Endoscopic Ultrasound-Guided Ethanol Injection Associated with Trans-arterial Embolization of a Giant Intra-abdominal Cavernous Hemangioma: Case Report and New Therapeutic Option.

BACKGROUND: Cavernous hemangiomas are congenital hamartomatous lesions that originate from mesodermal tissue composed of dilated blood vessels. Abdominal pain and palpable mass are the most common presenting symptoms. The different types of treatment for symptomatic patients remain controversial. However, surgical resection is always the most preferred method when possible. To date, there are no reports of endoscopic ultrasound-guided (EUS-guided) absolute ethanol injection as a treatment for such disease when surgery is not an option. CASE PRESENTATION: A 19-year-old girl with giant cavernous intra-abdominal hemangioma extending to the hepatic hilum, also affecting the gastric wall and occupying the entire supra-mesocolic cavity, initially presents with upper gastrointestinal bleeding and loss of 20 kg in 1 year (BMI = 18 kg/m2). Percutaneous angiography identified a mass with arterial blood supply by the left gastric artery that was embolized. After re-bleeding, an alternative treatment with EUS-guided injection of alcohol was proposed once resection was not feasible without major risks to a young patient. This procedure was repeated 15 and 45 days after the initial treatment, with the ethanol injection of 25 cc and 15 cc, respectively. On the second and third procedure dates, there was evident regression of the hemangioma. On the third procedure, it was possible to identify all anatomic structures that were not clear on the first EUS. After 45 days of last injection, abdominal CT and EUS showed notorious regression of the lesion. Eight months later, abdominal CT showed only a remnant lesion in the hepatogastric ligament with 129 cm3 on volumetry (87% lower in comparison to the initial image), and the patient remains asymptomatic with BMI of 26. In the most recent follow-up CT, 4 years and 2 months after first treatment, the patient presents with a slight increase in the hemangioma-now with 183 cm3 on volumetry. CONCLUSION: Transgastric EUS-guided ethanol injection in the treatment of giant intra-abdominal cavernous hemangioma can provide good outcomes without major complications and can be repeated if necessary.

Alternative Biomarkers to Predict Tumor Biology in Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the most frequent primary malignant liver tumor, with more than 800,000 new cases diagnosed each year and with high mortality, ranking fourth in the world in cancer deaths. The worst prognosis is related to the late diagnosis, in which the tumor is at an advanced stage and curative treatments are not efficient in terms of increasing overall survival. Currently, screening and monitoring tests based on current guidelines have limited accuracy, which points to the need for the development of new biomarkers that improve HCC detection as well as its early diagnosis. This review will discuss the five phases of development of a biomarker, from its discovery to its application in clinical practice, and indicate the main biomarkers per development phase. Potential emerging technologies such as "Radiomics", "Proteomics" and "Metabolomics" will also be discussed, which should serve as tools for the elucidation of tumor heterogeneity, as well as provide data for future studies on HCC biomarkers.

Overall survival predictors in hepatocellular carcinoma patients treated with sorafenib.

OBJECTIVE: Malignant liver tumors are the fourth leading cause of cancer death worldwide. Hepatocellular carcinoma (HCC) accounts for 75-85% of these. Most patients are diagnosed at incurable stages. Palliative care is the appropriate treatment course in these circumstances (chemoembolization and sorafenib). There are few national studies on sorafenib. The objective is to evaluate survival predictors of HCC patients treated with sorafenib and evaluate the compliance of its indication in relation to BCLC recommendations. METHODS: A total of 88 patients with an indication of sorafenib from 2010 to 2017 at the ISCMSP were retrospectively analyzed. Univariate and multivariate analyzes were performed in the search for predictors of survival. RESULTS: The mean age was 61.2 years, 70.5% were men, most were classified as Child-Pugh A (69.3%), and BCLC C (94.3%). Cirrhosis was present in 84.6% and portal hypertension in 55.7%. Hepatitis C virus was the most common etiology (40.9%). Sixty-nine (78.4%) patients received the medication, with the average duration of treatment being 9.7 months. The mean overall survival was 16.8 months. Significant differences were observed in the multivariate analysis: ECOG PS (p = 0.024): Child-Pugh (p = 0.013), time of medication use (p <0.001), clinical worsening (p = 0.031) and portal thrombosis (p = 0.010). CONCLUSION: Absence of portal thrombosis, Child-Pugh A, longer time of medication use, ECOG PS 0, and absence of suspension due to clinical worsening were predictors of better overall survival in the study. The drug's indication complies with BCLC guidelines in 94% of patients.

Hepatic subcapsular hematoma post-ERCP: Case report and literature review.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed minimally invasive procedures currently available for diagnosis and treatment of biliary and pancreatic diseases. Though considered a safe procedure, it has the highest rate of complications among the other endoscopic procedures, such as duodenal perforation and hepatic subcapsular hematoma (HSH). We are a presenting a case report and review of the current literature. METHOD: We report one case HSH rupture, in a 25 years old female patient, 15 cm in diameter, affecting liver segments VI, VII and VIII, who underwent surgical treatment and performed a systematic literature review with the descriptors: endoscopic retrograde colangiopancreatography and hepatic subcapsular hematoma. All articles were reviewed and data on cases that presented rupture of the HSH analyzed separately. RESULTS: Sixty one cases of HSH were described in the literature, fourteen of them ruptured. When analyzing only the subgroup of patients who had ruptured subcapsular hematoma, we showed a significant increase in the mortality rate of patients when compared to non-ruptured (21.4% × 2.2%). We also report that patients with rupture required some type of intervention, of which 78.6% required surgery. Conservative treatment may be the conduct and will suffice for most cases of non-ruptured hematomas. For patients who evolve with rupturing, surgical resolution, although non-mandatory, is necessary in most cases. CONCLUSION: HSH ruptured is a rare and potentially fatal post-ERCP complication whose treatment is eminently surgical.

Overall survival predictors in hepatocellular carcinoma patients treated with sorafenib

SUMMARY Malignant liver tumors are the fourth leading cause of cancer death worldwide. Hepatocellular carcinoma (HCC) accounts for 75-85% of these. Most patients are diagnosed at incurable stages. Palliative care is the appropriate treatment course in these circumstances (chemoembolization and sorafenib). There are few national studies on sorafenib. The objective is to evaluate survival predictors of HCC patients treated with sorafenib and evaluate the compliance of its indication in relation to BCLC recommendations. METHODS A total of 88 patients with an indication of sorafenib from 2010 to 2017 at the ISCMSP were retrospectively analyzed. Univariate and multivariate analyzes were performed in the search for predictors of survival. RESULTS The mean age was 61.2 years, 70.5% were men, most were classified as Child-Pugh A (69.3%), and BCLC C (94.3%). Cirrhosis was present in 84.6% and portal hypertension in 55.7%. Hepatitis C virus was the most common etiology (40.9%). Sixty-nine (78.4%) patients received the medication, with the average duration of treatment being 9.7 months. The mean overall survival was 16.8 months. Significant differences were observed in the multivariate analysis: ECOG PS (p = 0.024): Child-Pugh (p = 0.013), time of medication use (p <0.001), clinical worsening (p = 0.031) and portal thrombosis (p = 0.010). CONCLUSION Absence of portal thrombosis, Child-Pugh A, longer time of medication use, ECOG PS 0, and absence of suspension due to clinical worsening were predictors of better overall survival in the study. The drug's indication complies with BCLC guidelines in 94% of patients.

RESUMO Tumores malignos do fígado são a quarta maior causa de morte por câncer, sendo que o carcinoma hepatocelular (CHC) corresponde a 85-90% desses casos. A maioria dos doentes apresenta-se, ao diagnóstico, sem possibilidade de tratamento curativo, restando apenas as opções paliativas (quimioembolização e sorafenibe). Há poucos estudos nacionais acerca do sorafenibe. OBJETIVO Avaliar fatores preditivos de sobrevida em pacientes com CHC que tiveram indicação de tratamento com sorafenibe na Irmandade da Santa Casa de Misericórdia de São Paulo (ISCMSP) e avaliação da conformidade da indicação da medicação em relação às recomendações do BCLC. MÉTODOS Foram analisados retrospectivamente os dados de 88 pacientes que tiveram indicação de tratamento com sorafenibe no período de 2010 a 2017 na ISCMSP. Análises univariada e multivariada foram realizadas na busca de preditores de sobrevida global nos pacientes que receberam a medicação. RESULTADOS Idade média de 61,2 anos, sendo 70,5% homens. A maioria (69,3%) foi classificada como Child Pugh A e BCLC C (94,3%). A cirrose esteve presente em 84,6% e a hipertensão portal em 55,7% desses. O vírus da hepatite C foi a etiologia mais comum (40,9%) do CHC. Sessenta e nove (78,4%) pacientes receberam a medicação, sendo o tempo médio de duração do tratamento 9,7 meses e a sobrevida global média, 16,8 meses. Diferenças significativas foram observadas na análise multivariada: Ecog PS (p=0,024), CP (p=0,013), tempo de uso de medicação (p<0,001), suspensão por piora clínica (p=0,031) e trombose portal (p=0,010). CONCLUSÃO Ausência de trombose portal, Child Pugh A, Ecog PS 0, tempo maior de uso de medicação e ausência de suspensão por piora clínica foram fatores preditores de melhor sobrevida global e a indicação da medicação esteve em conformidade com as orientações do BCLC em 94% dos pacientes.

Duodenal diverticulization as treatment of complex duodeno-pancreatic lesions: Case report.

INTRODUCTION: Duodenal and pancreatic lesions are uncommon, but severe and responsible for high incidence in morbidity and mortality. Differences between the mechanisms of trauma, the severity of lesions and the time between trauma, diagnosis and treatment influence the evolution of the case. PRESENTATION OF CASE: We report a case of a 20-year-old patient with several lesions in stomach, duodenum, pancreas and jejunum due to three gunshots treated at our service. Duodenal diverticulalization was used on treatment of complex duodeno-pancreatic lesions. The patient presented good evolution, with discharge conditions in the 10th PO. DISCUSSION: We discussed the positives and negatives of this technique, with the approval of the Ethics Committee number 13736519.8.0000.5479. CONCLUSION: The duodenal diverticulization leads to an irreversible change to the food transit. However, this is a feasible bypass option in cases of high chances of fistula and scar stenosis complex duodenal injury, particularly in the context of associated gastric injury.

Elevated Gastric Antrum Erosions in Portal Hypertension Patients: Peptic Disease or Mucosal Congestion?

BACKGROUND/AIMS: Portal hypertension (PH) is a syndrome characterized by chronic increase in the pressure gradient between the portal vein and inferior vena cava. Previous studies have suggested an increased frequency of antral elevated erosive gastritis in patients with PH, as well as an etiologic association; however, there has not been any histological evidence of this hypothesis to date. Our aim was to evaluate the histological features found in elevated antral erosions in patients with portal hypertension. METHODS: Sixty-nine patients were included; 28 with and 41 without PH. All patients underwent endoscopy, and areas with elevated antral erosion were biopsied. RESULTS: In the PH group, 24 patients had inflammatory infiltration with or without edema and vascular congestion, and 4 patients had no inflammation. In the group without PH, all patients showed inflammatory infiltration of variable intensity. There was no statistical significance between the two groups in the presence of Helicobacter pylori. There as a histological similarity between the two groups, if PH patients without inflammation were excluded; however, more edema and vascular congestion were observed in the PH group (p=0.002). CONCLUSIONS: The findings show that elevated antral erosions in patients with PH have more evident edema and vascular congestion in addition to lymphocytic infiltration.

Model for End-Stage Liver Disease, Model for Liver Transplantation Survival and Donor Risk Index as predictive models of survival after liver transplantation in 1,006 patients.

OBJECTIVES: Liver transplantation has not increased with the number of patients requiring this treatment, increasing deaths among those on the waiting list. Models predicting post-transplantation survival, including the Model for Liver Transplantation Survival and the Donor Risk Index, have been created. Our aim was to compare the performance of the Model for End-Stage Liver Disease, the Model for Liver Transplantation Survival and the Donor Risk Index as prognostic models for survival after liver transplantation. METHOD: We retrospectively analyzed the data from 1,270 patients who received a liver transplant from a deceased donor in the state of São Paulo, Brazil, between July 2006 and July 2009. All data obtained from the Health Department of the State of São Paulo at the 15 registered transplant centers were analyzed. Patients younger than 13 years of age or with acute liver failure were excluded. RESULTS: The majority of the recipients had Child-Pugh class B or C cirrhosis (63.5%). Among the 1,006 patients included, 274 (27%) died. Univariate survival analysis using a Cox proportional hazards model showed hazard ratios of 1.02 and 1.43 for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival, respectively (p<0.001). The areas under the ROC curve for the Donor Risk Index were always less than 0.5, whereas those for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival were significantly greater than 0.5 (p<0.001). The cutoff values for the Model for End-Stage Liver Disease (≥29.5; sensitivity: 39.1%; specificity: 75.4%) and the Model for Liver Transplantation Survival (≥1.9; sensitivity 63.9%, specificity 54.5%), which were calculated using data available before liver transplantation, were good predictors of survival after liver transplantation (p<0.001). CONCLUSIONS: The Model for Liver Transplantation Survival displayed similar death prediction performance to that of the Model for End-Stage Liver Disease. A simpler model involving fewer variables, such as the Model for End-Stage Liver Disease, is preferred over a complex model involving more variables, such as the Model for Liver Transplantation Survival. The Donor Risk Index had no significance in post-transplantation survival in our patients.

Model for End-Stage Liver Disease, Model for Liver Transplantation Survival and Donor Risk Index as predictive models of survival after liver transplantation in 1,006 patients

OBJECTIVES: Liver transplantation has not increased with the number of patients requiring this treatment, increasing deaths among those on the waiting list. Models predicting post-transplantation survival, including the Model for Liver Transplantation Survival and the Donor Risk Index, have been created. Our aim was to compare the performance of the Model for End-Stage Liver Disease, the Model for Liver Transplantation Survival and the Donor Risk Index as prognostic models for survival after liver transplantation. METHOD: We retrospectively analyzed the data from 1,270 patients who received a liver transplant from a deceased donor in the state of São Paulo, Brazil, between July 2006 and July 2009. All data obtained from the Health Department of the State of São Paulo at the 15 registered transplant centers were analyzed. Patients younger than 13 years of age or with acute liver failure were excluded. RESULTS: The majority of the recipients had Child-Pugh class B or C cirrhosis (63.5%). Among the 1,006 patients included, 274 (27%) died. Univariate survival analysis using a Cox proportional hazards model showed hazard ratios of 1.02 and 1.43 for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival, respectively (p<0.001). The areas under the ROC curve for the Donor Risk Index were always less than 0.5, whereas those for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival were significantly greater than 0.5 (p<0.001). The cutoff values for the Model for End-Stage Liver Disease (≥29.5; sensitivity: 39.1%; specificity: 75.4%) and the Model for Liver Transplantation Survival (≥1.9; sensitivity 63.9%, specificity 54.5%), which were calculated using data available before liver transplantation, were good predictors of survival after liver transplantation (p<0.001). CONCLUSIONS: The Model for Liver Transplantation Survival displayed similar death prediction ...

Association of nonalcoholic fatty liver disease and liver cancer.

AIM: To investigate the association between nonalcoholic fatty liver disease (NAFLD) and liver cancer, and NAFLD prevalence in different liver tumors. METHODS: This is a retrospective study of the clinical, laboratory and histological data of 120 patients diagnosed with primary or secondary hepatic neoplasms and treated at a tertiary center where they underwent hepatic resection and/or liver transplantation, with subsequent evaluation of the explant or liver biopsy. The following criteria were used to exclude patients from the study: a history of alcohol abuse, hepatitis B or C infection, no tumor detected in the liver tissue examined by histological analysis, and the presence of chronic autoimmune hepatitis, hemochromatosis, Wilson's disease, or hepatoblastoma. The occurrence of NAFLD and the association with its known risk factors were studied. The risk factors considered were diabetes mellitus, impaired glucose tolerance, impaired fasting glucose, body mass index, dyslipidemia, and arterial hypertension. Presence of reticulin fibers in the hepatic neoplasms was assessed by histological analysis using slide-mounted specimens stained with either hematoxylin and eosin or Masson's trichrome and silver impregnation. Analysis of tumor-free liver parenchyma was carried out to determine the association between NAFLD and its histological grade. RESULTS: No difference was found in the association of NAFLD with the general population (34.2% and 30.0% respectively, 95%CI: 25.8-43.4). Evaluation by cancer type showed that NAFLD was more prevalent in patients with liver metastasis of colorectal cancer than in patients with hepatocellular carcinoma and intrahepatic cholangiocarcinoma (OR = 3.99, 95%CI: 1.78-8.94, P < 0.001 vs OR = 0.60, 95%CI: 0.18-2.01, P = 0.406 and OR = 0.70, 95%CI: 0.18-2.80, P = 0.613, respectively). There was a higher prevalence of liver fibrosis in patients with hepatocellular carcinoma (OR = 3.50, 95%CI: 1.06-11.57, P = 0.032). Evaluation of the relationship between the presence of NAFLD, nonalcoholic steatohepatitis, and liver fibrosis, and their risk factors, showed no significant statistical association for any of the tumors studied. CONCLUSION: NAFLD is more common in patients with liver metastases caused by colorectal cancer.

Reliability in endoscopic diagnosis of portal hypertensive gastropathy.

AIM: To analyze reliability among endoscopists in diagnosing portal hypertensive gastropathy (PHG) and to determine which criteria from the most utilized classifications are the most suitable. METHODS: From January to July 2009, in an academic quaternary referral center at Santa Casa of São Paulo Endoscopy Service, Brazil, we performed this single-center prospective study. In this period, we included 100 patients, including 50 sequential patients who had portal hypertension of various etiologies; who were previously diagnosed based on clinical, laboratory and imaging exams; and who presented with esophageal varices. In addition, our study included 50 sequential patients who had dyspeptic symptoms and were referred for upper digestive endoscopy without portal hypertension. All subjects underwent upper digestive endoscopy, and the images of the exam were digitally recorded. Five endoscopists with more than 15 years of experience answered an electronic questionnaire, which included endoscopic criteria from the 3 most commonly used Portal Hypertensive Gastropathy classifications (McCormack, NIEC and Baveno) and the presence of elevated or flat antral erosive gastritis. All five endoscopists were blinded to the patients' clinical information, and all images of varices were deliberately excluded for the analysis. RESULTS: The three most common etiologies of portal hypertension were schistosomiasis (36%), alcoholic cirrhosis (20%) and viral cirrhosis (14%). Of the 50 patients with portal hypertension, 84% were Child A, 12% were Child B, 4% were Child C, 64% exhibited previous variceal bleeding and 66% were previously endoscopic treated. The endoscopic parameters, presence or absence of mosaic-like pattern, red point lesions and cherry-red spots were associated with high inter-observer reliability and high specificity for diagnosing Portal Hypertensive Gastropathy. Sensitivity, specificity and reliability for the diagnosis of PHG (%) were as follows: mosaic-like pattern (100; 92.21; High); fine pink speckling (56; 76.62; Unsatisfactory); superficial reddening (69.57; 66.23; Unsatisfactory); red-point lesions (47.83; 90.91; High); cherry-red spots (39.13; 96.10; High); isolated red marks (43.48; 88.31; High); and confluent red marks (21.74; 100; Unsatisfactory). Antral elevated erosive gastritis exhibited high reliability and high specificity with respect to the presence of portal hypertension (92%) and the diagnosis of portal hypertensive gastropathy (88.31%). CONCLUSION: The most suitable endoscopic criteria for the diagnosis of PHG were mosaic-like pattern, red-point lesions and cherry-red spots with no subdivisions, which were associated with a high rate of inter-observer reliability.

[Hepatogastric fistula after chemoembolization of liver metastasis: a case report]. / Fistula hepatogástrica após quimioembolização de metástase hepática.

Liver metastases of colorectal cancer are a challenge in current oncology. Less than 5% of untreated patients are alive after 5 years of diagnosis. The only curative treatment is surgical resection, but there are other options for palliative or neoadjuvant treatment such as transarterial chemoembolization. Serious complications after liver chemoembolization are very rare, and one of the possible complications is a liver abscess. We report a case of hepatogastric fistula caused by a liver abscess ten days after the chemoembolization of a liver metastasis. It was treated surgically with left hepatectomy and parcial gastrectomy, with good outcome. There are only a few reported cases of hepatogastric fistula after liver transarterial chemoembolization.

Cisto esplênico não parasitário: tratamento por laparoscopia / Non-parasitic splenic cyst: treatment by laparoscopy

Contexto: Os cistos esplênicos não parasitários são eventos raros, muitas vezes assintomáticos e encontradosincidentalmente durante exames de imagem.Descrição do caso: Paciente do sexo feminino, 25 anos, parda, foi atendida pelo Grupo de Fígado e Hipertensão Portalda Faculdade de Ciências Médicas da Santa Casa de São Paulo, e o quadro clínico inicial corroborou com o achadoincidental do cisto. O diagnóstico foi confirmado pela ressonância nuclear magnética de abdome superior e pelo examehistopatológico de fragmento obtido no intraoperatório. O tratamento instituído foi o destelhamento do cisto por viavideolaparoscópica, com a colocação de epíplon no interior do leito cístico.Discussão: A paciente encaixa-se no clássico quadro de achado incidental em exames de imagem, sendo os primeirossintomas inespecíficos. Além disso, este caso se sobressai devido à sua raridade, tanto entre os vistos diariamenteno serviço como nos casos descritos na literatura. Foi optado pelo tratamento videolaparoscópico que apresentouexcelente resultado, com melhora dos sintomas, tempo cirúrgico curto e evitou a esplenectomia total.Conclusões: Os cistos esplênicos são achados incidentais dentro de um quadro clínico assintomático ou inespecífico.Apesar da raridade, devem estar sempre no acervo de conhecimento de todo médico para que a conduta seja adequadae os resultados satisfatórios.

[Pre-operative care for liver disease patients]. / Cuidados pré-operatórios em hepatopatas.

Patients with impaired hepatic functional reserve when submitted to surgeries may have high rates of morbidity and mortality. Pre-existing liver disease should be detected without need for invasive methods. Clinical history and physical examination provide important clues. Laboratory liver function is not necessary unless there are changes in history or physical examination. Liver disease has many effects on surgery and anesthesia. A decrease in oxygenation and increased risk of liver dysfunction can be caused by anesthesia, hemorrhage, hypoxemia, hypotension, vasoactive drugs or the patient's position on the operating table during and after surgery. Emergency surgery is a major predictor of poor prognosis as well as sepsis and reoperations. The nature of liver disease, severity and type of surgery to be performed should take into account for a correct preoperative preparation. Some actions must be taken at preoperative to decrease chances of complications in patients with liver disease undergoing surgical procedures. Very close attention should be given to coagulopathy, encephalopathy, ascites, renal and pulmonary dysfunction, spontaneous bacterial peritonitis and esophageal varices. Patients with Child-Pugh score C and MELD>15 should not undergo elective surgery. Patients with Child-Pugh score B and MELD 10 to 15 may undergo minor surgical procedures with care in cases of extreme necessity. Patients with Child-Pugh score A and MELD<10 may be submitted to elective surgery.

Cuidados pré-operatórios em hepatopatas / Pre-operative care for liver disease patients

Cirurgias realizadas em pacientes com reserva funcional hepática reduzida podem apresentar altos índices de morbi-mortalidade. Uma triagem pré-operatória ideal visa detectar a doença hepática pré-existente, sem necessidade de métodos invasivos. A história clínica e o exame físico fornecem pistas importantes. A quantificação da função hepática de rotina não é necessária, a menos que exista alguma alteração na história ou exame físico. A doença hepática causa diversos efeitos na cirurgia e anestesia. A indução anestésica, hemorragias, hipoxemia, hipotensão, drogas vasoativas e até a posição do paciente na mesa cirúrgica podem provocar diminuição na oxigenação e maior risco de disfunção hepática no intra e pós-operatório. A cirurgia de emergência é um grande preditor de mau prognóstico assim como a sepse e as reoperações. Para uma correta preparação pré-operatória, deve-se levar em consideração a natureza da doença hepática, sua gravidade e o tipo de cirurgia a ser realizada. Algumas ações devem ser tomadas no pré-operatório para diminuir as chances de complicações em pacientes portadores de hepatopatias submetidos a procedimentos cirúrgicos. O combate à coagulopatia, encefalopatia, ascite, disfunção renal e pulmonar, peritonite bacteriana espontânea e varizes de esôfago deve ser precoce e agressivo. Doentes Child-Pugh C e MELD > 15 não devem ser submetidos a cirurgias eletivas. Doentes Child-Pugh B e com MELD de 10 a 15 podem ser submetidos a pequenos procedimentos cirúrgicos em caso de extrema necessidade e com cautela. Finalmente doentes Child-Pugh A e MELD < 10 podem ser operados.

Patients with impaired hepatic functional reserve when submitted to surgeries may have high rates of morbidity and mortality. Pre-existing liver disease should be detected without need for invasive METHODS. Clinical history and physical examination provide important clues. Laboratory liver function is not necessary unless there are changes in history or physical examination. Liver disease has many effects on surgery and anesthesia. A decrease in oxygenation and increased risk of liver dysfunction can be caused by anesthesia, hemorrhage, hypoxemia, hypotension, vasoactive drugs or the patient's position on the operating table during and after surgery. Emergency surgery is a major predictor of poor prognosis as well as sepsis and reoperations. The nature of liver disease, severity and type of surgery to be performed should take into account for a correct preoperative preparation. Some actions must be taken at preoperative to decrease chances of complications in patients with liver disease undergoing surgical procedures. Very close attention should be given to coagulopathy, encephalopathy, ascites, renal and pulmonary dysfunction, spontaneous bacterial peritonitis and esophageal varices. Patients with Child-Pugh score C and MELD>15 should not undergo elective surgery. Patients with Child-Pugh score B and MELD 10 to 15 may undergo minor surgical procedures with care in cases of extreme necessity. Patients with Child-Pugh score A and MELD<10 may be submitted to elective surgery.

Doppler ultrasound could predict varices progression and rebleeding after portal hypertension surgery: lessons from 146 EGDS and 10 years of follow-up.

BACKGROUND: Surgical treatment of variceal hemorrhagic complications for patients with schistosomal portal hypertension in our group comprised an esophagogastric devascularization procedure with splenectomy (EGDS). There are two different kinds of postoperative follow-up: prophylactic or on-demand endoscopic program of varices eradication. This program implies risks and costs and only proves necessary in 6-29% of cases. This study was designed to assess portal vein Doppler ultrasound data in these patients, and to verify correlations with progression in the number and size of varices, as well as the appearance of red spots and rebleeding during the postoperative period after EGDS. METHODS: Data on portal vein Doppler ultrasound from 146 patients with schistosomal portal hypertension and previous history of upper digestive bleeding due to esophagogastric varices rupture was analyzed. All subjects underwent EGDS and were analyzed before and after the procedure and compared postoperatively at four time points: 1 year, 2 years, up to 5 years, and up to 10 years. The following portal hemodynamic parameters were analyzed: diameter and mean blood flow velocity. Variceal size and number, presence of red spots, and rebleeding were all determined by endoscopic examination. Patients were divided into two groups at the each of the four time points, according to esophagogastric varices progression. RESULTS: Patients with variceal progression had significantly higher values of portal blood flow velocity. At time points I, II, III, and IV, the measured flow velocity from first postoperative year was 17.64 +/- 4.84 vs. 13.81 +/- 5.61 (p = 0.025); 16.74 +/- 4.8 vs. 13.75 +/- 5.8 (p = 0.039); 16.01 +/- 5.00 vs. 13.23 +/- 5.86 (p = 0.036); and 16.01 +/- 5.00 vs. 13.23 +/- 5.86 (p = 0.036), respectively. CONCLUSIONS: Patients with schistosomal portal hypertension submitted to EGDS who had portal blood flow velocity >15.5 cm per second at the first postoperative year ha d progression of esophagogastric varices and a greater chance of rebleeding and, therefore, should be included in the endoscopic program for varices eradication.

Influência da retirada de pâncreas e fígado de um mesmo doador cadavérico na funçäo precoce dos enxertos hepáticos - experiência de 29 casos / Influence of combined pancreas and liver retrieval from the cadaveric donor on early liver graft function - a 29 case experience

A necessidade de órgäos frente a escassez de doadores cadavéricos levou ao desenvolvimento de técnicas que permitem a retirada do fígado e pâncreas de um mesmo doador. Nesse estudo analisa-se a experiência com a técnica de retirada de fígado e pâncreas de um mesmo doador e a influência sobre o resultado precoce do enxerto hepático. Entre janeiro de 1996 e junho de 2000 participamos de 36 captações de pâncreas para transplante. Em 29 casos houve remoçäo simultânea de fígado e pâncreas. Através de pesquisa aos respectivos grupos de transplante hepático, investigou-se a funçäo inicial precoce do enxerto hepático e eventuais complicações vasculares precoces que porventura estivessem relacionados ao acréscimo da retirada do pâncreas na cirurgia do doador. Três receptores de fígado tiveram óbito intra-operatório e portanto foram excluídos da análise. Dos 26 pacientes analisados, 2 receptores de fígado faleceram precocemente, 1 por trombose arterial e 1 por näo funçäo primária. O sucesso precoce do enxerto foi de 92,4 por cento (24 casos em 26), semelhante aos resultados obtidos na literatura quando há retirada de fígado sem associaçäo da captaçäo do pâncreas. Analisando esta experiência, concluímos que a remoçäo do pâncreas e fígado de um mesmo doador cadavérico é factível na grande maioria dos casos e näo incorre em prejuízo para a funçäo precoce do enxerto hepático

Tratamento da síndrome de Budd-Chiari / Treatment of the Budd-Chiari syndrome

Supressão da drenagem venosa hepática com ou sem o comprometimento da veia cava resulta na Síndrome de Budd-Chiari (SBC). Neste artigo os autores discutem o tratamento e aspectos controversos publicados na literatura médica

Fisiopatologia e diagnóstico da síndrome de Budd-Chiari / Physiopathology and diagnosis of the Budd-Chiari syndrome

A Síndrome de Budd-Chiari (SBC) compreende grupo heterogêneo de distúrbios caracterizados pela supressão parcial ou completa da drenagem venosa hepática. Sua apresentação clínica depende da causa e do sítio de obstrução venosa e as opções de tratamento são variáveis. Neste trabalho os autores revisam temas relacionados a fisiopatologia, diagnóstico, discutindo aspectos controversos publicados na literatura