New translational and experimental insights into the role of pro-resolving lipid mediators in inflammatory bowel disease.

The resolution of inflammation is an active process, guided by specialized pro-resolution lipid mediators (SPMs). These mediators originate from polyunsaturated fatty acids, such as omega-3. Sufficient evidence suggests that the beneficial effects attributed to omega-3 are, at least in part, the result of the immunomodulatory action of the SPMs, which act systemically by overcoming inflammation and repairing tissue damage, without suppressing the immune response. Recent studies suggest that an imbalance in the synthesis and/or activity of these compounds may be associated with the pathogenesis of several inflammatory conditions, such as inflammatory bowel disease (IBD). Thus, this review highlights the advances made in recent years with regard to the endo-genous synthesis and the biological role of lipoxins, resolvins, protectins, and maresins, as well as their precursors, in the regulation of inflammation; and provides an update on the participation of these mediators in the development and evolution of IBD and the therapeutic approaches that these immunomodulating substances are involved in this context.

Histological grading evaluation of non-alcoholic fatty liver disease after bariatric surgery: a retrospective and longitudinal observational cohort study.

Non-alcoholic fatty liver disease (NAFLD) is a chronic disease with several degrees of histological features which may progress to cirrhosis. Obesity is an important risk factor and although NAFLD has no specific pharmacological treatment, bariatric surgery has been associated with NAFLD regression in severely obese patients. However, few longitudinal histological studies support this finding. Therefore, firstly, a retrospective study was performed including clinical and histological data of 895 obese patients who underwent bariatric surgery. In addition, histological analyses of 30 patient's liver biopsies were evaluated at two timepoints (T1 and T2). The retrospective analysis of the total number of patients revealed that the average body mass index (BMI) was 35.91 ± 2.81 kg/m2. The liver biopsies during bariatric surgery showed that 53.52% did not present NAFLD, 30.16% had NASH, 15.98% isolated steatosis and 0.34% liver cirrhosis. The median BMI of the longitudinal cohort decreased from 37.9 ± 2.21 kg/m2 at the time of bariatric surgery (T1) to 25.69 ± 3.79 kg/m2 after 21 ± 22 months after the procedure (T2). The prevalence of NAFLD in T1 was 50%, and 16.67% in T2. The histological area of collagen fiber was lower in T2 compared to T1 (p = 0.0152) in the majority of patients, which was also illustrated by immunohistochemistry for Kupffer cell and myofibroblast formation markers. These findings confirmed the NAFLD regression after bariatric surgery and, for the first time, showed the amelioration of these features using more accurate histopathological techniques.

Video-Laparoscopic Treatment of Intrathoracic Gastric Volvulus.

BACKGROUND: Gastric volvulus is a rare condition, characterized by abnormal rotation of the stomach, causing obstruction with risk of ischemia, necrosis, and perforation. It is associated with high morbidity and mortality rates and, as it is life threatening, early diagnosis and treatment are crucial. METHODS: Retrospective study of medical records of intrathoracic gastric volvulus patients treated by video-laparoscopy from January 2000 to December 2018, in a University Hospital. RESULTS: Thirty patients (34 surgical procedures - 4 re-operations), 9 (30%) male and 21 (70%) female. The mean age was 57.65 ± 32.65 and the mean body mass index was 27.11 ± 3.5 kg/m2. The most prevalent symptoms were epigastric pain and dysphagia. In 41.17% of the cases, the contrast X-ray confirmed the diagnosis. All 34 cases were intrathoracic volvulus, 24 of which were organo-axial (70.58%). The surgical technique used was hiatoplasty, without mesh (25 cases; 73.52%) and with reinforcement mesh (9 cases; 26.47%), mostly associated with Nissen fundoplication (52.94%). The mean surgical time was 215.7 ± 62.9 minutes, with conversion in 5 cases (15.62%). Hospitalization ranged from 4 ± 2 days. There was no record of operative mortality, and symptom improvement occurred in 100% of patients. The mean follow-up time for patients was 41.8 ± 32.6 months. CONCLUSIONS: Surgical treatment should be indicated to reduce morbidity and mortality, and associated with improved symptoms and patient prognosis. Video-laparoscopic surgery on intrathoracic gastric volvulus proved to be safe and effective and should be the option of choice in the management of this disease.

EARLY WEIGHT LOSS OUTCOMES AND GLUCOSE METABOLISM PARAMETERS AFTER BANDED VERSUS NON-BANDED ONE ANASTOMOSIS GASTRIC BYPASS: A PROSPECTIVE RANDOMIZED TRIAL.

BACKGROUND: The influence of the placement of a band on the outcomes of one anastomosis gastric bypass (OAGB) has not been appropriately studied yet. OBJECTIVE: To compare early weight loss and glucose metabolism parameters following banded versus non-banded OAGB. METHODS: A prospective randomized study, which evaluated 20 morbidly obese individuals who underwent banded and non-banded OAGB and were followed-up for three months. Weight loss (percentage of excess weight loss - %EWL and percentage of body mass index loss - %BMIL) and glucose metabolism outcomes (glucose, insulin and homeostasis model assessment - HOMA) were compared. RESULTS: The banded group presented a significantly higher %EWL at one month (29.6±5.5% vs 17.2±3.4%; P<0.0001) and two months post-surgery (46±7% vs 34.2±9%; P=0.004544), as well as a significantly higher %BMIL at one month (9.7±1.1% vs 5.8±0.8%; P<0.0001), two months (15±1.4% vs 11.5±2.1; P=0.000248), and three months (18.8±1.8% vs 15.7±3.2%; P=0.016637). At three months, banded OAGB led to significant decreases of insulin (14.4±4.3 vs 7.6±1.9; P=0.00044) and HOMA (3.1±1.1 vs 1.5±0.4; P=0.00044), whereas non-banded OAGB also led to significant decreases of insulin (14.8±7.6 vs 7.8±3.1; P=0.006) and HOMA (3.2±1.9 vs 1.6±0.8; P=0.0041). The percent variation of HOMA did not significantly differ between banded and non-banded OAGB (P=0.62414); overall, the percent variation of HOMA was not correlated with %EWL (P=0.96988) or %BMIL (P=0.82299). CONCLUSION: Banded OAGB led to a higher early weight loss than the standard technique. Banded and non-banded OAGB led to improvements in insulin resistance regardless of weight loss.

Efeitos precoces do bypass gástrico de anastomose única com e sem anel sobre a perda de peso e o metabolismo glicêmico: um estudo prospectivo randomizado / Early weight loss outcomes and glucose metabolism parameters after banded versus non-banded one anastomosis gastric bypass: a prospective randomized trial

ABSTRACT BACKGROUND: The influence of the placement of a band on the outcomes of one anastomosis gastric bypass (OAGB) has not been appropriately studied yet. OBJECTIVE: To compare early weight loss and glucose metabolism parameters following banded versus non-banded OAGB. METHODS: A prospective randomized study, which evaluated 20 morbidly obese individuals who underwent banded and non-banded OAGB and were followed-up for three months. Weight loss (percentage of excess weight loss - %EWL and percentage of body mass index loss - %BMIL) and glucose metabolism outcomes (glucose, insulin and homeostasis model assessment - HOMA) were compared. RESULTS: The banded group presented a significantly higher %EWL at one month (29.6±5.5% vs 17.2±3.4%; P<0.0001) and two months post-surgery (46±7% vs 34.2±9%; P=0.004544), as well as a significantly higher %BMIL at one month (9.7±1.1% vs 5.8±0.8%; P<0.0001), two months (15±1.4% vs 11.5±2.1; P=0.000248), and three months (18.8±1.8% vs 15.7±3.2%; P=0.016637). At three months, banded OAGB led to significant decreases of insulin (14.4±4.3 vs 7.6±1.9; P=0.00044) and HOMA (3.1±1.1 vs 1.5±0.4; P=0.00044), whereas non-banded OAGB also led to significant decreases of insulin (14.8±7.6 vs 7.8±3.1; P=0.006) and HOMA (3.2±1.9 vs 1.6±0.8; P=0.0041). The percent variation of HOMA did not significantly differ between banded and non-banded OAGB (P=0.62414); overall, the percent variation of HOMA was not correlated with %EWL (P=0.96988) or %BMIL (P=0.82299). CONCLUSION: Banded OAGB led to a higher early weight loss than the standard technique. Banded and non-banded OAGB led to improvements in insulin resistance regardless of weight loss.

RESUMO CONTEXTO: A influência da colocação de bandas sobre os resultados do bypass gástrico de anastomose única (BGAU) não foi profundamente estudada. OBJETIVO: Comparar a perda precoce de peso e os parâmetros do metabolismo da glicose após bypass gástrico de anastomose única (BGAU) com e sem anel. MÉTODOS: Estudo prospectivo randomizado que avaliou 20 obesos mórbidos submetidos ao BGAU com e sem anel e acompanhados por três meses. A perda de peso (percentual de perda do excesso de peso - %PEP e percentual de perda de peso - %PP) e parâmetros do metabolismo da glicose (glicemia, insulina e modelo homeostático de avaliação - HOMA) foram comparados. RESULTADOS: O grupo com anel apresentou %PEP significativamente maior em um mês (29,6±5,5% vs 17,2±3,4%; P<0,0001) e dois meses após a cirurgia (46±7% vs 34,2±9%; P=0,004544), bem como %PP significativamente maior em um mês (9,7±1,1% vs 5,8±0,8%; P<0,0001), dois meses (15±1,4% vs 11,5±2,1; P=0,000248) e três meses (18,8±1,8% vs 15,7±3,2%; P=0,016637). Aos três meses, o BGAU com anel resultou em reduções significativas de insulina (14,4±4,3 vs 7,6±1,9; P=0,00044) e HOMA (3,1±1,1 vs 1,5±0,4; P=0,00044), enquanto o BGAU sem anel também levou a reduções significativas de insulina (14,8±7,6 vs 7,8±3,1; P=0,006) e HOMA (3,2±1,9 vs 1,6±0,8; P=0,0041). A variação percentual de HOMA não diferiu significativamente entre BGAU com bandas ou sem anel (P=0,62414); no geral, a variação percentual do HOMA não foi correlacionada com %PEP (P=0,96988) ou %PP (P=0,82299). CONCLUSÃO: O BGAU com anel levou a uma maior perda de peso precoce do que a técnica padrão. O BGAU com ou sem anel levou à melhora precoce na resistência à insulina, independentemente da perda de peso.

Solitary pancreatic metastasis from breast cancer: case report and review of literature.

CONTEXT: Pancreatic metastases from primary malignant tumors at other sites are rare, constituting about 2% of the neoplasms that affect the pancreas. Pancreatic metastasis from breast cancer is extremely rare and difficult to diagnose, because its clinical and radiological presentation is similar to that of a primary pancreatic tumor. CASE REPORT: A 64-year-old female developed a lesion in the pancreatic tail 24 months after neoadjuvant therapy, surgery and adjuvant radiation therapy for right-side breast cancer (ductal carcinoma). She underwent distal pancreatectomy with splenectomy and left adrenalectomy, and presented an uneventful outcome. The immunohistochemical analysis on the surgical specimen suggested that the lesion originated from the breast. CONCLUSION: In cases of pancreatic lesions detected in patients with a previous history of breast neoplasm, the possibility of pancreatic metastasis should be carefully considered.

Type 2 Diabetes Mellitus and Simple Glucose Metabolism Parameters may Reliably Predict Nonalcoholic Fatty Liver Disease Features.

OBJECTIVE: This study aims to investigate the correlation between features of NAFLD among individuals with morbid obesity and the surrogate IR markers homeostasis model assessment (HOMA), product of triglycerides and glucose (TyG), and triglyceride-to-high-density-lipoprotein ratio (TG/HDL-c). METHODS: A cross-sectional study, which enrolled 89 individuals who consecutively underwent bariatric surgery from February through December 2015, was conducted. NAFLD was assessed through histological examination of liver biopsies and correlated with the values of HOMA, TyG, and TG/HDL-c and their respective cutoff points for insulin resistance (IR). RESULTS: xThe prevalence of liver steatosis was 68.5%; the affected individuals presented significantly higher fasting glucose levels (p < 0.01) and hemoglobin A1c (p < 0.01), and a significantly higher prevalence of type 2 diabetes mellitus (T2DM) (p < 0.001). Fibrosis occurred in 66.3% of the individuals and was significantly associated with higher levels of HbA1c (p < 0.05) and a higher prevalence of T2DM (p < 0.05). Steatohepatitis was present in 64% of the individuals and was significantly associated with older age (p < 0.05), higher levels of fasting glucose (p < 0.05), and a higher prevalence of T2DM (p < 0.001). After Bonferroni's adjustment, T2DM was significantly correlated with fibrosis (p < 0.01) and steatohepatitis (p < 0.001) and older age was significantly correlated with fibrosis (p < 0.05). T2DM was the only variable independently associated with fibrosis and steatohepatitis (p < 0.05 in both cases). CONCLUSION: T2DM was a significant predictor of NAFLD features among individuals undergoing bariatric surgery; higher Hb A1c was correlated with fibrosis. T2DM was independently associated with fibrosis and steatohepatitis. HOMA, TyG, and TG/HDL-c ratio did not present significant associations with NAFLD.

Rotinas e condutas em cirurgias para as doenças malignas e benignas do esôfago, estômago e duodeno / Preoperative care in surgeries for the malignant and benign diseases of oesophagus, stomach and duodenum

Resumo: As doenças que acometem o trato digestivo alto, mais precisamente o esôfago, estômago e duodeno revestem-se de grande importância não só devido à relevância epidemiológica (com incidências elevadas e crescentes), mas também pela intensidade dos sintomas e a gravidade das complicações, comprometendo de forma significativa a qualidade de vida dos seus portadores. Nas últimas décadas, os avanços nos cuidados a pacientes portadores de doenças benignas e malignas do aparelho digestivo superior se manifestaram por meio da introdução de novos métodos de diagnóstico e estadiamento, mudanças no paradigma das estratégias perioperatórias e desenvolvimento de novos procedimentos, técnicas e vias de acesso cirúrgicos; ampliando ainda mais o espectro de opções diagnósticas e terapêuticas. Diante do amplo acesso a uma quantidade imensa de informações provida pela medicina atual, o desenvolvimento de protocolos de cuidados pré- e pós-operatórios baseados em evidências, resulta em auxílio na tomada de decisão e certamente também contribui para melhoria dos resultados cirúrgicos. Pela complexidade associada, é imperativo que o seguimento destes pacientes seja realizado em serviços terciários, muitos dos quais também se constituem em hospitais de ensino, com participação contínua de profissionais em treinamento e aprendizado. O presente projeto objetiva à elaboração de manual de rotinas e condutas específicas para o tratamento cirúrgico das doenças malignas e benignas do esôfago, estômago e duodeno; fundamentado em evidências clínicas e com aplicação em hospital de nível terciário. No contexto de hospitais universitários, de ensino e de referência ¿ que contem com equipes médicas, de enfermagem e multidisciplinares, além do envolvimento de alunos e médicos residentes em treinamento ¿ a implementação de protocolos de assistência possui relevância ainda maior, visto que não apenas diferencia e favorece melhores resultados operatórios, menor morbimortalidade e maior sobrevida em geral, mas também uniformiza condutas facilitando o processo de aprendizagem(AU)

Abstract: The diseases that affect the upper digestive tract, the esophagus, stomach and duodenum, are of great importance not only due to the epidemiological relevance (with high and increasing incidence), but also the intensity of the symptoms and the severity of the complications, compromising patients quality of life. Lately, the advances in patients care with benign and malignant diseases of the upper digestive system have consisted in the introduction of new diagnostic methods, changes in the paradigm of perioperative strategies and the development of new procedures, techniques and surgical access; expanding the spectrum of diagnostic and therapeutic options. Given the broad access to a vast amount of information provided by current medicine, the development of pre-and post-operative guidelines based on evidence, results in better decision making and certainly also contributes to improved surgical outcomes. Because of the associated complexity, it is imperative that the follow-up of these patients be performed in tertiary services, many of which also constitute teaching hospitals, with continuous participation of professionals in training and learning. The present project aims the elaboration of a guideline of specific routines and procedures for the surgical treatment of malignant and benign diseases of the esophagus, stomach and duodenum; based on clinical evidence. In the context of university, teaching and reference hospitals - which includes medical, nursing and multidisciplinary teams, as well as the involvement of students and physicians in training - the implementation of assistance protocols will have even greater influence, since it not only favors better overall survival, but also facilitates the learning process(AU)

MANAGEMENT OF PANCREATICOPLEURAL FISTULAS SECONDARY TO CHRONIC PANCREATITIS.

INTRODUCTION: Pancreaticopleural fistula is a rare complication of chronic pancreatitis. OBJECTIVE: To describe pancreaticopleural fistula due to chronic pancreatitis and perform an extensive review of literature on this topic. METHODS: Comprehensive narrative review through online research on the databases Medline and Lilacs for articles published over the last 20 years. There were 22 case reports and four case series selected. RESULTS: The main indication for surgical treatment is the failure of clinical and/or endoscopic treatments. Surgery is based on internal pancreatic drainage, especially by means of pancreaticojejunostomy, and/or pancreatic resections. CONCLUSION: Pancreaticopleural fistula is a rare complication of chronic pancreatitis and the Frey procedure may be an appropriate therapeutic option in selected cases when clinical and endoscopic treatments are unsuccessful.

Management of pancreaticopleural fistulas secondary to chronic pancreatitis / Tratamento das fístulas pancreaticopleurais secundárias à pancreatite crônica

ABSTRACT Introduction: Pancreaticopleural fistula is a rare complication of chronic pancreatitis. Objective: To describe pancreaticopleural fistula due to chronic pancreatitis and perform an extensive review of literature on this topic. Methods: Comprehensive narrative review through online research on the databases Medline and Lilacs for articles published over the last 20 years. There were 22 case reports and four case series selected. Results: The main indication for surgical treatment is the failure of clinical and/or endoscopic treatments. Surgery is based on internal pancreatic drainage, especially by means of pancreaticojejunostomy, and/or pancreatic resections. Conclusion: Pancreaticopleural fistula is a rare complication of chronic pancreatitis and the Frey procedure may be an appropriate therapeutic option in selected cases when clinical and endoscopic treatments are unsuccessful.

RESUMO Introdução: A fístula pancreaticopleural é complicação rara da pancreatite crônica. Objetivo: Descrever a fístula pancreaticopleural consequente à pancreatite crônica e fazer revisão extensa da literatura sobre o tópico. Métodos: Revisão narrativa abrangente através de pesquisa online nas bases de dados Medline e Lilacs para artigos publicados nos últimos 20 anos. Resultados: Houve 22 relatos de casos e quatro séries de casos selecionadas. A principal indicação para o tratamento cirúrgico é a falha de tratamentos clínicos e/ou endoscópicos. A cirurgia é baseada na drenagem pancreática interna, especialmente por meio de pancreaticojejunostomias e/ou ressecções pancreáticas. Conclusão: A fístula pancreaticopleural é complicação rara da pancreatite crônica e o procedimento de Frey pode ser opção terapêutica apropriada em casos selecionados quando os tratamentos clínico e endoscópico não obtiverem êxito.