Carcinoma hepatocelular : diagnóstico e manejo cirúrgico

Introduction: Hepatocellular carcinoma is an aggressive malignant tumor with high lethality. Aim: To review diagnosis and management of hepatocellular carcinoma. Methods: Literature review using web databases Medline/PubMed. Results: Hepatocellular carcinoma is a common complication of hepatic cirrhosis. Chronic viral hepatitis B and C also constitute as risk factors for its development. In patients with cirrhosis, hepatocelular carcinoma usually rises upon malignant transformation of a dysplastic regenerative nodule. Differential diagnosis with other liver tumors is obtained through computed tomography scan with intravenous contrast. Magnetic resonance may be helpful in some instances. The only potentially curative treatment for hepatocellular carcinoma is tumor resection, which may be performed through partial liver resection or liver transplantation. Only 15% of all hepatocellular carcinomas are amenable to operative treatment. Patients with Child C liver cirrhosis are not amenable to partial liver resections. The only curative treatment for hepatocellular carcinomas in patients with Child C cirrhosis is liver transplantation. In most countries, only patients with hepatocellular carcinoma under Milan Criteria are considered candidates to a liver transplant. Conclusion: Hepatocellular carcinoma is potentially curable if discovered in its initial stages. Medical staff should be familiar with strategies for early diagnosis and treatment of hepatocellular carcinoma as a way to decrease mortality associated with this malignant neoplasm.Introdução: O carcinoma hepatocelular é neoplasia maligna agressiva com elevada morbidade e mortalidade. Objetivo: Revisão sobre a fisiopatologia, o diagnóstico e o manejo do carcinoma hepatocelular nos vários estágios da doença. Método: Revisão da literatura utilizando a base Medline/PubMed e literatura adicional. Resultados: O carcinoma hepatocelular é geralmente complicação da cirrose hepática. As hepatites virais crônicas B e C também são fatores de risco para o surgimento do carcinoma hepatocelular. Quando associado à cirrose hepática, ele geralmente surge a partir da evolução de um nódulo regenerativo hepatocitário que sofre degeneração maligna. O diagnóstico é efetuado através de tomografia computadorizada de abdome com contraste endovenoso, e a ressonância magnética pode auxiliar nos casos que não possam ser definidos pela tomografia. O único tratamento potencialmente curativo para o carcinoma hepatocelular é a ressecção do tumor, seja ela realizada através de hepatectomia parcial ou de transplante. Infelizmente, apenas cerca de 15% dos carcinomas hepatocelulares são passíveis de tratamento cirúrgico. Pacientes portadores de cirrose hepática estágio Child B e C não devem ser submetidos à ressecção hepática parcial. Para esses pacientes, as opções terapêuticas curativas restringem-se ao transplante de fígado, desde que selecionáveis para esse procedimento, o que na maioria dos países dá-se através dos Critérios de Milão. Conclusão: Quando diagnosticado em seus estágios iniciais, o carcinoma hepatocelular é potencialmente curável. O melhor conhecimento das estratégias de diagnóstico e tratamento propiciam sua identificação precoce e a indicação de tratamento apropriado

HEPATECTOMIA DIREITA AMPLIADA COM RESSECÇÃO TOTAL DE LOBO CAUDADO E DE VIAS BILIARES EXTRA-HEPÁTICAS

A hepatectomia direita ampliada é indicada para tratar tumores localizados no fígado direito e que se estendem ao segmento IV do fígado esquerdo, incluindo ou não a ressecção do segmento I (lobo caudado). Ocasionalmente, esses tumores são muito grandes e alcançam a fissura umbilical e podem envolver o ducto hepático esquerdo e / ou a confluência dos ductos hepáticos direito e esquerdo. Relatamos o caso de uma paciente com uma metástase hepática de câncer colorretal localizada no lado direito do fígado e envolvendo também os segmentos IV e I e o ducto hepático esquerdo submetida a hepatectomia direita ampliada, com manejo alternativo do ducto hepático esquerdo. Unitermos: Hepatectomia direita ampliada; ressecção de lobo caudado; ressecção de vias biliares extra-hepáticas; tumores hepático

Transarterial embolization for hepatocellular carcinoma : a comparison between nonspherical PVA and microspheres

Transarterial chemoembolization (TACE) and transarterial embolization (TAE) have improved the survival rates of patients with unresectable hepatocellular carcinoma (HCC); however, the optimal TACE/TAE embolic agent has not yet been identified. Theaim of this study was to compare the effect of two different embolic agents such as microspheres (ME) and polyvinyl alcohol (PVA) on survival, tumor response, and complications in patients with HCC submitted to transarterial embolization (TAE). Eighty HCC patients who underwent TAE between June 2008 and December 2012 at a single center were retrospectively studied. A total of 48 and 32 patients were treated with PVA and ME, respectively. There were no significant differences in survival ( = 0.679) or tumoral response ( = 0.369) between groups (PVA or ME). Overall survival rates at 12, 18, 24, 36, and 48months were 97.9, 88.8, 78.9, 53.4, and 21.4% in the PVA-TAE group and 100, 92.9, 76.6, 58.8, and 58% in the ME-TAE group ( = 0.734). Patients submitted to TAE withME presented postembolization syndromemore frequently when compared with the PVA group ( = 0.02). According to our cohort, the choice of ME or PVA as embolizing agent had no significant impact on overall survival

Botryomycosis mimicking acute abdome: a case report

Botryomycosis is a rare chronic granulomatous bacterial infection involving mostly the skin and subcutaneous tissues. The nomenclature is a misnomer as it is caused by true bacteria and not by fungus. This uncommon infection sometimes simulates neoplasia and actinomycosis. Staphylococcus aureus is the agent isolated in most cases, followed by Pseudomonas sp. cepas. The authors present an uncommon case of invasive umbilical Botriomycosis simulating an acute abdome. A combination of surgery and antibiotic therapy treatment was applied with complete resolution of the infection. More often seen in the skin, this is the first report of Botryomycosis affecting this site

Morphine influence on esophageal carcinogenesis induced by diethylnitrosamine in rats : preliminary results

OBJETIVOS: A alta incidência de câncer esofagiano no norte do Irã foi associada ao ópio. A dietilnitrosamina (DEN) é uma das nitrosaminas com maior potencial de produzir câncer experimental no esôfago. Morfina, o maior alcalóide do ópio, quando administrada em altas doses a ratos, aumentou a etilação do DNA esofágico pela DEN e reduziu seu metabolismo hepático de primeira passagem. O presente trabalho objetivou estudar o efeito da administração conjunta de morfina e DEN na carcinogênese esofágica. MATERIAIS E MÉTODOS: Durante 23 semanas, estudamos o efeito da administração conjunta de morfina e DEN na carcinogênese esofágica em ratos. RESULTADOS: Encontrou-se maior incidência tumoral nos animais que receberam somente DEN em relação aos que receberam DEN e morfina. CONCLUSÃO: Concluiu-se que a morfina não apresentou influência sobre a carcinogênese esofágica induzida pela DEN em ratos.OBJECTIVE: In northern Iran, the high incidence of esophageal cancer was associated to opium. Diethylnitrosamine (DEN) is one of the nitrosamines that presents high risk for experimental cancer of the esophagus. Morphine, the largest alkaloid of opium, has been reported to increase the ethylation of esophageal DNA through DEN and to reduce first-passage hepatic metabolism, when administered in high doses to rats. Our objective was to study the effect of joint administration of morphine and DEN on esophageal carcinogenesis in rats. MATERIAL AND METHODS: For 23 weeks, we studied the effect of joint administration of morphine and DEN on the esophageal carcinogenesis in rats. RESULTS: The animal models that received only DEN presented a higher incidence of tumors than those that received DEN and morphine. CONCLUSION: We concluded that morphine did not influence esophageal carcinogenesis induced by DEN in rats

Estimating basal energy expenditure in liver transplant recipients : the value of the Harris-Benedict Equation

Racional: Estimativa confiável do metabolismo basal em pacientes transplantados de fígado é necessária para adaptar os requerimentos energéticos, melhorar o estado nutricional e prevenir ganho de peso. Calorimetria indireta (CI) é o padrão-ouro para a medição do metabolismo basal. No entanto, ele pode ser estimado utilizando-se métodos alternativos, incluindo a bioimpedância (BI), a Equação de Harris-Benedict (EHB), e também a Equação de Mifflin-St. Jeor (MSJ). Esses métodos alternativos possuem aplicabilidade mais fácil e custo inferior quando comparados à CI. Objetivo: Determinar qual dos três métodos alternativos para a estimativa do metabolismo basal (EHB, BI e MSJ) seria o mais confiável em pacientes transplantados de fígado. Métodos: Foi realizado estudo transversal prospectivo incluindo pacientes transplantados de fígado com dislipidemia, em acompanhamento ambulatorial. Comparações dos valores calculados de metabolismo basal via CI aos valores estimados por cada um dos três métodos alternativos (EHB, BI e MSJ) foram realizadas utilizando o de Bland- Altman e o teste de Wilcoxon-Mann-Whitney. Resultados: Quarenta e cinco pacientes foram incluídos com idade 58±10 anos. O metabolismo basal medido via CI foi 1664±319 kcal para pacientes do gênero masculino, e 1409±221 kcal para o feminino. A diferença média entre a taxa de metabolismo basal aferida por CI (1534±300 kcal) e estimada por BI (1584±377 kcal) foi +50 kcal (p=0.0384). A diferença média entre a taxa de metabolismo basal aferida via CI (1534±300 kcal) e estimada por MSJ (1479.6±375 kcal) foi -55 kcal (p=0.16). A diferença média entre os valores de taxa de metabolismo basal medidos via CI (1534±300 kcal) e estimados por EHB (1521±283 kcal) foi -13 kcal (p=0.326). Além disso, a diferença entre a taxa de metabolismo basal estimada via CI e a aferida por EHB foi menor que 100 kcal para 39 de todos os 43 pacientes avaliados. Conclusões: A EHB foi o mais confiável dos três métodos de estimativa da taxa de metabolismo basal em pacientes transplantados de fígado em acompanhamento ambulatorial.Background: Reliable measurement of basal energy expenditure (BEE) in liver transplant (LT) recipients is necessary for adapting energy requirements, improving nutritional status and preventing weight gain. Indirect calorimetry (IC) is the gold standard for measuring BEE. However, BEE may be estimated through alternative methods, including electrical bioimpedance (BI), Harris-Benedict Equation (HBE), and Mifflin-St. Jeor Equation (MSJ) that carry easier applicability and lower cost. Aim: To determine which of the three alternative methods for BEE estimation (HBE, BI and MSJ) would provide most reliable BEE estimation in LT recipients. Methods: Prospective cross-sectional study including dyslipidemic LT recipients in follow-up at a 735-bed tertiary referral university hospital. Comparisons of BEE measured through IC to BEE estimated through each of the three alternative methods (HBE, BI and MSJ) were performed using Bland-Altman method and Wilcoxon Rank Sum test. Results: Fortyfive patients were included, aged 58±10 years. BEE measured using IC was 1664±319 kcal for males, and 1409±221 kcal for females. Average difference between BEE measured by IC (1534±300 kcal) and BI (1584±377 kcal) was +50 kcal (p=0.0384). Average difference between the BEE measured using IC (1534±300 kcal) and MSJ (1479.6±375 kcal) was -55 kcal (p=0.16). Average difference between BEE values measured by IC (1534±300 kcal) and HBE (1521±283 kcal) was -13 kcal (p=0.326). Difference between BEE estimated through IC and HBE was less than 100 kcal for 39 of all 43patients. Conclusions: Among the three alternative methods, HBE was the most reliable for estimating BEE in LT recipients

Botryomycosis mimicking acute abdome: a case report

Botryomycosis is a rare chronic granulomatous bacterial infection involving mostly the skin and subcutaneous tissues. The nomenclature is a misnomer as it is caused by true bacteria and not by fungus. This uncommon infection sometimes simulates neoplasia and actinomycosis. Staphylococcus aureus is the agent isolated in most cases, followed by Pseudomonas sp. cepas. The authors present an uncommon case of invasive umbilical Botriomycosis simulating an acute abdome. A combination of surgery and antibiotic therapy treatment was applied with complete resolution of the infection. More often seen in the skin, this is the first report of Botryomycosis affecting this site

Esophagogastric junction outflow obstruction successfully treated with laparoscopic Heller myotomy and Dor fundoplication : first case report in the literature

BACKGROUND Esophagogastric junction outflow obstruction (EGJOO) is a rare syndrome, characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations in esophageal motility that may lead to the criteria for achalasia. We were unable to find any prior report of the combination of Heller myotomy with anterior partial fundoplication (Dor) as the treatment for EGJOO. We herein report a case of EGJOO treated with laparoscopic Heller myotomy combined with Dor fundoplication. CASE SUMMARY A 26-year-old man presented with a 3-year history of solid dysphagia and a 30-kg weight loss. He was treated with oral nifedipine, isosorbide, and omeprazole, without resolution of symptoms. An upper gastrointestinal series (barium swallow) revealed a “bird’s beak” sign. Esophagogastroduodenoscopy was positive for Los Angeles grade A peptic esophagitis. High-resolution esophageal manometry was compatible with EGJOO. Esophageal pH monitoring showed pathological acid reflux both in orthostatic and decubitus position. An 8-cm laparoscopic Heller myotomy combined with an anterior 220° Dor fundoplication was performed. Solid diet was introduced on postoperative day 2, and the patient was discharged home the same day. At 17-mo follow-up, he reported no symptoms. Barium swallow was compatible with complete radiologic resolution. Both esophageal manometry and upper endoscopy showed normal findings 9 mo after the operation. CONCLUSION Surgical treatment with Heller myotomy and Dor fundoplication is a potential treatment option for EGJOO refractory to medical treatment