Risk Factors for Hemorrhagic Adverse Events in Percutaneous Transhepatic Biliary Drainage: A Prospective Multicenter Study.

PURPOSE: To determine risk factors (RFs) for hemorrhagic adverse events (AEs) associated with percutaneous transhepatic biliary drainage (PTBD) and to develop a risk assessment model. MATERIALS AND METHODS: This was a multicenter, prospective, case control study between 2015 and 2020. Adults with an indication for PTBD were included. Patients who had undergone recent previous drainage procedures were excluded. Multiple variables were controlled. The exposure variables were the number of capsular punctures and passes (using the same puncture). A multivariate analysis was performed (logistic regression analysis). RESULTS: A total of 304 patients (mean age, 63 years ± 14 [range, 23-87 years]; female, 53.5%) were included. Hemorrhagic AEs occurred in 13.5% (n = 41) of the patients, and 3.0% (n = 9) of the cases were severe. Univariate analysis showed that the following variables were not associated with hemorrhagic AEs: age, sex, bilirubin and hemoglobin levels, type of pathology, portal hypertension, location of vascular punctures, ascites, nondilated bile duct, intrahepatic tumors, catheter features, blood pressure, antiplatelet drug use, and tract embolization. Multivariate analysis showed that number of punctures (odds ratio [OR], 2.5; P = .055), vascular punctures (OR, 4.1; P = .007), fatty liver or cirrhosis (OR, 3.7; P = .021), and intrahepatic tumor obstruction (Bismuth ≥ 2; OR, 2.4; P = .064) were associated with hemorrhagic AEs. Patients with corrected coagulopathies had fewer hemorrhagic AEs (OR, -5.5; P = .026). The predictability was 88.2%. The area under the curve was 0.56 (95% confidence interval, 0.50-0.61). CONCLUSIONS: Preprocedural and intraprocedural RFs were identified in relation to hemorrhage with PTBD. AE risk assessment information may be valuable for prediction and management of hemorrhagic AEs.

Image-Guided Surgery for Common Bile Duct Stones After Roux-en-Y Gastric Bypass.

Background: The relationship between obesity with common bile duct stone (CBDS) is close and increases after a Roux-en-Y gastric bypass (RYGB). Due to the anatomical modification, direct endoscopic access is not always possible. For this reason, image-guided surgery (IGS) by percutaneous transhepatic biliary drainage (PTBD) of the common bile duct (CBD) could be a first-line approach for the treatment of post-RYGB choledocholithiasis. The aim of this study was to analyze the feasibility and safety of CBDS treatment after RYGB with IGS. Materials and Methods: We present a descriptive retrospective observational multicentric study on the treatment of choledocholithiasis in patients operated on for RYGB using IGS through a minimally invasive approach by PTBD. The diagnosis of CBDS was made according to the symptoms of the patients, supported by blood tests, and medical images. Treatment was planned in two stages: in the first step, a PTBD was performed, and in the second step the choledocholithiasis was removed. Results: Of a total of 1403 post-RYGB patients, 21 presented choledocholithiasis. Of these, n = 18 were included. Symptoms were reported in n = 15 (8 cholestatic jaundice, 7 cholangitis), whereas n = 3 were asymptomatic. Percutaneous treatment was performed in all these patients, treated with a balloon and stone basket. A hyperamylasemia without pancreatitis was observed in 3 patients. No complications or deaths associated with the procedure were reported. The average hospital stay was 8.6 days. Conclusion: IGS is an interesting option for the treatment CBDS after RYGB. For these patients, PTBD is feasible and safe.

Image-Guided Surgical Training in Percutaneous Hepatobiliary Procedures: Development of a Realistic and Meaningful Bile Duct Dilatation Porcine Model.

Background: Malignant or benign biliary obstructions can be successfully managed with minimally invasive percutaneous interventions. Since percutaneous approaches are challenging, extensive training using relevant models is fundamental to improve the proficiency of percutaneous physicians. The aim of this experimental study was to develop an in vivo training model in pigs to simulate bile duct dilatation to be used during percutaneous biliary interventions. Materials and Methods: Twenty-eight large white pigs were involved and procedures were performed in an experimental hybrid operating room. Under general anesthesia, animals underwent a preoperative magnetic resonance cholangiography (MRC). Afterward, the common bile duct was isolated and ligated laparoscopically. A postoperative MRC was performed 72 hours after the procedure to evaluate bile duct dilatation. The In vivo models presenting an effective dilatation model were included in the hands-on part of a percutaneous surgery training course. Animals were euthanized at the end of the training session. Results: Postoperative MRC confirmed the presence of bile duct dilatation in the survival pigs (n = 25). No intraoperative complications occurred and mean operative time was 15.8 ± 5.27 minutes. During the course, 27 trainees could effectively perform percutaneous transhepatic cholangiography, bile duct drainage, biliary duct dilatation, and stent placement, with a > 90% success rate, thereby validating the experimental model. All animals survived during the training procedures and complications occurred in 28.3% of cases. Conclusion: The creation of an in vivo bile duct dilatation animal model is feasible with a low short-term mortality. It provides a realistic and meaningful training model in percutaneous biliary procedures.

Acute Gastric Dilation of the Post-Roux-en-Y Gastric Bypass Remnant Stomach: Image-Guided Surgery Approach.

Background: Bariatric surgery is an effective treatment for obesity and its associated morbidities. They are safe surgeries, their general complication rate is 0%-10%. However, acute gastric dilation is an unusual complication. It requires rapid diagnosis and treatment to avoid major complications. Image-guided surgery represents a group of minimally invasive procedures. Acute gastric dilation is a complication that can benefit from the application of this type of procedure. We present a report of patients with acute gastric dilation of the remnant as a complication after bariatric surgery, its resolution through image-guided surgery, and updating. Materials and Methods: A retrospective review of patients who presented postoperative complications after bariatric surgery was carried out. The time period was 10 years. All patients were operated on in a single center by the same surgical team. Results: A total of 3507 bariatric procedures were analyzed (sleeve gastrectomy, 1929-55.1% ± 0.49%; Roux-en-Y gastric bypass [RYGB], 1403-40% ± 0.48%; other techniques, 175-4.9% ± 0.21%). The RYGB branch reported a total of 11 (0.78% ± 0.08%) complications, of which 2 (0.14% ± 0.03%) were reported as acute gastric dilation of the remnant. Conclusions: Acute gastric dilation of the post-RYGB remnant is a rare complication, but it can be serious. It is necessary to have a high suspicion to obtain an early diagnosis and treatment. Percutaneous gastrostomy is an image-guided procedure that can solve the problem temporarily or permanently.

Transhepatic Percutaneous Sustained Dilation with Multiple Catheters for the Management of Hepaticojejunostomy Benign Stricture.

Background: Benign biliary strictures (BBS) befall in ∼7%-23% after hepaticojejunostomy and in 0.3%-0.6% after cholecystectomies. Their treatment options include surgical, endoscopic, and percutaneous management. The percutaneous approach is an excellent mini-invasive option including balloon dilation, biodegradable stents, and sustained dilation, a procedure born endoscopically. However, when the endoscopic approach fails or it is not available, it is possible to perform it percutaneously. Aim: To estimate the technical and clinical success of sustained percutaneous dilation with multiple catheters (SPDMC) in hepaticojejunostomy strictures and the percentage of complications and recurrence. Materials and Methods: We conducted a retrospective study, from a prospective database from January 2010 to March 2019, of 17 patients with postoperative BBS who failed to percutaneous pneumatic balloon dilation and underwent SPDMC with a mean follow-up of 2 years. Results: Seventeen patients between 28 and 71 years of age underwent SPMDC with technical success of 100%; the average number of catheters used was 5.59 (95% confidence interval [CI] 5.12-6.06) achieving a dilatation diameter of 16.15 mm (95% CI 14.71-17.60), and the therapeutic success rate was 71%, with recurrences of stricture and complications of 29% and 18%, respectively. The mean time with SPMDC was 7.06 months (95% CI 5.56-8.56). The median follow-up after dilation was 16 months, with an average of 27.75 months (95% CI 14.15-41.34). Conclusion: SPMDC is a feasible technique with a high technical success rate, therapeutic success rate, and low morbidity and mortality.

RISK OF BLEEDING COMPLICATIONS IN PERCUTANEOUS BILIARY DRAINAGE: THE PARADOX OF THE NORMAL HEMOSTASIS.

BACKGROUND: Percutaneous biliary drainage is a safe procedure. The risk of bleeding complications is acceptable. Frequently, patients with biliary obstructions usually have coagulation disorders thus increasing risk of bleeding. For this reason, patients should always fit the parameters of hemostasis. AIM: To determine whether the percentage of bleeding complications in percutaneous biliary drainage is greater in adults with corrected hemostasis prior to the procedure regarding those who did not require any. METHODS: : Prospective, observational, transversal, comparative by independent samples (unpaired comparison). Eighty-two patients with percutaneous biliary drainage were included. The average age was 64±16 years (20-92) being 38 male and 44 female. Patients who presented altered hemostasis were corrected and the presence of bleeding complications was evaluated with laboratory and ultrasound. RESULTS: Of 82 patients, 23 needed correction of hemostasis. The approaches performed were: 41 right, 30 left and 11 bilateral. The amount of punctures on average was 3±2. There were 13 (15.8%) bleeding complications, 12 (20%) in uncorrected and only one (4.34%) in the corrected group with no statistical difference. There were no differences in side, number of punctures and type of drainage, but number of passes and the size of drainage on the right side were different. There was no related mortality. CONCLUSION: Bleeding complications in patients requiring hemostasis correction for a percutaneous biliary drainage was not greater than in those who did not require any.

Percutaneous Image-Guided Abdominal Interventions for Leaks and Fistulas Following Sleeve Gastrectomy and Roux-en-Y Gastric Bypass.

BACKGROUND: Bariatric surgery offers the only effective long-term weight loss therapy for morbidly obese patients. Numerous studies have demonstrated a mortality and morbidity reduction associated with weight loss surgery, but these interventions also have significant rates of complications. It is important for the bariatric surgeons to recognize these complications and acknowledge which of them can be solved in a minimally invasive manner in order to offer to patients the best treatment. The aim of this article was to review factors and success rates associated with percutaneous image guide abdominal interventions to treat the complications of bariatric surgery. MATERIALS AND METHODS: Retrospective descriptive study. Eighty-two patients with complications after bariatric surgery were included. Of these, 56 presented fistula with or without abdominal collection. RESULTS: Of the total patients, 54% are male and 46% female. The average age was 49.4 (range 16-62). Of the 56 cases, 37 (66.1%) occurred after laparoscopic sleeve gastrectomy, and 19 (33.9%) post-Roux-en-Y gastric bypass. The fistula was resolved by percutaneous image guide abdominal interventions in 49 opportunities, of which 67% required only conservative treatment afterwards, the remaining 33% required endoscopic treatment with prostheses, fibrin sealants, and/or clips. No mortality was reported in the series. CONCLUSION: Percutaneous image-guided abdominal interventions play a significant role in the treatment of complications following bariatric surgery. The minimally invasive treatment of fistula after bariatric surgery is safe and effective.

STAGES AND FACTORS OF THE "PERIOPERATIVE PROCESS": POINTS IN COMMON WITH THE AERONAUTICAL INDUSTRY.

BACKGROUND: The aeronautical industry is one of the disciplines that most use control systems. Its purpose is to avoid accidents and return safer flights. The flight of an airplane, from its takeoff to its landing is a process divided into stages under strict control. A surgical procedure has the same characteristics. We try to identify and develop the stages of the surgical process using the experience of the aviation industry in order to optimize the results and reduce surgical complications. AIM: To identify and develop the stages of the surgical process so that they could be applied to surgery departments. METHODS: A search, review and bibliographic analysis of the application of aeronautical control and safety to medical practice in general and to surgery, in particular, were carried out. RESULTS: Surgical process comprises the perioperative period. It is composed of Preoperative Stage (it is divided into 2 "sub-steps": hospital admission and control of preoperative studies) Operative Stage (it is divided into 3 "sub-steps": anesthetic induction, surgery, and anesthetic recovery) and Postoperative Stage (it is divided into 2 "sub-steps": control during hospitalization and ambulatory control). Two checkpoints must be developed. Checkpoint #1 would be located between the preoperative and operative stages, and checkpoint #2 would be located between the operative and postoperative stages. Surgical factors are surgeons, instrumental and technology, anesthesiology and operating room environment. CONCLUSION: It is possible and necessary to develop a systematic surgical procedure. Its application in the department of surgery could optimize the results and reduce the complications and errors related to daily practice.

Prospective Comparison of Bleeding Complications Between Right and Left Approaches in Percutaneous Biliary Drainage.

PURPOSE: The present study aimed to determine whether the percentage of bleeding complications differs between the right and the left approaches in percutaneous biliary drainage (PBD) in adult patients. MATERIALS AND METHODS: This was a prospective, descriptive, nonrandomized comparative and longitudinal study. We included adult patients over 18 years of age who underwent a PBD. We excluded those with a bilateral PBD for the comparative study. Usually, but not exclusively, we performed the right approach under fluoroscopic guidance and the left one under ultrasound and fluoroscopy. RESULTS: Of 150 cases, 63 were performed using the right approach and 61 with the left; 26 were performed with the bilateral. The right approach faced less dilated biliary ducts and more benign diseases. We experienced 20 bleeding complications (13.33%, confidence intervals of 95%=8.3-19.8), 7 in the bilateral approach, 10 in the right approach, and 3 in the left one. The difference between the right and the left approaches was statistically significant (Fisher P=0,04). No procedures were required to obtain hemostasis, and only one patient (0.66%, confidence intervals of 95%=0.009-3.66) (in the right side) required a red blood cell transfusion. We found no related mortality. CONCLUSIONS: Global bleeding complications are more likely to appear in the right approach in which less dilated biliary ducts and more benign diseases probably contributed to a higher number of needle passes, portal and hepatic vein punctures, and, therefore, to an increase in the risk of bleeding complications. The significant bleeding complication rate was low (0.66%).

Risk of bleeding complications in percutaneous biliary drainage: the paradox of the normal hemostasis / Risco de complicações de sangramento na drenagem biliar percutânea: o paradoxo da hemostase normal

ABSTRACT Background: Percutaneous biliary drainage is a safe procedure. The risk of bleeding complications is acceptable. Frequently, patients with biliary obstructions usually have coagulation disorders thus increasing risk of bleeding. For this reason, patients should always fit the parameters of hemostasis. Aim: To determine whether the percentage of bleeding complications in percutaneous biliary drainage is greater in adults with corrected hemostasis prior to the procedure regarding those who did not require any. Methods : Prospective, observational, transversal, comparative by independent samples (unpaired comparison). Eighty-two patients with percutaneous biliary drainage were included. The average age was 64±16 years (20-92) being 38 male and 44 female. Patients who presented altered hemostasis were corrected and the presence of bleeding complications was evaluated with laboratory and ultrasound. Results: Of 82 patients, 23 needed correction of hemostasis. The approaches performed were: 41 right, 30 left and 11 bilateral. The amount of punctures on average was 3±2. There were 13 (15.8%) bleeding complications, 12 (20%) in uncorrected and only one (4.34%) in the corrected group with no statistical difference. There were no differences in side, number of punctures and type of drainage, but number of passes and the size of drainage on the right side were different. There was no related mortality. Conclusion: Bleeding complications in patients requiring hemostasis correction for a percutaneous biliary drainage was not greater than in those who did not require any.

RESUMO Racional: A drenagem biliar percutânea é procedimento seguro. O risco de complicações hemorrágicas é aceitável. Frequentemente, os pacientes com obstruções biliares apresentam distúrbios de coagulação, aumentando o risco de sangramento. Por esse motivo, eles devem sempre ser adequados aos parâmetros da hemostasia. Objetivo: Determinar se a porcentagem de complicações hemorrágicas na drenagem biliar percutânea é maior em adultos com hemostasia corrigida antes do procedimento em relação àqueles que necessitaram nenhuma. Métodos: Estudo prospectivo, observacional, transversal, comparativo por amostras independentes (comparação não pareada). Oitenta e dois pacientes foram submetidos à drenagem biliar percutânea. A idade média foi de 64±16 anos (20-92), 38 eram homens e 44 mulheres. Os pacientes que apresentaram hemostasia alterada foram corrigidos, e a presença de complicações hemorrágicas foi avaliada com exames laboratoriais e ultrassonográficos. Resultados: Dos 82 pacientes, 23 necessitaram de correção da hemostasia. O acesso à direita foi em 41 casos, 30 à esquerda e 11 bilaterais. A quantidade de punções em média foi de 3±2. Houve 13 (15,8%) complicações hemorrágicas, 12 (20%) no grupo não corrigido e apenas uma (4,34%) no corrigido sem diferença estatística. Não houve diferenças no lado, no número de perfurações e no tipo de drenagem, mas o número de passagens e o tamanho da drenagem no lado direito foram diferentes. Não houve mortalidade. Conclusão: As complicações hemorrágicas em pacientes que necessitam de correção da hemostasia antes da drenagem biliar percutânea não são maiores do que naqueles que não a requerem.

Stages and factors of the "perioperative process": points in common with the aeronautical industry / Etapas e fatores do "processo perioperatório": pontos em comum com a indústria aeronáutica

ABSTRACT Background: The aeronautical industry is one of the disciplines that most use control systems. Its purpose is to avoid accidents and return safer flights. The flight of an airplane, from its takeoff to its landing is a process divided into stages under strict control. A surgical procedure has the same characteristics. We try to identify and develop the stages of the surgical process using the experience of the aviation industry in order to optimize the results and reduce surgical complications. Aim: To identify and develop the stages of the surgical process so that they could be applied to surgery departments. Methods: A search, review and bibliographic analysis of the application of aeronautical control and safety to medical practice in general and to surgery, in particular, were carried out. Results: Surgical process comprises the perioperative period. It is composed of Preoperative Stage (it is divided into 2 "sub-steps": hospital admission and control of preoperative studies) Operative Stage (it is divided into 3 "sub-steps": anesthetic induction, surgery, and anesthetic recovery) and Postoperative Stage (it is divided into 2 "sub-steps": control during hospitalization and ambulatory control). Two checkpoints must be developed. Checkpoint #1 would be located between the preoperative and operative stages, and checkpoint #2 would be located between the operative and postoperative stages. Surgical factors are surgeons, instrumental and technology, anesthesiology and operating room environment. Conclusion: It is possible and necessary to develop a systematic surgical procedure. Its application in the department of surgery could optimize the results and reduce the complications and errors related to daily practice.

RESUMO Racional: A indústria aeronáutica é uma das disciplinas que mais utiliza sistemas de controle. Sua finalidade é evitar acidentes e retornar voos mais seguros. O voo de um avião, desde a decolagem até a aterrissagem, é processo dividido em etapas com estrito controle. Um procedimento cirúrgico tem as mesmas características. Tentar identificar e desenvolver etapas no processo cirúrgico, utilizando a experiência da indústria aeronáutica, poderá otimizar os resultados e reduzir as complicações cirúrgicas. Objetivo: Identificar e desenvolver etapas no processo cirúrgico para que possam ser aplicadas nos serviços de cirurgia. Métodos: Foram realizadas pesquisas, revisão e análise bibliográfica sobre o controle e segurança aeronáutica e aplicando-as na prática médica em geral e à cirurgia em particular. Resultados: O processo cirúrgico compreende o período perioperatório. É composto de pré-operatório (dividido em duas sub-etapas: admissão hospitalar e controle de estudos pré-operatórios); fase operatória (dividida em três sub-etapas: indução anestésica, operação e recuperação anestésica) e fase pós-operatória (dividida em duas "sub-etapas": controle durante a hospitalização e controle ambulatorial). Dois pontos de verificação devem ser desenvolvidos. O ponto de checagem nº 1 estaria localizado entre os estágios pré-operatório e operatório, e o ponto de checagem nº 2 entre os estágios operatório e pós-operatório. Fatores cirúrgicos são cirurgiões, instrumental e tecnologia, anestesiologia e ambiente de sala de cirurgia. Conclusão: É possível e necessário desenvolver um procedimento cirúrgico sistemático. Sua aplicação no departamento de cirurgia poderia otimizar os resultados e reduzir as complicações e erros relacionados à prática diária.

THE CRITICAL VIEW OF SAFETY PREVENTS THE APPEARANCE OF BILIARY INJURIES? ANALYSIS OF A SURVEY.

BACKGROUND: The risk of bile duct injury (BDI) during cholecystectomy remains a concern, despite efforts proposed for increasing safety. The Critical View of Safety (CVS) has been adopted promoting to reduce its risk. AIM: To perform a survey to assess the awareness of the CVS, estimating the proportion of surgeons that correctly identified its elements and its relationship with BDI. METHODS: An anonymous online survey was sent to 2096 surgeons inquiring on their common practices during cholecystectomy and their knowledge of the CVS. RESULTS: A total of 446 surgeons responded the survey (21%). The percentage of surgeons that correctly identified the elements of CVS was 21.8% and 24.8% among surgeons claiming to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS (p=0.03). In the multivariate analysis, career length was the most significant factor related to BDI (p=0.002). CONCLUSIONS: The percentage of surgeons that correctly identified the Critical View of Safety was low, even among those who claimed to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS.

PERCUTANEOUS RADIOFREQUENCY ASSISTED LIVER PARTITION WITH PORTAL VEIN EMBOLIZATION FOR STAGED HEPATECTOMY (PRALPPS).

BACKGROUND: When a major hepatic resection is necessary, sometimes the future liver remnant is not enough to maintain sufficient liver function and patients are more likely to develop liver failure after surgery. AIM: To test the hypothesis that performing a percutaneous radiofrecuency liver partition plus percutaneous portal vein embolization (PRALPPS) for stage hepatectomy in pigs is feasible. METHODS: Four pigs (Sus scrofa domesticus) both sexes with weights between 25 to 35 kg underwent percutaneous portal vein embolization with coils of the left portal vein. By contrasted CT, the difference between the liver parenchyma corresponding to the embolized zone and the normal one was identified. Immediately, using the fusion of images between ultrasound and CT as a guide, radiofrequency needles were placed percutaneouslyand then ablated until the liver partition was complete. Finally, hepatectomy was completed with a laparoscopic approach. RESULTS: All animals have survived the procedures, with no reported complications. The successful portal embolization process was confirmed both by portography and CT. In the macroscopic analysis of the pieces, the depth of the ablation was analyzed. The hepatic hilum was respected. On the other hand, the correct position of the embolization material on the left portal vein could be also observed. CONCLUSION: "Percutaneous radiofrequency assisted liver partition with portal vein embolization" (PRALLPS) is a feasible procedure.

Percutaneous Image-guided Surgery Training: Model IHU-DAICIM.

The evolution of guided imaging surgery is well known in recent years. As the field of action becomes more specific, learning and teaching are also more specific. State-of-the-art medical training should be mandatory in the field of general medicine and surgery in particular. In this work, we report on how to create a model for the formation of guided surgery by images in a simple and fast way, and its implementation by young surgeons. Pig models have been used in which collections made by bovine small intestine and simulated tumor lesions have been placed. Several types of image-guided procedures have been performed. No major complications were found during the development of the model or during its use. It is possible to develop a quick, simple, and safe living training model that can be used immediately after preparation.

Percutaneous radiofrequency assisted liver partition with portal vein embolization for staged hepatectomy (pralpps) / Divisão hepática assistida com embolização da veia porta para hepatectomia regrada usando radiofrequência percutânea

ABSTRACT Background: When a major hepatic resection is necessary, sometimes the future liver remnant is not enough to maintain sufficient liver function and patients are more likely to develop liver failure after surgery. Aim: To test the hypothesis that performing a percutaneous radiofrecuency liver partition plus percutaneous portal vein embolization (PRALPPS) for stage hepatectomy in pigs is feasible. Methods: Four pigs (Sus scrofa domesticus) both sexes with weights between 25 to 35 kg underwent percutaneous portal vein embolization with coils of the left portal vein. By contrasted CT, the difference between the liver parenchyma corresponding to the embolized zone and the normal one was identified. Immediately, using the fusion of images between ultrasound and CT as a guide, radiofrequency needles were placed percutaneouslyand then ablated until the liver partition was complete. Finally, hepatectomy was completed with a laparoscopic approach. Results: All animals have survived the procedures, with no reported complications. The successful portal embolization process was confirmed both by portography and CT. In the macroscopic analysis of the pieces, the depth of the ablation was analyzed. The hepatic hilum was respected. On the other hand, the correct position of the embolization material on the left portal vein could be also observed. Conclusion: "Percutaneous radiofrequency assisted liver partition with portal vein embolization" (PRALLPS) is a feasible procedure.

RESUMO Racional: Quando grande ressecção hepática é necessária, às vezes, o fígado remanescente não é suficiente para manter a função hepática e os pacientes são mais propensos a desenvolver insuficiência hepática após a operação. Objetivo: Testar a hipótese de que a realização de uma divisão do fígado com radiofreqüência percutânea mais a embolização percutânea da veia porta (PROPS) para a hepatectomia regrada em porcos é viável. Métodos: Quatro porcos (Sus scrofa domesticus) ambos os sexos com pesos entre 25 a 35 kg foram submetidos à embolização percutânea da veia porta com espirais da veia porta esquerda. Por TC contrastada, a diferença entre o parênquima hepático correspondente à zona embolizada e a normal foi identificada. Imediatamente, usando a fusão de imagens entre ultrassom e CT guiada, as agulhas de radiofrequência foram colocadas percutaneamente e depois foram cortando até a partição do fígado estar completa. Finalmente, a hepatectomia foi completada com abordagem laparoscópica. Resultados: Todos os animais sobreviveram aos procedimentos, sem complicações. O sucesso do processo de embolização do portal foi confirmado por portografia e CT. Na análise macroscópica das peças, analisou-se a profundidade da ablação. O hilo hepático foi respeitado. Por outro lado, a posição correta do material de embolização na veia porta esquerda também pôde ser observada. Conclusão: "Partição do fígado assistida por radiofrequência percutânea com embolização da veia porta" (PRALLPS) é um procedimento viável.

BIODEGRADABLE BILIARY STENTS: A NEW APPROACH FOR THE MANAGEMENT OF HEPATICOJEJUNOSTOMY STRICTURES FOLLOWING BILE DUCT INJURY. PROSPECTIVE STUDY.

BACKGROUND: Once a biliary injury has occurred, repair is done by a hepaticojejunostomy. The most common procedure is to perform a dilatation with balloon with a success of 70 %. Success rates range using biodegradable stents is from 85% to 95%. Biodegradable biliary stents should change the treatment of this complication. AIM: To investigate the use of biodegradable stents in a group of patients with hepaticojejunonostomy strictures. METHODS: In a prospective study 16 biodegradable stents were placed in 13 patients with hepaticojejunostomy strictures secondary to bile duct repair of a biliary surgical injury. Average age was 38.7 years (23-67), nine were female and four male. All cases had a percutaneous drainage before at the time of biodegradable stent placement. RESULTS: In one case, temporary haemobilia was present requiring blood transfusion. In another, pain after stent placement required intravenous medication. In the other 11 patients, hospital discharge was the next morning following stent placement. During the patient´s follow-up, none presented symptoms during the first nine months. One patient presented significant alkaline phosphatase elevation and stricture recurrence was confirmed. One case had recurrence of cholangitis 11 months after the stent placement. 84.6% continued asymptomatic with a mean follow-up of 20 months. CONCLUSION: The placement of biodegradable stents is a safe and feasible technique. Was not observed strictures caused by the stent or its degradation. It could substitute balloon dilation in strictures of hepaticojejunostomy.

RACIONAL: Uma vez que lesão biliar ocorreu, o reparo é feito por hepaticojejunostomia. O procedimento mais comum é efetuar dilatação com balão com sucesso de 70%. As taxas de sucesso utilizando stents biodegradáveis ​​é de 85% a 95%. Stents biliares biodegradáveis ​​devem mudar o tratamento desta complicação. OBJETIVO: Investigar o uso de stents biodegradáveis em um grupo de pacientes com estenose hepaticojejunal. MÉTODOS: Em estudo prospectivo 16 stents biodegradáveis ​​foram colocados em 13 pacientes com estenose de hepaticojejunostomia secundárias usados para reparação do ductos biliares de lesão cirúrgica. A média de idade foi de 38,7 anos (23-67), nove pacientes eram homens e quatro mulheres. Todos os casos tiveram drenagem percutânea antes do momento da colocação de stent biodegradável. RESULTADOS: Em um caso, haemobilia temporária estava presente com necessidade de transfusão de sangue. Em outro, dor após a colocação do stent necessitou de medicação intravenosa. Nos outros 11 pacientes, alta hospitalar foi na manhã seguinte após o procedimento. Durante o seguimento, nenhum apresentou sintomas durante os primeiros nove meses. Um paciente apresentou significativa elevação da fosfatase alcalina por recidiva da estenose. Um caso teve recorrência de colangite 11 meses após a colocação do stent. Continuaram assintomáticos 84,6% com média de acompanhamento de 20 meses. CONCLUSÃO: A colocação de stents biodegradáveis ​​é técnica segura e viável. Não foram observadas restrições causadas pelo stent ou pela sua degradação. Stent pode substituir dilatação com balão na estenose de hepaticojejunostomia.

Biodegradable biliary stents: a new approach for the management of hepaticojejunostomy strictures following bile duct injury. prospective study / Stent biliar biodegradável: uma nova abordagem para as estenoses hepaticojejunais após lesão do ducto biliar. estudo prospectivo

ABSTRACT Background: Once a biliary injury has occurred, repair is done by a hepaticojejunostomy. The most common procedure is to perform a dilatation with balloon with a success of 70 %. Success rates range using biodegradable stents is from 85% to 95%. Biodegradable biliary stents should change the treatment of this complication. Aim: To investigate the use of biodegradable stents in a group of patients with hepaticojejunonostomy strictures. Methods: In a prospective study 16 biodegradable stents were placed in 13 patients with hepaticojejunostomy strictures secondary to bile duct repair of a biliary surgical injury. Average age was 38.7 years (23-67), nine were female and four male. All cases had a percutaneous drainage before at the time of biodegradable stent placement. Results: In one case, temporary haemobilia was present requiring blood transfusion. In another, pain after stent placement required intravenous medication. In the other 11 patients, hospital discharge was the next morning following stent placement. During the patient´s follow-up, none presented symptoms during the first nine months. One patient presented significant alkaline phosphatase elevation and stricture recurrence was confirmed. One case had recurrence of cholangitis 11 months after the stent placement. 84.6% continued asymptomatic with a mean follow-up of 20 months. Conclusion: The placement of biodegradable stents is a safe and feasible technique. Was not observed strictures caused by the stent or its degradation. It could substitute balloon dilation in strictures of hepaticojejunostomy.

RESUMO Racional: Uma vez que lesão biliar ocorreu, o reparo é feito por hepaticojejunostomia. O procedimento mais comum é efetuar dilatação com balão com sucesso de 70%. As taxas de sucesso utilizando stents biodegradáveis ​​é de 85% a 95%. Stents biliares biodegradáveis ​​devem mudar o tratamento desta complicação. Objetivo: Investigar o uso de stents biodegradáveis em um grupo de pacientes com estenose hepaticojejunal Métodos: Em estudo prospectivo 16 stents biodegradáveis ​​foram colocados em 13 pacientes com estenose de hepaticojejunostomia secundárias usados para reparação do ductos biliares de lesão cirúrgica. A média de idade foi de 38,7 anos (23-67), nove pacientes eram homens e quatro mulheres. Todos os casos tiveram drenagem percutânea antes do momento da colocação de stent biodegradável. Resultados: Em um caso, haemobilia temporária estava presente com necessidade de transfusão de sangue. Em outro, dor após a colocação do stent necessitou de medicação intravenosa. Nos outros 11 pacientes, alta hospitalar foi na manhã seguinte após o procedimento. Durante o seguimento, nenhum apresentou sintomas durante os primeiros nove meses. Um paciente apresentou significativa elevação da fosfatase alcalina por recidiva da estenose. Um caso teve recorrência de colangite 11 meses após a colocação do stent. Continuaram assintomáticos 84,6% com média de acompanhamento de 20 meses. Conclusão: A colocação de stents biodegradáveis ​​é técnica segura e viável. Não foram observadas restrições causadas pelo stent ou pela sua degradação. Stent pode substituir dilatação com balão na estenose de hepaticojejunostomia.

REDUCE PORT LAPAROSCOPIC SPLENECTOMY FOR GIANT EPITELIAL CYST / ESPLENECTOMIA LAPAROSCÓPICA COM PORTAIS REDUZIDOS PARA TRATAR CISTO EPITELIAL GIGANTE

Background: Delaitre and Maignien performed the first successful laparoscopic splenectomy in 1991. After that, laparoscopic splenectomy has become one of the most frequently performed laparoscopic solid organ procedures. Aim: To demonstrate the surgical techique of laparoscopic splenetomy with reduced portals. Methods: A reduce port laparoscopic splenectomy was performed by using a 10 mm and two 5 mm trocars. To entered the abdomen a trans-umbilical open technique was done and a 10 mm trocar was placed. A subcostal 5 mm trocar was placed under direct vision at the level of the anterior axillary line and another 5 mm port was inserted at the mid-epigastric region. Once it was completely dissected and freed from all of its attachments the hilum, splenic artery and vein, was clipped with hem-o-lock and divided with scissors. Then an endobag was used to retrieve the spleen after being morcellated trough the umbilical incision. Results: This technique was used in a 15 years old female with epigastric and left upper quadrant pain. An abdominal ultrasound demonstrated a giant cyst located in the spleen. Laboratory tests findings were normal. The CT scan was also done, and showed a giant cyst, which squeeze the stomach. The patient tolerated well the procedure, with an unremarkable postoperative. She was discharge home 72 h after the surgery. Conclusion: The use of reduce port minimizes abdominal trauma and has the hypothetical advantages of shorter postoperative stay, greater pain control, and better cosmesis. Laparoscopic splenectomy for giant cysts by using reduce port trocars is safe and feasible and less invasive.

Racional: Delaitre e Maignien realizaram a primeira esplenectomia laparoscópica bem sucedida em 1991. Depois disso, a esplenectomia laparoscópica tornou-se um dos procedimentos laparoscópicos de órgãos sólidos mais frequentemente realizadas. Objetivo: Demonstrar a técnica cirúrgica de esplenectomia laparoscópica com portais reduzidos. Métodos: A esplenectomia laparoscópica reduzida em potais foi realizada usando um trocarte de 10 mm e dois de 5 mm. A entrada abdominal se dá pela técnica aberta trans-umbilical e um trocarte de 10 mm foi aí colocado. Um de 5 mm subcostal foi colocado sob visão direta no nível da linha axilar anterior e outra trocarte de 5 mm foi inserido na região médio-epigástrica. Uma vez completamente dissecado e liberado todos os seus ligamentos do hilo, a artéria e veia esplênicas foram ligadas com hem-o-lock e seccionado com tesoura. Em seguida, um Endobag foi usado para retirar o baço após ser ele morcelado através da incisão umbilical. Resultado: Esta técnica foi utilizada em uma jovem de 15 anos com dor epigástrica e em hipocôndrio esquerdo. Ultrassom abdominal mostrou um cisto gigante localizado no baço. Exames complementares tiveram resultados normais. TC mostrou um cisto gigante, que projetava-se para o estômago. A paciente tolerou bem o procedimento, com pós-operatório normal. Ela teve alta hospitalar em 72 h após a operação. Conclusão: A diminuição de portais minimiza o trauma abdominal e tem as vantagens conhecidas de menor tempo de pós-operatório, maior controle da dor, e melhor efeito cosmético. A esplenectomia laparoscópica para cistos gigantes usando trocárteres reduzidos é segura, viável e menos invasiva.

Hernioplasty with and without mesh: analysis of the immediate complications in a randomized controlled clinical trial.

BACKGROUND: Inguinal hernia repair is the most common procedure in general surgery and 80,000 operations are performed annually in Great Britain, 100,000 in France and 700,000 in the US. Given its high frequency has a major impact, both in the medical and economic aspects. AIM: Analyze the immediate postoperative complications comparing mesh versus non mesh hernioplasty. METHOD: Randomized control trial, with the enrollment of 263 patients underwent surgery for inguinal hernia randomized by randomization table. Treatment (mesh, Lichtenstein or without mesh, Bassini technique) was assigned using sequentially numbered opaque envelopes having fulfilled the inclusion criteria. The variables analyzed were: postoperative pain, seroma, hematoma, infection, return to normal activities and recurrence. RESULTS: The mean age was 55.5 years, 88% patients were male and 12% female. The pain was higher in patients operated with mesh. CONCLUSIONS: The inguinal hernia repair mesh group had less immediate postoperative complications and significantly earlier return to work than hernioplasty without mesh, this being one of the most important conclusions.

Most common robotic bariatric procedures: review and technical aspects.

Since its appear in the year 1997, when Drs. Cadiere and Himpens did the first robotic cholecystectomy in Brussels, not long after the first cholecystectomy, they performed the first robotic bariatric procedure. It is believed that robotically-assisted surgery's most notable contributions are reflected in its ability to extend the benefits of minimally invasive surgery to procedures not routinely performed using minimal access techniques. We describe the 3 most common bariatric procedures done by robot. The main advantages of the robotic system applied to the gastric bypass appear to be better control of stoma size, avoidance of stapler costs, elimination of the potential for oropharyngeal and esophageal trauma, and a potential decrease in wound infection. While in the sleeve gastrectomy and adjustable gastric banding its utility is more debatable, giving a bigger advantage during surgery on patients with a very large BMI or revisional cases.