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1.
Surg Obes Relat Dis ; 17(1): 12-19, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33127321

RESUMO

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgery in super-obese patients, although technically complex and time consuming. As a primary surgery, single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is similar to BPD/DS in terms of short-term outcomes, but long-term and comparative data are lacking. OBJECTIVES: The aim of this study was to compare the outcomes of patients submitted to SADI-S and BPD/DS. SETTING: Public hospital. METHODS: Obese patients (n = 112) submitted to SADI-S (n = 83) and BPD/DS (n = 29) for obesity treatment were prospectively compared. RESULTS: The mean preoperative body mass indexes (BMIs) were 53.41 ± .93 for BPD/DS and 50.61 ± .52 kg/m2 for SADI-S. Follow-up of 48 months was achieved in 18% (n = 21) of patients, with a nonsignificant difference in the percentage of excess BMI loss (%EBMIL; 81.20 ± 3.71 for BPD/DS; 74.82 ± 3.45 for SADI-S). Operative time (164.30 ± 7.78 minutes for BPD/DS; 132.70 ± 7.19 minutes for SADI-S; P = .006) and hospital stay (4.90 ± 1.10 days for BPD/DS; 4.35 ± .70 days for SADI-S; P = .006) were significantly shorter for SADI-S. There was no significant difference in the 30-day postoperative complication rate. No mortality was reported. After surgery, significant improvements were observed in glucose and lipid profiles for both groups. The type 2 diabetes remission rate was 100% for BPD/DS and ranged from 60 to 80% for SADI-S across follow-up times. Dyslipidemia remission followed a similar pattern. Protein deficiency was observed in up to 50% of patients after BPD/DS and 20% after SADI-S, without statistically significances. CONCLUSION: SADI-S and BPD/DS as primary surgery for obesity treatment result in no significant differences in %EBMIL, improvement in obesity-related diseases, nutritional deficiencies, and postoperative morbidity. Nevertheless, there was greater total weight loss after BPD/DS. SADI-S, being less time consuming and technically simpler, can represent an advantage over BPD/DS.

2.
Rev Port Cir Cardiotorac Vasc ; 27(4): 293-294, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33280319

RESUMO

Introduction Esophageal compression due to vascular anomalies is well known since Bayford's description of dysphagia lusoria in 1787. This condition is due to an aberrant origin of the right subclavian artery and is the most common vascular variation associated with symptomatic esophageal compression. Other vascular anomalies can also lead to dysphagia being extremely uncommon. Objectives We present two clinical cases of different vascular anomalies with consequent symptomatic pharyngeal or esophageal compression. Materials and Methods The clinical process of two patients with dysphagia associated with vascular anomalies was reviewed. Clinical and iconographic data were collected. Results A 77-year-old man, with multiple vascular risk factors, with a history of atrial fibrillation, had been followed for a descending thoracic aortic aneurysm. The last computed tomography angiography (CTA) performed showed a descending thoracic aorta diameter of 42mm. Two years after this last control, the patient starts complaints of gradual worsening dysphagia predominantly for solids. Clinical investigation did not reveal a defined etiology. Thus, the patient repeated the CTA, which revealed the presence of a penetrating aortic ulcer in the medial portion of the aortic arch, about 18 mm deep, conditioning marked compression of the adjacent trachea and esophagus (fig 1). The patient was proposed to perform a hybrid treatment with TEVAR plus surgical de- -branching of the aortic arch using a carotid-carotid and a carotid-subclavian bypass. A 62-year-old woman with a history of obesity and epilepsy, presents with dysphagia mainly for solids with several months of evolution and occasional episodes of choking. After the most common causes have been excluded, a CTA of the cervical and thoracic region was performed, which revealed the presence of a left internal carotid artery kinking with marked pharyngeal compression (fig 2). Bearing in mind that the complaints conditioned her a marked reduction in the quality of life, surgical correction was proposed. The patient underwent vascular reconstruction surgery with excision of the redundant segment of the internal carotid artery and direct end-to-end anastomosis. The patient showed a marked improvement in quality of life. At the follow-up, 14 days after the procedure, she no longer had symptoms of dysphagia. Conclusions Overall, vascular anomalies are very rare causes of dysphagia, and are often diagnosed in imaging studies after the most common causes have been excluded. When compressive symptoms condition a significant impact in quality of lie, invasive treatment should be considered, however the therapeutic decision must be individualized.

3.
Artigo em Inglês | MEDLINE | ID: mdl-33280321

RESUMO

Introduction It is well recognized that the Ankle-Arm Index is unreliable in the diagnosis and prognosis of peripheral arteriopathy in patients with incompressible vessels, such as diabetics and chronic kidney patients. It is therefore important to define alternative strategies for assessing distal perfusion in this population. Arterial Doppler, a non-invasive technique available in any vascular laboratory, can be used to directly assess foot perfusion by interrogating the plantar arch and its nourishing arteries. This technique, recently described and still not widespread, can help to overcome the diagnostic limitations of ABI. Objectives This work aims to review the model and the results obtained with the evaluation of the Pedal Acceleration Time (PAT) as well as to evaluate its practical applicability. Materials and Methods In an initial phase, the recently published literature on the topic was analysed. Subsequently, the clinical applicability of the technique was tested in 2 non-diabetic and non- -revascularized patients, admitted to the Angiology and Vascular Surgery Service of our center. In both, the acceleration time of the systolic flow, measured in milliseconds, were evaluated in the Arched, Plantar Medial, Lateral Plantar and Deep Plantar Arteries. Results In patient A, with ABI of 0.27, the acceleration time in the 4 evaluated arteries varied between 210-260ms, values that according to standardization in the literature fall into a category of moderate to severe ischemia. Patient B, with a 0.35 ABI, had low-amplitude monophasic flows in all arteries, failing to obtain a correct measurement of the acceleration time. Thus, the morphology of the curve has become a limitation for the application of this modality. The technical complexity, time consuming, with an average duration of the exam of 30-40 minutes, were other limitations found, also revealing an exam with some discomfort for the patient with ischemic rest pain. Conclusions In patient A, the values obtained by measuring the PAT were comparable in severity of ischemia with the ABI, with the advantage of demonstrating with greater specificity the perfusion defects corresponding to each angiosome. However, it would be important to understand the reliability of this test in patients with incompressible arteries and the ease of its clinical application, taking into account their technical requirements.

4.
Ann Vasc Surg ; 2020 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-33227481

RESUMO

Splenic artery aneurysms (SAA) are more frequent in women and have a high rupture risk during pregnancy, with catastrophic outcomes. It is advisable to treat these aneurysms in pregnant and fertile women, whatever their diameter, given their increased risk for rupture. There are several therapeutic approaches: endovascular surgery using coil embolization or stent graft coverage; laparoscopic or open surgical resection with arterial reconstruction and ligation followed by splenectomy when necessary. This paper aims to report the successful treatment of SAA in second-trimester pregnant women using a laparoscopic approach with aneurysm resection and arterial reconstruction. This is a unique report of a minimally invasive approach with arterial reconstruction in a pregnant woman, thus reducing the risk of spleen infarction and potentially avoiding splenectomy.

9.
J Vasc Access ; : 1129729820946654, 2020 Jul 29.
Artigo em Inglês | MEDLINE | ID: mdl-32723132

RESUMO

BACKGROUND: Hemodialysis access-induced distal ischemia consists of symptomatic extremity malperfusion after vascular access creation. It is usually caused by discordant vascular resistance, with arteriovenous shunting of a high blood volume from arterial into venous system and subsequent hand hypoperfusion. Less often, hemodialysis access-induced distal ischemia is caused by arterial stenosis. In these cases, access frequently has normal/low flow, radial pulse is usually absent and not recoverable with vascular access digital compression, diabetes is often present, and percutaneous transluminal angioplasty can be critical for access and limb salvage. METHODS: Retrospective study conducted between June 2011 and February 2018 of patients with vascular access submitted to arterial percutaneous transluminal angioplasty for limb-threatening ischemia. RESULTS: Twenty-nine patients were referred for arterial angiography after hemodialysis access-induced distal ischemia diagnosis and physical examination or ultrasound findings suggestive of arterial disease. In 11 patients, percutaneous transluminal angioplasty was not technically feasible. Among 18 treated patients, 83.3% had diabetes and 60% had skin ulcerations. Target arteries were radial (11), brachial (7), axillar (2), ulnar (2), and subclavian (1). Clinical success, defined as arteriovenous maintenance and wound healing/pain resolution, was observed in 12 patients (66.7%). Concomitant procedures included adjuvant banding (n = 2) and finger amputation (n = 1), and one reintervention was performed. No intra- or postoperative complications were reported. CONCLUSION: Hemodialysis access-induced distal ischemia is a serious complication of hemodialysis vascular access, with multifactorial etiology. Correct and timely diagnosis is crucial for maintaining access and limb salvage. Percutaneous transluminal angioplasty is a minimally invasive procedure that may be effective and long-lasting in carefully selected patients with ischemic complaints.

11.
Artigo em Inglês | MEDLINE | ID: mdl-32554827

RESUMO

Summary: Gonadotropin-releasing hormone (GnRH) agonists, currently used in the treatment of advanced prostate cancer, have been described as a rare cause of pituitary apoplexy, a potentially life-threatening clinical condition. We report the case of a 69-year-old man with a known pituitary macroadenoma who was diagnosed with prostate cancer and started treatment with GnRH agonist leuprorelin (other hormones were not tested before treatment). Few minutes after drug administration, the patient presented with acute-onset severe headache, followed by left eye ptosis, diplopia and vomiting. Pituitary MRI revealed tumor enlargement and T1-hyperintense signal, compatible with recent bleeding sellar content. Laboratory endocrine workup was significant for low total testosterone. The patient was managed conservatively with high-dose steroids, and symptoms significantly improved. This case describes a rare phenomenon, pituitary apoplexy induced by GnRH agonist. We review the literature regarding this condition: the pathophysiological mechanism involved is not clearly established and several hypotheses have been proposed. Although uncommon, healthcare professionals and patients should be aware of this complication and recognize the signs, preventing a delay in diagnosis and treatment. Learning points: Pituitary apoplexy (PA) is a potentially life-threatening complication that can be caused by gonadotropin-releasing hormone agonist (GnRHa) administration for the treatment of advanced prostate cancer. This complication is rare but should be taken into account when using GnRHa, particularly in the setting of a known pre-existing pituitary adenoma. PA presents with classic clinical signs and symptoms that should be promptly recognized. Patients should be instructed to seek medical care if suspicious symptoms occur. Healthcare professionals should be aware of this complication, enabling its early recognition, adequate treatment and favorable outcome.

12.
ACS Appl Mater Interfaces ; 12(28): 31282-31291, 2020 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-32569459

RESUMO

Self-assembled colloidal gels are highly versatile 3D nanocluster platforms with potential to overcome the rapid clearing issues associated with standard free nanotherapeutics administration. However, the development of nanoassembled colloidal gels exhibiting autonomous multiparticle release from the bulk particle network remains elusive. Herein, we generated multiparticle colloidal gels from two nanosized building blocks: cationic poly(d,l-lactide-co-glycolide)-polyethylenimine (PLGA-PEI) nanoparticles and anionic zein-hyaluronan (HA) nanogels that assemble into macrosized 3D constructs via attractive electrostatic forces. The resulting colloidal gels exhibited high stability in complex culture medium as well as fit-to-shape moldable properties and injectability. Moreover, nanoassembled colloidal gels encapsulated bioactive quercetin flavonoids with high loading efficacy and presented remarkable anti-inflammatory activities, reducing key proinflammatory biomarkers in inflammation-activated macrophages. More importantly, because of their rationally selected building blocks zein-HA/PLGA-PEI, self-assembled colloidal platforms displayed autonomous multiparticle shedding. Both positive and negative particles released from the colloidal system were efficiently internalized by macrophages along time as evidenced by quantitative particle uptake analysis. Overall, the generated nanostructured gels represent an implantable versatile platform for focalized multiparticle delivery. In addition, the possibility to combine a higher number of particle species with different properties or stimuli-responsiveness enables the manufacturing of combinatorial nanostructured gels for numerous biomedical applications.

13.
Obes Surg ; 30(10): 4019-4028, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32564307

RESUMO

PURPOSE: Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective weight loss surgical procedure. Yet, BPD-DS is technically difficult to perform and carries a higher risk of nutrient deficiencies as compared with other surgical interventions. Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modified BPD-DS procedure conceived with the aim of decreasing the technical complexity, while retaining the weight loss efficiency. Whether the two surgical procedures diverge in nutrient absorption rates and malnutrition risk is still matter of debate. Our aim was to determine if postprandial nutrient absorption rates are different in patients subjected to BPD-DS or SADI-S for weight loss. MATERIALS AND METHODS: Plasma amino acid metabolomic profiling during mixed-meal tolerance test (MMTT) was performed in subjects (N = 18) submitted to BPD-DS (n = 9) or SADI-S (n = 9) 1.6 ± 0.1 years earlier. RESULTS: Patients submitted to SADI-S or BPD-DS presented distinct postprandial metabolomic profiles. Postprandial excursions of total and essential amino acids-leucine, isoleucine, and valine-were higher after SADI-S as compared with BPD-DS. CONCLUSION: Our study demonstrates that a simplified malabsorptive bariatric surgery procedure SADI-S results in greater essential branched-chain amino acid absorption when compared with the classical BPD-DS intervention. These findings suggest that SADI-S can potentially lower lifetime risk of postoperative protein malnutrition, as well as have a positive impact on systemic metabolism and glucose homeostasis.

15.
GE Port J Gastroenterol ; 27(2): 124-127, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32266310

RESUMO

Background: Hemorrhagic rupture of a hepatic cyst is rare. To date, very few cases have been reported in the literature. Case Report: A patient with a history of a suspected liver hydatid cyst presented to the emergency department with abdominal pain and fever. She was admitted with the presumptive diagnosis of acute cholecystitis. During hospitalization, the patient presented with hemodynamic instability and abrupt worsening of the abdominal pain. The abdominal angio-chemotherapy scan showed an abundant free peritoneal effusion and an apparent effacement of the anterior wall of a hepatic cyst of 16 cm. The patient underwent an exploratory laparotomy, deroofing of the cyst, and peritoneal lavage. The anatomopathological results showed a simple hepatic cyst. Discussion: Hemorrhagic rupture of simple hepatic cysts is a life-threatening complication and, although rare, should be included in the differential diagnosis of sudden abdominal pain in patients with a history of simple hepatic cysts.

16.
Artigo em Inglês | MEDLINE | ID: mdl-32111431

RESUMO

OBJECTIVE: Various methods for cardiothoracic, cardiovascular, and cardiac surgical training exist across the globe, with the common goal of producing safe, independent surgeons. A comparative analysis of international training paradigms has not been undertaken, and our goal in doing so was to offer insights into how to best prepare future trainees and ensure the health of our specialty. METHODS: We performed a comparative analysis of available publications offering detailed descriptions of various cardiothoracic, cardiovascular, and cardiac surgical training paradigms. Corresponding authors from previous publications and other international collaborators were also reached directly for further data acquisition. RESULTS: We report various approaches to common challenges surrounding (1) selection of trainees and plans for the future surgical workforce; (2) trainee assessments and certification of competency before independent practice; and (3) challenges related to a changing practice landscape. CONCLUSIONS: Cardiothoracic surgery remains a dynamic and rewarding specialty. Current and future trainees face several challenges that transcend national borders. To foster collaboration and adoption of best practices, we highlight international strengths and weaknesses of various nations in terms of workforce selection, trainee operative experience and assessment, board certification, and preparation for future changes anticipated in cardiothoracic surgery.

18.
J Gastrointest Surg ; 24(6): 1269-1277, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31140062

RESUMO

BACKGROUND: Gastrointestinal (GI) surgery involving gastric resection and bypass of intestinal segments was reported to facilitate glucose control in obese patients with type 2 diabetes (T2D). AIM: Our aim was to assess whether the type of post-gastrectomy GI reconstruction also influences glucose control in T2D patients with BMI below 35 kg/m2 submitted to gastrointestinal surgery without bariatric intention. METHODS: A cohort of T2D Caucasian patients (n = 40) with upper GI malignancy (n = 33) or complicated reflux disease (n = 7) were submitted to either a gastrectomy plus Billroth II (BII) gastrojejunal anastomosis (n = 17), a gastrectomy plus Roux-en-Y gastrojejunostomy (RY) reconstruction (n = 18; subtotal gastrectomy n = 7 and total gastrectomy n = 11), or atypical gastrectomy without reconstruction (no-R) (n = 5). Patients were evaluated before and 2 years after surgery for body weight, Hb1Ac, need of glucose lowering drugs, and presence of diabetes. RESULTS: Body mass index (BMI) decreased after every surgical procedure when compared to baseline (- 0.9 ± 0.8 kg/m2 for BII vs - 4.3 ± 2.6 kg/m2 for RY vs - 4.6 ± 2.5 kg/m2 for no-R, p < 0.05), which was only significantly different after RY surgeries. Diabetes remission occurred in 5.9% of BII patients, in 27.8% of RY patients, and 0% of no-R patients, while in patients with persistent T2D, the needs for glucose-lowering drugs were significantly also decreased after RY (31.3% BII vs 66.7% RY vs 25% no-R, p = 0.03). CONCLUSIONS: T2D Caucasian patients undergoing post-gastrectomy GI reconstructions without a bariatric intention experience a significant improvement of T2D, in a magnitude that could be influenced by the technical procedure performed in favor of RY reconstruction. Thus, presence of T2D should be taken into consideration when deciding for the type of post-gastrectomy GI reconstruction.

19.
J Vasc Surg ; 71(1): 318-327, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31676179

RESUMO

OBJECTIVE: The management of vascular anomalies is complex and requires a multidisciplinary team with a combination of medical, surgical, and intervention treatments. Medical treatment is limited and has conflicting results. Off-label use of mammalian target of rapamycin inhibitors shows promising results. The objective of this study was to systematically evaluate the literature published about the efficacy and safety of sirolimus in the treatment of vascular anomalies. METHODS: A systematic review of the published literature was conducted using the PubMed database and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: There were 73 articles included: 2 randomized controlled studies, 2 nonrandomized prospective studies, and 69 retrospective case reports and case series. In total, 373 patients were included. Sirolimus was administered topically to 56 patients and orally to 317 patients. Sirolimus was highly effective in the treatment of vascular tumors associated with Kasabach-Merritt phenomenon (95.5% of the patients clinically improved and 93% had normalization of coagulopathy), venous malformations (size reduction was observed in 88.9% of patients), and lymphatic malformations (clinical improvement in 94.9% of patients). Topical sirolimus results were conflicting. Arteriovenous malformations were not improved by sirolimus. CONCLUSIONS: Low-level evidence suggests that sirolimus can improve the prognosis of vascular anomalies, most notably vascular tumors associated with life-threatening coagulopathy and venous and lymphatic malformations. Further research is needed to establish the benefits of sirolimus in the management of vascular anomalies.


Assuntos
Fármacos Cardiovasculares/administração & dosagem , Sirolimo/administração & dosagem , Malformações Vasculares/tratamento farmacológico , Neoplasias Vasculares/tratamento farmacológico , Administração Oral , Administração Tópica , Fármacos Cardiovasculares/efeitos adversos , Feminino , Humanos , Masculino , Uso Off-Label , Sirolimo/efeitos adversos , Resultado do Tratamento , Malformações Vasculares/diagnóstico por imagem , Malformações Vasculares/fisiopatologia , Neoplasias Vasculares/diagnóstico por imagem , Neoplasias Vasculares/fisiopatologia
20.
Ann Vasc Surg ; 63: 456.e1-456.e4, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31622748

RESUMO

Traditional open total zone 0 replacement of the aortic arch is one of the most complex, challenging, and demanding operative procedures in cardiovascular surgery, associated with significant morbidity (30-40%) and mortality (8-20%). Total endovascular zone 0 replacement of the aortic arch with chimney/sandwich techniques as described by Lobato and Camacho-Lobato is a feasible, less invasive, less demanding, and time-consuming option to hybrid and/or traditional open replacement of the aortic arch, particularly in the urgent/emergent settings. We are reporting a case of a 49-year-old patient with chronic type B aortic dissection complicated with descending thoracic aortic aneurysm and an unsuccessful zone 3 thoracic endovascular aortic repair, complicated with type Ia endoleak. He presented with an enlarging and symptomatic descending thoracic aortic aneurysm. An extended proximal (to the zone 0) and distal thoracic endovascular aortic repair was performed to ensure appropriate proximal and distal landing zones (C-TAG). Left subclavian artery endorevascularization was undertaken with periscope sandwich technique (Viabahn), while brachiocephalic trunk and left carotid artery endorevascularizations were carried on with the chimney graft technique (Viabahn). The procedure was uneventful and the one-month and one-year follow-up angio-computed tomography revealed no endoleaks, patency of all branches, and exclusion of the aneurysm.


Assuntos
Aneurisma Dissecante/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Endoleak/cirurgia , Procedimentos Endovasculares , Aneurisma Dissecante/diagnóstico por imagem , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Doença Crônica , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/fisiopatologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Humanos , Pessoa de Meia-Idade , Stents , Resultado do Tratamento , Grau de Desobstrução Vascular
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