[Robotic Colorectal Surgery: Analysis of the First Three Years of Activity in a Hospital of the Portuguese National Health Service]. / Cirurgia Robótica em Patologia Colorretal: Análise dos Primeiros Três Anos de Atividade num Hospital do Serviço Nacional de Saúde em Portugal.

INTRODUCTION: Minimally invasive surgery has been increasingly accepted and used in colorectal surgery. Several studies report that robotic surgery may provide advantages over 'conventional' laparoscopy, namely in rectal surgery. This paper provides an account of the first three years of experience with robotic surgery in the Unidade de Patologia Colorretal of the Unidade Local de Saúde S. José. METHODS: Variables were defined to develop a prospective database containing the data of consecutive patients operated by three internationally certified colorectal surgeons using the Da Vinci Xi® system between November 2019 and October 2022. The database was converted into an anonymized version that was used for this study. The analysis was performed on the data of all the patients operated during this period. RESULTS: Eighty patients were included, 47 male, median age 70 years, and median BMI 26 kg/m2 . ASA score was II in 53.7% and III in 41.3% of pa- tients. Of the total, 97.6% had malignant or potentially malignant disease. Operative procedures consisted of 34 colectomies proximal to the splenic flexure, 20 distal colectomies and 26 anterior resections. There were two synchronous resections of liver metastases. Early perioperative outcomes and histopathological results were analyzed: median operative time: 300 minutes; median estimated blood loss: 50 mL; conversion rate: 2.5%; median days until first bowel movement: three days; median length of hospital stay: six days; complication rate: 20%, of which 5% were Clavien III and 0% Clavien IV/V; anastomotic leak rate: 2.5%; 30-day readmission rate: 1.3%; median lymph nodes resected: 20; R0 resection rate: 100%; mesorectal integrity rate: 95,8% complete/near complete. CONCLUSION: Our results show that the adoption of robotic colorectal surgery in our center was safe and resulted in similar or improved short-term clinical outcomes and histopathological results when compared to those described in the literature.

Introdução: A utilização da cirurgia minimamente invasiva no tratamento da patologia colorretal é hoje cientificamente aceite e o seu uso na prática clí- nica diária tem vindo a aumentar de forma sustentada. Diversos estudos indicam que a abordagem robótica pode trazer vantagens sobre a laparoscopia 'convencional', especialmente na cirurgia do reto. Este trabalho descreve e analisa os resultados dos primeiros três anos de cirurgia robótica na Unidade de Patologia Colorretal da Unidade Local de Saúde S. José. Métodos: Foram definidas as variáveis a analisar e construída uma base de dados prospetiva com os dados referentes aos doentes operados conse- cutivamente por três cirurgiões colorretais, acreditados internacionalmente na utilização do sistema Da Vinci Xi®, entre novembro de 2019 e outubro de 2022. A base de dados foi convertida numa versão anonimizada e foi sobre essa mesma que se procedeu à análise de dados. Foram analisados os dados de todos doentes operados nesse período. Resultados: Foram incluídos 80 doentes, 47 homens, mediana de idade de 70 anos e de IMC de 26 kg/m2 . O score ASA era II em 53,7% e III em 41,3% dos doentes. Do total, 97,6% apresentavam doença maligna ou potencialmente maligna. Realizaram-se 34 colectomias proximais ao ângulo esplénico, 20 distais e 26 ressecções anteriores do reto. Houve ressecção síncrona de metástases hepáticas em dois casos. Foram analisados os resultados peri-operatórios a curto prazo e histopatológicos: duração (mediana): 300 minutos; perda hemática estimada (mediana): 50 mL; taxa de conversão: 2,5%; dias até retomar trânsito intestinal (mediana): três dias; dias de internamento (mediana): seis dias; taxa de complicações pós-operatórias: 20%, das quais 5% Clavien III e 0% Clavien IV/V; taxa de deiscência anastomótica: 2,5%; taxa de reintervenção: 2,5%; taxa de readmissão pós-alta: 1,3%; gânglios linfáticos ressecados (mediana): 20; taxa de ressecção R0: 100%; taxa de integridade mesorretal: 95,8% completo/quase completo. Conclusão: Os nossos resultados mostram que a introdução da cirurgia colorretal robótica no nosso centro foi segura e garantiu resultados clínicos a curto prazo e histopatológicos semelhantes ou favoráveis face aos descritos na literatura.

Combined Stellate Ganglion Blockade and Epidural Thoracic Anesthesia for the Management of Ventricular Storm: A Case Report.

ABSTRACT: The term "ventricular storm (VS)" is defined as the occurrence of two or more separate episodes of ventricular tachycardia or fibrillation (VT/VF) or three or more appropriate discharges of an implantable cardioverter defibrillator for VT/VF during a 24-h period. A patient in his early 40s was observed in the emergency department of our hospital and was admitted to the cardiac intensive care unit due to multiple episodes of VT. This led to the need for deep sedation with orotracheal intubation and mechanical ventilation. Intravenous lidocaine treatment was started; however, the patient had a recurrence of the episodes of VT. We decided to combine stellate ganglion block with epidural thoracic anesthesia. After the sympathetic block, there was no recurrence of the arrhythmic episodes. The patient was then transferred for ablation treatment. We demonstrated the efficacy of both techniques in managing a patient with multiple episodes of ventricular storm.

Hepatic Venous Pressure Gradient: Measurement and Pitfalls.

Measurement of hepatic venous pressure gradient (HVPG) effectively mirrors the severity of portal hypertension (PH) and offers valuable insights into prognosis of liver disease, including the risk of decompensation and mortality. Additionally, HVPG offers crucial information about treatment response to nonselective beta-blockers and other medications, with its utility demonstrated in clinical trials in patients with PH. Despite the widespread dissemination and validation of noninvasive tests, HVPG still holds a significant role in hepatology. Physicians treating patients with liver diseases should comprehend the HVPG measurement procedure, its applications, and how to interpret the results and potential pitfalls.

Advances in the Early Warning of Shellfish Toxification by Dinophysis acuminata.

In Western Europe, the incidence of DST is likely the highest globally, posing a significant threat with prolonged bans on shellfish harvesting, mainly caused by species of the dinoflagellate genus Dinophysis. Using a time series from 2014 to 2020, our study aimed (i) to determine the concentration of D. acuminata in water at which shellfish toxin levels could surpass the regulatory limit (160 µg OA equiv kg-1) and (ii) to assess the predictability of toxic events for timely mitigation actions, especially concerning potential harvesting bans. The analysis considered factors such as (i) overdispersion in the data, (ii) distinct periods of presence and absence, (iii) the persistence of cells, and (iv) the temporal lag between cells in the water and toxins in shellfish. Four generalized additive models were tested, with the Tweedie (TW-GAM) model showing superior performance (>85%) and lower complexity. The results suggest existing thresholds currently employed (200 and 500 cells L-1) are well-suited for the Portuguese coast, supported by empirical evidence (54-79% accuracy). The developed algorithm allows for thresholds to be tailored on a case-by-case basis, offering flexibility for regional variations.

Clear cell carcinoma of the ovary: Clues for radiologists to perform a correct diagnosis.

Ovarian clear cell carcinoma (OCCC) is an uncommon high-grade primary epithelial ovarian cancer, covering about 10-12 % of all ovarian malignancies. It has a strong association with endometriosis. OCCC diagnosis, at advanced stages, has an aggressive biological behaviour, and the therapeutic strategies for ovarian OCCC are somehow different from other ovarian carcinomas. Therefore, early diagnosis of these tumours is of extreme importance. As some ovarian tumours subtypes have distinguishing features, it is possible to differentiate them based on their imaging characteristics, which can guide patient management and help the clinicians and pathologists in their diagnosis. A large mass on one side of the ovary that is mostly cystic, with a focal or multifocal irregular eccentric growing solid mural nodules or projections protruding into the cystic space, may suggest clear cell carcinoma of the ovary diagnosis. The solid nodules usually have an intermediate signal on T2-weighted images. The cystic component can be either single or multilocular, and the contents may contain protein or blood. CT scanning is still the preferred method for preoperative staging and postoperative restaging, and radiologists are crucial in identifying this type of tumour. We reviewed the imaging files of patients with surgically proven clear cell carcinoma at the specimens, and our findings agree with previous studies. This paper aims to perform a comprehensive revision of OCCC's radiological and clinic-pathological features and assist radiologists in recognizing OCCC and narrowing down the possibilities of differential diagnosis.

Improving primary prophylaxis of variceal bleeding by adapting therapy to the clinical stage of cirrhosis. A competing-risk meta-analysis of individual participant data.

BACKGROUND & AIMS: Non-selective ß-blockers (NSBBs) and endoscopic variceal-ligation (EVL) have similar efficacy preventing first variceal bleeding. Compensated and decompensated cirrhosis are markedly different stages, which may impact treatment outcomes. We aimed to assess the efficacy of NSBBs vs EVL on survival in patients with high-risk varices without previous bleeding, stratifying risk according to compensated/decompensated stage of cirrhosis. METHODS: By systematic review, we identified RCTs comparing NSBBs vs EVL, in monotherapy or combined, for primary bleeding prevention. We performed a competing-risk, time-to-event meta-analysis, using individual patient data (IPD) obtained from principal investigators of RCTs. Analyses were stratified according to previous decompensation of cirrhosis. RESULTS: Of 25 RCTs eligible, 14 failed to provide IPD and 11 were included, comprising 1400 patients (656 compensated, 744 decompensated), treated with NSBBs (N = 625), EVL (N = 546) or NSBB+EVL (N = 229). Baseline characteristics were similar between groups. Overall, mortality risk was similar with EVL vs. NSBBs (subdistribution hazard-ratio (sHR) = 1.05, 95% CI = 0.75-1.49) and with EVL + NSBBs vs either monotherapy, with low heterogeneity (I2 = 28.7%). In compensated patients, mortality risk was higher with EVL vs NSBBs (sHR = 1.76, 95% CI = 1.11-2.77) and not significantly lower with NSBBs+EVL vs NSBBs, without heterogeneity (I2 = 0%). In decompensated patients, mortality risk was similar with EVL vs. NSBBs and with NSBBs+EVL vs. either monotherapy. CONCLUSIONS: In patients with compensated cirrhosis and high-risk varices on primary prophylaxis, NSBBs significantly improved survival vs EVL, with no additional benefit noted adding EVL to NSBBs. In decompensated patients, survival was similar with both therapies. The study suggests that NSBBs are preferable when advising preventive therapy in compensated patients.

A 15-Year Retrospective Review of Ciguatera in the Madeira Islands (North-East Atlantic, Portugal).

The first ciguatera fish poisoning (CFP) in Portugal dates from 2008 when 11 people reported CFP symptoms after consuming a 30 kg amberjack caught around the Selvagens Islands (Madeira Archipelago). Since then, 49 human poisonings have been reported. The emergence of a new threat challenged scientists and regulators, as methods for toxic microalgae analyses and ciguatoxin (CTX) detection were not implemented. To minimise the risk of ciguatera, the Madeira Archipelago authorities interdicted fisheries in Selvagens Islands and banned the capture of amberjacks weighing more than 10 kg in the entire region of Madeira Archipelago. The accurate identification and quantification of the benthic toxin-producing algae species spreading to new areas require efforts in terms of both microscopy and molecular techniques. Two ciguatera-causing dinoflagellates, Gambierdiscus excentricus and Gambierdiscus australes, were identified in the Madeira Island and Selvagens sub-archipelago, respectively. Regarding the CTX analysis (N2a cell-based assay and LC-MS) in fish, the results indicate that the Selvagens Islands are a ciguatera risk area and that fish vectoring CTX are not limited to top predator species. Nevertheless, advances and improvements in screening methods for the fast detection of toxicity in seafood along with certified reference material and sensitive and selective targeted analytical methods for the determination of CTX content are still pending. This study aims to revise the occurrence of ciguatera cases in the Madeira Archipelago since its first detection in 2008, to discuss the risk management strategy that was implemented, and to provide a summary of the available data on the bioaccumulation of CTX in marine fish throughout the marine food web, taking into consideration their ecological significance, ecosystem dynamics, and fisheries relevance.

Transjugular intrahepatic portosystemic shunt in patients with hepatocellular carcinoma: A systematic review.

BACKGROUND/AIMS: Transjugular intrahepatic portosystemic shunts (TIPS) in patients with hepatocellular carcinoma (HCC) may improve access to curative therapies, treat portal hypertension (PH)-related complications without worsening liver function, and increase overall survival. Data on the efficacy and safety of TIPS to treat PH complications in HCC patients, as well as the HCC treatment response, were evaluated. METHODS: Studies reporting efficacy in controlling bleeding/ascites or response to HCC therapy, safety, and survival in patients with HCC and TIPS were searched systematically on PubMed and Embase. An extraction of articles using predefined data fields and quality indicators was used. RESULTS: We selected 19 studies and found 937 patients treated for ascites/bleeding and 177 evaluating HCC treatment response. Over half were under 5 cm and solitary lesions, and most studies included tumours with portal vein thrombosis. Regarding PH studies, TIPS resolved bleeding/ascites in >60% of patients, more effective for bleeding. There were no lethal complications reported and procedural bleeding occurred in <5%. Hepatic encephalopathy occurred in 15%-30% within three months. In the HCC treatment-response studies, major complication rates were low with no mortality. In the studies that evaluated the response to transarterial chemoembolization, complete response rate of patients with TIPS varied from 16% to 75%. Liver transplantation rate varied from 8% to 80%, with >40% rate in half of the studies. CONCLUSIONS: In the published studies, TIPS is effective in treating PH complications in patients with HCC. Prospective studies on TIPS placement in patients with HCC are urgently needed to evaluate the efficacy and safety of TIPS in this setting.

Alcohol-related liver disease phenotype impacts survival after an acute variceal bleeding episode.

BACKGROUND & AIMS: Alcohol-related hepatitis (AH) encompasses a high mortality. AH might be a concomitant event in patients with acute variceal bleeding (AVB). The current study aimed to assess the prevalence of AH in patients with AVB and to compare the clinical outcomes of AH patients to other alcohol-related liver disease (ALD) phenotypes and viral cirrhosis. METHODS: Multicentre, observational study including 916 patients with AVB falling under the next categories: AH (n = 99), ALD cirrhosis actively drinking (d-ALD) (n = 285), ALD cirrhosis abstinent from alcohol (a-ALD) (n = 227) and viral cirrhosis (n = 305). We used a Cox proportional hazards model to calculate adjusted hazard ratio (HR) of death adjusted by MELD. RESULTS: The prevalence of AH was 16% considering only ALD patients. AH patients exhibited more complications. Forty-two days transplant-free survival was worse among AH, but statistical differences were only observed between AH and d-ALD groups (84 vs. 93%; p = 0.005), when adjusted by MELD no differences were observed between AH and the other groups. At one-year, survival of AH patients (72.7%) was similar to the other groups; when adjusted by MELD mortality HR was better in AH compared to a-ALD (0.48; 0.29-0.8, p = 0.004). Finally, active drinkers who remained abstinent presented better survival, independently of having AH. CONCLUSIONS: Contrary to expected, AH patients with AVB present no worse one-year survival than other patients with different alcohol-related phenotypes or viral cirrhosis. Abstinence influences long-term survival and could explain these counterintuitive results.

Studying the Influence of Multisensory Stimuli on a Firefighting Training Virtual Environment.

How we perceive and experience the world around us is inherently multisensory. Most of the Virtual Reality (VR) literature is based on the senses of sight and hearing. However, there is a lot of potential for integrating additional stimuli into Virtual Environments (VEs), especially in a training context. Identifying the relevant stimuli for obtaining a virtual experience that is perceptually equivalent to a real experience will lead users to behave the same across environments, which adds substantial value for several training areas, such as firefighters. In this paper, we present an experiment aiming to assess the impact of different sensory stimuli on stress, fatigue, cybersickness, Presence and knowledge transfer of users during a firefighter training VE. The results suggested that the stimulus that significantly impacted the user's response was wearing a firefighter's uniform and combining all sensory stimuli under study: heat, weight, uniform, and mask. The results also showed that the VE did not induce cybersickness and that it was successful in the task of transferring knowledge.

Bivalve Shellfish Safety in Portugal: Variability of Faecal Levels, Metal Contaminants and Marine Biotoxins during the Last Decade (2011-2020).

Bivalves are a high-value product whose production has markedly increased, reaching 9863 tonnes in Portugal in 2021. Bivalves' habitats-lagoons, estuaries and coastal waters-are exposed to biological and anthropogenic contaminants, which can bioaccumulate in these organisms and pose a significant public health risk. The need to obtain a safe product for human consumption led to the implementation of standardised hygiene regulations for harvesting and marketing bivalve molluscs, resulting in routine monitoring of bivalve production areas for microbial quality, metal contaminants, and marine biotoxins. While excessive levels of biotoxins and metal contamination lead to temporary harvesting bans, high faecal contamination leads to area reclassification and impose post-harvest treatments. In this study, the seasonal and temporal variability of these parameters were analysed using historical data generated by the monitoring programme during the last decade. Moreover, the impact of the monitoring program on bivalve harvesting from 2011 to 2020 was assessed. This program presented a considerable improvement over time, with an increase in the sampling effort and the overall program representativeness. Finally, contamination risk, revising control measures, and defining recommendations for risk mitigation measures are given in the light of ten years' monitoring.

Using Heart Rate Variability for Comparing the Effectiveness of Virtual vs Real Training Environments for Firefighters.

The use of Virtual Reality (VR) technology to train professionals has increased over the years due to its advantages over traditional training. This paper presents a study comparing the effectiveness of a Virtual Environment (VE) and a Real Environment (RE) designed to train firefighters. To measure the effectiveness of the environments, a new method based on participants' Heart Rate Variability (HRV) was used. This method was complemented with self-reports, in the form of questionnaires, of fatigue, stress, sense of presence, and cybersickness. An additional questionnaire was used to measure and compare knowledge transfer enabled by the environments. The results from HRV analysis indicated that participants were under physiological stress in both environments, albeit with less intensity on the VE. Regarding reported fatigue and stress, the results showed that none of the environments increased such variables. The results of knowledge transfer showed that the VE obtained a significant increase while the RE obtained a positive but non-significant increase (median values, VE: before - 4 after - 7, p = .003; RE: before - 4 after - 5, p = .375). Lastly, the results of presence and cybersickness suggested that participants experienced high overall presence and no cybersickness. Considering all results, the authors conclude that the VE provided effective training but that its effectiveness was lower than that of the RE.

Non-invasive tools for compensated advanced chronic liver disease and portal hypertension after Baveno VII - an update.

Non-invasive tests (NITs) and liver stiffness measurement (LSM) in particular, have entered clinical practice over 20 years ago as point-of-care tests to diagnose liver fibrosis in patients with compensated chronic liver disease. Since then, NITs use has evolved thanks to a large number of studies in all major etiologies of liver disease, and they have become important tools to stratify the risk of portal hypertension and liver-related events. The Baveno VII consensus workshop provided several novel recommendations regarding the use of well-established and novel NITs in the specific setting of portal hypertension screening, diagnosis and follow-up. The Baveno VII expert panels paid special attention to summarizing the existing data into simple clinical rules able to guide clinicians in their practice. The "rule of five" for LSM is a tool to stratify the risk of liver-related events, and LSM alone or in combination with platelet count, can be used now to rule-in and rule-out compensated advanced chronic liver disease (cACLD) and clinically significant portal hypertension, as well as to rule-out high-risk varices. Use of NITs in obese subjects with non-alcoholic fatty liver disease (NAFLD) and patients with viral hepatitis C that has been successfully treated, require specific knowledge. This review will update the reader on these aspects.

Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding.

BACKGROUND: A pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) reduces mortality in high-risk patients with cirrhosis (Child-Pugh C/B+active bleeding) with acute variceal bleeding (AVB). Real-life studies point out that <15% of patients eligible for pTIPS ultimately undergo transjugular intrahepatic portosystemic shunt (TIPS) due to concerns about hepatic encephalopathy (HE). The outcome of patients undergoing pTIPS with HE is unknown. We aimed to (1) assess the prevalence of HE in patients with AVB; (2) evaluate the outcome of patients presenting HE at admission after pTIPS; and (3) determine if HE at admission is a risk factor for death and post-TIPS HE. PATIENTS AND METHODS: This is an observational study including 2138 patients from 34 centres between October 2011 and May 2015. Placement of pTIPS was based on individual centre policy. Patients were followed up to 1 year, death or liver transplantation. RESULTS: 671 of 2138 patients were considered at high risk, 66 received pTIPS and 605 endoscopic+drug treatment. At admission, HE was significantly more frequent in high-risk than in low-risk patients (39.2% vs 10.6%, p<0.001). In high-risk patients with HE at admission, pTIPS was associated with a lower 1-year mortality than endoscopic+drug (HR 0.374, 95% CI 0.166 to 0.845, p=0.0181). The incidence of HE was not different between patients treated with pTIPS and endoscopic+drug (38.2% vs 38.7%, p=0.9721), even in patients with HE at admission (56.4% vs 58.7%, p=0.4594). Age >56, shock, Model for End-Stage Liver Disease score >15, endoscopic+drug treatment and HE at admission were independent factors of death in high-risk patients. CONCLUSION: pTIPS is associated with better survival than endoscopic treatment in high-risk patients with cirrhosis with variceal bleeding displaying HE at admission.

Mycophenolate mofetil as second line treatment in autoimmune hepatitis - A retrospective single center analysis.

Background: Most patients with autoimmune hepatitis respond to standard treatment with steroids and azathioprine. While the disease is usually fatal if untreated, patients who respond well to therapy have an excellent prognosis. Nevertheless, second-line treatment is necessary in approximately 20% of patients, due to either intolerance or insufficient response to first line treatment.While data for mycophenolate mofetil (MMF) in patients intolerant to azathioprine is encouraging, MMF seems of less benefit in patients with insufficient response to first line treatment, but analyzed data on this issue is limited. Aim: To evaluate the efficacy and safety of MMF as a second-line therapy in patients with AIH. Methods: Retrospective analysis of a monocentric database of AIH patients who received medical care from 2000 to 2022. Clinical, immunological and biochemical parameters were assessed at different time points including last follow-up. Results: Overall, 144 patients with AIH were identified. Fifty out of 144 (35%) AIH patients received MMF. Forty (80%) received MMF due to first line treatment intolerance, while ten (20%) due to insufficient response to first line treatment.Remission with MMF monotherapy was 81.5% in the intolerance group versus 30% in the insufficient response group. Patients switched to MMF because of an insufficient response, more often needed additional prednisolone doses higher than 5 mg/day, a switch to third-line treatment or combination regiments, to achieve disease control. Conclusions: Patients treated with MMF because of intolerance to first line treatment show a good disease control under MMF in the majority of cases. Efficacy is considerably lower in the patients switched to MMF because of an insufficient response to first line treatment.