Current clinical practice in the management of Brazilian patients with potentially resectable pancreatic ductal adenocarcinoma (PDAC).

BACKGROUND AND OBJECTIVES: We aimed to describe the routine clinical practice of physicians involved in the treatment of patients with localized pancreatic ductal adenocarcinoma (PDAC) in Brazil. METHODS: Physicians were invited through email and text messages to participate in an electronic survey sponsored by the Brazilian Gastrointestinal Tumor Group (GTG) and the Brazilian Society of Surgical Oncology (SBCO). We evaluated the relationship between variable categories numerically with false discovery rate-adjusted Fisher's exact test p values and graphically with Multiple Correspondence Analysis. RESULTS: Overall, 255 physicians answered the survey. Most (52.5%) were medical oncologists, treated patients predominantly in the private setting (71.0%), and had access to multidisciplinary tumor boards (MTDTB; 76.1%). Medical oncologists were more likely to describe neoadjuvant therapy as beneficial in the resectable setting and surgeons in the borderline resectable setting. Most physicians would use information on risk factors for early recurrence, frailty, and type of surgery to decide treatment strategy. Doctors working predominantly in public institutions were less likely to have access to MTDTB and to consider FOLFIRINOX the most adequate regimen in the neoadjuvant setting. CONCLUSIONS: Considerable differences exist in the management of localized PDAC, some of them possibly explained by the medical specialty, but also by the funding source of health care.

BRAZILIAN CONSENSUS ON INCIDENTAL GALLBLADDER CARCINOMA.

BACKGROUND: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. AIM: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. METHODS: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. RESULTS: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. CONCLUSIONS: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

Brazilian consensus on incidental gallbladder carcinoma / Consenso brasileiro de carcinoma incidental de vesícula biliar

ABSTRACT Background: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. Aim: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. Methods: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. Results: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. Conclusions: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

RESUMO Racional: Carcinoma incidental da vesícula biliar é definido como uma neoplasia descoberta por exame histológico após colecistectomia videolaparoscópica. É potencialmente uma doença curável. Entretanto algumas questões relacionadas ao seu manuseio permanecem controversas e uma estratégia definida está associada com melhor prognóstico. Objetivo: Desenvolver o primeiro consenso baseado em evidências para o manuseio de pacientes com carcinoma incidental da vesícula biliar no Brasil. Métodos: Dezesseis questões foram selecionadas e para responder as questões e 36 membros das sociedades brasileiras e internacionais foram incluídos. As recomendações foram baseadas em evidências da literatura atual. Um relatório final foi enviado para os membros do painel para avaliação de concordância. Resultados: Avaliação intraoperatória da peça cirúrgica, uso de bolsas para retirar a peça cirúrgica e exame histopatológico de rotina, foram recomendados. Avaliação pré-operatória completa é necessária e deve ser realizada assim que o estadiamento final esteja disponível. Avaliação da margem do ducto cístico e biópsia de rotina do linfonodo 16b1 são recomendadas. Quimioterapia deve ser considerada e quimioradioterapia indicada se a margem cirúrgica microscópica seja positiva. Os portais devem ser ressecados excepcionalmente. O estadiamento laparoscópico antes da operação é recomendado, mas o tratamento radical por abordagem minimamente invasiva deve ser realizado apenas em centros especializados em cirurgia hepatopancreatobiliar minimamente invasiva. A extensão da ressecção hepática é aceitável até que seja alcançada a ressecção R0. A linfadenectomia padrão é indicada para tumores iguais ou superiores a T2, mas a ressecção da via biliar não é recomendada de rotina. Conclusões: Recomendações seguras foram preparadas para carcinoma incidental da vesícula biliar, destacando os mais frequentes tópicos do trabalho diário do cirurgião do aparelho digestivo e hepatopancreatobiliar.

FUNCTIONAL AND CELLULAR EVALUATION OF THE LIVER AFTER LOW-POWER LASER STIMULATION DURING SURGERY.

BACKGROUND: Partial hepatectomy is a surgical intervention of the liver that can trigger its regenerative process, where the residual lobes deflagrate a compensatory hyperplasia, causing its restoration almost to the original volume. Nevertheless, depending on the extent of liver damage its regeneration might be impaired. The low-power laser has been studied with beneficial results. AIM: To investigate the possible functional and mutagenic damage arising from the use of low-power laser used in liver regeneration after partial hepatectomy. METHODS: Fifteen male adult Wistar rats were hepatectomizated in 70% and laser irradiated or not with dose of 70 J/cm2, 650 nm, 100 mW, directly on the remaining liver, during the perioperative period. These animals were divided into four groups: G1 (control, 7 days); G2 (laser, 7 days); G3 (control, 14 days); G4 (laser, 14 days). Were analyzed the liver weight; number of hepatocytes; deposition of collagen fibers; liver function tests: serum alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma glutamyl transferase, bilirubin and micronucleus test in peripheral blood erythrocyte. RESULTS: The liver weight was greater in G3 and G4 (p=0.001 and p=0.002) compared to other groups. The deposition of collagen fibers in G1 was statistically higher than the other groups (p=0.01). In tests of liver function and micronucleus test was not found significant differences between the studied groups. CONCLUSION: Low-power laser stimulation did not cause loss of liver function or mutagenic damage.

Functional and cellular evaluation of the liver after low-power laser stimulation during surgery / Avaliação celular e funcional do fígado estimulada por laser de baixa potência no transoperatório

ABSTRACT Background: Partial hepatectomy is a surgical intervention of the liver that can trigger its regenerative process, where the residual lobes deflagrate a compensatory hyperplasia, causing its restoration almost to the original volume. Nevertheless, depending on the extent of liver damage its regeneration might be impaired. The low-power laser has been studied with beneficial results. Aim: To investigate the possible functional and mutagenic damage arising from the use of low-power laser used in liver regeneration after partial hepatectomy. Methods: Fifteen male adult Wistar rats were hepatectomizated in 70% and laser irradiated or not with dose of 70 J/cm2, 650 nm, 100 mW, directly on the remaining liver, during the perioperative period. These animals were divided into four groups: G1 (control, 7 days); G2 (laser, 7 days); G3 (control, 14 days); G4 (laser, 14 days). Were analyzed the liver weight; number of hepatocytes; deposition of collagen fibers; liver function tests: serum alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma glutamyl transferase, bilirubin and micronucleus test in peripheral blood erythrocyte. Results: The liver weight was greater in G3 and G4 (p=0.001 and p=0.002) compared to other groups. The deposition of collagen fibers in G1 was statistically higher than the other groups (p=0.01). In tests of liver function and micronucleus test was not found significant differences between the studied groups. Conclusion: Low-power laser stimulation did not cause loss of liver function or mutagenic damage.

RESUMO Racional: A hepatectomia parcial é intervenção cirúrgica que pode desencadear processo regenerativo, onde os lobos residuais deflagram resposta de hiperplasia compensatória, ocasionando restauração próxima ao seu volume original. Contudo, dependendo da extensão das lesões hepáticas a regeneração pode ser prejudicada. O laser de baixa potência tem sido pesquisado com resultados benéficos no processo de regeneração hepática. Objetivo: Investigar os possíveis danos funcionais e mutagênicos decorrentes da utilização do laser de baixa potência utilizado na regeneração hepática após hepatectomia parcial. Métodos: Quinze ratos adultos Wistar foram hepatectomizados a 70%, irradiados ou não com laser, dose de 70 J/cm2, 650 nm,100 mW, de forma direta sobre o fígado remanescente, durante o período transoperatório. Os animais foram distribuídos em quatro grupos: G1 (controle, 7 dias); G2 (laser, 7 dias); G3 (controle 14 dias); G4 (laser,14 dias). Foram analisados o peso do fígado; número de hepatócitos; deposição de fibras colágenas; teste de função hepática: alanina aminotransferase, aspartato aminotransferase, fosfatase alcalina, gama glutamiltransferase, bilirrubinas e teste de micronúcleo em eritrócitos. Resultados: O peso do fígado apresentou-se aumentado nos grupos G3 e G4 (p=0,001 e p=0,002) comparados aos demais grupos. A deposição das fibras colágenas no G1 foi estatisticamente maior em relação aos demais grupos (p=0,01). Nos testes de função hepática e teste de micronúcleo não foram encontradas diferenças significativas entre os grupos. Conclusão: O laser de baixa potência não ocasionou perda de função hepática ou dano mutagênico.

I BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 2: APPROACH TO RESECTABLE METASTASES.

BACKGROUND: Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients. AIM: In the second module of this consensus, management of resectable liver metastases was discussed. METHOD: Concept of synchronous and metachronous metastases was determined, and both scenarius were discussed separately according its prognostic and therapeutic peculiarities. RESULTS: Special attention was given to the missing metastases due to systemic preoperative treatment response, with emphasis in strategies to avoid its reccurrence and how to manage disappeared lesions. CONCLUSION: Were presented validated ressectional strategies, to be taken into account in clinical practice.

I brazilian consensus on multimodal treatment of colorectal liver metastases. module 2: approach to resectable metastases / I consenso brasileiro de tratamento multidisciplinar de metástase hepática colorretais módulo 2: manejo das metástases ressecáveis

Background : Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients. Aim : In the second module of this consensus, management of resectable liver metastases was discussed. Method : Concept of synchronous and metachronous metastases was determined, and both scenarius were discussed separately according its prognostic and therapeutic peculiarities. Results : Special attention was given to the missing metastases due to systemic preoperative treatment response, with emphasis in strategies to avoid its reccurrence and how to manage disappeared lesions. Conclusion : Were presented validated ressectional strategies, to be taken into account in clinical practice.

Racional: As metástases hepáticas de câncer colorretal são evento frequente e potencialmente fatal na evolução dos pacientes. Objetivo : No segundo módulo desse consenso, foi discutido o manejo de metástases hepáticas ressecáveis. Método : Foi definido o conceito de metástases síncrônicas e metacrônicas, e ambos os cenários foram discutidos separadamente de acordo com as suas peculiaridades prognósticas e terapêuticas. Resultados : Foi dada especial atenção às missing metástases em resposta ao tratamento pré-operatório sistêmico, com ênfase em estratégias para evitar sua recorrência e como gerenciar as lesões desaparecidas. Conclusão : Foram apresentadas e validadas estratégias de ressecção em várias circunstâncias, para serem aplicadas na prática clínica.

Pesquisa do linfonodo sentinela em câncer gástrico com o corante azul patente / Sentinel lymph node mapping in gastric cancer using patent blue dye

OBJETIVO: Avaliar a factibilidade e os resultados de uma técnica pouco invasiva para a pesquisa do linfonodo sentinela (LFNsn) com o uso do corante vital azul patente. MÉTODO: A pesquisa do LFNsn foi realizada em 12 pacientes portadores de adenocarcinoma gástrico que não apresentavam linfonodos suspeitos de metastases durante o estadiamento clínico pré-operatório. Injetou-se nos quatro quadrantes do tumor, 0,5 ml de corante vital azul patente. Os linfonodos que se coraram de azul foram classificados como LFNsn e foram obtidos após a gastrectomia com linfadenectomia D2. Utilizou-se a coloração HE para avaliação anatomopatológica dos LFNsn, e nos casos com LFNsn negativo para HE, foi realizada imuno-histoquímica com pan-citoqueratinas AE1/AE3. RESULTADOS: Dos 12 pacientes, oito eram mulheres, com média de idade de 64,5 (48-87) anos. Identificaram-se em média 3,25 (2-6) LFNsn por paciente. A factibilidade da técnica foi de 100 por cento. A acurácia do método foi de 91,6 por cento . Em 11 de 12 casos foi possível predizer as características linfonodais regionais pela concordância da análise anatomopatológica entre os LFNsn e não sentinelas(LFNñsn). CONCLUSÃO: A pesquisa do linfonodo sentinela em câncer gástrico é factível com o uso da técnica do corante azul patente. O método mostrou ser promissor como técnica minimamente invasiva para estadiar tumores gástricos, nesta casuística inicial.

BACKGROUND: The objective was to determine the feasibility of using vital blue dye to map sentinel lymph nodes (SLN) in gastric cancer using a minimally invasive technique. METHODS: Sentinel lymph node biopsy was performed on 12 patients with gastric adenocarcinoma that did not have metastatic lymph nodes during clinical staging. Vital blue dye was injected around four quadrants of the tumor, 0.5 ml in each quadrant. The lymph nodes that stained blue 5 minutes after dye injection were classified as SLN. Histopathological analysis of the sentinel lymph nodes was done according to routine evaluation of other lymph nodes, with hematoxylin and eosin (HE) staining. If the SLN was negative for malignancy by means of HE, it was further examined by immunohistochemistry. RESULTS: Sentinel lymph node biopsies in gastric cancer patients were performed from July 2002 to December 2004. Twelve patients were enrolled at the study, being 8 women, with a mean age of 64.5 years (range, 48 to 87). A mean of 3.25 SLNs (range, 2 to 6) were identified in each patient. The feasibility of the procedure was 100 percent, and its accuracy was 91.6 percent. In 11 of 12 patients, it was possible to predict the regional lymph nodes status by concordance of the histopathological analysis of SLN and non-sentinel lymph nodes (nSLN). CONCLUSION: The sentinel lymph node biopsy in gastric cancer technique has demonstrated to be feasible, with the use of vital blue dye. The procedure is promising as a minimally invasive technique of gastric tumors staging, in our series.

Diagnóstico das lesöes elétricas / Electric burns diagnosis

Muito além de queimaduras de pele e tecidos vizinhos, a corrente elétrica determina alteraçoes importantes em varios órgaos internos. O objetivo deste trabalho é, a partir de uma revisao da literatura, apraesentar as principais complicaçoes decorrentes dos acidentes elétricos e os sinais e sintomas a elas associados. A importância do diagnóstico dessas lesoes se deve ao fato de que, junto com o tratamento inicial das lesoes da pele, deve-se iniciar, de imediato, o tratamento das outras lesoes que, muitas vezes, sao de extrema gravidade. Outro fator preocupante é que, muitas dessas lesoes, têm um início insidioso, podendo aparecer muito tempo após ocorrido o acidente. Também é importante uma avaliaçao inicial multidisciplinar dos pacientes no sentido de prevenir as seqüelas.