CARCINOMA HEPATOCELULAR: MANEJO CIRÚRGICO ATUAL

This review focuses on the surgical management of the hepatocellular carcinoma, an important complication of hepatic cirrhosis. Therefore, hepatic cirrhosis must bethought as a pre-malignant disease. B hepatitis and C chronic hepatitis are also important risk factors. When it reaches around 5 cm of diameter, the regenerative nodule begins to loose differentiation and to invade vessels. Only 15% of the diagnosed hepatocellular carcinomas may be surgically resected with curative criteria. Differential diagnosis with other hepatic tumors is made by ar terial phase of computed tomography. The only potentially curative treatment to hepatocellular carcinoma is surgery. This could be performed by partial hepatic resection or total hepatic resection followed by hepatic transplantation. Child C cirrhotic patients should not be submitted to a partial hepatic resection. The only available treatment for them is hepatic transplantation. Presently, cirrhotic patients with hepatocellular carcinoma could be submitted to liver transplantation only if they have a single nodule of less than 5 cm of diameter or if they have up to three nodules of less than 3 cm of diameter each. The 5-year survival period of patients that underwent a liver transplantation may be as high as 70%.Esta é uma revisão sobre o manejo cirúrgico do carcinoma hepatocelular, complicação freqüente e importante da cirrose hepática, e que é considerado, atualmente,uma doença pré-maligna. A hepatite B e a hepatite C crônica também são fatores de risco importantes. Com cerca de 5 cm de tamanho, o nódulo regenerativo passa a perder diferenciação e a demonstrar invasão vascular microscópica. Apenas cerca de 15% dos carcinomas hepatocelulares são passíveis de intervenção cirúrgica potencialmente curativa no momento do diagnóstico. O diagnóstico diferencial com outros tumores hepáticos é efetuado através da fase arterial da tomografia computadorizada. O único tratamento potencialmente curativo para carcinoma hepatocelular, atualmente, é a ressecção do tumor, seja esta realizada através de hepatectomia parcial ou de hepatectomia total com transplante hepático. Pacientes portadores de cirrose hepática Child C não devem ser submetidos a ressecção hepática parcial. Para estes, as opções terapêuticas restringem-se apenas ao transplante hepático quando selecionáveis. Atualmente, os pacientes cirróticos portadores de hepatocarcinoma podem ser transplantados desde que tenham lesão única com até 5 cm ou até três lesões de, no máximo, 3 cm cada. A sobrevida em 5 anos para pacientes transplantados pode alcançar 70%

Infecções por Nocardia species: relato de 22 casos

Twenty-two cases of nocardial infections were diagnosed in our city between 1977- 1998. All patients whose clinical specimens showed Nocardia spp. at Gram stain, which were further confirmed by culture, were selected to be included in the study. Data from patients who were cured were compared with those from patients who died by statistical tests using EPIINFO version 6.04 software. Six isolates were identified as Nocardia asteroides complex, one as Nocardia asteroides sensu stricto and other as Nocardia brasiliensis. We had 17 cases of lung nocardiosis, being one out of them also a systemic disease. Other four cases of systemic nocardiosis were diagnosed: nocardial brain abscesses (one); nocardiosis of the jejunum (one); multiple cutaneous abscesses (one); and a case of infective nocardial endocarditis of prosthetic aortic valve. One patient had a mycetoma by N. brasiliensis. Fifteen (68.2%) out of 22 patients were immunosuppressed, being most (93.3%) by high-doses corticotherapy. Mortality by nocardial infection was 41%; mortality of systemic nocardiosis was 60%. Nocardiosis has a bad prognosis in immunosuppressed patients and also in non-immunosuppressed patients if the diagnosis is delayed. We propose that the delay in diagnosis should be examined in larger series to document its influence in the prognosis of the disease.São apresentados 22 casos de infecção por Nocardia species entre 1977 e 1998, apresentando-se seu quadro clínico e evolução. Todos os pacientes cujos espécimes clínicos mostraram microorganismos sugestivos de Nocardia spp. à coloração de Gram, confirmados posteriormente por cultura, foram incluídos no estudo. Os dados dos pacientes que obtiveram cura foram comparados com aqueles dos pacientes que foram a óbito pelo programa EPIINFO versão 6.04; nível de significância menor que 5% foi considerado estatisticamente significativo. Foram obtidos 22 casos de infecção por Nocardia spp.: seis isolamentos identificados como Nocardia asteroides complex, um como Nocardia asteroides sensu stricto e outro como Nocardia brasiliensis, enquanto os restantes foram identificados como Nocardia spp. Tivemos 17 casos de nocardiose pulmonar (um com disseminação). Tivemos outros quatro casos de nocardiose sistêmica: múltiplos abscessos cerebrais (um); endocardite infecciosa de prótese valvular aórtica (um); nocardiose de intestino delgado (um); abscessos cutâneos múltiplos por Nocardia spp (um). Um paciente apresentou micetoma por Nocardia brasiliensis. Imunossupressão esteve presente em 15 pacientes (68,2%), predominantemente por corticoterapia (93,3%). Nossa mortalidade foi 41%; a mortalidade dos pacientes com nocardiose sistêmica foi de 60%. A nocardiose tem pior prognóstico em pacientes imunossuprimidos e em pacientes com nocardiose sistêmica

Severity of Ascites Is Associated with Increased Mortality in Patients with Cirrhosis Secondary to Biliary Atresia

Very few prior studies have investigated the presence of ascites as a prognostic factor in children with cirrhosis. To the best of our knowledge, there are no prior studies evaluating the relationship between severity of ascites and patient survival in children with biliary atresia and cirrhosis.Clinically detectable ascites is associated with decreased 1-year survival of children with biliary atresia. These patients should be treated with caution and prioritized for liver transplantation.Background Very few prior studies have investigated the presence of ascites as a prognostic factor in children with cirrhosis. To the best of our knowledge, there are no prior studies evaluating the relationship between severity of ascites and patient survival in children with biliary atresia and cirrhosis. Aims To evaluate the association between severity of ascites and survival of children with cirrhosis and biliary atresia. Methods All children with cirrhosis secondary to biliary atresia evaluated at our institution from 2000 to 2014 were included in this study. Patients were classified into four groups: NA = no ascites; A1 = grade 1 ascites; A2 = grade 2 ascites; and A3 = grade 3 ascites. The primary endpoint of the study was mortality within the first year after patient inclusion. Ninetyday mortality was also evaluated. Prognostic factors related to both endpoints also were studied. [...]info:eu-repo/semantics/publishedVersio

Transarterial Embolization and Percutaneous Ethanol Injection as an Effective Bridge Therapy before Liver Transplantation for Hepatitis C-Related Hepatocellular Carcinoma

Background. Transarterial chemoembolization alone or in association with radiofrequency ablation is an effective bridging strategy for patients with hepatocellular carcinoma awaiting for a liver transplant. However, cost of this therapy may limit its utilization. This study was designed to evaluate the outcomes of a protocol involving transarterial embolization, percutaneous ethanol injection, or both methods for bridging hepatocellular carcinomas prior to liver transplantation. Methods. Retrospective review of all consecutive adult patients who underwent a first liver transplant as a treatment to hepatitis C-related hepatocellular carcinoma at our institution between 2002 and 2012. Primary endpoint was patient survival. Secondary endpoint was complete tumor necrosis. Results. Forty patients were analyzed, age 58 ± 7 years. There were 23 males (57.5%). Thirty-six (90%) out of the total 40 patients were within Milan criteria. Complete necrosis was achieved in 19 patients (47.5%). One-, 3-, and 5-year patient survival were, respectively, 87.5%, 75%, and 69.4%. Univariate analysis did not reveal any variable to impact on overall patient survival. Conclusions. Transarterial embolization, ethanol injection, or the association of both methods followed by liver transplantation comprises effective treatment strategy for hepatitis C-related hepatocellular carcinoma. This strategy should be adopted whenever transarterial chemoembolization and/or radiofrequency ablation are not available options

Community-acquired pneumonia by Legionella pneumophila serogroups 1–6 in Brazil

SummaryA prospective cohort study of adult patients hospitalized due to community-acquired pneumonia was carried out for 1 year in a Brazilian university general hospital to detect the incidence of community-acquired pneumonia by Legionella pneumophila serogroups 1–6. During a whole year, a total of 645 consecutive patients who were hospitalized due to a initial presumptive diagnosis of respiratory disease by ICD-10 (J00–J99), excluding upper respiratory diseases, were screened to detect the patients with community-acquired pneumonia. Fifty-nine consecutive patients hospitalized due to community-acquired pneumonia between July 19, 2000 and July 18, 2001, were included in the study. They had determinations of serum antibodies to L. pneumophila serogroups 1–6 by indirect immunofluorescence antibody test at the Infectious Diseases Laboratory of University of Louisville (KY, USA) and urinary antigen tests for L. pneumophila serogroup 1. Three patients had community-acquired pneumonia by L. pneumophila serogroups 1–6, two patients being diagnosed by seroconversion and positive urinary antigen tests; the other had negative serologies but strongly positive urinary antigen test. The incidence of community-acquired pneumonia by L. pneumophila serogroups 1–6 in our hospital was 5.1%

COMPARAÇÃO MICROBIOLÓGICA ENTRE MEMBRANAS AMNIÓTICAS HUMANAS COLETADAS EM PARTOS VAGINAIS E CESARIANAS – PROJETO PILOTO

Objective: The amniotic membrane, a thin membrane, may be used as a temporary cover on deep burns. The objective of this study is to identify the differences regarding bacterial contamination between membranes of vaginal and cesarean deliveries, as well as to assess the possibility of the clinical use of stored membranes.Methods: Twelve membranes were obtained from women submitted to vaginal and cesarean deliveries at the Obstetric Center of Hospital de Clínicas de Porto Alegre. Each amniotic membrane was stored in five different flasks containing a physiological solution. Samples were obtained from these flasks for analysis on days 1, 7, 14, 21 and 28. These samples were tested for bacterial contamination, analyzing its relation to time of storage and type of delivery. This is a pilot study with a transversal design.Results: The comparison between types of delivery yielded a relative risk of contamination in vaginal delivery (RR) of 2.67 (95% CI: 1.09-6.52) and no significance (P = 0.08). No contamination was found on day 1 flasks.Conclusion: All membranes derived from vaginal deliveries ended up showing bacterial contamination during the storage period, which lead to a theoretical unavailability for its use on Amniotic Membrane Banks.Objetivo: A membrana amniótica, uma membrana fina, pode ser utilizada como cobertura temporária em queimaduras profundas. O objetivo deste estudo é o de verificar as possíveis diferenças quanto à contaminação bacteriana entre as membranas de partos cesáreo e vaginal, assim como avaliar a viabilidade ou não do uso clínico-cirúrgico da membrana armazenada.Métodos: Foram coletadas 12 membranas amnióticas de mulheres submetidas a parto cesáreo e vaginal no Centro Obstétrico do HCPA. Cada membrana amniótica foi armazenada em cinco frascos diferentes contendo soro fisiológico, dos quais foram obtidas amostras para análise no momento da coleta e nos dias 7, 14, 21 e 28. Essas amostras foram testadas quanto à contaminação bacteriana, analisando sua relação com o tempo de armazenamento e com o tipo de parto realizado. O estudo é um piloto e tem um delineamento transversal. Resultados: A comparação entre os tipos de parto mostrou um risco relativo (RR) de 2,67 de contaminação no parto vaginal em relação à cesariana (IC de 95%: 1,09 a 6,52), P = 0,08. Não foi verificada contaminação em nenhum dos frascos no momento da coleta. Conclusão: Todas as membranas coletadas de parto vaginal apresentaram crescimento bacteriano no processo de estocagem, levando à sua inviabilidade teórica para uso em Bancos de Membrana Amniótica

CARCINOMA HEPATOCELULAR: MANEJO CIRÚRGICO ATUAL

This review focuses on the surgical management of the hepatocellular carcinoma, an important complication of hepatic cirrhosis. Therefore, hepatic cirrhosis must bethought as a pre-malignant disease. B hepatitis and C chronic hepatitis are also important risk factors. When it reaches around 5 cm of diameter, the regenerative nodule begins to loose differentiation and to invade vessels. Only 15% of the diagnosed hepatocellular carcinomas may be surgically resected with curative criteria. Differential diagnosis with other hepatic tumors is made by ar terial phase of computed tomography. The only potentially curative treatment to hepatocellular carcinoma is surgery. This could be performed by partial hepatic resection or total hepatic resection followed by hepatic transplantation. Child C cirrhotic patients should not be submitted to a partial hepatic resection. The only available treatment for them is hepatic transplantation. Presently, cirrhotic patients with hepatocellular carcinoma could be submitted to liver transplantation only if they have a single nodule of less than 5 cm of diameter or if they have up to three nodules of less than 3 cm of diameter each. The 5-year survival period of patients that underwent a liver transplantation may be as high as 70%.Esta é uma revisão sobre o manejo cirúrgico do carcinoma hepatocelular, complicação freqüente e importante da cirrose hepática, e que é considerado, atualmente,uma doença pré-maligna. A hepatite B e a hepatite C crônica também são fatores de risco importantes. Com cerca de 5 cm de tamanho, o nódulo regenerativo passa a perder diferenciação e a demonstrar invasão vascular microscópica. Apenas cerca de 15% dos carcinomas hepatocelulares são passíveis de intervenção cirúrgica potencialmente curativa no momento do diagnóstico. O diagnóstico diferencial com outros tumores hepáticos é efetuado através da fase arterial da tomografia computadorizada. O único tratamento potencialmente curativo para carcinoma hepatocelular, atualmente, é a ressecção do tumor, seja esta realizada através de hepatectomia parcial ou de hepatectomia total com transplante hepático. Pacientes portadores de cirrose hepática Child C não devem ser submetidos a ressecção hepática parcial. Para estes, as opções terapêuticas restringem-se apenas ao transplante hepático quando selecionáveis. Atualmente, os pacientes cirróticos portadores de hepatocarcinoma podem ser transplantados desde que tenham lesão única com até 5 cm ou até três lesões de, no máximo, 3 cm cada. A sobrevida em 5 anos para pacientes transplantados pode alcançar 70%