Evaluation of extracorporeal circulation effects on gallstone formation

OBJECTIVE: The objective of the present study was to clarify the relationship between cardiopulmonary bypass with the use of a heart-lung machine and gallstones in a short-term follow-up. METHOD: A total of 135 patients with ischaemic heart disease were included in this study. All were followed up by the Cardiology Department of Hospital São Paulo, Federal University of São Paulo. They were divided into three groups: Group 1 - 51 patients who were treated clinically; Group 2 - 43 patients who underwent coronary artery grafting bypass without cardiopulmonary bypass; and Group 3 - 41 patients who underwent coronary artery grafting bypass with cardiopulmonary bypass and the use of a heart-lung machine. There were no statistically significant differences between the groups in relation to gender, age, body mass index or associated diseases (p<0.05). All the patients underwent ultrasound examination 12 months after beginning their cardiological treatment (clinical treatment alone or surgical plus follow-up). RESULTS: The prevalence of gallstones in the groups was: Group 1 - 7.84%, Group 2 - 11.62%, and Group 3 - 19.51%. There was no statistically significant differences between the groups (p = 0.248). CONCLUSION: It was concluded that cardiopulmonary bypass does not appear to have a close relationship with gallstone formation one year after coronary artery bypass grafting. However, long-term follow-up is advisable.OBJETIVO: Verificar a associação entre o uso da circulação extracorpórea e o desenvolvimento de colelitíase. MÉTODO: Foram estudados 135 pacientes coronariopatas acompanhados na Disciplina de Cardiologia da Universidade Federal de São Paulo (UNIFESP) - Escola Paulista de Medicina, no período de janeiro de 2000 a setembro de 2002, distribuídos em três grupos: Grupo 1 - 51 pacientes tratados clinicamente; Grupo 2 - 43 pacientes revascularizados sem circulação extracorpórea e Grupo 3 - 41 pacientes revascularizados com circulação extracorpórea. Foram controladas as variáveis sexo, idade, índice de massa corpórea e doenças associadas entre os grupos e foi realizada ultra-sonografia total de abdome em todos os pacientes, aos doze meses de tratamento (clínico ou cirúrgico), para verificar a existência de colelitíase. RESULTADOS: A prevalência de colelitíase encontrada nos grupos foi: Grupo 1 - 7,84 %; Grupo 2 - 11,62 % e Grupo 3 - 19,51 %. Não houve diferença estatisticamente significante entre os grupos quanto à existência de colelitíase (p=0,248). CONCLUSÃO: Baseado neste estudo não se pode afirmar que o uso da circulação extracorpórea predisponha a maior prevalência de colelitíase.UNIFESP-EPMUNIFESP-EPM Departamento de CirurgiaUniversidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM) Disciplina de Cirurgia CardiovascularUNIFESP, EPM, Depto. de CirurgiaUNIFESP, EPM, Disciplina de Cirurgia CardiovascularSciEL

Laparoscopic left lateral segmentectomy for metachronic metastases of small intestine adenocarcinoma: a case report

Hepatectomy has been the standard treatment for metachronic metastases of non-colorectal (NCR) origin, mainly when the disease-free interval is more than two years. Laparoscopic hepatectomy has become the golden standard mainly for left side resections, due to lower morbidity, shorter hospital stay, early recovery and good cosmetic outcome. The authors report the case of a female patient with two metachronic metastases (ten years of disease-free survival), of non-colorectal origin (adenocarcinoma of small intestine), treated by laparoscopic left lateral segmentectomy (left hepatic lobectomy) with success. The postoperative progress was satisfactory. To date, the patient has presented no tumoral recurrence (six months of follow-up period). Laparoscopic left lateral segmentectomy can be satisfactorily performed in selected cases of hepatic metastasis. This approach presents low morbidity and good cosmetic result. The lack of alternative treatments and the poor prognosis of untreated cases have justified surgical resection in order to increase overall survival. Nevertheless, this approach should be performed by hepatic surgery expertise teams trained on advanced laparoscopic procedures.A hepatectomia tem sido o tratamento padrão para metástase de origem não colorretal (NCR) metacrônica, principalmente quando o intervalo livre de doença é maior do que dois anos. A hepatectomia por laparoscopia tem se tornado padrão principalmente para as ressecções à esquerda, haja vista a menor morbidade, menor tempo de internação, reabilitação precoce e melhor resultado estético. Os autores relatam um caso de paciente com duas metástases metacrônicas (10 anos de sobrevida livre de doença), de etiologia não colorretal (adenocarcinoma de intestino delgado), tratada com segmentectomia lateral esquerda (lobectomia hepática esquerda) laparoscópica. Paciente apresentou boa evolução pós-operatória sem recidiva (seis meses de seguimento). Segmentectomia lateral esquerda laparoscópica pode ser satisfatoriamente realizada em casos selecionados de metástases hepáticas, acarretando menor morbidade e melhor resultado estético. A falta de tratamentos alternativos e o prognóstico reservado nos casos de metástases NCR não operadas justificam a ressecção com o objetivo de prolongar a sobrevida. No entanto, essa abordagem deve ser realizada por equipe especializada em cirurgia hepática com treinamento em procedimentos laparoscópicos avançados.Universidade Federal de São Paulo (UNIFESP)Hospital Santa LuciaUniversidade de Brasília (UNB)Hospital de Base do Distrito FederalUniversidade de Brasilia (UNB)UNIFESPSciEL

Extended right hepatectomy with partial resection of the vena cava from colorectal metastases: case report

Introduction: Hepatectomy has been standard treatment for metastases from colorectal origin (CR). Metastases with inferior vena cava (IVC) involvement may require combined resection of the liver and IVC. This approach may present high surgical risk, Both profuse bleeding and gas embolism are letal intraoperative complications. Case: The authors present a case of single hepatic CR metastasis that was treated by means extended right hepatectomy with partial inferior vena cava resection and primary reconstruction. Patient present good postoperative course without neoplasm recurrence (one year follow-up period). Conclusion: Resection of VCI and combined reconstruction with hepatectomy may be satisfactorily done in selected cases. Lack of alternative treatments associated poor prognosis of untreated cases has justified this aggressive conduct. Therefore, this approach should be realized by hepatic surgery expertise team.Introdução: A hepatectomia tem sido o tratamento padrão para metástase de origem colorretal (CR). Metástase com invasão da veia cava inferior (VCI) pode requerer ressecção combinada do fígado e VCI. Esta abordagem pode apresentar alto risco cirúrgico. Sangramento profuso e embolia gasosa são complicações intra-operatorias letais. Relato de Caso: Os autores relatam um caso de metástase colorretal única tratada com hepatectomia direita ampliada e ressecção parcial da veia cava com reconstrução primaria. Paciente apresentou boa evolução pós-operatória sem recidiva (um ano de seguimento). Conclusão: Ressecção da VCI e reconstrução combinada com hepatectomia pode ser satisfatoriamente realizada em casos selecionados. A falta de tratamentos alternativos e o prognostico reservado nos casos não operados justificam esta conduta agressiva. No entanto, esta abordagem deve ser realizada por equipe especializada em cirurgia hepática.UNIFESPHospital Regional da Asa Norte Serviço de Cirurgia GeralUFPRUSP-RPUNIFESPSciEL

Successful surgical management of an extrahepatic biliary cystadenocarcinoma

Extrahepatic bile duct cancer is an uncommon disease, and few cases are curable by surgery. We report a case of extrahepatic biliary cystadenocarcinoma (BCAC) associated with atrophy of the left hepatic lobe. A 54-year old male was admitted with painless obstructive jaundice and a hepatic palpable mass noticed one month before presentation. Liver functions tests were consistent with cholestatic damage and serum carbohydrate antigen 19.9 (CA 19-9) was increased before treatment. Magnetic resonance imaging (MRI) disclosed dilatation of the left hepatic bile duct with irregular wall thickening close to the hepatic confluence, and atrophy of left hepatic lobe. The patient was submitted to en bloc extended left hepatectomy with resection of caudate lobe, hilar lymphadenectomy, and suprapancreatic biliary tree resection. All surgical margins were grossly negative, and postoperative course was uneventful, except for a minor bile leak. The patient was discharged on the 15th postoperative day; he is alive without tumor recurrence one year after primary therapy. Although technically challenging, extended en bloc resection is feasible in adults with extrahepatic BCAC and can improve survival with acceptable and manageable morbidity

Gallbladder adenocarcinoma: evaluation of the prognostic factors in 100 resectable cases in Brazil

BACKGROUND: In spite its relative rarity, gallbladder adenocarcinoma is a neoplasm who presents an aggressive biologic behavior. The single curative treatment has been radical surgical resection with free margin. Prognostic factors has been studied because are very important to identify long-term survival patients which may benefit of aggressive surgical resection. AIM: To evaluate long-term prognostic predictors from gallbladder cancer. METHODS: The medical records of all patients that presented confirmed histological diagnosis of gallbladder adenocarcinoma operated over a 14 year period were identified and retrospectively reviewed. Uni and multivariate analysis was done. RESULTS: Total sample was 100 patients. Median age was 71 years (34 to 93). There were 17 men and 83 women. Lesion distribution according to TNM stage system was: I (n=22), II (n=59), III (n=6), IV (n=4) and unknown (n=9). Fifty two patients underwent radical resection (R0) while 48 to palliative surgery (R1-R2). Overall major morbidity was 14%, while postoperative surgical mortality rate (30th postoperative day) was 12 %. Five-year survival rate was 28% while median of survival was 10 months. Multivariate analysis identified six prognostic factors: T stage, serum level of CA 19.9, gallbladder perforation, lymphatic embolization, surgical historical cohort (after 2002) and hilar lymphadenectomy. CONCLUSION: Prognostic factors were: T stage, serum level of CA 19.9, gallbladder perforation, lymphatic embolization, surgical historical cohort and hilar lymphadenectomy.RACIONAL: A despeito da sua relativa raridade, o adenocarcinoma de vesícula biliar é neoplasia que apresenta comportamento biológico agressivo. O único tratamento curativo tem sido a ressecção cirúrgica radical com margem livre. Fatores prognósticos têm sido estudados por serem importantes para identificar pacientes que podem se beneficiar de ressecção cirúrgica agressiva. OBJETIVO: Avaliar preditores prognósticos em longo prazo de pacientes com câncer da vesícula biliar. MÉTODOS: Foram identificados e retrospectivamente revisados os prontuários médicos de todos os doentes submetidos a tratamento cirúrgico que apresentavam diagnóstico histológico confirmado de adenocarcinoma de vesícula biliar durante período de 14 anos. Os dados foram submetidos à análise estatística uni e multivariada. RESULTADOS: A amostra total foi de 100 doentes. A mediana de idade foi de 71 anos (34 a 93). Houve 17 mulheres e 83 homens. A distribuição das lesões de acordo com o sistema de estadiamento TNM foi: I (n=22), II (n=59), III (n=6), IV (n=4) e desconhecido (n=9). Cinquenta e dois doentes foram submetidos à ressecção radical (R0) enquanto 48 à cirurgia paliativa (R1-R2). A morbidade global foi de 14% enquanto que a mortalidade pós-operatória (até 30º dia do pós-operatório) foi de 12 %. A taxa de sobrevida em cinco anos foi de 28% enquanto a mediana de sobrevida foi de 10 meses. A análise multivariada identificou seis fatores prognósticos: estádio T, nível sérico de CA 19.9, perfuração da vesícula biliar, embolização linfática, coorte cirúrgico histórico e linfadenectomia hilar. CONCLUSÃO: O tratamento do câncer de vesícula biliar apresenta alta morbimortalidade. Os fatores prognósticos foram: estádio T, nível sérico de CA 19.9, perfuração da vesícula biliar, embolização linfática, coorte cirúrgico histórico e linfadenectomia hilar.HSPE FMO Hospital Francisco Morato de OliveiraUniversidade Federal de São Paulo (UNIFESP)UNIFESPSciEL

Evaluation of extracorporeal circulation effects in gallstones formation

BV UNIFESP: Teses e dissertaçõe

Apocrine gland carcinoma on the right thigh

The authors report a case of cutaneous apocrine ductal carcinomaof the right thigh in a 78-year-old female. Histological examinationrevealed a solid, ductal and glandular tumor with a significantdesmoplastic reaction. The tumor cells showed high-grade cellularatypia, and occasional peritumoral inflammatory infiltration wasalso observed. There were no characteristics of extramammaryPaget´s Disease on the overlying skin. The neoplastic cells wereimmunohistochemically positive for S-100 protein, lysozyme andalpha-chymotrypsin, but negative for CEA, EMA, and HMB-45. On thebasis of these findings, the diagnosis of apocrine ductal carcinomawas confirmed. The patient then underwent wide resection of thetumor plus en-bloc radical inguinal lymphadenectomy. The localreconstruction was done by means of a tensor fascia lata flap, noadjuvant treatment was performed. To date, one year on, the patientremains healthy, there being no evidence of tumor recurrence