Management of choledochal cysts:: 23 years of experience in a pediatric tertiary center

Introduction: Choledochal cyst is a rare pathology of the biliary tree, leading to hepatic cirrhosis and predisposition to malignancy if untreated. Excision and biliodigestive reconstruction is the standard treatment. Our objective in this study is to perform a retrospective analysis of choledochal cysts cases in our institution, focusing in diagnostic imaging and surgical management.Methods and materials: We analysed the medical records from patients with choledochal cysts in our institution from January 1994 to December 2017. Our research included gender, symptoms at presentation, age, preoperative and postoperative bilirubin levels, medical imaging, type of dilatation (following the Todani classification), performed surgery, complications and survival in 70 patients.Results: Ultrasonography was the only required exam to the diagnosis in 50 cases (71,4%), and used in 68 cases (97,1%). All Todani type I and IV cases were treated through cyst excision and biliodigestive reconstruction by proximal and distal hepaticojejunostomy through Roux-en-Y. Thirty-one patients were subjected to proximal hepaticojejunostomy. Eight (25,1%) presented postoperative complications, two of which died due to postoperative sepsis. Thirty-eight patients were subjected to distal hepaticojejunostomy. From this group, two patients (5,2%) presented postoperative complications. Thep-value between groups was 0.016.Conclusion: US is the only necessary diagnostic imaging prior to surgery. The surgeon should weight the risk of biliary cancer and postoperative complications upon choosing the height of the anastomosis in choledochal cysts. We preconize that it’s safer to perform a distal hepaticojejunostomy, maintaining the proximal part of a dilated common hepatic duct, than proximal hepaticojejunostomy.Keywords: Choledochal; Cyst; Management; Hepaticojejunostomy; Ultrasonography

Choledochal cysts in children: How to Diagnose and Operate on

OBJECTIVE: To identify the best mode for diagnosing and treating the patients with choledochal cysts. METHODS: A retrospective study was performed with medical records of patients diagnosed with choledochal cysts from January 1994 to December 2017. In all cases, the diagnosis was based on ultrasound examination. All the patients underwent cyst resection and were divided in two groups: bile enteric anastomosis in the high portion of the common hepatic duct or in the dilated lower portion. RESULTS: Eighty-one cases were studied. The age of presentation was 4 y 2 mo ± 4 y 1 mo, and the age for the surgical treatment was 5 y 5 mo ± 4 y 6 mo. In 61 cases, US was the only image examination performed. There were 67 cases of Todani type I (82.7%), 13 cases of type IV (16.0%) and one case of type III (1.2%). Nine patients (29.0%) in the first period and 2 patients (4.0%) in the second period presented with postoperative complications (p=0.016). CONCLUSION: In patients with choledochal cysts, US is the only necessary diagnostic imaging. Performing the bile enteric anastomosis in the lower portion of the common hepatic duct is safer and has a lower risk of complications

Current management of biliary atresia based on 35 years of experience at a single center

Biliary Atresia/SurgeryOBJECTIVE: The prognosis of patients with biliary atresia undergoing Kasai portoenterostomy is related to the timing of the diagnosis and the indication for the procedure. The purpose of the present study is to present a practical flowchart based on 257 children who underwent Kasai portoenterostomy. METHODS: We conducted a retrospective cohort study of patients who underwent Kasai portoenterostomy between 1981 and 2016. RESULTS: During the first period (1981 to 2009), 230 infants were treated, and the median age at the time of surgery was 84 days; jaundice was resolved in 77 patients (33.5%). During the second period, from 2010 to 2016, a new diagnostic approach was adopted to shorten the wait time for portoenterostomy; an ultrasonography examination suggestive of the disease was followed by primary surgical exploration of the biliary tract without complementary examination or liver biopsy. Once the diagnosis of biliary atresia was confirmed, a portoenterostomy was performed during the same surgery. During this period, 27 infants underwent operations; the median age at the time of surgery was 66 days (po0.001), and jaundice was resolved in 15 patients (55.6% - p=0.021), with a survival rate of the native liver of 66.7%. CONCLUSION: Primary surgical exploration of the biliary tract without previous biopsy was effective at improving the prognostic indicators of patients with biliary atresia undergoing Kasai portoenterostomy

Effects of the administration of pentoxifylline and prednisolone on the evolution of portal fibrogenesis secondary to biliary obstruction in growing animals: immunohistochemical analysis of the expression of TGF-BETA; and VEGF

OBJECTIVE: During the neonatal and infancy periods, some chronic liver diseases may lead to progressive hepatic fibrosis, which is a condition that can ultimately result in the loss of organ function and severe portal hypertension necessitating hepatic transplantation. In a previous report, pharmacological interventions were demonstrated to modulate hepatic fibrosis induced by bile duct ligation in young rats. The administration of pentoxifylline or prednisolone, or the combination of both, resulted in reduced fibrogenesis in portal spaces. The objectives of the present study were to evaluate the expression of transforming growth factor beta and vascular endothelial growth factor after bile duct ligation in young rats and to assess the effect of those same drugs on cytokine expression. METHODS: In this experimental study, 80 young rats (21 or 22 days old) were submitted either to laparotomy and common bile duct ligation or to sham surgery. The animals were allocated into four groups according to surgical procedure, and the following treatments were administered: (1) common bile duct ligation + distilled water, (2) sham surgery + distilled water, (3) common bile duct ligation + pentoxifylline, or (4) common bile duct ligation + prednisolone. After 30 days, a hepatic fragment was collected from each animal for immunohistochemical analysis using monoclonal antibodies against transforming growth factor beta and vascular endothelial growth factor. Digital morphometric and statistical analyses were performed. RESULTS: The administration of pentoxifylline reduced the transforming growth factor beta-marked area and the amount of transforming growth factor beta expressed in liver tissue. This effect was not observed after the administration of prednisolone. There was a significant reduction in vascular endothelial growth factor expression after the administration of either drug compared with the non-treatment group. CONCLUSIONS: The administration of pentoxifylline to cholestatic young rats resulted in the diminished expression of transforming growth factor beta and vascular endothelial growth factor in liver tissue. The administration of steroids resulted in the diminished expression of vascular endothelial growth factor only. These pathways may be involved in hepatic fibrogenesis in young rats submitted to bile duct ligation and exposed to pentoxifylline or prednisolone.FAPESP (Fundacao de Amparo a Pesquisa do Estado de Sao Paulo) [2009/07225-2]Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP

Avanços na cirurgia de trauma abdominal: uma análise comparativa entre abordagens minimamente invasivas e abordagens abertas

Este artigo revisa as recentes evoluções nas abordagens cirúrgicas para a doença inflamatória intestinal (DII), destacando o impacto e os benefícios das técnicas minimamente invasivas, como a cirurgia laparoscópica e robótica. Fornecemos uma visão abrangente dos principais estudos que comparam as intervenções cirúrgicas convencionais e modernas em termos de eficácia, segurança, recuperação do paciente e qualidade de vida. Os resultados indicam que as técnicas minimamente invasivas podem proporcionar melhorias significativas nos resultados dos pacientes, incluindo recuperação mais rápida, menor dor pós-operatória, menor tempo de internação e melhor qualidade de vida. No entanto, a implementação dessas técnicas apresenta desafios, incluindo a necessidade de treinamento especializado e a gestão de custos associados. Este artigo ressalta a importância de mais pesquisas para otimizar a implementação dessas técnicas e para esclarecer o seu papel na gestão da DII

A percepção do pai sobre o aleitamento materno / The father's perception of breastfeeding

o acolhimento do pai no pré-natal visa prepará-lo para paternidade ativa, contudo a ausência de sua participação nas consultas durante a gestação tem forte associação com desmame precoce. O objetivo deste estudo é identificar qual a percepção do pai diante do aleitamento materno. Tratar-se de um estudo descritivo-exploratório, com tratamento dos dados qualitativo. A amostra foi definida por saturação e foi constituída por  11 pais que tinham filhos de até seis meses de idade e estavam em aleitamento materno exclusivo ou que foram desmamados precocemente.  A partir da entrevista semi-estruturada, surgiram as categorias: conhecimento do pai sobre os benefícios do aleitamento materno; apoio paterno durante a amamentação ; amamentação como fonte de economia no âmbito familiar e de desenvolvimento sustentável. Foi evidenciado que os pais percebem a importância e os benefícios do aleitamento materno para saúde e desenvolvimento de seus filhos, bem como o aumento do vínculo afetivo e redução de gastos financeiros. 

Sentinelas de risco familiar em uma Estratégia Saúde da Família de Manaus / Family risk sentinels in a Family Health Strategy in Manaus

O estudo tem como principal escopo avaliar as sentinelas do risco de vulnerabilidade biológica e social das famílias de uma Estratégia Saúde da Família (ESF) da cidade de Manaus – AM. Como estratégia, adotou-se um estudo do tipo descritivo, de abordagem quantitativa. A pesquisa coligiu dados secundários junto ao sistema de informações e-SUS, advindos do cadastro individual e familiar da área da ESF. A partir dos dados coletados foi possível mensurar a frequência de ocorrências de cada uma das sentinelas de risco avaliadas no estudo. A sistematização dos dados demonstrou que o território analisado não é homogêneo, pois, as microáreas apresentam níveis diferenciados de risco. Os resultados desse estudo, associados à teoria pertinente, possibilitaram a realização do diagnóstico das microáreas que apresentam graus mais elevados de vulnerabilidade biológica e social, permitindo o desenvolvimento de subsídios para o planejamento estratégico de ações em saúde, que tenham maior efetividade. Dentre outros aspectos, os dados permitiram a percepção da dinâmica territorial diferenciada e que se reflete sobre os níveis de risco familiar. O conhecimento acerca dos diferentes níveis de risco, permite aos gestores um planejamento mais eficiente das ações e organização dos serviços em saúde ofertados à população adscrito

Patrimônio e desenvolvimento: as políticas de patrimônio cultural nos anos 1960

This article aims at analyzing aspects of 1960s Brazilian cultural heritage policies, highlighting changes related to the articulation of concepts such as development, culture and heritage within the Directory of National Historical and Artistic Heritage - DPHAN, today Institute of National Historical and Artistic Heritage (IPHAN). It discusses the effects of industrialization, urban growth and development improvement measures on heritage concepts and policies, analyzing initiatives that focus on preserving cultural assets acknowledged as national historical and artistic heritage and enhancing their economical potential. The discussion emphasizes notions and understandings on heritage and preservation that had substantial bearing on preservation measures carried on by DPHAN from the 1960s on regarding the identification, valorization and protection of cultural heritage, as well as the disciplinary and institutional debates this Directory proposed.O objetivo deste artigo é analisar especificidades dos anos 1960 no que diz respeito às políticas de patrimônio, destacando algumas mudanças de entendimentos, noções e propostas, notadamente referentes às relações entre desenvolvimento, cultura e patrimônio trabalhadas pelo Instituto do Patrimônio Histórico e Artístico Nacional, então Diretoria do Patrimônio Histórico e Artístico Nacional (DPHAN). Para tanto, vai-se partir das discussões e debates desse momento acerca dos efeitos da industrialização, do crescimento urbano e das políticas desenvolvimentistas sobre as políticas de patrimônio a partir dessa década, analisando as iniciativas voltadas à patrimonialização de bens culturais, à preservação do acervo que compunha o patrimônio histórico e artístico nacional e ao fomento de suas potencialidades econômicas. Na discussão proposta neste artigo, priorizar-se-ão os entendimentos e ações de preservação da DPHAN relacionados a identificação, valoração e proteção dos bens culturais, assim como os diálogos disciplinares e institucionais que a diretoria procurou estabelecer