Ten years of IRCAD, Barretos, SP, Brazil

Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.

Combination of preoperative pulmonary and nutritional preparation for esophagectomy

Purpose: To compare pulmonary and nutritional parameters before and after inspiratory muscle training (IMT) and enteral feeding support in patients with esophageal disease undergoing preoperative outpatient follow-up.Methods: Thirty patients with a mean age of 55.83 years, 16 men and 14 women, were included. Pulmonary assessment consisted of the measurement of MIP, MEP, and spirometry. Anthropometric measurements and laboratory tests were performed for nutritional assessment. After preoperative evaluation, inspiratory muscle training and enteral nutrition support were started. A p<0.05 was considered statistically significant. Results: After an outpatient follow-up period of 4 weeks, a significant increase in MIP (-62.20 ± 25.78 to -81.53 ± 23.09), MEP (73.4 ± 31.95 to 90.33 ± 28.39), and FVC (94.86 ± 16.77 to 98.56 ± 17.44) was observed. Regarding the anthropometric variables, a significant increase was also observed in BMI (20.18 ± 5.04 to 20.40 ± 4.69), arm circumference (23.38 ± 3.28 to 25.08 ± 4.55), arm muscle circumference (21.48 ± 3.00 to 22.07 ± 3.36), and triceps skinfold thickness (5.62 ± 2.68 to 8.33 ± 6.59). Conclusion: Pulmonary and nutritional preparation can improve respiratory muscle strength, FVC and anthropometric parameters. However, further studies are needed to confirm the effectiveness of this preoperative preparation.(AU)

Preservation of the vagus nerves in subtotal esophagectomy without thoracotomy

Purpose: To evaluate the outcome of transhiatal esophagectomy without thoracotomy and with preservation of the vagal trunks for the treatment of advanced megaesophagus. Methods: Between March 2006 and September 2017, it was performed 136 transhiatal esophagectomies without thoracotomy by laparoscopy, with preservation of the vagus nerves. All patients were evaluated pre and postoperatively for respiratory and nutritional aspects Post operatively, some surgical aspects were evaluated like radiology and endoscopy of the digestive tract. Results: Follow-up for 7 months to 12 years by clinical, radiologic, endoscopic and pH monitoring revealed satisfactory and encouraging outcomes of the procedure. Conclusion: The laparoscopic transhiatal esophagectomy is a feasible and safe technique with good postoperative outcomes.(AU)

Comparative study of respiratory muscle strength in women undergoing conventional and single-port laparoscopic cholecystectomy

Purpose: To evaluate respiratory muscle strength (PImax and PEmax) before and 24 and 48 h after conventional and single-port laparoscopic cholecystectomy. Methods: Forty women with symptomatic cholelithiasis (18 to 70 years) participated in the study. The patients were divided into two groups: 21 patients undergoing conventional laparoscopic cholecystectomy and 19 patients undergoing single-port laparoscopic cholecystectomy. Differences were considered to be significant when p 0.05. Results: The results showed a greater decline in PImax after 24 h in the group submitted to conventional laparoscopic cholecystectomy, with a significant difference between groups (p=0.0308). Conclusion: Recovery of the parameters studied was more satisfactory and respiratory muscle strength was less compromised in the group submitted to single-port laparoscopic cholecystectomy.(AU)

Comparative study of pain in women submitted to conventional laparoscopic cholecystectomy versus single-port laparoscopic cholecystectomy

Purpose: To evaluate postoperative pain in patients submitted to conventional laparoscopic cholecystectomy with four ports versus single-port laparoscopic cholecystectomy with only one port. Methods: Twenty-one patients were included in the conventional laparoscopic cholecystectomy group and 19 other patients in the single-port laparoscopic cholecystectomy group. A VAS was used for the assessment of postoperative pain at three time points. Differences were considered statistically significant when p 0.05. Results: Intergroup analysis showed no significant difference in VAS scores between the conventional laparoscopic cholecystectomy and single-port laparoscopic cholecystectomy groups at any of the time points studied. Conclusion: This study found no significant difference in postoperative pain between the two groups.(AU)

Outcome of superficial squamous cell carcinoma of the esophagus: a clinicopathological study

PURPOSE: To analyze the clinicopathological features and outcome of patients with pathologically proven superficial squamous cell carcinoma of the esophagus. METHODS: A total of 234 consecutive cases of esophageal carcinoma in a 15-year period were reviewed. RESULTS: Superficial esophageal cancer was found in five patients (2.1%). They were four men and one woman and the mean age was 52.5 years. Smoking and alcohol were the main risk factors. Achalasia due to Chagas disease occurred in one patient and a second primary tumor developed in the larynx in another patient. Four patients underwent esophagectomy and one patient received chemoradiotherapy. The histopathologic diagnosis was of squamous cell carcinoma in all cases. Intramucosal tumor (Tis) was identified in three cases and superficially invasive carcinoma in two cases. Four patients are free of disease with survival times of two, four, six and nine years. The patient who developed laryngeal cancer died six years after esophagectomy. CONCLUSION: Long-term survival in patients with esophageal cancer is related to early diagnosis. Therefore, a less aggressive surgical approach, such as endoscopic resection, may be a good option for these patients, if depth of tumor invasion can be accurately predicted by the new imaging tools.(AU)

Evaluation of breathing exercise in hormonal and immunological responses in patients undergoing abdominal surgery

PURPOSE: To evaluate the effects of sustained deep inspiration in the prevention of postoperative pulmonary complications, the hormonal and immunological responses in patients submitted to abdominal surgery. METHODS: This randomized clinical trial study included 75 patients submitted to abdominal surgery, of which 36 were randomly allocated in the experimental group and underwent sustained deep inspiration during five seconds, in three sets of ten repetitions per day. The others 39 patients were allocated in the control group and were not submitted to any breathing exercise. The following parameters were measured preoperatively, 24h and 48h postoperatively: chest x-ray, serum ACTH, cortisol, IL-4, IL-10, TNF-α, forced expiratory volume in first second (FEV1), forced expiratory flow 25-75% (FEF 25-75), forced vital capacity (FVC), paO2 and paCO2. RESULTS: Mean serum cortisol in patients of the experimental and control groups before surgery were 12.8 mcg/dl (4.6-50) and 10.48 mcg/dl (1-29.1), respectively (p=0.414). The experimental group had significantly increase in serum cortisol levels, 23.6 mcg/dl (9.3-45.8), especially 24h postoperatively (p=0.049). CONCLUSION: Sustained deep inspiration in patients submitted to abdominal surgery determined important changes in serum cortisol, however, without significantly influence the postoperative pulmonary complications and the endocrine and immune responses.(AU)

Intraoperative cholangiography during elective laparoscopic cholecystectomy: selective or routine use?

PURPOSE: To investigate clinical, laboratory and ultrasonographic parameters in patients with and without preoperative criteria for intraoperative cholangiography (IOC) during laparoscopic cholecystectomy in order to define predictive factors of choledocolithiasis. METHODS: As a criterion for inclusion in the study the patients should present chronic calculous cholecystitis in the presence or absence of any recent clinical, laboratory of ultrasonographic finding suggesting choledocolithiasis, who were therefore submitted to cholangiography during surgery. RESULTS: A total of 243 laparoscopic cholecystectomies with IOC were performed on patients with chronic calculous cholecystitis with or without a preoperative formal indication for contrast examination. Choledocolithiasis was detected in 33 (13.58%) of the 243 patients studied. The incidence of previously unsuspected choledocolithiasis was only one case (1.0%) among 100 patients without an indication for this exam. However, 32 (22.37%) cases of choledocolithiasis were observed among the 143 patients with a preoperative indication for IOC. CONCLUSION: The use of selective cholangiography is safe for the diagnosis of choledocolithiasis. Only 22.37% of the cholangiography results were positive in cases of suspected choledocolithiasis.(AU)

Evaluation of anatomical and functional changes esophageal stump of patients with advanced megaesophagus submitted to subtotal laparoscopic esophagectomy / Avaliação das alterações anatômicas e funcionais do coto esofágico de pacientes portadores de megaesôfago avançado submetidos à esofagectomia subtotal laparoscópica

PURPOSE: Evaluate anatomical and functional changes of the esophageal stump and gastric fundus of patients with advanced megaesophagus, submitted to laparoscopic subtotal esophagectomy. METHODS: Twenty patients with advanced megaesophagus, previously submitted to a videolaparoscopic subtotal esophagectomy , were evaluated. Were conducted: radiological evaluation of the stump esophagus with transposed stomach, electromanometric, endoscopic examination and histopathology of the esophageal stump and gastric fundus, without making gastric tube or pyloroplasty. RESULTS: It was observed that the average height and pressure of the anastomosis, in the electromanometric evaluation, were 23.45cm (±1.84cm) and 7.55mmHg (±5.65mmHg). In patients with megaesophagus III, the pressure of the anastomosis was 10.91mmHg (±6.33mmHg), and pressure from the UES, 31.89mmHg (±14.64mm Hg), were significantly higher than those in grade IV. The pathological evaluation detected mild esophagitis in 35% of patients, moderate in 20% and acanthosis glicogenica in 45%. The examination of the gastric fundus showed that 50% of patients were infected with Helicobacter pylori. Chronic gastritis occurred in 95% of the patients. CONCLUSIONS: The laparoscopic esophagectomy shown to be effective in the treatment of advanced achalasia. The cervical level anastomosis protects the esophageal stump from the aggression resulted from gastric reflux after the esophagectomy.(AU)

OBJETIVO: Avaliar as alterações anatômicas e funcionais do coto esofágico e fundo gástrico de pacientes com megaesôfago avançado, submetidos à esofagectomia subtotal laparoscópica. MÉTODOS: Vinte pacientes com megaesôfago avançado, previamente submetidos à esofagectomia subtotal videolaparoscópica, foram avaliados. Foram realizados: avaliação radiológica do coto esofágico com o estômago transposto, eletromanometria endoscopia e exame histopatológico do coto esofágico e fundo gástrico,sem fazer tubo gástrico ou piloroplastia. RESULTADOS: Observou-se que a altura média e pressão da anastomose, na avaliação eletromanométrica, foram: 23,45cm (± 1,84cm) e 7,55mmHg (± 5,65mmHg), Em pacientes com megaesôfago III, a pressão da anastomose foi de 10,91mmHg (± 6,33mmHg), e a pressão do ESE, 31,89mmHg (±14,64mmHg) foram significativamente mais elevados do que aqueles em grau IV. A avaliação patológica detectou esofagite leve em 35% dos pacientes, moderada em 20% e acantose glicogênica em 45%. O exame do fundo gástrico mostrou que 50% dos pacientes foram infectados com Helicobacter pylori. Gastrite crônica ocorreu em 95% dos pacientes. CONCLUSÕES: A esofagectomia laparoscópica mostrou-se eficaz no tratamento de acalasia avançada. A anastomose em nível cervical tem um papel protetor para o coto esofágico ao evitar a agressão resultante de refluxo gástrico após a esofagectomia.(AU)

Innovative technique for the study of pneumoperitoneum in the evaluation of abdominal pain after chemical irritation with zymozan / Técnica original para o estudo da influência do pneumoperitônio na avaliação da intensidade da dor abdominal após irritação química com zimozan

PURPOSE: To assess the influence of pneumoperitoneum in mice submitted to peritoneal irritation provoked by the biological agent Saccharomyces cerevisae, by counting the number of abdominal contractions elicited. METHODS: To study the effects of pneumoperitoneum analgesic action, 60 mice were divided into two groups: the experimental group, subjected to pneumoperitoneum; and the control group, without pneumoperitoneum. The both groups received intraperitoneal injection of zymosan at a dose of 1mg/0,2ml/mouse. RESULTS: The sum of the number of abdominal contractions of the experimental group (with pneumoperitoneum) was significantly lower than that of the control group (without pneumoperitoneum). In the experimental group, a lower number of contractions occurred in each min compared to the control. CONCLUSION: The observation of the analgesic effect of pneumoperitoneum using CO2 in mice submitted to peritoneal irritation by zymosan was verified.(AU)

OBJETIVO: Avaliar a influência do pneumoperitônio em animais submetidos à irritação peritoneal provocada pelo agente biológico Saccharomyces cerevisae mediante a contagem do número de contrações abdominais. MÉTODOS: Para o estudo do efeito da ação analgésica do pneumoperitônio os 60 camundongos foram divididos em dois grupos, grupo experimento (com pneumoperitôneo) e controle (sem pneumoperitôneo). Os dois grupos receberam injeção intraperitoneal de zimosan na dose de 1mg/0,2ml/camundongo. RESULTADOS: O somatório do número de contrações abdominais do grupo experimento (com pneumoperitôneo) foi significativamente menor que no grupo controle (sem pneumoperitôneo). O número médio de contrações no grupo controle foi significativamente maior quando comparado com o grupo experimento. CONCLUSÃO: Observou-se efeito analgésico do pneumoperitônio com CO2 em animais submetidos à irritação peritoneal pelo zimosan.(AU)

Proposal of a new technique for bile duct reconstruction after iatrogenic injury: study in dogs and review of the literature / Reconstrução da via biliar após lesão iatrogênica, proposta de nova técnica. Estudo em cães e revisão da literatura

PURPOSE: Interposition of a jejunal tube between the common bile duct and duodenum. METHODS: Five adult mongrel dogs of both sexes, weighing on average 22.3 kg (18 to 26.5 kg), were used. Obstructive jaundice was induced by ligation of the distal common bile duct. After one week, a 2.5-cm long jejunal tube was fabricated from a segment of the loop removed 15 cm from the Treitz angle and interposed between the common bile duct and duodenum. RESULTS: The animals presented good clinical evolution and no complications were observed. After 6 weeks, complete integration was noted between the bile duct mucosa, tube and duodenum and a significant reduction in total bilirubin and alkaline phosphatase was observed when compared to the values obtained one week after ligation of the common bile duct. CONCLUSION: The jejunal tube interposed between the dilated bile duct and duodenum showed good anatomic integration and reduced total bilirubin and alkaline phosphatase levels in the animals studied.(AU)

OBJETIVO: Interposição de um tubo de jejuno entre o colédoco e o duodeno. MÉTODOS: Foram utilizados cinco cães adultos, sem raça definida, de ambos os sexos, com peso médio de 22,3 Kg (18 e 26,5 Kg). Após provocar icterícia obstrutiva pela ligadura do colédoco distal, após uma semana, praticou-se confecção do tubo de jejuno de 2,5 cm de extensão, que foi realizado com um segmento de alça retirado a 15 cm do ângulo de Treitz e a interposição do tubo entre o colédoco e o duodeno. RESULTADOS: Os animais tiveram boa evolução clínica e não apresentaram complicações. Notou-se total integração entre a mucosa da via biliar, do tubo e do duodeno e redução significativa dos valores da bilirrubina total e da fosfatase alcalina após seis semanas, quando comparado com os valores após uma semana de ligadura do colédoco. CONCLUSÃO: O tubo de jejuno interposto entre a via biliar dilatada e o duodeno, apresentou boa integração anatômica e reduziu os níveis de bilirrubina total e fosfatase alcalina dos animais estudados.(AU)

Comparative analysis of preparation of human hepatocytes by the ethylenediamine tetraacetic acid and collagenase technique / Estudo comparativo da obtenção de hepatócitos humanos pela técnica ácido etilenodiaminotetracético e da colegenase

PURPOSE: To compare the viability of human hepatocytes dissociated by the ethylenediaminetetraacetic acid and collagenase techniques. METHODS: Hepatocytes were prepared by dissociation of liver fragments obtained from hepatectomies performed for therapeutic purposes at the Service of Digestive Tract Surgery, Federal University of Triângulo Mineiro. RESULTS: During the first 4 days of the experiment, 70 percent of the cells presented birefringent membranes and were not stained with 2 percent erythrosine, and were therefore considered to be viable. During the first 3 days, hepatocyte viability was on average 71 percent in the EDTA group and 76 percent in the collagenase group, with no significant difference between groups. No significant difference was observed between groups at any time. The secretion of albumin by the cultured hepatocytes was preserved up to the seventh day. Mean albumin secretion during the first 3 days was 50 æg/ml in the two groups and a reduction of albumin production was observed from the fourth to the seventh day. Again, no significant difference was observed between groups at any time. CONCLUSION: Cell viability and preservation of albumin secretion by hepatocytes are similar for the EDTA and collagenase techniques.(AU)

OBJETIVO: Comparar a viabilidade dos hepatócitos humanos dissociados pelas técnicas do ácido etilenodiaminotetracético e da colagenase. MÉTODOS: Hepatócitos foram preparados pela dissociação de fragmentos de fígado, provenientes de hepatectomias realizadas com o objetivo terapêutico no Serviço de Cirurgia do Aparelho Digestivo da Universidade Federal do Triângulo Mineiro. RESULTADOS: Detectou-se que nos quatro primeiros dias de experimento 70 por cento das células estavam com suas membranas biorrefringentes e não se coravam pela eritrosina a 2 por cento portanto foram consideradas viáveis. Observou-se que nos três primeiros dias a viabilidade dos hepatócitos foi em média 71 por cento no grupo EDTA e 76 por cento na colagenase, diferença esta sem significado estatístico entre os grupos. Em nenhum momento, detectou-se diferença estatística entre os grupos. Com relação a preservação da secreção de albumina pelos hepatócitos em cultura observou-se que foi mantida até o sétimo dia. Da mesma forma, notou-se que nos três primeiros dias a média de secreção de albumina de ambos os grupos foi de 50 ìg/dl e que após o quarto dia verificou-se redução da produção até o sétimo dia. Também não foi observado diferença significativa em nenhum momento entre os grupos. CONCLUSÃO: A viabilidade celular e a preservação da função de secretar albumina pelos hepatócitos são semelhantes pelas técnica do EDTA e da colagenase.(AU)