High versus low mean arterial pressure target in liver transplant patients. An open, controlled, single-center, randomized clinical trial - Protocol and methods (LIVER-PAM).

OBJECTIVE: To explain the rationale and protocol of the methods and analyses to be used in the LIVER-PAM randomized clinical trial, which seeks to understand whether a higher mean arterial pressure is capable of reducing the incidence of renal dysfunction postoperatively after liver transplantation. METHODS: LIVER-PAM is an open-label, randomized, controlled, singlecenter clinical trial. Patients randomized to the intervention group will have a mean arterial pressure of 85 - 90mmHg in the initial 24 hours of postoperative management, while patients in the control group will have a mean arterial pressure of 65 - 70mmHg in the same period. A sample of 174 patients will be required to demonstrate a 20% reduction in the absolute incidence of renal dysfunction, with a power of 80% and an alpha of 0.05. CONCLUSION: If a 20% reduction in the absolute incidence of renal dysfunction in the postoperative period of liver transplantation is achieved with higher target mean arterial pressure in the first 24 hours, this would represent an inexpensive and simple therapy for improving current outcomes in the management of liver transplant patients.ClinicalTrials.gov Registry: NCT05068713.

Small bowel transplantation in outbred rats / Transplante de intestino delgado em ratos não-isogênicos

PURPOSE: To investigate the clinical evolution of orthotopic small bowel transplantation in outbred rats. METHODS: Seventy-two outbred Wistar rats weighting from 250 to 300g were used as donor and recipient in 36 consecutives ortothopic small intestine transplantation without immunosuppression. The graft was transplanted into the recipient using end-to-side aortic and portacaval microvascular anastomosis. Procedure duration, animal clinical course and survival were evaluated. Survival shorter than four days was considered technical failure. Recipients were sacrificed with signs of severe graft rejection or survival longer than 120 days. Necropsies were performed in all recipients to access histopathological changes in the graft. RESULTS: Median time for the procedure was 107 minutes. Six recipients (16.7 percent) presented technical failure. Twenty-seven recipients were sacrificed due to rejection, being nineteen (52.7 percent) between 7th and 15th postoperative day and eight (22.2 percent) between 34th and 47th postoperative day. Graft histology confirmed severe acute cellular rejection in those recipients. Uneventful evolution and survival longer than 120 days without rejection were observed in three recipients (8.3 percent). CONCLUSION: Intestinal transplantation in outbred rats without immunosuppressant regiment accomplishes variable clinical evolution.

OBJETIVO: Investigar a evolução clínica do transplante de intestino delgado ortotópico em ratos não-isogênicos. MÉTODOS: Setenta e dois ratos Wistar não-isogênicos, com peso variando entre 250 e 300g, foram utilizados como doadores e receptores em 36 transplantes ortotópicos de intestino delgado sem regime de imunossupressão. Os enxertos foram implantados nos receptores por meio de anastomose microvascular término-lateral aorta-aorta e porto-cava. A duração do procedimento, evolução clínica dos animais e sobrevida foram avaliados. Sobrevida menor que quatro dias foi considerada falha técnica. Os receptores foram sacrificados quando apresentaram sinais de rejeição grave do enxerto ou sobrevida maior que 120 dias. Necropsias foram realizadas em todos os receptores para avaliar alterações histopatológicas no enxerto. RESULTADOS: O tempo médio para o procedimento foi de 107 minutos. Seis receptores (16,7 por cento) apresentaram falha técnica Vinte e sete receptores (75 por cento) foram sacrificados por rejeição sendo dezenove (52,7 por cento) entre o 7º e 15º dia de pós-operatório e oito (22,2 por cento) entre o 34º e 47º. Análise histopatológica confirmou rejeição celular aguda severa nesses recipientes. Evolução sem complicações e sobrevida maior que 120 dias sem sinais de rejeição foi observada em três receptores (8,3 por cento). CONCLUSÃO: O transplante de intestino delgado ortotópico em ratos Wistar não-isogênicos sem regime de imunossupressão apresenta evolução clínica variada.

Small bowel transplantation in outbred rats.

PURPOSE: To investigate the clinical evolution of orthotopic small bowel transplantation in outbred rats. METHODS: Seventy-two outbred Wistar rats weighting from 250 to 300g were used as donor and recipient in 36 consecutives ortothopic small intestine transplantation without immunosuppression. The graft was transplanted into the recipient using end-to-side aortic and portacaval microvascular anastomosis. Procedure duration, animal clinical course and survival were evaluated. Survival shorter than four days was considered technical failure. Recipients were sacrificed with signs of severe graft rejection or survival longer than 120 days. Necropsies were performed in all recipients to access histopathological changes in the graft. RESULTS: Median time for the procedure was 107 minutes. Six recipients (16.7%) presented technical failure. Twenty-seven recipients were sacrificed due to rejection, being nineteen (52.7%) between 7(th) and 15(th) postoperative day and eight (22.2%) between 34(th) and 47(th) postoperative day. Graft histology confirmed severe acute cellular rejection in those recipients. Uneventful evolution and survival longer than 120 days without rejection were observed in three recipients (8.3%). CONCLUSION: Intestinal transplantation in outbred rats without immunosuppressant regiment accomplishes variable clinical evolution.

Beneficial effects of N-acetyl cysteine on pancreas and kidney following experimental pancreatic ischemia-reperfusion in rats.

OBJECTIVE: To evaluate the protective effects of N-acetyl cysteine on the pancreas and kidney after pancreatic ischemia reperfusion injury in a rat model. METHODS AND MATERIALS: Pancreatic ischemia reperfusion was performed in Wistar rats for 1 hour. Revascularization was achieved followed by 4 h of reperfusion. A total of 24 animals were divided into four groups: Group 1: sham; Group 2: pancreatic ischemia reperfusion without treatment; Group 3: pancreatic ischemia reperfusion plus N-acetyl cysteine intravenously; and Group 4: pancreatic ischemia reperfusion plus N-acetyl cysteine per os. Blood and tissue samples were collected after reperfusion. RESULTS: There were significant differences in amylase levels between Group 1 (6.11+/-0.55) and Group 2 (10.30+/-0.50) [p=0.0002] as well as between Group 2 (10.30+/-0.50) and Group 4 (7.82+/-0.38) [p=0.003]; creatinine levels between Group 1 (0.52 +/- 0.07) and Group 2 (0.77+/-0.18) [p=0.035] as well as between Group 2 (0.77+/-0.18) and Group 3 (0.48+/-0.13) [p=0.012]; and pancreatic tissue thiobarbituric acid reactive substance levels between Group 1 (1.27+/-0.96) and Group 2 (2.60+/-3.01) [p=0.026] as well as between Group 2 (2.60+/-3.01) and Group 4 (0.52+/-0.56) [p=0.002]. A decrease in pancreatic tissue GST-alpha3 gene expression was observed in Group 2 in comparison to Group 1 (p =0.006), and an increase was observed in Groups 3 and 4 when compared to Group 2 (p= 0.025 and p=0.010, respectively). CONCLUSION: This study provides evidence that N-acetyl cysteine has a beneficial effect on pancreatic ischemia reperfusion injury and renal function in a rat model.

Beneficial effects of n-acetyl cysteine on pancreas and kidney following experimental pancreatic ischemia-reperfusion in rats

OBJECTIVE: To evaluate the protective effects of N-acetyl cysteine on the pancreas and kidney after pancreatic ischemia reperfusion injury in a rat model. METHODS AND MATERIALS: Pancreatic ischemia reperfusion was performed in Wistar rats for 1 hour. Revascularization was achieved followed by 4 h of reperfusion. A total of 24 animals were divided into four groups: Group 1: sham; Group 2: pancreatic ischemia reperfusion without treatment; Group 3: pancreatic ischemia reperfusion plus N-acetyl cysteine intravenously; and Group 4: pancreatic ischemia reperfusion plus N-acetyl cysteine per os. Blood and tissue samples were collected after reperfusion. RESULTS: There were significant differences in amylase levels between Group 1 (6.11±0.55) and Group 2 (10.30±0.50) [p=0.0002] as well as between Group 2 (10.30±0.50) and Group 4 (7.82±0.38) [p=0.003]; creatinine levels between Group 1 (0.52 ± 0.07) and Group 2 (0.77±0.18) [p=0.035] as well as between Group 2 (0.77±0.18) and Group 3 (0.48±0.13) [p=0.012]; and pancreatic tissue thiobarbituric acid reactive substance levels between Group 1 (1.27±0.96) and Group 2 (2.60±3.01) [p=0.026] as well as between Group 2 (2.60±3.01) and Group 4 (0.52±0.56) [p=0.002]. A decrease in pancreatic tissue GST-á3 gene expression was observed in Group 2 in comparison to Group 1 (p =0.006), and an increase was observed in Groups 3 and 4 when compared to Group 2 (p= 0.025 and p=0.010, respectively). CONCLUSION: This study provides evidence that N-acetyl cysteine has a beneficial effect on pancreatic ischemia reperfusion injury and renal function in a rat model.

Transplante intestinal em ratos utilizando nova técnica de microanastomose sem sutura com cola e molde tubular (Cuff-Glue) / Intestinal transplantation in rats using the new technique of Cuff-Glue sutureless microanastomosis

Introdução: A necessidade de sutura microvascular complexa dificulta a pesquisa do transplante intestinal no rato. A técnica de microanastomose com dispositivo tubular (cuff) é simples, porém, a persistência do dispositivo na anastomose desencadeia reação de corpo estranho e trombose. Neste trabalho descrevemos um modelo de transplante intestinal no rato com nova técnica de anastomose sem sutura com cuff e cola...

Introduction: Microsurgical difficulties hamper intestinal transplantation in the rat. Cuff anastomosis is a simple microanastomosis technique, but the tube inside anastomosis grounds foreign body reaction and thrombosis. We describe an intestinal transplantation in the rat using a new microanastomosis using adhesive called Cuff-Glue...

Pre- and postoperative systemic hemodynamic evaluation in patients subjected to esophagogastric devascularization plus splenectomy and distal splenorenal shunt: a comparative study in schistomomal portal hypertension.

AIM: To investigate the systemic hemodynamic effects of two surgical procedures largely employed for treatment of schistosomal portal hypertension. METHODS: Thirty-six patients undergoing elective surgical treatment of portal hypertension due to hepatosplenic mansonic schistosomiasis were prospectively evaluated. All patients were subjected to preoperative pulmonary artery catheterization; 17 were submitted to esophagogastric devascularization and splenectomy (EGDS) and 19 to distal splenorenal shunt (DSRS). The systemic hemodynamic assessment was repeated 4 d after the surgical procedure. RESULTS: Preoperative evaluation revealed (mean +/- SD) an increased cardiac index (4.78 +/- 1.13 L/min per m(2)), associated with a reduction in systemic vascular resistance index (1457 +/- 380.7 dynes.s/cm(5).m(2)). The mean pulmonary artery pressure (18 +/- 5.1 mmHg) as well as the right atrial pressure (7.9 +/- 2.5 mmHg) were increased, while the pulmonary vascular resistance index (133 +/- 62 dynes x s/cm(5) x m(2)) was decreased. Four days after EGDS, a significant reduction in cardiac index (3.80 +/- 0.4 L/min per m(2), P < 0.001) and increase in systemic vascular resistance index (1901.4 +/- 330.2 dynes x s/cm(5) x m(2), P < 0.001) toward normal levels were observed. There was also a significant reduction in pulmonary artery pressure (12.65 +/- 4.7 mmHg, P < 0.001) and no significant changes in the pulmonary vascular resistance index (141.6 +/- 102.9 dynes x s/cm(5) x m(2)). Four days after DSRS, a non-significant increase in cardiac index (5.2 +/- 0.76 L/min per m(2)) and systemic vascular resistance index (1389 +/- 311 dynes x s/cm(5) x m(2)) was observed. There was also a non-significant increase in pulmonary artery pressure (19.84 +/- 5.2 mmHg), right cardiac work index (1.38 +/- 0.4 kg x m/m(2)) and right ventricular systolic work index (16.3 +/- 6.3 g x m/m(2)), without significant changes in the pulmonary vascular resistance index (139.7 +/- 67.8 dynes xs/cm(5) x m(2)). CONCLUSION: The hyperdynamic circulatory state observed in mansonic schistosomiasis was corrected by EGDS, but was maintained in patients who underwent DSRS. Similarly, the elevated mean pulmonary artery pressure was corrected after EGDS and maintained after DSRS. EGDS seems to be the most physiologic surgery for patients with schistosomal portal hypertension.

Management of hepatic hemangiomas: a 14-year experience.

Hemangioma is the most common primary tumor of the liver and its diagnosis has become increasingly prevalent. Most of these lesions are asymptomatic and are managed conservatively. Large hemangiomas are often symptomatic and reports of surgical intervention are becoming increasingly frequent. We present our experience, over the last 14 years, with diagnosis and management of 249 liver hemangiomas, with special attention to a conservative strategy. Clinical presentation, diagnosis, treatment, and long-term outcome are analyzed. Of 249 patients, 77 (30.9%) were symptomatic, usually with right abdominal upper quadrant pain. Diagnosis was based on a radiologic algorithm according to the size and characteristics of the tumor; diagnosis by this method was not possible in only one case (0.4 %). Giant hemangiomas (>4 cm) were found in 68 patients (27.3%) and in 16 were larger than 10 cm. Eight patients (3.2%) underwent surgical treatment; indications were incapacitating pain in 6, diagnostic doubt in 1, and stomach compression in 1. No postoperative complications or mortality were observed in this series. Patients who did not undergo surgery (n = 241) did not present any complication related to the hemangioma during long-term follow-up (mean = 78 months). Hemangioma is a benign course disease with easy diagnosis and management. We propose a conservative approach for these lesions. Resection, which can be safely performed, should be reserved for the rare situations such as untreatable pain, diagnostic uncertainty, or compression of adjacent organs.

Mesotelioma maligno primário difuso em cavidade abdominal / Diffuse primary malignant mesothelioma in abdominal cavity

Säo analisados dois casos de mesotelioma maligno difuso presentes na cavidade abdominal. Este tumor primário origina-se do mesotélio peritoneal, da pleura visceral e parietal, pericárdio e túnica vaginal. Todos eles, infra ou supra-diafragmáticos, associam-se com exposiçäo a asbestos em pelo menos 80 por cento dos casos. Dificuldade existe, no entanto, em explicar como asbestos inalados induzem ao aparecimento da neoplasia peritoneal. Estes aspectos säo importantes para realizaçäo do diagnóstico predominantemente definido por laparotomia ou laparoscopia e biopsias das lesöes e, ocasionalmente, pela identificaçäo de células mesoteliais malignas no líquido ascítico. Säo, também, estabelecidas consideraçöes sobre diagnóstico realizado na maioria dos casos em fases avançadas, apresentando grave evoluçäo e opçöes terapêuticas baseadas em ressecçäo cirúrgica radical das lesöes, radio ou quimioterapia isoladas ou combinadas.

Tratamento cirúrgico do cisto solitário de fígado / Surgical treatment of solitary liver cysts

Os cistos hepáticos simples, incomuns no passado, sao atualmente achados incidentais freqüentes em exames como ultra-sonografia e tomografia computadorizada. Os cistos muitas vezes atingem grandes proporçoes, levando à sintomatologia dolorosa ou complicaçoes, necessitando tratamento cirúrgico. A ressecçao cirúrgica ampla da cúpula do cisto, conhecida como "unroofing" ou marsupializaçao é uma técnica simples, advogada para o tratamento dos cistos sintomáticos. Dez pacientes com cistos simples, foram tratados através desta técnica, com bons resultados imediatos e tardios.