Optimization of Surgical Time Through the Implementation of a Rational Protocol to Prevent Bleeding in Sleeve Gastrectomy.

Introduction: Staple line oversewing (SLO) is a prophylactic alternative due to its low cost and its effect of decreasing the incidence and severity of bleeding complications in sleeve gastrectomy (SG). However, this approach significantly increases the surgical time and may be associated with stenosis. The study aims to identify whether its usage was sufficient to optimize the surgical time in patients whose screening for the risk of occult bleeding was negative. Materials and Methods: The study enrolled 103 patients. Having the systolic blood pressure goal of 140 mmHg, the staple line is checked for bleeding points, counting as follows: >5 bleeding points proceed to SLO, <5 bleeding points are managed using clips, and if no bleeding points are found, the procedure can be completed. Results: The bleeding test was positive in 79.6% of the cases and oversewing was necessary for 44.7% of the total. The bleeding test result was significant for the increased surgical time. The mean surgical time in SLO was 16.4% higher than in clipping. There was a significant difference in surgical time between SLO and clipping; however, no significant difference was identified between clipping and continuing the procedure without further measures. No postoperative complication related to staple line bleeding was identified. Discussion: In a scenario with limitations for the use of high-cost homeostatic agents, the stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time without significant added risks. Conclusion: A stratified protocol to prevent bleeding in SG stapling line was able to significantly reduce surgical time.

Improvement in Muscle Strength and Metabolic Parameters Despite Muscle Mass Loss in the Initial Six Months After Bariatric Surgery.

BACKGROUND: An aggravation in pre-existing sarcopenia or the onset of sarcopenia may occur in the scenario of extensive and fast weight loss in the initial months following bariatric surgery. The accurate identification of sarcopenia criteria and its metabolic repercussions is vital for its correct management. The aim of this study is to evaluate the correlation between the diagnosis criteria for sarcopenia and metabolic repercussions during the first 6 months following bariatric surgery. METHODS: A prospective single-center cohort study was conducted. Convenience sampling was performed among patients with severe obesity undergoing preoperative evaluation for bariatric surgery. Metabolic parameters, nutritional evaluation, and skeletal muscle evaluation were assessed before surgery and 6 months later. RESULTS: A total of 129 patients were selected, 62 participants were included in the final analysis. Mean age was 37.7 years and 88.4% of participants were women. Mean body mass index was 41.8 kg/m2 and 47.8% of patients were sedentary. Sleeve gastrectomy was performed in 41 patients and Roux-en-Y gastric bypass in 21 patients. Significant improvement regarding muscle strength and function after surgery was observed. Sarcopenia criteria were not met by any participant before and after surgery. Blood glucose and ferritin levels remained independently associated with change in muscle strength. CONCLUSIONS: Functional evaluation methods did not reflect the reduction in skeletal muscle mass demonstrated in bioelectrical impedance analysis 6 months after bariatric surgery in comparison to the preoperative baseline. Improvement in muscle strength was followed by improvement in metabolic parameters.

Interest in research among medical students: Challenges for the undergraduate education.

INTRODUCTION:: In recent decades, there has been a reduction in the number of graduates from medical schools who choose to pursue a career in scientific research. That has an impact on the profile of graduates, since medical education depends on understanding the formation of scientific evidence. The construction of new knowledge is also hampered by the reduction of medical scientists, whose clinical experience with patients provides an essential step towards medical Science evolution. OBJECTIVE:: The present cross-sectional study sought to identify the interest in research among medical students from a federal university in southern Brazil. METHOD:: Medical students from a federal university were asked to respond to a self-administered questionnaire that sought to identify the level of knowledge about the importance of scientific research in medical training, and the interest of this population in this element of their training. RESULTS:: 278 medical students from the first to the sixth year responded to the questionnaire, and 81.7% stated their interest in medical research. However, only 4.7% of respondents considered research as first in degree of importance to their medical training. The variable "interest in research" showed no statistically significant association with age, gender, presence of physicians in the family, or other prior college courses. CONCLUSION:: Although interest in research is clearly present among the students, this is still an underexplored element among the population studied. The incorporation of research in the learning process depends on stimulus and guidance until it becomes culturally consolidated as an essential element of the medical training.

Interest in research among medical students: Challenges for the undergraduate education / Interesse em pesquisa entre estudantes de medicina: desafios para a graduação

Summary Introduction: In recent decades, there has been a reduction in the number of graduates from medical schools who choose to pursue a career in scientific research. That has an impact on the profile of graduates, since medical education depends on understanding the formation of scientific evidence. The construction of new knowledge is also hampered by the reduction of medical scientists, whose clinical experience with patients provides an essential step towards medical Science evolution. Objective: The present cross-sectional study sought to identify the interest in research among medical students from a federal university in southern Brazil. Method: Medical students from a federal university were asked to respond to a self-administered questionnaire that sought to identify the level of knowledge about the importance of scientific research in medical training, and the interest of this population in this element of their training. Results: 278 medical students from the first to the sixth year responded to the questionnaire, and 81.7% stated their interest in medical research. However, only 4.7% of respondents considered research as first in degree of importance to their medical training. The variable "interest in research" showed no statistically significant association with age, gender, presence of physicians in the family, or other prior college courses. Conclusion: Although interest in research is clearly present among the students, this is still an underexplored element among the population studied. The incorporation of research in the learning process depends on stimulus and guidance until it becomes culturally consolidated as an essential element of the medical training.

Resumo Introdução: nas últimas décadas, diminuiu o número de egressos de escolas médicas que optam por se dedicar à pesquisa científica. Isso tem impacto sobre o perfil dos profissionais formados, já que o aprendizado médico é indissociável da compreensão da formação da evidência científica. A formação de novo conhecimento é prejudicada com a redução de pesquisadores médicos, cujo contato clínico com os pacientes fornece etapa essencial na evolução da ciência médica. Objetivo: o presente estudo transversal buscou identificar o interesse em pesquisa entre estudantes de medicina de uma universidade federal do Sul do Brasil. Método: estudantes de medicina de uma universidade federal foram convidados a responder um questionário autoaplicável que buscou identificar o nível de conhecimento sobre a importância da pesquisa científica na formação do médico, bem como o interesse dessa população por esse elemento da formação. Resultados: 278 estudantes de todas as séries do curso de medicina responderam ao questionário, e 81,7% declararam interesse pela pesquisa científica. Contudo, apenas 4,7% dos entrevistados consideraram a pesquisa em primeiro lugar em grau de importância para a sua formação. A variável "interesse em pesquisa" não apresentou associação estatisticamente significativa com idade, gênero, presença de médicos na família ou outro curso superior prévio. Conclusão: embora o interesse em pesquisa esteja claramente presente entre os estudantes, este é um elemento da formação ainda pouco explorado pela população estudada. A incorporação da pesquisa na rotina do aprendizado depende de estímulo e orientação até que esteja culturalmente consolidada como matriz essencial da formação.

Use of Left Gastric Vein as an Alternative for Portal Flow Reconstruction in Liver Transplantation.

Portal vein thrombosis is observed in up to 10% of liver transplant candidates, hindering execution of the procedure. A dilated gastric vein is an alternative to portal vein reconstruction and decompression of splanchnic bed. We present two cases of patients with portal cavernoma and dilated left gastric vein draining splanchnic bed who underwent liver transplantation. The vein was dissected and sectioned near the cardia; the proximal segment was ligated with suture and the distal segment was anastomosed to the donor portal vein. Gastroportal anastomosis is an excellent option for portal reconstruction in the presence of thrombosis or hypoplasia. It allows an adequate splanchnic drainage and direction of hepatotrophic factors to the graft.

AMBULATORY LAPAROSCOPIC CHOLECYSTECTOMY IS SAFE AND COST-EFFECTIVE: a Brazilian single center experience.

BACKGROUND: - Laparoscopic cholecystectomy is the treatment of choice for gallstone disease, and has been perfomed as an outpatient surgery in many Institutions over the last few years. OBJECTIVE: - This is a retrospective study of a single center in Brazil, that aims to analyze the outcomes of 200 cases of ambulatory laparoscopic cholecystectomy performed by the same Hepato-Pancreato-Biliary team, evaluating the safety and cost-effectiveness of the method. METHODS: - Two hundred consecutive patients who underwent elective laparoscopic cholecystectomy were retrospectively analyzed; some of them underwent additional procedures, as liver biopsies and abdominal hernias repair. RESULTS: - From a total of 200 cases, the outpatient surgery protocol could not be carried out in 22 (11%). Twenty one (95.5%) patients remained hospitalized for 1 day and 1 (4.5%) patient remained hospitalized for 2 days. From the 178 patients who underwent ambulatory laparoscopic cholecystectomy, 3 (1.7 %) patients returned to the emergency room before the review appointment. Hospital cost was on average 35% lower for the ambulatory group. CONCLUSION: - With appropriate selection criteria, ambulatory laparoscopic cholecystectomy is feasible, safe and effective; readmission rate is low, as well as complications related to the method. Cost savings and patient satisfaction support its adoption. Other studies are necessary to recommend this procedure as standard practice in Brazil.

Ambulatory laparoscopic cholecystectomy is safe and cost-effective

ABSTRACT Background - Laparoscopic cholecystectomy is the treatment of choice for gallstone disease, and has been perfomed as an outpatient surgery in many Institutions over the last few years. Objective - This is a retrospective study of a single center in Brazil, that aims to analyze the outcomes of 200 cases of ambulatory laparoscopic cholecystectomy performed by the same Hepato-Pancreato-Biliary team, evaluating the safety and cost-effectiveness of the method. Methods - Two hundred consecutive patients who underwent elective laparoscopic cholecystectomy were retrospectively analyzed; some of them underwent additional procedures, as liver biopsies and abdominal hernias repair. Results - From a total of 200 cases, the outpatient surgery protocol could not be carried out in 22 (11%). Twenty one (95.5%) patients remained hospitalized for 1 day and 1 (4.5%) patient remained hospitalized for 2 days. From the 178 patients who underwent ambulatory laparoscopic cholecystectomy, 3 (1.7 %) patients returned to the emergency room before the review appointment. Hospital cost was on average 35% lower for the ambulatory group. Conclusion - With appropriate selection criteria, ambulatory laparoscopic cholecystectomy is feasible, safe and effective; readmission rate is low, as well as complications related to the method. Cost savings and patient satisfaction support its adoption. Other studies are necessary to recommend this procedure as standard practice in Brazil.

RESUMO Contexto - A colecistectomia laparoscópica é o tratamento de escolha da colelitíase, e tem sido realizada de maneira ambulatorial em diversas instituições nos últimos anos. Objetivo - Esse é um estudo retrospectivo de um grande centro no Brasil, que tem por objetivo analisar os resultados de 200 casos de colecistectomia laparoscópica ambulatorial realizadas pela mesma equipe de cirurgia Hepato-Pancreato-Biliar, avaliando a segurança e custo-efetividade do método. Métodos - Duzentos pacientes consecutivos submetidos à colecistectomia laparoscópica eletiva foram analisados retrospectivamente; alguns realizaram em conjunto outros procedimentos adicionais, como biópsias hepáticas e reparo de hérnias de parede abdominal. Resultados - De um total de 200 casos, o protocolo de cirurgia ambulatorial não pôde ser concluído em 22 (11%). Vinte e um (95.5%) pacientes permaneceram hospitalizados por 1 dia e um (4,5%) paciente por 2 dias apenas. Dos 178 pacientes que foram submetidos à colecistectomia laparoscópica ambulatorial, 3 (1,7%) retornaram à emergência antes da data prevista. O custo hospitalar foi em média 35% menor no grupo ambulatorial. Conclusão - Com critérios de seleção apropriados, a colecistectomia laparoscópica ambulatorial é factível, segura e custo-efetiva; a taxa de readmissão é baixa, assim como as complicações relacionadas ao método. A redução de custos e a satisfação dos pacientes respaldam sua realização. Outros estudos são necessários para recomendar esse procedimento como padrão no Brasil.

ASSOCIATION BETWEEN MURINE DOUBLE MINUTE 2 - T309G polymorphism and recurrence of hepatocellular carcinoma after surgical treatment

Background - Discovery and incorporation of biomarker panels to cancer studies enabled the understanding of genetic variation and its interference in carcinogenesis at molecular level. The potential association between single nucleotide polymorphism (SNP) 309 and increased development of tumors, such as hepatocellular carcinoma, has been subject to several studies. This is the first study on this association conducted in Brazil. Methods - 62 cases of cirrhotic patients with hepatocellular carcinoma surgically treated by partial hepatectomy (HPT) or by liver transplantation (LTX) from 2000 to 2009 at Santa Casa Hospital Complex, in the city of Porto Alegre, were retrospectively analyzed. Tumor samples from surgical specimen were collected and prepared for study in paraffin blocks. Results - Overall survival was 26.7 months in the HPT group and 62.4 months in the LTX group (P <0.01). Overall tumor recurrence was 66.7% in the HPT group (10/15) and 17% in the LTX group (8/47) (X²=13.602, P <0.01). Alpha-fetoprotein levels >200ng/mL, microvascular invasion and histological grade were associated with tumor recurrence (P <0.01). Recurrence rates in each surgical group and analysis of factors associated with tumor recurrence, when stratified for each genotypic pattern, were both not statistically significant. Conclusion - G/G genotype was not associated with tumor recurrence after surgical treatment and it did not show any correlation with other prognostic factors.

Contexto - A descoberta e incorporação de painéis de biomarcadores aos estudos do câncer permitiram o conhecimento de variações genéticas e sua interferência no processo de carcinogênese. A possibilidade de associação do polimorfismo de nucleotídeo simples T309G do gene MDM2 com o aumento da formação de tumores, dentre eles o hepatocarcinoma, tem sido alvo de diversos estudos. Objetivo - Analisar a influência do polimorfismo T309G do gene MDM2 na recidiva tumoral de pacientes cirróticos com hepatocarcinoma submetidos a tratamento cirúrgico. Métodos - Foram analisados retrospectivamente pacientes cirróticos com carcinoma hepatocelular submetidos a tratamento cirúrgico (hepatectomia parcial ou transplante hepático) no período de 2000 a 2009, na Santa Casa Hospital Complex in Porto Alegre, South Brazil. Foram coletadas amostras de fragmentos tumorais da peça operatória (fígado explantado ou segmento hepático), as quais foram preparadas para estudo em bloco parafinado. Resultados - A sobrevida global foi de 26,7 meses para o grupo hepatectomias e 62,4 meses para o grupo transplante hepático (P <0,01), havendo 66,7% de recidiva global no grupo hepatectomias (10/15), e 17% no grupo transplante hepático (8/47) (X²=13,602, P <0.01). Níveis de AFP>200ng/mL correlacionaram-se com a recidiva tumoral em ambos os subgrupos cirúrgicos. Observou-se que 83,3% dos pacientes com recidiva também apresentaram invasão microvascular ao exame anátomo-patológico (P <0,01). Não houve significância estatística quando a recidiva neoplásica foi avaliada para os diferentes genótipos e analisada para cada subgrupo cirúrgico. A análise dos fatores prognósticos relacionados à recidiva do hepatocarcinoma, quando estratificada para cada padrão genotípico, também não se mostrou significante. Conclusão - O nosso estudo revelou que o genótipo G/G não esteve associado à recidiva tumoral após o tratamento cirúrgico, seja nas hepatectomias parciais ou transplante hepático. Além disso, a presença desse genótipo não mostrou correlação com os fatores prognósticos estudados.

ASSOCIATION BETWEEN MURINE DOUBLE MINUTE 2 - T309G polymorphism and recurrence of hepatocellular carcinoma after surgical treatment.

BACKGROUND: Discovery and incorporation of biomarker panels to cancer studies enabled the understanding of genetic variation and its interference in carcinogenesis at molecular level. The potential association between single nucleotide polymorphism (SNP) 309 and increased development of tumors, such as hepatocellular carcinoma, has been subject to several studies. This is the first study on this association conducted in Brazil. METHODS: 62 cases of cirrhotic patients with hepatocellular carcinoma surgically treated by partial hepatectomy (HPT) or by liver transplantation (LTX) from 2000 to 2009 at Santa Casa Hospital Complex, in the city of Porto Alegre, were retrospectively analyzed. Tumor samples from surgical specimen were collected and prepared for study in paraffin blocks. RESULTS: Overall survival was 26.7 months in the HPT group and 62.4 months in the LTX group (P <0.01). Overall tumor recurrence was 66.7% in the HPT group (10/15) and 17% in the LTX group (8/47) (X²=13.602, P <0.01). Alpha-fetoprotein levels >200ng/mL, microvascular invasion and histological grade were associated with tumor recurrence (P <0.01). Recurrence rates in each surgical group and analysis of factors associated with tumor recurrence, when stratified for each genotypic pattern, were both not statistically significant. CONCLUSION: G/G genotype was not associated with tumor recurrence after surgical treatment and it did not show any correlation with other prognostic factors.