Eventos Tromboembólicos Em Cirurgia Bariátrica

 Background: The escalating prevalence of obesity demands an effective but also safe approach of the patients. The physician has the challenging task of selecting the most adequate approach for each patient. Bariatric surgery is the treatment with the highest success rate in severe cases of obesity. However, like every surgical procedure, is not risk-free and complications often occur, such as venous thromboembolism. Thromboembolic events, such as deep vein thrombosis and pulmonary embolism, contribute to the increase of morbimortality rate. In furtherance of preventing this deadly complication, it is imperative to establish an optimal prophylactic plan. Nonetheless, this preventive approach remains debatable. This review aims to analyse the previous literature to identify the risk factors for venous thromboembolic events, determine the clinical approach according to the risk and establish the ideal prophylaxis protocol after bariatric surgery. Methods: A literature search was performed in PubMed, with “bariatric surgery”, “thromboembolism” and “thrombosis” as search terms. Then, exclusion and inclusion criteria were applied for the final selection of studies. Results: The most significant risk factors for venous thromboembolism are high body mass index, previous history of venous thromboembolism, presence of congestive heart failure, laparoscopic Roux-en-Y gastric bypass operation, a long operative time and receiving a transfusion. Using a risk calculator, it is possible to sum up all the risks for each individual and attribute a score. With the thromboembolic risk score and the haemorrhagic risk, it is possible to determine the most appropriate prophylactic plan for each patient. Risk calculators specific for bariatric surgery are not yet validated. Regarding prophylactic approaches, preoperative assessment with duplex ultrasound should only be performed in high-risk patients. Early ambulation and the use of mechanical prophylaxis (use of compression stockings and/or intermittent pneumatic compression) are recommended in all patients. Pharmacological prophylaxis is recommended for all patients in whom the bleeding risk does not exceed the risk of thromboembolism. The dose of pharmacological prophylaxis, its initiation and duration are topics of controversy. The use of inferior vena cava filters should be evaluated on a case-by-case basis, in patients with high thromboembolic risk. In the long term, there is a decrease in the risk of thromboembolism that compensates for the surgical intervention and the short-term risk. Conclusion: The patient’s approach should be based on the set of individual risk factors. The recommended prophylaxis for all patients includes early ambulation and mechanical prophylaxis. Depending on the patient’s risk, pharmacological prophylaxis, the use of inferior vena cava filters and preoperative assessment with duplex ultrasound may be considered. Introdução: A crescente prevalência da obesidade exige uma abordagem eficaz, mas simultaneamente segura dos doentes. O médico tem a incumbência desafiante de eleger a abordagem mais adequada para cada doente. A cirurgia bariátrica é o tratamento com a maior taxa de sucesso em casos graves de obesidade. No entanto, como qualquer intervenção cirúrgica, não é isenta de riscos e, frequentemente, ocorrem complicações, tais como o tromboembolismo venoso. Os eventos tromboembólicos, tais como a trombose venosa profunda e a embolia pulmonar, contribuem para o aumento da taxa de morbimortalidade. Com o intuito de prevenir esta complicação mortal, é imperativo traçar um plano profilático otimizado. No entanto, esta abordagem de prevenção continua a ser controversa. O objetivo desta revisão consiste em analisar a literatura existente de forma a identificar os fatores de risco para eventos tromboembólicos venosos, determinar a abordagem clínica de acordo com o risco e estabelecer o protocolo de profilaxia ideal após cirurgia bariátrica. Métodos: Procedeu-se a uma pesquisa bibliográfica na PubMed, com “cirurgia bariátrica”, “tromboembolismo” e “trombose” como termos de pesquisa. Subsequentemente, os estudos foram selecionados de acordo com os critérios de exclusão e inclusão para serem revistos. Resultados: Os fatores de risco tromboembólico mais relevantes são o elevado índice de massa corporal, a história prévia de tromboembolismo venoso, a presença de insuficiência cardíaca congestiva, a cirurgia laparoscópica de bypass gástrico em Y de Roux, o tempo cirúrgico prolongado e a necessidade de transfusão. Utilizando uma calculadora de risco é possível fazer a soma de todos os riscos de cada indivíduo e atribuir um score. Com o score de risco tromboembólico e com o risco hemorrágico é possível determinar o plano profilático mais adequado para cada doente. As calculadoras de risco especificas para cirurgia bariátrica ainda não estão validadas. Relativamente a abordagens profiláticas, a avaliação pré-operatória com ecografia doppler apenas deve ser realizada em doentes de alto risco. A deambulação precoce e a utilização de profilaxia mecânica (uso de meias elásticas e/ou compressão pneumática intermitente) estão recomendadas em todos os doentes. A profilaxia farmacológica está recomendada para todos os doentes em que o risco hemorrágico não ultrapasse o risco de tromboembolismo. A dose dos fármacos, o início e a duração da profilaxia são temas controversos. O uso de filtros da veia cava inferior deve ser avaliado caso a caso, em doentes de alto risco tromboembólico. A longo prazo, verifica-se uma diminuição do risco de tromboembolismo que compensa a intervenção cirúrgica e o risco a curto prazo. Conclusão: A abordagem do doente deve ter por base o conjunto de fatores de risco individuais. A profilaxia recomendada para todos os doentes passa por deambulação precoce e profilaxia mecânica. Conforme o risco do doente pondera-se a profilaxia farmacológica, o uso de filtros da veia cava inferior e a avaliação pré-operatória com ecografia doppler

Groove Pancreatitis with Biliary and Duodenal Stricture: An Unusual Cause of Obstructive Jaundice

INTRODUCTION: Groove pancreatitis is an uncommon cause of chronic pancreatitis that affects the groove anatomical area between the head of the pancreas, duodenum, and common bile duct. CLINICAL CASE: A 67-year-old man with frequent biliary colic and an alcohol consumption of 30-40 g/day was admitted to the hospital complaining of jaundice and pruritus. Laboratory analysis revealed cholestasis and the ultrasound scan showed intra-hepatic biliary ducts dilatation, middle third cystic dilatation of common bile duct, enlarged Wirsung and pancreatic atrophy. The magnetic resonance cholangiopancreatography showed imaging findings compatible with groove pancreatitis. An esophagogastroduodenoscopy later excluded duodenal neoplasia. He was submitted to a Roux-en-Y cholangiojejunostomy because of common bile duct stricture. Five months later a gastrojejunostomy was performed due to a duodenal stricture. The patient remains asymptomatic during follow-up. DISCUSSION: Groove pancreatitis is a benign cause of obstructive jaundice, whose main differential diagnosis is duodenal or pancreatic neoplasia. When this condition causes duodenal or biliary stricture, surgical treatment can be necessary.info:eu-repo/semantics/publishedVersio

Cholangiocarcinoma: from molecular biology to treatment

Abstract Cholangiocarcinoma is a rare tumor originating in the bile ducts, which, according to their anatomical location, is classified as intrahepatic, extrahepatic and hilar. Nevertheless, incidence rates have increased markedly in recent decades. With respect to tumor biology, several genetic alterations correlated with resistance to chemotherapy and radiotherapy have been identified. Here, we highlight changes in KRAS and TP53 genes that are normally associated with a more aggressive phenotype. Also IL-6 and some proteins of the BCL-2 family appear to be involved in the resistance that the cholangiocarcinoma presents toward conventional therapies. With regard to diagnosis, tumor markers most commonly used are CEA and CA 19-9, and although its use isolated appears controversial, their combined value has been increasingly advocated. In imaging terms, various methods are needed, such as abdominal ultrasound, computed tomography and cholangiopancreatography. Regarding therapy, surgical modalities are the only ones that offer chance of cure; however, due to late diagnosis, most patients cannot take advantage of them. Thus, the majority of patients are directed to other therapeutic modalities like chemotherapy, which, in this context, assumes a purely palliative role. Thus, it becomes urgent to investigate new therapeutic options for this highly aggressive type of tumor

Acção anti-cancerígena da Quercetina no Carcinoma Hepatocelular: o papel do GLUT-1

Hepatocellular Carcinoma (HCC) is one of the most fatal cancers, with rising incidence. Without specific treatment, the prognosis is very poor and diminished survival. The most effective therapy is liver transplantation and complete surgical resection, however, since only 15% of patients are candidates for such therapies, a wide range of patients are subjected to treatment with conventional therapies, and the rate success is greatly diminished. It is thought that the expression of glucose transporter 1 (GLUT-1) may be altered in HCC. A recent study showed that suppression of GLUT-1 expression, using siRNA (small interfering RNA) could significantly reduce tumorigenesis in HCC cell lines, suggesting that GLUT-1 may be a therapeutic target for this highly aggressive tumor. Thus, this project aims to evaluate the anticancer effect of quercetin, a possible inhibitor of GLUT-1, in a human HCC cell line HepG2, as well as check the effect of theis compound on 18F-FDG (a glucose radiolabelled analogue) uptake in this cell line. These results shown that quercetin have anti-proliferative effect on HCC cell line studied. This compound also have shown ability to decrease the 18F-FDG uptake. However, using flow cytometry it was found that HepG2 cells remain viable after treatment with quercetin, and this compound doesn’t inhibit the GLUT-1 protein expression. These results indicate that quercetin inhibits the GLUT-1 function, but doesn’t inhibit the expression of this transporter.Keywords: Quercetin, Hepatocellular Carcinoma, GLUT-1 O Carcinoma Hepatocelular (CHC) é um dos cancros mais letais, com uma crescente incidência em diversas regiões por todo o mundo. Sem tratamento específico, o prognóstico é muito pobre e a sobrevida diminuta. A terapia mais eficaz consiste no transplante hepático e na ressecção cirúrgica, no entanto, e uma vez que apenas 15% dos doentes são candidatos a tratamento cirúrgico, torna-se urgente a procura de novas opções terapêuticas para este tipo de tumor. Alguns estudos demonstraram que a expressão do transportador de glucose-1 (GLUT-1) pode estar alterada neste tipo de tumor. Um estudo recente demonstrou que a supressão da expressão de GLUT-1, recorrendo a siRNA (small interfering RNA) conseguiu reduzir significativamente a tumorigénese em culturas celulares de CHC, sugerindo que o GLUT-1 pode ser um alvo terapêutico para este tipo de tumor altamente agressivo. Assim, o objectivo deste trabalho experimental foi avaliar o efeito anti-cancerígeno da quercetina, um possível inibidor do GLUT-1, numa linha celular humana de CHC (HepG2, ATCC), assim como avaliar o seu efeito na captação de 18F-FDG, um análogo da glucose radiomarcado com Flúor-18. Com os resultados obtidos verificou-se que a quercetina possui a capacidade de inibir a proliferação da linha celular em estudo e, para além disso, parece ter influência na captação de 18F-FDG já que conseguiu diminuir a percentagem de captação do radiofármaco nesta linha celular. No entanto, através da técnica de citometria de fluxo verificou-se que as células permanecem viáveis, e que este composto não inibe a expressão proteica do GLUT-1. Estes resultados indicam que a quercetina inibe este transportador de glucose quanto à função, mas não quanto à expressão. Palavras-chave: Quercetina, Carcinoma Hepatocelular, GLUT-1

Plasmatic Oxidative and Metabonomic Profile of Patients with Different Degrees of Biliary Acute Pancreatitis Severity

Acute pancreatitis (AP) is an inflammatory process of the pancreas with variable involvement of the pancreatic and peripancreatic tissues and remote organ systems. The main goal of this study was to evaluate the inflammatory biomarkers, oxidative stress (OS), and plasma metabolome of patients with different degrees of biliary AP severity to improve its prognosis. Twenty-nine patients with biliary AP and 11 healthy controls were enrolled in this study. We analyzed several inflammatory biomarkers, multifactorial scores, reactive oxygen species (ROS), antioxidants defenses, and the plasma metabolome of biliary AP and healthy controls. Hepcidin (1.00), CRP (0.94), and SIRI (0.87) were the most accurate serological biomarkers of AP severity. OS played a pivotal role in the initial phase of AP, with significant changes in ROS and antioxidant defenses relating to AP severity. Phenylalanine (p < 0.05), threonine (p < 0.05), and lipids (p < 0.01) showed significant changes in AP severity. The role of hepcidin and SIRI were confirmed as new prognostic biomarkers of biliary AP. OS appears to have a role in the onset and progression of the AP process. Overall, this study identified several metabolites that may predict the onset and progression of biliary AP severity, constituting the first metabonomic study in the field of biliary AP

Guideline-directed medical therapy use and decision making in chronic and acute, pre-existing and de novo, heart failure with reduced, mildly reduced, and preserved ejection fraction – the ESC EORP Heart Failure III Registry

Funding Information: This work was supported by the following companies since the start of EORP and for the period of the ESC Heart Failure III study: Abbott Vascular Int. (2018\u20132021), Amgen Cardiovascular (2016\u20132018), AstraZeneca AB (2017\u20132020), Bayer AG (2016\u20132018), Boehringer Ingelheim (2016\u20132019), Bristol Myers Squibb (2017\u20132019), Daichii Sankyo Europe GmbH (2017\u20132020), Edwards Lifesciences (2016\u20132019), Novartis Pharma AG (2018\u20132020), Servier (2015\u20132021), and Vifor (2019\u20132021). Publisher Copyright: © 2024 European Society of Cardiology.Aims: We analysed baseline characteristics and guideline-directed medical therapy (GDMT) use and decisions in the European Society of Cardiology (ESC) Heart Failure (HF) III Registry. Methods and results: Between 1 November 2018 and 31 December 2020, 10 162 patients with acute HF (AHF, 39%, age 70 [62–79], 36% women) or outpatient visit for HF (61%, age 66 [58–75], 33% women), with HF with reduced (HFrEF, 57%), mildly reduced (HFmrEF, 17%) or preserved (HFpEF, 26%) ejection fraction were enrolled from 220 centres in 41 European or ESC-affiliated countries. With AHF, 97% were hospitalized, 2.2% received intravenous treatment in the emergency department, and 0.9% received intravenous treatment in an outpatient clinic. AHF was seen by most by a general cardiologist (51%) and outpatient HF most by a HF specialist (48%). A majority had been hospitalized for HF before, but 26% of AHF and 6.1% of outpatient HF had de novo HF. Baseline use, initiation and discontinuation of GDMT varied according to AHF versus outpatient HF, de novo versus pre-existing HF, and by ejection fraction. After the AHF event or outpatient HF visit, use of any renin–angiotensin system inhibitor, angiotensin receptor–neprilysin inhibitor, beta-blocker, mineralocorticoid receptor antagonist and loop diuretics was 89%, 29%, 92%, 78%, and 85% in HFrEF; 89%, 9.7%, 90%, 64%, and 81% in HFmrEF; and 77%, 3.1%, 80%, 48%, and 80% in HFpEF. Conclusion: Use and initiation of GDMT was high in cardiology centres in Europe, compared to previous reports from cohorts and registries including more primary care and general medicine and regions more local or outside of Europe and ESC-affiliated countries.publishersversionepub_ahead_of_prin

Cinética da regeneração hepática e sua correlação com a função hepática após hepatectomia

Resumo da comunicação apresentado ao XII Congresso Nacional de Medicina Nuclear, 12-14 Novembro 2009, Mealhad

Estudo da cinética da regeneração hepática no homem pós-hepatectomia por métodos radioisotopicos

Resumo da comunicação apresentado ao XII Congresso Nacional de Medicina Nuclear, 12-14 Novembro 2009, Mealhad