DRAIN AMYLASE ON THE FIRST POSTOPERATIVE DAY OF WHIPPLE SURGERY: WHAT VALUE IS THE BEST PREDICTOR FOR EARLY DRAIN REMOVAL?

BACKGROUND: The value of drain amylase on the first postoperative day after pancreatic resections has been described as an efficient predictor of pancreatic fistula. In spite of this, the cut-off point below which the drains can be removed early remains controversial. AIM: Validate the use of the amylase on the 1st postoperative day in the correlation with pancreatic fistula and define the value at which early drain removal is safe. METHOD: Were included patients undergoing Whipple surgery in the period of 2007 to 2016. Group 1 enrolled the ones who did not develop fistula and those who developed biochemical fistula for less than seven days postoperatively and group 2 included patients who developed persistent biochemical fistula between seven and 21 days and those with grade B and C fistula. RESULTS: Sixty-one patients were included, 41 comprised group 1 and 20 group 2. The incidence of abdominal collections, need for reoperation and time of hospitalization were for group 1 and 2, respectively: 17.1%, 17.1% and 9.5 days, and 65%, 40% and 21.1 days. The median of the amylase from the drain at 1st postoperative day was in group 1 and 2, respectively: 175 U/l and 3172.5 U/l (p=0.001). Using a cut-off of 180 to predict the group to which the patient would belong there was obtained sensitivity, specificity, positive predictive value and negative predictive value of 100%, 48.8%, 50% and 100% respectively. CONCLUSION: It was validated the cut-off value of 180 U/l as appropriate to early drain removal.

Drain amylase on the first postoperative day of whipple surgery: what value is the best predictor for early drain removal? / Amilase do dreno no primeiro dia de pós-operatório de operaçao de whipple: qual valor é melhor preditor para a retirada precoce do dreno?

ABSTRACT Background: The value of drain amylase on the first postoperative day after pancreatic resections has been described as an efficient predictor of pancreatic fistula. In spite of this, the cut-off point below which the drains can be removed early remains controversial. Aim: Validate the use of the amylase on the 1st postoperative day in the correlation with pancreatic fistula and define the value at which early drain removal is safe. Method: Were included patients undergoing Whipple surgery in the period of 2007 to 2016. Group 1 enrolled the ones who did not develop fistula and those who developed biochemical fistula for less than seven days postoperatively and group 2 included patients who developed persistent biochemical fistula between seven and 21 days and those with grade B and C fistula. Results: Sixty-one patients were included, 41 comprised group 1 and 20 group 2. The incidence of abdominal collections, need for reoperation and time of hospitalization were for group 1 and 2, respectively: 17.1%, 17.1% and 9.5 days, and 65%, 40% and 21.1 days. The median of the amylase from the drain at 1st postoperative day was in group 1 and 2, respectively: 175 U/l and 3172.5 U/l (p=0.001). Using a cut-off of 180 to predict the group to which the patient would belong there was obtained sensitivity, specificity, positive predictive value and negative predictive value of 100%, 48.8%, 50% and 100% respectively. Conclusion: It was validated the cut-off value of 180 U/l as appropriate to early drain removal.

RESUMO Racional: O valor da amilase do dreno no primeiro dia pós-operatório após ressecções pancreáticas é descrito como eficiente preditor de fístula pancreática. Entretanto, o valor abaixo do qual os drenos podem ser removidos precocemente permanece controverso. Objetivo: Validar o uso da amilase do primeiro dia pós-operatório na correlação com a fístula pancreática e definir o valor em que seja segura a retirada precoce do dreno. Método: Foram incluídos pacientes submetidos à operação de Whipple no período de 2007 a 2016. No grupo 1 entraram os que não desenvolveram fístula e os que desenvolveram fístula bioquímica por menos de sete dias de pós-operatório e no grupo 2 os que desenvolveram fístula bioquímica persistente entre 7 e 21 dias e aqueles com fístula grau B e C. Resultados: Sessenta e um pacientes foram incluídos, sendo 41 do grupo 1 e 20 do grupo 2. A incidência de coleções abdominais, necessidade de reoperação e tempo de internação foram para o grupo 1 e 2, respectivamente 17,1%, 17,1% e 9,5 dias, e 65%, 40% e 21,1 dias. A mediana da amilase no grupo 1 e 2, respectivamente foi de 175 U/l e 3172,5 U/l (p=0,001). Utilizando o ponto de corte de 180 para predizer o grupo a que o paciente pertenceria, obteve-se sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de: 100%, 48,8%, 50% e 100% respectivamente. Conclusão: Esta amostra pôde validar o ponto de corte de 180 U/l como adequado para a retirada precoce do dreno.

Venous occlusion test applied to the tributaries of the superior mesenteric veins of the pancreas head infiltrated by tumor.

A 64-year-old white woman presented with cholestatic jaundice, weight loss and a solid lesion in the pancreas head. At multislice computed tomography, a superior mesenteric vein (SMV) and one of it tributaries showed signs of tumor infiltration. At surgery, a venous occlusion test applied to the infiltrated tributary of the SMV showed immediate venous congestion in two-thirds of the distal small intestine. No reconstruction attempt was made due to the small size of the vessel. A biliodigestive anastomosis and lymph node biopsy was performed. The herein assessed case report suggests that the ileal tributary occlusion test applied to patients presenting pancreatic adenocarcinoma, with invasion of the tributaries of the SMV, may be effective in contraindicating resection procedures.

HYPERVASCULAR LIVER LESIONS IN RADIOLOGICALLY NORMAL LIVER.

Background: The hypervascular liver lesions represent a diagnostic challenge. Aim: To identify risk factors for cancer in patients with non-hemangiomatous hypervascular hepatic lesions in radiologically normal liver. Method: This prospective study included patients with hypervascular liver lesions in radiologically normal liver. The diagnosis was made by biopsy or was presumed on the basis of radiologic stability in follow-up period of one year. Cirrhosis or patients with typical imaging characteristics of haemangioma were excluded. Results: Eighty-eight patients were included. The average age was 42.4. The lesions were unique and were between 2-5 cm in size in most cases. Liver biopsy was performed in approximately 1/3 of cases. The lesions were benign or most likely benign in 81.8%, while cancer was diagnosed in 12.5% of cases. Univariate analysis showed that age >45 years (p< 0.001), personal history of cancer (p=0.020), presence of >3 nodules (p=0.003) and elevated alkaline phosphatase (p=0.013) were significant risk factors for cancer. Conclusion: It is safe to observe hypervascular liver lesions in normal liver in patients up to 45 years, normal alanine aminotransaminase, up to three nodules and no personal history of cancer. Lesion biopsies are safe in patients with atypical lesions and define the treatment to be established for most of these patients.

Racional: As lesões hepáticas hipervasculares representam um desafio diagnóstico. Objetivo: Identificar fatores de risco para câncer em pacientes portadores de lesão hepática hipervascular não-hemangiomatosa em fígado radiologicamente normal. Método: Estudo prospectivo que incluiu pacientes com lesões hepáticas hipervasculares em que o diagnóstico final foi obtido por exame anatomopatológico ou, presumido a partir de seguimento mínimo de um ano. Diagnóstico prévio de cirrose ou radiológico de hemangioma foram considerados critérios de exclusão. Resultados: Oitenta e oito pacientes foram incluídos. A relação mulher/homem foi de 5,3/1. A idade média foi de 42,4 anos. Na maior parte das vezes as lesões hepáticas foram únicas e com tamanho entre 2-5 cm. Em aproximadamente 1/3 dos casos foi realizada biópsia hepática. Em 81,8% dos casos as lesões eram benignas ou provavelmente benignas enquanto que em 12,5% dos casos o diagnóstico foi de câncer. A análise univariada mostrou que idade superior a 45 anos (p<0,001), antecedente familiar pessoal de câncer (p=0,020), presença de mais de três nódulos (p=0,003) e elevação da alanina aminotransaminase (p=0,013) foram fatores de risco relevantes para o câncer. Conclusões: È indicado observar lesões hepáticas hipervasculares em fígado normal em pacientes com até 45 anos, alanina aminotransaminase normal, com até três nódulos e sem antecedente pessoal de câncer. Para os demais com lesões atípicas, a biópsia da lesão é segura e define na maior parte dos pacientes o tratamento a ser instituído.

Hypervascular liver lesions in radiologically normal liver / Lesão hepática hipervascular em fígado radiologicamente normal

ABSTRACT Background: The hypervascular liver lesions represent a diagnostic challenge. Aim: To identify risk factors for cancer in patients with non-hemangiomatous hypervascular hepatic lesions in radiologically normal liver. Method: This prospective study included patients with hypervascular liver lesions in radiologically normal liver. The diagnosis was made by biopsy or was presumed on the basis of radiologic stability in follow-up period of one year. Cirrhosis or patients with typical imaging characteristics of haemangioma were excluded. Results: Eighty-eight patients were included. The average age was 42.4. The lesions were unique and were between 2-5 cm in size in most cases. Liver biopsy was performed in approximately 1/3 of cases. The lesions were benign or most likely benign in 81.8%, while cancer was diagnosed in 12.5% of cases. Univariate analysis showed that age >45 years (p< 0.001), personal history of cancer (p=0.020), presence of >3 nodules (p=0.003) and elevated alkaline phosphatase (p=0.013) were significant risk factors for cancer. Conclusion: It is safe to observe hypervascular liver lesions in normal liver in patients up to 45 years, normal alanine aminotransaminase, up to three nodules and no personal history of cancer. Lesion biopsies are safe in patients with atypical lesions and define the treatment to be established for most of these patients.

RESUMO Racional: As lesões hepáticas hipervasculares representam um desafio diagnóstico. Objetivo: Identificar fatores de risco para câncer em pacientes portadores de lesão hepática hipervascular não-hemangiomatosa em fígado radiologicamente normal. Método: Estudo prospectivo que incluiu pacientes com lesões hepáticas hipervasculares em que o diagnóstico final foi obtido por exame anatomopatológico ou, presumido a partir de seguimento mínimo de um ano. Diagnóstico prévio de cirrose ou radiológico de hemangioma foram considerados critérios de exclusão. Resultados: Oitenta e oito pacientes foram incluídos. A relação mulher/homem foi de 5,3/1. A idade média foi de 42,4 anos. Na maior parte das vezes as lesões hepáticas foram únicas e com tamanho entre 2-5 cm. Em aproximadamente 1/3 dos casos foi realizada biópsia hepática. Em 81,8% dos casos as lesões eram benignas ou provavelmente benignas enquanto que em 12,5% dos casos o diagnóstico foi de câncer. A análise univariada mostrou que idade superior a 45 anos (p<0,001), antecedente familiar pessoal de câncer (p=0,020), presença de mais de três nódulos (p=0,003) e elevação da alanina aminotransaminase (p=0,013) foram fatores de risco relevantes para o câncer. Conclusões: È indicado observar lesões hepáticas hipervasculares em fígado normal em pacientes com até 45 anos, alanina aminotransaminase normal, com até três nódulos e sem antecedente pessoal de câncer. Para os demais com lesões atípicas, a biópsia da lesão é segura e define na maior parte dos pacientes o tratamento a ser instituído.

IMMEDIATE COMPLICATIONS AFTER 88 HEPATECTOMIES - BRAZILIAN CONSECUTIVE SERIES.

Background: Hepatectomies have been increasingly recommended and performed in Brazil; they present great differences related to immediate complications. Aim: Assessing the immediate postoperative complications in a series of 88 open liver resections. Method: Prospective database of patients subjected to consecutive hepatectomies over nine years. The post-hepatectomy complications were categorized according to the Clavien-Dindo classification; complications presenting grade equal to or greater than 3 were considered major complications. Hepatic resections involving three or more resected liver segments were considered major hepatectomies. Results: Eighty-four patients were subjected to 88 hepatectomies, mostly were minor liver resections (50 cases, 56.8%). Most patients had malignant diseases (63 cases; 71.6%). The mean hospitalization time was 10.9 days (4-43). Overall morbidity and mortality rates were 37.5% and 6.8%, respectively. The two most common immediate general complications were intra-peritoneal collections (12.5%) and pleural effusion (12.5%). Bleeding, biliary fistula and liver failure were identified in 6.8%, 4.5% and 1.1% of the cases, respectively, among the hepatectomy-specific complications. Conclusion: The patients operated in the second half of the series showed better results, which were apparently influenced by the increased surgical expertise, by the modification of the hepatic parenchyma section method and by the increased organ preservation.

Racional: No Brasil as hepatectomias têm sido cada vez mais indicadas e realizadas, apresentando grandes diferenças relacionadas às complicações imediatas. Objetivo: Avaliar as complicações pós-operatórias imediatas em uma série de 88 ressecções hepáticas abertas. Método: Foi utilizada uma base de dados prospectiva de pacientes submetidos à hepatectomias consecutivas em nove anos. As complicações pós-hepatectomia seguiram a Classificação de Clavien-Dindo, sendo consideradas complicações maiores aquelas as quais apresentaram grau igual ou maior que 3. Foram consideradas hepatectomias maiores as ressecções hepáticas que envolveram três ou mais segmentos hepáticos ressecados. Resultados: Oitenta e quatro pacientes foram submetidos a 88 hepatectomias, sendo a maioria ressecções hepáticas menores (50 casos; 56,8%). A maior parte dos pacientes apresentou doença maligna (63 casos; 71,6%). O tempo médio de internação foi de 10,9 dias (4-43). A taxa de morbidade e mortalidade global foi, respectivamente, de 37,5% e 6,8%. As duas complicações gerais imediatas mais frequentes foram as coleções intraperitoneais (12,5%) e o derrame pleural (12,5%). Já as complicações específicas das hepatectomias - sangramento, fístula biliar e insuficiência hepática - foram respectivamente de 6,8%, 4,5% e 1,1% dos casos. Conclusão: Os pacientes operados na segunda metade da presente casuística tiveram melhores resultados influenciados, aparentemente, pela maior experiência cirúrgica, modificação do método de secção do parênquima hepático e maior preservação do fígado.

Immediate complications after 88 hepatectomies - brazilian consecutive series / Complicações imediatas após 88 hepatectomias - série consecutiva brasileira

ABSTRACT Background: Hepatectomies have been increasingly recommended and performed in Brazil; they present great differences related to immediate complications. Aim: Assessing the immediate postoperative complications in a series of 88 open liver resections. Method: Prospective database of patients subjected to consecutive hepatectomies over nine years. The post-hepatectomy complications were categorized according to the Clavien-Dindo classification; complications presenting grade equal to or greater than 3 were considered major complications. Hepatic resections involving three or more resected liver segments were considered major hepatectomies. Results: Eighty-four patients were subjected to 88 hepatectomies, mostly were minor liver resections (50 cases, 56.8%). Most patients had malignant diseases (63 cases; 71.6%). The mean hospitalization time was 10.9 days (4-43). Overall morbidity and mortality rates were 37.5% and 6.8%, respectively. The two most common immediate general complications were intra-peritoneal collections (12.5%) and pleural effusion (12.5%). Bleeding, biliary fistula and liver failure were identified in 6.8%, 4.5% and 1.1% of the cases, respectively, among the hepatectomy-specific complications. Conclusion: The patients operated in the second half of the series showed better results, which were apparently influenced by the increased surgical expertise, by the modification of the hepatic parenchyma section method and by the increased organ preservation.

RESUMO Racional: No Brasil as hepatectomias têm sido cada vez mais indicadas e realizadas, apresentando grandes diferenças relacionadas às complicações imediatas. Objetivo: Avaliar as complicações pós-operatórias imediatas em uma série de 88 ressecções hepáticas abertas. Método: Foi utilizada uma base de dados prospectiva de pacientes submetidos à hepatectomias consecutivas em nove anos. As complicações pós-hepatectomia seguiram a Classificação de Clavien-Dindo, sendo consideradas complicações maiores aquelas as quais apresentaram grau igual ou maior que 3. Foram consideradas hepatectomias maiores as ressecções hepáticas que envolveram três ou mais segmentos hepáticos ressecados. Resultados: Oitenta e quatro pacientes foram submetidos a 88 hepatectomias, sendo a maioria ressecções hepáticas menores (50 casos; 56,8%). A maior parte dos pacientes apresentou doença maligna (63 casos; 71,6%). O tempo médio de internação foi de 10,9 dias (4-43). A taxa de morbidade e mortalidade global foi, respectivamente, de 37,5% e 6,8%. As duas complicações gerais imediatas mais frequentes foram as coleções intraperitoneais (12,5%) e o derrame pleural (12,5%). Já as complicações específicas das hepatectomias - sangramento, fístula biliar e insuficiência hepática - foram respectivamente de 6,8%, 4,5% e 1,1% dos casos. Conclusão: Os pacientes operados na segunda metade da presente casuística tiveram melhores resultados influenciados, aparentemente, pela maior experiência cirúrgica, modificação do método de secção do parênquima hepático e maior preservação do fígado.

Fifty consecutive pancreatectomies without mortality.

OBJECTIVE: to report the group's experience with a series of patients undergoing pancreatic resection presenting null mortality rates. METHODS: we prospectively studied 50 consecutive patients undergoing pancreatic resections for peri-ampullary or pancreatic diseases. Main local complications were defined according to international criteria. In-hospital mortality was defined as death occurring in the first 90 postoperative days. RESULTS: patients' age ranged between 16 and 90 years (average: 53.3). We found anemia (Hb < 12g/dl) and preoperative jaundice in 38% and 40% of cases, respectively. Most patients presented with peri-ampullary tumors (66%). The most common surgical procedure was the Kausch - Whipple operation (70%). Six patients (12%) needed to undergo resection of a segment of the mesenteric-portal axis. The mean operative time was 445.1 minutes. Twenty two patients (44%) showed no clinical complications and presented mean hospital stay of 10.3 days. The most frequent complications were pancreatic fistula (56%), delayed gastric emptying (17.1%) and bleeding (16%). CONCLUSION: within the last three decades, pancreatic resection is still considered a challenge, especially outside large specialized centers. Nevertheless, even in our country (Brazil), teams seasoned in such procedure can reach low mortality rates.

Fifty consecutive pancreatectomies without mortality / Cinquenta pancreatectomias consecutivas sem mortalidade

Objective: to report the group's experience with a series of patients undergoing pancreatic resection presenting null mortality rates. Methods: we prospectively studied 50 consecutive patients undergoing pancreatic resections for peri-ampullary or pancreatic diseases. Main local complications were defined according to international criteria. In-hospital mortality was defined as death occurring in the first 90 postoperative days. Results: patients' age ranged between 16 and 90 years (average: 53.3). We found anemia (Hb < 12g/dl) and preoperative jaundice in 38% and 40% of cases, respectively. Most patients presented with peri-ampullary tumors (66%). The most common surgical procedure was the Kausch - Whipple operation (70%). Six patients (12%) needed to undergo resection of a segment of the mesenteric-portal axis. The mean operative time was 445.1 minutes. Twenty two patients (44%) showed no clinical complications and presented mean hospital stay of 10.3 days. The most frequent complications were pancreatic fistula (56%), delayed gastric emptying (17.1%) and bleeding (16%). Conclusion : within the last three decades, pancreatic resection is still considered a challenge, especially outside large specialized centers. Nevertheless, even in our country (Brazil), teams seasoned in such procedure can reach low mortality rates.

Objetivo: apresentar uma série de casos consecutivos de ressecções pancreáticas com mortalidade nula, discutindo os aspectos relacionados ao preparo pré-operatório, técnica cirúrgica e cuidados pós-operatórios. Métodos: foram analisados prospectivamente 50 pacientes consecutivos submetidos à ressecções pancreáticas para o tratamento de doenças pancreáticas ou periampulares. As principais complicações locais foram definidas segundo critérios internacionais. A mortalidade intra-hospitalar foi considerada quando o óbito ocorreu nos primeiros 90 dias do pós-operatório. Resultados: a faixa etária variou entre 16 e 90 anos (média: 53,3 anos). Anemia (Hb<12g/dl) e icterícia pré-operatória estavam presentes, respectivamente, em 38% e 40% dos casos. A maior parte dos pacientes era portadora de tumor periampular (66%). O procedimento cirúrgico mais realizado foi a operação de Kausch-Whipple (70%). Em seis pacientes (12%) houve necessidade de ressecção de segmento do eixo mesentericoportal. O tempo cirúrgico médio foi 445,1 minutos. Vinte e dois pacientes (44%) evoluíram sem nenhuma complicação clínica e tiveram tempo médio de internação de 10,3 dias. As complicações mais frequentes foram: fístula pancreática (56%), retardo do esvaziamento gástrico (17,1%) e sangramento (16%). Conclusão: nas últimas três décadas a ressecção pancreática ainda é considerada um desafio, principalmente fora dos grandes centros especializados. Apesar disso, com uma equipe habituada com esse procedimento, um baixo índice de mortalidade é possível.

Splenic vein graft for the reconstruction of the mesenteric-portal trunk after gastroduodenopancreatectomy.

Resection of the confluence of the superior mesenteric and portal veins has been performed most frequently in the treatment of adenocarcinoma of the pancreas, in view of the reported positive results, but it can also be used in cases of benign pancreatic neolpasias when they are strongly adhered to the mesenteric-portal trunk. Nevertheless, there is no study on the best type of venous grafts for reconstruction of the mesenteric-portal trunk when required. The choice of graft depends on the preference of the surgeon or the institution. This technical note critically discusses the use of the splenic vein as an option for mesenteric-portal trunk reconstruction after gastroduodenopancreatectomy.

Outcomes from mesenteric-portal axis resection during pancreatectomy / Resultados da ressecção do eixo mesentérico-portal durante a pancreatectomia

BACKGROUND: Due to their complexity and risks, mesenteric-portal axis resection and reconstruction during the pancreatectomy procedure were not recommended back in the early nineties. However, as per technical improvements and the reduction in morbidity and mortality rates, they have been routinely indicated in large medical centers. AIM: To show results from cases of patients subjected to mesenteric-portal axis resection during pancreatectomy. METHOD: Patients subjected to mesenteric-portal axis resection during pancreatectomy were prospectively and consecutively assessed. The procedure was indicated according to anatomical criteria defined by imaging exams or intraoperative assessment. RESULTS: Ten patients, half of them were male, with mean age of 55.7 years (40-76) were included. The most frequent underlying diseases were pancreatic adenocarcinoma and Frantz tumor. The circumferential resection of the portal vein associated with the superior mesenteric vein with splenic vein ligature (4 cases=40%) and the primary anastomosis of the vascular stumps (5 cases=50%) were, respectively, the most performed types of vascular resection and reconstruction. Surgery time ranged from 480 to 600 minutes (average=556 minutes) and postoperative hospitalization time ranged from 9 to 114 days (average=34.8 days). Morbidity rate was 60%, and clinical pancreatic fistula (grade B and C) was the most common complication (3 cases=30%). Mortality rate was 10% (1 case). CONCLUSION: Mesenteric-portal axis resection is a valid technical procedure. It should be taken into account after a clinical assessment that included not only the patients' clinical condition but also the technical and anatomical conditions of the mesenteric-portal axis tumor infiltration as well as life expectancy based on the patient's cancer prognosis. .

RACIONAL: Devido à complexidade e riscos, a ressecção e reconstrução do eixo mesentérico-portal durante pancreatectomia até o início dos anos noventa não era recomendada. Entretanto, com o aprimoramento técnico e redução da morbimortalidade ela tem sido indicada de forma rotineira nos grandes centros. OBJETIVO: Demostrar os resultados de uma série de casos submetida à ressecção do eixo mesentérico-portal durante a pancreatectomia. MÉTODO: Foram avaliados prospectivamente e consecutivamente pacientes submetidos à ressecção do eixo mesentérico-portal durante pancreatectomias. A indicação do procedimento baseou-se em critérios anatômicos definidos por exames de imagem ou por avaliação intra-operatória. RESULTADOS: Foram incluídos 10 pacientes, metade do sexo masculino, com idade média de 55,7 anos (40-76). As doenças de base mais frequentes foram o adenocarcinoma de pâncreas e o tumor de Frantz. O tipo de ressecção e reconstrução vascular mais realizado foi respectivamente a ressecção circunferencial da veia porta associada à veia mesentérica superior com ligadura da veia esplênica (4 casos=40%) e a anastomose primária dos cotos vasculares (5 casos=50%). O tempo operatório variou entre 480 e 600 minutos (média=556 minutos) e o tempo de internação pós-operatória variou de 9 a 114 dias (média=34,8 dias). A morbidade foi de 60%, sendo a fístula pancreática clínica (grau B e C) a complicação mais frequente (3 casos=30%). A mortalidade foi de 10% (um caso). CONCLUSÃO: A ressecção do eixo mesentérico-portal é artifício técnico válido. Deve ser considerada após consideração que contemple não apenas as condições clínicas dos pacientes, as condições técnicas e anatômicas da infiltração tumoral do eixo mesentérico-portal, mais também, e de forma não menos importante, a expectativa de sobrevida com base no prognóstico oncológico do paciente. .

Outcomes from mesenteric-portal axis resection during pancreatectomy.

BACKGROUND: Due to their complexity and risks, mesenteric-portal axis resection and reconstruction during the pancreatectomy procedure were not recommended back in the early nineties. However, as per technical improvements and the reduction in morbidity and mortality rates, they have been routinely indicated in large medical centers. AIM: To show results from cases of patients subjected to mesenteric-portal axis resection during pancreatectomy. METHOD: Patients subjected to mesenteric-portal axis resection during pancreatectomy were prospectively and consecutively assessed. The procedure was indicated according to anatomical criteria defined by imaging exams or intraoperative assessment. RESULTS: Ten patients, half of them were male, with mean age of 55.7 years (40-76) were included. The most frequent underlying diseases were pancreatic adenocarcinoma and Frantz tumor. The circumferential resection of the portal vein associated with the superior mesenteric vein with splenic vein ligature (4 cases=40%) and the primary anastomosis of the vascular stumps (5 cases=50%) were, respectively, the most performed types of vascular resection and reconstruction. Surgery time ranged from 480 to 600 minutes (average=556 minutes) and postoperative hospitalization time ranged from 9 to 114 days (average=34.8 days). Morbidity rate was 60%, and clinical pancreatic fistula (grade B and C) was the most common complication (3 cases=30%). Mortality rate was 10% (1 case). CONCLUSION: Mesenteric-portal axis resection is a valid technical procedure. It should be taken into account after a clinical assessment that included not only the patients' clinical condition but also the technical and anatomical conditions of the mesenteric-portal axis tumor infiltration as well as life expectancy based on the patient's cancer prognosis.

Complications after pancreatectomies: prospective study after ISGFP and ISGPS new classifications.

BACKGROUND: Scientific publications focusing on the results of pancreatic resections in Brazil are scarce. AIM: To present the surgical results of pancreatic resections. METHODS: Were analyzed prospectively 54 consecutive cases of patients undergoing consecutive pancreatectomy evaluating the occurrence of postoperative complications (pancreatic fistula, delayed gastric emptying and postoperative hemorrhage) based on the criteria of the International Study Group on Pancreatic Fistula Definition and International Study Group of Pancreatic Surgery. RESULTS: Of the 54 pancreatectomy, 32 occurred in women (59,26%) and 22 in men (40,74%). The mean age of patients was 54,5 years. The most performed procedure was the Whipple operation, in 38 patients. In eight of those cases, mesenteric-portal confluence was ressected. The mean period of hospitalization was 20,7 days. The hospitalization in 51% of patients was up to 10 days. A pancreatic fistula was observed in 50% of the cases submitted to the Whipple surgery. The postoperative hemorrhage and delayed gastric emptying in patients undergoing the surgery occurred respectively in 13,15% and 18,41%. The overall morbidity and mortality was respectively 62.9% and 5.5%. CONCLUSION: There is a need for the national publications to assimilate the concepts and criteria presented by the ISGFP(2) and ISGPS(23,25) to enable comparison of the results obtained with surgical treatment of pancreatic disorders, in the Brazilian context. Who knows, therefore, whether the great advanced seen in the last 40 years in terms of the reduction in mortality rates associated with pancreatic resections may also occur with the persistently high levels of postoperative complications.

Complicações após pancreatectomias: estudo prospectivo após as novas classificações GIEDFP e GIECP / Complications after pancreatectomies: prospective study after ISGFP and ISGPS new classifications

RACIONAL: No Brasil existe escassa publicação científica destinada à divulgação dos resultados das ressecções pancreáticas. OBJETIVO: Apresentar os resultados cirúrgicos das ressecções pancreáticas. MÉTODOS: Analisou-se prospectivamente 54 casos consecutivos de pacientes submetidos à pancreatectomias. Foi avaliada a ocorrência de complicações pós-operatórias (fístula pancreática, retardo do esvaziamento gástrico e hemorragia pós-operatória) fundamentadas nos critérios dos Grupos Internacionais de Estudo sobre a Definição de Fístula Pancreática e de Cirurgia Pancreática. RESULTADOS: Das 54 pancreatectomias, 32 foram realizadas em mulheres (59,26%) e 22 em homens (40,74%). A média de idade dos pacientes foi de 54,5 anos. O procedimento mais praticado foi à cirurgia de Whipple em 38 pacientes. Em oito destes, houve ressecção do eixo mesentérico-portal. O tempo médio de internação foi de 20,7 dias. A maioria dos pacientes (51%) esteve internada por até 10 dias. A fístula pancreática foi observada em 50% da amostra em 44,7% dos pacientes submetidos à operação de Whipple. O sangramento pós-operatório e o retardo do esvaziamento gástrico nos pacientes submetidos à essa operação ocorreram, respectivamente, em 13,15% e 18,41%. Na amostra a taxa global de morbidade e mortalidade foi respectivamente de 62,9% e 5,5%. CONCLUSÃO: Há necessidade das publicações nacionais assimilarem os conceitos e critérios apresentados pelas classificações GIEDFP e GIECP para permitir a comparação dos resultados obtidos com o tratamento cirúrgico de doenças pancreáticas, no contexto brasileiro. Quem sabe, se o grande avançado visto nos últimos 40 anos em termos de redução das taxas de mortalidade associadas com ressecções pancreáticas também pode ocorrer com os níveis persistentemente elevados de complicações pós-operatórias.

BACKGROUND: Scientific publications focusing on the results of pancreatic resections in Brazil are scarce. AIM: To present the surgical results of pancreatic resections. METHODS: Were analyzed prospectively 54 consecutive cases of patients undergoing consecutive pancreatectomy evaluating the occurrence of postoperative complications (pancreatic fistula, delayed gastric emptying and postoperative hemorrhage) based on the criteria of the International Study Group on Pancreatic Fistula Definition and International Study Group of Pancreatic Surgery. RESULTS: Of the 54 pancreatectomy, 32 occurred in women (59,26%) and 22 in men (40,74%). The mean age of patients was 54,5 years. The most performed procedure was the Whipple operation, in 38 patients. In eight of those cases, mesenteric-portal confluence was ressected. The mean period of hospitalization was 20,7 days. The hospitalization in 51% of patients was up to 10 days. A pancreatic fistula was observed in 50% of the cases submitted to the Whipple surgery. The postoperative hemorrhage and delayed gastric emptying in patients undergoing the surgery occurred respectively in 13,15% and 18,41%. The overall morbidity and mortality was respectively 62.9% and 5.5%. CONCLUSION: There is a need for the national publications to assimilate the concepts and criteria presented by the ISGFP² and ISGPS23,25 to enable comparison of the results obtained with surgical treatment of pancreatic disorders, in the Brazilian context. Who knows, therefore, whether the great advanced seen in the last 40 years in terms of the reduction in mortality rates associated with pancreatic resections may also occur with the persistently high levels of postoperative complications.

Translocation of 99mTc labelled bacteria after intestinal ischemia and reperfusion

PURPOSE: Ischemia and reperfusion of the small intestine disrupts gut barrier, causes bacterial translocation and activates inflammatory responses. An experimental study was planned to evaluate if 99mTc labelled Escherichia coli translocates to mesenteric lymph nodes, liver, spleen, lung and serum of rats submitted to mesenteric ischemia/reperfusion. Additionally, it was observed if the time of reperfusion influences the level of translocation. METHODS: Forty male Wistar rats underwent 45 minutes of gut ischemia by occlusion of the superior mesenteric artery. The translocation of labelled bacteria to different organs and portal serum was determined in rats reperfused for 30 minutes, 24 hours, sham(S) and controls(C), using radioactivity count and colony forming units/g (CFU). RESULTS: All the organs from rats observed for 24 hours after reperfusion had higher levels of radioactivity and positive cultures (CFU) than did the organs of rats reperfused for 30 minutes, C and S, except in the spleen (p<0,01). CONCLUSION: The results of this study indicated that intestinal ischemia/reperfusion led to bacterial translocation, mostly after 24 hours of reperfusion.

Síndrome de chilaiditi associada a megaduodeno e megacólon transverso / Chilaiditi syndrome associated to megaduodenum and transverse megacolon

Chilaiditi syndrome is a rare abnormality, uncommon in children, whith an incidence increasing with the age, ranging from 0.025 per cents to 0.28 per cents in the general population usually affecting males. The patients are usually asymptomatics and the syndrome is incidently discover through radiologic exams. However, abdominal pain and distention, nauseas, vomits and changes in intestinal habits, and even intestinal obstruction can occur. The authors report a case of a patient with Chilaiditi's syndrome associated to megastomach, megaduodenum and megacolon