UMBILICAL AND EPIGASTRIC HERNIA REPAIR: A SYSTEMATIC REVIEW.

BACKGROUND: Umbilical and epigastric hernias are among the most common hernias of the abdominal wall; however, there is a lack of standardization for their treatment. AIMS: To clarify the controversies regarding therapeutic possibilities, indications, and surgical techniques for umbilical and epigastric hernia repair. METHODS: A systematic review and qualitative analysis of randomized clinical trials published in the last 20 years, involving adults (aged 18 years and over) with umbilical and/or epigastric hernias, was performed by systematically searching the PubMed/Medline, Cochrane, SciELO, and LILACS databases. The risk of bias in individual studies was assessed using the Cochrane Risk of Bias Tool. RESULTS: Initially, 492 studies were selected and, subsequently, 15 randomized controlled clinical trials were chosen that met the inclusion criteria and underwent full reading and qualitative analysis, considering possible bias. CONCLUSIONS: This review concluded that it is evident the superiority of the use of meshes in the repair of epigastric/primary umbilical hernias with a defect larger than 1 cm, even in certain emergency situations. However, suture repair is a good option for patients with a defect smaller than 1 cm. In the laparoscopic approach, recent evidence points towards possible superiority in fixation with fibrin sealant, and fascial defect closure is recommended. In addition, due to a scarcity of randomized controlled trials with low risk of bias, further studies are needed on types, positioning and fixation techniques, as well as the real role of video-assisted laparoscopic surgery in the correction of hernias, especially umbilical.

ASYMPTOMATIC CHOLELITHIASIS: EXPECTANT OR CHOLECYSTECTOMY. A SYSTEMATIC REVIEW.

BACKGROUND: Asymptomatic cholelithiasis is a highly prevalent disease, and became more evident after the currently greater access to imaging tests. Therefore, it is increasingly necessary to analyse the risks and benefits of performing a prophylactic cholecystectomy. AIMS: To seek the best evidence in order to indicate prophylactic cholecystectomy or conservative treatment (clinical follow-up) in patients with asymptomatic cholelithiasis. METHODS: A systematic review was performed using the PubMed/Medline database, according to PRISMA protocol guidelines. The review was based on studies published between April 26, 2001 and January 07, 2022, related to individuals older than 18 years., The following terms/operators were used for search standardization: (asymptomatic OR silent) AND (gallstones OR cholelithiasis). RESULTS: We selected 18 studies eligible for inference production after applying the inclusion and exclusion criteria. Also, the Tokyo Guideline (2018) was included for better clarification of some topics less or not addressed in these studies. CONCLUSIONS: Most evidence point to the safety and feasibility of conservative treatment (clinical follow-up) of asymptomatic cholelithiasis. However, in post-cardiac transplant patients and those with biliary microlithiasis with low preoperative surgical risk, a prophylactic cholecystectomy is recommended. To establish these recommendations, more studies with better levels of evidence must be conducted.

Asymptomatic cholelithiasis: expectant or cholecystectomy. a systematic review / Colelitíase assintomática: expectante ou colecistectomia. revisão sistemática

ABSTRACT BACKGROUND: Asymptomatic cholelithiasis is a highly prevalent disease, and became more evident after the currently greater access to imaging tests. Therefore, it is increasingly necessary to analyse the risks and benefits of performing a prophylactic cholecystectomy. AIMS: To seek the best evidence in order to indicate prophylactic cholecystectomy or conservative treatment (clinical follow-up) in patients with asymptomatic cholelithiasis. METHODS: A systematic review was performed using the PubMed/Medline database, according to PRISMA protocol guidelines. The review was based on studies published between April 26, 2001 and January 07, 2022, related to individuals older than 18 years., The following terms/operators were used for search standardization: (asymptomatic OR silent) AND (gallstones OR cholelithiasis). RESULTS: We selected 18 studies eligible for inference production after applying the inclusion and exclusion criteria. Also, the Tokyo Guideline (2018) was included for better clarification of some topics less or not addressed in these studies. CONCLUSIONS: Most evidence point to the safety and feasibility of conservative treatment (clinical follow-up) of asymptomatic cholelithiasis. However, in post-cardiac transplant patients and those with biliary microlithiasis with low preoperative surgical risk, a prophylactic cholecystectomy is recommended. To establish these recommendations, more studies with better levels of evidence must be conducted.

RESUMO RACIONAL: A colelitíase assintomática é uma doença altamente prevalente, e atualmente tornou-se mais evidente, após o maior acesso a exames de imagem. Portanto, é cada vez mais necessário analisar os riscos e benefícios de realizar uma colecistectomia profilática. OBJETIVOS: Buscar as melhores evidências para indicar colecistectomia profilática ou tratamento conservador (acompanhamento clínico) em pacientes com colelitíase assintomática. MÉTODOS: Foi realizada revisão sistemática, no PubMed/Medline, de acordo com as diretrizes do protocolo PRISMA, selecionando estudos publicados entre 26/04/2001 e 01/07/2022, relacionados a indivíduos maiores de 18 anos, com padronização de busca usando os seguintes termos/operadores: (Assintomático OU Silencioso) E (Cálculos biliares OU colelitíase). RESULTADOS: Foram selecionados 18 estudos elegíveis após a aplicação dos critérios de inclusão e exclusão. Além disso, a Tokyo Guideline (2018) foi incluída para melhor esclarecimento de alguns tópicos menos ou não abordados nestes estudos. CONCLUSÕES: A maioria das evidências aponta para a segurança e viabilidade do tratamento conservador (acompanhamento clínico) da colelitíase assintomática. Entretanto, em pacientes com transplante pós-cardíaco e aqueles com microlitíase biliar com baixo risco cirúrgico pré-operatório, a colecistectomia profilática é recomendada. Para estabelecer completamente estas recomendações, mais estudos com melhores níveis de evidência devem ser conduzidos.

SEROUS CYSTADENOMA OF PANCREAS: WHY THERE IS LOW ACCURACY IN IMAGING EXAMS? / CISTOADENOMA SEROSO DE PÂNCREAS. POR QUE A ACURÁCIA É BAIXA AOS EXAMES DE IMAGEM?

AIM: Many patients with serous cystadenoma of the pancreas (SCP) underwent surgery due to diagnostic doubt. The aim of this study was to analyze the causes of low accuracy in diagnosing SCP. METHODS: This is a retrospective study of patients with SCP from a database of two hepatopancreatic biliary surgery outpatient clinics between 2006 and 2020. Patients with typical SCP lesions in imaging exams (e.g., tomography, magnetic resonance imaging [MRI], and endoscopic ultrasound [EUS]) and patients whose pathological testing confirmed this diagnosis were included. RESULTS: A total of 27 patients were included in this study. Most patients were women (85.18%), and the mean age was 63.4 years. Only one patient had typical pancreatitis symptoms. MRI was the most performed method (62.9%). The lesion was single in 88.9%, and the average size was 4 cm. The typical microcystic aspect was found in 66.6%. EUS was performed in 29.6% of cases. The mean carcinoembryonic antigen value in patients undergoing cyst puncture was 198.25 ng/mL. Surgical treatment was performed in 10 cases (37%). The cause of surgery in seven of these cases was due to a suspicion of mucinous cystadenoma based on an identification of atypical lesions (unilocular with or without septa and macrocystic) in imaging exams. A suspicion of intraductal papillary mucinous neoplasm with "worrying factors" was the indication for surgery in two cases. The last case underwent surgical treatment for a solid-looking lesion which was suspected of cancer. The complication rate ≥Clavien-Dindo 2 was 30%, and the clinically relevant pancreatic fistula rate (B and C) was 30%. Mortality was nil. CONCLUSION: The atypical morphological presentation of SCP, particularly unilocular and macrocystic lesions, is the main indication for surgery. Only the implementation of new, efficient, and reproducible diagnostic methods can reduce the number of unnecessary surgeries among these patients.

OBJETIVO: Apesar da recomendação atual que o cistoadenoma seroso deva ser tratado de forma conservadora, significativa parte dos pacientes com essa condição ainda é operada por dúvida diagnóstica. Analisar causas da baixa acurácia diagnóstica do cistoadenoma seroso. MÉTODOS: Estudo retrospectivo de portadores de cistoadenoma seroso de um banco de dados de dois ambulatórios de cirurgia hepatopancreaticobiliar entre 2006 e 2020. Foram incluídos pacientes com lesões típicas de cistoadenoma seroso aos exames de imagem (tomografia computadorizada, ressonância magnética e ecoendoscopia) e pacientes que o anatomopatológico confirmasse esse diagnóstico. RESULTADOS: 27 pacientes foram incluídos. 85,18% eram do sexo feminino. A idade média foi de 63,4 anos. Apenas um apresentava sintomas típicos de pancreatite. A Ressonância magnética foi o exame mais realizado (62,9%). A lesão era única em 88,9% e o tamanho médio foi 4 cm. O aspecto típico microcístico foi encontrado em 66,6% dos casos, os demais foram considerados atípicos. A ecoendoscopia foi realizada em 29,6%. O valor médio de antígeno carcinoembrionário nos pacientes submetidos à punção do cisto foi de 198,25 ng/mL. O tratamento cirúrgico foi realizado em 10 casos (37%). Em 7, a causa cirúrgica foi a suspeita do cistoadenoma mucinoso mediante identificação de lesões atípicas (unilocular com ou sem septos e macrocística). Em 2, a suspeita de neoplasia papilar intraductal mucinosa com "fatores preocupantes" foi a indicação cirúrgica. O último foi submetido à cirurgia por lesão de aspecto sólido e suspeita de câncer. O índice de complicações > ou = Clavien-Dindo 2 foi 30%, o índice de fístula pancreática clinicamente relevante (B e C) foi 30%. A mortalidade foi nula. CONCLUSÃO: A apresentação morfológica atípica do cistoadenoma seroso, particularmente lesões uniloculares e macrocísticas, é a principal responsável pela indicação cirúrgica. Apenas a implementação de novos, eficientes e reprodutíveis métodos diagnósticos poderá reduzir o número de cirurgias desnecessárias nesses pacientes.

Non-inflammatory pancreatic cysts: from diagnosis to treatment (97 cases series).

OBJECTIVE: to describe the implications of the diagnosis and treatment of non-inflammatory pancreatic cysts in a series of patients. METHODS: we included patients with pancreatic cysts ≥1.0 cm, excluding those with a presumptive diagnosis of a pseudocyst. Imaging tests, echoendoscopy, and histopathology determined the diagnosis of the type of cyst. We applied the guidelines of the International Association of Pancreatology, with some modifications, in patients with mucinous or indeterminate lesions. RESULTS: 97 adult patients participated in the study. A cystic neoplasm of the pancreas was diagnosed in 82.5% of cases. Diagnosis was mainly made by magnetic resonance (46% of cases). The two most common diagnoses were intraductal papillary mucinous neoplasm (43.3%) and serous cystadenoma (26%). Twenty-nine patients underwent surgery (33.3%). The most common surgical procedure was distal pancreatectomy associated with splenectomy in 19 cases (65.5%). Among the operated patients, 11 were diagnosed with cancer. None of the followed, non-operated patients had a diagnosis of cancer. CONCLUSIONS: magnetic resonance showed good accuracy, particularly in the diagnosis of intraductal papillary mucinous neoplasm. The guidelines of the International Association of Pancreatology, as applied in this study, showed a negative predictive value for cancer of 100%. A development of better diagnostic tests can reduce the number of unnecessary operations.

Meckel's Diverticulum Perforation by Foreign Body: A Case Report.

Meckel's diverticulum is the most common gastrointestinal congenital defect, which, although asymptomatic in adults, may present symptoms in obstruction, inflammation, bleeding and foreign body perforation. There are only 8 reported cases of Meckel's diverticulum perforation by chicken bone. We report a case of a 24-year-old man presenting a 2-day-history of periumbilical pain that shifted to the right lower quadrant in 24 hours. Clinical and laboratory findings led to an appendicitis diagnosis, followed by laparotomy. Normal appendix was found intraoperatively along with an incidental finding of an inflamed and perforated Meckel's diverticulum by chicken bone. Diverticulectomy and enteroanastomosis were performed and the patient had a successful recovery, being discharged after 5 days. Although rare, its clinical presentation might be similar to acute appendicitis, which restate the importance of collecting a detailed clinical history and examining the small bowel in order to investigate a possible Meckel's diverticulum complication in the differential diagnosis.

Importance of esophageal pH monitoring and manometry in indicating surgical treatment of gastroesophageal reflux disease.

OBJECTIVE: To demonstrate the need of performing esophageal pH monitoring and manometry in patients with clinical suspicion of Gastroesophageal reflux disease, as more accurate and practical complementary exams in the indication of surgical treatment. METHODS: A systematic review was carried out in the PubMed/Medline database, based on the recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol, selecting studies in humans, published in Portuguese, Spanish, and English, from January 1, 2009 to August 5, 2020. The following descriptors were used: "reflux gastroesophageal" AND "surgery" AND "surgical treatment" AND "esophageal manometry" OR "pH monitoring". After that, retrospective or prospective observational studies with a sample of less than 100 individuals, or with limited access, reports or case series, review articles, letters, comments, or book chapters were excluded. To facilitate the application of the exclusion criteria, the Rayyan management base was used. RESULTS: Out of the 676 studies found, 19 valid and eligible studies were selected to make inferences. CONCLUSIONS: Based on the best evidence, currently, considering national particularities, performing a 24-hour esophageal pH monitoring and esophageal manometry for all patients undergoing anti-reflux surgery.

THE ACCEPTANCE OF CHANGES IN THE MANAGEMENT OF PATIENTS WITH ACUTE PANCREATITIS AFTER THE REVISED ATLANTA CLASSIFICATION.

BACKGROUND: New recommendations for the management of patients with acute pancreatitis were set after the Atlanta Classification was revised in 2012. OBJECTIVE: The aim of the present systematic review is to assess whether these recommendations have already been accepted and implemented in daily medical practices. METHODS: A systematic literature review was carried out in studies conducted with humans and published in English and Portuguese language from 10/25/2012 to 11/30/2018. The search was conducted in databases such as PubMed/Medline, Cochrane and SciELO, based on the following descriptors/Boolean operator: "Acute pancreatitis" AND "Atlanta". Only Randomized Clinical Trials comprising some recommendations released after the revised Atlanta Classification in 2012 were included in the study. RESULTS: Eighty-nine studies were selected and considered valid after inclusion, exclusion and qualitative evaluation criteria application. These studies were stratified as to whether, or not, they applied the recommendations suggested after the Atlanta Classification revision. Based on the results, 68.5% of the studies applied the recommendations, with emphasis on the application of severity classification (mild, moderately severe, severe); 16.4% of them were North-American and 14.7% were Chinese. The remaining 31.5% just focused on comparing or validating the severity classification. CONCLUSION: Few studies have disclosed any form of acceptance or practice of these recommendations, despite the US and Chinese efforts. The lack of incorporation of these recommendations didn't enable harnessing the benefits of their application in the clinical practice (particularly the improvement of the communication among health professionals and directly association with the worst prognoses); thus, it is necessary mobilizing the international medical community in order to change this scenario.

Aceitação das mudanças no manejo dos pacientes com pancreatite aguda após a revisão da Classificação de Atlanta / The acceptance of changes in the management of patients with acute pancreatitis after the revised atlanta classification

ABSTRACT BACKGROUND: New recommendations for the management of patients with acute pancreatitis were set after the Atlanta Classification was revised in 2012. OBJECTIVE: The aim of the present systematic review is to assess whether these recommendations have already been accepted and implemented in daily medical practices. METHODS: A systematic literature review was carried out in studies conducted with humans and published in English and Portuguese language from 10/25/2012 to 11/30/2018. The search was conducted in databases such as PubMed/Medline, Cochrane and SciELO, based on the following descriptors/Boolean operator: "Acute pancreatitis" AND "Atlanta". Only Randomized Clinical Trials comprising some recommendations released after the revised Atlanta Classification in 2012 were included in the study. RESULTS: Eighty-nine studies were selected and considered valid after inclusion, exclusion and qualitative evaluation criteria application. These studies were stratified as to whether, or not, they applied the recommendations suggested after the Atlanta Classification revision. Based on the results, 68.5% of the studies applied the recommendations, with emphasis on the application of severity classification (mild, moderately severe, severe); 16.4% of them were North-American and 14.7% were Chinese. The remaining 31.5% just focused on comparing or validating the severity classification. CONCLUSION: Few studies have disclosed any form of acceptance or practice of these recommendations, despite the US and Chinese efforts. The lack of incorporation of these recommendations didn't enable harnessing the benefits of their application in the clinical practice (particularly the improvement of the communication among health professionals and directly association with the worst prognoses); thus, it is necessary mobilizing the international medical community in order to change this scenario.

RESUMO CONTEXTO: Após a revisão da Classificação de Atlanta, em 2012, foram estabelecidas novas recomendações no manejo dos pacientes com pancreatite aguda. OBJETIVO: Objetiva-se avaliar o grau de aceitação e implementação dessas recomendações na prática clínica. MÉTODOS: Foi realizada revisão sistemática da literatura com auxílio das bases: PubMed/Medline, Cochrane e SciELO, por meio de busca de estudos em humanos, publicados em inglês e português, no período de 25/10/2012 até 30/11/2018, utilizando os descritores e operador booleano: "Acute pancreatitis" E "Atlanta". Foram incluídos apenas estudos do tipo Ensaios Clínicos Randomizados que avaliaram alguma recomendação relacionada a revisão da Classificação de Atlanta após 2012. RESULTADOS: Foram selecionados 89 estudos após aplicação dos critérios de inclusão, exclusão e avaliação qualitativa. Esses foram estratificados quanto à aplicação ou não das recomendações propostas após a revisão da Classificação de Atlanta. Verificou-se que 68,5% dos estudos aplicaram essas recomendações, principalmente, na classificação da gravidade dos pacientes (leve, moderadamente grave, grave). Desses 16,4% eram estudos de origem norte-americana e 14,7% chineses. Os outros 31,5% limitaram-se a comparar ou apenas validar essa classificação de gravidade. CONCLUSÃO: Poucos estudos divulgaram alguma forma de implementação das novas recomendações, apesar dos esforços norte-americanos e chineses. A falta da aparente incorporação dessas recomendações na prática clínica, não permitiu o aproveitamento de suas vantagens (principalmente a melhora da comunicação entre os profissionais e estabelecimento da classificação e identificação precoce dos pacientes mais graves), sendo necessário toda a comunidade médica internacional se mobilizar de alguma forma para mudar esse cenário.

Importance of esophageal pH monitoring and manometry in indicating surgical treatment of gastroesophageal reflux disease

SUMMARY OBJECTIVE: To demonstrate the need of performing esophageal pH monitoring and manometry in patients with clinical suspicion of Gastroesophageal reflux disease, as more accurate and practical complementary exams in the indication of surgical treatment. METHODS: A systematic review was carried out in the PubMed/Medline database, based on the recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol, selecting studies in humans, published in Portuguese, Spanish, and English, from January 1, 2009 to August 5, 2020. The following descriptors were used: "reflux gastroesophageal" AND "surgery" AND "surgical treatment" AND "esophageal manometry" OR "pH monitoring". After that, retrospective or prospective observational studies with a sample of less than 100 individuals, or with limited access, reports or case series, review articles, letters, comments, or book chapters were excluded. To facilitate the application of the exclusion criteria, the Rayyan management base was used. RESULTS: Out of the 676 studies found, 19 valid and eligible studies were selected to make inferences. CONCLUSIONS: Based on the best evidence, currently, considering national particularities, performing a 24-hour esophageal pH monitoring and esophageal manometry for all patients undergoing anti-reflux surgery.

Cistoadenoma seroso de pâncreas. por que a acurácia é baixa aos exames de imagem? / Serous cystadenoma of pancreas: why there is low accuracy in imaging exams?

RESUMO - RACIONAL: Apesar da recomendação atual que o cistoadenoma seroso deva ser tratado de forma conservadora, significativa parte dos pacientes com essa condição ainda é operada por dúvida diagnóstica. OBJETIVO: Analisar causas da baixa acurácia diagnóstica do cistoadenoma seroso. MÉTODOS: Estudo retrospectivo de portadores de cistoadenoma seroso de um banco de dados de dois ambulatórios de cirurgia hepatopancreaticobiliar entre 2006 e 2020. Foram incluídos pacientes com lesões típicas de cistoadenoma seroso aos exames de imagem (tomografia computadorizada, ressonância magnética e ecoendoscopia) e pacientes que o anatomopatológico confirmasse esse diagnóstico. RESULTADOS: 27 pacientes foram incluídos. 85,18% eram do sexo feminino. A idade média foi de 63,4 anos. Apenas um apresentava sintomas típicos de pancreatite. A Ressonância magnética foi o exame mais realizado (62,9%). A lesão era única em 88,9% e o tamanho médio foi 4 cm. O aspecto típico microcístico foi encontrado em 66,6% dos casos, os demais foram considerados atípicos. A ecoendoscopia foi realizada em 29,6%. O valor médio de antígeno carcinoembrionário nos pacientes submetidos à punção do cisto foi de 198,25 ng/mL. O tratamento cirúrgico foi realizado em 10 casos (37%). Em 7, a causa cirúrgica foi a suspeita do cistoadenoma mucinoso mediante identificação de lesões atípicas (unilocular com ou sem septos e macrocística). Em 2, a suspeita de neoplasia papilar intraductal mucinosa com "fatores preocupantes" foi a indicação cirúrgica. O último foi submetido à cirurgia por lesão de aspecto sólido e suspeita de câncer. O índice de complicações > ou = Clavien-Dindo 2 foi 30%, o índice de fístula pancreática clinicamente relevante (B e C) foi 30%. A mortalidade foi nula. CONCLUSÃO: A apresentação morfológica atípica do cistoadenoma seroso, particularmente lesões uniloculares e macrocísticas, é a principal responsável pela indicação cirúrgica. Apenas a implementação de novos, eficientes e reprodutíveis métodos diagnósticos poderá reduzir o número de cirurgias desnecessárias nesses pacientes.

ABSTRACT - BACKGROUND: Many patients with serous cystadenoma of the pancreas (SCP) underwent surgery due to diagnostic doubt. AIM: The aim of this study was to analyze the causes of low accuracy in diagnosing SCP. METHODS: This is a retrospective study of patients with SCP from a database of two hepatopancreatic biliary surgery outpatient clinics between 2006 and 2020. Patients with typical SCP lesions in imaging exams (e.g., tomography, magnetic resonance imaging [MRI], and endoscopic ultrasound [EUS]) and patients whose pathological testing confirmed this diagnosis were included. RESULTS: A total of 27 patients were included in this study. Most patients were women (85.18%), and the mean age was 63.4 years. Only one patient had typical pancreatitis symptoms. MRI was the most performed method (62.9%). The lesion was single in 88.9%, and the average size was 4 cm. The typical microcystic aspect was found in 66.6%. EUS was performed in 29.6% of cases. The mean carcinoembryonic antigen value in patients undergoing cyst puncture was 198.25 ng/mL. Surgical treatment was performed in 10 cases (37%). The cause of surgery in seven of these cases was due to a suspicion of mucinous cystadenoma based on an identification of atypical lesions (unilocular with or without septa and macrocystic) in imaging exams. A suspicion of intraductal papillary mucinous neoplasm with "worrying factors" was the indication for surgery in two cases. The last case underwent surgical treatment for a solid-looking lesion which was suspected of cancer. The complication rate ≥Clavien-Dindo 2 was 30%, and the clinically relevant pancreatic fistula rate (B and C) was 30%. Mortality was nil. CONCLUSION: The atypical morphological presentation of SCP, particularly unilocular and macrocystic lesions, is the main indication for surgery. Only the implementation of new, efficient, and reproducible diagnostic methods can reduce the number of unnecessary surgeries among these patients.

Non-inflammatory pancreatic cysts: from diagnosis to treatment (97 cases series) / Cistos não inflamatórios de pâncreas: do diagnóstico ao tratamento (série de 97 casos)

ABSTRACT Objective: to describe the implications of the diagnosis and treatment of non-inflammatory pancreatic cysts in a series of patients. Methods: we included patients with pancreatic cysts ≥1.0 cm, excluding those with a presumptive diagnosis of a pseudocyst. Imaging tests, echoendoscopy, and histopathology determined the diagnosis of the type of cyst. We applied the guidelines of the International Association of Pancreatology, with some modifications, in patients with mucinous or indeterminate lesions. Results: 97 adult patients participated in the study. A cystic neoplasm of the pancreas was diagnosed in 82.5% of cases. Diagnosis was mainly made by magnetic resonance (46% of cases). The two most common diagnoses were intraductal papillary mucinous neoplasm (43.3%) and serous cystadenoma (26%). Twenty-nine patients underwent surgery (33.3%). The most common surgical procedure was distal pancreatectomy associated with splenectomy in 19 cases (65.5%). Among the operated patients, 11 were diagnosed with cancer. None of the followed, non-operated patients had a diagnosis of cancer. Conclusions: magnetic resonance showed good accuracy, particularly in the diagnosis of intraductal papillary mucinous neoplasm. The guidelines of the International Association of Pancreatology, as applied in this study, showed a negative predictive value for cancer of 100%. A development of better diagnostic tests can reduce the number of unnecessary operations.

RESUMO Objetivo: descrever as implicações do diagnóstico e tratamento dos cistos não inflamatórios do pâncreas em série de pacientes. Metódos: foram incluídos pacientes com cisto de pâncreas ≥1,0cm excluindo aqueles com diagnóstico presuntivo de pseudocisto. Exames de imagem, ecoendoscopia e anatomia-patológica determinaram o diagnóstico do tipo de cisto. As diretrizes da Associação Internacional de Pancreatologia foram aplicadas, com algumas modificações, nos pacientes com lesões mucinosas ou indeterminadas. Resultados: noventa e sete pacientes adultos participaram do estudo. A neoplasia cística de pâncreas foi diagnosticada em 82,5% dos casos. O diagnóstico foi feito principalmente por ressonância magnética (46% dos casos). Os dois diagnósticos mais frequentes foram a neoplasia papilar intraductal mucinosa (43,3%), e o cistoadenoma seroso (26%). Vinte e nove pacientes foram submetidos a operação (33,3%). O procedimento cirúrgico mais comum foi a pancreatectomia corpo-caudal associada à esplenectomia em 19 casos (65,5%). Entre os pacientes operados, 11 tiveram o diagnóstico de câncer. Nenhum dos pacientes seguidos teve o diagnóstico de câncer. Conclusões: a ressonância magnética apresentou boa acurácia, particularmente no diagnóstico da neoplasia papilar intraductal mucinosa. As diretrizes da Associação Internacional de Pancreatologia da forma que foram aplicadas no presente estudo, mostraram valor preditivo negativo para o câncer de 100%. O desenvolvimento de estratégias diagnósticas com melhor acurácia podem reduzir o número de cirurgias desnecessárias.

DIAGNOSIS, TREATMENT AND FOLLOW-UP OF BARRETT'S ESOPHAGUS: A SYSTEMATIC REVIEW.

BACKGROUND: Barrett's esophagus (BE) is a premalignant condition that raises controversy among general practitioners and specialists, especially regarding its diagnosis, treatment, and follow-up protocols. OBJECTIVE: This systematic review aims to present the particularities and to clarify controversies related to the diagnosis, treatment and surveillance of BE. METHODS: A systematic review was conducted on PubMed, Cochrane, and SciELO based on articles published in the last 10 years. PRISMA guidelines were followed and the search was made using MeSH and non-MeSH terms "Barrett" and "diagnosis or treatment or therapy or surveillance". We searched for complete randomized controlled clinical trials or Phase IV studies, carried out with individuals over 18 years old. RESULTS: A total of 42 randomized controlled trials were selected after applying all inclusion and exclusion criteria. A growing trend of alternative and safer techniques to traditional upper gastrointestinal endoscopy were identified, which could improve the detection of BE and patient acceptance. The use of chromoendoscopy-guided biopsy protocols significantly reduced the number of biopsies required to maintain similar BE detection rates. Furthermore, the value of BE chemoprophylaxis with esomeprazole and acetylsalicylic acid was relevant, as well as the establishment of protocols for the follow-up and endoscopic surveillance of patients with BE based predominantly on the presence and degree of dysplasia, as well as on the length of the follow-up affected by BE. CONCLUSION: Although further studies regarding the diagnosis, treatment and follow-up of BE are warranted, in light of the best evidence presented in the last decade, there is a trend towards electronic chromoendoscopy-guided biopsies for the diagnosis of BE, while treatment should encompass endoscopic techniques such as radiofrequency ablation. Risks of ablative endoscopic methods should be weighted against those of resective surgery. It is also important to consider lifetime endoscopic follow-up for both short and long term BE patients, with consideration to limitations imposed by a range of comorbidities. Unfortunately, there are no randomized controlled trials that have evaluated which is the best recommendation for BE follow-up and endoscopic surveillance (>1 cm) protocols, however, based on current International Guidelines, it is recommended esophagogastroduodenoscopy (EGD) every 5 years in BE without dysplasia with 1 up to 3 cm of extension; every 3 years in BE without dysplasia with >3 up to 10 cm of extension, every 6 to 12 months in BE with low grade dysplasia and, finally, EGD every 3 months after ablative endoscopic therapy in cases of BE with high grade dysplasia.

Diagnóstico, tratamento e seguimento do esôfago de Barrett: revisão sistemática / Diagnosis, treatment and follow-up of barretts esophagus: a systematic review

ABSTRACT BACKGROUND: Barrett's esophagus (BE) is a premalignant condition that raises controversy among general practitioners and specialists, especially regarding its diagnosis, treatment, and follow-up protocols. OBJECTIVE: This systematic review aims to present the particularities and to clarify controversies related to the diagnosis, treatment and surveillance of BE. METHODS: A systematic review was conducted on PubMed, Cochrane, and SciELO based on articles published in the last 10 years. PRISMA guidelines were followed and the search was made using MeSH and non-MeSH terms "Barrett" and "diagnosis or treatment or therapy or surveillance". We searched for complete randomized controlled clinical trials or Phase IV studies, carried out with individuals over 18 years old. RESULTS: A total of 42 randomized controlled trials were selected after applying all inclusion and exclusion criteria. A growing trend of alternative and safer techniques to traditional upper gastrointestinal endoscopy were identified, which could improve the detection of BE and patient acceptance. The use of chromoendoscopy-guided biopsy protocols significantly reduced the number of biopsies required to maintain similar BE detection rates. Furthermore, the value of BE chemoprophylaxis with esomeprazole and acetylsalicylic acid was relevant, as well as the establishment of protocols for the follow-up and endoscopic surveillance of patients with BE based predominantly on the presence and degree of dysplasia, as well as on the length of the follow-up affected by BE. CONCLUSION: Although further studies regarding the diagnosis, treatment and follow-up of BE are warranted, in light of the best evidence presented in the last decade, there is a trend towards electronic chromoendoscopy-guided biopsies for the diagnosis of BE, while treatment should encompass endoscopic techniques such as radiofrequency ablation. Risks of ablative endoscopic methods should be weighted against those of resective surgery. It is also important to consider lifetime endoscopic follow-up for both short and long term BE patients, with consideration to limitations imposed by a range of comorbidities. Unfortunately, there are no randomized controlled trials that have evaluated which is the best recommendation for BE follow-up and endoscopic surveillance (>1 cm) protocols, however, based on current International Guidelines, it is recommended esophagogastroduodenoscopy (EGD) every 5 years in BE without dysplasia with 1 up to 3 cm of extension; every 3 years in BE without dysplasia with >3 up to 10 cm of extension, every 6 to 12 months in BE with low grade dysplasia and, finally, EGD every 3 months after ablative endoscopic therapy in cases of BE with high grade dysplasia.

RESUMO CONTEXTO: O esôfago de Barrett (EB) é uma condição que aumenta o risco de ocorrência de displasias e câncer no esôfago, a qual apresenta inúmeras controvérsias entre médicos generalistas e até especialistas, em especial no que tange o seu diagnóstico, tratamento e seguimento. OBJETIVO: Tentar esclarecer as controvérsias relacionadas ao estabelecimento do diagnóstico, tratamento, seguimento e vigilância do EB. MÉTODOS: Foi realizado revisão sistemática da literatura fundamentada apenas em ensaios clínicos randomizados e controlados (completos ou em fase IV), em indivíduos maiores que 18 anos, publicados nos últimos 10 anos, por meio de busca, nas bases de dados: PubMed, Cochrane e SciELO (utilizando os termos MeSH e não-MeSH: "Barrett" no título AND diagnosis or treatment or therapy or surveillance" em todos os campos). RESULTADOS: Um total de 42 ensaios clínicos controlados e randomizados foram identificados e selecionados após aplicação dos critérios de inclusão e exclusão. Evidenciou-se, principalmente, o surgimento de técnicas seguras, alternativas à endoscopia digestiva alta (EDA) tradicional para aprimorar a detecção do esôfago de Barrett, associadas a boa aceitação por parte dos pacientes, quando realizadas por meio de acesso nasal. Ainda, o uso de protocolo de biópsias guiadas por cromoendoscopia eletrônica favoreceu reduzir significativamente o número de biópsias necessárias para alcançar as melhores taxas de identificação histológica do EB. Ademais, foi evidenciado que o uso de esomeprazol 40 mg 2x/dia associado ao ácido acetil salicílico 300 mg/dia pode ter efeito protetivo em relação ao desenvolvimento de câncer no EB, além de ser identificado protocolos de seguimento e vigilância endoscópica dos pacientes com EB >1 cm fundamentados, especialmente, no grau de displasia e comprimento do EB (EB sem displasia com 1 a 3 cm = EDA a cada 5 anos; EB sem displasia com >3 a 10 cm = EDA a cada 3 anos; EB com displasia de baixo grau = EDA a cada 6 a 12 meses; EB com displasia de alto grau = realização de terapia endoscópica ablativa e EDA a cada 3 meses). CONCLUSÃO: Foi verificado a necessidade do desenvolvimento de mais ensaios clínicos randomizados e controlados relacionados ao tema, especialmente no que tange o estabelecimento do seguimento e vigilância do EB, entretanto, na luz das melhores evidências apresentadas na última década, o diagnóstico de EB deve seguir, idealmente, protocolos de biópsias guiadas por cromoendoscopia eletrônica. Ademais, o tratamento deve ser fundamentado primeiramente em técnicas endoscópicas, especialmente aquelas terapias com radiofrequência, e quando associado a displasia de alto grau, deverá ser ponderado quanto aos riscos de se insistir em métodos endoscópicos ablativos ou considerar um tratamento cirúrgico ressectivo. Por fim, reforça-se a necessidade de todo paciente com EB >1 cm permanecer em seguimento endoscópico por toda a sua vida, conforme protocolos pré-estabelecidos, exceto se apresentar comorbidades limitantes que impediriam a realização de alguma conduta mais intervencionista. Infelizmente, não há ensaios clínicos randomizados que avaliaram qual é a melhor recomendação de protocolo para o seguimento endoscópico de EB (>1cm), porém, baseado nas atuais Guidelines Internacionais, é recomendado esofagogastroduodenoscopia (EGD) a cada 5 anos em EB sem displasia com 1 a 3 cm de extensão; a cada 3 anos em EB com displasia com 3 a 10 cm de extensão, a cada 6 a 12 meses em EB com displasia de baixo grau e, finalmente, EGD a cada 3 meses após terapia ablativa endoscópica nos casos de EB com displasia de alto grau.

Serous Pancreatic Cystadenoma with Compression of Wirsung's Duct.

Serous cystadenoma of the pancreas is a common cystic neoplasm typically of benign evolution that rarely communicates with the pancreatic ductal system. We present several images originating from two cases of serous cystadenoma of the pancreas which led to compression and dilatation of Wirsung's duct. These cases suggest that when the diagnosis of pancreatic microcystic lesion is detected, associated, or not associated with a central fibrous scar and a low carcinoembryonic antigen level in the aspirated fluid, the presence of dilatation of Wirsung's duct does not exclude the diagnosis of serous pancreatic cystadenoma.

Venous occlusion test applied to the tributaries of the superior mesenteric veins of the pancreas head infiltrated by tumor.

A 64-year-old white woman presented with cholestatic jaundice, weight loss and a solid lesion in the pancreas head. At multislice computed tomography, a superior mesenteric vein (SMV) and one of it tributaries showed signs of tumor infiltration. At surgery, a venous occlusion test applied to the infiltrated tributary of the SMV showed immediate venous congestion in two-thirds of the distal small intestine. No reconstruction attempt was made due to the small size of the vessel. A biliodigestive anastomosis and lymph node biopsy was performed. The herein assessed case report suggests that the ileal tributary occlusion test applied to patients presenting pancreatic adenocarcinoma, with invasion of the tributaries of the SMV, may be effective in contraindicating resection procedures.

HYPERVASCULAR LIVER LESIONS IN RADIOLOGICALLY NORMAL LIVER.

Background: The hypervascular liver lesions represent a diagnostic challenge. Aim: To identify risk factors for cancer in patients with non-hemangiomatous hypervascular hepatic lesions in radiologically normal liver. Method: This prospective study included patients with hypervascular liver lesions in radiologically normal liver. The diagnosis was made by biopsy or was presumed on the basis of radiologic stability in follow-up period of one year. Cirrhosis or patients with typical imaging characteristics of haemangioma were excluded. Results: Eighty-eight patients were included. The average age was 42.4. The lesions were unique and were between 2-5 cm in size in most cases. Liver biopsy was performed in approximately 1/3 of cases. The lesions were benign or most likely benign in 81.8%, while cancer was diagnosed in 12.5% of cases. Univariate analysis showed that age >45 years (p< 0.001), personal history of cancer (p=0.020), presence of >3 nodules (p=0.003) and elevated alkaline phosphatase (p=0.013) were significant risk factors for cancer. Conclusion: It is safe to observe hypervascular liver lesions in normal liver in patients up to 45 years, normal alanine aminotransaminase, up to three nodules and no personal history of cancer. Lesion biopsies are safe in patients with atypical lesions and define the treatment to be established for most of these patients.

Racional: As lesões hepáticas hipervasculares representam um desafio diagnóstico. Objetivo: Identificar fatores de risco para câncer em pacientes portadores de lesão hepática hipervascular não-hemangiomatosa em fígado radiologicamente normal. Método: Estudo prospectivo que incluiu pacientes com lesões hepáticas hipervasculares em que o diagnóstico final foi obtido por exame anatomopatológico ou, presumido a partir de seguimento mínimo de um ano. Diagnóstico prévio de cirrose ou radiológico de hemangioma foram considerados critérios de exclusão. Resultados: Oitenta e oito pacientes foram incluídos. A relação mulher/homem foi de 5,3/1. A idade média foi de 42,4 anos. Na maior parte das vezes as lesões hepáticas foram únicas e com tamanho entre 2-5 cm. Em aproximadamente 1/3 dos casos foi realizada biópsia hepática. Em 81,8% dos casos as lesões eram benignas ou provavelmente benignas enquanto que em 12,5% dos casos o diagnóstico foi de câncer. A análise univariada mostrou que idade superior a 45 anos (p<0,001), antecedente familiar pessoal de câncer (p=0,020), presença de mais de três nódulos (p=0,003) e elevação da alanina aminotransaminase (p=0,013) foram fatores de risco relevantes para o câncer. Conclusões: È indicado observar lesões hepáticas hipervasculares em fígado normal em pacientes com até 45 anos, alanina aminotransaminase normal, com até três nódulos e sem antecedente pessoal de câncer. Para os demais com lesões atípicas, a biópsia da lesão é segura e define na maior parte dos pacientes o tratamento a ser instituído.

Hypervascular liver lesions in radiologically normal liver / Lesão hepática hipervascular em fígado radiologicamente normal

ABSTRACT Background: The hypervascular liver lesions represent a diagnostic challenge. Aim: To identify risk factors for cancer in patients with non-hemangiomatous hypervascular hepatic lesions in radiologically normal liver. Method: This prospective study included patients with hypervascular liver lesions in radiologically normal liver. The diagnosis was made by biopsy or was presumed on the basis of radiologic stability in follow-up period of one year. Cirrhosis or patients with typical imaging characteristics of haemangioma were excluded. Results: Eighty-eight patients were included. The average age was 42.4. The lesions were unique and were between 2-5 cm in size in most cases. Liver biopsy was performed in approximately 1/3 of cases. The lesions were benign or most likely benign in 81.8%, while cancer was diagnosed in 12.5% of cases. Univariate analysis showed that age >45 years (p< 0.001), personal history of cancer (p=0.020), presence of >3 nodules (p=0.003) and elevated alkaline phosphatase (p=0.013) were significant risk factors for cancer. Conclusion: It is safe to observe hypervascular liver lesions in normal liver in patients up to 45 years, normal alanine aminotransaminase, up to three nodules and no personal history of cancer. Lesion biopsies are safe in patients with atypical lesions and define the treatment to be established for most of these patients.

RESUMO Racional: As lesões hepáticas hipervasculares representam um desafio diagnóstico. Objetivo: Identificar fatores de risco para câncer em pacientes portadores de lesão hepática hipervascular não-hemangiomatosa em fígado radiologicamente normal. Método: Estudo prospectivo que incluiu pacientes com lesões hepáticas hipervasculares em que o diagnóstico final foi obtido por exame anatomopatológico ou, presumido a partir de seguimento mínimo de um ano. Diagnóstico prévio de cirrose ou radiológico de hemangioma foram considerados critérios de exclusão. Resultados: Oitenta e oito pacientes foram incluídos. A relação mulher/homem foi de 5,3/1. A idade média foi de 42,4 anos. Na maior parte das vezes as lesões hepáticas foram únicas e com tamanho entre 2-5 cm. Em aproximadamente 1/3 dos casos foi realizada biópsia hepática. Em 81,8% dos casos as lesões eram benignas ou provavelmente benignas enquanto que em 12,5% dos casos o diagnóstico foi de câncer. A análise univariada mostrou que idade superior a 45 anos (p<0,001), antecedente familiar pessoal de câncer (p=0,020), presença de mais de três nódulos (p=0,003) e elevação da alanina aminotransaminase (p=0,013) foram fatores de risco relevantes para o câncer. Conclusões: È indicado observar lesões hepáticas hipervasculares em fígado normal em pacientes com até 45 anos, alanina aminotransaminase normal, com até três nódulos e sem antecedente pessoal de câncer. Para os demais com lesões atípicas, a biópsia da lesão é segura e define na maior parte dos pacientes o tratamento a ser instituído.

IMMEDIATE COMPLICATIONS AFTER 88 HEPATECTOMIES - BRAZILIAN CONSECUTIVE SERIES.

Background: Hepatectomies have been increasingly recommended and performed in Brazil; they present great differences related to immediate complications. Aim: Assessing the immediate postoperative complications in a series of 88 open liver resections. Method: Prospective database of patients subjected to consecutive hepatectomies over nine years. The post-hepatectomy complications were categorized according to the Clavien-Dindo classification; complications presenting grade equal to or greater than 3 were considered major complications. Hepatic resections involving three or more resected liver segments were considered major hepatectomies. Results: Eighty-four patients were subjected to 88 hepatectomies, mostly were minor liver resections (50 cases, 56.8%). Most patients had malignant diseases (63 cases; 71.6%). The mean hospitalization time was 10.9 days (4-43). Overall morbidity and mortality rates were 37.5% and 6.8%, respectively. The two most common immediate general complications were intra-peritoneal collections (12.5%) and pleural effusion (12.5%). Bleeding, biliary fistula and liver failure were identified in 6.8%, 4.5% and 1.1% of the cases, respectively, among the hepatectomy-specific complications. Conclusion: The patients operated in the second half of the series showed better results, which were apparently influenced by the increased surgical expertise, by the modification of the hepatic parenchyma section method and by the increased organ preservation.

Racional: No Brasil as hepatectomias têm sido cada vez mais indicadas e realizadas, apresentando grandes diferenças relacionadas às complicações imediatas. Objetivo: Avaliar as complicações pós-operatórias imediatas em uma série de 88 ressecções hepáticas abertas. Método: Foi utilizada uma base de dados prospectiva de pacientes submetidos à hepatectomias consecutivas em nove anos. As complicações pós-hepatectomia seguiram a Classificação de Clavien-Dindo, sendo consideradas complicações maiores aquelas as quais apresentaram grau igual ou maior que 3. Foram consideradas hepatectomias maiores as ressecções hepáticas que envolveram três ou mais segmentos hepáticos ressecados. Resultados: Oitenta e quatro pacientes foram submetidos a 88 hepatectomias, sendo a maioria ressecções hepáticas menores (50 casos; 56,8%). A maior parte dos pacientes apresentou doença maligna (63 casos; 71,6%). O tempo médio de internação foi de 10,9 dias (4-43). A taxa de morbidade e mortalidade global foi, respectivamente, de 37,5% e 6,8%. As duas complicações gerais imediatas mais frequentes foram as coleções intraperitoneais (12,5%) e o derrame pleural (12,5%). Já as complicações específicas das hepatectomias - sangramento, fístula biliar e insuficiência hepática - foram respectivamente de 6,8%, 4,5% e 1,1% dos casos. Conclusão: Os pacientes operados na segunda metade da presente casuística tiveram melhores resultados influenciados, aparentemente, pela maior experiência cirúrgica, modificação do método de secção do parênquima hepático e maior preservação do fígado.

Immediate complications after 88 hepatectomies - brazilian consecutive series / Complicações imediatas após 88 hepatectomias - série consecutiva brasileira

ABSTRACT Background: Hepatectomies have been increasingly recommended and performed in Brazil; they present great differences related to immediate complications. Aim: Assessing the immediate postoperative complications in a series of 88 open liver resections. Method: Prospective database of patients subjected to consecutive hepatectomies over nine years. The post-hepatectomy complications were categorized according to the Clavien-Dindo classification; complications presenting grade equal to or greater than 3 were considered major complications. Hepatic resections involving three or more resected liver segments were considered major hepatectomies. Results: Eighty-four patients were subjected to 88 hepatectomies, mostly were minor liver resections (50 cases, 56.8%). Most patients had malignant diseases (63 cases; 71.6%). The mean hospitalization time was 10.9 days (4-43). Overall morbidity and mortality rates were 37.5% and 6.8%, respectively. The two most common immediate general complications were intra-peritoneal collections (12.5%) and pleural effusion (12.5%). Bleeding, biliary fistula and liver failure were identified in 6.8%, 4.5% and 1.1% of the cases, respectively, among the hepatectomy-specific complications. Conclusion: The patients operated in the second half of the series showed better results, which were apparently influenced by the increased surgical expertise, by the modification of the hepatic parenchyma section method and by the increased organ preservation.

RESUMO Racional: No Brasil as hepatectomias têm sido cada vez mais indicadas e realizadas, apresentando grandes diferenças relacionadas às complicações imediatas. Objetivo: Avaliar as complicações pós-operatórias imediatas em uma série de 88 ressecções hepáticas abertas. Método: Foi utilizada uma base de dados prospectiva de pacientes submetidos à hepatectomias consecutivas em nove anos. As complicações pós-hepatectomia seguiram a Classificação de Clavien-Dindo, sendo consideradas complicações maiores aquelas as quais apresentaram grau igual ou maior que 3. Foram consideradas hepatectomias maiores as ressecções hepáticas que envolveram três ou mais segmentos hepáticos ressecados. Resultados: Oitenta e quatro pacientes foram submetidos a 88 hepatectomias, sendo a maioria ressecções hepáticas menores (50 casos; 56,8%). A maior parte dos pacientes apresentou doença maligna (63 casos; 71,6%). O tempo médio de internação foi de 10,9 dias (4-43). A taxa de morbidade e mortalidade global foi, respectivamente, de 37,5% e 6,8%. As duas complicações gerais imediatas mais frequentes foram as coleções intraperitoneais (12,5%) e o derrame pleural (12,5%). Já as complicações específicas das hepatectomias - sangramento, fístula biliar e insuficiência hepática - foram respectivamente de 6,8%, 4,5% e 1,1% dos casos. Conclusão: Os pacientes operados na segunda metade da presente casuística tiveram melhores resultados influenciados, aparentemente, pela maior experiência cirúrgica, modificação do método de secção do parênquima hepático e maior preservação do fígado.