Paliação cirúrgica no câncer de cabeça pancreática : experiência com 53 pacientes

Para o câncer de cabeça pancreática, a ressecção do tumor é o único tratamento curativo existente. No entanto, a cirurgia paliativa é a mais realizada porque a grande maioria dos pacientes no momento do diagnóstico apresenta tumor incurável. Os autores apresentam sua experiência com 53 pacientes portadores de adenocarcinoma de cabeça pancreática submetidos à cirurgia paliativa, focalizando o alívio da obstrução biliar, da obstrução duodenal e da dor, e discutem as alternativas da paliação à luz de uma revisão atualizada da literatura.Tumor ressection is the only curative treatment for carcinoma of the head of the pancreas. However, most patients have incurable disease at diagnosis, making palliative surgery the most commonly used approach. The authors present their experience with 53 patients with adenocarcinoma of the head ofthe pancreas that underwent palliative surgery, emphasizing the bypass of biliary and duodenal obstructions and chronic pain relief. Alternatives of palliation are discussed based on an updated literature review

Colecistectomias videolaparoscópicas : experiência inicial em um hospital universitário

O presente trabalho tem por objetivo analisar a experiência inicial de um hospital universitário em colecistectomia videolaparoscópica. No período de agosto de 1992 a junho de 1993, 219 pacientes foram operados no Hospital de Clínicas de Porto Alegre, sendo 171 mulheres (78%). A média de idade foi 47,4 anos. Trinta e três casos (15%) eram obesos. Colecistite aguda foi o diagnóstico pré-operatório em 15 pacientes (7%). O tempo operatório médio (94,6 minutos) foi prolongado na presença de colecistite aguda (114 versus 92 min; p<0,02). Houve 6 casos de conversão para cirurgia clássica (2,7%). Os pacientes obesos apresentaram uma maior freqüência de conversões (9% versus 1,6%; p<0,05). Complicações pósoperatórias foram observadas em 23 casos (10,5%), sendo que dois exigiram laparotomia (hemorragia e perfuração intestinal). Os pacientes com mais de 65 anos de idade apresentaram um maior índice de complicações pós-operatórias (22% versus 8,5%; p<0,05). A mortalidade foi nula. O tempo médio de permanência hospitalar total (74,2 horas) foi maior nos pacientes com colecistite aguda (96 versus 72 horas; p<0,03). Esses dados iniciais demonstram que a colecistectomia videolaparoscópica vem sendo efetuada em nosso meio com resultados comparáveis aos apresentados na literatura.The present study aims to analyse the initial experience with videolaparoscopic cholecystectomy in an university hospital. Between August 1992 and June 1993, 219 patients were operated on at the Hospital de Clínicas de Porto Alegre, of which 171 (78%) were women. Mean age was 47,4 years. Thirty-three patients (15%) were obese. Acute cholecystitis was the preoperative diagnosis in 15 patients (7%). Mean operative time (94,6 minutes) was increased in patients with acute cholecystitis (114 versus 92 minutes; p<0,02). There were 6 conversions to open cholecystectomy (2,7%). Conversion was more likely in obese patients (9% versus 1,6%; p<0,05). Postoperative complications were present in 23 cases (10,5 %), two of them required laparotomy (hemorrhage and bowel injury). Patients older than 65 years of age showed a greater complication rate (22% versus 8,5%; p<0,05). There were no deaths. The median length of hospitalization (74,2 hours) was longer in patients with acute cholecystitis (96 versus 72 hours; p<0,03). These initial data demonstrate that videolaparoscopic cholecystectomy has been performed at our institution with results comparable to those of literature

Pancreatic resections : experience of the pancreato-biliary group at Hospital de Clínicas de Porto Alegre, Brazil, between 2000 and 2003

Este trabalho apresenta a experiência de 20 ressecções pancreáticas e tem como objetivo principal ressaltar a importância dos centros de referência para doenças de tratamento cirúrgico complexo, como é o caso dos portadores de neoplasia da confluência biliopancreática. De 60 doentes com neoplasia biliopancreática tratados no período de janeiro de 2000 a janeiro de 2003, 20 foram submetidos a ressecção: 16 a duodenopancreatectomia, três a ressecção corpo-caudal e um a ressecção da papila de Vater. As complicações mais freqüentes foram: cinco fístulas pancreáticas, sete abscessos intra-abdominais e oito infecções do aparelho respiratório. A mortalidade foi de 0%. Nos Estados Unidos, em hospitais com pequena experiência, nos anos de 1984 a 1991, a mortalidade foi de 21,8%; já em centros de referência, foi de 4%. Em série anterior do Hospital de Clínicas de Porto Alegre, referente ao período de 1988 a 1999, a mortalidade foi de 20%. A presente série confirma a experiência internacional: o resultado das ressecções pancreáticas é melhor em centros de referência. A indicação da cirurgia, os cuidados pré e pós-operatórios e a experiência de uma equipe que realiza o procedimento no mínimo de 10 a 15 vezes por ano são fundamentais para a obtenção de bons resultados, com a gradativa diminuição do tempo de internação e dos custos hospitalares.This paper presents the experience of 20 pancreatic resections. The main purpose of the study was to emphasize the importance of high-volume hospitals to improve results with complex surgery procedures such as pancreaticoduodenectomies. Out of 60 patients with periampullary neoplasia treated from January 2000 to January 2003, 20 underwent resections: 16 pancreaticoduodenectomies, three body and tail pancreatectomies, and one local excision of the Vater’s ampulla. The most frequent complications were five pancreatic fistulae, seven intra-abdominal abscesses and eight respiratory tract infections. In this series, mortality was 0%. In previous studies carried out in the United States (1984 to 1991), mortality has been reported to reach21.8% in minimal-volume hospitals, against 4% in high-volume hospitals. In addition, in a previous series from Hospital de Clínicas de Porto Alegre (1988 to 1999), mortality was 20%. The experience described in this study confirms that pancreatic resections have better results when performed in high-volume centers. The correct indication of surgery, pre and postoperative care and the experience of a surgical staff that carries out at least 10 to 15 resections per year, are of paramount importance for obtaining good results, with a gradual decrease in hospital stay and related costs

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

In situ electrical resistivity of thin-film beta-nial under ar irradiation at 77 k

We report on the dose dependence of the in sítu electrical resistivity of a thin-film NiAl alloy under 120-keV-Ar-ion irradiation at 77 K. The results show two different behaviors. First, the values of resistivity increase, exhibiting a maximum, and then, for higher doses, the electrical resistivity decreases down to saturation. Our results are interpreted in terms of simple composite models that assume local transformation of the solid by successive ion impacts

In situ electrical resistivity of thin-film beta-nial under ar irradiation at 77 k

We report on the dose dependence of the in sítu electrical resistivity of a thin-film NiAl alloy under 120-keV-Ar-ion irradiation at 77 K. The results show two different behaviors. First, the values of resistivity increase, exhibiting a maximum, and then, for higher doses, the electrical resistivity decreases down to saturation. Our results are interpreted in terms of simple composite models that assume local transformation of the solid by successive ion impacts

Acute pancreatitis induced by the closed duodenalloop technique : experimental model in rats

O desenvolvimento recente de inúmeros modelos experimentais de pancreatite aguda tem permitido o estudo das alterações patológicas que ocorrem nesta doença, bem como o efeito de determinados fármacos. O modelo experimental da técnica da alça duodenal fechada foi testado no desencadeamento de pancreatite aguda em ratos. Foram utilizados 20 ratos machos, alocados em dois grupos, grupo-controle e grupo da pancreatite aguda. A dosagem sérica de amilase e de lipase e o escore histológico de pancreatite aguda foram significativamente maiores no grupo da pancratite aguda em comparação com o grupocontrole, demonstrando que o modelo experimental da técnica da alça duodenal fechada desencadeou pancreatite aguda em ratos.The recent development of various animal models of acute pancreatitis has allowed the study ofthe pathological alterations lhat occur in this disease, as well as the effects of some drugs. The animal model of the closed duodenalloop technique has been tested in the development ofanlfe pa/l.creatitis in rats. Twenty adult male rats were allocated imo two groups, the control group (sham operation) and the acute pancreatitis group (closed duodenal loop technique). The serum amilase and lipase leveis and the histhological score of acute pancreatitis were significantly higher (p<O,OS) in the acute pancreatitis group in comparision with the control group, demonstrating that the experimental model of the closed duodenalloop technique developed acute pancreatitis in rats

Acute biliary pancreatitis : a prospective cohort study

OBJETIVO: A pancreatite aguda biliar (PAB) é uma doença com morbidade e mortalidade elevadas mas pouco estudada no Brasil. O objetivo deste trabalho é detalhar o diagnóstico diferencial etiológico, a gravidade e o tratamento da PAB no Hospital de Clínicas de Porto Alegre em 1999. MATERIAIS E MÉTODOS: Foram avaliados em estudo de coorte, prospectivo, todos os pacientes com amilase superior a 440 mg/dl e incluídos 65 (78,4%) que apresentavam PAB. Esta amostra foi submetida à determinação de gravidade pelos critérios de Ranson biliar, Glasgow modificado, APACHE-II e APACHE-O e acompanhada durante a evolução da doença RESULTADOS: Doze pacientes (18,5%) apresentaram evolução clínica com 19 complicações. As sistêmicas foram: falência renal (n = 4), insuficiência respiratória (n = 3), choque (n = 3) e sepse por colangite (n = 1). As complicações locais foram: coleções líquidas peripancreáticas (n = 3), necroses pancreáticas (n = 3), pseudocisto pancreático (n = 1), fístula pancreática (n = 1). Houve apenas uma morte relacionada a infarto agudo do miocárdio e hipocalcemia refratária. Os critérios prognósticos, conforme o número de parâmetros positivos, apresentaram um risco relativo que variou de 4,7 a 11,2, sensibilidade de 33,3% a 83,3%, especificidade de 79,2% a 98,1%, valor preditivo positivo de 45,0% a 83,3%, valor preditivo negativo de 86,4% a 95,5% e acurácia de 78,5% a 89,6%. Isoladamente, os parâmetros que apresentaram correlação com a gravidade foram leucograma >18000/mm3, LDH >400 UI/L, queda ³10% hematócrito, cálcio sérico 2 mg/dL, AST >200 mg/dL, LDH >600 UI/L, leucograma >15000 mm3, uréia >45 mg/dL, pH arterial £7,33 ou ³7,49, creatinina £0,6 ou ³1,4, Ht £30 ou ³45,9, leucócitos £ 3 ou ³14,9 (mil). CONCLUSÕES: Os critérios de Ranson, Glasgow, APACHE-II e APACHE-O apresentam boa sensibilidade e especificidade. O manejo da PAB deve ser revisto a partir de protocolos institucionais multidisciplinares.OBJECTIVE: Acute biliary pancreatitis (ABP) is a disease with high morbidity and mortality rates but poorly studied in Brazil. Our objective was to describe the differential diagnosis for the etiology of ABP and assess the severity and treatment of the disease at the Hospital de Clínicas de Porto Alegre, in 1999. MATERIALS AND METHODS: We carried out a cohort, prospective study in 65 (78.4%) patients who presented amylase greater than 440 mg/dl and acute biliary pancreatitis (ABP). We assessed biliary Ranson scores, modified Glasgow scores, APACHE-II and APACHE-O of our population in order to determine the severity of the disease. These scores and values were followed-up during the evolution of the disease. RESULTS: Twelve patients presented clinical evolution of the disease. The systemic complications were kidney failure (n=4), respiratory failure (n=3), shock (n=3), and sepsis associated with cholangitis (n=1). The local complications, in turn, were peripancreatic fluid collection (n=3), pancreatic necroses (n=3), pancreatic pseudocyst (n=1), and pancreatic fistula (n=1). There was only one case of death, which occurred due to acute myocardial infarction and refractory hypocalcemia. The prognostic criteria, according to the number of positive parameters, indicated relative risk (RR) from 4.7 to 11.2, sensitivity from 33.3% to 83.3%, specificity from 79.2% to 98.1%, positive predictive value from 45.0% to 83.3%, negative predictive value from 86.4% to 95.5%, and accuracy from 78.5% to 89.6%. The parameters that presented a separate correlation with severity were white blood cell count >18,000/mm3, LDH >400 UI/l, 10% decrease in hematocrit levels, serum calcium levels 2 mg/dl, AST >200 mg/dl, LDH >600 UI/l, white cell count >15,000/mm3, urea >45 mg/dl, arterial pH £7.33 or ³7.49, creatinine levels £0.6 or ³1.4, hematocrit levels £30 or ³45,9, white cell count £3,000 or ³14,900. CONCLUSION: biliary Ranson scores, modified Glasgow scores, APACHE-II and APACHE-O presented good sensitivity and specificity. Multidisciplinary protocols should be implemented in order to achieve optimal treatment results