Anatomia Cirúrgica da REGIÃO INGUINAL
A hérnia inguinal é uma condição comum que ocorre quando um órgão abdominal protraí através de uma fraqueza na parede abdominal na região abdominal. O orifício miopectineal é a principal área de fraqueza na parede abdominal onde a hérnia inguinal pode se desenvolver. O conhecimento da anatomia da parede abdominal é importante para entender a patofisiologia da hérnia inguinal e para ajudar no diagnóstico e tratamento dessa condição médica comum.
GASTROSTOMY: INDICATIONS, TECHNICAL DETAILS AND POSTOPERATIVE CARE.
Ozimo Pereira Gama Filho
Adjunct Professor at the Federal University of Maranhão
No conflict of interest
- HISTORICAL ASPECTS
- ANATOMICAL FUNDAMENTALS
- TYPES & TECHNIQUES
- ADVERSE EVENTS
- CUSTO RATIO x EFFECTIVENESS
In the last decade, the use of gastrostomies has been widely indicated as the preferred form of access to the gastrointestinal tract for feeding in chronic conditions and during recovery from acute conditions such as trauma. Together with this increase in indications, new techniques have been developed that have made gastrostomies simpler and less risky. From the classical technique of Stamm performed by laparotomy, two new alternatives that do not require laparotomy emerged: percutaneous endoscopic gastrostomy (PEG) and fluoroscopy gastrostomy. Its main benefit is to avoid a laparotomy, with less associated postoperative pain and earlier return of gastrointestinal function. Although peg is currently widely accepted as the insertion technique of choice due to its simplicity and efficacy, there are patients who are not candidates for an endoscopic approach. In this article we seek to clarify the indications, technical aspects and perioperative care of patients undergoing gastrostomy.
Keywords: Surgical Procedures; Ostomies; Gastrostomy.
Area of Knowledge: General Surgery
The main indication for enteral or parenteral feeding in the perioperative period is the provision of nutritional support to supply the metabolism of patients with inadequate oral intake. Enteral feeding is the preferred method in relation to parenteral feeding in patients with gastrointestinal dysfunction in the perioperative period due to the inherent risks associated with parenteral nutritional support, such as: infectious complications of the access routes, higher operational cost, and the inability to parenteral nutrition to provide adequate enteral stimulation and subsequent involvement of the intestinal defense barrier [1,2]. In addition, enteral feeding may decrease the risk of bacterial translocation and corresponding bacteremia . Gastric nutritional support is the most common type used. Access to insert the gastrostomy probe can be achieved using endoscopy, interventional radiologia, or surgical techniques (open or laparoscopic). However, since its description in the 1980s , percutaneous endoscopic gastrostomy (PEG) is currently considered the method of choice for medium and long-term enteral support.
1.1 Objective: This article reviews the current knowledge about GOSTROSTOMIA in the medical literature, emphasizing the technical and perioperative aspects.
- HISTORICAL ASPECTS
In 876, Verneoil  successfully made the first gastrostomy in humans. Since then, several technical modifications have been suggested, such as witzel’s technique in 1891, in which a subseroso tunnel is made on the probe . Stamm, in 1894 , described one of the most performed techniques today and in the history of surgical gastrostomy, which consists in the making of suture in a pouch to invaginate the probe inserted into the stomach . In 1980, percutaneous endoscopic gastrostomy was described by Gauderer et al.  , which transformed the technique of making gastrostomy.
- ANATOMICAL FUNDAMENTALS
The stomach is a J-shaped dilated cylindrical organ that rests in the left epigastric and hypochodrial region of the abdomen at the level of the first lumbar vertebra. It is previously limited by the left hemidiaphragm, the left lobe of the liver and a triangular portion of the anterior abdominal wall. Subsequently, the pancreas, left kidney and adrenal delimit the stomach. The spleen is posterolaterally and the transverse colon is inferior. It is fixed at two points of continuity: gastroesophageal, superiorly and the duodenal, retroperitoneally. Its ligament attachments also help you in fixation to adjacent organs: gastrophemic (diaphragm), hepatogastric or minor omentum (liver), gastrosplenic or gastrolienal (spleen), and gastrocholic or omentum major (transverse colon). The anatomical regions of the stomach can be distinguished as this: começa superiorly in the continuity of the abdominal part of the esophagus and dthe gastroesophageal junction, the cardiac part of the stomach. Soon below this portion, lies the bottom of the stomach that expands to the left extending above thegastroesophageal junction, forming an acute angle with the distal esophagus known as cardiac notches. The body s andextends as a distensible reservoir and forms a medial edge called the smallest curvature to the right and a side edge called the largest curvature on the left. The gastric den of the stomach is not anatomically distinguishable, but it is estimated to be a region of the angular isis along the distal minor curvature to a point along a lower line to the distal major curvature. It thus ends bymouthing r into the pyloric canal limited by the pyloric sphincter, a palpable thickened ring of muscle that is continuous with the first part of the duodenum.
Gastrostomy is used in the following situations:
- Gastric decompression: can be obtained by means of temporary gastrostomy, occasionally recommended, as a complement to large abdominal operations for which gastric stems, prolonged “adynamic ileus” and digestive fistulas are foreshadowed.
- Nutritional Support: b.1 Temporary; indicated when access to the digestive tract is temporarily impaired for recovery and maintenance of nutritional status (E.g. CEsophageal EC); b.2 Definitive; as palliative therapy in patients with unresectable malignant neoplasia of the head and neck, as wellas n degenerative neurological diseases that lead to irreversible disorders of deglutition.
However, the decision to perform a gastrostomy, as well as its route (surgical, radiological or endoscopic) should be individualizedaccording to the needs, diagnosis, life expectancy of the patient and the available hospital logistics. The objective is not only to optimize perioperative recovery, to improve survival and nutritional status of the patient, but also to promote quality of life, which is not necessarily correlated with nutritional improvement only . Therefore, the appropriate indication, like any other surgical intervention, must be clearly establishedand informed before it is performed. Some of the absolute contraindications of gastrostomy are summarized in Table 1. In addition to absolute contraindication conditions, other situations such as the presence of non-obstructive oromyctological oresophageal malignancy, hepatomegaly, splenomegaly, peritoneal dialysis, portal hypertension with gastric varicose veins, and a history of partial gastrectomy are also considered relative contraindications.
|ABSOLUTE CONTRA – INDICATIONS|
|Coagulopatia Severa (INR > 5, Plaquetas < 50.000 e TPT > 50s)|
|Dermatological infection in the upper abdomen|
|Interposition of organs that prevent gastric access|
|History of Total Gastrectomy|
|Stenosis or Pyloric Obstruction|
|Severe gastroparesis, in cases of indication for nutritional support|
|Absence of Informed Consent|
- TYPES & TECHNIQUES
Currently there are three techniques for performing gastrostomy: radiological, through percutaneous gastrostomy by fluoroscopy, percutaneous endoscopic gastrostomy (PEG) and surgical gastrostomy. Due to the didactic characteristics of this material, we will focus on endoscopic and surgical gastrostomy , which becomes the main option in the following situations: 1) when the patient will already undergo a laparotomy due to some abdominal condition ; 2) impossibility of performing gastroscopy to perform gastrostomy endoscopic percutaneous (PEG) ; 3) in case of peg technical failure; 4) unavailability of resources for the preparation of PEG or percutaneous gastrostomy by fluoroscopy.
- ENDOSCOPIC PERCUTANEOUS GASTROSTOMY
The informed consent form must be obtained from patients or their legal representatives. Patients should fast for a minimum of 8 hours and receive prophylactic antibiotics one hour before proceeding and intravenous administration of 1-2 g of cefazolin is recommended. The technique introduced by Gauderer et al  is the most used technique to insert the PEG gastrostomy probe. In this method, a guide wire is used, inserted in the distal gastric chamber through a needle puncture n to the anterior abdominal wall. This guide wire is then seized endoscopically with a handle and then removed through the esophagus and mouth. Subsequently, the guide wire is fixed to the end of the gastrostomy probe and then pulled from the mouth to the esophagus, stomach and then out to the abdominal wall, where it will be fixed.
- SURGICAL GASTROSTOMY
Surgical gastrostomy can be performed in two ways: 1) via laparotomy – the predominant form; and 2) laparoscopic approach. The preparations are the same as the endoscopic pathway.
5.2.1. GASTROSTOMIA At STAMM
After adequate asepsis and antisepsis, with the patient under anesthesia and in horizontal dorsal decubitus, the technical steps are as follows: 1. Median laparotomy (supraumbilical median incision); 2. Identification of the gastric body; 3. Stomach hold with Babcock tweezers (to evaluate the approach of the stomach to the peritoneum); 4. Suture in pouch (circular area of 2cm) – atraumatic absorbable thread; 5. Section of the stomach wall (0.5cm) – (incision with scalpel or Electrocautery in the center of the suture, of sufficient size, for the placement of a probe with 20 to 26 French); 6. Placement of the Gastrostomy probe in the extension of 5-6 cm, followed by suture closure in a pouch); 7. Tie the suture threads in a pouch around the probe; 8. Apply a second suture in a pouch 1cm above the first (seromuscular stitches); 9. Externalization of the probe by counter opening on the left flank; 10. Fix the stomach wall to the abdominal wall in 4 cardinal points (external ration with the two Kocher tweezers used for grip of the alba line and against traction by means of the index fingers of the wall of the left hipochondrio to approach the parietal peritoneum of the gastric wall); 11. Fixation of the probe to the skin (point with nonabsorbable wire); 12. Closure of the abdominal wall (synthesis of the wall with approximation of the alba thread by continuous suture with monofilament thread 1-0 or 2-0 and of the skin with separate points of nylon 3-0); 13. Dressing.
5.2.1 GASTROSTOMIA EM WITZEL
The initial technical steps from gastrostomy to Witzel are like those of gastrostomy to Stamm, including fixation of the probe to the stomach by a pouch suture. Then, the probe is placed on the gastric wall and a tunnel of 8-10 cm is made by seromuscular suture (continuous or with separate points of absorbable or nonabsorbable thread) covering it and externalization is performed by counteropening.
- ADVERSE EVENTS
According to the literature, the rate of complications for different procedures varies due to the heterogeneity of the samples evaluated. For surgical gastrostomy, the reported complication rates are between 1% and 35%, while for percutaneous radiological gastrostomy it is 3% to 11%, and for percutaneous endoscopic, 17%–32%, the main related adverse event is surgical site infection [10, 11]. Although considered a basic procedure, gastrostomy is associated with an extensive list of related technical complications, care and use of the probe. Serious problems related to the technique include separation of the stomach from the abdominal wall (leading to peritonitis), separation of wounds, hemorrhage, infection, lesion of the posterior gastric wall or other organs, and placement of the tube in an inappropriate place of gastric position. Separation of the stomach from the abdominal wall usually occurs due to inadvertent and premature displacement of the tube, particularly with balloon-like devices, or a rupture during a catheter change. It requires immediate attention, being treated with laparotomy, although in selected cases laparoscopic correction is possible. Most complications can be avoided with the careful choice of the type of procedure, from the appropriate ostomy device, considering it an important intervention and using meticulous technique with the proper approximation of the stomach to the abdominal wall and outflow of the probe through a counter-incision (in conventional procedures), thus avoiding probes in the midline or awfully close to the costal edge.
- COST VS. EFFECTIVENESS
A recent study  compared the cost associated with the different gastrostomy techniques, and the results of the evaluation showed variable the benefits of each of the individual percutaneous procedures, indicating that surgical gastrostomy was the onerous mais of the three modalities due to higher costs, complications, and recovery time, as well as the endoscopic technique presenting the cost effectiveness ratio.
Despite the technique employed, the decision to performa gastrostomy is not based only on the patient’s survival expectancy, because the adequate indication provides a better quality of life even when the survival of the patient after the procedure is severely limited. Therefore, understanding of techniques, indications, complication rates is essential to guide the surgical team in the scope of multidisciplinary care, as well as the education of patients and their caregivers is vital to ensure the correct maintenance of the devices, thus ensuring adequate nutritional intake of the patient and minimizes complication rates.
1 Alverdy J, Chi HS, Sheldon GF. The effect of parenteral nutrition in gastrointestinal immunity. The importance of de estimulação enteral. Ann Surg, 1985; 202: 681-684 [PMID:3935061]
2 Deitch EA, Ma WJ, Ma L, Berg RD, Specian RD. Protein malnutrition predisposes to inflammation-induced intestinal origin septic states. Ann Surg, 1990; 211: 560-567; discussion 560-567 [PMID: 2111125]
3 Deitch EA, Winterton J, Li M, Berg R. The intestine as a portal of entry to bacteremia. Role of protein malnutrition. Ann Surg 1987; 205: 681-692 [PMID: 3592811]
4 Gauderer MW, Ponsky JL, Izant RJ. Gastrostomia sem laparotomy: percutaneous endoscopic technique. J Pediatrician Surg, 1980; 15: 872-875 [PMID: 6780678]
5 Anselmo CB, Tercioti Júnior V, Lopes LR, Coelho Neto JS, Andreollo NA. Surgical gastrostomy: current indications and complications in patients of a university hospital. Rev Col Bras Cir. [Internet journal] 2013;40(6). Available in URL: http://www.scielo.br/rcbc
6 Witzel O. For gastric fistula technique. Chir Zbl. 1891;18:601-4.
7 Stamm M. Gastrostomy: a new method. Med News. 1894;65:324.
8 JP grant. Comparison of percutaneous endoscopic gastrostomy com gastrostomia strain. Ann Surg. 1988;207(5):598-603
9 Bannerman E, Pendlebury J, Phillips F, Ghosh S. Cross-sectional and longitudinal study of health-related quality of life after percutaneous gastrostomy. Eur J Gastroenterol Hepatol 2000; 12: 1101-1109 [PMID: 11057455]
10 Möller P, Lindberg CG, Zilling T. Gastrostomy by various techniques: evaluation of indications, outcome and complications. Scand J Gastroenterol. 1999;34(10):1050-4.
11 Clarke E, Pitts N, Latchford A, Lewis S. A major prospective audit of morbidity and mortality associated with food gastrostomies in the community. Clin Nutr. 2017 Apr;36(2):485-490. DOI: 10.1016/j.clnu.2016.01.008. EPub 2016 January 21. PMID: 26874913.
12 Wollman B, D’Agostino HB, Walus-Wigle JR, Easter DW, Beale A (1995) Radiological, endoscopic and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology 197: 699–704.
A Arte da Anatomia (EBook)
Desde a Antiguidade, os médicos, anatomistas e artistas se dedicaram a descrever e representar o corpo humano, por meio de desenhos, pinturas, esculturas e outras formas de representação artística. Com o passar dos séculos, houve uma evolução significativa na forma como as ilustrações anatômicas eram produzidas, desde as primeiras representações rudimentares até as ilustrações altamente detalhadas e realistas que temos hoje.
A Anatomia na obra de MICHELANGELO
Michelangelo Buonarroti (1475-1564) foi um artista italiano do Renascimento, considerado um dos maiores gênios da história da arte ocidental. Nascido em uma família modesta de Florença, Michelangelo começou sua carreira artística aos 13 anos, como aprendiz na oficina de um pintor renomado. Logo se destacou por seu talento e foi contratado por diversos patronos importantes, que o apoiaram em seus primeiros projetos. Michelangelo é famoso por suas esculturas em mármore, como a “Pietà” e o “David”, e pelos afrescos que decoram a Capela Sistina, no Vaticano. Além disso, ele também foi um pintor, arquiteto e poeta prolífico, deixando um legado impressionante de obras de arte em diferentes meios. Ao longo de sua vida, Michelangelo trabalhou para vários patronos importantes, incluindo os papas Júlio II e Paulo III, e foi um dos artistas mais requisitados da sua época. Ele também era conhecido por sua personalidade forte e teimosia, o que às vezes o colocava em conflito com seus clientes e colegas. Além de seu talento artístico, Michelangelo também se destacou como estudioso da anatomia humana, realizando dissecações de cadáveres para aprimorar sua compreensão da estrutura do corpo humano. Seus estudos de anatomia foram uma contribuição significativa para a compreensão da ciência médica na época. Chegando a falecer aos 88 anos em Roma, deixando um legado duradouro de obras de arte que ainda hoje são estudadas e admiradas em todo o mundo.
Michelangelo obteve os cadáveres para estudar anatomia por meio da dissecação de corpos de condenados à morte, que eram fornecidos a ele pelo Hospital de Santa Maria Nuova, em Florença. Naquela época, a dissecação de corpos humanos era proibida pela Igreja Católica, por ser considerada uma violação do corpo humano, e era punida com a excomunhão. No entanto, em Florença, havia uma exceção: a dissecação era permitida para fins de ensino médico. De acordo com registros históricos, Michelangelo iniciou seus estudos de anatomia no início dos anos 1500, quando tinha cerca de 25 anos de idade. Ele trabalhou em segredo, dissecando cadáveres em uma sala alugada próxima ao Hospital de Santa Maria Nuova, acompanhado apenas por um ajudante de confiança. Segundo relatos, Michelangelo teria realizado pelo menos duas dissecações completas, uma de um homem e outra de uma mulher.
Acredita-se que Michelangelo tenha estudado os cadáveres por um período de cerca de 18 meses. Durante esse tempo, ele fez centenas de desenhos e anotações, registrando detalhadamente os órgãos, ossos e músculos do corpo humano. Esses estudos foram uma contribuição significativa para a compreensão da anatomia humana na época. É importante notar que, apesar de ter sido uma prática comum na época, a dissecação de cadáveres para fins de estudo médico era vista com desconfiança pela sociedade em geral e era considerada imoral. Além disso, os corpos usados eram geralmente de pessoas marginalizadas ou criminosos, o que aumentava o estigma em torno da prática. No entanto, graças aos esforços de Michelangelo e outros estudiosos da época, a anatomia humana passou a ser vista como uma ciência importante e legítima, abrindo caminho para avanços significativos no campo da medicina.
Michelangelo deixou poucas obras anatômicas concluídas, uma das fontes históricas mais importantes que mostram a sua compreensão da anatomia humana é um conjunto de desenhos anatômicos que ele criou durante seu estudo para produção de algumas obras de arte. Esses desenhos foram feitos por Michelangelo durante sua estadia em Florença, no início do século XVI. Eles mostram detalhes precisos da anatomia humana, incluindo músculos, ossos e órgãos internos. Estes desenhos são considerados uma das maiores contribuições de Michelangelo para o estudo da anatomia humana. As principais obras de caráter anatômico deixadas por Michelangelo foram:
- “Estudo para a Leda e o Cisne” – Um desenho a carvão que retrata uma figura feminina em uma pose que permite visualizar a musculatura das costas, braços e pernas.
- “Estudo para o Braço Direito da Leda e o Cisne” – Outro desenho a carvão que mostra em detalhes a musculatura do braço direito da figura feminina.
- “Desenho da Cabeça de Lutador” – Um desenho que mostra a anatomia detalhada da cabeça e do pescoço de um lutador, incluindo músculos e tendões.
- “Anatomia dos Músculos da Perna” – Um desenho a carvão que mostra a musculatura da perna em diferentes ângulos, com atenção especial aos músculos da panturrilha.
- “Anatomia da Cabeça” – Uma série de desenhos que mostram diferentes aspectos da anatomia da cabeça, incluindo a musculatura da face e do crânio.
- “Anatomia do Braço” – Outra série de desenhos que mostram a musculatura do braço em diferentes ângulos, com atenção especial aos músculos do antebraço.
Embora Michelangelo não tenha publicado nenhum trabalho anatômico durante sua vida, seus desenhos foram muito valorizados por médicos e estudiosos da anatomia da época e serviram de referência para o desenvolvimento posterior da anatomia humana.
A ANATOMIA DA ARTE
Existem vários segredos anatômicos escondidos na obra de Michelangelo, especialmente em suas obras menos conhecidas, como seus desenhos anatômicos. Aqui estão alguns exemplos:
- Músculos e Veias
Michelangelo foi um mestre em retratar músculos e veias com grande precisão. Em muitas de suas esculturas, ele retrata os músculos e veias de maneira que parecem estar saltando para fora da pele. Ele também era conhecido por retratar veias de maneira exagerada em certas partes do corpo, como nos braços e pernas. Em suas obras de arte, Michelangelo frequentemente destacava a musculatura para enfatizar a força e a energia dos personagens retratados.
Michelangelo também tinha uma compreensão profunda da estrutura óssea humana. Ele era capaz de retratar ossos com grande precisão, especialmente em suas esculturas. Em suas obras mais conhecidas, como “David”, ele retrata a estrutura óssea do personagem de maneira tão realista que é possível identificar cada osso individualmente.
- Órgãos Internos
Além de retratar a musculatura, veias e ossos, Michelangelo também era conhecido por retratar os órgãos internos do corpo humano. Seus desenhos anatômicos incluem detalhes precisos dos órgãos internos, como o coração, pulmões e estômago. Esses desenhos são considerados uma das maiores contribuições de Michelangelo para o estudo da anatomia humana.
- Detalhes Ocultos
Em algumas de suas obras de arte, Michelangelo incluiu detalhes anatômicos ocultos que só podem ser vistos por meio de análise minuciosa. Por exemplo, em sua escultura “Moisés”, ele retrata uma protuberância embaixo da barba do personagem que muitos acreditam ser uma nodulação. Essa observação só foi possível com a ajuda de modernas técnicas de análise de imagem. Outra obra de Michelangelo que mostra sua compreensão da anatomia humana é o túmulo do Papa Júlio II. O túmulo inclui várias figuras retratadas com grande precisão anatômica, incluindo os músculos, veias e ossos. Embora a obra tenha sido concebida como um monumento funerário, a precisão anatômica é tão impressionante que muitos estudiosos acreditam que Michelangelo pode ter usado sua compreensão da anatomia humana para explorar temas mais profundos, como a mortalidade e a natureza da vida.
Em resumo, Michelangelo era um artista que possuía uma compreensão profunda da anatomia humana. Ele foi capaz de retratar a musculatura, veias, ossos e órgãos internos com grande precisão em suas obras de arte. Além disso, ele incluiu detalhes anatômicos ocultos que só podem ser vistos por meio de uma análise minuciosa. A obra de Michelangelo é uma rica fonte de conhecimento anatômico e continua a nos inspirar os dias de hoje.
“A anatomia é a ciência que nos ensina a conhecer a natureza do homem, e é indispensável para quem quer entender a arte de curar.” – Hippocrates, médico grego considerado o pai da medicina ocidental.
Specific Competence of Surgical Leadership
Surgeons are uniquely prepared to assume leadership roles because of their position in the operating room (OR). Whether they aspire to the title or not, each and every surgeon is a leader, at least within their surgical team. Their clinical responsibilities offer a rich variety of interpretations that prepare them for a broader role in health care leadership. They deal directly with patients and their families, both in and out of the hospital setting, seeing a perspective that traditional health care administrative leaders rarely experience. They work alongside other direct providers of health care, in varied settings, at night, on weekends, as well as during the typical workday. They understand supply-chain management as something more than lines on a spreadsheet.
The Challenges for a Surgical Leader
Surgeons prefer to lead, not to be led. Surgical training has traditionally emphasized independence, self-reliance, and a well-defined hierarchy as is required in the OR. However, this approach does not work well outside the OR doors. With colleagues, nurses, staff, and patients, they must develop a collaborative approach. Surgeons are entrusted with the responsibility of being the ultimate decision maker in the OR. While great qualities in a surgeon in the OR, it hinders their interactions with others. They have near-absolute authority in the OR, but struggle when switching to a persuasive style while in committees and participating in administrative activities. Most surgeons do not realize they are intimidating to their patients and staff. With patients, a surgeon needs to be empathetic and a good listener. A surgeon needs to slow the pace of the discussion so that the patient can understand and accept the information they are receiving. As perfectionists, surgeons demand a high level of performance of themselves. This sets them up for exhaustion and burnout, becoming actively disengaged, going through the motions, but empty on the inside. Given the many challenges surgeons face, it is difficult for them to understand the leadership role, given its complex demands.
Although teams and all team members provide health care should be allowed input, the team leader makes decisions. The leader must accept the responsibility of making decisions in the presence of all situations. They will have to deal with conflicting opinions and advice from their team, yet they must accept that they will be held accountable for the performance of their team. The surgeon–leader cannot take credit for successes while blaming failures on the team. Good teamwork and excellent communication do not relieve the leader of this responsibility.
A surgeon often has a position of authority based on their titles or status in an organization that allows them to direct the actions of others. Leadership by this sort of mandate is termed “transactional leadership” and can be successful in accomplishing specific tasks. For example, a surgeon with transactional leadership skills can successfully lead a surgical team through an operation by requesting information and issuing directives. However, a leader will never win the hearts of the team in that manner. The team will not be committed and follow through unless they are empowered and feel they are truly heard. A transformational leader is one who inspires each team member to excel and to take action that supports the entire group. If the leader is successful in creating a genuine atmosphere of cooperation, less time will be spent giving orders and dealing with undercurrents of negativity. This atmosphere can be encouraged by taking the time to listen and understand the history behind its discussion. Blame should be avoided. This will allow the leader to understand the way an individual thinks and the group processes information to facilitate the introduction of change. While leadership style does not guarantee results, the leader’s style sets the stage for a great performance. At the same time, they should be genuine and transparent. This invites the team members to participate, creating an emotional connection. Leaders try to foster an environment where options are sought that meet everyone’s desires.
Conflict is pervasive, even in healthy, well-run organizations and is not inherently bad. Whether conflict binds an organization together or divides it into factions depends on whether it is constructive or destructive. A good leader needs to know that there are four essential truths about conflict. It is inevitable, it involves costs and risks, the strategies we develop to deal with the conflict can be more damaging than the conflict itself, and conflict can be permanent if not addressed. The leader must recognize the type of conflict that exists and deal with the conflict appropriately. Constructive discussion and debate can result in better decision making by forcing the leader to consider other ideas and perspectives. This dialog is especially helpful when the leader respects the knowledge and opinions of team members with education, experience, and perspective different from the leader’s. Honesty, respect, transparency, communication, and flexibility are all elements that a leader can use to foster cohesion while promoting individual opinion. The leader can create an environment that allows creative thinking, mutual problem solving, and negotiation. These are the hallmarks of a productive conflict. Conflict is viewed as an opportunity, instead of something to be avoided.
Communication is the primary tool of a successful leader. On important topics, it is incumbent on the leader to be articulate, clear, and compelling. Their influence, power, and credibility come from their ability to communicate. Research has identified the primary skills of an effective communicator. They are set out in the LARSQ model: Listening, Awareness of Emotions, Reframing, Summarizing, and Questions. These are not set in a particular order, but rather should move among each other freely. In a significant or critical conversation, it is important for a leader to listen on multiple levels. The message, body language, and tone of voice all convey meaning. You cannot interrupt or over-talk the other side. They need an opportunity to get their entire message out. Two techniques that enhance listening include pausing and the echo statement. Pausing before speaking allows the other conversant time to process what they have said to make sure the statement is complete and accurate. Echo statements reflect that you have heard what has been said and focuses on a particular aspect needing clarification. Good listening skills assure that the leader can get feedback that is necessary for success.
Vision, Strategy, Tactics, and Goals
One of the major tasks of a leader is to provide a compelling vision, an overarching idea. Vision gives people a sense of belonging. It provides them with a professional identity, attracts commitment, and produces an emotional investment. A leader implements vision by developing strategy that focuses on specific outcomes that move the organization in the direction of the vision. Strategy begins with sorting through the available choices and prioritizing resources. Through clarification, it is possible to set direction. Deficits will become apparent and a leader will want to find new solutions to compensate for those shortfalls. For example, the vision of a hospital is to become a world class health care delivery system. Strategies might include expanding facilities, improving patient satisfaction, giving the highest quality of care, shortening length of hospital stay with minimal readmissions, decreased mortality, and a reduction in the overall costs of health care. Tactics are specific behaviors that support the strategy with the aim to achieve success. Tactics for improving patient satisfaction may include reduced waiting time, spending more time with patients, taking time to communicate in a manner that the patient understands, responding faster to patient calls, etc. These tactics will then allow a leader to develop quantitative goals. Patient satisfaction can be measured. The surgical leader can then construct goals around each tactic, such as increasing satisfaction in specific areas. This information allows a surgical leader to identify barriers and they can take steps to remedy problem areas. This analysis helps a leader find the weakest links in their strategies as they continue toward achieving the vision.
The world of health care is in continuous change. The intense rate of political, technical, and administrative change may outpace an individual’s and institution’s ability to adapt. Twenty-first century health care leaders face contradictory demands. They must navigate between competing forces. Leaders must traverse a track record of success with the ability to admit error. They also must maintain visionary ideas with pragmatic results. Individual accountability should be encouraged, while at the same time facilitating teamwork. Most leaders do not understand the change process. There are practical and psychological aspects to change. From an institutional perspective, we know that when 5% of the group begins to change, it affects the entire group. When 20% of a group embraces change, the change is unstoppable.
Succession Planning and Continuous Learning
An often-overlooked area of leadership is planning for human capital movement. As health care professionals retire, take leaves of absences, and move locations, turmoil can erupt in the vacuum. Leaders should regularly be engaging in activities to foster a seamless passing of institutional knowledge to the next generation. They also should seek to maintain continuity to the organization. Ways to accomplish this include senior leaders actively exposing younger colleagues to critical decisions, problem solving, increased authority, and change management. Leaders should identify promising future leaders, give early feedback for areas of improvement, and direct them toward available upward career tracks. Mentoring and coaching help prepare the younger colleagues for the challenges the institution is facing. Teaching success at all levels of leadership helps create sustainable high performance.
Gallstone ileus is a misnomer: this condition is not a physiologic ileus at all, but a mechanical obstruction of the intestinal lumen (most commonly the small bowel) by a large gallstone that has passed through a cholecystoenteric fistula. Cholecystoenteric fistulae may occur from the gallbladder to the adjacent luminal viscera-duodenum (most common), stomach, or colon. Gallstone obstruction of the stomach at the pylorus is known as Bouveret’s syndrome. Cholecystocolic fistula is less common. Colonic obstruction in this situation typically occurs at the sigmoid colon. Most common is cholecystoduodenal fistula, with a large (usually >2 cm) gallstone passing through the small bowel and becoming lodged in the terminal ileum. Cholecystoenteric fistula is felt to be caused by a combination of pressure, necrosis, and inflammation with chronic longstanding gallstone disease. Up to 25% of patients who develop gallstone ileus will harbor multiple stones in the alimentary tract; therefore, a close inspection of the entire intestine is important at the time of operation.
Over the past few years, however, the incidence of gallstone ileus has been shown to be greater than previously thought. Several recent large population-based series have found that gallstone ileus accounts for approximately 0.1% of all small bowel obstructions. The disease usually affects women (70%) and those in the seventh or eighth decade of life. Most patients present with bloating, crampy abdominal pain, and vomiting, symptoms typical of mechanical small bowel obstruction. A careful history may reveal earlier episodic colicky right upper quadrant abdominal pain consistent with gallstone disease. The classic finding on plain abdominal radiograph is that of Rigler’s triad (pneumobilia, dilated small bowel loops with air-fluid levels, and a large, calcified gallstone in the lumen of the small bowel). Currently, computed tomography (CT) is used ubiquitously. CT has 99% accuracy for diagnosing gallstone ileus. Typical CT findings include pneumobilia, dilated loops of small bowel with air-fluid levels consistent with small bowel obstruction, and transition point with the ectopic stone always visible radiologically.
Operation is required for all patients with gallstone ileus, as spontaneous passage of these large stones is rare once the patient has become symptomatic. It is crucial to optimize the patient physiologically as much as possible in this semi urgent situation, with the understanding that most gallstone ileus patients are elderly and commonly have numerous medical comorbidities. Two contemporary series of registry data have expanded our understanding of gallstone ileus. This condition was once thought to be relatively rare; however, the National Inpatient Sample study identified 3268 gallstone ileus patients, which accounts for approximately 0.1% of all patients admitted to the hospital with mechanical small bowel obstruction during this time period. In this series, overall hospital mortality was substantial at 6.7%. Mortality was significantly higher in patients who underwent cholecystectomy and closure of the biliary fistula compared to those who simply had small bowel obstruction addressed by cholecystolithotomy. Overall, 77% of the 3268 patients had small bowel obstruction pathology treated and the remaining 23% had biliary fistula closed and cholecystectomy at the same operation. An interesting finding was the substantial incidence of postoperative renal insufficiency, or approximately 30% in the entire group of patients. The latter finding highlights the need for preoperative resuscitation and close attention to postoperative fluid management. The surgeon must consider carefully feasibility of same operation intervention to repair biliary pathology: It is safe to defer biliary operation to a later date with a second staged operation. When this strategy of two stage operation is selected, surgeons should consider and counsel their patient regarding the substantial incidence of recurrent biliary symptoms.
Tratamento Cirúrgico da ACALASIA ESOFÁGICA
A acalasia, definida como a falha ou relaxamento incompleto do esfíncter esofágico inferior (EEI), acompanhada de aperistalse do corpo esofágico na ausência de obstrução mecânica, é o tipo mais comum de distúrbio da motilidade esofágica. Tem uma incidência de 1 em 100.000 pessoas, com uma prevalência de 10 em 100.000. Não há diferença na prevalência de gênero entre as idades de 30 e 60 anos. A causa primária da acalasia ainda é indeterminada, mas acredita-se que surja da degeneração das células ganglionares inibitórias no plexo miontérico do EEI e corpo esofágico. Fatores associados a um risco aumentado de acalasia incluem distúrbios virais/neurodegenerativos, síndrome de Down, diabetes mellitus tipo 1, hipotireoidismo e condições autoimunes, como a síndrome de Sjögren, o lúpus eritematoso sistêmico e a uveíte. Os casos familiares são raros.
O diagnóstico de acalasia deve ser suspeitado em pacientes com disfagia para sólidos e líquidos que não melhora com o uso de inibidores da bomba de prótons. Se não for tratada, a acalasia é uma doença progressiva que pode evoluir para megaesôfago e está associada a um aumento do risco de carcinoma de células escamosas do esôfago. Embora não existam critérios padronizados para determinar a gravidade da doença, o diâmetro e a confirmação do esôfago dentro da cavidade torácica são geralmente considerados os dois principais fatores. A escala de Eckardt é uma escala frequentemente usada para avaliar a gravidade da doença e a eficácia da terapia. Qualitativamente, a acalasia grave é definida como um diâmetro esofágico maior que 6 cm; a acalasia em estágio avançado inclui a angulação distal, um esôfago sigmóide/tortuoso com diâmetro maior que 6 cm ou um megaesôfago com diâmetro maior que 10 cm. Aproximadamente 5% a 15% das pessoas com acalasia evoluem para acalasia em estágio avançado, são geralmente resistentes aos tratamentos endoscópicos e cirúrgicos iniciais e, em última instância, requerem uma esofagectomia.
MIOTOMIA Á HELLER
A miotomia laparoscópica de Heller (LHM) com fundoplicatura parcial, desenvolvida como uma alternativa minimamente invasiva à miotomia anterior aberta tradicional e posteriormente à miotomia toracoscópica, tem sido o padrão ouro para o tratamento da acalasia nas últimas três décadas. O objetivo da miotomia é abrir completamente o EEI e aliviar a disfagia. A LHM proporciona alívio sintomático inicial da disfagia em cerca de 90% dos pacientes com tipos I e II de acalasia e em 50% dos pacientes com tipo III de acalasia, enquanto diminui as taxas de refluxo pós-operatório. Em comparação com os procedimentos de miotomia aberta, a LHM está associada a menor dor pós-operatória, menor tempo de internação hospitalar e retorno mais precoce à função. A LHM é indicada como tratamento de primeira linha para todos os candidatos à cirurgia com acalasia que estejam dispostos a se submeter à cirurgia ou para aqueles que falharam na dilatação endoscópica. A operação consiste em dividir os músculos do EEI, seguida por uma fundoplicatura para diminuir o refluxo pós-operatório. A fundoplicatura parcial é favorecida em relação à fundoplicatura total porque reduz a falha do tratamento. As duas principais complicações da cirurgia são perfuração da mucosa e DRGE.
Surgical Management of Chronic Pancreatitis
Chronic pancreatitis is a progressive, destructive inflammatory process that ends in destruction of the pancreatic parenchyma resulting in malabsorption, diabetes mellitus, and severe pain. The etiology of chronic pancreatitis is multifactorial. About 65–70% of patients have a history of alcohol abuse, the remaining patients are classified as idiopathic chronic pancreatitis (20–25%), including tropical pancreatitis, a major cause of childhood chronic pancreatitis in tropical regions, or unusual causes including hereditary pancreatitis, cystic fibrosis, and chronic pancreatitis-associated metabolic and congenital factors. Current evidence suggests that a combination of predisposing factors, including environmental, toxic, and genetic, are involved in most patients rather than one single factor. The best-known hypotheses about the pathogenesis of chronic pancreatitis include necrosis-fibrosis, toxic-metabolic, oxidative stress, plug and stone formation with duct obstruction, and primary duct obstruction. Repeated episodes of inflammation initiated by autodigestion, one or more episodes of severe pancreatitis, oxidative stress, and/or toxic-metabolic factors lead to activation and continued stimulation of parenchymal pancreatic stellate cells. These stellate cells cause the fibrosis characteristic of chronic pancreatitis. Nevertheless, multiple hypotheses exist to explain the pathophysiology in the various subgroups of patients with chronic pancreatitis, but to date there is no single unifying theory.
There are several different concepts for the operative treatment of chronic pancreatitis. The concept of preservation of functioning pancreatic parenchyma (drainage operations) would be the goal for protection against further loss of pancreatic function. The second main concept is based on resective procedures either in the situation where there is no dilation of the pancreatic duct, if the pancreatic head is enlarged, or if a pancreatic carcinoma is suspected in the setting of chronic pancreatitis. These two concepts involve different operative procedures.
Sphincterotomy of the pancreatic duct was one of the first operative procedures proposed for patients with a dilated pancreatic duct in chronic pancreatitis with presumed obstruction or stenosis at the papilla Vater. Unfortunately, this procedure was associated with minimal lasting success for the amelioration of pain, indicating that a stenosis at the papilla of Vater is not the cause of pain in chronic pancreatitis nor the cause of ductal dilation. In contrast, direct ductal-enteric drainage by the original Puestow procedure or its modification by Partington and Rochelle is more successful in patients with chronic pancreatitis and a dilated pancreatic duct. The original Puestow procedure included resection of the tail of the pancreas with filleting open the pancreatic duct proximally along the body of the pancreas with anastomosis to a Roux-en-Y loop of jejunum. Partington and Rochelle modified the Puestow procedure by eliminating the resection of the pancreatic tail. A recent procedure involves a wedge-shaped opening of the pancreatic duct (even when the duct is <5 mm) with a subsequent pancreatico-jejunostomy. The preservation of functional tissue and reduction of operative mortality to less than 1% and morbidity to less than 10% are the goals and benefits of this operation. Unfortunately, large series have reported persistence or recurrence of pain at long-term follow up (>5 year) in 30–50% of patients; in addition, patients with a dominant mass in the head of the pancreas and a non-dilated pancreatic duct do not appear to profit from a drainage procedure at all. A recent randomized controlled trial demonstrated that operative drainage in selected patients with a large duct was more effective than endoscopic treatment in patients with obstruction of the pancreatic duct.
Pancreatoduodenectomy (Kausch-Whipple procedure). For many surgeons, a pancreatoduodenectomy is the gold standard for patients with the pain of chronic pancreatitis, although the newer, duodenum-preserving procedures are good (and possibly better) alternatives as well (see below). The approach of resection of the proximal gland is based on Longmire’s tenet that the ‘‘pacemaker’’ of pain is in the head of the pancreas. The indications for pancreatoduodenectomy in patients with chronic pancreatitis and pain are:
(1) a non-dilated pancreatic duct (diameter < 6 mm measured in the body of the gland),
(2) an enlarged head of the pancreas, often containing cysts and calcifications,
(3) a previous, ineffective ductal drainage procedure, and/or
(4) when there is the possibility of malignancy in the head of the gland.
This latter subgroup comprises up to 6–10% of patients undergoing operative intervention for chronic pancreatitis. After pancreatoduodenectomy, > 80% of patients have permanent pain relief, which is greater than after a drainage operation. In experienced centers, a pancreatoduodenectomy can be performed with a low operative mortality rate (< 2%), and a morbidity of 40%. Although the classic pancreatoduodenectomy has these advantages, there is some long-term morbidity in chronic pancreatitis patients, especially regarding quality of life. In addition to development of diabetes, patients experience postoperative digestive dysfunction, including dumping, diarrhea, peptic ulcer, and dyspeptic complaints. To address these effects of the classic pancreatoduodenectomy which involved a distal gastrectomy, ‘‘organ-preserving’’ operations like the pylorus-preserving pancreatoduodenectomy. Symptoms of dumping and bile-reflux gastritis can be decreased by preserving the stomach, the pylorus, and the first part of the duodenum. In addition, regarding quality of life, a pylorus-preserving technique provides better results than the classic pancreatoduodenectomy procedure; weight gain occurs in 90% of the patients postoperatively while still leading to long-lasting pain relief in 85–90% of the patients. Pylorus-preserving resections, however, appear to have a greater incidence of transient delayed gastric emptying postoperatively (20–30% of the patients) as well as the risk of cholangitis and the long-term occurrence of exocrine and endocrine pancreatic insufficiency (seen in >45% of patients), representing the possible drawbacks of this operation in chronic pancreatitis patients. The relevant studies (level I and II) comparing classic with pylorus preserving pancreatoduodenectomy could not demonstrate a clear advantage for either resection. One should remember, however, that pancreatoduodenectomy was originally introduced to treat malignant pancreatic or periampullary disease by an oncologic resection. Therefore, for a benign disorder such as chronic pancreatitis, there is no reason – other than the occasional inability to exclude pancreatic cancer definitely – to remove peripancreatic organs (the distal stomach, the duodenum, and the extrahepatic bile ducts), which are involved only secondarily in chronic pancreatitis. This concept stimulated the development of organ-preserving pancreatic resections.
Duodenum-preserving pancreatic head resection (DPPHR).
This procedure addresses patients with a dominant mass in the head of the pancreas with or without a dilated main pancreatic duct. The duodenum-preserving resection (Beger procedure) includes a ventral dissection and dorsal mobilization of the head of the pancreas. After division of the pancreas anterior to the porto-mesenteric vein (as with a pancreatoduodenectomy), the resection is carried out toward the papilla of Vater. A subtotal resection of the pancreatic head is carried out leaving a small margin of pancreatic tissue associated with the duodenum containing the common bile duct; a small rim of pancreatic tissue toward the vena cava should be preserved as well during removal of most all of the uncinate process. In most patients, it is possible to free the bile duct from the surrounding scarring without disrupting continuity with the ampulla of Vater, thereby avoiding the need for a bilio-digestive anastomosis.
In some patients (20%), the common bile duct is obstructed and should be opened, so that the bile will drain into the cavity of the resected pancreatic head which is drained into a Roux-en-Y limb of jejunum. The standard reconstruction consists of a Roux-en- pancreaticojejunostomy to the distal pancreatic remnant (body and tail of pancreas) and a pancreatojejunostomy to the rim of pancreas at the duodenum (including the opened bile duct if needed). In up to 10% of patients, this DPPHR procedure is combined with a lateral pancreaticojejunostomy to drain multiple stenoses of the main pancreatic duct. The mortality rate is low (1%), and the morbidity rate is around 15%, less than after pancreatoduodenectomy.
When compared with pancreatoduodenectomy in patients with chronic pancreatitis, the DPPHR offers the advantage of preserving the duodenum and extrahepatic biliary tree, and its superiority over even the pylorus-preserving resection has been shown in prospective studies. Patients who underwent the DPPHR had greater weight gain, a better glucose tolerance, and a higher capacity for insulin secretion. In long-term follow-up, about 20% of the patients developed new onset of diabetes mellitus, like the incidence of diabetes after pancreatoduodenectomy. There is some evidence that endocrine function may be better preserved after DPPHR when compared with patients with chronic pancreatitis not undergoing operation, secondary to the relief of pancreatic ductal obstruction/hypertension. Regarding pain status, 90% of patients after DPPHR have long-term relief of pain. Regarding quality of life, 69% of the patients in one study were rehabilitated professionally, 26% retired, and only 5% of the patients were unimproved. Considering the better pain status, a lesser frequency of acute episodes of chronic pancreatitis, especially in those patients with an enlarged pancreatic head, marked decrease in the need for further hospitalization, low early and late mortality rate, and the restoration of a better quality of life, evidence suggests that DPPHR may delay the natural course of the disease of chronic pancreatitis.
The DPPHR was modified by Frey and colleagues to include a longitudinal pancreatico-jejunostomy combined with a local ‘‘coring out’’ of the pancreatic head without the need for an extensive dissection near the superior mesenteric vessels as with the DPPHR. The Frey and DPPHR have undergone evaluation in multiple comparative trials, confirming their effectiveness as operative procedures for chronic pancreatitis. A modified technique (Bern procedure) of the Beger and Frey procedures has been described recently in patients with chronic pancreatitis. This extended Frey procedure combines the advantages of the Beger and Frey procedure by maintaining a non-anatomic, subtotal central pancreatic head resection but without the need for transsection of the gland over the superior mesenteric vein (SMV), the most tedious part of the DPPHR procedure which was the major advantage offered by the Frey procedure. This modified technique reduces the risk of intraoperative bleeding which is especially increased in the presence of portal hypertension.
Left-sided pancreatic resection (distal pancreatectomy)
Most surgeons believe that the pancreatic head is the pacemaker in chronic pancreatitis, and therefore, pancreatic head resections should be the target for most patients with chronic pancreatitis affecting the entire gland. There is, however, a small and carefully selected group of patients in whom a left-sided pancreatic resection is the appropriate treatment. This subgroup is selected by imaging techniques, including CT, ERCP, or MRI outlining inflammatory complications, such as pseudocysts, fistula, and pancreatic duct stenosis, involving only (or primarily) the body and/or tail region of the pancreas. A good example is the patient who develops a mid-ductal stricture after an episode of necrotizing pancreatitis secondary to gallstone pancreatitis. Similarly, suspicion of a neoplasm or recurrent acute pancreatitis believed secondary to an isolated, mid-ductal stricture may be justification for a left-sided pancreatic resection. Overall, about 10% of all patients who undergo operative intervention for chronic pancreatitis may be candidates for a distal pancreatectomy. These distal pancreatectomies for benign disease can be performed without splenectomy, but conservation of the splenic artery and vein can be difficult and is time-consuming. Nevertheless, the advantage of avoiding the possibility of overwhelming postsplenectomy sepsis should be taken into consideration as well as the importance of the spleen for maintenance of the host defense system. Thus, preservation of the spleen is desirable if there is no clear indication for splenectomy, such as perisplenic pseudocyst or inflammatory/fibrotic encasement of the splenic vessels.
Central pancreatectomy (middle segmentectomy).
Benign lesions of the neck and proximal body of the pancreas, such as the exceedingly rare focal chronic pancreatitis or post-traumatic pancreatitis, pose an interesting operative challenge. If the lesions are not amenable to simple enucleation, surgeons may be faced with the choice of performing a right-sided resection (pancreatoduodenectomy) or a left-sided resection (distal pancreatectomy) to include the lesion, resulting in resection of a substantial amount of otherwise functioning pancreatic parenchyma. Central pancreatic resections have been reported primarily for benign or low-grade neoplasms with Roux-en-Y pancreatojejunostomy reconstruction. Central pancreatectomy affords the possibility of saving functional pancreatic tissue in attempt to avoid the complications of pancreatic insufficiency. Further studies, however, must prove the effectiveness of such an operation for patients with chronic pancreatitis. Central resections in patients with chronic pancreatitis must be viewed with caution and considered only in highly selected cases.
Pancreatic resection with islet cell autotransplantation.
Because of the concerns of pancreatic endocrine insufficiency after any pancreatic resection for chronic pancreatitis, renewed interest has focused on the possibility of performing a total pancreatectomy, isolating the islets, and reinfusing (autotransplanting) the islets into the liver. Improvements in islet cell harvesting and preservation for islet cell allotransplantation for diabetics have allowed new enthusiasm in this technique for patients with chronic pancreatitis. Results to date are encouraging, but the inability to harvest reliably an adequate number of islets and to prove successful engraftment within the liver remain current limitations. This approach may be more effective early in the disease when islets have not been depleted.
In summary, definite evidence for the best operative method for treating painful chronic pancreatitis is still not fully accepted. The study designs in the few randomized controlled trials (evidencebased Level I data) available today have some limitations in design and reporting of morbidity and include only small numbers of patients. Nevertheless, the different variations of the DPPHR, Beger, Frey, and Bern procedures appear to be as equally successful in achieving long-term pain control as pancreatoduodenectomy, but they have fewer postoperative complications and appear to be superior with regard to preservation of pancreatic function and quality of life.
Aula de Anatomia do Dr Nicolaes Tulp (1632)
O valor da obra “A Aula de Anatomia do Dr. Nicolaes Tulp” é incalculável, pois ela pertence ao acervo do Mauritshuis, em Haia, na Holanda, e é considerada uma das mais importantes e valiosas obras do museu. Além disso, a pintura é uma das mais famosas obras de Rembrandt e uma das mais importantes do período Barroco holandês. Por isso, é considerada uma obra-prima da arte ocidental e tem um valor histórico, artístico e cultural inestimável. Embora não haja um valor monetário exato para a pintura, pode-se dizer que é uma das obras mais valiosas e procuradas do mundo da arte, tanto pelo seu significado histórico quanto pela sua qualidade artística.
“A Aula de Anatomia do Dr. Nicolaes Tulp” é uma pintura a óleo sobre tela, criada por Rembrandt van Rijn em 1632. A obra mede 169,5 cm x 216,5 cm e está atualmente exposta no Mauritshuis, em Haia, na Holanda. A composição da pintura apresenta um grupo de homens em torno de uma mesa de dissecação, liderados pelo médico Nicolaes Tulp, que está realizando uma demonstração de anatomia. O corpo sendo dissecado é o de um criminoso enforcado chamado Aris Kindt. A composição apresenta uma disposição simétrica e organizada das figuras em torno da mesa, com Tulp no centro da imagem.
A luz na pintura é focada no corpo sendo dissecado, destacando-o em relação ao fundo escuro da sala. A técnica de chiaroscuro usada por Rembrandt acentua o realismo e o drama da cena. As figuras são pintadas em tons de marrom, cinza e preto, com destaques de branco. A obra apresenta detalhes precisos e realistas da anatomia do corpo, bem como das ferramentas médicas utilizadas na dissecação. O corpo do criminoso apresenta uma ferida na cabeça e uma perna amputada, o que sugere que ele pode ter sido executado por um crime violento.
No canto inferior direito da pintura, há um livro aberto com o título “Spiegel der Konst” (“Espelho da Arte”), um tratado de anatomia escrito por Adriaan van de Spiegel e utilizada pelos médicos da época. Em geral, a “Aula de Anatomia do Dr. Nicolaes Tulp” é uma obra-prima devido à sua técnica precisa e detalhada, bem como à sua habilidade em transmitir um senso de realismo e drama. A pintura é considerada uma das obras mais importantes do período Barroco holandês e é frequentemente citada como um exemplo do estilo de pintura de Rembrandt.
A seguir estão algumas das características artísticas e estéticas da obra:
- Composição: A pintura apresenta uma composição equilibrada e organizada, com as figuras dos membros da guilda cirúrgica em torno da mesa de dissecação centralizada.
- Luz e Sombra: Rembrandt usa uma técnica conhecida como chiaroscuro, ou contraste entre luz e sombra, para dar profundidade e dimensão à cena. A luz focaliza no cadáver e no médico principal, destacando-os do fundo escuro.
- Realismo: A pintura é altamente realista, mostrando detalhes precisos das ferramentas cirúrgicas, do cadáver e das expressões dos personagens.
- Cores: O uso limitado de cores em tons de marrom e cinza dá à pintura uma atmosfera austera e solene.
- Simbolismo: A pintura inclui vários elementos simbólicos, como a presença de uma coruja, que representa sabedoria, e a posição da mão do cadáver, que simboliza a morte.
- Técnica: A pintura foi executada com uma técnica de pincelada solta e fluida, que enfatiza a textura e a superfície da pintura.
Em geral, a “Aula de Anatomia do Dr. Nicolaes Tulp” é considerada uma obra-prima devido à sua habilidade técnica e sua capacidade de transmitir um senso de realismo e drama. A pintura é considerada uma das obras mais importantes do período Barroco holandês e é frequentemente citada como um exemplo do estilo de pintura de Rembrandt.
“Ao CADÁVER DESCONHECIDO, todo nosso respeito e agradecimento!”
O estudo da anatomia humana é essencial para o ensino e avanço da medicina, e o cadáver desempenha um papel fundamental nesse processo. O cadáver é uma ferramenta valiosa que permite aos estudantes de medicina, anatomia e outras áreas da saúde aprenderem sobre a estrutura e a organização do corpo humano de uma maneira muito mais eficaz do que seria possível apenas com modelos em duas dimensões ou imagens de realidade virtual.
A dissecação de um cadáver permite que os estudantes examinem as diferentes camadas de tecido e órgãos que compõem o corpo humano, geralmente ensinadas na disciplina de ANATOMIA TOPOGRÁFICA. Isso pode ajudá-los a entender como as estruturas funcionam juntas para manter a homeostase. Ao dissecar um cadáver, os estudantes podem observar as relações anatômicas entre as estruturas, entender as diferenças entre os diferentes sistemas do corpo humano e identificar as variações individuais que ocorrem em cada pessoa. Essas informações são fundamentais para o diagnóstico e o tratamento de doenças e distúrbios.
Além disso, o estudo do cadáver permite que os estudantes observem as variações normais que ocorrem no corpo humano, bem como as anomalias e patologias que podem afetar diferentes sistemas e órgãos. Isso pode ajudar os estudantes a entender as causas e os efeitos de doenças e distúrbios e a desenvolver habilidades práticas para o diagnóstico e o tratamento. Por exemplo, ao estudar um cadáver com uma patologia específica, os estudantes podem aprender a identificar essa condição em pacientes vivos e determinar o melhor tratamento para cada caso.
Além de fornecer informações valiosas sobre a estrutura do corpo humano, o estudo do cadáver também é importante para a investigação científica e o desenvolvimento de novas técnicas e tecnologias médicas. Por exemplo, ao estudar a anatomia do sistema nervoso central de um cadáver, os pesquisadores podem identificar áreas do cérebro que controlam funções específicas, como a fala ou a visão. Isso pode levar ao desenvolvimento de novas técnicas cirúrgicas que preservam essas funções durante procedimentos no cérebro.
O estudo do cadáver também é fundamental para o treinamento de cirurgiões. Através da dissecação de cadáveres, os cirurgiões podem praticar técnicas cirúrgicas complexas e aprimorar suas habilidades antes de realizar procedimentos em pacientes vivos. Isso pode ajudar a reduzir o risco de complicações durante as cirurgias e melhorar os resultados para os pacientes. A anatomia é a disciplina fundamental da formação cirúrgica desde tempos remotos na história da medicina.
No entanto, o uso de cadáveres para o estudo da anatomia humana é uma questão ética e legal complexa. Para garantir que o uso de cadáveres seja feito de forma ética e responsável, muitos países têm leis e regulamentações rigorosas que governam a dissecação de corpos humanos. Essas leis e regulamentações visam garantir que os cadáveres sejam tratados com respeito e dignidade, que o consentimento adequado seja obtido antes da dissecação e que a privacidade e a confidencialidade dos doadores sejam protegidas.
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Visão Crítica de Segurança (Colecistectomia)
A colecistectomia laparoscópica (CL) é o padrão-ouro para tratamento de cálculos biliares. No entanto, o risco de lesão do ducto biliar (BDI) continua a ser preocupação significativa, uma vez que CL ainda tem taxa de BDI maior do que a via laparotômica, apesar de muitos esforços propostos para aumentar sua segurança. A Visão Crítica da Segurança (CVS) proposta por Strasberg é a técnica para a identificação dos elementos críticos do triângulo de Calot durante a CL. Esta técnica foi adotada em vários programas de ensino e com a proposta de reduzir o risco de BDI e o uso da adequado da CVS está associado a menores taxas de BDI. O objetivo deste #Webinar é abordar a Anatomia Cirúrgica Fundamental para a realização de uma Colecistectomia Laparoscópica.
Intraoperative cholangiography: Selective or Routine?
Intraoperative cholangiography (IOC), described by Mirizzi in 1932, represented a significant advance in the diagnosis of choledocolithiasis during cholecystectomy. The natural history of asymptomatic choledocolithiasis has been investigated in different populations and its therapeutic management continues to be controversial. IOC is traditionally advocated as a procedure to be adopted in all laparoscopic cholecystectomies since it permits to define the anatomy of the biliary tract and to detect common bile duct stones. However, in the laparoscopic era, technological advances in radiologic-endoscopic workup have markedly increased the costs of investigation of patients with suspected choledocolithiasis. The routine use of IOC has raised the question of which cases require the exploration of bile tract anatomy during surgery and whether there are methods to predict preoperatively unsuspected choledocolithiasis. Therefore, the most appropriate management of preoperatively unsuspected choledocolithiasis, i.e., the routine or selective use of IOC, still remains undefined. In this respect, well-defined criteria for the inclusion of patients with possible choledocolithiasis who should be submitted to cholangiography exist in the literature, but there is no safe approach to exclude asymptomatic patients without an indication for contrast examination.
A systematic literature search was performed by KOVACS N, et al (2022) using the following search keys: cholangiogra* and cholecystectomy. The primary outcomes were BDI and retained stone rate. To investigate the differences between the groups (routine IOC vs selective IOC and IOC vs no IOC), they calculated weighted mean differences (WMD) for continuous outcomes and relative risks (RR) for dichotomous outcomes, with 95% confidence intervals (CI). Of the 19,863 articles, 38 were selected and 32 were included in the quantitative synthesis. Routine IOC showed no superiority compared to selective IOC in decreasing BDI (RR = 0.91, 95% CI 0.66; 1.24). Comparing IOC and no IOC, no statistically significant differences were found in the case of BDI, retained stone rate, readmission rate, and length of hospital stay. They found an increased risk of conversion rate to open surgery in the no IOC group (RR = 0.64, CI 0.51; 0.78). The operation time was significantly longer in the IOC group compared to the no IOC group (WMD = 11.25 min, 95% CI 6.57; 15.93). So this data findings suggest that IOC may not be indicated in every case, however, the evidence is very uncertain.
Postoperative complications represent one of the most debated topics in pancreatic surgery. Indeed, the rate of complications following pancreatectomy is among the highest in abdominal surgery, with morbidity ranging between 30 and 60%. They are often characterized by elevated clinical burden, with a consequent challenging postoperative management. Mortality rates can exceed 5%. The impact on patient recovery and hospital stay eventually leads to massive utilization of resources and increases costs for the health system. The International Study Group of Pancreatic Surgery (ISGPS) provides standardized definitions and clinically based classifications for the most common complications after pancreatectomy, including postoperative pancreatic fistula (POPF), post pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), bile leakage, and chyle leak.
Post Pancreatectomy Hemorrhage
Despite its lower incidence compared with POPF with reported rates of 3–10% after pancreatectomy, PPH remains one of the major of postoperative complications, with mortality rates ranging from 30 to 50%. According to current ISGPS recommendations, PPH is classified in three grades (A, B, and C) based on two main criteria: timing of the hemorrhage and severity of the bleeding. The timing is dichotomized as early, occurring within 24 hours from the index surgery, and late, when it happens afterwards.
Management is tailored according to the clinical picture, the timing of onset, and the presumptive location. Early hemorrhage is generally due to either unsuccessful intraoperative hemostasis or to an underlying coagulopathy. The vast majority of patients are basically asymptomatic, with PPH having no influence on the postoperative course. However, when the bleeding is severe, re-laparotomy is recommended, with the aim of finding and controlling the source of bleeding. This approach usually guarantees an uneventful subsequent course. Late PPH is often challenging and the pathogenesis is diverse. Vascular erosion secondary to POPF or intraabdominal abscess, late failure of intraoperative hemostatic devices, arterial pseudoaneurysm, and intraluminal ulceration are some of the most common causes. In this setting, surgical access to the source of bleeding may be challenging. Angiography (if extraluminal) and endoscopy (if intraluminal) represent the primary approaches to treatment. Surgery is reserved for hemodynamically unstable patients and for those who present with deteriorating condition, multiorgan failure or sepsis. Given these assumptions, except for early mild events, contrast-enhanced abdominal CT is crucial in all cases of PPH, possibly allowing identification of the source and planning the management accordingly. Also, it should be noted that late massive hemorrhages may be preceded by mild self-limiting sentinel bleeds. A prompt abdominal CT scan aimed at excluding vascular lesions is therefore strongly recommended in these cases.
The incidence of complications following pancreatic resection remains high. The ISGPS established standardized definitions and clinical grading systems for POPF, PPH, DGE, and biliary and chyle leak. These classification systems have enabled unbiased comparisons of intraoperative techniques and management decisions. However, the management policies of these complications are most often driven by a patient’s condition and local surgical expertise and is not always based on the available high-level evidence. The development of high-volume specialized units with appropriate resources and multidisciplinary experience in complication management might further improve the evidence and the outcomes.
Subtotal cholecystectomy for difficult acute cholecystitis
Laparoscopic cholecystectomy is considered the gold standard for treatment of benign gallbladder diseases. Cholecystectomy using this method can be completed in 90% of elective cholecystectomies and 70% of emergency cholecystectomies. Acute cholecystitis, especially if difficult, can change the above paradigm, resulting in open conversion or change of technique. The conditions that define a difficult cholecystectomy are as follows: necessity of conversion from laparoscopic to open surgery; duration of procedure greater than 180 min; blood loss greater than 300 ml; and urgent need for involvement of a more experienced surgeon. One of the “rescue” procedures to complete the surgery safely (both for the surgeons and patients) is subtotal cholecystectomy (STC). Open and laparoscopic subtotal cholecystectomy have been reported. For many surgeons, this is considered a bail out technique, and the timing of decision making is crucial to avoid catastrophic complications. Te capability to perform STC in laparoscopy is increasingly requested during difficult laparoscopic cholecystectomy. Difficult LC has a risk of BDI from 3 to 5 times higher in laparoscopy than open surgery. In case of operative difficulties of young surgeons mostly trained in laparoscopy the help of senior surgeons is strongly recommended. The purpose of the present study is to clarify how laparoscopic subtotal cholecystectomy may be used to complete a difficult cholecystectomy for acute cholecystitis without serious complications.
Biliary leakage represents the most frequent complication of incomplete resection of the gallbladder wall in cases of difficult acute cholecystectomy treated with subtotal cholecystectomy. This complication is rarely fatal but requires correct treatment. If bile leakage does not stop spontaneously seven days postoperatively, the possible treatments are endoscopic biliary sphincterotomy, endoscopic plastic stent, and a fully covered self-expanding metal stent. When performing closure of the gallbladder stump, suturing the anterior residual of both anterior and posterior wall represents the best method to have fewer complications. Complications, if not lethal, decrease the patient’s quality of life. Intraoperatively, it is of utmost importance to carefully expose the gallbladder stump to avoid left-in-place stones, wash the entire cavity and drain the abdomen. Bile duct injuries can be a significant complication in this type of surgery. Prevention of the lesions with conversion from laparoscopic to open, or the opinion of older surgeon in case of difficulties is strongly recommended. Mortality is a very rare complication. The limitations of our study are given by the heterogeneity of the techniques used for LSC and the lack of a long-term follow-up analyzing the related complications.
Timing of Elective Surgery after #COVID19 Infection
The options to clear a recovered COVID-19 patient for surgery could be a symptom or test-based strategy. The studies recommend a hybrid strategy until more information is available. Surgical procedures should be delayed if possible for 4–6 weeks. The scientific data recommend against routine testing in this group as patients are likely not infectious any-more and risk of airway reactivity or ARDS will be reduced. Between 2 and 4 weeks after symptom onset, scientific data recommend a test-based strategy due to insufficient data that recovered COVID patients are completely uninfectious. Data from China suggest that patients with severe symptoms have higher viral burden and prolonged viral shedding. For surgery completion<2 weeks after COVID-19 symptoms or diagnosis, scientific data recommend no testing and operating under COVID isolation precautions in the operating room. Immunocompromised patients are likely to shed longer and may be at higher risk of other infectious or pulmonary complications. The scientific data suggest individualized case-based decisions by involved providers until more information is available.
Obstrução Intestinal por ADERÊNCIAS pós-operatórias
A obstrução intestinal ocorre quando a propulsão do conteúdo entérico em direção ao ânus sofre interferência. Há vários critérios para classificá-la: quanto ao nível (delgado alto e baixo ou cólon), quanto ao grau (completa, incompleta – suboclusão ou “alça fechada”), quanto ao estado de circulação sangüínea (simples ou estrangulada), quanto ao tipo de evolução (aguda ou crônica) e quanto à natureza da obstrução (mecânica, vascular ou funcional). Ao que se a figura, em torno de 20% das cirurgias por quadros de abdome agudo são de pacientes com obstrução intestinal. Atualmente, as aderências pós-operatórias são a principal causa em todas os grupos etários. Hérnia inguinal estrangulada, outrora causa mais comum, figura em segundo lugar, seguida de neoplasia intestinal. Esses três agentes etiológicos respondem por mais de 80% de todas as obstruções.
Os sintomas cardinais são: dor, náuseas e vômitos, parada da eliminação de gases e fezes com distensão abdominal, sendo que esta manifestação ocorre mais tarde. A dor é tipicamente em cólica, de início brusco, em salva, ocorrendo a intervalos regulares, de localização epigástrica, periumbilical ou hipogástrica, dependendo do nível da obstrução. Se a dor se tornar contínua, localizada ou difusa nos intervalos entre as cólicas, é grande a suspeita de comprometimento vascular, ou seja, isquemia intestinal. Nas obstruções mecânicas altas os vômitos são freqüentes, surgem precocemente e são constituídos de material estagnado e de aspecto bilioso; nas obstruções de cólon as náuseas e vômitos podem inexistir. Na obstrução mecânica os sintomas de obstipação são tardios. A parada total da eliminação de gases e fezes é o apanágio da obstrução completa. Na suboclusão, o paciente pode continuar eliminando gases. A distensão abdominal pode surgir algumas horas depois de iniciados os sintomas, em função do nível de obstrução, sendo ausente ou discreta nas oclusões altas do intestino delgado, intensa e precoce nas baixas e mais tardias nas obstruções do cólon.
O exame físico nas primeiras 24 horas pode revelar pouquíssimos achados anormais, a não ser durante os períodos de cólica, os sinais vitais mantêm-se normais, e a desidratação e distensão ainda não são pronunciadas. Há defesa de parede durante a palpação, e a descoberta de massa ou área restrita de dor é sugestiva de estrangulamento. A ausculta é de grande valor, pois o abdome é silencioso, exceto nos ataques de cólica, nos quais os ruídos são altos, agudos e metálicos. Em torno do segundo ou terceiro dia a doença agrava-se visivelmente, quando a desidratação e a distensão estão acentuadas e os sinais vitais se alteram, apesar da obstrução simples só acarretar choque tardiamente.
Podem ser feitos exames complementares não só para o diagnóstico, como também para terapêutica. Exemplo disto é o tratamento do volvo de sigmóide com o auxílio da retossigmoidoscopia ou colonoscopia pela passagem, sob visão direta, de sonda além da zona de torção. A radiografia do abdome e a Tomografia Computadorizada é fundamental para confirmação diagnóstica, melhor compreensão dos dados clínicos e também pode ajudar a elucidar etiologias. Os exames laboratoriais, permitem avaliar o grau e tipo de desequilíbrio metabólico, o que será fundamental para a terapêutica, definindo se há ou não sofrimento vascular.
Os princípios da terapêutica são a reposição de líquidos e eletrólitos, a descompressão do intestino e a intervenção cirúrgica no momento adequado. Absolutamente todos os pacientes com obstrução intestinal COMPLETA, devem ser operados. Há 5 categorias de manobras cirúrgicas: extraluminares, enterotomia para retirada de corpos estranhos da luz, ressecção intestinal, operações de desvio de trânsito e operações de descompressão. Pelo fato de ser intervenção cirúrgica de urgência, as complicações pós-operatórias são mais freqüentes. As mais observadas são: infecção de parede, íleo prolongado, sepse, complicações pulmonares e infecção urinária.
#Bolsonaro #ObstruçãoIntestinal #Aderências
The “BAD” Gallbladder
Once the decision for surgery has been made, an operative plan needs to be discussed and implemented. Should one initially start with laparoscopic surgery for the “bad gallbladder”? If a laparoscopic approach is taken, when should bail-out maneuvers be attempted? Is converting to open operation still the standard next step? A 2016 study published by Ashfaq and colleagues sheds some light on our first question. They studied 2212 patients who underwent laparoscopic cholecystectomy, of which 351 were considered “difficult gallbladders.” A difficult gallbladder was considered one that was necrotic or gangrenous, involved Mirizzi syndrome, had extensive adhesions, was converted to open, lasted more than 120 minutes, had a prior tube cholecystostomy, or had known gallbladder perforation. Seventy of these 351 operations were converted to open. The indications for conversion included severe inflammation and adhesions around the gallbladder rendering dissection of triangle of Calot difficult (n 5 37 [11.1%]), altered anatomy (n 5 14 [4.2%]), and intraoperative bleeding that was difficult to control laparoscopically (n 5 6 [1.8%]). The remaining 13 patients (18.5%) included a combination of cholecystoenteric fistula, concern for malignancy, common bile duct exploration for stones, and inadvertent enterotomy requiring small bowel repair. Comparing the total laparoscopic cholecystectomy group and the conversion groups, operative time and length of hospital stay were significantly different; 147 +- 47 minutes versus 185 +- 71 minutes (P<.005) and 3+-2 days versus 5+-3 days (P 5 .011), respectively. There was no significant difference in postoperative hemorrhage, subhepatic collection, cystic duct leak, wound infection, reoperation, and 30-day mortality.2 From these findings, we can glean that most cholecystectomies should be started laparoscopically, because it is safe to do so. It is the authors’ practice to start laparoscopically in all cases.
Despite the best efforts of experienced surgeons, it is sometimes impossible to safely obtain the critical view of safety in a bad gallbladder with dense inflammation and even scarring in the hepatocystic triangle. Continued attempts to dissect in this hazardous region can lead to devastating injury, including transection of 1 or both hepatic ducts, the common bile duct, and/or a major vascular injury (usually the right hepatic artery). Therefore, it is imperative that any surgeon faced with a bad gallbladder have a toolkit of procedures to safely terminate the operation while obtaining maximum symptom and source control, rather than continue to plunge blindly into treacherous terrain. If the critical view of safety cannot be achieved owing to inflammation, and when further dissection in the hepatocystic triangle is dangerous, these authors default to laparoscopic subtotal cholecystectomy as our bail-out procedure of choice. The rationale for this approach is that it resolves symptoms by removing the majority of the gallbladder, leading to low (although not zero) rates of recurrent symptoms. It is safe, and can be easily completed laparoscopically, thus avoiding the longer hospital stay and morbidity of an open operation. There is now significant data supporting this approach. In a series of 168 patients (of whom 153 were laparoscopic) who underwent subtotal cholecystectomy for bad gallbladders, the mean operative time was 150 minutes (range, 70–315 minutes) and the average blood loss was 170 mL (range, 50–1500 mL). The median length of stay for these patients was 4 days (range, 1–68 days), and there were no common bile duct injuries.23 There were 12 postoperative collections (7.1%), 4 wound infections (2.4%), 1 bile leak (0.6%), and 7 retained stones (4.2%), but the 30-day mortality was similar to those who underwent a total laparoscopic cholecystectomy. A systematic review and meta-analysis by Elshaer and colleagues showed that subtotal cholecystectomy achieves comparable morbidity rates compared with total cholecystectomy. These data support the idea that we should move away from the idea that the only acceptable outcome for a cholecystectomy is the complete removal of a gallbladder, especially when it is not safe to do so. This shift toward subtotal cholecystectomy has been appropriately referred to as the safety first, total cholecystectomy second approach.
Management of HEPATIC ADENOMA
At a minimum, cessation of exogenous hormones is recommended, followed by serial imaging, as these lesions will shrink when the inciting hormone has been removed. In general, to obtain either CT or MRI every 6 months for the first 2 years and then once annually for lesions that we are following. Intervention is dictated by the risk of hemorrhage and malignant transformation, which is directly correlated to size. Hepatocellular carcinoma is seen in 5% of patients with lesions exceeding 8 cm. The rate of rupture is strongly associated with size > 5 cm.
Surgical resection is recommended for lesions ≥ 5 cm, those that are enlarging, those for which malignancy cannot be excluded, and those that are symptomatic. Additionally, adenomas in men, regardless of size, and especially those that are associated with anabolic steroid use, those with glycogen storage disease, and those that harbor ß-catenin mutations should also be given serious consideration for surgical extirpation.
Pregnant women with HA pose a management challenge. Since adenomas respond to hormones, they can increase in size with pregnancy and thus put the patient at risk for rupturing and bleeding. For women who would like to become pregnant, close monitoring without discouraging the patient’s wish is
recommended for lesions < 5 cm. However, for those patients with lesions > 5 cm or those who had complications from the adenomas from previous pregnancies, we recommend surgical resection prior to proceeding with the pregnancy. In situations where HA is discovered during pregnancy, we recommend close monitoring for lesions < 5 cm. However, for lesions > 5 cm, surgical resection should be considered during the second trimester but delayed in the third trimester since surgical intervention during this trimester is fraught with complications.
Managing the “difficult” gallbladder
The gold standard for the surgical treatment of symptomatic cholelithiasis is conventional laparoscopic cholecystectomy (LC). The “difficult gallbladder” is a scenario in which a cholecystectomy turns into an increased surgical risk compared with standard cholecystectomy. The procedure may be difficult due to processes that either obscure normal biliary anatomy (such as acute or chronic inflammation) or operative exposure (obesity or adhesions caused by prior upper abdominal surgery). So, when confronted with a difficult cholecystectomy, the surgeon has a must: to turn the operation into a safe cholecystectomy, which can mean conversion (to an open procedure), cholecystostomy, or partial/ subtotal cholecystectomy. The surgeon should understand that needs to rely on damage control, to prevent more serious complications if choosing to advance and progress to a complete cholecystectomy.
When to Predict a Difficult Laparoscopic Cholecystectomy
A difficult cholecystectomy may be predicted preoperatively based on patient characteristics and ultrasound and laboratory findings. This is probably a very important step in mitigating the high risk associated with a difficult procedure and may serve either to reschedule the procedure or design intraoperative strategies of management to guarantee a safe performance of the surgical procedure.
The following situations are associated with a higher chance of a difficult cholecystectomy:
• Acute cholecystitis (more than 5 days of onset)
• Previous cholecystitis episode
• Male sex
• Sclero-atrophic gallbladder
• Thick walls (>5 mm)
• Previous signs of canalicular dwelling (clinical and laboratory)
Through multivariate analysis, Bourgoin identified these elements of predictive help to identify difficult LC: male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase levels. Another important point is the fact of conversion from a laparoscopic procedure to an open and traditional cholecystectomy, usually through a right subcostal incision. Conversion should not be considered as a personal failure, and the surgeon needs to understand the concept of “safety first,” considering that conversion is performed in order to complete the procedure without additional risks and preventing complications and not solving intraoperative complications. It is also useful to define a time threshold to aid in the decision to convert. It is not worth taking an hour and a half and still dissecting adhesions, preventing the correct visualization of the cystic pedicle. This time limit represents a method to prevent inefficiencies in the operating room (OR) schedule as well as additional expenditures.
A smart surgeon should rely to conversion in the following situations:
• Lack of progress in the procedure
• Unclear anatomy/any grade of uncertainty
• CVS not achieved
• Bleeding/vascular injury
• BD injury
• Lack of infrastructure, expertise, and support
The primary goal of a laparoscopic cholecystectomy in the treatment of symptomatic cholelithiasis is the safe remotion of the gallbladder and the absence of common bile duct injury. Some tips to take into account:
– Never perform a laparoscopic cholecystectomy without a skilled surgeon close by.
– Beware of the easy gallbladder.
– Slow down, take your time.
– Knowledge is power, conversión can be the salvation!
– Do not repair a bile duct injury (unless you have performed at least 25 hepaticojejunostomies).
– Do not ignore postoperative complaints (pain, jaundice, major abdominal discomfort, fever)
Other options when confronted with a difficult laparoscopic cholecystectomy are:
– A percutaneous cholecystostomy, if the risk was identified preoperatively or the patient is a poor surgical candidate;
– An intraoperative cholangiography, which may aid in identifying an injury to the bile duct and solve it, if you are an experienced surgeon;
– A subtotal or partial cholecystectomy;
– Ask for help;
– Conversion to an open procedure;
Donor Evaluation and Management
There are very few absolute contraindications for abdominal organ donation, which can be summarized in the short form CHUMP: (1) Creutzfeldt-Jakob disease, (2) active HIV infection, (3) uncontrolled donor sepsis, (4) history of melanoma or other malignancy that poses a risk for transmission regardless of the apparent disease – free period, and (5) past history of non-curable malignancy (curable malignancy such as localized small kidney tumors, localized prostate cancer, localized colon malignancy >5 years previously may be considered after careful risk/benefit assessment). In addition to these general criteria, there are organ-specific criteria for guiding the acceptance of a liver for transplantation. A history of hepatitis or alcoholism is certainly a warning sign, but both livers from HBsAg-positive and/or HCV-positive donors are currently used worldwide, and suitability for transplant must be judged on a case-by-case basis. In general, in the case of a marginal liver donor, the intraoperative assessment by the donor surgeon, in addition to liver biopsy pathological evaluation, is the best single piece of information.
Technical Aspects of Liver Procurement
A midline laparotomy from the xyphoid to the pubis is performed and the round ligament divided. The intra-abdominal organs are explored to check for eventual malignancies, and the quality of the liver is assessed: in the absence of contraindications for a transplant, a sternotomy can be performed. Of note, in the presence of prior heart surgery, the complete warm dissection should be made prior to the sternotomy. It is also prudential to isolate and encircle the aorta prior to sternotomy in order to be ready to cannulate in the event of cardiac arrest/injury at thoracotomy. A blunt dissection behind the sternum just below the jugular notch should be performed until the fingertip can be placed retrosternal around the jugular notch. The sternotomy is then performed in a cranial to caudal direction with the sternum saw to avoid left innominate vein injury. The division of the left triangular ligament allows the mobilization of the left lateral segments of the liver and the exposure of the supraceliac aorta just below the diaphragm to be encircled. The division of the falciform ligament up to the suprahepatic inferior vena cava (IVC) provides more mobility of the liver, necessary when the IVC must be divided from a cardiac graft. Before starting the dissection of the hepatoduodenal ligament, the hepatogastric ligament must be inspected by dividing the lesser omentum. This ligament is usually very thin and transparent so that any replaced or accessory left hepatic artery should be easily visible. In addition, palpation of the ventral border of the foramen of Winslow makes it possible to identify a possible accessory or replaced right hepatic artery. Variations in the hepatic arterial supply can complicate the hilar dissection in up to one third of donors.
THE HILAR STRUCTURES
The hilar structures of the liver are then dissected free; the common bile duct (CBD) is dissected on the level of the edge of the second duodenal portion after opening of the peritoneum and visualization of the duct. In difficult cases, due to a high BMI, following the cystic duct out of the gall bladder can help to identify the CBD. The CBD should be encircled from the lateral border of the hepatoduodenal ligament in order to avoid injury of the portal vein. The CBD and the gallbladder are opened and flushed with normosaline solution. The origins of the gastroduodenal, gastric, and splenic arteries are then identified and encircled and, in the case of liver only procurement, will be taped just before cross-clamping in order to increase flushing through the hepatic artery to the liver.
VASCULAR CANULATION / SOLUTION PRESERVATION
The aorta can be isolated by two approaches. One approach requires mobilization of the right colon on top of Gerota’s fascia and should be extended into a Kocher maneuver to uncover both the inferior vena cava and the abdominal aorta; the other approach is performed by opening the root of the mesentery from the Treitz fascia, along the margin of the duodenum until visualization of the right iliac vessels and ureter is achieved. The inferior mesenteric artery can be tied and divided, and the abdominal aorta, just 2–3 cm above the bifurcation, isolated and encircled. The lumbar arteries could be either tied or clipped and then cut in order to provide mobility of the aorta and facilitate the cannulation. Two umbilical tapes are placed around the dissected segment of the aorta and secured by clamps and will be used to secure aortic cannulae to the vessel. The inferior mesenteric vein (IMV) is most commonly used for access into the portal system by ligating the distal part of it but leaving it uncut to retract the vein with a mosquito clamp. Another tie is then placed around the cranial portion of the vein, using it for occlusion of the vein by retracting it while a partial incision of the vein is performed. The portal cannula can be inserted into the IMV while the tension of the occluding tie is decreased before tying it around the vein and inserted cannula. At this point, 30,000-IU heparin should be given to prevent the blood from clotting after the cross-clamping. Once these preliminary procedures have been completed, the aortic cannulae (20-F armed cannulae) can be inserted into the distal abdominal aorta and secured with the umbilical tapes.
The subdiaphragmatic aorta is now clamped (cross-clamp), and cold preservation solution is then rapidly infused through the aortic and portal cannulae; the liver flow is decompressed by dividing the inferior vena cava in the chest. The abdomen is filled with water and ice. The choice of solution for infusion and its amount varies from center to center. The quality of the flush can be assessed by evaluating the outflow of the supradiaphragmatic IVC which should become more transparent with time as the blood in the abdominal organs is replaced by the preservation solution. After the flush is completed, some of the ice is removed from the abdomen to allow the cold dissection of the structures. The gastroduodenal, gastric, and splenic arteries can now be divided. Just below the gastroduodenal artery, the portal vein can be found and can be followed back, if pancreas procurement is not performed, by dividing the head of the pancreas. The cannulae in the IMV can now be removed, the splenic vein ligated and divided, and the venous cannulae replaced in the superior mesenteric vein once it is divided from its distal branches. The superior mesenteric artery (SMA) can now be found in the retro-pancreatic laminae and should be ligated, secured to a clamp and divided in order to find the aortic plane by following back the SMA. This dissection must be made on the left side of the SMA in order to avoid damage to a possible replaced or accessory right hepatic artery. The renal arteries are usually just below the SMA. They should be visualized before the suprarenal aorta is divided. This section must be made in 45°, first looking for ostia of accessory renal arteries before performing complete separation of the aorta. By following back the splenic and gastric arteries, the celiac trunk can be visualized. The aorta must now be divided just below the diaphragm, obtaining a patch containing the celiac trunk and the origin of the mesenteric artery. At this time point, a finger is placed in the supradiaphragmatic IVC helping to identify it while the diaphragm is cut. A portion of the diaphragm should be kept with the liver to ensure that this gross and fast dissection does not damage the organ. The diaphragm is cut to the right, and the incision is then continued between the right kidney and the liver, usually dividing the adrenal gland which is a good sign that none of the adjacent organs are damaged. The location for division of the infrahepatic IVC depends on the renal veins. These are identified on both sides, and the IVC can be safely divided on the virtual line about 1 cm above the renal veins. The only structures now holding the liver in the abdomen are the diaphragmatic pillars. By keeping the liver to the right thoracic cavity and holding the aortic patch, the resected IVC, and the portal vein with its cannulae, the liver removal can be completed by cutting the diaphragmatic muscles. The liver is freed and taken out of the abdomen. A further perfusion with cool preservation solution should be performed on the back table before packing the liver in the transportation box usually with 1 l of preservation solution. The liver can now be packed in the transportation box.
Liver Disease and Perioperative Risk
The liver is the biggest intestinal organ and plays a central role in the homeostasis of different physiological systems including nutrition and drug metabolism, the synthesis of plasma proteins and haemostatic factors, as well as the elimination of different endogenous and exogenous substances. Although the liver contributes with only 3% to total body weight, given its major role in homeostasis and high energy consumption, it receives 25% of total cardiac output (CO). Two vessels contribute to the perfusion of the liver. The majority (70%) of the hepatic perfusion is provided by the portal vein, which contributes 50% of the organ’s oxygen demand. The other 50% is provided by the hepatic artery, which makes up around 30% of total liver perfusion. Hepatic arterial blood flow is mainly dependent on the organ’s metabolic demands and controlled via autoregulatory mechanisms, whereas blood supply through the portal vein depends on the perfusion throughout the whole gastrointestinal tract and the spleen. This unique, dual perfusion system provides constant perfusion rates and oxygen supply, which is crucial for adequate liver function. These high oxygen demands are reflected in a hepatic vein saturation of almost 30%.
The liver is also unique in its ability of regeneration, which allows the performance of major surgery including, amongst others, extended resections of liver tumours, living donations and so on. Many patients have normal liver function parameters when they present for liver surgery, especially when the reason for resection is metastasis or a benign liver tumour. The most common causes of liver resections are the hepatocellular carcinoma (HCC) and the cholangiocellular carcinoma (CCC). Hepatocellular carcinoma (HCC) often develops in patients with underlying liver cirrhosis; many of these patients show signs of chronic liver dysfunction (CLD).
As explained previously, the liver plays a central role in a great deal of physiological systems. Therefore, in case of chronic liver dysfunction (CLD) or liver failure, several effects on other organ systems have to be expected. Consequently liver resections and bile duct surgery as having a high risk for perioperative cardiac events, with an estimated 30-day cardiac event rate (cardiac death and myocardial infarction) of more than 5%. Patients undergoing liver surgery pose a significant challenge to treating physicians in the perioperative period. Due to the improvement of surgical techniques, the “liver patient” is becoming more and more complex, confronting surgeons, anaesthetists and intensive care personnel with difficult intra- and postoperative courses, and considerable multiorgan disorders. The cornerstones of an optimal management are careful selection of the patients, appropriate monitoring and protection of the liver and other vital organs.
Role of The SURGEON
Attributes of a Good Surgeon
Realising the benefits that good leadership and teamwork can deliver requires commitment from all those involved in patient care. From the surgeon’s viewpoint there are numerous desirable attributes which are developed through medical school education, foundation training, core training and into professional practice. These are outlined below:
1. Clinical Care
An obvious consideration of what makes a “good surgeon” is the care provided to patients throughout the patient journey. This includes technical ability in the operating theatre and non-technical skills.
2. Maintenance and Improvement
Remaining up-to-date with innovations in surgical practice and patient are is an important attribute of a good surgeon. In doing so, one is able to inform patients and explain the reasons for and against procedures, allowing them to make an informed decision. Willingness to learn from others and improve from others by reviewing personal practice forms part of Continuing Professional Development; this is a requirement in a portfolio to meet revalidation and recertification criteria.
3. Teaching, Training and Supervision
Educating others forms part of professional development and surgeons frequently oversee projects for medical students or trainees. This requires knowledge of the objectives of the tasks undertaken, knowledge of what technical and non-technical skills should be improved and knowledge of how to encourage the development of these skills. The mentormentee relationship should work both ways, such that the mentee is able to approach their supervisor for assistance and is accepting of any constructive criticism delivered.
4. Relationships with Patients
Relationships with patients are fundamentally based on trust; the patient trusts that the surgeon will do all in their power to help them and their surgical journey. Obtaining informed consent prior to clinical care is based on trust and allows patient autonomy to be upheld. Developing relationships with patients begins from the first consultation and is continued after the day of an operation being undertaken. Acknowledging the needs of the individual and employing effective communication helps in developing an open relationship. In this way patients disclose their medical history and admit underlying fears, allowing better patient care to be delivered.
5. Relationships with Colleagues
Partnership with all members of the multidisciplinary clinical team, management, technicians and support staff fosters healthy working relationships. Consequently, patient care is enhanced through communication, enhanced productivity and an improved team dynamic. Understanding how a colleague works and taking action to facilitate a positive working environment is beneficial to all. Emotional intelligence forms an important component of working relationships, through the ability “to understand and recognize emotional states and to use that understanding to manage one’s self and other individuals or teams”.
Maintenance of good personal health and knowing when you must stop working is important in the protection of patient safety. The relevant senior staff must be informed of communicable disease or blood-borne disease transmission. In addition, being vigilant of the health of colleagues forms part of protecting patient safety, for example, failure to report suspicion that the consultant consistently operates after several glasses of wine or that the CT2 has been seen smoking drugs can facilitate the propagation of errors in the workplace. Finally, surgeons are renowned for working at all hours, however acknowledgement that we all need rest is crucial in good patient care.
Not Only SURGEONS
SURGERY, A NOBLE PROFESSION
Surgery is, indeed, one of the noblest of professions. Here is how Dictionary defines the word noble: 1) possessing outstanding qualities such as eminence, dignity; 2) having power of transmitting by inheritance; 3) indicating superiority or commanding excellence of mind, character, or high ideals or morals. These three attributes befit the profession of surgery. Over centuries, the surgical profession has set the standards of ethical and humane practice. Surgeons have made magnificent contributions in education, clinical care, and science. Their landmark accomplishments in surgical science and innovations in operative technique have revolutionized surgical care, saved countless lives, and significantly improved longevity and the quality of human life. Generations of surgeons have developed their craft and passed it on to succeeding generations, as they have to me and to each one of you, to take into the future.
Beyond its scientific and technical contributions, surgery is uniquely fulfilling as a profession. It has disciplined itself over the centuries and dedicated its practice to the best welfare of all human beings. In return, it has been accorded the respect of society, of other professions, and of policy makers. Its conservative stance has served it well and has been the reason for its constancy and consistency. At the beginning of the 21st century, however, profound changes are taking place at all levels and at a dizzying pace, providing both challenges and opportunities to the surgical profession. These changes are occurring on a global level, on the national level, in science and technology, in healthcare, and in surgical education and practice.
To retain its leadership position in innovation and its attractiveness as a career choice for students, surgery must evolve with the times. It is my belief that surgery needs to introduce changes to create new priorities in clinical practice, education, and research; to increase the morale and prestige of surgeons; and to preserve general surgery as a profession. I am reminded of a Chinese aphorism that says, “You cannot prevent the birds of unhappiness from flying over your head, but you can prevent them from building a nest in your hair.”
ADVANCES IN SCIENCE
The coalescence of major advances in science and technology made the end of the 20th century unique in human history. Notable among the achievements are the development of microchips and miniaturization, which fueled the explosion in information technology. The structure of the human genome is nearly completely elucidated, ushering in the genomic era in which genetic information will be used to predict, on an individual basis, susceptibility to disease and responsiveness to drug therapy. The field of nanotechnology allows scientists to work at a resolution of less than one nanometer, the size of the atom. By comparison, the DNA molecule is 2.5 nanometers.
In the last 50 years, biomedical research became increasingly reductionist, turning physiologists and anatomists into molecular biologists. As a result, two basic science fields—integrative physiology and gross anatomy—now have a lower standing in medical education and surgical science than they once did. Surgery and surgical departments can and possibly should claim these fields, but the window of opportunity is narrow. Research is now moving back from discipline-based reductionist science to multidisciplinary science of complexity, in which biomedical scientists work side by side with engineers, mathematicians, and bioinformatists. The ability of high-speed computers to quickly process tens of millions of pieces of data now allows for data-driven rather than hypothesis-based research. This collaboration among different disciplines has already been successful.
TRANSFORMATION OF HEALTHCARE SYSTEM
During the past 75 years, we have seen the entire healthcare system undergo a profound transformation. In the 1930s and for a considerable period thereafter, medical practice was fee-for-service, the doctor–patient relationship was strong, and the physician perceived himself or herself as being responsible nearly exclusively to his or her individual patients. The texture of medical practice started to change when the federal government became involved in the provision of healthcare in 1965. The committee on “Crossing the Quality Chasm” identified six key attributes of the 21st-century healthcare system. It must be:
- Safe, avoiding injuries to patients;
- Effective, providing services based on scientific knowledge;
- Patient-oriented, respectful of and responsive to individual patients’ needs, values, and preferences;
- Timely, reducing waits, eliminating harmful delays for both care receiver and caregiver;
- Efficient, avoiding wasted equipment, supplies, ideas, and energy;
- Equitable, providing equal care across genders, ethnicities, geographic locations, and socioeconomic strata;
No one knows at present what this 21st-century healthcare system will look like. While care in the old system was reactive, in the new system it will be proactive. The “find it, fix it” approach of the old system will be replaced by a “predict it, prevent it, and if you cannot prevent it, fix it” approach. Sporadic intervention, provided only when patients present with illness, will give way to a system in which physicians and other healthcare providers plan 1-, 5-, and 10-year care programs for each patient. Care will be more interactive, with patients taking a more important role in their own care. The technology-oriented system will become a system that provides graded intervention. Delivery systems will not be fractionated but integrated. Even more importantly, care will not be based simply on experience and clinical impression but on evidence of proven outcome measures. If the old system was cost-insensitive, the new system will be cost-sensitive.
There are many reasons for the declining interest in general surgery, some of which parallel reasons for the drop in medical school applicants in general. One problem specific to surgery is that medical students are given less and less exposure to surgery, due to the shortening of required surgical rotations. Most important, however, is their perception that the life of the surgical resident is stressful, the work hours too long, and the time for personal and family needs inadequate. The workload of the surgical resident over the years has increased significantly both in amount and intensity, without concomitant increase in the number of residents and at a time when hospitals have significantly reduced the support personnel on the surgical ward and in the operating rooms. Students graduating with debts close to $100,000 simply find the years of training in surgery too long, followed by uncertain practice income after graduation.
From several recent studies, lifestyle is the critical and most pressing issue in surgical residency. Some studies have also shown that the best students tend to select specialties that provide controllable lifestyles, such as radiology, dermatology, and ophthalmology. We have a problem not only in the declining number of students applying for surgical training but also in the declining quality of those who do apply. In a preliminary survey of 153 responding general surgery programs, we found that attrition (i.e., categorical residents leaving the training programs) occurred at a rate of 13% to 19% in the last 5 years. In 2001, 46% of those leaving general surgery training programs cited lifestyle as the major reason.
Unless these trends are reversed, general surgery as a specialty is threatened, and a future shortage of general surgeons is inevitable. I know that the Council of the American Surgical Association is most concerned about the crisis in general surgery. We must do a better job of communicating to students and residents that the practice of surgery is as rewarding as ever and full of opportunities in this new era. Innovations in minimal access and computer-assisted surgery and simulation technology provide exciting new possibilities in surgical training. We must also look very carefully at the demands of surgical residency and improve the life of residents without compromising their surgical experience. Unless we deal with work hours and quality of life issues, we are likely to see continuing decline in the interest of medical students in surgical training.
In conclusion, the noble profession of surgery must rise to meet numerous challenges as the world in which it operates continues to undergo profound change. These challenges represent opportunities for the profession to develop an international perspective and a global outreach and to address the growing needs of an aging population undergoing major demographic and workforce shifts. The leadership of American surgery has a unique role to play in the formulation of a new healthcare system for the 21st century. This task will require commitment to quality of care and patient safety, and it will depend on harnessing the trust and support of the American public. Advances in science and technology—particularly in minimal access surgery, robotics, and simulation technology—provide unprecedented opportunity for surgeons to continue to make landmark contributions that will improve surgical care and the human condition. I believe it is also crucially important that we train surgeon-scientists who will keep surgery at the cutting edge in the genomic and bioinformatics era. Ours is a noble profession imbued with eminence, dignity, high ideals, and ethical values. It has a rich and proud heritage… and I quote, “The highest intellects, like the tops of mountains, are the first to catch and reflect the dawn.”
Source: Lecture from Haile T. Debas, MD (UCSF School of Medicine, San Francisco, California) Presented at the 122nd Annual Meeting of the American Surgical Association, April 25, 2002, The Homestead, Hot Springs, Virginia.
Biliary Tree Vascularization
The gallbladder lies at the equator between the right and left hemiliver, an imaginary line known as Cantlie’s line or the Rex-Cantlie line coursing between segments 4b and 5, through the bed of the gallbladder towards the vena cava posteriorly. The gallbladder is mostly peritonealized, except for its posterior surface which lies on the cystic plate, a fibrous area on the underside of the liver.
The proportion if its circumference varies, from a pedicled gallbladder with little to no contact with the cystic plate to a mostly intrahepatic gallbladder surrounded by liver parenchyma. The gallbladder carries no muscularis mucosa, no submucosa, and a discontinuous muscularis and only carries a serosa on the visceral peritonealized surface. These anatomical specificities facilitate the direct invasion of gallbladder cancer into the liver. This is why the surgical treatment of gallbladder cancer mandates a radical cholecystectomy, which includes resection of a wedge of segments 4b and 5, when the T stage is higher or equal to T1b. From the body of the gallbladder, a conical infundibulum becomes a cystic duct that extends as the lower edge of the hepatocystic triangle towards the porta hepatis and joins with the common hepatic duct (CHD) to form the CBD. As in the rest of the biliary system, variation is the rule when it comes to the cystic duct confluence with the CHD. It can variably run parallel to it for a distance prior to inserting or spiral behind it and insert on its medial aspect. It can variably insert into the RHD or the RPD, the latter in 4% of livers and particularly when the RPD inserts into the CHD (i.e., below the left-right ductal confluence). This configuration is notorious for exposing the RPD to a risk of injury at the time of cholecystectomy. Rare variations of gallbladder anatomy, including gallbladder duplication and gallbladder agenesis, are also described but are rare. The CBD courses anterolaterally within the hepatoduodenal ligament, usually to the right of the hepatic artery and anterolaterally to the portal vein. However, hepatic arterial anatomy can vary, and when an accessory or replaced hepatic artery is present arising from the superior mesenteric artery, the accessory or replaced vessel courses lateral to the CBD. In its conventional configuration, the right hepatic artery crosses posteriorly to the RHD as it heads towards the right liver, but 25% of the time it crosses anteriorly. These anatomical variants are all relevant to developing a sound surgical strategy to treat hilar CCA. Of note, while left hepatic artery anatomy can also be quite variable, rarely does it affect surgical decision-making in CCA to the same degree as right hepatic artery anatomy.
Distally, the CBD enters the head of the pancreas, joining the pancreatic duct to form the hepatopancreatic ampulla. Just distal to this is the sphincter of Oddi, which controls emptying of ampullary contents into the second portion of the duodenum. When the junction of the CBD and the pancreatic duct occurs before the sphincter complex, reflux of pancreatic enzymes into the biliary tree can lead to chronic inflammatory changes and anatomical distortion resulting in choledochal cysts, known risk factors for the development of CCA. Unlike the rest of the liver parenchyma, which receives dual supply from the arterial and portal venous circulation, the biliary tree is exclusively alimented by the arterial system. The LHD and RHD are alimented respectively by the left hepatic artery and right hepatic artery, which can frequently display replaced, accessory, and aberrant origins – the left artery arising conventionally from the hepatic artery proper but alternatively from the left gastric artery and the right hepatic artery arising from the hepatic artery proper but also variably from the superior mesenteric artery. In hilar CCA, variable combinations of hepatic arterial anatomy and tumor location can either favor resectability or make a tumor unresectable.
Within the hilum of the liver, a plexus of arteries connects the right and left hepatic arteries. Termed the “hilar epicholedochal plexus,” this vascular network provides collateral circulation that can maintain arterial supply to one side of the liver if the ipsilateral vessel is damaged. The preservation of arterial blood supply to the liver remnant is crucial, particularly when creating an enterobiliary anastomosis. Its absence leads to ischemic cholangiopathy and liver abscesses that can be difficult to treat. The CBD receives arterial supply inferiorly from paired arterioles arising from the gastroduodenal artery and the posterior superior pancreaticoduodenal artery, the most important and constant arterial supply to the distal CBD. Proximally the CBD is alimented by paired arterioles of the right hepatic artery. These vessels, known as the marginal arteries, run in parallel to the CBD, laterally and medially to it. Denuding the CBD of this arterial supply risks stricture formation after choledochoenteric anastomosis.
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References : https://bit.ly/3fOmcv2
Surgical Management of PANCREATIC CANCER
Pancreatic ductal adenocarcinoma (PDAC) carries one of the poorest overall prognosis of all human malignancies. The 5-year survival in patients with PDAC, for all stages, remains as low as 6–7%. The low survival rate is attributed to several factors, of which the two most important are aggressive tumor biology and late stage at which most patients are diagnosed. Only 10–20% of patients are eligible for resection at presentation, 30–40% are unresectable/locally advanced, and 50–60% are metastatic. Pancreatic cancer without distant metastasis can be divided into three categories: resectable, borderline resectable, and locally advanced. In absence of metastatic disease, the most important factor for improving survival and possibly offer cure is to achieve a margin-negative resection. Even after potential curative resection, most patients develop recurrences eventually, and 5-year survival of completely resected patients is only up to 25%. The aggressive tumor biology and its inherent resistance to chemotherapy and radiotherapy contributes to early recurrence and metastasis.
Pancreatic cancer surgery has evolved over the past few decades and remains the cornerstone of treatment of resectable and borderline resectable tumors. Advances in modern imaging give precise information on disease extension and vascular involvement that aids in surgical planning in order to achieve a margin-negative resection.
Surgical techniques for pancreatic cancer include pancreaticoduodenectomy, distal pancreatectomy with splenectomy, and total pancreatectomy. Standard lymphadenectomy for pancreatoduodenectomy should include removal of lymph node stations 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a, 14b, 17a, and 17b. Involvement of superior mesenteric vein (SMV)/portal vein(PV) was previously considered as a contraindication for resection. However, curative resection along with SMV/PV with vascular reconstruction has now become a standard practice in specialized high-volume centers. To improve margin-negative resections, specially in borderline resectable tumors with proximity to vascular structures, SMA first approach was proposed as a new modification of standard pancreatico-duodenectomy. In a systematic review, SMA first approach was shown to be associated with better perioperative outcomes, such as blood loss, transfusion requirements, pancreatic fistula, delayed gastric emptying, and reduced local and metastatic recurrence rates. In case of arterial involvement, there is no good evidence at present to justify arterial resections for right-sided pancreatic tumors. However, the modified Appleby procedure, which includes en bloc removal of celiac axis with or without arterial reconstruction, when used in appropriately selected patients, offers margin negative resection with survival benefit for locally advanced pancreatic body and tail tumors and should be performed in high-volume centers. Most evidence does not support advantage of more extended resections such as removal of the para-aortic lymph nodes and nerve plexus and multivisceral resections routinely. Such extended resections are associated with compromised quality of life because of associated higher perioperative morbidity and intractable diarrhea. However, in highly selected patients, with preserved performance status and stable or nonprogressive disease on neoadjuvant treatment, such extended resections can provide survival advantage over palliative treatments. Radical surgery in the presence of oligometastatic disease has also been reported to prolong survival in highly selected patients.
Adverse events in SURGERY
The surgical domain can be seen as more complex and high risk in its delivery of care than other non-interventional specialities. It is therefore not surprising that in the majority of studies of adverse events in healthcare, at least 50% occurred within the surgical domain and the majority of these in the operating theatre. Furthermore, at least half of these adverse events were also deemed preventable. Just as the multiple studies in the developed world have similar figures for adverse events in hospitalised patients across all specialities, there appears to be a similar rate of harm in surgery. A review of 14 studies, incorporating more than 16000 surgical patients, quoted an adverse event occurring in 14.4% of surgical patients. This was not simply minor harm; a full 3.6% of these adverse events were fatal, 10% severe and 34% moderately harmful. Gawande, a surgeon from Boston, made one of the first attempts to clarify the source of these adverse events.
This paper pioneered the concept that the majority of these adverse events were not due to lack of technical expertise or surgical skill on the part of the surgeon, finding instead that ‘systems factors’ were the main contributing factor in 86% of adverse events. The most common system factors quoted were related to the people involved and how they were functioning in their environment. Communication breakdown was a factor in 43% of incidents, individual cognitive factors (such as decision-making) were cited in 86%, with excessive workload, fatigue and the design or ergonomics of the environment also contributing.
These findings were confirmed in the systematic review of surgical adverse events, where it was found that errors in what were described as ‘nonoperative management’ were implicated in 8.32% of the study population versus only 2.5% contributed to by technical surgical error. In accordance with other high-risk industries, such as commercial aviation, the majority of these adverse events are therefore not caused by failures of technical skill on the part of the individual surgeon, but rather lie within the wider healthcare team, environment and system. Lapses and errors in communication, teamworking, leadership, situational awareness or decision-making all feature highly in post-hoc analysis of surgical adverse events. This knowledge of error causation has been prominent and acknowledged in most other high-risk industries for many years, but it is only recently that healthcare has appreciated this.
Benign liver tumours are common and are frequently found coincidentally. Most benign liver lesions are asymptomatic, although larger lesions can cause non-specific complaints such as vague abdominal pain. Although rare, some of the benign lesions, e.g. large hepatic adenomas, can cause complications such as rupture or bleeding. Asymptomatic lesions are often managed conservatively by observation. Surgical resection can be performed for symptomatic lesions or when there is a risk of malignant transformation. The type of resection is variable, from small, simple, peripheral resections or enucleations, to large resections or even liver transplantation for severe polycystic liver disease.
Hepatocellular adenomas (HCA) are rare benign hepatic neoplasms in otherwise normal livers with a prevalence of around 0.04% on abdominal imaging. HCAs are predominantly found in women of child-bearing age (2nd to 4th decade) with a history of oral contraceptive use; they occur less frequently in men. The association between oral contraceptive usage and HCA is strong and the risk for a HCA increases if an oral contraceptive with high hormonal potency is used, and if it is used for over 20 months. Long-term users of oral contraceptives have an estimated annual incidence of HCA of 3–4 per 100000. More recently, an increase in incidence in men has been reported, probably related to the increase in obesity, which is reported as another risk factor for developing HCA. In addition, anabolic steroid usage by body builders and metabolic disorders such as diabetes mellitus or glycogen storage disease type I are associated with HCAs. HCAs in men are generally smaller but have a higher risk of developing into a malignancy. In the majority of patients, only one HCA is found, but in a minority of patients more than 10 lesions have been described (also referred to as liver adenomatosis).
Small HCAs are often asymptomatic and found on abdominal imaging being undertaken for other purposes, during abdominal surgery or at autopsy. Some patients present with abdominal discomfort, fullness or (right upper quadrant) pain due to an abdominal mass. It is not uncommon that the initial symptoms of a HCA are acute onset of abdominal pain and hypovolaemic shock due to intraperitoneal rupture. In a series of patients who underwent resection, bleeding was reported in up to 25%. The risk of rupture is related to the size of the adenoma. Exophytic lesions (protruding from the liver) have a higher chance of bleeding compared to intrahepatic or subcapsular lesions (67% vs 11% and 19%, respectively, P<0.001). Lesions in segments II and III are also at higher risk of bleeding compared to lesions in the right liver (35% vs 19%, P = 0.049).
There is no guideline for the treatment of HCAs, although there are general agreements. In men, all lesions should be considered for surgical resection independent of size, given the high risk of malignant transformation, while taking into account comorbidity and location of the lesion. Resection should also be considered in patients with HCAs due to a metabolic disorder. In women, lesions <5 cm can be observed with sequential imaging after cessation of oral contraceptive treatment. In larger tumours, treatment strategies vary. Some clinicians have proposed non-surgical management if hormone therapy is stopped and patients are followed up with serial radiological examinations. The time period of waiting is still under debate, however recent studies indicate that a waiting period of longer than 6 months could be justified.
More recently, the subtypes of the Bordeaux classification of HCA have been studied related to their risk of complications. Some groups report that percutaneous core needle biopsy is of limited value because the therapeutic strategy is based primarily on patient sex and tumour size. Others report a different therapeutic approach based on subtype. Thomeer et al. concluded that there was no evidence to support the use of subtype classification in the stratification and management of individual patients related to risk of bleeding. Size still remains the most important feature to predict those at risk of bleeding during follow-up. However, malignant transformation does seem to be related to differences in subtypes. β-catenin-mutated HCAs trigger a potent mitogenic signalling pathway that is prominent in HCC. Cases of inflammatory HCAs can also show activation of the β-catenin pathway with a risk of developing malignancy. Therefore, β-catenin-mutated and inflammatory HCAs are prone to malignant degeneration, and particularly if >5cm. In these circumstances, invasive treatment should be considered.
Liver Uptake on Cadaveric Donors for Transplant
Since the initial descriptions of orthotopic liver transplantation (OLT) in the 1960s, both the number of patients receiving transplants and the indications for the procedure have increased significantly. OLT represents the only treatment modality for many patients with a diverse spectrum of disease, with the predominant common factor end-stage liver failure. Advances in perioperative care of the donor and recipient, organ preservation methods, and surgical techniques have resulted in a 5 year overall survival of 78% for all recipients (Kim et al, 2015).
The first published description of human liver transplantation was by Starzl and colleagues in 1963 at the University of Colorado. In this seminal paper, the dismal outcomes of three OLT recipients were described, including one intraoperative death from uncorrectable coagulopathy and two survivors of 7 and 22 days. In addition to the pioneering conceptual framework and implementation of LT, the advanced techniques included grafts from non–heart-beating donors, venovenous bypass in the recipients, choledochocholedochostomy, and coagulation monitoring by using thromboelastography (TEG). Many of these concepts remain or have reentered the realm of LT more than 40 years after their initial description. Based largely on the initial body of work by Starzl and colleagues, this section describes the surgical procedures commonly used worlwide.
The typical deceased donor has had a catastrophic head injury or an intracerebral bleed, with brain death but without multisystem organ failure. Electrolyte imbalance and hepatic steatosis in the donor are predictors of graft nonfunction. A “donor risk index” has been derived to assess the likelihood of good graft function. Key adverse factors include older donor age (especially >60 years of age), use of a split or partial graft, and a non–heart-beating donor, from which the organs are harvested after the donor’s cardiac output ceases, in contrast to the more typical deceased donation in which the organs are harvested prior to cardiovascular collapse. Use of non–heart-beating donors is associated with reduced rates of long-term graft survival and increased risk of biliary complications, which correlate with the duration of “warm ischemia” after cardiovascular collapse and before retrieval of the organ. With the critical shortage of deceased organ donors, expansion of the donor pool has included acceptance of donors 70 years of age and older for selected recipients. Prior to hepatectomy, the harvesting team makes a visual and, if necessary, histologic assessment of the donor organ. Particular attention is paid to anatomic variants in the hepatic artery that may complicate the graft arterial anastomosis in the recipient. Once donor circulation is interrupted, the organ is rapidly infused with a cold preservation solution (e.g., University of Wisconsin, histidine-tryptophan-ketoglutarate, or Institut Georges Lopez solution). Donor iliac arteries and veins are also retrieved in case vascular grafting is required. After its arrival at the recipient institution, further vascular dissection, with arterial reconstruction if necessary, is performed before implantation.
Major challenges remain in LT, including the shortage of donor organs, threat of recurrent disease, and morbidity associated with lifelong therapeutic immunosuppression. Nevertheless, the availability of LT has transformed the lives of patients with advancing liver disease and their health care providers from an ultimately futile effort to manage the complications of cirrhosis into a life-prolonging and life-enhancing intervention.
Necrotizing Gallstone Pancreatitis
The AGA recently published a Clinical Practice Update reviewing the best available evidence on pancreatic necrosis, regardless of cause. The update provides 15 best practice advice points that include the need for multidisciplinary care coordination and referral to a tertiary-care center as appropriate. The update describes supportive care, avoidance of prophylactic antibiotics, and optimization of nutrition. In addition, there is an included algorithm for the management of pancreatic necrosis requiring debridement. Debridement within the early acute phase of pancreatitis (within the first 2–4 weeks) should be avoided if possible secondary to increased morbidity and mortality. Intervention in the late phase (> 2–4 weeks) is indicated for patients with infected necrosis or persistent organ dysfunction and failure to thrive. Multiple approaches are available for the management of infected necrosis, including but not limited to percutaneous, endoscopic, or laparoscopic transgastric, or open debridement. In addition, a combination approach using percutaneous drainage followed by videoscopic retroperitoneal debridement or step-up approach can also be used. Since the publication of a multicenter RCT (PANTER) in 2010, the step-up approach for necrotizing pancreatitis has been increasingly used.
The step-up approach or video-assisted retroperitoneal debridement (VARD) is a minimally invasive technique that begins with percutaneous drain placement for necrotizing pancreatitis followed by a minimally invasive retroperitoneal necrosectomy. Patients who underwent the step-up approach versus open necrosectomy had less multiple-organ failure, incisional hernias, and newonset diabetes, but no difference in mortality. The 2020 AGA Clinical Practice Update on the management of pancreatic necrosis suggests that best practice is that ‘‘minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity’’. However, the update also notes that open necrosectomy still has a role in the modern management of acute necrotizing pancreatitis, particularly for cases whereby less invasive techniques are not feasible.
POPF after Distal Pancreatectomy
Minimally Invasive Versus Open Techniques
Despite advances in laparoscopic and robotic approaches, the vast majority of distal pancreatectomies continue to be performed via an open approach. Recent retrospective data have demonstrated that minimally invasive distal pancreatectomy is associated with decreased blood loss and shorter hospital stays than open pancreatectomy. A large recent study utilizing the Nationwide Inpatient Sample database suggested, first, that the minimally invasive approach is becoming more widely utilized, increasing from 2.4 to 7.3 % over a study period from 1998 to 2009. Second, that study reported that the minimally invasive approach was associated with decreased length of stay as well as decreased incidence of infectious complications, bleeding complications, and blood transfusions. This population-based study echoes conclusions drawn by a large multi-institutional study performed several years previously. Drawing on a combined patient sample of 667 patients, with 24 % initially attempted laparoscopically, the authors were able to demonstrate lower overall complication rate, decreased blood loss, and shorter hospital stays among patients undergoing laparoscopic approach via a multivariate analysis.
Notably, there was no significant difference in the pancreatic leak rate between the open and laparoscopic approaches, although there was a nonsignificant trend favoring the laparoscopic approach. More recently, the robotic approach has generated significant interest as a technique for performing distal pancreatectomy. Retrospective analysis has suggested that the robotic approach is well suited for pancreatectomy. Fistula rates, however, remain a concern. A retrospective review of patients undergoing robotic pancreatic operations included 83 patients who underwent distal pancreatectomy. About 27 % were identified as having a ISPGF type A pancreatic leak; 12 and 4.8 % were identified as having a grade B or C leak, respectively.
Identifying Risk Factors
For pancreaticoduodenectomy (PTD) , a fistula risk score has been recently developed that has been shown to be highly predictive of POPF. This score assigns points based on gland texture, gland pathology, duct diameter, and intraoperative blood loss. In general, high blood loss, soft gland texture, and smaller duct diameter confer increased risk of POPF, whereas pancreatic adenocarcinoma and pancreatitis as the indication for PTD confer protection for the development of pancreatic fistula versus other diagnoses. Also of note, higher fistula risk scores correlated with greater incidence of clinically relevant (ISGPF grade B or C) fistula. The adaptation of this risk score to patients undergoing distal pancreatectomy is yet to be validated; however, at least one published study indicates that this scoring system may have limitations in the setting of distal pancreatectomy. In that study, risk factors for pancreatic fistula after stapled gland transection in patients undergoing distal pancreatectomy were examined, and in a multivariate analysis, only the presence of diabetes and the use of a 4.1-mm staple cartridge were associated with increased risk of pancreatic fistula formation.
Surgical Management of CHOLANGIOCARCINOMA
Cholangiocarcinoma is an uncommon cancer that occurs within the intrahepatic and extrahepatic portions of the bile duct system. In North America, the incidence of extrahepatic cholangiocarcinoma is 0.5–2 per 100,000 and 0.95 per 100,000 for intrahepatic cholangiocarcinoma. Up to 50% of patients will be lymph node (LN) positive at presentation, 5% are multifocal tumors, and 10–20% will have peritoneal involvement at presentation. Risk factors for cholangiocarcinoma are primary sclerosing cholangitis (PSC) with a lifetime risk 10–40%, parasitic infection, previous sphincteroplasty, congenital anomalies of the biliary tree (choledochal cyst, Caroli’s disease, anomalous pancreaticobiliary duct junction), and chronic biliary inflammatory disease (hepatitis B/C, liver cirrhosis, recurrent pyogenic cholangitis). The most common presentation is painless jaundice and weight loss in the setting of extrahepatic duct involvement. In Western countries, 80% are extrahepatic (20% distal and 60% hilar) and 20% are intrahepatic.
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• Ca 19–9 can be elevated in up to 85% of patients with cholangiocarcinoma, but is not specific; elevation can also occur in the setting of obstructive jaundice without malignancy. If it remains elevated after biliary decompression, it could indicate the presence of malignancy. Elevated pre- and postoperative Ca 19–9 predict poor survival.
• For perihilar tumors, decisions regarding which side of the liver to resect depend on right- or left-sided dominance, volume of future liver remnant, and the extent of vascular and ductal involvement.
• Some centers report that 30–50% of tumors will be deemed unresectable at the time of surgery, despite accurate preoperative imaging.
• Quality Indicators: Pathologic Analysis—R0 margin, regional lymphadenectomy includes three or more LN.
Intrahepatic cholangiocarcinoma: Surgical resection is the only potential cure with removal of involved liver segments. There is emerging evidence that recommends a routine hilar LN and dissection for its prognostic value, M1 disease includes involvement of celiac,periaortic or caval LN.
Distal bile duct (below the cystic duct): Surgical resection is the only potential cure. Pancreaticoduodenectomy including en bloc resection of extrahepatic bile duct and gallbladder. Regional nodes include: Hilar (CBD, common hepatic, portal, cystic), Posterior and anterior pancreaticoduodenal Nodes along SMV, Nodes along right and lateral wall of SMA.
Hilar (above the cystic duct): En bloc resection of extrahepatic bile duct and gallbladder, including right and left hepatectomy, or extended right/left hepatectomy, Caudate lobe should be removed. Regional nodes include: Hilar (CBD, hepatic,portal, cystic), Pericholedochal nodes in hepatoduodenal ligament.
Ao Cadáver DESCONHECIDO
Hic locus est ubi mors gaudet succurrere vitae
“É este o lugar onde a morte se alegra de socorrer a vida”
Égide do respeito ao Cadáver no estudo da Anatomia Humana*.
A utilização do cadáver representa uma tríplice lição educativa:
- Instrutiva/Informativa: como meio de conhecimento da organização do corpo humano, procedendo ao estudo no vivo;
- Normativa/Disciplinadora: através do seu caráter metodológico e de precisão técnica da linguagem;
- Estético/Moral: pela natureza do material de estudo, o cadáver, e pelo método primeiro de aprendizado, a dissecção, que é experiência e trabalho repousante na contemplação da beleza e harmonia de construção do organismo humano.
Contudo e essencialmente, porém, lição de ética e de humildade, porque:
- Não é o cadáver, doado ou indigente, fato isolado da comunidade, mas seu reflexo, dela provindo. O cadáver que é o meio de aprendizado para adequada assistência do vivo, assim portanto tão importante para a sociedade como o é o paciente;
- Esses corpos sem vida são vivificados de forma reiteradas pelo calor da juventude estudiosa através do sentimento de gratidão; O cadáver, antes de tudo “um irmão em Humanidade, se entrega despojadamente ao conhecimento que proporciona aos futuros profissionais, de maneira anônima oriunda do jogo do acaso da vida;
- O cadáver anônimo ao receber este título – cadáver desconhecido – e assim ultrapassar o limite estreito de um nome e, despersonalizado, distribui elementos para o bem coletivo, sem ter conhecimento quer antes, durante ou depois de sua imolação, do seu destino a um tempo sublime e sagrado;
- O Cadáver desconhecido tudo oferece ao conhecimento sem nada haver recebido daquele que o estuda, que dá sem saber que dá e por isso, sem conhecer recompensa da gratidão e sem sentimento do valor da sua dádiva generosa, na mais nobre expressão de poderosa caridade universal;
- O cadáver que dissecado, desmembrado, simboliza outra forma de crucificação para o bem comum e marca o sentido profundamente humano da Medicina;
Portanto o nosso material de estudo transcende pois ao simples valor de meio e objeto de aprendizado; e nos fala em linguagem universal que nos educa na humildade da limitação humana. Eis porque na austeridade do ambiente do Laboratório de Anatomia a atitude física, mental e verbal do aluno deve ser de sobriedade, respeito, meditação e elevada compostura, manuseando as peças anatômicas com o mais profundo sentimento de respeito e carinho.
Nulla Medicina Sine Anatomia
“Ao curvar-te sobre o cadáver desconhecido…
lembra-te que este corpo nasceu do amor de duas almas; cresceu embalado pela fé e esperança daquela que em seu seio o agasalhou, sorriu e fitou os mesmos sonhos das crianças e dos jovens; por certo amou, foi amado e também acalentou um amanhã feliz. Seu nome só Deus o sabe e agora nesta fria lousa, o destino inexorável deu-lhe o poder e a grandeza de servir a humanidade numa última missão, ENSINAR.
Ó irmão ignoto que tivestes a morada do espirito, o seu corpo, perturbado em seu repouso imutável por nossas mãos ávidas de saber, apresentamos a ti o nosso respeito permanente e infindo AGRADECIMENTO.”
*Adaptação do texto original “Aula Inaugural”
Professor Renato Locchi (1896-1978) / Emérito de Anatomia Humana da Escola Paulista de Medicina.
História da Anatomia Humana
Atualmente, o conhecimento da anatomia se junta a um universo de outros conhecimentos que, não menos importantes, vão se somando e contribuindo de forma muito rápida para o desenvolvimento científico, para a melhoria da qualidade de vida e para a maior longevidade do ser humano. A anatomia e a medicina são ciências distintas, porém não há como separar a história de ambas. Estão ligadas intimamente e por muito tempo sendo que, na antiguidade, foram tratadas como uma só história. Ana, em partes; tome, cortar. O termo anatomia, de origem grega, significa “cortar em partes”. Antigamente referia-se ao ato de explorar as estruturas do corpo humano por uso de instrumentos cortantes como anatomizar, hoje substituído pela palavra dissecar. E foi a dissecção de cadáveres humanos que serviu como método de estudo para o entendimento da estrutura e função do corpo humano durante vários séculos. Devido ao incessante trabalho de centenas de anatomistas dedicados ao aprendizado e evolução do conhecimento acerca do corpo humano, e suas de funções, é que hoje nós, estudantes, podemos aprender e familiarizar com os termos anatômicos utilizados para designar cada estrutura dessa engenhosa “máquina” que é o ser humano. Grande parte dos termos que compõe a linguagem anatômica é de procedência grega ou latina. Latim era a língua do império romano, época em que o interesse nas descrições científicas foi cultivado. No passado, a anatomia humana era acadêmica, ciência puramente descritiva, interessada principalmente em identificar e dar nomes às estruturas do corpo. Embora a dissecção e descrição formem a base da anatomia, a importância desta, hoje, está em sua abordagem funcional e nas aplicações clínicas, de forma a entender o desempenho físico e a saúde do corpo.
Aprendendo a Aprender
As oportunidades de aprendizado nos são oferecidas a cada momento, o tempo todo. Aprendemos toda vez que nos damos ao trabalho de pensar sobre o que determinado momento nos trouxe, o que nos ensinou que ainda não sabíamos, o que nos mostrou a respeito dos outros e de nós mesmos, e que antes ignorávamos. E esse processo é tão longo quanto a vida.
O caminho mais curto e certo para a estagnação é perder a disposição de aprender, seja pela arrogância de achar que já sabe tudo, seja pela enganosa convicção de que é cedo demais para adquirir tal conhecimento. A acomodação é outra inimiga do aprendizado, pois paralisa o segundo requisito necessário para que ele ocorra: o esforço. É preciso esforçar-se para manter a mente aberta ao novo, para não se deixar limitar pelos preconceitos e opiniões preconcebidas. E também é preciso esforço para ampliar as oportunidades de aprendizado, reservando tempo para as leituras, para as conversas e atividades instrutivas, para se atualizar e aprofundar seu conhecimento.
Não refiro apenas ao conhecimento necessário à sua profissão, mas a todos os aspectos de sua vida, por exemplo, conhecer mais a fundo sua família – acreditar que já sabemos tudo sobre nossos familiares é um erro fatal em qualquer tipo de relacionamento. Outro equívoco é negligenciar o autoconhecimento: uma série de frustrações, angústias e motivações. Conhecê-las também é um aprendizado constante, talvez o mais árduo de todos.
“Todas me pareceram tão cheias de si”, contou Sócrates, “tão seguras de suas verdades e certezas que, se sou de fato mais sábio do que elas, é pela simples razão de que sei de que não sei aquilo que elas acham que sabem”. Como nos sugere o filósofo com toda a sua perspicácia e sabedoria, a admissão de que ainda temos muito a aprender é o primeiro passo para transformarmos nossa vida em um constante aprendizado. A consciência desse fato enriquece nossas vidas, ampara nossas escolhas e direciona nossas ações. A importância de aprender sempre é tamanha que Stephen R. Covey, autor do best-seller Os 7 Hábitos das Pessoas Altamente Eficazes e 8° Hábito, a coloca entre as quatro necessidades básicas do ser humano – as demais serão afetadas.
O aprendizado, porém, está presente em todas: aprendemos a viver, a amar, a deixar um legado e, até mesmo, aprendemos a aprender.
PhD THESIS (Ozimo Gama, MD)
COMPARATIVE STUDY BETWEEN THE SLEEVE GASTRECTOMY AND GASTRIC PLICATION IN OBESE RATS
INTRODUCTION: Obesity results from a prolonged imbalance between energy intake and energy expenditure. Studies with experimental models of bariatric surgery provided a fundamental contribution to the understanding of morphological and functional changes in obesity and after bariatric surgery. The restrictive bariatric surgery techniques currently used are gastric banding, sleeve gastrectomy and the gastric plication. The latter is considered an experimental technique and has therefore not yet enough studies that shed light on the postoperative rates of weight loss, surgical complications, resolution of comorbidities and the mechanisms responsible for weight loss. The aim of this study was to conduct a comparative study in rats with cafeteria diet-induced, between gastric plication and sleeve gastrectomy in variation late postoperative in body weight ,plasma biochemistry and gross and microscopic alterations gastric effects obesity.
MATERIAL AND METHOD: 28 male Wistar rats were randomized into three groups after induction period of obesity by cafeteria diet and underwent sleeve gastrectomy (GV group), gastric plication (GP group) and sham operation (control group). The animals were assessed daily postoperatively and the variables were recorded: (initial seven days, 14 and 21 days) body weight and presence of complications until day 21 postoperatively, when they were euthanized and evaluated: biochemistry (glucose, insulin, HDL, total cholesterol, triglycerides, AST, ALT and serum ghrelin), degree of intra-abdominal adhesions, resistance testing will air insufflation in the stomach and microscopic evaluation of the gastric mucosa.
RESULTS: In relation to body weight variation of animals GV group (initial weight: 318 ± 7.89 g / Final weight: 213 ± 9.03g) was significantly decreased (p<0.05) at 21 post-surgery day compared to the GP group (initial weight: 314.11 ± 20.79 g / final weight: 239.16 ± 14.71 g) and control (initial weight: 315.16±17.54g / final weight: 317.91±16.06 g). The animals in the GV group had a significant decrease (p<0.001) in blood glucose, insulin, transaminases, serum HDL and ghrelin compared to animals in GP and control. Was also significantly lower the burst pressure of the stomach in the GV group, the insufflation test the atmospheric air in relation to the GP and control groups. The GP and GV groups showed even different histological grade of inflammation
(subacute inflammation) and control group (chronic inflammation).
CONCLUSIONS: The sleeve gastrectomy is more effective than gastric plication weight loss, metabolic control and reduction of serum ghrelin in obesity rats, and presents the same rates of postoperative complications (adhesions, deaths and grade inflammation).
KEYWORDS: 1. Obesity; 2. Bariatric Surgery; 3.Wistar rats.
Tradicionalmente, a marca de um grande cirurgião está relacionada à habilidade técnica, conhecimento e perspicácia diagnóstica, enquanto pouco foco é dado a outras habilidades de Liderança. Hoje, as habilidades não técnicas, como habilidades de comunicação e liderança, acabam se traduzindo em maior segurança do paciente, experiência e resultados. O dia em que o cirurgião inicia seu primeiro trabalho o define como um líder, e isso é particularmente verdadeiro para o cirurgião do Aparelho Digestivo, pois é imediatamente considerado um especialista. Os cirurgiões são líderes preparados para aproveitar as muitas oportunidades de desempenho que as posições acadêmicas fornecem para executar seus interesses fora do atendimento tradicional ao paciente. Algumas pessoas nascem com habilidades de liderança e outras as desenvolvem com o tempo. É claro que esse processo deve começar cedo e que os estudantes de medicina e residentes devem estar preparados para papéis de liderança conforme RODRIGO VIANA explica neste vídeo para ajudar no desenvolvimento das habilidades críticas e não clínicas relacionadas à liderança de uma equipe e ao ensino. Para alguns, os papéis principais podem mudar ou desviar a carreira do atendimento ao paciente. Para outros, um equilíbrio entre as carreiras clínicas e administrativas pode ser cumprido em um papel definido. Independentemente disso, estabelecer metas e trabalhar para alcançá-las dentro da construção de uma equipe é a marca de todos os líderes de sucesso.
Preoperative Biliary Drainage
The most common presenting sign for patients with malignancy of the periampullary region is obstructive jaundice. While a significant proportion of these patients will be asymptomatic, the deleterious systemic consequences of uncontrolled hyperbilirubinemia may still occur. Furthermore, symptoms such as pruritus can be debilitating and have a significant impact on the quality of life. Thus, some have advocated preoperative drainage of the biliary system in patients with resectable periampullary malignancies, given widespread availability of endoscopic retrograde cholangiopancreatography and its perceived safety profile. On the other hand, the purported benefits of routine preoperative drainage in this patient population (namely, resolution of symptoms in symptomatic patients while awaiting surgery, restoration of the enterohepatic cycle, and a potential decrease in postoperative morbidity) have proven to be largely theoretical, and now there are high-quality phase III data that demonstrate the deleterious effects of routine stenting. A seminal study originating from the Netherlands in 2010 evaluated this issue in the only modern randomized controlled trial to date evaluating preoperative endoscopic biliary decompression for these patients. In their multicenter study, they randomized 202 patients with newly diagnosed pancreatic head cancer and bilirubin levels between 2.3 and 14.6 mg/dL to preoperative biliary drainage for 4–6 weeks vs. immediate surgery which was to be performed within a week of enrollment. The primary endpoint was the development of serious complications within 120 days after randomization. Serious complications were defined as complications related to the drainage procedure or the surgical intervention that required additional medical, endoscopic, or surgical management, and that resulted in prolongation of the hospital stay, readmission to the hospital, or death. The reported overall rate of serious complications in this study favored the immediate surgery group (39 vs. 74%; RR 0.54–95% [CI], 0.41–0.71; P < 0.001), complications related to surgery were equivalent (37 vs. 47%; P = 0.14), and there was no difference in mortality rates or length of hospital stay. The observed drainage-related complications included a 15% rate of stent occlusion, 30% need for exchange, and 26% incidence of cholangitis.
“Based on these results, the authors concluded that the morbidity associated with the drainage procedure itself had an additive effect on the postoperative morbidity of patients undergoing pancreatic head resection for cancer and recommended against its routine use in this population.“
A Cochrane systematic review of all available randomized studies (including the abovementioned study by van der Gaag et al.) evaluating preoperative biliary drainage was published in 2012. In this study, Fang et al. assessed the impact of this intervention on survival, serious morbidity (defined as Clavien-Dindo grade 3 or 4), and quality of life. Furthermore, they sought to assess differences in total length of hospital stay and cost. They identified six randomized trials of which four used percutaneous transhepatic biliary drainage and the remaining two used endoscopic sphincterotomy and stenting. The pooled analysis of 520 patients (of which 51% underwent preoperative biliary drainage) showed no difference in mortality, but importantly, it showed a significantly higher incidence of serious morbidity in the preoperative drainage group with a rate ratio (RaR) of 1.66 (95% CI 1.28–2.16;P = 0.002). There was no difference in length of hospital stay and not enough data reported for analysis of cost or quality of life.
“Based on the available level 1 data, the authors concluded that there was no evidence to support or refute routine preoperative biliary drainage in patients with obstructive jaundice.“
However, this review also underscored the fact that preoperative biliary drainage may be associated with an increased rate of adverse events and thus questioned the safety of this practice. This Cochrane review included old studies that evaluated patients undergoing percutaneous drainage, a technique used less frequently today for periampullary malignancies. Furthermore, several of these trials included patients with hilar and other types of biliary obstruction. However, the concept of preoperative decompression, as well as its purported benefits and observed results, may be reasonably extrapolated to patients with periampullary lesions.
Surgical Options of Hepatocellular carcinoma
Liver cancer is the sixth most common cancer and, in 2018, was the fourth leading cause of cancer-related death worldwide. The rates of incidence and mortality are approximately 2 to 3 times higher for men than for women. Hepatocellular carcinoma (HCC) is the most common primary liver cancer and accounts for 75% to 85% of diagnoses, followed by intrahepatic cholangiocarcinoma (10%–15%), and other rare liver histologies. The improvement and safety of surgical techniques for liver resection and transplant, and advancements in ablation, transarterial chemoembolization (TACE), and systemic therapies have expanded the treatment options for patients with HCC. Liver transplant is the ideal treatment option for patients with HCC and poorly compensated liver disease because it removes both HCC and damaged liver and reduces the risk for early recurrence. However, shortages in donor liver and long waiting times to transplant are significant barriers to this treatment approach. As such, liver resection remains an effective treatment option for patients with HCC. The use of a multidisciplinary approach and the knowledge of each therapeutic option is critical in the management of patients with HCC.
Minimal future liver remnant requirements
Liver resection remains the treatment of choice for HCC. Two major preoperative considerations for HCC resection are the patient’s liver function and the predicted future liver remnant (FLR). The intrinsic liver function of patients with HCC is often impaired because this patient population generally has chronic liver disease, including viral hepatitis, alcoholic hepatitis, and nonalcoholic steatohepatitis. As such, studies report that more FLR is needed for patients undergoing resection for HCC than for patients undergoing resection of secondary liver cancer (ie, metastatic disease). The minimal requirement of FLR/standardized liver volume (standardized liver volume 5 x 794 1 1267.28 x body surface area) is 30% in patients with hepatic injury and fibrosis and 40% in patients with cirrhosis, whereas it is 20% to 25% for patients with normal liver.
Anatomic resection versus nonanatomic resection
Anatomic resection of Couinaud segment for small HCC was reported in 1981 by Makuuchi and colleagues. HCC frequently invades to the intrahepatic vascular structures and spreads through the portal vein. As such, the complete removal of tumor-bearing portal territory was reported to be theoretically superior to nonanatomic resection. The technique proposed by Makuuchi and colleagues is detailed as follows: (1) under the guidance of intraoperative ultrasonography, the portal vein of interest is identified and punctured using a 22-gauge needle; (2) blue dye is injected into the portal vein; (3) the territory of the dyed surface is marked using electrocautery; and (4) liver resection is performed using ultrasonography guidance and intersegmental hepatic veins are exposed. This technique was recently refined using fluorescence imaging. By using transportal injection or systemic intravenous injection of indocyanine green, the portal vein territory was more clearly visualized on the liver surface compared with the traditional method. Many retrospective studies reported that anatomic resection was associated with better survival and lower recurrence than nonanatomic resection. In contrast, other studies showed that survival did not differ significantly between patients undergoing anatomic resection and those undergoing nonanatomic resection. Therefore, this clinical question remains unanswered and needs to be further elucidated.
Laparoscopic liver resection
Laparoscopic liver resection (LLR) has been increasingly used worldwide. In their systemic review, Nguyen and colleagues reported on the safety of LLR with low rates of morbidity and mortality for both major and minor resections, as well as appropriate oncologic results compared with open liver resection (OLR). These results are most likely caused by patient selection and the advantages of the laparoscopic approach, including a magnified view and the hemostatic effect caused by pneumoperitoneum. Three retrospective studies including more than 200 patients showed that the 5-year overall survival (OS) was not significantly different between patients undergoing LLR for HCC and those undergoing OLR for HCC. However, no randomized controlled trials (RCTs) comparing long-term outcomes in patients undergoing LLR versus OLR for HCC have been reported. For patients with colorectal liver metastases, a recent RCT (Oslo-CoMet study) showed that median OS in patients undergoing LLR was similar to those undergoing OLR: 80 months versus 81 months.
Liver Resection Versus Ablation
It remains unclear whether liver resection or ablation is the most effective treatment of small HCC lesions. To answer this clinical question, 5 RCTs have been reported. Two of these studies showed that liver resection was associated with better survival than radiofrequency ablation and 3 showed that survival did not differ significantly between patients undergoing resection and those undergoing ablation. The shortcomings of these RCTs include insufficient patient follow-up; unclear treatment allocation; and different inclusion criteria, including tumor number, tumor diameter, and Child-Pugh grade. Nonetheless, for patients with small HCCs (ie,<3 cm), the current evidence shows that both resection and ablation can be recommended.
Liver Resection Versus Transarterial Chemoembolization
There has been 1 RCT comparing the outcomes of patients undergoing resection for HCC with those undergoing TACE. For patients outside of Milan criteria, resection was associated with better survival than TACE. The authors found 8 cohort studies comparing outcomes after resection with TACE using the propensity score adjustment. Although the studies had different inclusion criteria, the data show that resection is associated with better survival than TACE in selected patients who have multiple HCCs.
Liver Resection Versus Liver Transplant
Liver transplant is an established treatment option for patients who have early-stage HCC and poorly compensated cirrhosis and/or portal hypertension. However, the preferred treatment of patients who have early-stage HCC and wellcompensated cirrhosis is not established. Several retrospective studies have evaluated outcomes after liver resection for HCC in this setting, comparing them with those of transplant. However, most are limited by small sample sizes and low statistical power. No prospective studies have been performed on this topic given the inability to randomize patients to liver resection versus transplant. The authors found 2 studies including more than 200 patients. They both suggest that transplant is associated with better survival than liver resection in patients within Milan criteria and Child-Pugh A or B. Nonetheless, it should be noted that graft availability and waiting times for transplant differ between countries, which greatly influences the selection of liver resection versus transplant for patients with early-stage HCC.
The current evidence suggests that, for patients with small HCC lesions (<3 cm), OS is likely to be similar for patients undergoing liver resection versus ablation. For selected patients with multiple HCCs, liver resection may be associated with better OS than TACE. For the past 10 years, sorafenib has been the only effective medical therapy available for unresectable HCC. Recently, several promising new therapies, including multikinase inhibitors and immunotherapies, have been reported. Perioperative use of these new therapies may further improve outcomes in patients undergoing liver resection for HCC and potentially change the current treatment guidelines.
III Jornada Maranhense de Cirurgia Digestiva
Com imensa satisfação é realizada a 3ª Edição da JORNADA MARANHENSE DE CIRURGIA DIGESTIVA, com abordagem de temas inovadores sobre a cirurgia digestiva, os avanços na medicina em relação a essa especialidade e procedimentos de mínima invasibilidade a fim de atualização e aprendizado da comunidade médica maranhense. Para isso, contamos com grandes nomes da área de Cirurgia do Aparelho Digestivo da região meio-norte brasileiro que trouxeram para a Jornada palestras enriquecedoras e discussões de casos.
Critical View Of Safety
“The concept of the critical view was described in 1992 but the term CVS was introduced in 1995 in an analytical review of the emerging problem of biliary injury in laparoscopic cholecystectomy. CVS was conceived not as a way to do laparoscopic cholecystectomy but as a way to avoid biliary injury. To achieve this, what was needed was a secure method of identifying the two tubular structures that are divided in a cholecystectomy, i.e., the cystic duct and the cystic artery. CVS is an adoption of a technique of secure identification in open cholecystectomy in which both cystic structures are putatively identified after which the gallbladder is taken off the cystic plate so that it is hanging free and just attached by the two cystic structures. In laparoscopic surgery complete separation of the body of the gallbladder from the cystic plate makes clipping of the cystic structures difficult so for laparoscopy the requirement was that only the lower part of the gallbladder (about one-third) had to be separated from the cystic plate. The other two requirements are that the hepatocystic triangle is cleared of fat and fibrous tissue and that there are two and only two structures attached to the gallbladder and the latter requirements were the same as in the open technique. Not until all three elements of CVS are attained may the cystic structures be clipped and divided. Intraoperatively CVS should be confirmed in a “time-out” in which the 3 elements of CVS are demonstrated. Note again that CVS is not a method of dissection but a method of target identification akin to concepts used in safe hunting procedures. Several years after the CVS was introduced there did not seem to be a lessening of biliary injuries.
Operative notes of biliary injuries were collected and studied in an attempt to determine if CVS was failing to prevent injury. We found that the method of target identification that was failing was not CVS but the infundibular technique in which the cystic duct is identified by exposing the funnel shape where the infundibulum of the gallbladder joins the cystic duct. This seemed to occur most frequently under conditions of severe acute or chronic inflammation. Inflammatory fusion and contraction may cause juxtaposition or adherence of the common hepatic duct to the side of the gallbladder. When the infundibular technique of identification is used under these conditions a compelling visual deception that the common bile duct is the cystic duct may occur. CVS is much less susceptible to this deception because more exposure is needed to achieve CVS, and either the CVS is attained, by which time the anatomic situation is clarified, or operative conditions prevent attainment of CVS and one of several important “bail-out” strategies is used thus avoiding bile duct injury.
CVS must be considered as part of an overall schema of a culture of safety in cholecystectomy. When CVS cannot be attained there are several bailout strategies such a cholecystostomy or in the case of very severe inflammation discontinuation of the procedure and referral to a tertiary center for care. The most satisfactory bailout procedure is subtotal cholecystectomy of which there are two kinds. Subtotal fenestrating cholecystectomy removes the free wall of the gallbladder and ablates the mucosa but does not close the gallbladder remnant. Subtotal reconstituting cholecystectomy closes the gallbladder making a new smaller gallbladder. Such a gallbladder remnant is undesirable since it may become the site of new gallstone formation and recurrent symptoms . Both types may be done laparoscopically.”
Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.
First described by Pablo Mirizzi in 1948 as “functional hepatic syndrome”, Mirizzi’s syndrome was initially thought to be the result of a “physiologic sphincter” of the hepatic duct. It is now understood to be a result of mechanical obstruction of the common hepatic duct secondary to an impacted stone in the gallbladder neck, Hartmann’s pouch, or the cystic duct. The syndrome is very uncommon in Western populations with a reported prevalence of 0.05%-5.7% in large modern series of patients undergoing biliary surgery. With chronic stone impaction, inflammation and recurrent cholangitis can develop with subsequent erosion into the common bile duct (CBD) and resultant biliobiliary fistula between the gallbladder and CBD.
The syndrome encompasses a spectrum of disease. Broadly speaking, Mirizzi’s syndrome can be grouped into two major categories: (1) external compression of the CBD without a fistula (Type 1), and (2) erosion into the CBD causing a cholecystobiliary fistula (Type II-IV). Csendes classification is currently being used to reflect the above classification. Retrospective studies have identified an association between Mirizzi’s syndrome and gallbladder cancer, with an incidence as high as 28%, relative to an incidence of 1-2% in patients with uncomplicated gallstone disease. As with other malignant processes of the biliary tract, biliary stasis and chronic inflammation have been suggested to play a role. In general, it is difficult to distinguish benign Mirizzi’s syndrome from a neoplastic process preoperatively, although older patient age, significantly elevated Ca 19-9, and imaging features suggestive of invasion into the liver or a mass filling the gallbladder should raise suspicion for malignancy.
The most common presenting symptoms are right upper quadrant pain, jaundice, nausea/vomiting, and fever. This spectrum of findings overlaps with several other pathologic processes of the hepatobiliary tract, making preoperative diagnosis difficult. Additionally, the clinical picture may be complicated by the concurrent presence of acute cholecystitis, pancreatitis, or even gallstone ileus. Mirizzi’s syndrome should be suspected in any patient presenting with right upper quadrant pain and abnormal liver enzymes (particularly elevated bilirubin and alkaline phosphatase) or imaging suggestive of an impacted stone. Three findings on imaging together suggest a diagnosis of Mirizzi’s: 1) dilation of the biliary system above the level of the gallbladder neck, 2) the presence of a stone impacted in the gallbladder neck, and 3) an abrupt change to a normal width of the common duct below the level of the stone. Such findings should prompt further imaging to better define the biliary tree, either indirectly though magnetic resonance cholangiopancreatography (MRCP), or directly through endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). No imaging modality is entirely sensitive for Mirizzi’s syndrome and the key is to maintain a high index of suspicion.
Management of Mirizzi’s syndrome depends on the degree of fistula. In Type I disease, laparoscopic cholecystectomy is usually achievable, either total (classic) or subtotal, depending on the specific intraoperative findings. If the view of safety can be attained with the critical structures isolated, a classic cholecystectomy may be performed. If the view of safety cannot be achieved due to inflammation or adhesions, the gallbladder is taken down retrograde and opened near the cystic duct orifice. All stones are removed, including any impacted stones, and the cystic duct orifice is examined for the presence of bile to determine whether it is patent. If the cystic duct is patent, it should be ligated (if possible), or the remnant gallbladder should be sutured closed over it (choledochoplasty). An external closed suction drain may be left in the gallbladder fossa and removed the following day if drainage is non-bilious. More commonly, the cystic duct is obliterated, and a subtotal cholecystectomy with removal of all stones is sufficient.
Management of Mirizzi’s syndrome in the presence of a biliobiliary fistula is more complex. If the fistula involves <1/3 of the CBD circumference (Type II), options include primary repair using absorbable suture, closure over a T-tube, or choledochoplasty using the remnant gallbladder. The last approach is preferable to maintain the diameter of the CBD and minimize the risk of subsequent stricture but requires that sufficient gallbladder remnant be available to allow closure. In the presence of a more extensive fistula (Type III or IV), bilioenteric anastomosis is usually the best option.
Transplantation for nonalcoholic steatohepatitis
The global obesity epidemic has dramatically increased the prevalence of NAFLD and made it the leading cause of chronic liver disease in Western nations. NAFLD is considered the hepatic manifestation of the metabolic syndrome and shares a strong association with type 2 diabetes mellitus, obstructive sleep apnea (OSA), and cardiovascular disease. Although cardiovascular disease is the leading cause of death in patients with NAFLD, the subset of patients who meet histopathologic criteria for NASH are those at greatest risk of liver-related morbidity and mortality. Ludwig and colleagues coined the term NASH in 1980 to describe a cohort of middle-aged patients with elevated serum liver enzyme levels who had evidence of alcohol-associated hepatitis on biopsy specimens in the absence of alcohol consumption. Subsequent study led to the proposed “2-hit” hypothesis in which a sequential progression from isolated fatty liver (IFL) to NASH involved the initial “hit” of hepatic steatosis followed by a second “hit” of oxidative stress resulting in liver injury. It was subsequently recognized that patients who have steatohepatitis on a liver biopsy specimen are at greatest risk for progression to cirrhosis compared with those who have IFL. Correspondingly, our understanding of the pathogenesis of NAFLD has evolved from the 2-hit hypothesis. NASH is expected to become the most common cause of cirrhosis and the leading indication for LT in the USA in the 2020s. As a major public health concern, an understanding of its epidemiology and pathogenesis is paramount to facilitate our ability to effectively diagnose and treat patients with NAFLD and NASH.
NAFLD is an increasingly frequent cause of cirrhosis and HCC. In fact, a report published in 2018 listed NAFLD as the second leading non-neoplastic indication for LT in adults in the USA, following alcohol-associated liver disease. Obesity (BMI ≥30 kg/m2) and type 2 diabetes mellitus are commonly encountered in patients with NAFLD; these 2 diseases have been recognized as risk factors for HCC, irrespective of the presence or etiology of cirrhosis. Although BMI is not necessarily a reliable indicator of adiposity in patients with end-stage liver disease, particularly in those with fluid retention and ascites, it is commonly used by many LT centers during the patient selection process. Morbid obesity (BMI ≥40 kg/m2 without significant obesity-related comorbidities or BMI ≥35 kg/m2 associated with obesity-related comorbidities) is commonly regarded as a relative contraindication to LT; however, data from the Organ Procurement and Transplantation Network demonstrate that 16.5% and 5% of patients who underwent LT in 2016 had a BMI greater than or equal to 35 kg/m2 and greater than or equal to 40 kg/m2, respectively.
NAFLD and Liver Transplantation
Analysis of data from the UNOS registry has suggested that the risk of primary graft nonfunction is increased and short- and long-term survival is poorer in morbidly obese liver transplant recipients with various causes of end-stage liver disease. However, when analyzed as an entire cohort and not stratified by BMI, patients with NAFLD have patient and graft survival rates that are comparable to those for other indications for LT. Many of the key precipitants of NAFLD (obesity, hyperlipidemia, and insulin resistance) are exacerbated by immunosuppression. Recurrence of NAFLD after LT causes graft injury, although graft loss does not typically occur. De novo NAFLD after LT has also been described. In the absence of specific therapy for NAFLD, therapeutic efforts after LT should center on weight control, optimal diabetic management, and use of a lipid-lowering agent, if indicated. Intensive noninvasive weight loss interventions pre-LT appear to be successful (reduction of BMI to <35 kg/m2) in a large proportion of patients (84%) enrolled in carefully monitored multidisciplinary protocols; however, 60% of patients regained weight to a BMI ≥35 kg/m2 post-LT. Although bariatric surgery is feasible in selected patients with NAFLD, this intervention is typically reserved for patients with early stages of liver disease and, as is the case for many other abdominal surgical procedures, is contraindicated in those with decompensated cirrhosis because of high morbidity and mortality. A strategy of combining LT with sleeve gastrectomy during the same operation has only been evaluated in small prospective series. The mean surgical time was not significantly different between LT and combined LT/sleeve gastrectomy, and the mean BMI reduction with the combined surgical approach was 20 kg/m2. Metabolic complications, such as post-transplant diabetes mellitus, as well as steatosis of the graft noted by US were significantly less frequent in patients undergoing LT/sleeve gastrectomy compared with patients who lost weight noninvasively pre-LT. The safety and efficacy of this combined surgical approach and other combinations of less invasive weight loss interventions, such as endoscopic techniques, pre-LT must be confirmed by large prospective studies before they can be recommended. Bariatric interventions are still an option post-LT; however, the procedure should be performed by an experienced surgeon, and the role of less invasive endoscopic techniques postLT is still under investigation.
Sleeve Gastrectomy vs NAFLD
Bariatric surgery leads to substantial weight loss that results in improved metabolic parameters and hepatic histology in patients with NAFLD, according to numerous large retrospective and prospective cohort studies. In one study of 109 patients with NASH who underwent follow-up liver biopsy one year after bariatric surgery, 85% of patients had resolution of NASH, and 33% had improvement in fibrosis. Initial concerns that fibrosis would worsen with rapid weight loss were unfounded, as demonstrated in a meta-analysis in which fibrosis improved by 11.9% from baseline after bariatric surgery. Although bariatric surgery is not recommended as a treatment for NASH, the abundant positive data in its favor suggest that surgical weight loss is a viable option for patients with comorbid conditions that would warrant the surgery for other reasons. Patients with NASH cirrhosis are at potentially higher risk for surgical complications, although some centers have demonstrated encouraging results with sleeve gastrectomy in patients with Child-Pugh class A cirrhosis.
NOTTS: OR Etiquette
If OR etiquette represents a code of conduct—respect, communication, shared mental model, and teamwork—then manners represent the behaviors that embody this code of behavior. These seem like simple rules that should have been learned at an early age, but a few pointers will go a long way toward integrating junior residents and students into the OR team.
1. Be polite.
2. Be respectful.
3. Be humble.
4. Learn everyone’s name.
5. Offer help without being asked.
6. Ask for help when needed.
7. Thank your colleagues.
8. Keep the patient at the center of all you do.
Rude, disruptive, or disrespectful behavior is not tolerated. Do not yell or make sarcastic comments. Do not make jokes with sexual or racial themes. Do not gossip or denigrate others. Many surgeons enjoy listening to music in the operating room, but in choosing a playlist, be aware that some music may have offensive lyrics that should not be played in the workplace. It is most polite to ask before playing music and to check in with music preferences, as not everyone in the OR may appreciate loud death metal. Music should be turned off during critical times such as the initial time-out. Surgeons use social media like many others, but the OR is not the place to check Facebook or Instagram. When posting to social media, be professional—anything posted to the Internet can be screen captured and spread, no matter what privacy settings you may have turned on. A recent study of publicly accessible Facebook posts showed 14.1% of surgery residents had posted potentially unprofessional content, and 12.2% had clearly unprofessional content, with violations of patient privacy being one of the most common problems, along with description of binge drinking and racially or sexually offensive material. Specific to the OR, be aware that social media postings with potentially identified patient information are absolutely forbidden. This does not need to include a name of a patient to be identifiable information—a few details of a particularly unique case and a timestamped posting can be enough to cause trouble.
NOTTS: Giving and Receiving Feedback
Feedback has gained an increasingly important role in surgical education. Feedback may be summative and/or formative. Summative feedback is often given at discrete time points such as the end of a rotation and is a culmination of observations of performance. Formative feedback involves an ongoing assessment of skills or knowledge and may be given throughout an education experience. There is an often misunderstood distinction between teaching and feedback. As an example, teaching is when the attending surgeon corrects the resident’s needle angle during a bowel anastomosis. Feedback is when the attending surgeon and resident meet after the case and discuss performance—either technical or nontechnical. For example, a feedback session might discuss room setup, efficiency, technical maneuvers, and communication. Giving and receiving feedback are distinct skills that require both parties to be attentive and open. To facilitate this process, several methods have been described that turn feedback into an active process for both parties. Ideally, the mentor and the trainee have a briefing prior to the case in order to set learning objectives and then formally debrief after the case to discuss how well the learning objectives were met as well as ways to improve this in the future. In the press of clinical concerns and the drive toward efficiency, the debrief session is often skipped or missed. It is incumbent on the learner, therefore, to specifically seek out and ask the attending surgeon for feedback and if necessary to schedule formal meeting times. It is also important for feedback to flow both ways, and the attending surgeon should ask for feedback from the residents as well. A good methodology for providing feedback is to ask an open-ended question such as “How did you think that operation went?” Which can be followed with “What went well?” and “What could have gone better?” This allows the person providing feedback with a baseline to start from and allow for self-reflection on the part of the learner. This can be followed with specific feedback about one to two actionable items, preferably relating back to the goals stated during the initial briefing.
NOTTS: Leadership and Followership
Although the OR may seem like a highly regimented environment, each member of the surgical team will serve as both a “leader” and a “follower” at different points during the operation. This includes everyone from the most senior attending surgeon to the most junior medical student. Within the OR, the surgical attending has ultimate responsibility for the patient. However, surgical residents will often act as leaders to junior residents and medical students. In the setting of “progressive autonomy” for surgical trainees, the attending surgeon may also formally or informally cede control of the case to the resident or fellow and may take a follower role him or herself. In fact, more often than not, the surgical attending will assist a senior resident through a case, rather than perform the operation with the resident’s assistance. In the OR, the team leader is responsible for setting the tone. It is up to the leader to make sure that all team members have a shared understanding of how the day will proceed as well as any potential problems that may arise. In many cases, the surgical attending does not arrive to the OR until the patient has arrived, been intubated, and prepped and draped. In this case, it is up to the senior-most resident to lead the team. A resident who arrives early, completes the surgical timeout in a thorough but efficient manner, and moves the room forward is much more effective than one who arrives late or is not familiar with the patient or the case. While an extensive discussion of successful leadership traits is outside of the realm of this chapter, in general a good leader is one who outlines a clear vision of the work that needs to be accomplished while also empowering those around them to take ownership over their individual work. While leadership is a commonly discussed topic, what is less commonly discussed is the importance of “followership.” While there are several different descriptions of the various types of “followers” on any given team, many focus on a spectrum from passive to active and from dependent, uncritical thinking to independent, critical thinking. Compared to the field of leadership, the study of followership is relatively new, but it is generally agreed that effective followers are those who are paying attention to what is going on around them, taking an active interest in the process, and questioning or challenging leadership or the status quo when necessary. This last point is especially critical. In the OR, being a good follower is a crucial component to maintaining patient safety as it is incumbent upon the followers (including residents, medical students, nursing staff, and all other participants) to speak up if they notice that something is going wrong or that the environment has become unsafe. Especially for more junior members of the team, it can be intimidating to alert the attending that he or she may be making a mistake or misjudging the situation. However, it is important to remember that such actions, when carried out with tact and respect, are in the best interest of the patient and may actually prevent serious harm from occurring.