Hepatite fulminante: estudo dos fatores associados à mortalidade hospitalar de 100 pacientes priorizados para transplante de fígado

Introdução. A despeito dos avanços nos cuidados de terapia intensiva e no transplante de fígado (TF), a hepatite fulminante (HF) ainda hoje apresenta alta taxa de mortalidade. A identificação de fatores prognósticos de maior acurácia deve ajudar a otimizar a priorização dos pacientes em lista de espera para o TF. Objetivo. Avaliar fatores prognósticos de mortalidade hospitalar dos pacientes com HF priorizados para TF. Métodos. Foram estudados retrospectivamente 100 pacientes adultos (78 mulheres, idade média 35,5 ± 14,7 anos) com HF priorizados para TF, em um único centro, de fevereiro de 2002 a junho de 2011. O diagnóstico etiológico foi hepatite viral em 17% dos casos, medicamentosa em 29%, autoimune em 13%, criptogênica em 34% e outras causas em 7%. A indicação do TF foi determinada de acordo com os critérios de O’Grady. Foram avaliados: idade, sexo, etiologia, intervalo icterícia/encefalopatia, intervalo entre a priorização e o TF, grau de encefalopatia, tempo de internação, RNI, fator V, bilirrubina, creatinina, AST, ALT, lactato e Model for End-Stage Liver Disease (MELD). Todos os dados foram coletados do dia da priorização. Resultados. O intervalo entre a priorização e o TF foi de 1,5 dias (0 a 9) e o tempo de internação foi de 18 ± 27 dias. A mortalidade hospitalar foi de 69%. Os pacientes não sobreviventes apresentaram na priorização maior grau de encefalopatia [3 (1 a 4) vs. 2 (1 a 4)], MELD (41 ± 9 vs. 38 ± 7) e lactato (62,2 ± 45,2 vs. 33,9 ± 16,0 mg/dL) quando comparados com os sobreviventes (p<0,05). Dos 100 pacientes, 69% foram submetidos ao TF, os outros 31% morreram antes do TF. Os pacientes não transplantados apresentaram maior grau de encefalopatia [4 (1 a 4) vs. 3 (1 a 4)], MELD (44 ± 8 vs. 38 ± 8), lactato (78,4 ± 48,3 vs. 41,8 ± 30,6 mg/dL) e creatinina (2,60 ± 2,34 vs. 1,55 ± 1,54 mg/dL) quando comparados aos pacientes submetidos ao TF (p<0.05). Conclusão. No momento da priorização para o TF, os pacientes com HF que apresentam condição clínica mais grave, com encefalopatia graus 3 ou 4, insuficiência renal, escores mais elevados de MELD e lactato elevado, têm maior taxa de mortalidade hospitalar mesmo quando submetidos ao TF, indicando pior prognóstico

Laparoscopic Enucleation of Liver Tumors. Corkscrew Technique Revisited

Background: Enucleation of small lesions located near the hepatic surface can be achieved with low morbidity and mortality. This article describes a simple laparoscopic technique for enucleation of liver tumors. Methods: After inspection and intraoperative ultrasonography, Glisson`s capsule is marked with eletrocautery 2 cm away from the tumor margin. Ultrasonography is used to ascertain surgical margin right before liver transection. Hemihepatic ischemia is applied and marked area is anchored by stitches. The suture is held together by metallic clips and upward traction is performed, facilitating the transection of the parenchyma and correct identification of vascular and biliary structures. Results: This technique has been successfully employed in six consecutive patients. There were four men and two women, mean age 50.3 years. Four patients underwent liver resection for malignant disease and two for benign liver neoplasm. Pathologic surgical margins were free in all cases and mean hospital stay was 2 days. No postoperative mortality was observed. Conclusion: This technique may facilitate laparoscopic nonanatomical liver resection and reduce risk of positive surgical margins. It is also useful in combination with anatomical laparoscopic liver resections such as right or left hemihepatectomies in patients with bilateral liver tumors as occurred in one of our patients

First robotic-assisted laparoscopic liver resection in Latin America

Graças ao melhor conhecimento da anatomia segmentar do fígado e desenvolvimento de novas técnicas, houve aumento no número de indicações de hepatectomias. O desenvolvimento da cirurgia minimamente invasiva ocorreu paralelamente e o aumento da experiência, aliado ao desenvolvimento de novos instrumentais, resultaram no crescimento exponencial das ressecções hepáticas videolaparoscópicas. A abordagem laparoscópica pode tornar viável a ressecção hepática em pacientes cirróticos com hipertensão portal que não tolerariam este mesmo procedimento por via laparotômica. A cirurgia robótica surgiu nos últimos anos como a última fronteira de desenvolvimento técnico aplicado à videocirurgia. O presente trabalho descreve a experiência pioneira de ressecção hepática totalmente com o uso de robótica na América Latina, em paciente com carcinoma hepatocelular e cirrose hepática. A hepatectomia laparoscópica com o uso do sistema robótico Da Vinci permite refinamentos técnicos graças à visualização tridimensional do campo cirúrgico e utilização de instrumentais precisos e com grande amplitude de movimentação que simulam os movimentos da mão humana.The surgical robotic system is superior to traditional laparoscopy in regards to 3-dimensional images and better instrumentations. Robotic surgery for hepatic resection has not yet been extensively reported. The aim of this paper is to report the first known case of liver resection with use of a computer-assisted, or robotic, surgical device in Latin America. A 72-year-old male with cryptogenic liver cirrhosis and hepatocellular carcinoma was referred for surgical treatment. Preoperative clinical evaluation and laboratory data disclosed a Child-Pugh class A patient. Magnetic resonance imaging showed a 2.2 cm tumor in segment 5. Liver size was decreased and there were signs of portal hypertension, such as splenomegaly and enlarged portal vein collaterals. Preoperative upper digestive endoscopy disclosed esophageal varices. Five trocars were used. Liver transection was achieved with harmonic scalpel and bipolar forceps. Hemostasis of raw surface areas was accomplished with interrupted stitches. Operative time was 120 minutes. Blood loss was minimal and the patient did not receive transfusion. The recovery was uneventful and patient was discharged on the 3rd postoperative day without ascites formation. Laparoscopic hepatic resection can safely be performed. The laparoscopic approach may enable liver resection in patients with cirrhosis and evidence of liver failure that would contraindicate open surgery probably because it precludes the transection of major abdominal collaterals. The Da Vinci robotic system allowed for technical refinements of laparoscopic liver resection due to 3-dimensional visualization of the operative field and instruments with wrist-type end-effectors

Hepatectomia direita por videolaparoscopia

The first application of laparoscopic liver surgery consisted of wedge liver biopsies or resection of peripheral lesions, mostly benign. More recently, reports of anatomic left and right hepatectomy have been seen in the literature. Expertise in some centers has evolved to such an extent that even living related donor hepatectomy has been performed. The aim of this paper is to report a laparoscopic right hepatectomy and describe in detail the surgical technique employed. To our knowledge this is the first case performed in Brazil totally laparoscopically. The surgery followed four distinct phases: complete mobilization of the liver; hilum dissection with encircling of right portal vein and right hepatic artery, caval dissection using linear vascular stapler to divide right hepatic vein and parenchymal transection with harmonic shears and firings of linear staplers are used to divide segmental 5 and 8 branches of middle hepatic vein. The liver specimen was removed by Pfannenstiel incision. Intraoperative blood loss was estimated in 120 ml with no need for blood transfusion. Hospital stay was 5 days. Laparoscopic right hepatectomy is feasible, technically demanding but can be safely accomplished by surgeons who have experience in advanced laparoscopic procedures and open hepatic surgery. In Brazil laparoscopic liver surgery is still in its first years and there is a lack of technical description of this complex procedure