RESUMO
BACKGROUND: The clinical and economic impacts of enhanced recovery after surgery (ERAS) programmes have been demonstrated extensively. Whether ERAS protocols also have a biological effect remains unclear. This study aimed to investigate the biological impact of an ERAS programme in patients undergoing liver surgery. METHODS: A retrospective analysis of patients undergoing liver surgery (2010-2018) was undertaken. Patients operated before and after ERAS implementation in 2013 were compared. Surrogate markers of surgical stress were monitored: white blood cell count (WBC), C-reactive protein (CRP) level, albumin concentration, and haematocrit. Their perioperative fluctuations were defined as Δvalues, calculated on postoperative day (POD) 0 for Δalbumin and Δhaematocrit and POD 2 for ΔWBC and ΔCRP. RESULTS: A total of 541 patients were included, with 223 and 318 patients in non-ERAS and ERAS groups respectively. Groups were comparable, except for higher rates of laparoscopy (24.8 versus 11.2 per cent; P < 0.001) and major resection (47.5 versus 38.1 per cent; P = 0.035) in the ERAS group. Patients in the ERAS group showed attenuated ΔWBC (2.00 versus 2.75 g/l; P = 0.013), ΔCRP (60 versus 101 mg/l; P <0.001) and Δalbumin (12 versus 16 g/l; P < 0.001) compared with those in the no-ERAS group. Subgroup analysis of open resection showed similar results. Multivariable analysis identified ERAS as the only independent factor associated with high ΔWBC (odds ratio (OR) 0.65, 95 per cent c.i. 0.43 to 0.98; P = 0.038), ΔCRP (OR 0.41, 0.23 to 0.73; P = 0.003) and Δalbumin (OR 0.40, 95 per cent c.i. 0.22 to 0.72; P = 0.002). CONCLUSION: Compared with conventional management, implementation of ERAS was associated with an attenuated stress response in patients undergoing liver surgery.
Assuntos
Recuperação Pós-Cirúrgica Melhorada , Fígado/cirurgia , Estresse Fisiológico , Idoso , Biomarcadores/sangue , Proteína C-Reativa/metabolismo , Feminino , Hematócrito , Humanos , Laparoscopia/efeitos adversos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Albumina Sérica/metabolismoRESUMO
Fungal infections are generally observed in immunosuppressed patients only, with a diagnostic challenge due to non-specific symptoms. For this reason, appropriate management may be delayed. This case report concerns a 36-year-old man with history of pancreas and kidney transplantation. He had chemotherapy for post-transplant B-cell lymphoma and presented with left upper abdominal pain and fever. Multiple investigations led to a final diagnosis of disseminated abdominal mucormycosis with multiple Rhizomucor abscesses in the liver, spleen and kidney transplant. Treatment was antifungal therapy and laparotomy with splenectomy, wedge resection of two fungal abscesses in segments II and IVb, and segmental left colic resection.
Assuntos
Abscesso Abdominal/diagnóstico , Transplante de Rim , Mucormicose/diagnóstico , Transplante de Pâncreas , Complicações Pós-Operatórias/diagnóstico , Rhizomucor/isolamento & purificação , Abscesso Abdominal/etiologia , Abscesso Abdominal/cirurgia , Adulto , Hepatectomia , Humanos , Hepatopatias/diagnóstico , Hepatopatias/etiologia , Hepatopatias/cirurgia , Masculino , Mucormicose/etiologia , Mucormicose/cirurgia , Complicações Pós-Operatórias/cirurgia , Esplenectomia , Esplenopatias/diagnóstico , Esplenopatias/etiologia , Esplenopatias/cirurgiaRESUMO
In this clinical scenario, we report the case of a patient who presented multiple embolic complications due to mitral infective endocarditis (IE). A 68-year-old woman had extended right hepatectomy for hilar cholangiocarcinoma. Unfortunately, she had multiple postoperative complications and had to be transferred to the Intensive Care Unit. During this stay, we have diagnosed an Enterococcus faecium IE after the occurrence of multiple embolic complications (myocardial infarction, ischemic stroke, digital emboli, splenic emboli, and renal emboli). The case is presented hereunder with illustrative imagings. While embolism is a known complication of IE, the presence of multiple emboli in various organs is rare.
Assuntos
Embolia/complicações , Endocardite/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Idoso , Embolia/diagnóstico , Endocardite/microbiologia , Enterococcus faecium/isolamento & purificação , Feminino , Humanos , Unidades de Terapia Intensiva , Complicações Pós-Operatórias , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Acidente Vascular Cerebral/etiologia , Tomografia Computadorizada por Raios XRESUMO
Liver vascularization is known to present with several different variations. Generally, a normal vascular anatomy is reported in up to 50-80 % of cases. For this reason, a precise preoperative mapping of the hepatic vascularization prior to pancreatic surgery is essential to avoid injuries and subsequent complications. We report here a case of a young patient scheduled for Whipple procedure, who presented an arterial pattern type Michels IV, variation reported in 0.6 to 3 % in the literature. Another interesting particularity of this case was the fact that the right hepatic artery had a prepancreatic course. We think that every surgeon performing hepatopancreatic surgery should have heard of this special and rare situation.
Assuntos
Artéria Hepática/anormalidades , Pâncreas/irrigação sanguínea , Pancreaticoduodenectomia , Pancreatite/cirurgia , Adulto , Artéria Hepática/diagnóstico por imagem , Humanos , Masculino , Pâncreas/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
The attraction of walking as a pastime has grown enormously in Switzerland over the past few years. Synonym of health and wellbeing, this activity carries some risks which more and more patients are questioning; answering these questions is not always obvious, so we wanted to tackle the subject. This second section concerns risks linked to food which can be found in the forest. Echinococcosis is an underestimated parasite which affects a large proportion of foxes in Switzerland. This infectious disease can also affect man following contamination which usually occurs through eating berries. Prevention is the most effective way to avoid poisoning by mushrooms. In case of poisoning, the physician must try and determine the toxidrome. The key element is the length of time before symptoms develop. Treatment is always symptomatic, using activated charcoal.
Assuntos
Equinococose/prevenção & controle , Intoxicação Alimentar por Cogumelos/prevenção & controle , Caminhada , Algoritmos , Equinococose/diagnóstico , Humanos , Intoxicação Alimentar por Cogumelos/diagnóstico , Guias de Prática Clínica como AssuntoRESUMO
Hepatocellular carcinoma (HCC) is one of the most frequent malignant tumors worldwide and its incidence has increased over the last years in most developed countries. The majority of HCCs occur in the context of liver cirrhosis. Therefore, patients with cirrhosis and those with hepatitis B virus infection should enter a surveillance program. Detection of a focal liver lesion by ultrasound should be followed by further investigations to confirm the diagnosis and to permit staging. A number of curative and palliative treatment options are available today. The choice of treatment will depend on the tumor stage, liver function and the presence of portal hypertension as well as the general condition of the patient. A multidisciplinary approach is mandatory to offer to each patient the best treatment.
Assuntos
Carcinoma Hepatocelular/terapia , Neoplasias Hepáticas/terapia , Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/patologia , Quimioembolização Terapêutica , Humanos , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/patologia , Transplante de Fígado , Fatores de RiscoRESUMO
The widespread use of abdominal imaging technologies has led to an increase in the incidental finding of liver tumors. Most of these lesions are asymptomatic and will not require any treatment. With the use of contrast-enhanced radiological studies, most of the tumors can be reliably diagnosed by non-invasive means. In case of diagnostic uncertainty, patients should not undergo percutaneous biopsy but rather complete resection of the lesion for an unequivocal diagnosis. Such pathologies must be taken charge of in centers with expertise by interdisciplinary teams.
Assuntos
Hepatopatias/diagnóstico , Hepatopatias/terapia , Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/terapia , Colangiocarcinoma/diagnóstico , Colangiocarcinoma/terapia , Diagnóstico por Imagem , Hemangioma/diagnóstico , Hemangioma/terapia , HumanosRESUMO
More than the number of real novelties, trends and preliminary results characterise the annual development in surgery. The wealth and diversity of topics to be covered require arbitrary choices, therefore not necessarily complete. The constant development of choledocolithiasis management, dominated by minimal invasive technology, treatments of unusual nature of two frequent proctological conditions, fistulae and haemorrhoids, the increasing importance of metabolic bariatric surgery, as well as the strict rules of effective melanoma treatment, represent as many directions in which the operating procedure, although unseen, continue to gain quality and security.
Assuntos
Procedimentos Cirúrgicos Operatórios/tendências , Doenças do Sistema Digestório/cirurgia , Humanos , Melanoma/cirurgia , Neoplasias Cutâneas/cirurgiaRESUMO
Pancreaticoduodenectomy is a major procedure in visceral surgery. Post-operative mortality is around 5% in high-volume hospitals, thanks to improvement in global patients care. Morbidity remains high though. The treatment of complications most often require a multidisciplinary approach. Delayed gastric emptying, intraabdominal abscesses and pancreatic fistulas are the most frequent complications. Post-pancreatectomy hemorrhage, although more rare, is a severe and dreadful event. Despite its morbidity, duodenopancreatectomy significantly improves survival of patients with biliopancreatic cancer. Early recognition of these complications and a prompt treatment increase the safety of this procedure.
Assuntos
Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Humanos , Pancreaticoduodenectomia/mortalidade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapiaRESUMO
Colorectal cancer is the 2nd cause of cancer related death in industrialised countries. 20% of all patients present with metastatic disease at diagnosis and need systemic treatment. Since the introduction of irinotecan and oxaliplatin as part of standard chemotherapy, and recently the new targeted agents bevacizumab, cetuximab and panitumumab, the overall survival for patients suffering from metastatic colorectal cancer (mCRC) has increased significantly and nearly reaches 2 years nowadays. Surgery or radiofrequency ablation has become central in the care of metastatic disease. This article resumes recent therapeutic advances in the field and emphasizes the multidisciplinary concertation between specialists to obtain the best outcome.
Assuntos
Antineoplásicos/uso terapêutico , Neoplasias Colorretais/tratamento farmacológico , Antineoplásicos/farmacologia , Neoplasias Colorretais/secundário , HumanosRESUMO
Muir-Torre syndrome (MTS) is a rare cancer-predisposing syndrome that is autosomal dominantly inherited and characterized by the development of sebaceous skin lesions (adenomas, epitheliomas, basaliomas and carcinomas). These lesions are typically associated with tumors that belong to the spectrum of hereditary nonpolyposis colorectal cancer (HNPCC) (i.e., tumors of the colorectum, endometrium, stomach or ovary). Biliary malignancy in association with MTS has only rarely been reported. We report a case of Muir-Torre syndrome associated with intrahepatic cholangiocarcinoma, a location not previously described, and associated with a novel missense mutation of the MSH2 gene (c.2026T > C), predicted to disrupt the function of the gene.
Assuntos
Colangiocarcinoma/genética , Colangiocarcinoma/secundário , Mutação em Linhagem Germinativa , Neoplasias Hepáticas/genética , Proteína 2 Homóloga a MutS/deficiência , Neoplasias Primárias Múltiplas/genética , Síndromes Neoplásicas Hereditárias/genética , Neoplasias Cutâneas/genética , Adenocarcinoma Mucinoso/genética , Adenocarcinoma Mucinoso/cirurgia , Adenoma/genética , Adenoma/cirurgia , Adulto , Neoplasias Encefálicas/genética , Neoplasias Encefálicas/secundário , Neoplasias Encefálicas/cirurgia , Carcinoma/genética , Carcinoma/cirurgia , Colangiocarcinoma/cirurgia , Neoplasias Colorretais Hereditárias sem Polipose/genética , Neoplasias Colorretais Hereditárias sem Polipose/cirurgia , Análise Mutacional de DNA , Sondas de DNA , Proteínas de Ligação a DNA , Neoplasias do Endométrio/cirurgia , Feminino , Humanos , Neoplasias Hepáticas/cirurgia , Instabilidade de Microssatélites , Mutação de Sentido Incorreto , Neoplasias Primárias Múltiplas/cirurgia , Síndromes Neoplásicas Hereditárias/cirurgia , Pólipos/cirurgia , Prolina/genética , Neoplasias das Glândulas Sebáceas/genética , Neoplasias das Glândulas Sebáceas/cirurgia , Serina/genética , Neoplasias Cutâneas/secundário , Neoplasias Cutâneas/cirurgia , SíndromeRESUMO
The diagnostics of focal nodular hyperplasia is reached through the use of imaging. When the diagnostic is certain, surgical abstention is the rule. Nevertheless, we were confronted with two cases of a rare complication; that of intraperitoneal rupture. In this situation, we suggest to first do an arteriography to control the bleeding, then to perform surgery when the patient has reached hemodynamic stability. Spontaneous rupture as a complication of benign nodular hyperplasia remains a rare event and only five cases were reported in litterature.
Assuntos
Hiperplasia Nodular Focal do Fígado/complicações , Adulto , Feminino , Humanos , Ruptura EspontâneaRESUMO
The principal treatment for bleeding oesophageal varices is endoscopic ligation. Non-cardioselective beta-blockers are the gold-standard of primary prophylaxis. The principal treatment for ascites is a salt-free diet and diuretics, mainly spironolactone, if necessary associated with a loop diuretic. In refractory ascites, paracentesis or installation of a transjugular intrahepatic portosystemic shunt (TIPS) are two possible treatment options. Cirrhosis patients are at higher risk of developing hepato-cellular carcinoma. Surgery is only possible in a small number of cases. Percutaneous destruction techniques have nearly the same survival rate as that obtained by surgery and should be proposed to patients where surgery is not an option.
Assuntos
Ascite/etiologia , Ascite/terapia , Carcinoma Hepatocelular/etiologia , Carcinoma Hepatocelular/cirurgia , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/cirurgia , Cirrose Hepática/complicações , Neoplasias Hepáticas/etiologia , Neoplasias Hepáticas/cirurgia , Antagonistas Adrenérgicos beta/uso terapêutico , Endoscopia , Humanos , LigaduraRESUMO
BACKGROUND: The prevalence of diabetes is high after transplantation. We hypothesized that liver transplantation induces additional alterations of glucose homeostasis because of liver denervation. METHODS: Nondiabetic patients with a heart (n=9) or liver (n=9) transplant and healthy subjects (n=8) were assessed using a two-step hyperglycemic clamp (7.5 and 10 mmol/L). Thereafter, an oral glucose load (0.65 g/kg fat free mass) was administered while glucose was clamped at 10 mmol/L. Glucose appearance from the gut was calculated as the difference between glucose appearance (6,6 2H2 glucose) and exogenous glucose infusion. Plasma insulin, glucagon-like peptide (GLP)-1 and gastric inhibitory polypeptide(GIP) concentrations were compared after intravenous and oral glucose. RESULTS: After oral glucose, the glucose appearance from the gut was increased 52% and 81% in liver- and heart-transplant recipients (P<0.05). First-pass splanchnic glucose uptake was reduced by 39% in liver-transplant and 64% in heart-transplant patients (P<0.05). After oral but not intravenous glucose, there was an impairment of insulin secretion in both transplant groups relative to the controls. Plasma concentrations of GIP and GLP-1 increased similarly in all three groups after oral glucose. CONCLUSIONS: First-pass hepatic glucose extraction is decreased after heart and liver transplant. Insulin secretion elicited by oral, but not intravenous glucose, is significantly reduced in both groups of patients. There was no difference between liver- and heart-transplant recipients, indicating that hepatic denervation was not involved. These data suggest an impairment in the beta-cell response to neural factors or incretin hormones secondary to immunosuppressive treatment.
Assuntos
Glicemia/metabolismo , Técnica Clamp de Glucose/métodos , Transplante de Coração/fisiologia , Insulina/metabolismo , Transplante de Fígado/fisiologia , Administração Oral , Adulto , Índice de Massa Corporal , Feminino , Glucose/administração & dosagem , Humanos , Infusões Intravenosas , Insulina/sangue , Secreção de Insulina , Masculino , Valores de ReferênciaRESUMO
Postoperative chylous ascites is a classical but uncommon complication following extensive retroperitoneal or near the root of the mesentery dissection with an incidence ranging from 1.2 to 3%. Only 6 cases of chylous ascites have been described after ulcer surgery with troncal vagotomy associated with pyloroplasty and only 1 after gastrectomy. We report the second case of chylous ascites after a D2 distal gastrectomy. A 56-year-old female underwent a D2 distal gastrectomy and gastro-duodenostomy with omentectomy for a prepyloric T1N0M0 moderately differentiated adenocarcinoma. The patient was treated conservatively by both of parenteral nutrition and a fat free diet. By the end of 2(nd) postoperative week, the effusion became serous again and the output gradually ceased. The drain could be removed on the 20(th) postoperative day. Normal enteral nutrition was resumed, no recurrence of chylous ascites occurred. This conservative treatment proved to be effective as it as already be reported with resolution in almost 60% of the patients and remains the first choice option.
Assuntos
Ascite Quilosa/etiologia , Gastrectomia/efeitos adversos , Feminino , Gastrectomia/métodos , Humanos , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Robot surgery is a further step towards new potential developments in minimally invasive surgery. Surgeons must keep abreast of these new technologies and learn their limits and possibilities. Robot-assisted laparoscopic cholecystectomy has not yet been performed in our institution. The purpose of this report is to present the pathway of implementation of robotic laparoscopic cholecystectomy in a university hospital. METHODS: The Zeus(R) robot system was used. Experimental training was performed on animals. The results of our experimental training allowed us to perform our first two clinical cases. RESULTS: Robot arm set-up and trocar placement required 53 and 35 minutes. Operative time were 59 and 45 minutes respectively. The overall operative time was 112 and 80 minutes, respectively. There were no intraoperative complications. Patients were discharged from the hospital after an overnight stay. CONCLUSION: Robotic laparoscopic cholecystectomy is safe and patient recovery similar to those of standard laparoscopy. At present, there are no advantages of robotic over conventional surgery. Nevertheless, robots have the potential to revolutionise the way surgery is performed. Robot surgery is not reserved for a happy few. This technology deserves more attention because it has the potential to change the way surgery is performed.
Assuntos
Colecistectomia Laparoscópica/métodos , Robótica , Adulto , Idoso , Animais , Colecistectomia Laparoscópica/educação , Desenho de Equipamento , Feminino , Hospitais Universitários , Humanos , Centro Cirúrgico Hospitalar , Suínos , Suíça , Estudos de Tempo e Movimento , Resultado do TratamentoRESUMO
Ketorolac is the first injectable nonsteroidal antiinflammatory drug used as an analgesic in the perioperative period. However, gastrointestinal bleeding is a risk associated with its perioperative administration. A 23-year-old woman was admitted for elective laparoscopic cholecystectomy. Her medical history was unremarkable except for a complaint of intermittent right upper quadrant pain for several months. The operative procedure was uneventful. Thirty milligrams of ketorolac were given intravenously just prior to termination of surgery. Eighteen hours after surgery, the patient developed right upper quadrant pain associated with tachycardia and hypotension. Abdominal computed tomography (CT) scan demonstrated a large subcapsular hematoma of the liver. A few hours later, the hemodynamic condition worsened, and the patient was taken to the operating room. Laparoscopic exploration showed a ruptured subcapsular hematoma with active bleeding. No evidence of parenchymal injury of the gallbladder bed was found. The hematoma was evacuated and hemostasis was performed laparoscopically. Ketorolac has a strong antiplatelet activity and further acts by the inhibition of platelet function, which may last as long as 24 h after the last administration. Surgeons and anesthesiologists should be aware that ketorolac may cause or aggravate bleeding.
Assuntos
Anti-Inflamatórios não Esteroides/efeitos adversos , Doença Hepática Induzida por Substâncias e Drogas , Colecistectomia Laparoscópica , Hematoma/induzido quimicamente , Hematoma/cirurgia , Cetorolaco/efeitos adversos , Hepatopatias/cirurgia , Adulto , Coagulação Sanguínea/efeitos dos fármacos , Feminino , Hematoma/diagnóstico , Humanos , Laparoscopia , Hepatopatias/diagnóstico , Ruptura EspontâneaRESUMO
Isolated agenesis of the gallbladder (AG) is a rare anomaly. Twenty-three percent of the patients are symptomatic and present with right upper abdominal pain, nausea and fatty food intolerance. The condition is frequently mistaken with excluded or sclero-atrophic gallbladder, regardless of the imaging modality used. Consequently, AG leads often to unnecessary and potentially dangerous surgery. During laparoscopy, the absence of normal anatomical structures and the impossibility of pulling on the gallbladder to dissect the triangle of Callot represent an increased risk of iatrogenic injury to biliary or portal structures. The aim of this study is to discuss the pitfalls of the available radiological exams and the management of this rare condition. We describe two cases of AG, with a review of the literature. A high index of suspicion is necessary when interpreting the radiological images. In case of doubt, a MRI-cholangiography is mandatory. Because of possible inherited transmission, relatives with a history of biliary symptoms should be investigated, even when asymptomatic.
Assuntos
Anormalidades do Sistema Digestório/diagnóstico , Vesícula Biliar/anormalidades , Adulto , Idoso , Colangiografia , Diagnóstico Diferencial , Anormalidades do Sistema Digestório/cirurgia , Fibrose , Cálculos Biliares/diagnóstico , Cálculos Biliares/cirurgia , Humanos , Laparoscopia , Testes de Função Hepática , Masculino , Tomografia Computadorizada por Raios XRESUMO
Malabsorption can raise from several causes, including post surgical conditions. Noticeably, ileo-ileal anastomosis can lead to bacterial stagnation in the caecum, with recirculation of the intestinal content, and intestinal spreading of the colonic flora. We review here nine cases who were operated on in our department in the last 20 years. In five patients the syndrome appeared after an intestinal resection due to a postsurgical intestinal infarction due to adhesions. In four patients it appeared after an ileo-transverse derivation motivated by post-surgical occlusion. We conclude that any type of malabsorption appearing after abdominal surgery, even remotely from the surgical procedure should suggest this uncommon diagnosis. Surgical treatment, i.e. replacement of the intestinal anastomosis with a new termino-terminal anastomosis, is necessary and sufficient.
Assuntos
Síndrome da Alça Cega/cirurgia , Complicações Pós-Operatórias/cirurgia , Adulto , Anastomose Cirúrgica , Apendicectomia , Síndrome da Alça Cega/diagnóstico , Síndrome da Alça Cega/etiologia , Diagnóstico Diferencial , Feminino , Humanos , Íleo/cirurgia , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Reoperação , Aderências TeciduaisRESUMO
Acute appendicitis is the most common acute surgical infection during pregnancy. Although usually pyogenic in origin, parasitic infections account for a small percentage of cases. Despite the relatively high prevalence of acute appendicitis in our environment, it is not commonly associated with schistosomiasis. We report here the association of pregnancy and appendicitis caused by Schistosoma haematobium. Schistosomiasis is very common complication of pregnancy in hyperendemic areas. Schistosome egg masses can lodge throughout the body and cause acute inflammation of the appendix, liver and spleen. Congestion of pelvic vessels during pregnancy facilitates passage of eggs into the villi and intervillous spaces, causing an inflammatory reaction. Tourism and immigration make this disease a potential challenge for practitioners everywhere.