Giant hepatic hemangioma in a patient with cirrhosis: challenging to manage.

Giant hepatic hemangiomas are occasional in patients with cirrhosis. It remains a challenge to decide on the need for treatment and choose the most appropriate intervention. A 62-year-old woman was recently diagnosed with cirrhosis and complained of upper abdominal fullness, reduction in oral food intake, and weight loss of 6 kg over the last three years. Upper digestive endoscopy evidenced thin-caliber esophageal varices and significant extrinsic compression of the lesser gastric curvature. Abdominal computed tomography revealed an exophytic tumor in the left hepatic lobe, measuring 11.5 cm, which had progressive centripetal contrast enhancement from the arterial phase, compatible with hepatic hemangioma. Serum tumor markers were negative, and her liver function was unimpaired. The patient underwent surgical resection (non-anatomical hepatectomy of segments II and III) which had no immediate complications, and the histopathological evaluation confirmed cavernous hepatic hemangioma. Two weeks later, she was admitted to the emergency room with jaundice, signs of hepatic encephalopathy, and moderate ascites, and was further diagnosed with secondary bacterial peritonitis. As no perforations, abscesses, or fistulas were observed on subsequent imaging tests, clinical management was successfully carried out. This case highlights that giant hepatic hemangiomas may be symptomatic and warrant treatment. In the setting of cirrhosis and portal hypertension, physicians should be aware of the risk of hepatic decompensation following surgical resection, even in patients with Child-Pugh class A.

Liver Transplantation After Previous Vena Cava Resection: Case Report.

In some specific cases, the surgical technique involved in liver transplantation can be challenging, as, for example, in cases of Budd-Chiari syndrome. This case describes a case of liver transplantation in a patient diagnosed with Budd-Chiari syndrome due to a previous surgery that required retrohepatic vena cava resection. During the liver transplantation procedure, a cavo-atrial anastomosis was performed through transdiaphragmatic access, with a good postoperative result, showing that, although challenging, this technique is a feasible option in specific cases.

Silent Destruction: Fulminant Hepatitis and the Hidden Danger of Weight Loss Drugs.

INTRODUCTION: The use of natural products for therapeutic purposes is a common practice throughout the world, in part, due to the global obesity epidemic and the search for products with appetite suppression and weight loss properties, which include nutritional supplements, vitamins and minerals to herbal products. It is known that such products may be associated with various adverse health effects. Thus, the objective of this study is to report a series of cases of patients, who presented fulminant liver failure (HFI) requiring liver transplantation (LT), related to the consumption of products used for weight loss. MATERIAL AND METHODS: This is a retrospective cohort based on the evaluation of patients listed for LT due to IHF at the Hospital das Clínicas of the Universidade Estadual de Campinas, between 1991 and 2022, with patients who had confirmed consumption of products with the aim of loss being selected. RESULTS: During the studied period, 92 patients were listed for HT due to IHF according to the Kings College criteria, with 5 cases being selected with proven consumption of herbal products for weight loss, and other causes that could explain the IHF were excluded. Four (80%) of the patients were female, with a mean age of 40.5 years, and 40% of the cases died. DISCUSSION AND CONCLUSIONS: Unlike traditional pharmaceutical medicines, in most countries, the commercialization of these products is not conditioned on clinical and safety evidence or prior approval by regulatory bodies. Hepatoxicity can be related to several factors, such as the presence of toxins naturally found in plants, the presence of heavy metals, contamination during obtaining or processing and the addition of substances omitted from the labels. The use of weight loss products can evolve with IHF, a fact that deserves attention, due to ease of access and growing demand, and it is important to regulate the trade of these products and raise public awareness about the risks of use without professional supervision and guidance.

Acute Liver Failure Secondary to Anthocyanidin Use-A Case Report.

Drug-induced liver injury has become the main cause of acute liver failure (ALF). Injury may be dose-dependent or occur idiosyncratically. We report the case of a 37-year-old female patient admitted with grade 4 hepatic encephalopathy. Morosil use was initiated 30 days prior, and after 2 weeks, the case evolved with jaundice and diarrhea interspersed with constipation when the medication was discontinued. Morosil is a dry extract of the juice of red Moro oranges (Citrus species), grown in eastern Sicily (Italy). It is an important source of anthocyanidin pigments, which act as antioxidants and are used in the care and prevention of obesity, insulin resistance, hepatic steatosis, and cardiovascular diseases. According to the clinical picture and tests performed, the diagnosis of ALF was confirmed, by the criteria of Clichy and King's College. The patient was listed for liver transplantation as a priority, with the model for end stage liver disease (MELD) score: 41. Orthotopic liver transplantation was uneventfully performed using the Piggy-back technique. There are few reports in the literature of acute liver injury by other Citrus species, and we found no case reports of ALF related to the use of Morosil.

Understanding the Elevated Lethality of COVID-19 in Liver Transplant Recipients: Does Immunosuppression Management Matter? Results from a Brazilian Multicentric Historical Cohort.

BACKGROUND: Infections by SARS-CoV-2 in liver transplant recipients (LT) patients are of particular concern, notably due to perceived added risks related to immunosuppression and comorbidity burden. Current literature on this topic often relies on small, non-standardized, and geographically limited studies. This manuscript describes COVID-19 presentations and causes for elevated mortality in a large cohort of LT recipients. METHODS: This study was designed as a multicentric historical cohort, including LT recipient patients with COVID-19 in 25 study centers, with the primary endpoint being COVID-related death. We also collected demographic, clinical, and laboratory data regarding presentation and disease progression. RESULTS: Two hundred and thirty-four cases were included. The study population was predominantly male and White and had a median age of 60 years. The median time from transplantation was 2.6 years (IQR 1-6). Most patients had at least one comorbidity (189, 80.8%). Patient age (P = .04), dyspnea (P < .001), intensive care unit admission (P < .001), and mechanical ventilation (P < .001) were associated with increased mortality. Modifications of immunosuppressive therapy (P < .001), specifically the suspension of tacrolimus, maintained significance in multivariable analysis. CONCLUSIONS: Attention to risk factors and the individualization of patient care, especially regarding immunosuppression management, is crucial for delivering more precise interventions to these individuals.

Incidence and Impact of COVID-19 Cases in Brazilian Liver Transplant Recipients: An Academic, Single-center Experience.

BACKGROUND: Current literature reports diverge on the impact of COVID-19 in liver transplant (LT) recipients. Literature findings often report conflicting results, relying on small sample sizes, limited ethnic variability, and nonstandardized methodologies. Notably, there are no studies on this topic regarding Latin American populations. This study seeks to report the impact of COVID-19, disease characteristics, and progression in LT recipients in a Latin American academic center environment. METHODS: The study design was a historic cohort, including adult LT recipient patients with suspected or confirmed COVID-19 who sought care between December 2019 to October 2021. The primary end point was defined as COVID-19-related death. Demographic, clinical, and laboratory data was also collected. RESULTS: Twenty-seven patients were included, representing a 3.5% incidence within 752 patients in the follow-up. The mean age and years from transplantation were 54 (SD ± 11) and 6.3 years (SD ± 5.4), respectively. Most patients were white (23 - 85.2%) and male (21 - 25.2%). The hospitalization rate was 55.6%, and 5 patients (18.5%), all of whom subsequently died, were admitted to the intensive care unit. Neither the presence of comorbidities nor advanced age were related to lethality. Patients with immunosuppression modifications (P = 0.039) or isolated tacrolimus suspension (P = 0.006) were associated with increased mortality. CONCLUSIONS: This study described COVID-19 infections in LT recipients in Latin American populations. This group was not affected by common factors associated with higher lethality, and displayed a tendency toward lower hospitalization rates. Our study concurred with previously reported evidence of a protective association of tacrolimus maintenance during treatment in LT recipients affected by COVID-19.

Validation of New York/California Score in the Preoperative Period of Liver Transplant for Hepatocellular Carcinoma at University of Campinas's Hospital.

Liver transplant is the main treatment for hepatocellular carcinoma and there is currently an important demand from patients waiting in transplant queues. Thus, it is extremely important to improve the criteria for selecting patients who will undergo transplant to mitigate graft loss and reduce cases of recurrence. Thus, it becomes necessary to use models, such as the New York/California (NYCA), that include alpha fetoprotein as a marker of recurrence and prognosis. The aim of this study was to assess whether the NYCA score correlated with the presence of tumor recurrence after transplant in patients undergoing orthotopic liver transplant at the Clinics Hospital of the University of Campinas. We had 214 patients undergoing liver transplant who met the inclusion Milan criteria. The age of the patients ranged from 34 to 77 years, with a median age of 61 years. The mean waiting time on the transplant list was 6.12 months. After calculating the NYCA score, it was possible to stratify 13 patients (6.1%) as high risk, 64 patients (29.9%) as medium risk, and 137 patients (64%) as low risk. Patients with recurrence had higher scores with a mean of 4 points in relapse and 2 points in the absence of relapse (P = .0011). Patients with recurrence had statistically higher high- and medium-risk scores (P = .0010). Therefore, the NYCA score was higher in patients with recurrence. Therefore, in this study, our findings suggest the possibility of using the NYCA score as an aid to detect patients with a higher risk of tumor recurrence.

15-Year progression to liver cancer in the lack of treatment for lysosomal acid lipase deficiency: A case report.

RATIONALE: Lysosomal acid lipase deficiency (LAL-D) is a poorly diagnosed genetic disorder characterized by the accumulation of cholesteryl esters and triglycerides in many tissues, leading to dyslipidemia and cardiovascular complications. In the liver, deposits are found within hepatocytes and Kupffer cells, generating microvesicular steatosis, progressive fibrosis, and cirrhosis. Sebelipase alfa is the target therapy which can improve laboratory changes and reduce the progression of liver damage, but this is not yet widely available. PATIENT CONCERNS: We are reporting a 15-year follow-up of a Brazilian man who was diagnosed with cirrhosis at age 43 and with LAL-D at age 53, but he has never been treated with sebelipase alfa for economic reasons. During the coronavirus disease 2019 (COVID-19) pandemic, he lost follow-up and missed three 6-month ultrasound exams for liver cancer screening. DIAGNOSIS: At age 58, a remarkable deterioration in liver function was observed and he was diagnosed with hepatocellular carcinoma (HCC) outside the Milan Criteria (two nodules measuring 48mm and 25mm). Three other individuals with LAL-D and progression to liver cancer have been reported so far and none of them underwent enzyme replacement therapy: an 11-year-old girl with HCC, a 51-year-old male with cholangiocarcinoma, and a 21-year-old male with hepatocellular-cholangiocarcinoma. The latter had the same mutation in the gene LIPA as our patient, but a relationship between this variant and malignancies has not yet been established. LESSONS: We emphasize how important is to treat LAL-D patients after diagnosis in order to avoid worsening liver function and progression to neoplasms. Untreated individuals should be considered at a higher risk but the most appropriate liver cancer screening program for this subgroup is still unknown.

Refinement of the Milan Criteria: Role of α-Fetoprotein In Liver Transplantation for Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary neoplasm of the liver, mainly secondary to cirrhosis caused by hepatitis C virus. Liver transplant (LT) is considered the best treatment because, in addition to removing the tumor, it also removes the underlying cirrhotic liver. The Milan criteria for LT have limitations because they do not consider the biological characteristics of the tumor. Thus, our objective was to evaluate the association of α-fetoprotein (AFP) levels before LT performed for HCC with recurrence of this tumor, and, based on the results, a new predictive model that combines the AFP values at the list entry with the usual criteria of tumor size and number of nodules was validated. In present study, the Score AFP model, we were able to correlate a greater occurrence of relapse with scores of 3 and 4 (P = .0001), indicating the usefulness of using AFP as a predictor of recurrence.

Validation of Metroticket Score in the Preoperative Period of Liver Transplantation for Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the sixth leading cause of cancer in the world, and liver transplant (LT) is a good therapeutic option in selected cases because it treats the neoplasm and the underlying disease. Recurrence after LT is usually aggressive and has low survival; thus, an adequate selection of recipients is ideal. The new models aim to assess the individual risk of HCC recurrence in patients undergoing LT and to improve post-LT survival. In this study, our aim was to assess the applicability of the "Metroticket" score, correlating it with our rates of recurrence and survival after LT. Overall survival at 5 years in our study differed from that in Metroticket 2.0 because that study did not consider only recurrence as the cause of death; our study evaluated only patients with recurrence, so we were able to validate the score as a predictor of greater tumor aggressiveness after LT.

Clinical impact of the Model for End Liver Disease (MELD) score on the presence of microvascular invasion and on the postoperative outcome in patients undergoing liver transplantation.

OBJECTIVE: to correlate clinical and epidemiological data with the pathological analysis of liver explants from patients undergoing liver transplantation for hetapocarcinoma in the UNICAMP HC and to verify whether the MELD and MELD-Na scores are reliable factors to predict a worse post-transplant prognosis. METHODS: we studied liver transplants carried out between May 2010 and November 2017. After excluding 38 patients, we included 87, analyzing clinical and laboratory data for correlation with the outcome Microvascular Invasion (MVI). Subsequently, we computed the MELD and MELD-Na scores and performed a descriptive analysis of clinical and laboratory data and, finally, calculated ROC curves to assess the association between these laboratory parameters and mortality in these patients. RESULTS: most patients were male (78.30%), with an average age of 58.53 years. Most liver diseases were caused by HCV (53.26%). We found no predictors for MVI among the laboratory parameters. The ROC curves for death identified the MELD score as the cutoff point with the highest combined sensitivity (90.91%) and specificity (37.50%), with a value of 10 points, whereas in the MELD-Na the cutoff point was 7 points, with a sensitivity of 90.91% and a specificity of 33.33%, both scores being significant. CONCLUSIONS: there were no reliable predictors of MVI between clinical, laboratory, and epidemiological variables. The MELD-Na score is more sensitive than the MELD one for predicting mortality in patients undergoing liver transplantation.

COMPARATIVE EVALUATION OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY AND PERIOPERATIVE CHOLANGIOGRAPHY IN PATIENTS WITH SUSPECT CHOLEDOCHOLITHIASIS.

BACKGROUND: Cholelithiasis is a highly prevalent condition, and choledocholitiasis is a high morbidity complication and requires accurate methods for its diagnosis. AIM: To evaluate the population of patients with suspected choledocholitiasis and check the statistical value of magnetic resonance cholangiopancreatography, ultrasonography, the laboratory and the clinic of these patients comparing them to the results obtained by perioperative cholangiography. METHODS: This is a retrospective cohort study, which were evaluated 76 patients with cholelithiasis and suspected choledocholithiasis. RESULTS: It was observed that the presence of dilatation of the biliary tract or choledocholithiasis in the ultrasonography was four and eight times increased risk of perioperative cholangiography for positive choledocholithiasis, respectively. For each unit increased in serum alkaline phosphatase was 0.3% increased the risk of perioperative cholangiography for positive choledocholithiasis. In the presence of dilatation of the bile ducts in the ultrasonography was four times greater risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. In the presence of pancreatitis these patients had five times higher risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. On the positive magnetic resonance cholangiopancreatography presence to choledocholithiasis was 104 times greater of positive perioperative cholangiography for choledocholithiasis. CONCLUSIONS: The magnetic resonance cholangiopancreatography is a method with good accuracy for propedeutic follow-up for the diagnosis of choledocholithiasis, consistent with the results obtained from the perioperative cholangiography; however, it is less invasive, with less risk to the patient and promote decreased surgical time when compared with perioperative cholangiography.

Giant hepatic hemangioma in a patient with cirrhosis: challenging to manage

ABSTRACT Giant hepatic hemangiomas are occasional in patients with cirrhosis. It remains a challenge to decide on the need for treatment and choose the most appropriate intervention. A 62-year-old woman was recently diagnosed with cirrhosis and complained of upper abdominal fullness, reduction in oral food intake, and weight loss of 6 kg over the last three years. Upper digestive endoscopy evidenced thin-caliber esophageal varices and significant extrinsic compression of the lesser gastric curvature. Abdominal computed tomography revealed an exophytic tumor in the left hepatic lobe, measuring 11.5 cm, which had progressive centripetal contrast enhancement from the arterial phase, compatible with hepatic hemangioma. Serum tumor markers were negative, and her liver function was unimpaired. The patient underwent surgical resection (non-anatomical hepatectomy of segments II and III) which had no immediate complications, and the histopathological evaluation confirmed cavernous hepatic hemangioma. Two weeks later, she was admitted to the emergency room with jaundice, signs of hepatic encephalopathy, and moderate ascites, and was further diagnosed with secondary bacterial peritonitis. As no perforations, abscesses, or fistulas were observed on subsequent imaging tests, clinical management was successfully carried out. This case highlights that giant hepatic hemangiomas may be symptomatic and warrant treatment. In the setting of cirrhosis and portal hypertension, physicians should be aware of the risk of hepatic decompensation following surgical resection, even in patients with Child-Pugh class A.

Bloodstream Infections in Early Postsurgery Liver Transplant: An Analysis of 401 Patients Over 10 Years.

Bloodstream infections are a major factor contributing to morbidity and mortality following liver transplantation. The increasing occurrence of multidrug-resistant bloodstream infections represents a challenge for the prevention and treatment of those infections. The aim of this study was to evaluate the occurrence and microbiological profile of bloodstream infections during the early postoperative period (from day 0 to day 60) in patients undergoing liver transplantation from January 2005 to June 2016 at the State University of Campinas General Hospital. A total of 401 patients who underwent liver transplantation during this period were included in the study. The most common cause of liver disease was hepatitis C virus cirrhosis (34.01%), followed by alcoholic disease (16.24%). A total of 103 patients had 139 microbiologically proven bloodstream infections. Gram-negative bacteria were isolated in 63.31% of the cases, gram-positive bacteria in 28.78%, and fungi in 7.91%. Fifty-six infections (43.75%) were multidrug-resistant bacteria, and 72 (56.25%) were not. There was no linear trend concerning the occurrence of multidrug-resistant organisms throughout the study period. Patients with multidrug-resistant bloodstream infections had a significantly lower survival rate than those with no bloodstream infections and those with non-multidrug-resistant bloodstream infections. In conclusion, the occurrence of bloodstream infections during the early postoperative period was still high compared with other profile patients, as well as the rates of multidrug-resistant organisms. Even though the occurrence of multidrug resistance has been stable for the past decade, the lower survival rates associated with that condition and the challenge related to its treatment are of major concern.

Microvascular invasion in hepatocellular carcinoma: is it predictable with quantitative computed tomography parameters?

OBJECTIVE: To investigate whether quantitative computed tomography (CT) measurements can predict microvascular invasion (MVI) in hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This was a retrospective analysis of 200 cases of surgically proven HCCs in 125 consecutive patients evaluated between March 2010 and November 2017. We quantitatively measured regions of interest in lesions and adjacent areas of the liver on unenhanced CT scans, as well as in the arterial, portal venous, and equilibrium phases on contrast-enhanced CT scans. Enhancement profiles were analyzed and compared with histopathological references of MVI. Univariate and multivariate logistic regression analyses were used in order to evaluate CT parameters as potential predictors of MVI. RESULTS: Of the 200 HCCs, 77 (38.5%) showed evidence of MVI on histopathological analysis. There was no statistical difference between HCCs with MVI and those without, in terms of the percentage attenuation ratio in the portal venous phase (114.7 vs. 115.8) and equilibrium phase (126.7 vs. 128.2), as well as in terms of the relative washout ratio, also in the portal venous and equilibrium phases (15.0 vs. 8.2 and 31.4 vs. 26.3, respectively). CONCLUSION: Quantitative dynamic CT parameters measured in the preoperative period do not appear to correlate with MVI in HCC.

OBJETIVO: O objetivo deste estudo foi investigar se parâmetros quantitativos da tomografia computadorizada (TC) podem predizer invasão microvascular (IMV) no carcinoma hepatocelular (CHC). MATERIAIS E MÉTODOS: Foram analisados, retrospectivamente, 200 CHCs comprovados de 125 pacientes submetidos consecutivamente a transplante ou ressecção hepática entre março/2010 e novembro/2017. Foram realizadas medidas quantitativas da densidade das lesões e do parênquima hepático adjacente pré-contraste e nas fases arterial, portal e de equilíbrio das TCs. Parâmetros de impregnação foram comparados com a presença de IMV nos laudos anatomopatológicos. Regressões logísticas univariadas e multivariadas foram utilizadas para avaliar os parâmetros da TC como potenciais preditores de IMV. RESULTADOS: Dos 200 CHCs, 77 (38,5%) tinham IMV no anatomopatológico. Não houve diferença estatística na razão de atenuação entre CHCs com IMV e os sem IMV na fase portal (114,7 para IMV positiva e 115,8 para IMV negativa) ou de equilíbrio (126,7 para IMV positiva e 128,2 para IMV negativa), nem na razão de washout relativa nas fases portal e de equilíbrio (15,0 para IMV positiva e 8,2 para IMV negativa na fase portal, e 31,4 para IMV positiva e 26,3 para IMV negativa na fase de equilíbrio). CONCLUSÃO: Não houve relação entre os parâmetros quantitativos da TC pré-operatória e IMV dos CHCs.

Profile of potential organ donors and factors related to donation and non- donation of organs in an Organ Procurement Service. / Perfil dos potenciais doadores de órgãos e fatores relacionados à doação e a não doação de órgãos de uma Organização de Procura de Órgãos.

OBJECTIVE: to characterize the profile of potential and effective organ donors, and to identify the factors related to non-donation. METHODS: the data was collected from the Organization of Organ Donation forms during the period of January 2013 to April 2018. The statistical analysis was done by the Biostatistic Service of the School of Medical Sciences of UNICAMP. RESULTS: the study analyzed 1,772 potential donors; the male gender was predominant (57.39%). Vascular injuries (n=996) were the main cause of brain death. The family refusal (42.8%) was the leading cause of non-donation of organs. There was statistical difference between donors and non-donors in regard to the mean age and mean systolic blood pressure. There was also a relationship between the donation of organs and the absence of diabetes and smoking. CONCLUSION: the majority of effective organ donors were young males. The main causes of brain death (BD) and family refusal of organ donation were cerebrovascular disorder and no desire to donate organs after death, respectively. Alcoholics and males were more frequently found in traumatic causes of BD. Therefore, initiatives for population awareness and discussion among the families regarding organ donation can lead to increase the number of effective organ donors.

OBJETIVO: caracterizar o perfil dos potenciais e dos efetivos doadores de órgãos, e identificar os fatores relacionados a não efetivação da doação. MÉTODOS: estudo retrospectivo transversal com coleta de dados das fichas da Organização de Procura de Órgãos do Hospital das Clínicas da Unicamp, referente ao período de janeiro de 2013 a abril de 2018. RESULTADOS: o estudo contou com 1.772 potenciais doadores; predominou-se o sexo masculino (57,39%) e o evento vascular (n=996) foi a principal causa de morte encefálica. A recusa familiar (42,8%) foi o motivo mais comum para não doação de órgãos. Houve diferença estatística entre doadores e não doadores quanto à média de idade e pressão arterial sistólica, assim como houve relação entre a doação de órgãos e a ausência de diabetes e tabagismo. CONCLUSÃO: a maioria dos doadores efetivos foi do sexo masculino e jovem. As principais causas de morte encefálica e de recusa familiar foram, respectivamente, vasculares e não manifestação da vontade de ser doador após a morte. O etilismo foi mais presente nas causas traumáticas, assim como, o sexo masculino. Assim, iniciativas de conscientização populacional e abertura de discussão dentro da família sobre o ato da doação contribuem para o aumento do índice de doadores efetivos.

Using Lean tools to reduce patient waiting time.

Purpose This paper aims to address problems in patient flow and identify the reasons behind extensive wait time at a public liver transplant outpatient clinic in an education and research hospital through the use of Lean health-care theories. Design/methodology/approach This paper opted for the application of Lean thinking and action research strategy. Data were collected through personal observations, interviews with users and team brainstorming. A value stream map was developed, improvement possibilities were identified and non-value-added activities were attempted to be eliminated. Findings Significant problems were identified and improvements were implemented and measured. The major remedial measures were: change the scheduling pattern, create a flow chart and a Kanban visual guide for medical students. In addition, an institutional change in the medical appointment scheduling software collaborated in the reduction of time and in the patient's displacement. The waiting time was reduced by 4.5 h, and the per cent complete and accurate increased by 50 per cent. Practical implications The flow was redesigned, and a culture of continuous improvement was introduced. Visiting the place where work was being done, leaders identified and created more value to the process without significant costs. The Gemba Walk was a powerful tool, interacting with people and processes in a Kaizen spirit. Originality/value Public health services in developing countries are one of the most deprived social needs of good practice. It will be useful for those who need examples about how to apply Lean tools in health care.

Clinical impact of the Model for End Liver Disease (MELD) score on the presence of microvascular invasion and on the postoperative outcome in patients undergoing liver transplantation / Impacto clínico do Model For End Liver Disease (MELD) na presença de invasão microvascular e no desfecho pós-operatório em pacientes submetidos a transplante hepático

ABSTRACT Objective: to correlate clinical and epidemiological data with the pathological analysis of liver explants from patients undergoing liver transplantation for hetapocarcinoma in the UNICAMP HC and to verify whether the MELD and MELD-Na scores are reliable factors to predict a worse post-transplant prognosis. Methods: we studied liver transplants carried out between May 2010 and November 2017. After excluding 38 patients, we included 87, analyzing clinical and laboratory data for correlation with the outcome Microvascular Invasion (MVI). Subsequently, we computed the MELD and MELD-Na scores and performed a descriptive analysis of clinical and laboratory data and, finally, calculated ROC curves to assess the association between these laboratory parameters and mortality in these patients. Results: most patients were male (78.30%), with an average age of 58.53 years. Most liver diseases were caused by HCV (53.26%). We found no predictors for MVI among the laboratory parameters. The ROC curves for death identified the MELD score as the cutoff point with the highest combined sensitivity (90.91%) and specificity (37.50%), with a value of 10 points, whereas in the MELD-Na the cutoff point was 7 points, with a sensitivity of 90.91% and a specificity of 33.33%, both scores being significant. Conclusions: there were no reliable predictors of MVI between clinical, laboratory, and epidemiological variables. The MELD-Na score is more sensitive than the MELD one for predicting mortality in patients undergoing liver transplantation.

RESUMO Objetivo: correlacionar dados clínicos e epidemiológicos com a análise patológica dos explantes hepáticos dos pacientes submetidos ao transplante hepático por hetapocarcinoma no HC da UNICAMP e verificar se os scores MELD e MELD-Na apresentam diferenças estatísticas para predizer pior prognóstico pós-transplante. Métodos: considerando os transplantes hepáticos ocorridos entre maio/2010 e novembro/2017, após excluir 38, 87 pacientes foram incluídos, analisando-se dados clínicos e laboratoriais desses pacientes para verificar se há independência entre esses e desfecho Invasão Microvascular (IMV). Posteriormente, realizou-se o cálculo do MELD e MELD-Na, a análise descritiva dos dados clínicos e laboratoriais e, por fim, curvas ROC para avaliar a associação entre esses parâmetros laboratoriais e o desfecho óbito nestes pacientes. Resultados: a maior parte dos pacientes foi do sexo masculino (78,30%), com idade, em média, de 58,53 anos. A maior parte das hepatopatias foi causada pelo VHC (53,26%). Não foi encontrado preditores para o desfecho IMV entre os parâmetros laboratoriais. As curvas ROC para o desfecho óbito identificaram o score MELD como ponto de corte de maior sensibilidade (90,91%) e especificidade (37,50%) simultâneas com o valor de 10 pontos, ao passo que no MELD-Na o ponto de corte foi 7 pontos, com sensibilidade de 90,91% e especificidade de 33,33%, sendo ambas as escalas significativas. Conclusões: não foram encontrados preditores para IMV entre critérios clínicos, laboratoriais e epidemiológicos. O score MELD-Na é mais sensível que o MELD para predizer mortalidade nos pacientes submetidos a transplante hepático.

Comparative evaluation of magnetic resonance cholangiopancreatography and perioperative cholangiography in patients with suspect choledocholithiasis / Avaliação comparativa da colangiopancreatografia por ressonância magnética e da colangiografia peroperatória na suspeita de coledocolitíase

ABSTRACT Background: Cholelithiasis is a highly prevalent condition, and choledocholitiasis is a high morbidity complication and requires accurate methods for its diagnosis. Aim: To evaluate the population of patients with suspected choledocholitiasis and check the statistical value of magnetic resonance cholangiopancreatography, ultrasonography, the laboratory and the clinic of these patients comparing them to the results obtained by perioperative cholangiography. Methods: This is a retrospective cohort study, which were evaluated 76 patients with cholelithiasis and suspected choledocholithiasis. Results: It was observed that the presence of dilatation of the biliary tract or choledocholithiasis in the ultrasonography was four and eight times increased risk of perioperative cholangiography for positive choledocholithiasis, respectively. For each unit increased in serum alkaline phosphatase was 0.3% increased the risk of perioperative cholangiography for positive choledocholithiasis. In the presence of dilatation of the bile ducts in the ultrasonography was four times greater risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. In the presence of pancreatitis these patients had five times higher risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. On the positive magnetic resonance cholangiopancreatography presence to choledocholithiasis was 104 times greater of positive perioperative cholangiography for choledocholithiasis. Conclusions: The magnetic resonance cholangiopancreatography is a method with good accuracy for propedeutic follow-up for the diagnosis of choledocholithiasis, consistent with the results obtained from the perioperative cholangiography; however, it is less invasive, with less risk to the patient and promote decreased surgical time when compared with perioperative cholangiography.

RESUMO Racional: A colelitíase é afecção de alta prevalência, sendo a coledocolitíase complicação de elevada morbidade e que necessita de métodos acurados para seu diagnóstico. Objetivo: Avaliar o perfil populacional de pacientes com suspeita de coledocolitíase e verificar o valor estatístico da colangiopancreatografia por ressonância magnética, da ultrassonografia, dos exames laboratoriais e da clínica desses pacientes e compará-los aos resultados obtidos pela colangiografia peroperatória. Métodos: Trata-se de estudo longitudinal, de coorte, retrospectivo, no qual foram avaliados 76 pacientes com diagnóstico de colelitíase e suspeita de coledocolitíase. Resultados: Observou-se que na presença de dilatação das vias biliares ou coledocolitíase na ultrassonografia havia risco quatro e oito vezes maior, respectivamente, de colangiografia peroperatória positiva para coledocolitíase. Para cada unidade de aumento na fosfatase alcalina sérica houve aumento em 0,3% no risco de colangiografia peroperatória positiva para coledocolitíase. Na presença de dilatação das vias biliares na ultrassonografia ou clínica de pancreatite havia risco quatro e cinco vezes maior, respectivamente, de colangiopancreatografia por ressonância magnética positiva para coledocolitíase. Na presença de colangiopancreatografia por ressonância magnética positiva para coledocolitíase o risco foi 104 vezes maior de colangiografia peroperatória positiva para coledocolitíase. Conclusão: A colangiopancreatografia por ressonância magnética para seguimento propedêutico tem boa acurácia para o diagnóstico de coledocolitíase, e concordante com os resultados obtidos na colangiografia peroperatória. O método é menos invasivo, com menores riscos ao paciente e com diminuição do tempo cirúrgico dispendido para realização da colangiografia peroperatória.