Baixa conscientização da vacina pós-transplante de fígado: análise e estratégia educacional / Escaso conocimiento de vacunación tras un trasplante hepático: estrategia educativa y análisis / Low post-liver transplant vaccine awareness: analysis and educational strategy

Resumo Objetivo Avaliar o conhecimento de pacientes e profissionais de saúde sobre os protocolos de vacinação no pós-transplante hepático antes e após a aplicação de uma estratégia educativa de conscientização nessa população. Métodos Os pacientes (n=124) foram submetidos à intervenção educativa através do acesso a uma página web com vídeos educativos e, para os profissionais de saúde (n=111), através de um simpósio e acesso à informação na página virtual do projeto. Para analisar o efeito da intervenção, análises qualitativas de conhecimento foram realizadas por meio de questionários antes e depois das intervenções. Resultados Entre os pacientes, predominou o sexo masculino (66,9%) e a média de idade foi de 55,2 anos (DP + 15,9). 82,2% dos pacientes procuraram uma UBS para serem vacinados e 13,7% deles, os CRIEs (Centro de Referência para Imunobiológicos Especiais). Apenas 46,7% receberam orientações sobre vacinas após o transplante hepático. Dos 111 questionários respondidos pelos profissionais de saúde, 46,5% não consultaram a carteira de vacinas, 61,3% encaminharam os pacientes para UBS e 38,7%, para um CRIE. Na análise pós-intervenção, 66,1% dos pacientes assistiram a vídeos educativos sobre vacinação. Destes, 62,2% disseram ter melhorado seu entendimento sobre as vacinas e 91,4% se sentem mais seguros para vacinar. Após a intervenção educativa, 45 profissionais de saúde responderam ao questionário. 30,4% afirmaram saber quais vacinas prescrever e 67,4% indicaram vacinas para familiares de pacientes. Conclusão A estratégia educacional proposta aplicada neste estudo mostrou aumentar a conscientização sobre os protocolos de imunização pós-transplante hepático. Isso pode contribuir para evitar o risco potencial de falta de informação e não abordagem da vacinação pelos profissionais de saúde.

Resumen Objetivo Evaluar los conocimientos de pacientes y profesionales de la salud sobre protocolos de vacunación tras un trasplante hepático, antes y después de aplicar una estrategia educativa de sensibilización en esta población. Métodos Los pacientes (n=124) fueron sometidos a la intervención educativa mediante el acceso a un sitio web con videos educativos, y los profesionales de la salud (n=11), mediante un simposio y el acceso a información en la página web del proyecto. Para analizar el efecto de la intervención, se realizaron análisis cualitativos de conocimiento con cuestionaros antes y después de la intervención. Resultados Entre los pacientes, el sexo masculino fue predominante (66,9 %) y la edad promedio fue 52,2 años (SD + 15,9). El 82,2 % de los pacientes fue a una Unidad Básica de Salud (UBS) para recibir la vacuna y el 13,7 % de ellos acudió a un Centro de Referencia para Inmunobiológicos Especiales (CRIE). Solo el 46,7 % recibió instrucciones sobre vacunación tras el trasplante hepático. De los 111 cuestionarios respondidos por profesionales de la salud, el 46,5 % no consultó el catálogo de vacunas, el 61,3 % derivó a los pacientes a una UBS y el 38,7 % a un CRIE. En el análisis posintervención, el 66,1 % de los pacientes miró los videos educativos sobre vacunación. De ellos, el 62,2 % mencionó haber mejorado su comprensión sobre vacunas y el 91,4 % se sintió más seguro para vacunarse. Después de la intervención educativa, 45 profesionales de la salud respondieron el cuestionario. El 30,4 % afirmó saber qué vacunas prescribir y el 67,4 % recomendó vacunas a familiares de los pacientes. Conclusión La estrategia educativa propuesta aplicada en este estudio demostró un aumento de conocimiento sobre los protocolos de inmunización tras un trasplante hepático. Esto pude ayudar a evitar el riesgo potencial de la falta de información y el no abordar el tema de la vacunación por parte de los profesionales de la salud.

Abstract Objective To evaluate patients' and healthcare professionals' knowledge about vaccination protocols in post-liver transplantation before and after applying an educational awareness strategy in this population. Methods Patients (n=124) underwent the educational intervention through access to a webpage containing educational videos and, for health professionals (n=111), through a symposium and access to information on the project's virtual page. To analyze the effect of the intervention, qualitative analyses of knowledge were carried out using questionnaires before and after the interventions. Results Among patients, males were predominant (66.9%) and the mean age was 55.2 years old (SD + 15.9). 82.2% of patients visited a UBS to be vaccinated and 13.7% of them the CRIEs (Reference Center for Special Immunobiologicals). Only 46.7% received orientation about vaccines after liver transplantation. From the 111 questionnaires answered by health professionals, 46.5% did not check the vaccine portfolio, 61.3% referred patients to UBS and 38.7% to a CRIE. In the post-intervention analysis, 66.1% of patients watched educational videos about vaccination. Of these, 62.2% said they had improved their understanding about vaccines and 91.4% feel safer to vaccinate. After the educational intervention, 45 health professionals answered the questionnaire. 30.4% said they knew which vaccines to prescribe, and 67.4% recommended vaccines to patients' relatives. Conclusion The proposed educational strategy applied in this study shown to increase awareness regarding the post-liver transplant immunization protocols. This may contribute to avoiding the potential risk of lack of information and failure to address vaccination by healthcare professionals.

Evaluation of psychological symptoms in patients before and after simultaneous pancreas-kidney transplantation: a single-center cross-sectional study.

PURPOSE: Simultaneous pancreas-kidney transplantation (SPKT) brings several benefits for insulin-dependent type-1 diabetic patients associated with end-stage renal disease (ESRD). However, data on psychological outcomes for the waiting list and the transplanted patients are still lacking. METHODS: Using the psychological Beck inventories of anxiety (BAI) and depression (BDI), 39 patients on the waiting list were compared to 88 post-transplanted patients who had undergone SPKT. RESULTS: Significant differences were found regarding depression (p = 0.003) but not anxiety (p = 0.161), being the pretransplant patients more vulnerable to psychological disorders. Remarkable differences were observed relative to the feeling of punishment (p < 0.001) and suicidal thoughts (p = 0.008) between the groups. It was observed that patients who waited a longer period for the transplant showed more post-transplant anxiety symptoms due to the long treatment burden (p = 0.002). CONCLUSIONS: These results demonstrated the positive impact of SPKT on psychological aspects related to depression when comparing the groups. The high number of stressors in the pretransplant stage impacts more severely the psychosocial condition of the patient.

Autonomic dysfunction is common in liver cirrhosis and is associated with cardiac dysfunction and mortality: prospective observational study

ABSTRACT BACKGROUND: Although autonomic dysfunction has been shown to be associated with liver cirrhosis, the prevalence and prognostic implications are unclear. Abnormal heart rate variability (HRV), a measure of autonomic function, has not been well investigated in cirrhosis. OBJECTIVE: To evaluate the prevalence of high-risk HRV parameters in a cohort of cirrhotic patients and their association with cardiac dysfunction and mortality. DESIGN AND SETTING: Prospective observational study conducted in the Federal University of São Paulo. METHOD: A cohort of 120 patients, comprising 17 healthy controls and 103 cirrhotic outpatients, was evaluated and followed for 10 months. HRV analysis was based on 24-hour Holter monitoring and defined using time-domain and frequency-domain parameters. RESULTS: The HRV parameters were statistically lower in cirrhotic patients than in healthy subjects. High-risk HRV parameters were prevalent, such that 64% had at least one high-risk parameter. Time-domain parameters correlated with Child scores (P < 0.0001). In regression models, HRV parameters were independent predictors of diastolic dysfunction and mortality. During 10 months of follow-up, there were 11 deaths, all of patients with at least one high-risk HRV parameter. Kaplan-Meier analysis estimated low survival rates among patients with standard deviation of normal-to-normal RR intervals (SDNN) < 100. CONCLUSION: Reduced HRV is prevalent in liver cirrhosis and is related to cardiac dysfunction, severity of liver disease and mortality. Abnormal high-risk HRV parameters are prevalent among cirrhotic patients and are also predictors of mortality. Our findings highlight the need for a more careful cardiac evaluation of cirrhotic patients.

Autonomic dysfunction is common in liver cirrhosis and is associated with cardiac dysfunction and mortality: prospective observational study.

BACKGROUND: Although autonomic dysfunction has been shown to be associated with liver cirrhosis, the prevalence and prognostic implications are unclear. Abnormal heart rate variability (HRV), a measure of autonomic function, has not been well investigated in cirrhosis. OBJECTIVE: To evaluate the prevalence of high-risk HRV parameters in a cohort of cirrhotic patients and their association with cardiac dysfunction and mortality. DESIGN AND SETTING: Prospective observational study conducted in the Federal University of São Paulo. METHOD: A cohort of 120 patients, comprising 17 healthy controls and 103 cirrhotic outpatients, was evaluated and followed for 10 months. HRV analysis was based on 24-hour Holter monitoring and defined using time-domain and frequency-domain parameters. RESULTS: The HRV parameters were statistically lower in cirrhotic patients than in healthy subjects. High-risk HRV parameters were prevalent, such that 64% had at least one high-risk parameter. Time-domain parameters correlated with Child scores (P < 0.0001). In regression models, HRV parameters were independent predictors of diastolic dysfunction and mortality. During 10 months of follow-up, there were 11 deaths, all of patients with at least one high-risk HRV parameter. Kaplan-Meier analysis estimated low survival rates among patients with standard deviation of normal-to-normal RR intervals (SDNN) < 100. CONCLUSION: Reduced HRV is prevalent in liver cirrhosis and is related to cardiac dysfunction, severity of liver disease and mortality. Abnormal high-risk HRV parameters are prevalent among cirrhotic patients and are also predictors of mortality. Our findings highlight the need for a more careful cardiac evaluation of cirrhotic patients.

Evaluation of psychological symptoms in patients before and after simultaneous pancreas-kidney transplantation: a single-center cross-sectional study

Purpose: Simultaneous pancreas-kidney transplantation (SPKT) brings several benefits for insulin-dependent type-1 diabetic patients associated with end-stage renal disease (ESRD). However, data on psychological outcomes for the waiting list and the transplanted patients are still lacking. Methods: Using the psychological Beck inventories of anxiety (BAI) and depression (BDI), 39 patients on the waiting list were compared to 88 post-transplanted patients who had undergone SPKT. Results: Significant differences were found regarding depression (p = 0.003) but not anxiety (p = 0.161), being the pretransplant patients more vulnerable to psychological disorders. Remarkable differences were observed relative to the feeling of punishment (p < 0.001) and suicidal thoughts (p = 0.008) between the groups. It was observed that patients who waited a longer period for the transplant showed more post-transplant anxiety symptoms due to the long treatment burden (p = 0.002). Conclusions: These results demonstrated the positive impact of SPKT on psychological aspects related to depression when comparing the groups. The high number of stressors in the pretransplant stage impacts more severely the psychosocial condition of the patient.

Six-minute walking test performance is associated with survival in cirrhotic patients.

BACKGROUND: Patients with cirrhosis are at risk of cirrhotic cardiomyopathy, with resulting cardiac dysfunction and exercise limitations. Six minute walking test (6MWT) assesses functional status and predicts morbidity and mortality in cardiopulmonary diseases. AIM: To determine if it associates with mortality by analyzing 6MWT performance in patients with liver cirrhosis. METHODS: A cohort of 106 cirrhotic patients was evaluated in the outpatient setting with echocardiogram and 6MWT and follow up for one year to document hepatic decompensation and mortality. The distance in meters was recorded at the end of 6 min (6MWD). RESULTS: This cohort had a mean age of 51 years and 56% male; patients were staged as Child A in 21.7%, B 66% and C 12.3%. Walk distance inversely correlated with Child scores, and was significantly reduced as Child stages progresses. Patients who died (10.4%) showed shorter mean 6MWD (P = 0.006). Low 6MWD was an independent predictor of mortality (P = 0.01). CONCLUSION: 6MWT is a noninvasive inexpensive test whose result is related to Child scores and mortality. It is useful to identify patients with liver cirrhosis at high risk of mortality for closer monitoring and potential early intervention.

Transplantation in Hepatocellular Carcinoma: Observational Multivariate Analysis of Survival and Recurrence Factors in 414 Patients.

BACKGROUND: We sought to identify the risk factors involved in survival of and tumor recurrence in patients with hepatocellular carcinoma (HCC) undergoing liver transplant (LTx). METHODS: We conducted a retrospective observational study and analyzed the medical records of 414 patients with HCC undergoing deceased donor LTx in São Paulo between January 2007 and December 2011. Multifactorial analysis of survival and recurrence was performed using clinical, laboratory, and pathology data. RESULTS: The mortality rate was 27.5%; mean survival time was 68.1 months (95% confidence interval, 64.7-71.6); and estimated 1-, 3-, and 5-year survival probabilities were 83.8%, 75.8%, and 71.5%, respectively. Altered donor blood glucose, female sex, vascular invasion, advanced age, high Model for End-Stage Liver Disease, and tumor size were the main risk factors determining survival in LTx recipients. Recurrence was noted in 7.2% of patients during the study period and was more frequent in women (hazard ratio, 2.6). Vascular invasion increased the chance of recurrence by 5.4 times. Each additional 1-year increase in recipient age increased the chance of recurrence by 5.6%, and each 1-mm increase in tumor size increased the chance of recurrence by 3%. CONCLUSIONS: Risk factors for reduced survival are donor blood glucose, female recipient, older age, increased Model for End-Stage Liver Disease score, and nodule size. Tumor recurrence risk factors are vascular invasion, female sex, recipient age, and nodule size.

HCC Detection on Surveillance US: Comparing Focused Liver Protocol Using US LI-RADS Technical Guidelines to a General Complete Abdominal US Protocol.

OBJECTIVE: Focused US examinations of the liver in the routine hepatocellular carcinoma (HCC) screening reduce the time spent on evaluating other structures deemed irrelevant to the clinical setting. It is still unknown, however, if such a strategy may additionally improve the frequency of nodules detection. We aimed to assess the impact of an HCC surveillance program in high-risk patients by means of targeted liver US following LI-RADS technical guidelines in comparison to a complete upper abdominal scan. METHODS: In this IRB-approved, single-center, prospective study, patients at high-risk for HCC enrolled from 06/2016 to 09/2019 were randomly assigned to 1 of the 2 institutional protocols: Group A (targeted liver US) or Group B (complete upper abdominal scan). Twenty examiners with similar experience in abdominal US were randomly assigned to perform the examinations exclusively in 1 of the groups (10 in each group). Frequency of hepatic nodules between groups was compared by using Fisher's exact test. RESULTS: Four hundred and sixty-five patients were enrolled, with no significant differences in both groups regarding sex, age, etiology of liver disease, MELD scores, and alpha-fetoprotein levels. A significantly higher frequency of nodules detection was found in Group A (230 patients; 23 nodules detected; 10% of the sample) in comparison to Group B (235 patients; 3 nodules; 1.3% of the sample) (p <.001). Five patients in Group A and 1 in Group B were positive for HCC after full diagnostic work-up. CONCLUSION: Adopting an HCC screening program based on targeted liver US improved the detection of hepatic nodules among high-risk individuals.

Need for dental treatment in patients on the waiting list for liver and simultaneous pancreas-kidney transplant at a single center. / Necessidade de tratamento odontológico em pacientes candidatos a transplante simultâneo de pâncreas-rim e fígado num centro único.

OBJECTIVE: to evaluate the oral conditions and the main predisposing factors for dental treatment of patients on the waiting list for liver and simultaneous pancreas-kidney transplantation, in a single center. METHODS: we evaluated 100 patients in the waiting list, 50 candidates for liver transplantation and 50 for simultaneous kidney-pancreas transplantation, from August 2015 to February 2018. We correlated extra and intraoral examinations with pre-transplant demographic variables. RESULTS: the main oral alteration in the pancreas-kidney and liver transplant candidates were decayed, lost and filled teeth, present in 83% and 100% of the candidates, respectively (p=0.03). The need for dental treatment was equal in both groups: 71% and 70%. In liver transplant candidates, the predisposing factors for dental treatment were age, color and etiological diagnosis of liver cirrhosis. We did not identify predisposing factors for dental treatment in candidates for simultaneous pancreas-kidney transplant. CONCLUSION: candidates for liver and for simultaneous pancreas-kidney transplantation had poor oral hygiene, with cavities, residual roots, gingivitis and periodontitis, revealing that dental evaluation should be part of the transplantation waiting list.

OBJETIVO: avaliar as condições bucais e os principais fatores predisponentes para tratamento odontológico de pacientes em lista de espera para transplante simultâneo de pâncreas-rim e para transplante hepático, em um centro único. MÉTODOS: foram avaliados 100 pacientes na fila de espera, 50 candidatos a transplante hepático e 50 a transplante simultâneo de pâncreas-rim, no período de agosto de 2015 a fevereiro de 2018. Exames extra e intrabucais foram correlacionados com variáveis demográficas pré-transplante. RESULTADOS: a principal alteração bucal nos candidatos a transplante de pâncreas-rim e de transplante hepático foram dentes cariados, perdidos e obturados, presentes em 83% e 100% dos candidatos, respectivamente (P=0,03). A necessidade de tratamento odontológico foi igual nos dois grupos: 71% e 70%. Nos candidatos a transplante hepático, os fatores predisponentes para tratamento odontológico foram idade, cor e diagnóstico etiológico da cirrose hepática. Não identificamos fatores predisponentes para tratamento odontológico nos candidatos a transplante simultâneo pâncreas-rim. CONCLUSÃO: pacientes candidatos a transplante simultâneo de pâncreas-rim e transplante hepático apresentaram higiene bucal precária com presença de cárie, raízes residuais, gengivite e periodontite, revelando que a avaliação odontológica deve fazer parte do protocolo de atendimento dos pacientes em fila de espera para transplantes.

Simultaneous pancreas-kidney transplantation and the impact of postoperative complications on hospitalization cost. / Impacto das complicações pós-transplante simultâneo pâncreas-rim sobre o custo da internação hospitalar.

OBJECTIVE: considering simultaneous pancreas-kidney transplantation cases, to evaluate the financial impact of postoperative complications on hospitalization cost. METHODS: a retrospective study of hospitalization data from patients consecutively submitted to simultaneous pancreas-kidney transplantation (SPKT), from January 2008 to December 2014, at Kidney Hospital/Oswaldo Ramos Foundation (Sao Paulo, Brazil). The main studied variables were reoperation, graft pancreatectomy, death, postoperative complications (surgical, infectious, clinical, and immunological ones), and hospitalization financial data for transplantation. RESULTS: the sample was composed of 179 transplanted patients. The characteristics of donors and recipients were similar in patients with and without complications. In data analysis, 58.7% of the patients presented some postoperative complication, 21.8% required reoperation, 12.3% demanded graft pancreatectomy, and 8.4% died. The need for reoperation or graft pancreatectomy increased hospitalization cost by 53.3% and 78.57%, respectively. The presence of postoperative complications significantly increased hospitalization cost. However, the presence of death, internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not present statistical significance in hospitalization cost (in average US$ 18,516.02). CONCLUSION: considering patients who underwent SPKT, postoperative complications, reoperation, and graft pancreatectomy, as well as surgical, infectious, clinical, and immunological complications, significantly increased the mean cost of hospitalization. However, death, internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not statistically interfere in hospitalization cost.

OBJETIVO: avaliar o impacto financeiro das complicações pós-operatórias no transplante simultâneo pâncreas-rim durante a internação hospitalar. MÉTODOS: estudo retrospectivo dos dados da internação hospitalar dos pacientes submetidos consecutivamente ao transplante simultâneo pâncreas-rim no período de janeiro de 2008 a dezembro de 2014 no Hospital do Rim/Fundação Oswaldo Ramos. As principais variáveis estudadas foram a reoperação, pancreatectomia do enxerto, óbito, complicações pós-operatórias (cirúrgicas, infecciosas, clínicas e imunológicas) e os dados financeiros da internação para o transplante. RESULTADOS: a amostra foi composta de 179 pacientes transplantados. As características dos doadores e receptores foram semelhantes nos pacientes com e sem complicações. Na análise dos dados, 58,7% dos pacientes apresentaram alguma complicação pós-operatória, 21,8% necessitaram de reoperação, 12,3%, de pancreatectomia do enxerto e 8,4% evoluíram para o óbito. A necessidade de reoperação ou pancreatectomia do enxerto aumentou o custo da internação em 53,3% e 78,57%, respectivamente. A presença de complicação pós-operatória aumentou significativamente o custo. Entretanto, a presença de óbito, hérnia interna, infarto agudo do miocárdio, acidente vascular cerebral e disfunção do enxerto pancreático não apresentaram significância estatística no custo, cuja média foi de US$ 18,516.02. CONCLUSÃO: complicações pós-operatórias, reoperação e pancreatectomia do enxerto aumentaram significativamente o custo médio da internação hospitalar do SPK, assim como as complicações cirúrgicas, infecciosas, clínicas e imunológicas. No entanto, o óbito durante a internação, a hérnia interna, o infarto agudo do miocárdio, o acidente vascular cerebral e a disfunção do enxerto pancreático não interferiram estatisticamente neste custo.

Necessidade de tratamento odontológico em pacientes candidatos a transplante simultâneo de pâncreas-rim e fígado num centro único / Need for dental treatment in patients on the waiting list for liver and simultaneous pancreas-kidney transplant at a single center

RESUMO Objetivo: avaliar as condições bucais e os principais fatores predisponentes para tratamento odontológico de pacientes em lista de espera para transplante simultâneo de pâncreas-rim e para transplante hepático, em um centro único. Métodos: foram avaliados 100 pacientes na fila de espera, 50 candidatos a transplante hepático e 50 a transplante simultâneo de pâncreas-rim, no período de agosto de 2015 a fevereiro de 2018. Exames extra e intrabucais foram correlacionados com variáveis demográficas pré-transplante. Resultados: a principal alteração bucal nos candidatos a transplante de pâncreas-rim e de transplante hepático foram dentes cariados, perdidos e obturados, presentes em 83% e 100% dos candidatos, respectivamente (P=0,03). A necessidade de tratamento odontológico foi igual nos dois grupos: 71% e 70%. Nos candidatos a transplante hepático, os fatores predisponentes para tratamento odontológico foram idade, cor e diagnóstico etiológico da cirrose hepática. Não identificamos fatores predisponentes para tratamento odontológico nos candidatos a transplante simultâneo pâncreas-rim. Conclusão: pacientes candidatos a transplante simultâneo de pâncreas-rim e transplante hepático apresentaram higiene bucal precária com presença de cárie, raízes residuais, gengivite e periodontite, revelando que a avaliação odontológica deve fazer parte do protocolo de atendimento dos pacientes em fila de espera para transplantes.

ABSTRACT Objective: to evaluate the oral conditions and the main predisposing factors for dental treatment of patients on the waiting list for liver and simultaneous pancreas-kidney transplantation, in a single center. Methods: we evaluated 100 patients in the waiting list, 50 candidates for liver transplantation and 50 for simultaneous kidney-pancreas transplantation, from August 2015 to February 2018. We correlated extra and intraoral examinations with pre-transplant demographic variables. Results: the main oral alteration in the pancreas-kidney and liver transplant candidates were decayed, lost and filled teeth, present in 83% and 100% of the candidates, respectively (p=0.03). The need for dental treatment was equal in both groups: 71% and 70%. In liver transplant candidates, the predisposing factors for dental treatment were age, color and etiological diagnosis of liver cirrhosis. We did not identify predisposing factors for dental treatment in candidates for simultaneous pancreas-kidney transplant. Conclusion: candidates for liver and for simultaneous pancreas-kidney transplantation had poor oral hygiene, with cavities, residual roots, gingivitis and periodontitis, revealing that dental evaluation should be part of the transplantation waiting list.

Impacto das complicações pós-transplante simultâneo pâncreas-rim sobre o custo da internação hospitalar / Simultaneous pancreas-kidney transplantation and the impact of postoperative complications on hospitalization cost

RESUMO Objetivo: avaliar o impacto financeiro das complicações pós-operatórias no transplante simultâneo pâncreas-rim durante a internação hospitalar. Métodos: estudo retrospectivo dos dados da internação hospitalar dos pacientes submetidos consecutivamente ao transplante simultâneo pâncreas-rim no período de janeiro de 2008 a dezembro de 2014 no Hospital do Rim/Fundação Oswaldo Ramos. As principais variáveis estudadas foram a reoperação, pancreatectomia do enxerto, óbito, complicações pós-operatórias (cirúrgicas, infecciosas, clínicas e imunológicas) e os dados financeiros da internação para o transplante. Resultados: a amostra foi composta de 179 pacientes transplantados. As características dos doadores e receptores foram semelhantes nos pacientes com e sem complicações. Na análise dos dados, 58,7% dos pacientes apresentaram alguma complicação pós-operatória, 21,8% necessitaram de reoperação, 12,3%, de pancreatectomia do enxerto e 8,4% evoluíram para o óbito. A necessidade de reoperação ou pancreatectomia do enxerto aumentou o custo da internação em 53,3% e 78,57%, respectivamente. A presença de complicação pós-operatória aumentou significativamente o custo. Entretanto, a presença de óbito, hérnia interna, infarto agudo do miocárdio, acidente vascular cerebral e disfunção do enxerto pancreático não apresentaram significância estatística no custo, cuja média foi de US$ 18,516.02. Conclusão: complicações pós-operatórias, reoperação e pancreatectomia do enxerto aumentaram significativamente o custo médio da internação hospitalar do SPK, assim como as complicações cirúrgicas, infecciosas, clínicas e imunológicas. No entanto, o óbito durante a internação, a hérnia interna, o infarto agudo do miocárdio, o acidente vascular cerebral e a disfunção do enxerto pancreático não interferiram estatisticamente neste custo.

ABSTRACT Objective: considering simultaneous pancreas-kidney transplantation cases, to evaluate the financial impact of postoperative complications on hospitalization cost. Methods: a retrospective study of hospitalization data from patients consecutively submitted to simultaneous pancreas-kidney transplantation (SPKT), from January 2008 to December 2014, at Kidney Hospital/Oswaldo Ramos Foundation (Sao Paulo, Brazil). The main studied variables were reoperation, graft pancreatectomy, death, postoperative complications (surgical, infectious, clinical, and immunological ones), and hospitalization financial data for transplantation. Results: the sample was composed of 179 transplanted patients. The characteristics of donors and recipients were similar in patients with and without complications. In data analysis, 58.7% of the patients presented some postoperative complication, 21.8% required reoperation, 12.3% demanded graft pancreatectomy, and 8.4% died. The need for reoperation or graft pancreatectomy increased hospitalization cost by 53.3% and 78.57%, respectively. The presence of postoperative complications significantly increased hospitalization cost. However, the presence of death, internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not present statistical significance in hospitalization cost (in average US$ 18,516.02). Conclusion: considering patients who underwent SPKT, postoperative complications, reoperation, and graft pancreatectomy, as well as surgical, infectious, clinical, and immunological complications, significantly increased the mean cost of hospitalization. However, death, internal hernia, acute myocardial infarction, stroke, and pancreatic graft dysfunction did not statistically interfere in hospitalization cost.

The value of percutaneous transhepatic treatment of biliary strictures following pediatric liver transplantation.

OBJECTIVE: To evaluate the percutaneous transhepatic approach to the treatment of biliary strictures in pediatric patients undergoing liver transplantation. MATERIALS AND METHODS: This was a retrospective study of data obtained from the medical records, laboratory reports, and imaging examination reports of pediatric liver transplant recipients who underwent percutaneous transhepatic cholangiography, because of clinical suspicion of biliary strictures, between 1st September 2012 and 31 May 2015. Data were collected for 12 patients, 7 of whom were found to have biliary strictures. RESULTS: In the 7 patients with biliary strictures, a total of 21 procedures were carried out: 2 patients (28.6%) underwent the procedure twice; 3 (42.8%) underwent the procedure three times; and 2 (28.6%) underwent the procedure four times. Therefore, the mean number of procedures per patient was 3 (range, 2-4), and the average interval between them was 2.9 months (range, 0.8-9.1 months). The drainage tube remained in place for a mean of 5.8 months (range, 3.1-12.6 months). One patient presented with a major complication, hemobilia, which was treated with endovascular embolization. Clinical success was achieved in all 7 patients, and the mean follow-up after drain removal was 15.4 months (range, 5.3-26.7 months). CONCLUSION: The percutaneous transhepatic approach to treating biliary strictures in pediatric liver transplant recipients proved safe, with high rates of technical and clinical success, as well as a low rate of complications.

OBJETIVO: Demonstrar o valor da abordagem transparieto-hepática no tratamento de estenoses biliares em pacientes pediátricos submetidos a transplante de fígado. MATERIAIS E MÉTODOS: Estudo retrospectivo com revisão de prontuários, exames laboratoriais e de imagem dos pacientes pediá­tricos submetidos a transplante hepático. Foram incluídos pacientes com suspeita de estenose de vias biliares que realizaram colangiografia transparieto-hepática para diagnóstico, entre 1º de setembro de 2012 e 31 maio de 2015. Os dados de 12 pacientes foram coletados, dos quais 7 apresentaram estenose de vias biliares. RESULTADOS: No total foram realizados 21 procedimentos: 2 pacientes realizaram dois procedimentos (28,6%), 3 pacientes realizaram três procedimentos (42,8%) e 2 pacientes realizaram quatro procedimentos (28,6%). A média de procedimentos por paciente foi 3 (variação: 2­4) e o intervalo médio entre os procedimentos foi 2,9 meses (variação: 0,8­9,1 meses). A permanência média do dreno foi 5,8 meses (variação: 3,1­12,6 meses). Uma paciente apresentou hemobilia com instabilidade hemodinâmica, tratada com sucesso por via endovascular. O sucesso clínico foi alcançado nos 7 pacientes e o seguimento médio após retirada do dreno foi 15,4 meses (variação: 5,3­26,7 meses). CONCLUSÃO: A abordagem transparieto-hepática das estenoses biliares em crianças submetidas a transplante de fígado demonstrou ser tratamento eficaz, com baixo índice de complicações.

Evaluation of the treatment of the hepatocarcinoma nodules in the patients in waiting list for liver transplant. / Avaliação do tratamento dos nódulos do hepatocarcinoma nos pacientes em lista de espera para transplante hepático.

OBJECTIVE: to compare the outcome of liver transplantation for hepatocarcinoma in submitted or not to locoregional treatment and downstaging regarding survival and risk of recurrence in transplant waiting list patients. METHODS: retrospective study of patients with hepatocarcinoma undergoing liver transplantation in the metropolitan region of São Paulo, between January 2007 and December 2011, from a deceased donor. The sample consisted of 414 patients. Of these, 29 patients were included in the list by downstaging. The other 385 were submitted or not to locoregional treatment. RESULTS: the analysis of 414 medical records showed a predominance of male patients (79.5%) with average age of 56 years. Treatment of the lesions was performed in 56.4% of patients on the waiting list for transplant. The most commonly used method was chemoembolization (79%). The locoregional patients undergoing treatment had a significant reduction in nodule size greater (p<0.001). There was no statistical difference between groups with and without locoregional treatment (p=0.744) and on mortality among patients enrolled in the Milan criteria or downstaging (p=0.494). CONCLUSION: there was no difference in survival and recurrence rate associated with locoregional treatment. Patients included by downstaging process had comparable survival results to those previously classified as Milan/Brazil criteria.

OBJETIVO: comparar o resultado do transplante de fígado por hepatocarcinoma em pacientes submetidos ou não ao tratamento loco-regional e downstaging, em relação à sobrevida e risco de recidiva na fila de transplante. MÉTODOS: estudo retrospectivo dos pacientes portadores de hepatocarcinoma submetidos a transplante hepático na região metropolitana de São Paulo, entre janeiro de 2007 e dezembro de 2011, a partir de doador falecido. A amostra foi constituída de 414 pacientes. Destes, 29 foram incluídos na lista por downstaging. Os demais 385 foram submetidos ou não ao tratamento loco-regional. RESULTADOS: as análises dos 414 prontuários demonstraram um predomínio de pacientes do sexo masculino (79,5%) e com média de idade de 56 anos. O tratamento dos nódulos foi realizado em 56,4% dos pacientes em fila de espera para o transplante. O método mais utilizado foi a quimio-embolização (79%). Os pacientes submetidos ao tratamento loco-regional tiveram redução significativa no tamanho do maior nódulo (p<0,001). Não houve diferença estatística entre grupos com e sem tratamento loco-regional (p=0,744) e em relação à mortalidade entre pacientes incluídos no Critério de Milão ou ao downstaging (p=0,494). CONCLUSÕES: não houve diferença na sobrevida e ocorrência de recidiva associadas ao tratamento loco-regional. Os pacientes incluídos através do processo de downstaging apresentaram resultados de sobrevida comparáveis àqueles previamente classificados como Critério de Milão/Brasil.

The value of percutaneous transhepatic treatment of biliary strictures following pediatric liver transplantation / O valor do tratamento das estenoses biliares por via transparietal pós-transplante hepático pediátrico

Abstract Objective: To evaluate the percutaneous transhepatic approach to the treatment of biliary strictures in pediatric patients undergoing liver transplantation. Materials and Methods: This was a retrospective study of data obtained from the medical records, laboratory reports, and imaging examination reports of pediatric liver transplant recipients who underwent percutaneous transhepatic cholangiography, because of clinical suspicion of biliary strictures, between 1st September 2012 and 31 May 2015. Data were collected for 12 patients, 7 of whom were found to have biliary strictures. Results: In the 7 patients with biliary strictures, a total of 21 procedures were carried out: 2 patients (28.6%) underwent the procedure twice; 3 (42.8%) underwent the procedure three times; and 2 (28.6%) underwent the procedure four times. Therefore, the mean number of procedures per patient was 3 (range, 2-4), and the average interval between them was 2.9 months (range, 0.8-9.1 months). The drainage tube remained in place for a mean of 5.8 months (range, 3.1-12.6 months). One patient presented with a major complication, hemobilia, which was treated with endovascular embolization. Clinical success was achieved in all 7 patients, and the mean follow-up after drain removal was 15.4 months (range, 5.3-26.7 months). Conclusion: The percutaneous transhepatic approach to treating biliary strictures in pediatric liver transplant recipients proved safe, with high rates of technical and clinical success, as well as a low rate of complications.

Resumo Objetivo: Demonstrar o valor da abordagem transparieto-hepática no tratamento de estenoses biliares em pacientes pediátricos submetidos a transplante de fígado. Materiais e Métodos: Estudo retrospectivo com revisão de prontuários, exames laboratoriais e de imagem dos pacientes pediá­tricos submetidos a transplante hepático. Foram incluídos pacientes com suspeita de estenose de vias biliares que realizaram colangiografia transparieto-hepática para diagnóstico, entre 1º de setembro de 2012 e 31 maio de 2015. Os dados de 12 pacientes foram coletados, dos quais 7 apresentaram estenose de vias biliares. Resultados: No total foram realizados 21 procedimentos: 2 pacientes realizaram dois procedimentos (28,6%), 3 pacientes realizaram três procedimentos (42,8%) e 2 pacientes realizaram quatro procedimentos (28,6%). A média de procedimentos por paciente foi 3 (variação: 2-4) e o intervalo médio entre os procedimentos foi 2,9 meses (variação: 0,8-9,1 meses). A permanência média do dreno foi 5,8 meses (variação: 3,1-12,6 meses). Uma paciente apresentou hemobilia com instabilidade hemodinâmica, tratada com sucesso por via endovascular. O sucesso clínico foi alcançado nos 7 pacientes e o seguimento médio após retirada do dreno foi 15,4 meses (variação: 5,3-26,7 meses). Conclusão: A abordagem transparieto-hepática das estenoses biliares em crianças submetidas a transplante de fígado demonstrou ser tratamento eficaz, com baixo índice de complicações.

Use of fibrinogen and thrombin sponge in pediatric split liver transplantation.

PURPOSE:: To analyze the use of this sponge in pediatric patients undergoing split-liver transplantation. METHODS:: Retrospective study, including 35 pediatric patients undergoing split-liver transplantation, divided into two groups according to the use of the sponge: 18 patients in Group A (no sponge) and 17 in Group B (with sponge). RESULTS:: The characteristics of recipients and donors were similar. We observed greater number of reoperation due to bleeding in the wound area in Group A (10 patients - 55.5%) than in Group B (3 patients - 17.6%); p = 0.035. The median volume of red blood cells transfused in Group A was significantly higher (73.4 ± 102.38 mL/kg) than that in Group B (35.1 ± 41.67 mL/kg); p = 0.048. Regarding bile leak there was no statistical difference. CONCLUSION:: The use of the human fibrinogen and thrombin sponge, required lower volume of red blood cell transfusion and presented lower reoperation rates due to bleeding in the wound area.

Use of fibrinogen and thrombin sponge in pediatric split liver transplantation

Abstract Purpose: To analyze the use of this sponge in pediatric patients undergoing split-liver transplantation. Methods: Retrospective study, including 35 pediatric patients undergoing split-liver transplantation, divided into two groups according to the use of the sponge: 18 patients in Group A (no sponge) and 17 in Group B (with sponge). Results: The characteristics of recipients and donors were similar. We observed greater number of reoperation due to bleeding in the wound area in Group A (10 patients - 55.5%) than in Group B (3 patients - 17.6%); p = 0.035. The median volume of red blood cells transfused in Group A was significantly higher (73.4 ± 102.38 mL/kg) than that in Group B (35.1 ± 41.67 mL/kg); p = 0.048. Regarding bile leak there was no statistical difference. Conclusion: The use of the human fibrinogen and thrombin sponge, required lower volume of red blood cell transfusion and presented lower reoperation rates due to bleeding in the wound area.

Avaliação do tratamento dos nódulos do hepatocarcinoma nos pacientes em lista de espera para transplante hepático / Evaluation of the treatment of the hepatocarcinoma nodules in the patients in waiting list for liver transplant

RESUMO Objetivo: comparar o resultado do transplante de fígado por hepatocarcinoma em pacientes submetidos ou não ao tratamento loco-regional e downstaging, em relação à sobrevida e risco de recidiva na fila de transplante. Métodos: estudo retrospectivo dos pacientes portadores de hepatocarcinoma submetidos a transplante hepático na região metropolitana de São Paulo, entre janeiro de 2007 e dezembro de 2011, a partir de doador falecido. A amostra foi constituída de 414 pacientes. Destes, 29 foram incluídos na lista por downstaging. Os demais 385 foram submetidos ou não ao tratamento loco-regional. Resultados: as análises dos 414 prontuários demonstraram um predomínio de pacientes do sexo masculino (79,5%) e com média de idade de 56 anos. O tratamento dos nódulos foi realizado em 56,4% dos pacientes em fila de espera para o transplante. O método mais utilizado foi a quimio-embolização (79%). Os pacientes submetidos ao tratamento loco-regional tiveram redução significativa no tamanho do maior nódulo (p<0,001). Não houve diferença estatística entre grupos com e sem tratamento loco-regional (p=0,744) e em relação à mortalidade entre pacientes incluídos no Critério de Milão ou ao downstaging (p=0,494). Conclusões: não houve diferença na sobrevida e ocorrência de recidiva associadas ao tratamento loco-regional. Os pacientes incluídos através do processo de downstaging apresentaram resultados de sobrevida comparáveis àqueles previamente classificados como Critério de Milão/Brasil.

ABSTRACT Objective: to compare the outcome of liver transplantation for hepatocarcinoma in submitted or not to locoregional treatment and downstaging regarding survival and risk of recurrence in transplant waiting list patients. Methods: retrospective study of patients with hepatocarcinoma undergoing liver transplantation in the metropolitan region of São Paulo, between January 2007 and December 2011, from a deceased donor. The sample consisted of 414 patients. Of these, 29 patients were included in the list by downstaging. The other 385 were submitted or not to locoregional treatment. Results: the analysis of 414 medical records showed a predominance of male patients (79.5%) with average age of 56 years. Treatment of the lesions was performed in 56.4% of patients on the waiting list for transplant. The most commonly used method was chemoembolization (79%). The locoregional patients undergoing treatment had a significant reduction in nodule size greater (p<0.001). There was no statistical difference between groups with and without locoregional treatment (p=0.744) and on mortality among patients enrolled in the Milan criteria or downstaging (p=0.494). Conclusion: there was no difference in survival and recurrence rate associated with locoregional treatment. Patients included by downstaging process had comparable survival results to those previously classified as Milan/Brazil criteria.

Practical Considerations of Real Life of Hepatocellular Carcinoma in a Tertiary Center of Brazil

ABSTRACT Background. Hepatocellular carcinoma (HCC) is the most common malignancy that develops in cirrhotic livers. Its clinical and epidemiological characteristics and mortality rates vary according to geographical region. The objective of this study was to evaluate the clinical profile, epidemiological characteristics, laboratory parameters, treatment and survival of patients with HCC. Material and methods. Patients with HCC seen between 2000 and 2012 were studied. The Kaplan-Meier method was used for survival analysis according to variables in question. Results. The study included 247 patients with a mean age of 60 ± 10 years. There was a predominance of males (74%). The main etiologies of HCC were HCV infection (55%), excessive alcohol consumption (12%), and HBV infection (8%). Liver cirrhosis was present in 92% of cases. The mean tumor number and diameter were 2 and 5 cm, respectively. Patients meeting the Milan criteria corresponded to 43% of the sample. Liver transplantation was performed in 22.4% of patients of the Milan subset and in 10% of the whole sample. The overall mean survival was 60 months, with a 1-, 3- and 5-year survival probability of 74%, 40% and 29%, respectively. Lower survival was observed among patients with alcoholic etiology. Survival was higher among patients submitted to liver transplantation (P < 0.001), TACE (P < 0.001), or any kind of treatment (P < 0.001). However, no difference was found for surgical resection (P = 0.1) or sorafenib (P = 0.1). Conclusion. Patients with HCC were mainly older men diagnosed at an advanced stage. Treatment was associated with better overall survival, but few patients survived to be treated.

Pediatric liver transplantation with ex-situ liver transection and the application of the human fibrinogen and thrombin sponge in the wound area / Transplante hepático pediátrico com transecção hepática ex-situ e aplicação da esponja de fibrinogênio e trombina humana na área cruenta

ABSTRACT Background: Surgical strategy to increase the number of liver transplants in the pediatric population is the ex-situ liver transection (reduction or split). However, it is associated with complications such as hemorrhage and leaks. The human fibrinogen and thrombin sponge is useful for improving hemostasis in liver surgery. Aim: Compare pediatric liver transplants with ex-situ liver transection (reduction or split) with or without the human fibrinogen and thrombin sponge. Methods: Was performed a prospective analysis of 21 patients submitted to liver transplantation with ex-situ liver transection with the application of the human fibrinogen and thrombin sponge in the wound area (group A) and retrospective analysis of 59 patients without the sponge (group B). Results: The characteristics of recipients and donors were similar. There were fewer reoperations due to bleeding in the wound area in group A (14.2%) compared to group B (41.7%, p=0.029). There was no difference in relation to the biliary leak (group A: 17.6%, group B: 5.1%, p=0.14). Conclusion: There was a lower number of reoperations due to bleeding of the wound area of ​​the hepatic graft when the human fibrinogen and thrombin sponge were used.

RESUMO Racional: Estratégia cirúrgica para aumentar o número de transplantes hepáticos na população pediátrica é a transecção hepática ex-situ (redução ou split). No entanto, ela está associada com complicações, tais como hemorragia e fístulas. A esponja de fibrinogênio e trombina humana é útil para melhorar a hemostasia nas operações hepáticas. Objetivo: Comparar transplantes hepáticos pediátricos com transecção hepática ex-situ (redução ou split) com ou sem a esponja de fibrinogênio e trombina humana. Métodos: Foi realizada análise prospectiva de 21 pacientes submetidos ao transplante de fígado com transecção hepática ex-situ com a aplicação da esponja de fibrinogênio e trombina humana na área cruenta (grupo A) e análise retrospectiva de 59 pacientes sem a esponja (grupo B). Resultados: As características dos receptores e doadores eram semelhantes. Observou-se menor número de reoperações devido à hemorragia na área da cruenta no grupo A (14,2%) em comparação com o grupo B (41,7%, p=0,029). Não houve diferença em relação à fístula biliar (grupo A: 17,6%, grupo B: 5,1%, p=0,14). Conclusão: Houve menor número de reoperações por sangramento da área cruenta do enxerto hepático quando a esponja de fibrinogênio e trombina humana foi utilizada.