Simultaneous left colectomy and standard hepatectomy reformed by laparoscopy

As abordagens laparoscópicas têm sido cada vez mais utilizadas em pacientes com câncer colorretal ou hepático. Colectomia e hepatectomia simultâneas são consideradas técnicas seguras e apresentam resultados oncológicos semelhantes independente da localização do tumor primário quando associada à ressecções hepáticas com menos de quatro metástases, uma vez que não existe aumento da morbimortalidade nem prejuízo na sobrevida. O desenvolvimento de técnicas e materiais laparoscópicos tornou a ressecção combinada do cólon e do fígado uma opção bastante atraente. O objetivo do presente estudo é demonstrar a ressecção de um tumor sincrônico de sigmoide e metástase hepática única tratada por colectomia e setorectomia lateral esquerda puramente laparoscópicaLaparoscopic approaches have been increasingly used in patients with colorectal or liver cancer. Simultaneous colectomy and hepatectomy are considered safe techniques and present similar oncological results regardless of the location of the primary tumor when there are fewer than four liver metastases, since there is no increase in morbidity or decrease in survival. The development of laparoscopic techniques and materials has made the combined resection of the colon and liver a very attractive option. The aim of this study is to demonstrate the synchronous resection of the sigmoid tumor and single liver metastasis treated by purely laparoscopic colectomy and liver left lateral sectorectomy

Caractérisation anatomo-clinique et phénotypique des adénocarcinomes canalaires du pancréas avec instabilité des microsatellites

Pancreatic ductal adenocarcinoma (PDAC) is a major health problem in France and around the world. PDAC is developed mainly from two precursor lesions: pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasm (IPMN). There are several molecular mechanisms underlying pancreatic oncogenesis. Particularly, we were interested in the MSI (MicroSatellite Instability) which is due to a defective DNA Mismatch Repair (MMR) system, which normally functions to recognize and repair erroneous insertions, deletions, and mis-incorporation of bases that can arise during DNA replication and recombination. The MSI phenotype was first described in the familial cancer condition known as Lynch syndrome (LS), where the MMR genes MLH1, MSH2, MSH6 or PMS2 harbor germline mutations. Interest in MSI tumors has recently increased after studies have highlighted the concomitant expression of multiple active immune checkpoint (ICK) markers including PD-1 and PD-L1 and the role of the MSI status to predict clinical benefit from immune checkpoint blockade. A Our results indicate that the MSI phenotype occurs in PDAC with a frequency of 1-2%. Our data showed that IHC using antibodies against the four MMR proteins was more sensitive for the assessment of MSI status than PCR-based methods. In addition, we demonstrate for the first time a statistically significant positive association between MSI and IPMNs in PDAC. MSI PDAC, including IPMN, are unlikely to be sporadic since they display molecular features that are usually observed in LS-related neoplasms. Also, our results highlight that an MSI-driven immunogenic pathway to cancer is active in MSI PDACs but suggest that MSI-driven somatic events may be tissue-specific. We observed a stronger lymphocytic tumor infiltration by activated TCD8 cells in MSI PDAC compared to MSS PDAC and found a positive association between PD-L1 expression and MSI status, suggesting that MSI PDAC could be responsive to ICK blockade therapy.L’adénocarcinome canalaire du pancréas (ACP) est un problème majeur de santé publique. L’ACP se développe principalement à partir de deux lésions précurseurs : les néoplasies intra-épithéliales pancréatiques et les tumeurs intracanalaires papillaires et mucineuses du pancréas (TIPMP). Les mécanismes moléculaires sous-tendant l’oncogenèse pancréatique sont nombreux. Nous avons étudié le mécanisme de cancérogenèse MSI (MicroSatellite Instability) où il existe une déficience dans le système de réparation des erreurs de réplication de l’ADN ou système MMR (Mismatch Repair). Ce mécanisme de cancérogenèse original est caractérisé par une instabilité génétique de l’ADN affectant les séquences répétées microsatellites du génome. Le phénotype MSI a été décrit dans le syndrome de Lynch (SL), dans lequel il existe une mutation germinale d’un des gènes du système MMR (MLH1, MSH2, MSH6 et PMS2). L’intérêt de l’étude des cancers MSI s’est accru de façon considérable avec le développement des immunothérapies dirigées contre les checkpoints immunitaires (ICK), en particulier PD-1/PD-L1. Nous avons confirmé que la fréquence du phénotype MSI se situe entre 1-2%. Nous avons montré que l’immunohistochimie est la méthode de screening plus adaptée pour l’identification de l’ACP MSI en comparaison avec les techniques de biologie moléculaire. Le phénotype MSI a été plus fréquemment observé dans un contexte de TIPMP. Les cas MSI identifiés présentaient des caractéristiques biologiques évocatrices du SL. Egalement, nos résultats confirment la présence d’un processus de carcinogenèse MSI immunogénique, mais suggèrent des évènements somatiques spécifiques à l’organe d’origine du cancer. Par ailleurs, les ACP MSI étaient caractérisés par un infiltrat inflammatoire riche en lymphocytes cytotoxiques T CD8+ et surexprimaient l’ICK PD-L1 permettant de supposer une probable réponse clinique de l’ACP MSI à l’immunothérapie anti-PD1/PD-L1

Anatomo-clinical and phenotypic characterization of pancreatic adenocarcinoma with microsatellite instability

L’adénocarcinome canalaire du pancréas (ACP) est un problème majeur de santé publique. L’ACP se développe principalement à partir de deux lésions précurseurs : les néoplasies intra-épithéliales pancréatiques et les tumeurs intracanalaires papillaires et mucineuses du pancréas (TIPMP). Les mécanismes moléculaires sous-tendant l’oncogenèse pancréatique sont nombreux. Nous avons étudié le mécanisme de cancérogenèse MSI (MicroSatellite Instability) où il existe une déficience dans le système de réparation des erreurs de réplication de l’ADN ou système MMR (Mismatch Repair). Ce mécanisme de cancérogenèse original est caractérisé par une instabilité génétique de l’ADN affectant les séquences répétées microsatellites du génome. Le phénotype MSI a été décrit dans le syndrome de Lynch (SL), dans lequel il existe une mutation germinale d’un des gènes du système MMR (MLH1, MSH2, MSH6 et PMS2). L’intérêt de l’étude des cancers MSI s’est accru de façon considérable avec le développement des immunothérapies dirigées contre les checkpoints immunitaires (ICK), en particulier PD-1/PD-L1. Nous avons confirmé que la fréquence du phénotype MSI se situe entre 1-2%. Nous avons montré que l’immunohistochimie est la méthode de screening plus adaptée pour l’identification de l’ACP MSI en comparaison avec les techniques de biologie moléculaire. Le phénotype MSI a été plus fréquemment observé dans un contexte de TIPMP. Les cas MSI identifiés présentaient des caractéristiques biologiques évocatrices du SL. Egalement, nos résultats confirment la présence d’un processus de carcinogenèse MSI immunogénique, mais suggèrent des évènements somatiques spécifiques à l’organe d’origine du cancer. Par ailleurs, les ACP MSI étaient caractérisés par un infiltrat inflammatoire riche en lymphocytes cytotoxiques T CD8+ et surexprimaient l’ICK PD-L1 permettant de supposer une probable réponse clinique de l’ACP MSI à l’immunothérapie anti-PD1/PD-L1.Pancreatic ductal adenocarcinoma (PDAC) is a major health problem in France and around the world. PDAC is developed mainly from two precursor lesions: pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasm (IPMN). There are several molecular mechanisms underlying pancreatic oncogenesis. Particularly, we were interested in the MSI (MicroSatellite Instability) which is due to a defective DNA Mismatch Repair (MMR) system, which normally functions to recognize and repair erroneous insertions, deletions, and mis-incorporation of bases that can arise during DNA replication and recombination. The MSI phenotype was first described in the familial cancer condition known as Lynch syndrome (LS), where the MMR genes MLH1, MSH2, MSH6 or PMS2 harbor germline mutations. Interest in MSI tumors has recently increased after studies have highlighted the concomitant expression of multiple active immune checkpoint (ICK) markers including PD-1 and PD-L1 and the role of the MSI status to predict clinical benefit from immune checkpoint blockade. A Our results indicate that the MSI phenotype occurs in PDAC with a frequency of 1-2%. Our data showed that IHC using antibodies against the four MMR proteins was more sensitive for the assessment of MSI status than PCR-based methods. In addition, we demonstrate for the first time a statistically significant positive association between MSI and IPMNs in PDAC. MSI PDAC, including IPMN, are unlikely to be sporadic since they display molecular features that are usually observed in LS-related neoplasms. Also, our results highlight that an MSI-driven immunogenic pathway to cancer is active in MSI PDACs but suggest that MSI-driven somatic events may be tissue-specific. We observed a stronger lymphocytic tumor infiltration by activated TCD8 cells in MSI PDAC compared to MSS PDAC and found a positive association between PD-L1 expression and MSI status, suggesting that MSI PDAC could be responsive to ICK blockade therapy

Colorectal cancer liver metastasis: clinical impact of the mechanisms of intrahepatic tumor dissemination and the presence of mucin in surgically resected patients

INTRODUÇÃO: A ressecção de metástases hepáticas (MH) do câncer colorretal (CCR) é considerada segura e potencialmente curativa. Apesar dos avanços no diagnóstico e nas estratégias cirúrgicas até 70% dos pacientes operados vão apresentar recidiva. Os critérios prognósticos clínico-patológicos disponíveis são insuficientes e a utilidade de modelos prognósticos é considerada inconsistente. Deste modo, torna-se necessário o desenvolvimento de novos critérios que se apoiam em outras variáveis biológicas. A disseminação intra-hepática de metástases de câncer colorretal pode ocorrer através de diferentes vias: linfática, sanguínea (vasos portais), através dos sinusóides ou de ductos biliares. Embora estas vias tenham sido bem descritas, o valor prognóstico de cada uma após a ressecção hepática não está completamente definido. O adenocarcinoma colorretal mucinoso (ACM) é um subtipo de carcinoma colorretal com importante produção mucina, e que está associado clinicamente a tumores proximais, estágio avançado no momento do diagnóstico, instabilidade de microssatélites e mutação do gene BRAF. Há controvérsias sobre o impacto prognóstico da histologia mucinosa nos tumores colorretais primitivos e o seu papel nas lesões metastáticas hepáticas permanece desconhecido. O objetivo do nosso estudo foi determinar a frequência e elucidar o impacto prognóstico de quatro vias diferentes de disseminação intra-hepática assim como da histologia mucinosa em uma série consecutiva de pacientes operados por MH de CCR. PACIENTES E MÉTODOS: Os prontuários de 132 pacientes submetidos à ressecção cirúrgica de MH de CCR entre dezembro de 1999 e janeiro de 2010 foram revisados. Os pacientes que faleceram por complicações pós-operatórias (n= 3), aqueles com ressecções incompletas (R2; n= 2), ou nos quais não havia material disponível para o estudo (n= 14) foram excluídos. Os 113 pacientes restantes tiveram suas variáveis clínico-patológicas e resultados (recidiva e sobrevida) avaliados. Os espécimes cirúrgicos foram submetidos à avaliação histológica de rotina e agrupados de acordo com o conteúdo mucinoso da maior lesão hepática da seguinte forma: ACM >50 %; adenocarcinoma mucinoso intermediário (AIM) com componente mucinoso 50% (ACM) estão associadas a um pior prognóstico quando comparadas às lesões sem componente mucinoso (NMA). A presença de mucina pode, em um futuro próximo, influenciar a estratégia terapêutica e deve se tornar um ponto importante para discussão e investigação futurasBACKGROUND: Resection of colorectal cancer liver metastases (CRCLM) is generally accepted as a safe and potentially curative treatment. Despite advances in diagnosis and surgical strategies, up to 70% of patients will present recurrence of the disease after resection of CRCLM. Clinicopathological prognostic factors are inadequate to determine disease prognosis and the utility of prognostic models on general population is considered highly inconsistent. Herein, future attempts to develop prognostic scores may include additional biologic variables. Intrahepatic spread from CRLM may take place through four different routes: lymphatic vessels, portal vessels, sinusoids and biliary ducts. Although these routes have been well described, their prognostic value after hepatectomy is not completely understood. Colorectal mucinous adenocarcinoma (MAC) is a subtype of colorectal adenocarcinoma with prominent mucin production associated with tumor proximal location, advanced stage at diagnosis, microsatellite instability, and BRAF mutation. There are controversies about the prognostic impact of mucinous histology on colorectal cancer and the prognostic implication of MAC in CRCLM is unknown. The purpose of our study was to determine the frequency and elucidate the prognostic implication of four different routes for intrahepatic dissemination and the mucinous histology in a consecutive series of resected CRCLM. METHODS: Medical records of 132 patients who underwent a first resection of CRCLM between December 1999 and January 2010 were reviewed. Patients who died from postoperative complications (n=3), those with incomplete resections (R2; n=2), or no available tissue for the study (n=14) were excluded. The remaining 113 patients had their clinicopathologic variables and outcome parameters evaluated. Resected specimens were submitted to routine histological evaluation and were grouped according to metastasis mucinous content: > 50%, MAC; < 50%, adenocarcinoma with intermediated mucinous component (AIM); and without any mucinous component, non-MAC (NMA). Intrahepatic dissemination was analyzed by H&E and immunohistochemical staining with D2-40 (lymphatic vessels), CD34 (blood vessels), CK-7 (biliary epithelium), and CK-20 (CRC cells). RESULTS: Mean follow-up after resection was 37 months. Tumor recurrence was observed in 76 patients, with a median interval of 13 months after resection. Overall survival and disease-free survival (DFS) rates after hepatectomy were 62 and 56%, and 26 and 24% at 3 and 5 years, respectively. Intrahepatic spread was classified into discreet categories that were evaluated separately: invasion of the portal vein, sinusoids, bile duct, and lymphatic/perineural space. Intrahepatic microscopic invasion included portal vein in 49 patients, sinusoidal in 43 patients, biliary in 20 patients, and lymphatic in 33 patients. Intra-hepatic lymphatic invasion was the only route of dissemination independently associated with the risk of hepatic recurrence (OR=2.75) and shorter DFS (P= 0.006). All tumor foci of intrahepatic lymphatic invasion were detected within 2mm away from tumor edge. Tumors with mucinous component (AIM and MAC) were related to proximal location of the primary tumor and were more frequently observed in females. Multivariate analysis revealed that MAC was an independent negative prognostic factor (hazard ratio= 3.13; 95% CI, 1.30-6.68; P= 0.011) compared with non-MAC (NMA and AIM). CONCLUSION: Intrahepatic lymphatic invasion is a significant prognostic factor. Other mechanisms of invasion, although frequently observed, are not related to disease recurrence or survival, suggesting that the lymphatic system is the main route for dissemination of CRCLM. Furthermore, immunohistochemical detection of intrahepatic lymphatic invasion might be of value in clinical practice. MAC has an adverse prognostic impact compared with NMA, which may influence therapeutic strategy raising an important subject for discussion and future investigatio

Telescopic straight ileo-anal anastomosis in dogs Anastomose íleo-anal direta por telescopagem em cães

PURPOSE: To study outcomes and functional results of a telescopic straight ileo-anal anastomosis. METHODS: Thirty-six mongrel dogs were submitted to total proctocolectomy and telescopic straight ileo-anal anastomosis (ileal mucosa-submucosa pulled-through the rectal cuff). They were divided in 3 groups, sacrificed after one, two or eight weeks after the initial procedure. Gross and microscopic (degree of cooptation and signs of ischemia) aspects of the anastomosis, as well, the aspect of defecation were analyzed. RESULTS: On microscopy all anastomosis analysed showed a continuous epithelial line and were considered good. After two-months no signs of ischemia were identified. Defecation aspect has considerably changed during the study, so no dogs presented solid defecation within the first two weeks, whereas 80% of dogs presented solid stools after two months. CONCLUSION: Telescopic ileo-anal anastomosis is a safe alternative and may provide good functional results after some small period of time.<br>OBJETIVO: Estudar os resultados cirúrgicos e funcionais de uma anastomose íleo-anal por telescopagem. MÉTODOS: Trinta e seis cães sem raça definida foram submetidos à procto-colectomia total e anastomose ileo-anal por telescopagem da mucosa-submucosa ao coto retal. Os animais foram divididos em três grupos cujos sacrifícios ocorreram 1, 2 e 8 semanas após o procedimento inicial. O aspecto da anastomose foi analisado no momento do sacrifício e microscopicamente (grau de coaptação e sinais de isquemia), bem como o aspecto da evacuação nos canis de cada cão. RESULTADOS: O estudo microscópico evidenciou continuidade do epitélio em todas as anastomoses. Nos cães sacrificados após dois meses não houve sinais de isquemia nas anastomoses. O aspecto das fezes alterou-se consideravelmente com o tempo, assim, enquanto nenhum cão apresentou fezes sólidas nas primeiras duas semanas, ao término do segundo mês 80% dos cães apresentavam fezes sólidas na maior parte do tempo. CONCLUSÃO: A anastomose íleo-anal por telescopagem é uma alternativa segura e pode assegurar bons resultados funcionais após alguns meses

Diverticulopexia no tratamento do divertículo de Zenker

O divertículo de Zenker é um pseudodivertículo que se origina de um defeito muscular na parede posterior da faringe, na área de transição entre o músculo constritor inferior da faringe e o músculo cricofaringeo. Apesar do avanço das técnicas endoscópicas, o tratamento cirúrgico persiste como o tratamento padrão. Duas técnicas são possíveis: diverticulectomia (ressecção do divertículo) e a diverticulopexia. As vantagens da diverticulopexia estão ligadas à ausência de anastomose esofágica e suas possíveis complicações: fistulas cervicais, mediastinite, estenose esofágica e infecção de ferida. Em ambas as técnicas a secção das fibras musculares do músculo cricofaringeo (ou, esfíncter superior do esôfago) é fundamental. O objetivo do presente artigo é descrever em detalhes a técnica de diverticulopexia junto ao ligamento pré-vertebral associada à miotomia do músculo cricofaríngeo

Laparoscopic peritoneal dialysis catheter insertion

International audienc

Emphysematous cholecystitis Colecistite enfisematosa

BACKGROUND: Emphysematous cholecystitis is life-threatening condition characterized by gas-forming infection of the gallbladder. It is mostly seems in old male patients with systemic, specially diabetes and vascular diseases. CASE REPORT: - A 30-year-old man without previous diseases was admitted because of right upper quadrant pain and nausea. On admission the patient was febrile (38.7o) with normal bilirubin levels. The white blood count was 26700/µl and reactive protein C was 470. Axial sections of single slice computed tomography imaging (section thickness 5 mm), revealed gallbladder wall enhancement after i.v. contrast, as well as dilatation of the gallbladder with intraluminal air. The patient underwent open cholecystectomy. The culture of the bile showed clostridium perfringes. The postoperative course of the patient was uneventful. CONCLUSION: This is a rare form of cholecystitis that carries a high mortality and usually present insidious clinical signs. CT is the most accurate imaging technique. Antibiotic therapy should begin quickly and include coverage of common pathogens, particularly Clostridia. Surgical intervention should take place as early as possible.<br>INTRODUÇÃO: Colecistite enfisematosa é uma condição de risco de vida caracterizada por infecção da vesícula biliar por agentes produtores de gás. Na sua apresentação mais comum atinge preferencialmente homens idosos portadores de doenças sistêmicas em especial diabetes e vasculopatias. RELATO DO CASO: Paciente do sexo masculino, 30 anos de idade e sem co-morbidades que se apresenta ao pronto-socorro com história de dor abdominal em hipocôndrio direito há cinco dias, febre (38,7o) e náuseas. Os exames laboratoriais mostravam leucocitose (26700/µl) e elevação dos marcadores de inflamação (proteína C reativa, PCR 470). A tomografia computadorizada do abdome revelou realce da parede vesicular após injeção de contraste i.v., bem como dilatação da vesícula com a presença de ar intraluminal. O paciente foi submetido à colecistectomia através de incisão subcostal direita. A cultura da bile foi positiva para Clostridium perfringes. A evolução pós-operatória do paciente foi satisfatória. CONCLUSÃO: Esta é uma rara forma de colecistite com alta mortalidade e usualmente se apresenta com sinais clínicos insidiosos.Tomografia computadorizada é a mais acurada forma de diagnóstico de imagem. Antibioticoterapia de largo espectro deve começar rapidamente incluindo proteção à Clostridia. Procedimento cirúrgico deve ser indicado tão cedo quanto possível