença de esteatose após quimioterapia com risco relativo de 4 (2,7-5,9). CONCLUSÕES: Pacientes expostos ...

Análise epidemiológica dos adenocarcinomas gástricos ressecados em um serviço de cirurgia oncológica / Epidemiological analysis of resected gastric adenocarcinomas in a oncologic surgery service

Introdução: O adenocarcinoma de estômago é a quarta neoplasia mais incidente no mundo e a segunda causa de morte relacionada ao câncer. O objetivo deste estudo é determinar o perfil epidemiológico e patológico dos pacientes intervidos cirurgicamente por adenocarcinoma gástrico e sua sobrevida relacionada à classificação TNM. Métodos:Estudo de coorte histórica de 216 pacientes submetidos à gastrectomia por adenocarcinoma gástrico. Foram analisados dados epidemiológicos, patológicos e a sobrevida. Resultados: A média de idade foi de 61,84 anos. Foram 76 (35,2%) pacientes do gênero feminino e 140 (64,8%), masculino. Quanto à localização, 79 (36,6%) no antro, 45 (20,8%) na cárdia, 70 (32,4%) no corpo. Em relação à diferenciação celular, 5 (2,3%) bem diferenciados, 71 (32,9%) moderadamente diferenciados, 133 (61,6%) pouco diferenciados e 7 (3,2%) eram indeterminados. O estadiamento clínico demonstrou 11 (5,1%) pacientes com estádio 0, com sobrevida de 100%; 23 (10,6%) no estádio I, com sobrevida de 82%; 55 pacientes (25,5%), com sobrevida de 60% no estádio II; 101 pacientes (46,7%), com sobrevida de 25% no estádio III e 26 pacientes (12%), com sobrevida de 15% no estádio IV. Em relação às complicações pós-operatórias, 52,3% dos pacientes não tiveram complicações e 7,9% (17 pacientes) com óbito no período pós-operatório. Conclusões: Aproximadamente 70% das neoplasias eram distais, enquanto cerca de 30% eram proximais. A grande parte dos pacientes era de estádios mais avançados, o que conferiu um pior prognóstico, refletindo a necessidade de uma revisão das políticas públicas para câncer gástrico do Brasil, visando aprimorar o diagnóstico e tratamento, melhorando o prognóstico desses pacientes.

Introduction:The gastric adenocarcinoma is the fourth most frequent cancer worldwide and the second leading cause of cancer-related death. The aim of this study is to determine the epidemiological and pathological profile of gastric adenocarcinoma patients and their survival regarding the TNM classification. Methods: A historical cohort study of 216 patients undergoing gastrectomy for gastric adenocarcinoma. Epidemiological, pathological and survival data were analyzed. Results: The mean age was 61.84 years. There were 76 (35.2%) females and 140 (64.8%) males. Regarding location, 79 (36.6%) cases were in the antrum, 45 (20.8%) in the cardia, and 70 (32.4%) in the body. Regarding cell differentiation, 5 cases (2.3%) were well differentiated, 71 (32.9%) moderately differentiated, 133 (61.6%) poorly differentiated, and 7 (3.2%) were indeterminate. Clinical staging showed 11 (5.1%) patients with stage 0 with a survival rate of 100%, 23 (10.6%) in stage I with a survival rate of 82%, 55 patients (25.5%) in stage II with a survival rate of 60%,101 patients (46,7%) in stage III with a survival rate of 25% and 26 patients (12%) in stage IV with a survival rate of 15%. Regarding postoperative complications, 52.3% of the patients had no complications and 7.9% (17 patients) died in the postoperative period. Conclusions: Approximately 70% of tumors were distal, while approximately 30% were proximal. The majority of patients had more advanced stages, which conferred a worse prognosis, reflecting the need for a revision of public policies for gastric cancer in Brazil, aiming to improve the diagnosis and treatment and determining a better prognosis for these patients.

Hepatectomia em pacientes idosos / Liver ressection in elderly patients

INTRODUÇÃO: A expectativa de vida da população tem aumentado nos últimos anos, como também houve progressão da incidência de neoplasias primárias e secundárias do fígado. A medicina vem acompanhando esse processo, mas ainda há receios quanto ao uso de tratamentos cirúrgicos agressivos em pacientes idosos, especialmente no que tange à cirurgia do fígado. OBJETIVO: Analisar a influência da idade na morbimortalidade de pacientes submetidos à ressecção hepática. MÉTODOS: Revisão bilbliográfica através dos sites do PubMed, Scielo e Bireme, com os descritores "elderly", "hepatectomy", "hepatic resection", "postoperative complications", "morbidity", "mortality". Foram selecionados os trabalhos que compararam os resultados de hepatectomia entre grupos de pacientes jovens e idosos. CONCLUSÃO: A idade não é fator predisponente à piora dos resultados na ressecção hepática.

INTRODUCTION: Life expectancy of the population has increased in recent years as a result of human development, leading to an increase in the incidence of primary and secondary neoplasms of the liver. Medicine has been following this process, but there is still fear of aggressive surgical treatment in elderly patients, especially concerning to liver surgery. AIM: To analyze the influence of age on the morbidity and mortality of patients undergoing liver resection. METHOD: Literature review of scientific articles available in PubMed, Scielo and Bireme database with "elderly", "hepatectomy," "hepatic resection," "postoperative complications", "morbidity", "mortality". It was selected studies that compared the results of hepatectomy between groups of young and elderly patients. CONCLUSION: Age is not a predisposing factor for the worsening of results in liver resection.

Leiomioma hepático em paciente imunocompetente / Hepatic leyomioma in an immunocompetent patient

Diagnosis and treatment of hepatic tumors are a challenge for the surgeon in some situations. There are many histologic types of these neoplasms, and their diagnoses are increasing. Leyomioma of the liver is a rare pathology that is presented in this article in a 44 years old woman without immunosuppression. A review about its clinical aspects, image diagnosis and surgical therapy is discussed, based on the world medical literature.

Hepatectomia para metástases hepáticas de câncer de mama / Hepatectomy for liver metastases from breast cancer

Patients with metastatic breast cancer, whereas liver is the only site of dissemination, may benefit from hepatectomy. Literature suggests that surgical treatment of these metastases may offer a longer survival rate than systemic chemotherapy and/or isolated homonal therapy. We report two cases of hepatic resection for liver metastases from breast cancer, with survival of 11 and 16 months without recurrence. One patient had a single metastases and the other two. No post-operative complications were observed.

N-acetilcisteína diminui a congestão hepática na lesão de isquemia e reperfusão: estudo experimental / N-acetylcysteine decreases hepatic congestion in the ischemia-reperfusion injury: experimental study

OBJETIVOS: A isquemia tem sido utilizada na cirurgia hepática desde o início do século. Embora possibilite a diminuição da perda sangüínea durante as ressecções e a manutenção do órgão à espera de um transplante, a ausência de perfusão traz como conseqüência um dano ao órgão, que se amplifica por ocasião da sua reoxigenação. A N-Acetilcisteína é uma droga capaz de repor os estoques celulares de glutationa, um antioxidante fundamental no controle das lesões resultantes do restabelecimento da perfusão sangüínea, esperando-se dessa forma que diminua a lesão acima descrita. Com o propósito de avaliar a capacidade da N-Acetilcisteína reduzir o dano hepático, utilizou-se um modelo murino de isquemia e reperfusão normotérmica. MÉTODO: Foram utilizados vinte ratos Wistar fêmeas, divididos em dois grupos. No grupo tratado, 400mg/kg de N-Acetilcisteína foram administrados pela via intravenosa, 15 minutos antes do clampeamento do pedículo do lobo esquerdo por 90 minutos. No grupo controle foi administrado o volume equivalente de solução fisiológica. Foi estabelecido um período de quatro horas de reperfusão, após o qual os animais foram sacrificados para a realização de análise histopatológica do lobo esquerdo com coloração de Hematoxilina-Eosina. A lesão tecidual foi quantificada quanto à presença de congestão, esteatose e necrose. RESULTADOS: O estudo evidenciou a capacidade de a N-Acetilcisteína diminuir significativamente a congestão. Não houve diferenças quanto à presença de esteatose e necrose. CONCLUSÃO: Os resultados obtidos permitem-nos concluir que o uso prévio da N-Acetilcisteína nos processos de isquemia e reperfusão, em normotermia, é capaz de diminuir a congestão hepática. A N-Acetilcisteína não diminui a presença de esteatose e necrose.

BACKGROUND: Ischemia has been used in hepatic surgery since the beginning of the century. Its use results in less blood loss during hepatic resections and allow organ preservation while waiting for a transplant. Nevertheless, the lack of perfusion causes liver injury, worsen by the reoxygenation of the organ. N-Acetylcysteine is a drug capable of restoring cellular glutatione levels, essential to control reperfusion injury. Therefore, N-Acetylcysteine could be useful to lessen liver damage. To evaluate N-Acetylcysteine ability to reduce hepatic damage, a murine model of normothermic ischemia and reperfusion was used. METHODS: Twenty female Wistar rats were divided in two groups. In the first group, N-Acetylcysteine 400mg/kg was given intravenously fifteen minutes before the left hepatic lobe clamping. The clamp was kept in place for ninety minutes. In the control group, normal saline was given in an equivalent volume. After four hours of reperfusion, animals were killed and left lobes were submitted to histopathological analysis stained with Hematoxilin-Eosin. Specimens were evaluated for congestion, steatosis and necrosis. RESULTS: Analysis showed N-Acetylcysteine capability of significantly decrease hepatic congestion. There was no difference in regard of steatosis and necrosis. CONCLUSION: We concluded that previous N-Acetylcysteine administration reduces congestion in normothermic ischemia-reperfusion of the liver lobe. The drug does not reduce steatosis or necrosis.

Pseudotumor inflamatório do fígado: diagnóstico diferencial de carcinoma hepatocelular / Inflammatory pseudotumor of the liver: differential diagnosis of hepatocellular carcinoma

The authors present a rare case of inflammatory pseudotumor of the liver whose differential diagnosis with hepatocellular carcinoma - in some cases - is only possible with the histological examination. In this case, a female patient, 38 years-old was suffering from abdominal pain, enlarged liver, thinning, tiredness and fever; alpha-fetoprotein, the liver function tests, amylase and lipase were normal. Abdominal ultrasound and computed tomography showed a node in the right liver lobe. The patient was submitted to a right hepatectomy for hepatocellular carcinoma. Histological examination showed an inflammatory pseudotumor of the liver. The patient was discharged from the hospital on the seventh postoperative day; she is asymptomatic for three years.

Cateteres venosos totalmente implantáveis em pacientes com neoplasia hematológica e não hematológica / Totally implantable venous catheters in patients with hematological and non hematological neoplasias

OBJETIVO: Analisar se a presença de neoplasia hematológica acarreta maior risco de complicações para inserção de cateteres totalmente implantáveis e se há diferença de tempo cirúrgico quando o procedimento é realizado por punção ou dissecção venosa. MÉTODO: Foram avaliados 68 pacientes com neoplasia internados no Hospital Santa Rita de Porto Alegre entre fevereiro de 1998 e dezembro de 1999, os quais necessitavam de acesso venoso central para tratamento quimioterápico, sendo 48 do sexo feminino e com idade média de 55,6 anos. Desses, 31 apresentavam neoplasia hematológica. RESULTADOS: Complicações pós-operatórias ocorreram em 13 pacientes (19 por cento), sendo elas: obstrução do sistema (7 por cento), hematoma (6 por cento) e infecção (6 por cento), não havendo diferença quanto ao tipo de neoplasia (p = 0,56). Foram realizadas dissecção e punção venosa em 30 e 38 pacientes, respectivamente, sem diferença em relação ao tempo de implantação do cateter (p = 0,42). CONCLUSÃO: Neoplasias hematológicas não aumentaram o risco de complicações quando do uso de cateteres totalmente implantáveis no presente estudo, além disso, ambas as técnicas cirúrgicas - dissecção ou punção - são exeqüíveis, haja visto o tempo cirúrgico semelhante entre elas, desde que sejam respeitados o valor sérico mínimo de plaquetas (50.000/mL) e a técnica cirúrgica apropriada, com hemostasia rigorosa e curativo compressivo.

BACKGROUND: We analyse whether hematological tumors increase the risk of complications of totally implantable catheters and if there are differences regarding procedure time when it is perfomed through venous dissection or venous puncture. METHODS: We studied 68 patients with neoplasia in Hospital Santa Rita from Porto Alegre, between February 1998 and December 1999, who had required central venous access for chemotherapy. Forty-eight patients were female and the mean age was 55.6 years. Thirty-one patients had hematological tumors. RESULTS: Postoperative complications were observed in 13 patients (7 percent with device obstruction, 6 percent with hematoma and 6 percent with infection), but there was no difference regarding the pattern of the neoplasia (p = 0.56). Venous dissection and venous puncture were performed in 30 and 38 patients, respectively, with no difference concerning surgical time (p = 0.42). CONCLUSIONS: Hematological tumors did not increase the risk of complications of totally implantable catheters; furthermore, both surgical techniques (venous dissection or venous puncture) are acceptable choices, with similar surgical times, since one respects minimal platelet count of 50 000/mL and careful hemostasis techniques and compressive dressings.

Adenomioma da papila de vater em adulto jovem / Adenomyoma of the papilla of vater in a young adult

The authors report a case of adenomyoma of papilla of Vater in a young adult, a rare pathology in this age and site. The commonest clinical findings are abdominal pain, dyspepsia and jaundice, as in this case in which the patient refered these symptoms for several months. The diagnosis is usually difficult before surgery, because the radiological and endoscopic appearances are difficult to interpret, since they may only show obstruction and enlargement of the biliary tract; in this way, the endoscopic biopsy may be useful. In the present case the computed tomography, abdominal scan and intraoperative cholangiography only demonstrated obstruction and enlargement of the biliary tract, without the presence of gallstones. The treatment is usually lesion resection according to its size, performing the total resection in those cases of extensive involvement of the digestive tract, as it was performed in this case, due to the dimension of the lesion and its malignant appearance. The patient was discharged from hospital on the thirteenth postoperative day, with a histological diagnosis of adenomyoma of papilla of Vater. Three months after the procedure the patient was asymptomatic

Tuberculose hepática pseudotumoral / Pseudotumoral hepatic tuberculosis

Tuberculous involvement of the liver is usually a diffuse process, associated with miliary tuberculosis. However, localized tuberculosis of the liver producing a macronodular tuberculoma or an abscess is rare. The authors present a case of pseudotumoral hepatic tuberculosis in a 34-year old woman. This patient presented a 2 month history of fever, weight loss of 4kg and right upper quadrant abdominal pain. She denied jaundice, choluria, or acholia. Laboratory investigation, including renal and liver function tests, revealed normal levels. Chest X-ray was normal. Abdominal ultrasonography demonstrated a hypoechoic nodule in the right hepatic lobe. CT scan showed hypodense areas in the same place and no retroperitoneal lymphadenopathy. Due to the inespecificity of the signs, symptoms and image findings, a diagnostic laparoscopy was performed, it was however inconclusive. Then, the patient was submitted to a laparotomy with ressection of the lesion. Histological examination revealed a tuberculoid granulomatous lesion with caseous necrosis. Postoperatively, the patient was placed on antituberculous chemotherapy with rifampin, isoniazid and pyrazinamide. Eight months later, the patient is asymptomatic