Falciform ligament tubular graft for mesenteric-portal vein reconstruction during pancreaticoduodenectomy.

BACKGROUND: Portal vein resection and reconstruction in locally advanced pancreatic cancer represents a potentially curative treatment in selected patients without increasing surgical mortality. However, vascular reconstruction after segmental venous resection is challenging. The parietal peritoneum has emerged as a venous substitute but few reports include its use as a tubular graft. We report a retrospective series of portal vein reconstruction using a falciform ligament tubular graft during pancreaticoduodenectomy. MATERIAL AND METHODS: Technical aspects and short-term morbidity and mortality after pancreaticoduodenectomy with falciform ligament tubular graft interposition were analyzed. RESULTS: Among 21 patients who used parietal peritoneum for venous substitution between 2015 and 2019, eight underwent pancreaticoduodenectomy with venous resection and reconstruction using interposition of falciform ligament tubular graft. The mean duration of surgery and clamping time were 350 and 27 min, respectively. No perioperative blood transfusion was required. All the grafts were patent the day after surgery. No complication related to venous obstruction was detected during the hospital stay. Two patients had postoperative pancreatic fistula. No further intervention was needed. The 90-day mortality was null. CONCLUSIONS: The use of interposition of falciform ligament tubular graft for portal venous reconstruction during pancreaticoduodenectomy seems to be a reliable, inexpensive, and safe procedure.

Brazilian Society of Surgical Oncology guidelines for surgical treatment of endometrial cancer in regions with limited resources.

BACKGROUND: Approximately 70% of cancer-related deaths occur in low- and middle-income countries. In addition to social and racial inequalities, treatment options in these countries are usually limited because of the lack of trained staff and equipment, limited patient access to health services, and a small number of clinical guidelines. OBJECTIVES: The Brazilian Society of Surgical Oncology developed this guideline to address these barriers and guide physicians treating patients with endometrial cancer (EC) in regions with limited resources and few specialized centers. METHODS: The guideline was prepared from 10 January to 25 October 20192019 by a multidisciplinary team of 56 experts to discuss the main obstacles faced by EC patients in Brazil. Thirteen questions considered critical to the surgical treatment of these patients were defined. The questions were assigned to groups that reviewed the literature and drafted preliminary recommendations. Following a review by the coordinators and a second review by all participants, the groups made final adjustments for presentations in meetings, classified the level of evidence, and voted on the recommendations. RESULTS: For all questions including staging, fertility spearing treatment, genetic testing, sentinel lymph node use, surgical treatment, and other clinical relevant questions, major agreement was achieved by the participants, always using accessible alternatives. CONCLUSIONS: It is possible to provide adequate treatment for most EC patients in resource-limited areas, but the first option should be referral to specialized centers with more resources.

PREVALENCE OF HEPATIC ARTERIAL VARIATIONS WITH IMPLICATIONS IN PANCREATODUODENECTOMY.

BACKGROUND: Pancreaticoduodenectomy is the usual surgical option for curative treatment of periampullary cancer and carries a significant mortality. Arterial anomalies of the celiac axis are not uncommon and might lead to iatrogenic lesions or requiring arterial resection/reconstruction in a pancreatoduodenectomy. AIM: Determine the prevalence of arterial variations having implications in pancreatoduodenectomy. METHODS: Celiac trunk and hepatic arterial system anatomy was retrospectively evaluated in 200 abdominal enhanced computed tomography studies. RESULTS: Normal anatomy of hepatic arterial system was found in 87% of cases. An anomalous right hepatic artery was identified in 13% of cases. In 12 cases there was a substitute right hepatic artery arising from superior mesenteric artery and in two cases an accessory right hepatic artery with similar origin. A hepatomesenteric trunk was identified in seven cases and in five there was a right hepatic artery directly from the celiac trunk. All cases of anomalous right hepatic artery had a route was behind the pancreatic head and then, posteriorly and laterally, to the main portal vein before reaching the liver. CONCLUSIONS: Hepatic artery variations, such as anomalous right hepatic artery crossing posterior to the portal vein, are frequently seen (13%). These patients, when undergoing pancreatoduodenectomy, may require a change in the surgical approach to achieve an adequate resection. Preoperative imaging can clearly identify such variations and help to achieve a safer pancreatic head dissection with proper surgical planning.

Prevalence of hepatic arterial variations with implications in pancreatoduodenectomy / Prevalência de variações arteriais hepáticas com implicações em pancreatoduodenectomia

ABSTRACT Background: Pancreaticoduodenectomy is the usual surgical option for curative treatment of periampullary cancer and carries a significant mortality. Arterial anomalies of the celiac axis are not uncommon and might lead to iatrogenic lesions or requiring arterial resection/reconstruction in a pancreatoduodenectomy. Aim: Determine the prevalence of arterial variations having implications in pancreatoduodenectomy. Methods: Celiac trunk and hepatic arterial system anatomy was retrospectively evaluated in 200 abdominal enhanced computed tomography studies. Results: Normal anatomy of hepatic arterial system was found in 87% of cases. An anomalous right hepatic artery was identified in 13% of cases. In 12 cases there was a substitute right hepatic artery arising from superior mesenteric artery and in two cases an accessory right hepatic artery with similar origin. A hepatomesenteric trunk was identified in seven cases and in five there was a right hepatic artery directly from the celiac trunk. All cases of anomalous right hepatic artery had a route was behind the pancreatic head and then, posteriorly and laterally, to the main portal vein before reaching the liver. Conclusions: Hepatic artery variations, such as anomalous right hepatic artery crossing posterior to the portal vein, are frequently seen (13%). These patients, when undergoing pancreatoduodenectomy, may require a change in the surgical approach to achieve an adequate resection. Preoperative imaging can clearly identify such variations and help to achieve a safer pancreatic head dissection with proper surgical planning.

RESUMO Racional: Pancreatoduodenectomia consiste no procedimento cirúrgico usual para tratamento curativo de neoplasias periampulares e apresenta mortalidade significativa. Variações arteriais do tronco celíaco não são incomuns e podem favorecer lesões iatrogênicas ou exigirem realização de ressecção/reconstrução arterial durante pancreatoduodenectomia. Objetivo: Determinar a prevalência de variações arteriais que apresentam implicações durante pancreatoduodenectomia. Métodos: A anatomia do tronco celíaco e sistema arterial hepático foi investigada retrospectivamente em 200 exames tomográficos contrastados do abdome. Resultados: Anatomia normal do sistema arterial hepático foi observada em 87% dos casos. Presença de uma artéria hepática direita anômala foi identificada em 13%. Em 12 casos houve uma artéria hepática direita substituta originária da artéria mesentérica superior, em dois uma artéria hepática direita acessória com origem similar. Tronco hepaticomesentérico foi identificado em sete casos e em cinco houve uma artéria hepática direita originária diretamente do tronco celíaco. Em todos casos de artéria hepática direita anômala seu curso foi por trás da cabeça do pâncreas e com trajeto passando posteriormente ao tronco da veia porta e após percorrendo sua face lateral direita antes de alcançar o fígado. Conclusões: Variações arteriais hepáticas, como artéria hepática direita anômala com trajeto posterior à veia porta, são frequentes (13%). Nestes pacientes, quando submetidos à pancreatoduodenectomia, pode ser necessária alteração na abordagem cirúrgica para ressecção adequada. Exames de imagem pré-operatórios podem claramente identificar estas variações e auxiliar na realização de dissecção segura da cabeça do pâncreas com adequado planejamento cirúrgico.

Development and in vitro evaluation of potential electromodulated transdermal drug delivery systems based on carbon nanotube buckypapers.

Buckypapers based on different types of carbon nanotubes with and without the addition of four model drugs, two of basic nature (clonidine hydrochloride, selegiline hydrochloride) and the others of acidic character (flurbiprofen, ketorolac tromethamine) were prepared and characterized. The influence of the conditions employed in the preparation of the buckypapers (dispersion time and solvents used in the preparation, as well as the type of carbon nanotubes used and the characteristics of the drug involved) on their conductivity was especially examined. The in vitro performance of the drug loaded buckypapers as passive and active transdermal drug release systems, the latter being modulated by means of the application of electric voltages, was studied. Passive drug loaded buckypapers presented characteristic release profiles, also depending on the drug used, which indicate differences in the drug-carbon nanotubes non-covalent interactions. Application of electrical biases of appropriate polarities enabled the modulation of the drug release profiles in any desired direction. Different mathematical models were fitted to passive and electromodulated experimental release data for the four model drugs. Among these models, the most appropriate for data description was a two-compartment pseudo-second-order one.

Carbon nanotubes buckypapers for potential transdermal drug delivery.

Drug loaded buckypapers based on different types of carbon nanotubes (CNTs) were prepared and characterized in order to evaluate their potentialities for the design of novel transdermal drug delivery systems. Lab-synthesized CNTs as well as commercial samples were employed. Clonidine hydrochloride was used as model drug, and the influence of composition of the drug loaded buckypapers and processing variables on in vitro release profiles was investigated. To examine the influence of the drug nature the evaluation was further extended to buckypapers prepared with flurbiprofen and one type of CNTs, their selection being based on the results obtained with the former drug. Scanning electronic microscopy images indicated that the model drugs were finely dispersed on the CNTs. Differential scanning calorimetry, and X-ray diffraction pointed to an amorphous state of both drugs in the buckypapers. A higher degree of CNT-drug superficial interactions resulted in a slower release of the drug. These interactions were in turn affected by the type of CNTs employed (single wall or multiwall CNTs), their functionalization with hydroxyl or carboxyl groups, the chemical structure of the drug, and the CNT:drug mass ratio. Furthermore, the application of a second layer of drug free CNTs on the loaded buckypaper, led to decelerate the drug release and to reduce the burst effect.

Usefulness of intraoperative ultrasonography in liver resections due to colon cancer metastasis.

INTRODUCTION: Intraoperative ultrasonography (IOUS) of the liver has been used both as an aid for intraoperative anatomical definition and for the detection of new lesions. The present study aimed to evaluate the impact of IOUS and to identify factors that can predict the detection of new lesions intraoperatively. METHODS: In this observational and prospective study, with a cross-sectional design, patients with colorectal cancer metastases who underwent hepatectomy were selected. Abdominal computed tomography, magnetic resonance imaging, and positron emission tomography were the preoperative evaluation tests. All patients underwent IOUS performed by the same surgeon. The intraoperative findings were compared with the preoperative tests results. RESULTS: In total, 56 hepatectomies were evaluated. Half of the patients were men, with a mean age of 57 (30-85) years. New lesions were found intraoperatively in 12 patients (21.4% of cases) and were detected on both palpation and ultrasonography in 11 of these patients. Ultrasonography helped to revise the surgical plans by providing additional information in 35.7% of cases. On multivariate analysis, the presence of more than 4 preoperative nodules was predictive of the intraoperative occurrence of new lesions. CONCLUSIONS: IOUS remains the only way to evaluate the relationships between tumors, liver vascular structures, and bile ducts intraoperatively. Alone, IOUS was not useful for identifying new lesions intraoperatively, as all new lesions were also detected on palpation. The number of lesions diagnosed on preoperative tests influenced the probability of identifying new lesions intraoperatively. There may be additional influential factors.

Role of N-acetylcysteine on fibrosis and oxidative stress in cirrhotic rats.

BACKGROUND: Hepatic cirrhosis is the final stage of liver dysfunction, characterized by diffuse fibrosis which is the main response to the liver injury. The inhalatory carbon tetrachloride is an effective experimental model that triggers cirrhosis and allows to obtain histological and physiological modifications similar to the one seen in humans. AIM: To investigate the effects of N-acetylcysteine (NAC) on the fibrosis and oxidative stress in the liver of cirrhotic rats, analyzing liver function tests, lipoperoxidation, activity of glutathione peroxidase enzyme, collagen quantification, histopathology, as well as the nitric oxide role. METHODS: The animals were randomly in three experimental groups: control (CO); cirrhotic (CCl4) and CCl4 + NAC. Evaluate the lipid peroxidation, the glutathione peroxidase enzyme, the collagen and the expression of inducible nitric oxide synthase (iNOS). RESULTS: The cirrhotic group treated with N-acetylcysteine showed trough the histological analysis and collagen quantification lower degrees of fibrosis. This group has also shown less damage to the cellular membranes, less decrease on the glutathione peroxidase levels and less expression of inducible nitric oxide synthase when matched with the cirrhotic group without treatment. CONCLUSION: N-acetylcysteine seams to offer protection against hepatic fibrosis and oxidative stress in cirrhotic rat livers.

Role of N-acetylcysteine on fibrosis and oxidative stress in cirrhotic rats / Papel da N-acetilcisteína na fibrose e estresse oxidativo em ratos cirróticos

BACKGROUND: Hepatic cirrhosis is the final stage of liver dysfunction, characterized by diffuse fibrosis which is the main response to the liver injury. The inhalatory carbon tetrachloride is an effective experimental model that triggers cirrhosis and allows to obtain histological and physiological modifications similar to the one seen in humans. AIM: To investigate the effects of N-acetylcysteine (NAC) on the fibrosis and oxidative stress in the liver of cirrhotic rats, analyzing liver function tests, lipoperoxidation, activity of glutathione peroxidase enzyme, collagen quantification, histopathology, as well as the nitric oxide role. METHODS: The animals were randomly in three experimentals groups: control (CO); cirrhotic (CCl4) and CCl4 + NAC. Evaluate the lipid peroxidation, the glutathione peroxidase enzyme, the collagen and the expression of inducible nitric oxide synthase (iNOS). RESULTS: The cirrhotic group treated with N-acetylcysteine showed trough the histological analysis and collagen quantification lower degrees of fibrosis. This group has also shown less damage to the cellular membranes, less decrease on the glutathione peroxidase levels and less expression of inducible nitric oxide synthase when matched with the cirrhotic group without treatment. CONCLUSION: N-acetylcysteine seams to offer protection against hepatic fibrosis and oxidative stress in cirrhotic rat livers.

RACIONAL: A cirrose é o estágio final da disfunção hepática, sendo caracterizada por fibrose difusa, que compõe a resposta principal do organismo ao dano hepático. O tetracloreto de carbono inalatório é um modelo experimental efetivo, que desencadeia a cirrose e permite obter modificações histológicas e fisiológicas similares às vistas em humanos. OBJETIVO: Investigar os efeitos da N-acetilcisteina (NAC) sobre a fibrose e o estresse oxidativo no fígado de ratos cirróticos, analisando as provas hepáticas, a lipoperoxidação, a atividade da enzima glutationa peroxidase, a quantificação do colágeno, a histopatologia, bem como o papel do óxido nítrico. MÉTODOS: Os animais foram divididos em três grupos experimentais: controle (CO); cirrótico (CCl4) e CCl4 + NAC. Foram avaliados a lipoperoxidação, a enzima glutationa peroxidase, a histologia hepática, a quantificação de colágeno e a expressão da óxido nítrico síntase induzível (iNOS). RESULTADOS: O grupo cirrótico tratado com a NAC demonstrou, através da análise histológica e da quantificação de colágeno, menores graus de fibrose. Este grupo demonstrou, ainda, menos dano às membranas celulares, menor decréscimo nos níveis de glutationa peroxidase e menor expressão da iNOS quando comparado com o grupo cirrótico sem tratamento. CONCLUSÃO: A NAC parece oferecer proteção contra a fibrose hepática e o estresse oxidativo no fígado de ratos cirróticos.