Multiple colorectal liver metastases resection can offer long-term survival: The concept of a chronic neoplastic disease.

BACKGROUND: Resection for colorectal liver metastases has evolved significantly and, currently, there are no limits to the number of resected nodules. This study aimed to evaluate the outcomes and prognostic factors after liver resection for patients with ≥4 colorectal liver metastases, emphasizing long-term survival. METHODS: The study population consisted of 137 patients with ≥4 colorectal liver metastases out of a total of 597 patients with colorectal liver metastases who underwent curative intent liver resection from January 2010 to July 2019 in a single hepatobiliary center. RESULTS: The probability of overall and disease-free survival at 1, 3, and 5 years was 90.8%, 64.5%, 40.6%, and 37.7%, 19.3%, 18.1%, respectively. In a multivariate analysis for overall survival, the size of the largest metastatic nodule was the only unfavorable factor (P = .001). For disease-free survival, complete pathological response was a favorable factor (P = .04), and the following were negative factors: number of nodules ≥7 (P = .034), radiofrequency ablation during surgery (P = .04), positive primary tumor lymph nodes (P = .034), R1 resection (P = .011), and preoperative carcinoembryonic antigen >20 ng/mL (P = .015). After the first and second years of follow-up, 59 patients (45.3%) and 45 patients (34.6%), respectively, were not receiving chemotherapy. After 5 years of follow-up, 21 (16.1%) multimetastatic patients were chemotherapy-free. CONCLUSION: A significant number of patients with multiple colorectal liver metastases will present long-term survival and should not be denied surgery. The long-term survival rates, even in the presence of recurrence, characterize a chronic neoplastic disease.

A rare case of idiopathic congenital megaduodenum in adult misinterpreted during childhood: case report and literature review.

Intestinal malformations are common disorders in newborn and favorable outcomes have been reported for such conditions. Although, if the patient is treated in a not experienced center, misinterpretation of the clinical and radiological findings may lead to errors in treatment and possible complications in adulthood. We report a case of a congenital megaduodenum which was misinterpreted as an intestinal malrotation resulting in late complications. The patient underwent a successful surgical resection of the duodenum with improvement of his clinical symptoms and nutritional status. This case report emphasizes the importance of considering megaduodenum in the differential diagnosis of patients with feeding impairment, even during adulthood. Early diagnosis and treatment may improve patients' outcome and reduce morbidity.

Downstaging and resection after neoadjuvant therapy for fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare malignant liver neoplasm, commonly observed in adolescents and young adults of both genders. The disease is more common in Caucasians and in patients without a prior history of liver disease. The best treatment option is a surgical resection associated with liver hilum lymph node dissection. However, there is no established systemic drug treatment for patients with locally advanced or metastatic disease. We report on a patient with advanced FLHCC, initially considered unresectable due to invasion of the right and the middle hepatic veins and circumferential involvement of the left hepatic vein. Following the treatment with gemcitabine-oxaliplatin systemic chemotherapy, the patient exhibited a significant tumor reduction. As a result, a complete resection was performed with an extended right hepatectomy associated with a partial resection of the inferior vena cava, a wedge resection in segment 2, and lymphadenectomy of the hepatic hilum. The case was unusual due to the significant tumor downstaging with gemcitabine-oxaliplatin, potentially enabling curative resection. More studies are needed to confirm the efficacy of the systemic drug treatment for FLHCC.

Rare cause of abdominal incidentaloma: Hepatoduodenal ligament teratoma.

The occurrence of a hepatoduodenal ligament teratoma is extremely rare, with only a few cases reported in the literature. This case report describes the discovery of a hepatoduodenal ligament lesion revealed during abdominal ultrasonography for cholelithiasis-related abdominal pain in a 27-year-old female. Cross-sectional imaging identified a 5 cm × 4 cm heterogeneous mass of fat tissue with irregular calcification located in the posterior-superior aspect of the head of the pancreas. An encapsulated lesion showing no invasion to the common bile duct or adjacent organs and vessels was exposed during laparotomy and resected. Intraoperative cholangiography during the cholecystectomy showed no abnormalities. The postoperative course was uneventful. Pathological analysis of the resected mass indicated hepatoduodenal ligament teratoma. This case report demonstrates that cross-sectional imaging, such as computed tomography, can reveal suspected incidences of this rare type of teratoma, which can then be confirmed after pathologic analysis of the specimen. The prognosis after complete surgical resection of lesions presenting with benign pathological features is excellent.

Reduced population of interstitial cells of Cajal in Chagasic megacolon.

BACKGROUND/AIMS: In Chagasic megacolon, there is a reduction in the population of interstitial cells of Cajal. It was aimed to evaluate density of Cajal cells in the resected colon of Chagasic patients compared to control patients and to verify possible association between preoperative and postoperative bowel function of megacolon patients and cell count. METHODOLOGY: Sixteen megacolon patients (12 female; mean age 54.4 (31-73)) were operated on. Pre- and postoperative evaluation using Cleveland clinic constipation score was undertaken. Resected colons were examined. Cajal cells were identified by immunohistochemistry (anti-CD117). The mean cell number was compared to resected colons from 16 patients (7 female; mean age 62.8 (23-84)) with non-obstructive sigmoid cancer. Association between pre- and postoperative constipation scores and cell count for megacolon patients was evaluated using the Pearson test (r). RESULTS: A reduced number of Cajal cells (per field: 2.84 (0-6.6) vs. 9.68 (4.3-13); p<0.001) were observed in the bowel of megacolon patients compared to cancer patients. No correlation between constipation score before (r=- 0.205; p=0.45) or after surgery (r=0.291; p=0.28) and cell count in megacolon was observed. CONCLUSIONS: Patients with megacolon display marked reduction of interstitial cells of Cajal. An association of constipation severity and Cajal cells depopulation was not demonstrated.

Depopulation of interstitial cells of cajal in chagasic megacolon: towards tailored surgery? / Depleção de células intersticiais de Cajal no megacólon chagásico: a caminho do tratamento cirúrgico individualizado?

BACKGROUND: The mechanism of constipation in patients with Chagasic megacolon remains partially explained. In these patients, it was recently demonstrated a reduction in the population of interstitial cells of Cajal. AIM: To evaluate density of Cajal cells in the surgically resected colon of Chagasic patients in comparison to control patients, and to verify possible association between preoperative and postoperative bowel function of Chagasic patients and colonic cell count. METHOD: Sixteen patients with Chagasic megacolon were operated on. Clinical pre- and post-operative evaluation using the Cleveland Clinic Constipation Score was undertaken. Resected colons were examined. Cajal cells were identified by immunohistochemistry using anti-CD117 antibody. The mean cell number was compared to resected colons from 16 patients with non-obstructive sigmoid cancer. Association between pre-and post-operative constipation scores and cell count for megacolon patients was evaluated using the Pearson coefficient correlation test (r). RESULTS: A reduced number of Cajal cells [cells per field: 2.84 (0-6.6) vs. 9.68 (4.3-13) - p<0.001] was observed in the resected colon of Chagasic patients when compared to colon cancer patients. No correlation between constipation score before (r=-0.205; p=0.45) or after surgery (r=0,291; p=0.28) and cell count for megacolon patients was observed. CONCLUSIONS: Patients with Chagasic megacolon display marked reduction of interstitial cells of Cajal when compared to non-Chagasic patients. An association of constipation severity and Cajal cells depopulation in Chagasic megacolon could not be demonstrated.

RACIONAL: A fisiopatologia da constipação intestinal nos pacientes portadores de megacólon chagásico permanece parcialmente esclarecida. Recentemente demontrou-se que nesses pacientes, o contingente de células intersticiais de Cajal está reduzido assim como ocorre em outros distúrbios funcionais gastrointestinais. OBJETIVO: Avaliar a densidade de células intersticiais de Cajal no intestino ressecado de pacientes submetidos a tratamento cirúrgico eletivo de megacólon chagásico em comparação com a observada no cólon de pacientes controles, e verificar possível associação entre o grau de constipação intestinal de pacientes com megacólon chagásico no pré e no pós-operatório e o grau de despopulação de células de Cajal. MÉTODO: Dezesseis pacientes com megacólon chagásico foram operados. A avaliação da função intestinal através do escore de constipação da Cleveland Clinic foi registrada antes e após a operação. O espécime cirúrgico foi examinado e as células de Cajal foram identificadas pela técnica imunoistoquímica empregando o anticorpo anti-CD117 (c-kit). O número médio de células de Cajal nos megacólons foi comparado com o de cólons ressecados de 16 pacientes [7 mulheres; média de idade de 62,8 (23-84)] operados de câncer não-obstrutivo do sigmóide. A associação entre o escore de constipação no pré e no pós-operatório e a contagem de células de Cajal foi medida através do coeficente de correlação de Pearson (r). RESULTADOS: Redução significativa no número de células de Cajal (células por campo de 400X: 2,84 (0-6,6) vs. 9,68 (4,3-13) - ] foi observada nos megacólons quando comparados ao espécime de pacientes operados por câncer. Não foi observada associação entre o escore de constipação pré (r=-0.205; p=0.45) ou pós-operatório (r=0,291; p=0.28) a a contagem de células de Cajal para os pacientes com megacólon. CONCLUSÕES: Pacientes com megacólon chagásico exibem acentuada redução no número de células intersticiais de Cajal no intestino grosso...

Surgical outcomes after preceptored laparoscopic colorectal surgery: results of a Brazilian preceptorship program.

BACKGROUND/AIMS: Safety of laparoscopic colectomy education methods remains unknown. This study aimed at comparing the outcomes of patients undergoing preceptored laparoscopic colectomy with patients operated on by the same preceptor. METHODOLOGY: A prospective analysis of 30 pre-ceptored operations performed by nine surgeons (PD group) between 2006 and 2008 was conducted. Data of 30 operations matched for diagnosis and surgery type conducted by the same preceptor (P group) were evaluated. RESULTS: Median age was 56.2 (26-80) and 55.2 (22-81) respectively in P and PD group (p = 0.804). Eleven (36.7%) were male in P group, 16 (53.3%) in PD group (p = 0.194). Preceptored operations were not significantly longer than operations performed by the preceptor (198 vs. 156 min)--p = 0.072. Length of hospital stay did not differ [4 days (3-12) in P group, and 5 (3-15) in PD group, p = 0.296]. Conversion occurred in 4 cases in PD and in 2 in P group (p = 0.389). Morbidity was similar (23.3% in P and 26.7% in PD group). One patient from P and two from PD group needed reoperation. No deaths occurred. CONCLUSIONS: Laparoscopic colorectal surgery preceptorship programs in surgeon learner's place are safe. Surgeons' introduction through basic and hands-on courses is required for skills acquisition needed to minimize adverse outcomes.

Stapled hemorrhoidectomy vs closed diathermy-excision hemorrhoidectomy without suture-ligation: a case-controlled trial.

BACKGROUND/AIMS: We compared stapled hemorrhoidectomy to closed diathermy-excision hemorrhoidectomy without suture-ligation regarding postoperative pain, complications and long-term efficacy. METHODOLOGY: A series of 108 patients had indication for stapled hemorrhoidectomy. Patients who underwent stapled hemorrhoidectomy (76) were compared to patients submitted to closed diathermy-excision hemorrhoidectomy (32) due to non-insurance cover. Primary endpoints were postoperative pain, complications, and clinical results after one year. Patients completed a 10-cm visual analog pain scale postoperatively and fulfilled a questionnaire before and 12 months after surgery. RESULTS: After seven days, median and maximum daily pain scores were lower in the stapled group (P < 0.001). Resumption of activities occurred after 9 days (mean; range 2 to 17 days) after stapling and 14 days (7 to 24) after diathermy surgery - P < 0.001. There was no difference regarding complications during the follow-up. After one year, 45 (80.4%) patients in the stapled group and 18 (78.3%) in the diathermy group were asymptomatic (P = 1.000). After one year, none of the patients needed a second operation and there was no fecal incontinence. CONCLUSIONS: Stapled hemorrhoidectomy selectively indicated is less painful, not associated to greater morbidity and has the same long-term efficacy when compared to closed diathermy excision without suture-ligation.

Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial.

OBJECTIVE: The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation. METHOD: Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach. RESULTS: There was no significant difference (p<0,05) between the two studied groups regarding: gender, age, body mass index, patients with previous abdominal surgeries, intra and post operative complications, need for blood transfusion, hospital stay after surgery, length of resected segment and pathological staging. Mean operation time was 228 minutes for the laparoscopic abdominoperineal resection versus 284 minutes for the conventional approach (p=0.04). Mean anesthesia duration was shorter (p=0.03) for laparoscopic abdominoperineal resection when compared to conventional approach : 304 and 362 minutes, respectively. There was no need for conversion to open approach in this series. After a mean follow-up of 47.2 months and with the exclusion of two patients in the conventional abdominoperineal resection who presented with unsuspected synchronic metastasis during surgery, local recurrence was observed in two patients in the conventional group and in none in the laparoscopic group. CONCLUSIONS: We conclude that laparoscopic abdominoperineal resection is feasible, similar to conventional approach concerning surgery duration, intra operative morbidity, blood requirements and post operative morbidity. Larger number of cases and an extended follow-up are required to adequate evaluation of oncological results for patients undergoing laparoscopic abdominoperineal resection after chemoradiation for radical treatment of distal rectal cancer.

Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial

OBJECTIVE: The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation. METHOD: Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach. RESULTS: There was no significant difference (p<0,05) between the two studied groups regarding: gender, age, body mass index, patients with previous abdominal surgeries, intra and post operative complications, need for blood transfusion, hospital stay after surgery, length of resected segment and pathological staging. Mean operation time was 228 minutes for the laparoscopic abdominoperineal resection versus 284 minutes for the conventional approach (p=0.04). Mean anesthesia duration was shorter (p=0.03) for laparoscopic abdominoperineal resection when compared to conventional approach : 304 and 362 minutes, respectively. There was no need for conversion to open approach in this series. After a mean follow-up of 47.2 months and with the exclusion of two patients in the conventional abdominoperineal resection who presented with unsuspected synchronic metastasis during surgery, local recurrence was observed in two patients in the conventional group and in none in the laparoscopic group. CONCLUSIONS: We conclude that laparoscopic abdominoperineal resection is feasible, similar to conventional approach concerning surgery duration, intra operative morbidity, blood requirements and post operative morbidity. Larger number of cases and an extended follow-up are required to adequate evaluation of oncological results for patients undergoing laparoscopic abdominoperineal resection after chemoradiation for radical treatment of distal rectal cancer

Doenca inflamatoria intestinal e gestacao / Inflammatory bowel disease and pregnancy

As doencas inflamatorias intestinais podem se manifestar antes ou durante o periodo reprodutivo da mulher. Desta forma, gastroenterologistas e obstetras confrontam-se...

Gestacao e doenca hemorroidaria / Pregnancy and hemorrhoidal disease

Importantes alteracoes fisiologicas ocorrem na mulher no periodo gestacional, sendo que sintomas decorrentes da doenca hemorroidaria frequentemente iniciam-se nesta fase, podendo se agravar durante o parto. Muitas gestantes apresentam constipacao intestinal, fator desencadeante da...

Eficácia da cromoendoscopia de contraste do cólon com emprego do índigo-carmim administrado por via oral / Efficacy of contrast chromoscopy of the colon after oral administration of indigo carmine dye

RACIONAL: O índigo-carmim é empregado como corante de contraste habitualmente instilado sobre a mucosa colorretal objetivando melhor visualizar lesäo já detectada à colonoscopia convencional. O exame da mucosa colorretal previamente corada após administraçäo anterógrada do corante levaria a maior sensibilidade na detecçäo de lesöes menores e resultante maior sensibilidade da colonoscopia no diagnóstico de lesöes diminutas, fazendo da cromoendoscopia de contraste excelente opçäo de rastreamento do câncer colorretal. Os resultados da cromoendoscopia do cólon após administraçäo oral do índigo-carmim resultam de experiência individual restrita. OBJETIVO: Avaliar a qualidade da cromoendoscopia com índigo-carmim nos diversos segmentos cólicos após administraçäo por via oral desse corante. PACIENTES E MÉTODOS: Cinqüenta pacientes consecutivamente submetidos a videocolonoscopia foram analisados. Uma cápsula contendo 100 mg de índigo-carmim era oferecida aos pacientes 30 minutos antes da soluçäo de manitol empregada rotineiramente para preparo intestinal mecânico. O efeito do contraste foi avaliado em três segmentos intestinais: cólon direito, cólon esquerdo e reto e foi classificado pelo examinador como bom, regular ou ruim, de acordo com critérios pré-estabelecidos. RESULTADOS: O cólon direito apresentou-se com bom efeito de contraste em apenas 9 (18,8 por cento) pacientes, enquanto que em 32 (66,6 por cento) e em 7 (14,6 por cento) pacientes o efeito obtido foi regular e ruim, respectivamente. Quanto à avaliaçäo dos segmentos distais, näo foi observado bom resultado em nenhum paciente. Näo se observou coloraçäo da mucosa do cólon esquerdo (qualidade ruim) em 80,9 por cento dos pacientes; tampouco näo foi observada distribuiçäo do contraste no reto em 92 por cento dos casos. CONCLUSÄO: Apesar da simplicidade, a administraçäo de índigo-carmim por via oral parece ineficaz para o rastreamento de pequenas lesöes realizado por cromoendoscopia de contraste uma vez que a qualidade desta verificada no cólon, principalmente em segmentos mais distais, foi regular ou ruim para a grande maioria dos pacientes

[Efficacy of contrast chromoendoscopy of the colon after oral administration of indigo carmine dye]. / Eficácia da cromoendoscopia de contraste do cólon com emprego do índigo-carmim administrado por via oral.

INTRODUCTION: Indigo carmine dye is usually spread directly over the colon in many chromoscopic techniques aiming better visualization of a lesion already detected by conventional colonoscopy. Examination of the colon already stained by oral administration of indigo carmine dye may increase detection of small lesions resulting in higher sensibility of the colonoscopy in diagnosing diminutive lesions. OBJECTIVE: Analyze the results regarding the quality of chromoscopic technique and the indigo carmine dye distribution over the colon after oral administration. PATIENTS AND METHODS: Fifty patients undergoing colonoscopy were evaluated. A capsule containing 100 mg of indigo carmine dye was offered to these patients 30 min before oral mannitol prep routinely used. The indigo carmine dye contrast effect was graded as bad, regular or good according to preestablished criteria in three segments of the colon: right and left colon and the rectum. RESULTS: In the right colon, good indigo carmine dye contrast effect was observed in only 9 (18.8%) patients, while it was considered regular and bad in 32 (66.6%) and in 7 (14.6%) patients, respectively. A good indigo carmine dye contrast effect was never observed in this series for the left colon or in the rectum. As a matter of fact, no indigo carmine dye was observed in the left colon in 80.9% and in the rectum in 92% of patients in this series. CONCLUSION: Although it may be simple and desirable, oral administration of indigo carmine dye seems ineffective for enhancing detection of diminutive lesions by chromoscopy as result of poor colonic distribution of indigo carmine dye mainly at distal colonic sites.

Transplante de pancreas e rim simultaneo com enxerto renal proveniente de doador vivo / Pancreas-kidney simultaneous transplant with kidney graft from living donor

O transplante de pancreas e rim simultaneo (TPRS) assumiu na ultima decada, importante papel no tratamento dos pacientes diabeticos insulino-dependentes com...

Correlaçäo entre dados antropométricos de doadores de múltiplos órgäos com o peso do pâncreas / Correlation between the antropometric parameters of multiple organ doanors and the pancreas weight

O transplante de ilhotas de Langerhans representa técnica promissora no tratamento do Diabetes mellitus. Dados antropométricos do doador, estäo diretamente relacionados com a quantidade de ilhotas viáveis obtidas após o processamento do pâncreas, o que relaciona-se diretamente com o sucesso do transplante de ilhotas. o objetivo do trabalho é verificar se existe correlaçäo do peso e do IMC de doadores cadáveres com o peso do pâncreas. Para isso foram removidos 35 pâncreas de doadores de múltiplos órgäos e coletou-se os dados antropométricos e epidemiológicos dos doadores, realizando também a pesagem dos pâncreas. Através de índice de correlaçäo de Pearson e do modelo de regressäo linear múltipla - método Stepwise, analisamos a relaçäo entre altura, peso, IMC e idade dos doadores com o peso de seus respectivos pâncreas. Com um índice de correlaçäo de Pearson (CP) de 0,683 (p<0,000), a altura do doador representou a principal variável correlacionada com o peso do pâncreas. Entretanto, o peso com CP igual a 0,682 também foi significativo, com CP praticamente igual a da altura. Concluiu-se que a altura do doador pode ser um dado valorizado na estimativa da quantidade de ilhotas obtida a partir de pâncreas de doadores cadáveres