Sinusoidal dilation increases the risk of complications in hepatectomy for CRCLM - Protective effect of bevacizumab and diabetes mellitus, serum gamma-glutamyltranspeptidase as predictive factor.

INTRODUCTION: Advances in neoadjuvant chemotherapy (NCT) have allowed surgical treatment in otherwise unresectable patients with colorectal liver metastases (CRLM). It is well known that NCT induces liver lesions such as sinusoidal obstruction syndrome (SOS) and steatohepatitis (SH). However, whether it affects postoperative morbidity remains controversial. The aim of this study was both to evaluate the impact of NCT on liver parenchyma and postoperative morbidity, and to identify preoperative predictive markers for liver injury. PATIENTS AND METHODS: Among 140 patients undergoing liver resection for CRLM between 2010 and 2013, 70 underwent systemic NCT. Liver function tests, pathology, postoperative morbidity and mortality were compared between the two groups. RESULTS: Univariate analysis revealed NCT as a cause of sinusoidal dilation (p = 0.09), peliosis (p = 0.028) and moderate and severe SOS (p = 0.004) and bevacizumab as a protective agent against moderate and severe SOS (p = 0.045). Diabetic patients were identified as having a lower incidence of sinusoidal dilation (p = 0.034) and a higher incidence of steatosis (p = 0.003). Multivariate analysis confirmed sinusoidal dilation as an independent cause for morbidity (p = 0.02) and liver-specific complications (p = 0.016). Preoperative level of GGT was identified as predictive factor for moderate and severe SOS and peliosis (p < 0.001 and p = 0.004, respectively). CONCLUSION: The administration of NCT induces SOS-lesions, but can be partially prevented by bevacizumab and diabetes. Sinusoidal dilation is associated with increased postoperative morbidity. Preoperative GGT levels can be useful to predict the presence of SOS.

Germline MUTYH (MYH) mutations in Portuguese individuals with multiple colorectal adenomas.

Germinal mutations in the base excision repair (BER) gene MUTYH (MYH) have recently been described in association with predisposition to multiple colorectal adenomas and cancer. In contrast to the classic dominant condition of familial adenomatous polyposis (FAP) due to germinal mutations in the APC gene, the MYH polyposis is an autosomal recessive disease. The identification of individuals affected by MYH polyposis brings new and important implications for the diagnostic, screening, genetic counseling, follow up and therapeutic options in these patients. In this study, screening for germinal mutations in the MYH gene was performed in 53 Portuguese individuals with multiple colorectal adenomas or classic adenomatous polyposis, in whom no mutation had been identified in the APC gene. The results revealed the presence of biallelic germline MYH mutations in 21 patients. In addition, we here report 3 mutations (c.340T>C [p.Y114H]; c.503G>A [p.R168H]; and c.1186_1187insGG [p.E396fsX437]) which, to our knowledge, have not been previously described.

[Acute pancreatitis. An analysis of 91 consecutive cases (1988-1991) with a brief review of the literature)]. / Pancreatite aguda. Análise de 91 casos consecutivos (1988-1991) com breve revisão da literatura.

Acute pancreatitis (AP) remains a subject of great controversy from the standpoint of its aetiology, pathogeny and treatment. We present a study of 91 patients with AP consecutively admitted to a surgical ward. 50 Women and 41 men with a mean age of 59 +/- 19 years were treated. The aetiology of AP was attributed to gallstones in 54 patients, alcohol in 22, ERPC and trauma; in 14 patients the aetiology was considered idiopathic. The most frequent signs and symptoms were pain, vomiting, abdominal tenderness, jaundice and fever. The mean number of Ranson's prognostic criteria was 3 +/- 1.5 and 29 patients (31%) had more than three. Initial management was conservative in 84 patients (92.3%) and seven were operated on admission (acute abdomen in four, septic shock in two and common duct obstruction in another). Mortality rate was 11% (n = 10) and in 24 patients (26.3%) there were complications of AP. Most of the patients (80%) began oral feeding a week after admission. The mean number of Ranson's criteria of patients deceased was 5.4 +/- 1.6 and of those who survived was 2.8 +/- 1.3 (p < 0.001). Follow-up of patients allowed us to see that in five (5.5%) there was a relapse of AP.

[Esophageal perforations]. / Perfurações do esófago.

The opportunity of having successfully treated a patient with intrathoracic perforation of the Oesophagus and many surgical complications, led us to review the literature on the subject. We then discussed the advantages and disadvantages of the various technical options, concluding that immediate Oesophagectomy is the best solution for this type of perforation, with several hours of evolution and serious mediastinite, to reduce surgical complications and mortality.

[Prophylaxis of postoperative thromboembolism. Randomized prospective study]. / Profilaxia da tromboembolia pós-operatória. Estudo prospectivo randomizado.

The difference between a non fractioned heparin (Liquemine) and another of low molecular weight (Fraxiparine) was compared through: hemostasis difficulties, during and after surgery; the use of transfusions; clinical signs of inferior limb vein thrombosis or pulmonary emboli; laboratory results of blood (hemogramme, biochemistry, coagulation) and urine. The results observed in 500 patients, (250 of each heparin) statistically treated, show that no difference was found between the two groups of patients, which lead us to conclude that both heparins have the same effect. Low molecular weight has the advantage of being administrated only once a day.

[Plasma levels of alpha-fetoprotein and carcinoembryonic antigen in patients with malignant gastrointestinal tumors]. / Níveis plasmáticos da alfa-fetoproteína e do antigénico carcino-embrionário em doentes com tumores malignos gastro-intestinais.

Levels of alpha-fetoprotein (AEP) and carcinoembryonic antigen (CEA) were determined in the plasma of 142 patients with malignant gastrointestinal tumours. AEP was raised in only four patients (2.8%); two patients with carcinoma of the stomach showed relatively elevated levels. Abnormal CEA levels were found in 82 patients (57.7%). The patients' age with positive CEA levels was a greater than that of the patients with normal levels (p less than 0.05). In patients with gastric tumours CEA positivity was correlated with clinico-pathological stage (pTNM) and with the resectability rate (p less than 0.05). In patients with carcinoma of colon and rectum a greater incidence of elevated plasma CEA levels, as well as higher levels, were found in patients with carcinoma of the left colon than in those with right colon tumours. Statistically significant differences were found between the positivity rate and Dukes' grading (p less than 0.05), as well as between CEA levels in Dukes' stages C and 'D' (p less than 0.005). It is concluded that AFP has a very limited clinical role in patients with malignant extra-hepatic gastrointestinal tumours and that CEA may have a clinical role in tumours of the digestive tract, other than carcinoma of colon and rectum.

Water enema computed tomography (WE-CT) in the local staging of low colorectal neoplasms: comparison with transrectal ultrasound.

BACKGROUND: To determine the accuracy of computed tomography performed with a water enema application (WE-CT) in the local staging of low colorectal neoplasms and to compare the results with those of transrectal ultrasonography (TRUS). METHODS: Forty patients with low colorectal tumors were evaluated prospectively by CT with the simultaneous administration of a lukewarm rectal enema (0.5-1.5 L). Thin slices (5 mm) and intravenous application of iodinated contrast media were routinely used. TRUS was performed in 18 patients. Tumor size, location, and staging according to the TNM classification of the UICC were registered. Tumors were classified as < T3 (T1 or T2) or as T3 or T4. For staging peritumoral lymph node metastases on WE-CT, two criteria of positivity were tested: N+ if at least one peritumoral node > or 5 mm in diameter was seen (reading A); N+ if at least one peritumoral node > or = 5 mm or three peritumoral nodes < 5 mm were identified (reading B). RESULTS: For the tumor staging, WE-CT showed a sensitivity of 90%, a specificity of 73%, a positive predictive value (PPV) of 90%, a negative predictive value (NPV) of 73%, and an accuracy of 85%. For TRUS, the results were sensitivity of 73%, specificity of 29%, PPV of 62%, NPV of 40%, and an accuracy of 39%. Concerning nodal staging with WE-CT, results were superior when reading A was used: sensitivity = 84%, specificity = 83%, PPV = 73%, NPV = 91%, and accuracy = 84%. TRUS showed a sensitivity of 29%, specificity of 100%, PPV of 100%, NPV of 67%, and an accuracy of 71%. CONCLUSION: WE-CT is a reliable technique for the local staging of low colorectal tumors that can be superior to TRUS. For diagnosis of peritumoral metastatic lymph nodes on WE-CT, the 5-mm diameter cutoff value is the most appropriate size criterion.