BRAZILIAN GASTRIC CANCER ASSOCIATION GUIDELINES (PART 2): UPDATE ON TREATMENT.

BACKGROUND: : The II Brazilian Consensus on Gastric Cancer of the Brazilian Gastric Cancer Association BGCA (Part 1) was recently published. On this occasion, countless specialists working in the treatment of this disease expressed their opinion in the face of the statements presented. AIM: : To present the BGCA Guidelines (Part 2) regarding indications for surgical treatment, operative techniques, extension of resection and multimodal treatment. METHODS: To formulate these guidelines, the authors carried out an extensive and current review regarding each declaration present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases initially with the following descriptors: gastric cancer, gastrectomy, lymphadenectomy, multimodal treatment. In addition, each statement was classified according to the level of evidence and degree of recommendation. RESULTS: : Of the 43 statements present in this study, 11 (25,6%) were classified with level of evidence A, 20 (46,5%) B and 12 (27,9%) C. Regarding the degree of recommendation, 18 (41,9%) statements obtained grade of recommendation 1, 14 (32,6%) 2a, 10 (23,3%) 2b e one (2,3%) 3. CONCLUSION: : The guidelines complement of the guidelines presented here allows surgeons and oncologists who work to combat gastric cancer to offer the best possible treatment, according to the local conditions available.

Brazilian gastric cancer association guidelines (part 2): update on treatment / Diretrizes da associação brasileira de câncer gástrico (parte 2): atualização sobre o tratamento

ABSTRACT Background : The II Brazilian Consensus on Gastric Cancer of the Brazilian Gastric Cancer Association BGCA (Part 1) was recently published. On this occasion, countless specialists working in the treatment of this disease expressed their opinion in the face of the statements presented. Aim : To present the BGCA Guidelines (Part 2) regarding indications for surgical treatment, operative techniques, extension of resection and multimodal treatment. Methods: To formulate these guidelines, the authors carried out an extensive and current review regarding each declaration present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases initially with the following descriptors: gastric cancer, gastrectomy, lymphadenectomy, multimodal treatment. In addition, each statement was classified according to the level of evidence and degree of recommendation. Results : Of the 43 statements present in this study, 11 (25,6%) were classified with level of evidence A, 20 (46,5%) B and 12 (27,9%) C. Regarding the degree of recommendation, 18 (41,9%) statements obtained grade of recommendation 1, 14 (32,6%) 2a, 10 (23,3%) 2b e one (2,3%) 3. Conclusion : The guidelines complement of the guidelines presented here allows surgeons and oncologists who work to combat gastric cancer to offer the best possible treatment, according to the local conditions available.

RESUMO Racional: O II Consenso Brasileiro de Câncer Gástrico da Associação Brasileira de Câncer Gástrico ABCG (Parte 1) foi recentemente publicado. Nesta ocasião inúmeros especialistas que atuam no tratamento desta doença expressaram suas opiniões diante declarações apresentadas. Objetivo: Apresentar as Diretrizes da ABCG (Parte 2) quanto às indicações de tratamento cirúrgico, técnicas operatórias, extensão de ressecção e terapia combinada. Métodos: Para formulação destas diretrizes os autores realizaram extensa e atual revisão referente a cada declaração presente no II Consenso, utilizando as bases Medline/PubMed, Cochrane Library e SciELO, inicialmente com os seguintes descritores: câncer gástrico, gastrectomia, linfadenectomia, terapia combinada. Ainda, cada declaração foi classificada de acordo com o nível de evidência e grau de recomendação. Resultados: Das 43 declarações presentes neste estudo, 11 (25,6%) foram classificadas com nível de evidência A, 20 (46,5%) B e 12 (27,9%) C. Quanto ao grau de recomendação, 18 (41,9%) declarações obtiveram grau de recomendação 1, 14 (32,6%) 2a, 10 (23,3%) 2b e um (2,3%) 3. Conclusão: O complemento das diretrizes aqui presentes possibilita que cirurgiões e oncologistas que atuam no combate ao câncer gástrico possam oferecer o melhor tratamento possível, de acordo com as condições locais disponíveis.

BRAZILIAN GASTRIC CANCER ASSOCIATION GUIDELINES (PART 1): AN UPDATE ON DIAGNOSIS, STAGING, ENDOSCOPIC TREATMENT AND FOLLOW-UP.

BACKGROUND: The II Brazilian Consensus on Gastric Cancer by the Brazilian Gastric Cancer Association (ABCG) was recently published. On this occasion, several experts in gastric cancer expressed their opinion before the statements presented. AIM: To present the ABCG Guidelines (part 1) regarding the diagnosis, staging, endoscopic treatment and follow-up of gastric cancer patients. METHODS: To forge these Guidelines, the authors carried out an extensive and current review regarding each statement present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases with the following descriptors: gastric cancer, staging, endoscopic treatment and follow-up. In addition, each statement was classified according to the level of evidence and degree of recommendation. RESULTS: Of the 24 statements, two (8.3%) were classified with level of evidence A, 11 (45.8%) with B and 11 (45.8%) with C. As for the degree of recommendation, six (25%) statements obtained grade of recommendation 1, nine (37.5%) recommendation 2a, six (25%) 2b and three (12.5%) grade 3. CONCLUSION: The guidelines presented here are intended to assist professionals working in the fight against gastric cancer with relevant and current information, granting them to be applied in the daily medical practice.

Ii brazilian consensus on gastric cancer by the brazilian gastric cancer association / Ii consenso brasileiro de câncer gástrico realizado pela associação brasileira de câncer gástrico

ABSTRACT Background: Since the publication of the first Brazilian Consensus on Gastric Cancer (GC) in 2012 carried out by the Brazilian Gastric Cancer Association, new concepts on diagnosis, staging, treatment and follow-up have been incorporated. Aim: This new consensus is to promote an update to professionals working in the fight against GC and to provide guidelines for the management of patients with this condition. Methods: Fifty-nine experts answered 67 statements regarding the diagnosis, staging, treatment and prognosis of GC with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree A consensus was adopted when at least 80% of the sum of the answers "fully agree" and "partially agree" was reached. This article presents only the responses of the participating experts. Comments on each statement, as well as a literature review, will be presented in future publications. Results: Of the 67 statements, there was consensus in 50 (74%). In 10 declarations, there was 100% agreement. Conclusion: The gastric cancer treatment has evolved considerably in recent years. This consensus gathers consolidated principles in the last decades, new knowledge acquired recently, as well as promising perspectives on the management of this disease.

RESUMO Racional: Desde a publicação do primeiro Consenso Brasileiro sobre Câncer Gástrico em 2012 realizado pela Associação Brasileira de Câncer Gástrico (ABCG), novos conceitos sobre o diagnóstico, estadiamento, tratamento e seguimento foram incorporados. Objetivo: Promover uma atualização aos profissionais que atuam no combate ao câncer gástrico (CG) e fornecer diretrizes quanto ao manejo dos pacientes portadores desta afecção. Métodos: Cinquenta e nove especialistas responderam 67 declarações sobre o diagnóstico, estadiamento, tratamento e prognóstico do CG com cinco alternativas possíveis: 1) concordo plenamente; 2) concordo parcialmente; 3) indeciso; 4) discordo e 5) discordo fortemente. Foi considerado consenso a concordância de pelo menos 80% da soma das respostas "concordo plenamente" e "concordo parcialmente". Este artigo apresenta apenas as respostas dos especialistas participantes. Os comentários sobre cada declaração, assim como uma revisão da literatura serão apresentados em publicações futuras. Resultados: Das 67 declarações, houve consenso em 50 (74%). Em 10 declarações, houve concordância de 100%. Conclusão: O tratamento do câncer gástrico evoluiu consideravelmente nos últimos anos. Este consenso reúne princípios consolidados nas últimas décadas, novos conhecimentos adquiridos recentemente, assim como perspectivas promissoras sobre o manejo desta doença.

Endometriose do trato gastrintestinal: correlações clínicas e laparoscópicas / Endometriosis of the gastrointestinal tract: clinical and laparoscopic correlations

Neste estudo, quarenta pacientes selecionadas com endometriose pélvica e utilizando do método videolaparoscópico de corrida dos órgãos peritoneais na endometriose (COPE), puderam verificar se suas queixas encontram-se correlacionadas aos achados de lesões no trato gastrintestinal. O estudo avaliou 21 pacientes com e 19 pacientes sem sinais e sintomas gastrintestinais, visando estabelecer: associações e correlações entre os parâmetros clínicos que sinalizam a presença de focos endometrióticos e as localizações das lesões em cada segmento do trato gastrintestinal (TGI) e a correlação entre o estadiamento da endometriose (ASRM, 1996) e o comprometimento intestinal. A pesquisa atestou, de modo significativo, a correlação entre a presença dos sintomas gastrintestinais em conseqüência das lesões no trato gastrintestinal. Os sinais e sintomas gastrintestinais significativamente relacionados com a presença de endometriose ginecológica localizada no segmento retossigmóide e/ou íleo e com comprometimento do trato gastrintestinal foram: o puxo e o tenesmo cíclico, dor em cólica cíclica, obstipação cíclica, diarréia cíclica, dor acíclica, fezes afiladas e o sangramento intestinal cíclico. O estádio IV (ASRM) correlacionou-se com a presença de endometriose no trato gastrintestinal. O presente estudo demonstrou a correlação positiva dos sinais e sintomas gastrointestinais e ginecológicos e o estadiamento da doença ginecológica com o comprometimento gastrointestinal pela doença.

The peritoneal organs of 40 patients with pelvic endometriosis were scanned for endometriosis in this study by the videolaparoscopic method to verify the relation of their complaints with lesions found in the gastrointestinal tract. Twenty one of these patients who had gastrointestinal signs and symptoms and 19 who did not, were evaluated in order to establish associations and correlations between clinical parameters pointing to endometriotic lesions and sites of these lesions in each segment of the gastrointestinal tract as well as to correlate between the staging of the endometriosis and intestinal injury. Research significantly confirmed the correlation between gastrointestinal symptoms as a consequence of lesions in the gastrointestinal tract. Gastrointestinal signs and symptoms, significantly related with gynecological endometriosis in the rectum and sigmoid segment and/or ileum and with injury of the gastrointestinal tract, were cyclic tenesmus, cyclic colic pain, cyclic obstipation, cyclic diarrhea, acyclic pain, thin stools and cyclic intestinal bleeding. The ASRM l996 Stage IV correlated with the presence of endometriosis in the gastrointestinal tract. The study demonstrates the positive correlation of gastrointestinal and gynecological signs and symptoms and the staging of the gynecological disease with gastrointestinal injury from the disease.

Radiofrequency ablation of primary and metastatic liver tumors--4 years experience.

BACKGROUND/AIMS: Radiofrequency ablation of primary and metastatic liver tumors has been shown to be one of the promising new modalities to treat or to palliate liver tumors. It has been used as a bridge to liver transplantation as well as an approach to recurrent tumors after resection. METHODOLOGY: We present a series of 78 cases, 39 females and 39 males with a mean age of 61 years, the RFA has been used either by laparotomy or percutaneously to treat 117 lesions. There were 32 cases of hepatocellular carcinoma, 35 metastases of colorectal cancer and 11 cases of other tumors. RESULTS: The mean number of lesions treated were 1.5 per case with a average size of 3.6 cm per lesion. All liver segments were compromised specially IV, VII, VIII. The morbidity was 28% and the mortality was 2.5%. In 20.5% of the cases we were able to find recurrence after the procedure, with a mean time of 10.5 months. CONCLUSIONS: The RFA procedure is safe, can be performed by different ways and in the group of patients who are candidates to liver transplantation, while waiting for the organ. For the metastatic diseases it does not substitute surgery but can be used in patients who cannot be operated.

An unusual approach to the spontaneous rupture of hepatocellular carcinoma.

Our aim is to describe an unusual approach to the spontaneous rupture of a large hepatocellular carcinoma (HCC). A 45-year-old man, Hepatitis C virus (+) (HCV+), complaining of abdominal pain. During the investigation, a tumor affecting liver segments V, VI, VII and VIII, with the presence of fluid within the peritoneal cavity, suggesting hemoperitoneum, was found. The patient was submitted to an exploratory laparotomy, revealing a large hepatic tumor mass with capsule rupture in segment V, biopsy verified the diagnosis of HCC. After one week, a superselective chemoembolization of the nutrient artery of the tumor was performed; one month later, the patient was submitted to an embolization of the right portal branch, aimed at causing hypertrophy of the left lateral portion of the liver. A right hepatectomy was performed, as well as a nodulectomy in segment II, without complications along the 40 days subsequent to the portal embolization. The patient is currently on his 53rd postoperative month and evidences no tumor recurrence to the moment. Although the spontaneous rupture of HCC is uncommon, it can be today treated by combining interventionist radiology procedures and conventional liver resections, offering the patient a better chance of survival.

Acute pancreatitis associated with neuroendocrine tumor of the pancreas.

CONTEXT: Endocrine tumors are a less commonly known cause of acute pancreatitis. This report presents the case of a patient who have had acute pancreatitis secondary to a pancreatic endocrine neoplasm. The majority of the cases previously reported were non-functioning tumors and the pancreatitis tended to be mild. Moreover, the majority of the tumors were diagnosed in advanced stages, hindering curative treatment. CASE REPORT: A 31-year-old female patient presented with epigastric pain and a history of recurrent acute pancreatitis. Preoperative imaging investigation showed a dilation of the distal portion of the main pancreatic duct and intra-operative ultrasound demonstrated a mild stricture of the main pancreatic duct at the body of the pancreas. Frozen-section examination revealed a malignant neoplasm, subsequently identified as a neuroendocrine carcinoma, and a distal pancreatectomy with splenectomy was performed. Acute pancreatitis was an early symptom in this patient who underwent a hopefully curative resection. CONCLUSION: The authors conclude that, in patients with acute pancreatitis of unknown origin, the possibility of a non-functioning neuroendocrine tumor should be investigated.

Postoperative portal vein thrombosis in patients with hepatosplenic mansonic schistosomiasis: relationship with intraoperative portal pressure and flow. A prospective study.

BACKGROUND/AIMS: Portal vein thrombosis is a frequent postoperative complication after esophagogastric devascularization with splenectomy. The aim of this study was to analyze biochemical, hematological, coagulation blood tests and intraoperative portal vein hemodynamics after surgical treatment of hepatosplenic Mansonic schistosomal portal hypertension. METHODOLOGY: Forty patients with hepatosplenic schistosomiasis with indication for surgical treatment were prospectively studied. All patients underwent routine pre- and postoperative biochemical, hematologic, coagulation blood tests and intraoperative portal hemodynamic evaluation (portal pressure and portal flow) before and after esophagogastric devascularization and splenectomy using a 4-F thermodilution catheter introduced inside the portal vein. RESULTS: Portal vein thrombosis, diagnosed by routine postoperative Doppler ultrasonography was found in 22 patients (55%). It was partial in nineteen and total in three. In patients with postoperative portal thrombosis, we observed a reduction in portal flow of 971 +/- 592 mL/min (42 +/- 16%) at the end of the surgery, while this reduction was of 720 +/- 644mL/ min (33 +/- 30%) in those with postoperative pervious portal vein (p = 0.245). The decrease in portal pressure was the same in both groups: 7.2 +/- 3.0 mmHg (23 +/- 10%) and 7.6 +/- 3.8 mmHg (27 +/- 14%) with and without thrombosis respectively (p=0.759). There was also no significant difference between patients with and without portal vein thrombosis regarding pre- and postoperative hemoglobin level or platelet levels, coagulation tests, portal vein diameter and spleen's weight. CONCLUSIONS: Portal vein thrombosis was observed in 55% of the patients but this complication did not show any correlation with the decrease in portal flow or pressure or with biochemical, hematologic, coagulation blood tests, portal vein diameter or spleen's weight.

Estudo crítico da hernioplastia pela técnica de Bassini modificada quanto aos resultados mediatos / Hernioplasty by the modified Bassini technique: early results

Racional - A hernioplastia inguinal é a operação mais frequente realizada no mundo mas, apesar disso a escolhada da melhor técnica desperta opiniões, com frequência contraditórias. trabalhos recentes, com a utilizaçãosistemática de próteses, sugerem existir amplas vantagens no pós-operatório mediato em relação às técnicas que utilizam...

Tratamento cirúrgico das hérnias complexas da região inguinocrural pela técnica de Stoppa modificada: resultados a curto e médio prazos / Surgical treatment of complex hernias of the inguino femoral region by the modified Stoppa technique: short and medium term results

Racional - As correções cirúrgicas das hérnias inguinocrurais são os procedimentos operatórios mais realizados pelos cirurgiões gerais na França e nos Estados Unidos. Aproximadamente 20 (por cento) dos pacientes tem hérnia bilateral e 10 (por cento) de todos os procedimentos são para tratamento de hérnia recidivada...

Avaliação do risco cirúrgico no paciente portador de megaesôfago chagásico e sua relação com o grau de dilatação / Surgical risk assessment on the patient with chagasic megaesophagus and its correlation with the dilation grade

Racional - A avaliação clínica pré-operatória, prática comum em nosso meio, procura estimar o risco de complicações pós-operatórias. A compensação de fatores de risco trans-operatório, como controle da pressão arterial e do diabete melito, tratamento da doença pulmonar obstrutiva crônica e administração trans-operatória debetabloqueadores em pacientes portadores de coronariopatia, é capaz de reduzir significativamente as complicações pós-operatórias...

Modelo de intestino curto e de neoesfíncter no intestino delgado de suínos / A swine model of short bowel and samll intestine neosphincter

Racional - A perda de grande extensão do intestino delgado ocorre em diversas situações clínicas, geralmente relacionadas à necessidade de ressecção cirúrgica. A função primordial do intestino é absorção de nutrientes; sua integridade é fundamental para a sobrevivência de todo e qualquer animal...

Prevalence of pulmonary hypertension in patients with hepatosplenic Mansonic schistosomiasis--prospective study.

BACKGROUND/AIMS: Thirty-four patients with portal hypertension and previous history of esophageal varices hemorrhage due to hepatosplenic Mansonic schistosomiasis were prospectively studied. METHODOLOGY: All patients underwent invasive hemodynamic monitoring with introduction of a pulmonary artery catheter. Hemodynamic evaluation was characterized by an increased cardiac index (4.90 +/- 1.27 L/min/m2) associated to a decrease in systemic vascular resistance index (1461 +/- 443.04 dynes.sec/cm5.m2). RESULTS: Mean pulmonary artery pressure (17.97 +/- 6.97 mmHg) and right atrial pressure (7.65 +/- 3.67 mmHg) were increased while pulmonary vascular resistance index was decreased (147.95 +/- 126.21 dynes.sec/cm5.m2). Twenty-four patients (70.5%) presented pulmonary hypertension (mean pulmonary artery pressure > 15 mmHg); in fifteen (44.1%) pulmonary pressure was between 15 and 20 mmHg, in three between 20 and 25 mmHg and, in four patients, pulmonary pressure was higher than 25 mmHg. CONCLUSIONS: In conclusion, pulmonary hypertension is a frequent complication in patients with portal hypertension due to hepatosplenic Mansonic schistosomiasis and, in 20.6% of the cases, it can be considered as moderate or severe. Our results suggest that shunt surgeries, which can aggravate pulmonary hypertension, should be employed very cautiously in the treatment of schistosomal portal hypertension.

Ethnic difference in serology of Helicobacter pylori CagA between Japanese and non-Japanese Brazilians for non-cardia gastric cancer.

The usefulness of serology against CagA of Helicobacter pylori as a biomarker to identify high-risk individuals for non-cardia gastric cancer (ncGC) remains unclear among several ethnic populations with a high prevalence of cagA-positive strains. We investigated ethnic differences of CagA serology in two sets of case-control subjects, Japanese-Brazilians (JB) and non-Japanese Brazilians (NJB). We performed a cross-sectional comparison of IgG antibody titers to CagA (CagA-Ab) and the combination of CagA-Ab with conventional surface antigen (Hp-Ab) in 80 JB and 178 NJB ncGC patients and their controls (160 JB and 178 NJB). The level of CagA-Ab titer in cancer cases was significantly higher in NJB than in JB. The strength of the association between CagA-Ab seropositivity (+) (> or = 10 U/ml) and ncGC was almost 2-fold higher in NJB than in JB [odds ratio (OR) (95% confidence interval), 4.5 (2.6-7.8) and 2.1 (1.2-3.6), respectively]. However, in both JB and NJB, the OR was highest in CagA-Ab(+) subjects with low titer (10-29 U/ml), and decreased inversely with elevating CagA-Ab titer. In addition, the serological status of CagA-Ab(+) and Hp-Ab(-) showed a similar close association with ncGC between JB and NJB [5.4 (1.9-15.3) and 5.4 (2.0-15.0), respectively]. These results suggest that although the roles of CagA in the carcinogenic process of ncGC might be different between JB and NJB, the CagA-Ab could be a useful marker for ncGC, independently of ethnicity, particularly in high-risk individuals with the serological status of CagA-Ab(+) with low IgG titer or combined with Hp-Ab(-).

Risk factors for stomach cancer in Brazil (II): a case-control study among Japanese Brazilians in São Paulo.

BACKGROUND: Although stomach cancer is the most frequent cancer among Japanese Brazilians, the risk factor of this cancer has not been investigated among them. METHODS: A case-control study was conducted among Japanese residents in the city of São Paulo. Ninety-six consecutive cases of histologically confirmed stomach cancer were matched to 192 controls admitted for non-neoplastic diseases or healthy volunteer (n = 80) by age (+/-5 years) and gender. The socio-demographic characteristics, personal and family medical history, lifetime history of tobacco use and dietary habits were probed using a structured questionnaire. RESULTS: Frequent consumption of beef was associated with increased risk: odds ratio (OR) = 4.0 and 95% confidence interval (CI) = 1.9-8.4 for daily consumption, OR = 2.1 and 95% CI = 1.0-4.3 for 3-4 days/week) when compared with the category of lower consumption (<3 days/week) after adjustment for country of birth (Japan or Brazil), showing a dose-response pattern (P for trend = 0.001). These ORs became higher after further adjusted for fruit consumption: OR = 4.4, 95% CI = 2.1-9.4 and OR = 2.4 and 95% CI = 1.1-5.0, respectively. Daily consumption of fruit was associated with a reduction in risk (OR = 0.5, 95% CI = 0.3-1.0) after adjustment for country of birth and became statistically significant further adjusted for beef consumption (OR = 0.4, 95% CI = 0.2-0.9). There were no statistically significant associations with smoking or any other factors tested. Although some attenuation was observed in beef consumption, the observed associations were similar after excluding volunteer controls. CONCLUSIONS: The introduction of the habit of daily beef consumption among Japanese immigrants and their descendants may be associated with stomach cancer risk. The protective effect of fruit consumption was confirmed in this population.