Colangiopancreatografia endoscópica retrógrada transgástrica laparoscópica após cirurgia bariátrica / Laparoscopic transgastric endoscopic retrograde cholangiopancreatography after bariatric surgery

Access to the gastric remnant and duodenum is lost after Roux-en-Y gastric bypasses for morbid obesity. Laparoscopic transgastric endoscopic retrograde cholangiopancreatography has recently been described to manage biliary problems in such cases. We describe the first brazilian case of management of choledocholithiasis after a Roux-en-Y gastric bypass using this approach.

A comparison of hand-assisted and pure laparoscopic techniques in live donor nephrectomy

PURPOSE: To compare hand-assisted laparoscopic donor nephrectomy and pure laparoscopic live donor nephrectomy techniques in live donor nephrectomy. METHODS: In this retrospective study, we included all patients submitted to hand-assisted laparoscopic donor nephrectomy and pure laparoscopic live donor nephrectomy between May 2002 and December 2007. The operative data and post-operative courses were reviewed. Information was collected on the operative time, warm ischemia time, estimated blood loss, intra-operative complications, time to first oral intake, length of hospital stay, and post-operative complications. The data were analyzed using Student's t -tests and Fisher exact tests as appropriate, with statistical significance defined as p < 0.05. RESULTS: The means of the operative duration, warm ischemia time and intra-operative bleeding were 83 min, 3.6 min and 130.9 cc, respectively, for hand-assisted laparoscopic donor nephrectomy, and 78.4 min, 2.5 min and 98.9 cc, respectively, for pure laparoscopic live donor nephrectomy (p=0.29, p<0.0001 and p=0.08, respectively). Intra-operative complications occurred in 6 percent of patients submitted to hand-assisted laparoscopic donor nephrectomy and in 4.5 percent of those submitted to pure laparoscopic live donor nephrectomy (p=0.68). Only one patient from each group required conversion to open surgery; one person receiving hand-assisted laparoscopic donor nephrectomy had bleeding and one person receiving pure laparoscopic live donor nephrectomy had low carbon dioxide levels during the warm ischemia period. Compared with patients receiving hand-assisted laparoscopic donor nephrectomy, patients submitted to pure laparoscopic live donor nephrectomy were able to take their first meal earlier (12.5 vs. 9.2 hours, p=0.046), were discharged home sooner (2.8 vs. 1.4 days, p<0.0001) and had fewer post-operative complications (7.5 percent vs. 0.6 percent, p=0.04). CONCLUSIONS: Pure laparoscopic live...

Uso de balão intra-hepático para controle temporário da hemorragia em lesão da veia cava retro-hepática / Intrahepatic balloon tamponade for temporary control of retrohepatic vena cava injury bleeding

Juxtahepatic veins, retrohepatic vena cava or major hepatic veins injuries carry a very high mortality rate regardless the technique used for its repair. Isolated survivor reports have for the most part been managed by vascular isolation techniques, usually with atriocaval shunt. We report one case with a unique management technique in a patient who sustained gunshot wound to the retrohepatic vena cava. Hemorrhage control had been obtained by intrahepatic balloon tamponade after others maneuvers have failed. The balloon was left in situ for two days as damaged control laparotomy principles and planned reoperation has been chosen.

Gravidez após cirurgia bariátrica / Pregnancy following bariatric surgery

A obesidade é uma condição crônica que tem se tornado prevalente ao redor do mundo. Os tratamentos clínicos incluem dieta, exercícios, alteração comportamental e uso de medicações. A cirurgia deve ser reservada para os pacientes obesos mórbidos que não respondem às terapias não invasivas para perda de peso. Durante as últimas décadas, a cirurgia bariátrica se expandiu rapidamente e cada vez mais mulheres jovens estão procurando esta forma de tratamento, o que pode causar um aumento no número de gestações após a perda de peso. A gravidez após a cirurgia bariátrica nos traz uma série de questionamentos e preocupações a respeito da gestante e de seu feto. A suplementação nutricional e a monitorização intensiva antes, durante e após a gravidez podem ajudar a evitar complicações relacionadas à nutrição e melhorar a saúde materno-fetal, e os obstetras devem estar preparados para lidar com esse tipo de paciente, que será cada vez mais freqüente na prática diária em um futuro próximo.

Papel da laparoscopia no trauma abdominal penetrante / The role of laparoscopy in penetrating abdominal trauma

OBJETIVO: O papel da laparoscopia na redução da taxa de laparotomias não-terapêuticas e da morbidade em pacientes vítimas de trauma abdominal penetrante tem sido amplamente discutido durante os últimos anos. O objetivo do presente estudo é relatar a experiência inicial de um hospital universitário no manejo laparoscópico de pacientes com trauma abdominal penetrante. MÉTODO: Durante um período de três anos, a laparoscopia foi realizada em 37 pacientes vítimas de trauma abdominal penetrante, hemodinamicamente estáveis. Os prontuários médicos foram revisados e os parâmetros analisados foram as indicações do procedimento, lesões associadas, necessidade de conversão, tempo de permanência hospitalar e complicações. RESULTADOS: Houve 18 (48,6 por cento) casos de laparoscopias diagnósticas (LD) positivas e 19 (51,4 por cento) negativas. Dos pacientes com LD positiva, oito (44,4 por cento) foram submetidos à laparotomia exploradora com finalidade terapêutica ou para melhor delineamento da lesão. Houve 10 (55,6 por cento) LD positivas nas quais não foi realizada conversão para cirurgia aberta. Quatro pacientes apresentaram lesões reparáveis laparoscopicamente, sendo realizado hepatorrafia (n=2) e frenorrafia (n=2). Os outros seis pacientes apresentavam lesões isoladas sem sangramento ativo, e a laparotomia não-terapêutica foi evitada. Os pacientes receberam dieta no primeiro dia de pós-operatório e o tempo médio de hospitalização foi de 3,8 dias. CONCLUSÕES: Nossa experiência inicial confirma que a laparoscopia é um bom método de avaliação e tratamento no trauma penetrante. A morbidade relacionada à laparotomias desnecessárias pode ser minimizada quando o procedimento é bem indicado, e o tratamento pode ser realizado com sucesso em casos selecionados.

BACKGROUND: The role of laparoscopy in reducing the rate of non-therapeutic laparotomies and the morbidity in patients sustaining penetrating abdominal trauma has been widely discussed over the last years. The aim of this article is to report the initial experience from a university hospital in the laparoscopic management of penetrating abdominal traumas. METHODS: In a 3-year period, laparoscopy was performed in 37 patients who were hemodynamically stable and sustained penetrating abdominal trauma. Medical records were reviewed and the evaluation was conducted to determine indications for laparoscopy, associated injuries, the need for exploration, lenght of hospital stay and complications. RESULTS: There were 18 (48.6 percent) positive and 19 (51.4 percent) negative diagnostic laparoscopies (DL). In patients with positive DL, 8 (44.4 percent) underwent exploratory laparotomy. In this group, all of them had either therapeutic laparotomy or laparotomy for better lesion identification. There were 10 (55.6 percent) positive DLs, in whom laparotomy was not performed. Four of them had their injuries repaired laparocopically, hepatorraphy (n=2) and diaphragmatic repairs (n=2). The other ones had isolated nonbleeding injuries, and nontherapeutic laparotomy was successfully avoided. Patients were allowed a diet in the first postoperative day and the mean postoperative hospital stay was 3.8 days. CONCLUSION: Our initial experience confirms that laparoscopy is a good method of evaluation and treatment for penetrating trauma. The morbidity from an unnecessary laparotomy may be minimized when the procedure is well indicated, and treatment can be performed successfully in selected cases.