Tumor neuroectodérmico maligno del tracto gastrointestinal: a propósito de un caso / Malignant neuroectodermal tumor of the gastrointestinal tract: case report

El tumor neuroectodérmico maligno del tracto gastrointestinal es una neoplasia rara con pocos casos reportados en la literatura, especialmente en América Latina. Descrito por primera vez en 2003, se trata de una entidad sin tratamiento estandarizado y de pobre pronóstico. Se presenta el caso de una paciente de 22 años de edad que acude a la consulta por dolor abdominal, anemia y masa abdominal palpable. Luego de estudios pertinentes se decide la conducta resectiva y el posterior tratamiento oncológico. (AU)

Malignant gastrointestinal neuroectodermal tumor (GNET), formerly known as clear cell sarcoma of the gastrointestinal tract, is an extremely rare tumor of mesenchymal origin, which presents great microscopic and molecular similarity to clear cell sarcoma found in other parts of the body, such as tendons and aponeurosis. It is characterized by its rapid evolution, high recurrence rate and frequent diagnosis as metastatic disease.1,2 (AU)

Tumor de GIST, presentación no habitual / GIST tumor: an unusual presentation

RESUMEN El tumor estromal gastrointestinal representa el 3% de las neoplasias gastrointestinales; es el tumor mesenquimático más frecuente. Afecta a hombres mayores de 50 años. El 80% son benignos, la mayoría afectan el estómago e intestino delgado. La incidencia de localización extragastrointestinal es desconocida. Paciente masculino de 56 años, tabaquista, obeso, con hipertensión arterial (HTA) y diabético (DBT), anticoagulado, consulta por dolor en fosa ilíaca derecha, posterior a esfuerzo físico. Se realiza tomografía computarizada (TC) donde se visualiza lesión de aspecto expansivo intraperitoneal que muestra realce periférico. Se decide conducta quirúrgica. Se halla un tumor mesentérico. En su presentación, estos tumores hasta en un 60% suelen ser asintomáticos por lo que resultan solo un hallazgo imagenológico; es indispensable, pues, su sospecha clínica y fundamentalmente el aporte de la inmunohistoquímica para la definición de la patología. El CD 117 es el principal marcador. Su tratamiento de preferencia es siempre quirúrgico, acompañado de tratamientos quimioterápicos.

ABSTRACT Gastrointestinal stromal tumors (GISTs) account for < 3% of gastrointestinal neoplasms and are the most common mesenchymal tumors. They are more common in men > 50 years. They are benign in 80% of the cases and usually occur in the stomach and small intestine. The incidence of extragastrointestinal GISTs is unknown. A 56-year-old male patient sought medical care for abdominal pain in the right iliac fossa that appeared after exercising. The patient was a current smoker, obese, had a history of hypertension (HTN) and diabetes (DBT) and was receiving anticoagulants. A computed tomography (CT) scan showed an expansive mass within the peritoneum with peripheral enhancement. Surgical management was decided. During the procedure, a tumor was found in the mesentery. Up to 60% of these tumors are usually asymptomatic and are incidentally found in imaging tests; therefore, clinical suspicion and, most importantly immunohistochemistry, are essential for the diagnosis. CD117 is the main marker. Surgery is the treatment of choice for GISTs and chemotherapy is also indicated.

Condroma pulmonar y paraganglioma carotídeo como manifestaciones de la tríada de Carney: reporte de un caso / Pulmonary chondroma and carotid paraganglioma as expressions of Carney's triad: report of a case

Resumen Objetivos: Presentar caso clínico y revisión de la literatura sobre asociación de tumores poco frecuentes compatibles con diagnóstico de tríada de Carney. Paciente y Métodos: Revisión de ficha clínica de paciente de sexo femenino de 39 años de edad con antecedentes de asma, quien acude a servicio de urgencias por síntomas respiratorios. En estudio con imágenes se evidencia masa pulmonar en lóbulo superior derecho probablemente hamartoma y masa en la bifurcación carotídea izquierda compatible con posible paraganglioma. Se completó el estudio con endoscopia digestiva alta sin evidencia de tumor gástrico y PET-CT (tomografía de emisión de positrones-tomografía computarizada) que descartó otras lesiones. Resultados: La paciente fue sometida a resección quirúrgica de ambos tumores (pulmonar y carotídeo). En estudio histopatológico diferido, se plantean los diagnósticos de paraganglioma carotideo y hamartoma pulmonar, el cual, luego de una segunda revisión histopatológica, es corregido a condroma pulmonar. Discusión: La tríada de Carney se compone por la asociación de al menos 2 de 3 tumores: tumor estromal gastrointestinal (GIST), paraganglioma extra-adrenal y condroma pulmonar. Su expresión es variable, coexistiendo en forma completa en solo el 22% de los casos. Conclusión: Los pacientes con sospecha de tríada de Carney deben recibir evaluación multidisciplinaria, estudio completo en búsqueda de tumores asociados y seguimiento a largo plazo por posibles recurrencias o metástasis.

Objective: To present a clinical case and review of the literature on the infrequent association of pulmonary and extra thoracic tumors compatible with Carney's triad. Patient and Methods: Review of clinical records of a 39 years-old female patient with history of asthma who presented in the emergency department with respiratory symptoms. An imaging study showed a pulmonary mass in the right upper lobe with the aspect of hamartoma and a mass in the left carotid artery bifurcation compatible with a possible paraganglioma. Upper gastrointestinal endoscopy showed no evidence of gastric tumor and a PET-CT (Positron Emission Tomography - Computed Tomography) excluded other lesions. Results: Patient underwent surgical resection of both tumors (pulmonary and carotid). Diagnosis of carotid paraganglioma and pulmonary hamartoma were stated by histopathology. However, lung tumor after a second pathological analysis was confirmed to be a pulmonary chondroma. Discussion: Carney's triad is defined by the association of at least 2 of 3 tumors: Gastrointestinal Stromal Tumor (GIST), extraadrenal paraganglioma and pulmonary chondroma. Its expression is variable, coexisting completely in only 22% of cases. Conclusion: Patients with suspected Carney's triad should receive a multidisciplinary assessment, a complete study searching associated tumors and long-term follow-up for recurrences or metastases.

GIST gástrico complicado. Una forma de presentación inusual / Complicated gastric GIST. An unusual presentation

RESUMEN Los tumores GIST son un motivo de consulta cada vez más frecuente en las entrevistas de cirugía gastroenterológica. Suelen ser derivados como hallazgos incidentales o por presentar síntomas derivados de su crecimiento. Se presenta el caso clínico de una paciente que requirió internación de urgencia por síndrome anémico agudo. Se comenta su algoritmo diagnóstico y su resolución quirúrgica. Asimismo se comentan los estándares de diagnóstico y tratamiento actuales con especial foco en la estrategia quirúrgica, la cual debe ser individualizada según cada caso.

ABSTRACT Gastrointestinal stromal tumors (GISTs) are becoming an increasingly common reason for consultation in gastroenterology surgery interviews. Patients are usually referred for surgery due to an incidental finding or symptoms associated with tumor growth. We report the case of a female patient who required urgent hospitalization due to acute anemic syndrome. The diagnostic algorithm and surgical approach are described. The current standards of diagnosis and treatment are also discussed, with special focus on the surgical strategy, which must be tailored to each case.

Thinking and suggestions on pathway management of perioperative enhanced recovery after surgery in gastrointestinal tumors in China / 中华胃肠外科杂志

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care program to decrease the risk of delayed hospitalization, medical complications, readmission and to improve patient short- and long-term outcomes with minimized level of surgical stress responses through multidisciplinary cooperation. Despite its huge success, the program has challenges for further optimization with a primary focus on modification according to the specific pathophysiology and perioperative management characteristics of patients with gastrointestinal tumors to improve the compliance and implementation rate of items. Patient education, prehabilitation, multimodal analgesia, precision surgery, early mobilization, early oral feeding and oral nutrition supplement (ONS) should be regarded as core terms suitable for all the patients. During the application of ERAS pathway management, it is necessary to fully understand the perioperative changes of organ function and pathophysiology, and to strictly implement the ERAS program and items based on evidence-based medicine. Moreover, the close collaboration of multidisciplinary teams is needed to improve the compliance and increase the adherence rate of ERAS protocol for patients, which emphasizes the dynamic, gap-free and whole course management that covers pre-hospital, pre-operative, intra-operative, post-operative and post-hospital periods. Concurrently, we encourage our patients and their families to participate in the whole healthcare activities. Even more concerning, it is indispensable to adjust ERAS program for special time and special patients. At present, several consensus and guidelines on the ERAS management of gastrointestinal tumor surgery have come out for clinical practice in China, which, however, still lacks a high-level evidence from more high-quality clinical trials conducted by Chinese researchers. It is urgent to carry out a series of large-scale randomized controlled studies in accordance with international standards to obtain high-level evidence-based medical evidence for clinical practice, which is problem-oriented and integrated with features of metabolism and perioperative management of gastrointestinal tumor surgery.

Diagnosis and treatment status of perioperative anemia in patients with gastrointestinal neoplasms: a multi-center study in Hubei Province / 中华外科杂志

Objective: To investigate the incidence and treatment of perioperative anemia in patients with gastrointestinal neoplasms in Hubei Province. Methods: The clinicopathological data of 7 474 patients with gastrointestinal neoplasms in 62 hospitals in 15 cities (state) of Hubei Province in 2019 were collected in the form of network database. There were 4 749 males and 2 725 females. The median age of the patients was 62 years (range: 17 to 96 years). The hemoglobin value of the first time in hospital and the first day after operation was used as the criterion of preoperative anemia and postoperative anemia. Anemia was defined as male hemoglobin <120 g/L and female hemoglobin <110.0 g/L, mild anemia as 90 to normal, moderate anemia as 60 to <90 g/L, severe anemia as <60 g/L. The t test and χ2 test were used for inter-group comparison. Results: The overall incidence of preoperative anemia was 38.60%(2 885/7 474), and the incidences of mild anemia, moderate anemia and severe anemia were 25.09%(1 875/7 474), 11.37%(850/7 474) and 2.14%(160/7 474), respectively. The overall incidence of postoperative anemia was 61.40%(4 589/7 474). The incidence of mild anemia, moderate anemia and severe anemia were 48.73%(3 642/7 474), 12.20%(912/7 474) and 0.47%(35/7 474), respectively. The proportion of preoperative anemia patients receiving treatment was 26.86% (775/2 885), and the proportion of postoperative anemia patients receiving treatment was 14.93% (685/4 589). The proportions of preoperative anemia patients in grade ⅢA, grade ⅢB, and grade ⅡA hospitals receiving treatment were 26.12% (649/2 485), 32.32% (85/263), and 29.93% (41/137), and the proportions of postoperative anemia patients receiving treatment were 14.61% (592/4 052), 22.05% (73/331), and 9.71% (20/206). The proportion of intraoperative blood transfusion (16.74% (483/2 885) vs. 3.05% (140/4 589), χ²=434.555, P<0.01) and the incidence of postoperative complications (17.78% (513/2 885) vs. 14.08% (646/4 589), χ²=18.553, P<0.01) in the preoperative anemia group were higher than those in the non-anemia group, and the postoperative hospital stay in the preoperative anemia group was longer than that in the non-anemia group ((14.1±7.3) days vs. (13.3±6.2) days, t=5.202, P<0.01). Conclusions: The incidence of perioperative anemia in patients with gastrointestinal neoplasms is high. Preoperative anemia can increase the demand for intraoperative blood transfusion and affect the short-term prognosis of patients. At present, the concept of standardized treatment of perioperative anemia among gastrointestinal surgeons in Hubei Province needs to be improved.

Endoscopic diagnosis and treatment of gastrointestinal neuroendocrine neoplasms / 中华胃肠外科杂志

The incidence of neuroendocrine neoplasms (NEN) is increasing globally, and gastrointestinal NEN (GI-NEN) is the most common type of NEN. Diagnosis and treatment of GI-NEN are quite different, according to tumor's location, size, background, cell origin, and pathogenesis. Digestive endoscopy has unique advantages in detecting of GI-NEN. However, endoscopist should not perform endoscopic resection arbitrarily, due to the high heterogeneity and complexity of GI-NEN. We need to establish the concept about comprehensive assessment for GI-NEN, including medical history and physical signs, serology, imaging, radionuclide and end·oscopic examination, to make an individualized treatment after rigorous multidisciplinary discussion.

Holistic view of surgery based on membrane anatomy for gastrointestinal tumor / 中华胃肠外科杂志

The mesentery is a continuous unity and the operation of digestive carcinoma is the process of mesenteric resection. This paper attempts to simplify the formation process of all kinds of fusion fascia in the process of digestive tract embryogenesis, and to illuminate the continuity of fusion fascia with a holistic concept. This is helpful for beginners to reversely dissect the fusion fascia and maintain the correct surgical plane during operation, and to achieve the purpose of complete mesenteric resection.

The role of conventional echoendoscopy (eus) in therapeutic decisions in patients with neuroendocrine gastrointestinal tumors / O papel da ecoendoscopia convencional nas decisões terapêuticas em pacientes com tumores neuroendócrinos gastrointestinais

ABSTRACT Background: Gastrointestinal neuroendocrine tumors are rare, usually presented as subepithelial or polypoid tumors. Accurate diagnosis and indication of the type of resection are still challenging. Aim: To determine the effectiveness of echoendoscopy in determining the depth of the lesions (T) identified by endoscopy in order to evaluate surgical and/or endoscopic indication, and to evaluate the results of endoscopic removal in the medium term. Methods: Twenty-seven patients were included, all of whom underwent echoendoscopy for TN tumor staging and the evaluation of possible endoscopic resection. The parameters were: lesion size, origin layer, depth of involvement and identified perilesional adenopathies. The inclusion criteria for endoscopic resection were: 1) high surgical risk; 2) those with NET <2 cm; 3) absence of impairment of the muscle itself; and 4) absence of perilesional adenopathies in echoendoscopy and in others without distant metastases. Exclusion criteria were TNE> 2 cm; those with infiltration of the muscle itself; with perilesional adenopathies and distant metastases. The techniques used were: resection with polypectomy loop; mucosectomy with saline injection; and mucosectomy after ligation with an elastic band. The anatomopathological study of the specimens included evaluation of the margins and immunohistochemistry (chromogranin, synaptophysin and Ki 67) to characterize the tumor. Follow-up was done at 1, 6 and 12 months. Results: Resections with polypectomy loop were performed in 15 patients; mucosectomy in five; mucosectomy and ligation with elastic band in three and the remaining four were referred for surgery. The anatomopathological specimens and immunohistochemical analyzes showed positive chromogranin and synaptophysin, while Ki 67 was less than 5% among all cases. The medium-term follow-up revealed three recurrences. The average size of tumors in the stomach was 7.6 mm and in the duodenum 7.2 mm. Well-demarcated, hypoechoic, homogeneous lesions occurred in 75%; mucous layer in 80%; and the deep and submucosal mucosa in 70%. Conclusions: Echoendoscopy proved to be a good method for the study of subepithelial lesions, being able to identify the layer affected by the neoplasm, degree of invasion, echogenicity, heterogeneity, size of the lesion and perilesional lymph node involvement and better indicate the treatment option.

RESUMO Racional: Tumores neuroendócrinos gastrointestinais são raros geralmente apresentados como tumores subepiteliais ou polipoides. O diagnóstico preciso e a indicação do tipo de ressecção ainda são desafiadores. Objetivo: Determinar a eficácia da ecoendoscopia em determinar a profundidade das lesões (T) identificadas pela endoscopia com objetivo de avaliar indicação cirúrgica e/ou endoscópica, e avaliar os resultados da remoção endoscópica em seguimento em médio prazo. Métodos: Foram incluídos 27 pacientes todos submetidos à ecoendoscopia para estadiamento tumoral TN e à avaliação de possível ressecção endoscópica. Os parâmetros estudados foram: tamanho da lesão, camada de origem, profundidade do acometimento e adenopatias perilesionais identificadas. Os critérios de inclusão para ressecção endoscópica foram: 1) risco cirúrgico elevado; 2) aqueles com TNE <2 cm; 3) ausência de comprometimento da muscular própria; e 4) ausência de adenopatias perilesionais na ecoendoscopia e em outros sem metástases à distância. Os critérios de exclusão foram TNE >2 cm; os com infiltração da muscular própria; com adenopatias perilesionais e metástases à distância. As técnicas utilizadas foram: ressecção com alça de polipectomia; mucosectomia com injeção de solução salina; e mucosectomia após a ligadura com banda elástica. O estudo anatomopatológico dos espécimes incluiu avaliação das margens e imunoistoquímica (cromogranina, sinaptofisina e Ki 67) para caracterizar o tumor. O seguimento foi feito com 1, 6 e 12 meses. Resultados: Ressecções com alça de polipectomia foram realizadas em 15 pacientes; mucosectomia em cinco; mucosectomia e ligadura com banda elástica em três e os quatro restantes foram encaminhados para cirurgia. O anatomopatológico dos espécimes e as análises imunoistoquímicas mostraram cromogranina e sinaptofisina positivas, enquanto que o Ki 67 foi menor que 5% dentre todos os casos. O seguimento em médio prazo revelou três recidivas. A média de tamanho dos tumores no estômago foi de 7,6 mm e no duodeno 7,2 mm. As lesões bem demarcadas, hipoecóicas, homogêneas ocorreram em 75%; da camada mucosa em 80%; e da mucosa profunda e submucosa em 70%. Conclusões: A ecoendoscopia mostrou ser bom método para o estudo de lesões subepiteliais podendo identificar a camada acometida pela neoplasia, grau de invasão, ecogeneicidade, heterogeneidade, tamanho da lesão e acometimento linfonodal perilesional e melhor indicar a opção de tratamento.

Biochemical parameters and nutritional status of surgical patients with gastrointestinal cancer: a literature review / Parâmetros bioquímicos e estado nutricional de pacientes cirúrgicos com câncer gastrointestinal: revisão de literatura

ABSTRACT This is an integrative literature review with the objective of identifying the relationship between biochemical parameters and the nutritional status of surgical patients with cancer of the gastrointestinal tract, developed in April 2019, encompassing the databases SCOPUS (Elsevier), PubMed Central® (PMC), and the Cochrane Virtual Health Library (BVS). We used the terms "Gastrointestinal Neoplasm" AND "Nutritional Status" AND "Blood Chemical Analysis" with the aid of the Academical software after the protocol validation. Out of 147 articles analyzed, seven were included in the review, as they met the inclusion criteria. There were relevant associations between biochemical parameters and nutritional status. Impaired nutritional status can negatively influence the postoperative outcome. The monitoring of interdisciplinary teams can assist in the recovery of these patients and prevent unfavorable outcomes.

RESUMO Trata-se de revisão integrativa da literatura com o objetivo de identificar a relação dos parâmetros bioquímicos com o estado nutricional de pacientes cirúrgicos com câncer do trato gastrointestinal, desenvolvida em abril de 2019, incluindo as bases de dados SCOPUS (Elsevier), PubMed Central® (PMC) e Biblioteca Cochrane: Biblioteca Virtual em Saúde (BIREME). Utilizou-se a associação dos descritores "Gastrointestinal Neoplasm" AND "Nutritional Status" AND "Blood Chemical Analysis" com o auxílio do Programa Academical após a validação de protocolo. Dos 147 artigos analisados, sete foram incluídos na revisão por atender os critérios de inclusão. Dentre os resultados, evidenciaram-se associações relevantes entre os parâmetros bioquímicos e o estado nutricional. Observou-se que o estado nutricional depauperado pode influenciar negativamente o desfecho pós-operatório. O acompanhamento de equipes interprofissionais pode auxiliar na recuperação desses pacientes e evitar desfechos desfavoráveis.

Laparoscopic resection of gastrointestinal stromal tumors (GIST) of the small intestine: a case report

Although gastrointestinal stromal tumors (GISTs) are a rare type of cancer, they are the commonest mesenchymal tumors of the gastrointestinal tract (GIT). GISTs can affect any segment of the GIT, but the usual location is the stomach, followed by the small intestine. Surgical resection of the tumor is the gold standard treatment for localized GISTs, and in patients with inoperable and metastatic disease, imatinib mesylate is the standard treatment. Pathological diagnosis is based on morphology and immunohistochemical findings. We report the case of a 55-year-old man with jejunal GIST presenting with endophytic and exophytic growth, located in the proximal jejunum. He had history of melena, anemia and one episode of enterorrhagia, and was treated with surgical resection of the lesion. (AU)

Program of intestinal rehabilitation and early postoperative enteral nutrition: a prospective cohort study / Programa de reabilitação intestinal e introdução de nutrição enteral pós-operatória precoce: estudo de cohort prospectivo

ABSTRACT Background: Some factors can act on nutritional status of patients operated for a gastrointestinal cancer. A timely and appropriate nutritional intervention could have a positive effect on postoperative outcomes. Aim: To determine the effect of a program of intestinal rehabilitation and early postoperative enteral nutrition on complications and clinical outcomes of patients underwent gastrointestinal surgery for cancer. Methods: This is a prospective study of 465 patients underwent gastrointestinal surgery for cancer consecutively admitted in an oncological intensive care unit. The program of intestinal rehabilitation and early postoperative enteral nutrition consisted in: 1) general rules, and 2) gastrointestinal rules. Results: The mean age of analysed patients was 63.7±9.1 years. The most frequent operation sites were colon-rectum (44.9%), gynaecological with intestinal suture (15.7%) and oesophagus-gastric (11.0%). Emergency intervention was performed in 12.7% of patients. The program of intestinal rehabilitation and early postoperative enteral nutrition reduced major complication (19.2% vs. 10.2%; p=0.030), respiratory complications (p=0.040), delirium (p=0.032), infectious complications (p=0.047) and gastrointestinal complications (p<0.001), mainly anastomotic leakage (p=0.033). The oncological intensive care unit mortality (p=0.018), length of oncological intensive care unit (p<0.001) and hospital (p<0.001) stay were reduced as well. Conclusions: Implementing a program of intestinal rehabilitation and early postoperative enteral nutrition is associated with reduction in postoperative complications and improvement of clinical outcomes in patients undergoing gastrointestinal surgery for cancer.

RESUMO Racional: Alguns fatores podem atuar sobre o estado nutricional de pacientes operados por câncer gastrointestinal. Intervenção nutricional oportuna e adequada poderia ter efeito positivo nos resultados pós-operatórios. Objetivo: Determinar o efeito de um programa de reabilitação intestinal e nutrição enteral pós-operatória precoce em complicações e resultados clínicos de pacientes submetidos à cirurgia gastrointestinal para câncer. Métodos: É estudo prospectivo de 465 pacientes submetidos à cirurgia gastrointestinal para câncer consecutivamente admitido em uma unidade de terapia intensiva oncológica. O programa de reabilitação intestinal e nutrição enteral pós-operatória precoce consistiu em: 1) regras gerais e 2) regras gastrointestinais. Resultados: A idade média dos pacientes analisados ​​foi de 63,7±9,1 anos. Os locais de operação mais frequentes foram colorretais (44,9%), ginecológicos com sutura intestinal (15,7%) e esofagogástrico (11,0%). Intervenção de emergência foi realizada em 12,7% dos pacientes. O programa de reabilitação intestinal e nutrição enteral pós-operatória precoce reduziu complicações maiores (19,2% vs. 10,2%; p=0,030), complicações respiratórias (p=0,040), delírio (p=0,032), complicações infecciosas (p=0,047) e gastrointestinais complicações (p<0,001), principalmente vazamento anastomótico (p=0,033). A mortalidade da unidade oncológica de terapia intensiva (p=0,018), duração da unidade oncológica de terapia intensiva (p<0,001) e hospital (p<0,001) permaneceu também reduzida. Conclusões: A implantação de um programa de reabilitação intestinal e nutrição enteral pós-operatória precoce está associada à redução das complicações pós-operatórias e à melhora dos resultados clínicos em pacientes submetidos a operações gastrointestinais para câncer.

Functionality of upper gastrointestinal cancer patients which have undertaken surgery in hospital phase / Funcionalidade de pacientes com neoplasia gastrointestinal alta submetidos ao tratamento cirúrgico em fase hospitalar

ABSTRACT Background: Cancer patients present various physiological, metabolic, social and emotional changes as a consequence of the disease's own catabolism, and may be potentiated in the gastrointestinal tract cancer by their interference with food intake, digestion and absorption. Aim: T o evaluate the functionality of upper gastrointestinal cancer patients which have undertaken surgery and analyze the factors associated with changes in strength and functionality during hospitalization time. Methods: Prospective analytical study in patients with cancer of the upper gastrointestinal tract which have undertaken surgery. Was evaluated the handgrip strength using a hand dynamometer and functionality through the functional independence measure and Functional Status Scale for Intensive Care Unit in the preoperative period, 2nd and 7th postoperative day. Results: Were included 12 patients, 75% men, and mean age was 58.17 years old. The most prevalent tumor site was stomach (66.7%). There was a progressive reduction from the pre-operative palmar grip strength to the 2nd and 7th postoperative day, respectively. There was a decrease in functional performance from the preoperative period to the 2nd and a gain from the 2nd to the 7th postoperative day (p<0.001). Conclusion: An important reduction in the handgrip strength and functionality was evidenced during the postoperative period in relation to the basal value in the pre-operative period.

RESUMO Racional: Os pacientes com câncer apresentam diversas alterações fisiológicas, metabólicas, sociais e emocionais como consequências do próprio catabolismo provocado pela doença, podendo ser potencializadas nos canceres gastrointestinais pela sua interferência na ingestão, digestão e absorção dos alimentos. Objetivo: Avaliar o comportamento funcional de pacientes com neoplasia gastrointestinal alta submetidos ao tratamento cirúrgico e analisar os fatores associados às alterações da força e funcionalidade durante o tempo de internação. Métodos: Estudo prospectivo analítico de pacientes com câncer do trato gastrointestinal alto submetidos ao tratamento cirúrgico. Foram avaliadas a força de preensão palmar por meio do dinamômetro manual e funcionalidade por meio da Medida de Independência Funcional e Functional Status Scale for Intensive Care Unit no pré-operatório, no 2º e 7º dias do pós-operatório . Resultados: Foram incluídos 12 pacientes, 75% homens, com idade média de 58,17 anos. O sítio tumoral mais prevalente foi o estômago (66,7%). Houve redução progressiva da força de preensão palmar das fases pré-operatória em relação ao 2º e 7º dias do pós-operatório, respectivamente. Ocorreu diminuição do desempenho funcional do pré-operatório para o 2º dia e um ganho do 2º dia pós-operatório para o 7º dia (p<0,001). Conclusão: Houve importante redução na força de preensão palmar e funcionalidade durante o período pós-operatório em relação ao valor basal no pré-operatório.

Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors / Estado inflamatório e nutricional em pacientes submetidos à ressecção cirúrgica de tumores do trato gastrointestinal

ABSTRACT Objective: to evaluate the association between the nutritional and the inflammatory statuses of patients with cancer of the gastrointestinal tract undergoing surgical resection and to identify predictors of mortality in these patients. Methods: we conducted a prospective study of 41 patients with gastrointestinal tract cancer submitted to surgery between October 2012 and December 2014. We evaluated the nutritional status by subjective and objective methods. We assessed the inflammatory response and prognosis using the modified Glasgow Prognostic Score (mGPS), Neutrophil/Lymphocyte Ratio (NLR), Onodera Prognostic Nutritional Index (mPNI), Inflammatory-Nutritional Index (INI) and C-Reactive Protein/Albumin ratio (mPINI). Results: half of the patients were malnourished and 27% were at nutritional risk. There was a positive association between the percentage of weight loss (%WL) and the markers NLR (p=0.047), mPINI (p=0.014) and INI (p=0.015). Serum albumin levels (p=0.015), INI (p=0.026) and mPINI (p=0.026) were significantly associated with the PG-SGA categories. On multivariate analysis, albumin was the only inflammatory marker independently related to death (p=0.004). Conclusion: inflammatory markers were significantly associated with malnutrition, demonstrating that the higher the inflammatory response, the worse the PG-SGA (B and C) scores and the higher the %WL in these patients. However, further studies aimed at improving surgical outcomes and determining the role of these markers as predictors of mortality are required.

RESUMO Objetivo: avaliar a associação entre o estado nutricional e inflamatório em pacientes com câncer do trato gastrointestinal submetidos à ressecção cirúrgica e identificar variáveis preditoras de mortalidade nestes pacientes. Métodos: estudo prospectivo de 41 pacientes com câncer do trato gastrointestinal submetidos à cirurgia entre outubro de 2012 e dezembro de 2014. O estado nutricional foi avaliado por métodos subjetivos e objetivos. A resposta inflamatória e o prognóstico foram avaliados através do Escore Prognóstico de Glasgow modificado (mGPS), razão Neutrófilo/Linfócito (NLR), Índice Nutricional Prognóstico de Onodera (mPNI), Índice Inflamatório Nutricional (INI) e razão Proteína C-reativa/Albumina (mPINI). Resultados: metade dos pacientes estava desnutrida e 27% apresentavam-se em risco nutricional. Associação positiva foi encontrada entre percentual de perda de peso (%PP) e os marcadores NLR (p=0,047), mPINI (p=0,014) e INI (p=0,015) e os níveis séricos de albumina (p=0,015), INI (p=0,026) e mPINI (p=0,026) se associaram significativamente às categorias da ASG-PPP. Na análise multivariada, a albumina foi o único marcador inflamatório independentemente relacionado ao óbito (p=0,004). Conclusão: marcadores inflamatórios foram significativamente associados com a desnutrição, demonstrando que quanto maior a resposta inflamatória, piores foram os escores da ASG-PPP (B e C) e maior o %PP nesses pacientes. No entanto, mais estudos, com o objetivo de melhorar resultados cirúrgicos e determinar o papel desses marcadores como preditores de mortalidade são necessários.

Changes in bacterial number at different sites of oral cavity during perioperative oral care management in gastrointestinal cancer patients: preliminary study

Abstract Objective The objective of this study was to clarify differences in bacterial accumulation between gastrointestinal cancer patients who underwent severely invasive surgery and those who underwent minimally invasive surgery. Material and Methods We performed a preliminary investigation of gastrointestinal cancer patients who were treated at the Department of Surgery, Takarazuka Municipal Hospital, from 2015 to 2017 (n=71; 42 laparoscopic surgery, 29 open surgery) to determine changes in bacterial numbers at different sites of the oral cavity (tongue dorsum, gingiva of upper anterior teeth, palatoglossal arch), as well as mouth dryness and tongue coating indices. Specifically, patients received professional tooth cleaning (PTC), scaling, tongue cleaning, and self-care instruction regarding tooth brushing from a dental hygienist a day before the operation. Professional oral health care was also performed by a dental hygienist two and seven days after surgery. Oral bacteria numbers were determined using a bacterial counter with a dielectrophoretic impedance measurement method. Results The number of bacteria at all three examined sites were significantly higher in the open surgery group when compared to the laparoscopic surgery group on the second postoperative day. Relevantly, bacterial count in samples from the gingiva of the upper anterior teeth remained greater seven days after the operation in patients who underwent open surgery. Furthermore, the dry mouth index level was higher in the open surgery group when compared to the laparoscopic surgery group on postoperative days 2 and 7. Conclusions Even with regular oral health care, bacterial numbers remained high in the upper incisor tooth gingiva in gastrointestinal cancer patients who received open surgery. Additional procedures are likely needed to effectively reduce the number of bacteria in the gingival area associated with the upper anterior teeth.

Tumores del estroma gastrointestinal: Análisis de 40 casos / Gastrointestinal stromal tumors. Analysis of 40 cases

Los tumores del estroma gastrointestinal representan menos del 3% de los tumores digestivos. Se localizan principalmente en el estómago y el intestino delgado. El tratamiento radical es la resección quirúrgica. Cuando son inoperables o diseminados la administración de imatinib es el tratamiento de elección. La finalidad de este estudio retrospectivo fue describir las características de los pacientes con tumores del estroma gastrointestinal atendidos en nuestra institución en el período 2000-2015. Fueron analizados los casos de 40 pacientes consecutivos con diagnóstico de tumor del estroma gastrointestinal (edad media 58 años, rango 33-84). La supervivencia media a 5 años del total de pacientes fue 30.5%. Al diagnóstico, 30 (75%) tenían enfermedad localizada; de estos, 14 recibieron imatinib adyuvante y 15 seguimiento en observación. En este grupo, el intervalo libre de enfermedad fue 55 meses. En aquellos con enfermedad diseminada, el intervalo libre de progresión fue 30 meses.

Gastrointestinal stromal tumors represent less than 3% of all digestive tumors. They are primarily located in the stomach and the small intestine. The curative treatment is surgical resection. In the case of unresectable tumor or advanced disease, imatinib is the treatment of choice. The purpose of this retrospective study was to describe the characteristics of patients with gastrointestinal stromal tumors treated at our institution in the period 2000-2015. We analyzed 40 consecutive patients diagnosed with gastrointestinal stromal tumor (mean age 58-year old, range 33-84). The mean 5-year survival was 30.5%. At diagnosis, 30 patients had localized disease (75%); 14 of them received adjuvant imatinib and 15 follow-up on observation. In this group the disease-free interval was 55 months. In patients with advanced disease, the progression-free interval was 30 months.

Gastrectomía atípica laparoscópica en el tratamiento de GIST gástrico: Resultados a corto y mediano plazo / Laparoscopic atypical gastrectomy in the treatment of gastric GIST. Short-term and medium-term outcomes

Los tumores gastrointestinales del estroma son las neoplasias mesenquimatosas más frecuentes del tracto gastrointestinal. Numerosas investigaciones se han dirigido al tratamiento laparoscópico de los mismos. El propósito de este estudio es evaluar la seguridad y la eficacia de las gastrectomías atípicas en un hospital de alta complejidad de nuestro medio. En el período comprendido entre enero 2009 y diciembre 2015, 24 pacientes con sospecha de GIST gástrico fueron intervenidos quirúrgicamente vía laparoscópica, considerándose criterio de inclusión la ausencia de metástasis hepáticas y peritoneales a distancia, el tamaño tumoral < 5 cm de diámetro y la positividad del antígeno CD117 en los estudios inmunohistoquímicos. Se analizaron retrospectivamente las características clínico-patológicas, los resultados quirúrgicos, las complicaciones postoperatorias y los resultados oncológicos. Fueron incluidos en el estudio estadístico 14 pacientes. La edad promedio fue 60 años (10 mujeres y 4 hombres) y la hemorragia digestiva alta fue la sintomatología de diagnóstico más frecuente. El tiempo promedio de cirugía fue 113 minutos, con necesidad de conversión en un caso. No se registraron complicaciones mayores, reintervenciones ni reinternaciones. El tamaño tumoral promedio fue 41 mm, con márgenes quirúrgicos libres de enfermedad. El promedio de internación fue 3 días y el de seguimiento 44 meses, sin registro de recidivas tumorales. El abordaje laparoscópico a través de gastrectomías atípicas del GIST gástrico resultó una técnica segura y eficaz con buenos resultados a corto y mediano plazo en manos de cirujanos con experiencia.

Gastrointestinal stromal tumors are the most common mesenchymal neoplasms of the gastrointestinal tract. Recently, many studies have addressed the laparoscopic management of these tumors. The aim of this study was to evaluate the safety and efficacy of laparoscopic atypical gastrectomy in the resolution of these neoplasms. In the period between January 2009 and December 2015, 24 patients with suspected gastric GIST less than 5 cm in size underwent surgery under this approach. Abscense of peritoneal and liver metastases and immunohistochemistry expression of CD117 antigen were considered as inclusion criteria. We retrospectively analyzed clinical and histopathological characteristics, surgical outcomes, postoperative complications and oncological results. Statistical analysis included 14 patients. The mean age was 60 years (10 women and 4 men) and upper gastrointestinal bleeding was the chief complaint for consultation. Conversion to open surgery was necessary in one case and no major complications, readmissions or reoperations were recorded. The mean tumor size was 41 mm with negative resection margin in all samples. The mean hospital stay was 3 days and no tumor recurrences were recorded in 44 months of follow-up. Laparoscopic atypical gastrectomy for gastric GIST is a safe and effective technique with good outcomes in experienced hands.

Intususcepción gastroduodenal como presentación de un tumor del estroma gastrointestinal gástrico / Gastroduodenal intussusception as a presentation of gastric gastrointestinal stromal tumor

Objetivo Presentar un caso de GIST con presentación clínica poco usual. Caso clínico Presentamos una paciente de género femenino, de 70 años, con 5 días de dolor en hemiabdomen superior y vómitos; se le diagnóstica por TC de abdomen y pelvis con contraste una intususcepción gastroduodenal. Se ingresa a pabellón; confirmando diagnóstico, se realiza gastrectomía subtotal más Y de Roux. La biopsia diferida con inmunohistoquímica confirma un GIST gástrico con 2 mitosis cada 50 campos. Se decide manejo conservador y control anual con endoscopia digestiva alta. Buena evolución.

Aim To present a case of GIST with unusual clinical presentation. Case report We present a 70-year old female patient with 5 days of upper abdominal pain and vomiting, being diagnosed with a gastroduodenal intussusceptions by contrasted CT scan. She was admitted to the operating room, confirming the diagnosis and a subtotal gastrectomy with Roux-en-Y reconstruction was performed. A deferred biopsy with immunohistochemical confirmed GIST with 2 mitoses/50 high-powerfields. Conservative management was proposed and annual control with upper endoscopy decided. Satisfactory evolution.