CATÁSTROFE DA PAREDE ABDOMINAL, ESTRATÉGIA TERAPÊUTICA – RELATO DE UM CASO CLÍNICO E REVISÃO DA LITERATURA

A complete abdominal wall defect (AWD) is life-threatening, has a functional and cosmetic impact on patients’ quality of life and represents a significant challenge for surgeons, requiring a multidisciplinary treatment strategy. The goals of the reconstructive surgery in the management of these defects are to provide stable coverage of the abdominal contents, restore function and achieve complete wound closure. We present a case that shows that the use of a biological mesh (porcine dermis), negative wound pressure therapy (NPWT) and split skin grafting is suitable to manage such defects when visceral exposure is present. A biological mesh is a good and less aggressive alternative to the use of free flaps, closing the AWD in a tension-free manner in an infected field or in one that is suspected of being infected and it has been shown to be better tolerated than synthetic meshes in open abdomens, with the ability to provide vascular ingrowth and incorporate itself into the native tissue. On the other hand, NPWT showed to provide a firm bandage for the patient and a closed, moist environment, protected from the invasion of bacteria, while eliminating excessive exudation, stimulating angiogenesis and reducing the wound surface area. Um defeito completo da parede abdominal (AWD) ameaça a vida, tem um impacto funcional e cosmético na vida dos doentes e representa um grande desafio para os cirurgiões, exigindo uma estratégia de tratamento multidisciplinar. Os objetivos da cirurgia reconstrutiva no tratamento destes defeitos são fornecer uma cobertura estável do conteúdo abdominal, restaurar a função da parede abdominal e atingir um encerramento completo da ferida. Apresentamos um caso clínico que mostra que o uso de uma prótese biológica (derme suína), terapia de pressão negativa (NPWT) e enxertos cutâneos é adequado para tratar estes defeitos quando o doente tem exposição visceral. O uso de uma prótese biológica é uma alternativa boa e menos agressiva em comparação com o uso de retalhos livres, encerrando o AWD sem tensão num terreno infetado, e mostrou ser melhor tolerado do que o uso de próteses sintéticas num abdómen aberto, com a capacidade de fornecer um meio para crescimento vascular e de se incorporar aos tecidos do doente. Por outro lado, a NPWT mostrou fornecer um ambiente firme, fechado e húmido, protegido da invasão de bactérias, ao mesmo tempo que elimina a exsudação excessiva, estimula a angiogénese e reduz a área de superfície da ferida.&nbsp

Approach to synchronous liver metastases from colorectal carcinoma - results from a Portuguese reference center

About 15%-25% of patients with colorectal cancer, have synchronous liver metastases. The best surgical approach for the patients with asymptomatic primary colorectal tumor and synchronous liver metastases is still the subject of much debate. We aimed to evaluate the perioperative and long-term results as well as to identify possible prognostic factors of the two strategies:  liver- first and synchronous resection. Observational, retrospective study, which included patients with synchronous liver metastases from colorectal cancer, who underwent liver surgery between January 2016 and December 2021, in a Portuguese reference center. Patients were divided into two groups according to the therapeutic approach (synchronous resections vs Liver First) and into three groups according to the hepatic tumor burden (single liver lesion versus more than three liver lesions versus bilobar lesions). To determine the overall and disease-free survival, Kaplan-Meier curves and the log-rank test were performed and, to identify factors with an impact on the prognosis, a univariate and multivariate analysis were performed with the application of Cox regression (significance of 5%). Among the 46 patients included, 54,4% underwent the liver-first approach and 21 patients (45.7%) underwent simultaneous resection. The liver-first group had a greater number of patients with primary rectal tumor (84% vs.14.3%; p<0.001), with more than 3 hepatic lesions (56% vs.14%; p=0.004) and with more extensive hepatic resection. As for postoperative morbimortality, no statistically significant difference was observed between the two approaches (p=0.514). The median overall survival was similar even when considering the hepatic tumor burden (35.0 months (95%CI 15.91- 54.09) in the liver-first group vs. 48.0 months (95%CI 21.69-74.96) in the synchronous resection group; p=0.145). The same was observed for the median disease-free survival (16.0 months (95% CI 0-32.7) vs. 23.0 months (95% CI 16.3-29.7) p=0.651, respectively). The two strategies showed similar morbidity. No statistically significant difference was observed with regard to overall and disease-free survival even when the hepatic tumor burden was considered. One-year and three-year survival were also similar. However, it should be stressed that, the choice of the surgical approach for each group did not took into account the hepatic tumor burden, which we believe it is essential in choosing the best surgical approach.The existence of a multidisciplinary team is fundamental for the therapeutic success of these patients

Portal venous pressure variation during hepatectomy: a prospective study

Excessive portal venous pressure in the liver remnant is an independent factor in the occurrence of posthepatectomy liver failure and small-for-size syndrome. The baseline portal pressure prior to hepatectomy was not considered previously. The aim of this study is to assess the impact of portal pressure change during hepatectomy on the patient outcome.info:eu-repo/semantics/publishedVersio

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

De novo colorectal cancer after liver and kidney transplantation–Microenvironment disturbance

Colorectal cancer (CRC) is a major health burden and may arise as a complication of solid organ transplantation. Our study aimed to assess the incidence of the CRC in kidney and liver transplanted patients at a tertiary and reference center and to describe their clinical and pathological features. Twelve patients, 10 men and two women, with a mean age of 60 years, composed our cohort, ten of them submitted to CRC resection. Transplanted organ was liver in five patients and kidney in seven. Regarding overall survival, patients submitted to renal transplantation were all deceased 5 years after CRC diagnosis, while those subjected to hepatic transplantation had a survival of 60% at the fifth year. Pathology examination showed seven patients with advanced disease (stage III/IV) and high amount of necrosis. Tumor microenvironment was disturbed, with low inflammatory infiltrate, absence of natural killer cells and no PD-L1 expression. CRC exhibited microsatellite instability in 40%, with expression of cancer stem cell markers (CD133, CD44 and ALDH1), as well as P53 (50%) and KRAS mutations (41.7%). CRC cancer after kidney and hepatic transplantation is a rare, but aggressive and deadly event. Regular follow-up should be instituted in these patients

Liver Metastases and Histological Growth Patterns: Biological Behavior and Potential Clinical Implications-Another Path to Individualized Medicine?

Colorectal cancer is a major health burden and despite the recent advances in healthcare and screening programs, a great percentage of patients already present metastases once their disease is found. In those cases, liver surgery has an essential role, but even with neoadjuvant chemotherapy there is a high rate of intrahepatic recurrence. New prognostic factors are needed in order to decide the best surgical approach considering the biological behavior of the tumors in order to tailor the used therapies, moving towards individualized medicine/treatment. However, the majority of the factors described in literature are expensive, time consuming, and difficult to apply on a daily basis. Histological growth patterns have emerged over the past few years as a reproducible characteristic, an easy to apply one, and with very low costs since it only needs the standard Haematoxylin and Eosin stained slides of observation. In this article, we provide a review of the histological growth patterns of liver metastases and their prognostic significance, biological meaning, and therapeutic importance

ASSOCIAÇÃO DA PARTIÇÃO HEPÁTICA À LAQUEAÇÃO DA VEIA PORTA NO TRATAMENTO DE METÁSTASES HEPÁTICAS POR CANCRO COLORECTAL: REVISÃO DO TEMA E RESULTADOS DE UM CENTRO

The associating liver partitioning and portal vein ligation for staged hepatectomy has gained interest in the treatment of unresectable colorectal liver metastases as it has allowed to expand the limits of oncological resectability. Despite the initial poor outcomes associated to this procedure, recent reports have showed reduced morbimortality in well selected patients. The current study evaluates the outcomes of ALPPS procedure in treatment of colorectal liver metastasis at our department and identify morbimortality and survival prognostic factors. A retrospective cohort study was performed, all consecutive patients submitted to ALPPS procedure between 2015 and 2020 were included. Twenty-one patients with 61,8±10,8 (37-78), 76,2% were male, with 12,05±6,34 (5-30) hepatic nodules, whose largest size was 42.3 ± 17, 5 (18-75) mm. Among these, 71.4% underwent induction chemotherapy with FOLFIRI and 61,9% with plus Cetuximab, mean of 10,9±5,6 (4-24) cycles. At ALPPS stage 1, 6±4 (1-18) nodules were resected, 19% with concomitant splenic artery occlusion and a mean Pringle Maneuver of 33±26 (0-94) minutes. All patients did adjuvant CT. We report a global mortality of 9,6% and a major morbidity (MMb) of 28,6%. The multivariable analysis identified as risk factor for MMb: more than 10 nodules, size&gt;38mm, interstage interval&gt; 14 days and the resection of more than 4 lesions at stage 1. The overall survival and disease-free survival rates were 25,9± 4,2 (17,6- 34,1), 17,64 ±3,95 (9,9-25,4) moths, respectively. Age &gt;56 years and size &gt;38mm were identified as risk factor for poor outcome. More than 10 cycles of neoadjuvant chemotherapy were identified as risk factor for poor outcome at 2 years. Our results are similar to the recently established reference values.The associating liver partitioning and portal vein ligation for staged hepatectomy has gained interest in the treatment of unresectable colorectal liver metastases as it has allowed to expand the limits of oncological resectability. Despite the initial poor outcomes associated to this procedure, recent reports have showed reduced morbimortality in well selected patients. The current study evaluates the outcomes of ALPPS procedure in treatment of colorectal liver metastasis at our department and identify morbimortality and survival prognostic factors. A retrospective cohort study was performed, all consecutive patients submitted to ALPPS procedure between 2015 and 2020 were included. Twenty-one patients with 61,8±10,8 (37-78), 76,2% were male, with 12,05±6,34 (5-30) hepatic nodules, whose largest size was 42.3 ± 17, 5 (18-75) mm. Among these, 71.4% underwent induction chemotherapy with FOLFIRI and 61,9% with plus Cetuximab, mean of 10,9±5,6 (4-24) cycles. At ALPPS stage 1, 6±4 (1-18) nodules were resected, 19% with concomitant splenic artery occlusion and a mean Pringle Maneuver of 33±26 (0-94) minutes. All patients did adjuvant CT. We report a global mortality of 9,6% and a major morbidity (MMb) of 28,6%. The multivariable analysis identified as risk factor for MMb: more than 10 nodules, size&gt;38mm, interstage interval&gt; 14 days and the resection of more than 4 lesions at stage 1. The overall survival and disease-free survival rates were 25,9± 4,2 (17,6- 34,1), 17,64 ±3,95 (9,9-25,4) moths, respectively. Age &gt;56 years and size &gt;38mm were identified as risk factor for poor outcome. More than 10 cycles of neoadjuvant chemotherapy were identified as risk factor for poor outcome at 2 years. Our results are similar to the recently established reference values