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.
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.
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.
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.
Surgical Management of GERD After Sleeve Gastrectomy
Evaluation of a patient referring GERD after sleeve gastrectomy should start with a detailed history and physical examination; the presence or absence of GERD-related symptoms should be thoroughly documented as well as any prior treatments or therapy used to treat it. Obtaining preoperative and operative records is of paramount importance particularly in those patients who had their index procedure performed elsewhere. Any endoscopic findings and prior imaging available are important to determine what the best course of action would be. If the patient had preoperative and postoperative imaging such as UGI, it is useful to compare those with a recent study to look for anatomical problems that may have been not addressed at the time of the index operation or developed over time. After this information is obtained, we can classify the GERD after sleeve as:
1. De novo GERD
2. Preexisting GERD without improvement
3. Preexisting GERD with worsening/complication
Regardless of how we classify the GERD, an initial evaluation with imaging
studies such as UGI and EGD is recommended. Comparison with any prior films if available is of significant value. Based on the UGI, we can determine if the shape of the sleeve falls into one of the following categories: tubular, dilated bottom, dilated upper, or dumbbell-shaped sleeve; we will also be able to evaluate esophageal peristalsis in real time and if there is associated hiatal hernias. We believe UGI under fluoroscopy provides important physiologic and anatomic information that can help guide our management approach, and therefore we offer it to all patients. We follow the radiologic evaluation with endoscopy, and during endoscopy, we look for objective signs of reflux such as esophagitis, presence of bile in the stomach or esophagus, as well as missed or recurrent hiatal hernias. In patients with evidence of esophagitis or metaplasia, multiple biopsies are taken. During the endoscopy, subtle findings that suggest a kink or a stricture may be present. In the absence of objective signs of gastroesophageal reflux disease on both endoscopy and upper GI series, we pursue physiologic testing followed by highresolution manometry and pH monitoring. In those patients where clear reflux esophagitis is seen, this additional testing may not be necessary or may be performed in selected cases depending on what the surgical or endoscopic therapy would be.
While it is true that most sleeve-related GERD will be effectively treated with a conversion to Roux-en-Y gastric bypass, not every patient with GERD after reflux will require a bypass or would agree to have one. First key step in addressing the patient is to evaluate whether the patient was selected appropriately to have a sleeve and second is to determine the exact sleeve anatomy; are there anatomical factors that will make it more likely for this patient to experience reflux; is there dilated fundus? Is there a kink or stricture in the sleeve or is it an anatomically appropriate operation? We should pay important attention to the weight loss the patient has experienced with the sleeve. Patients who do not have adequate weight loss and have GERD symptoms should not undergo other therapies and should probably undergo a bypass; however it is our unpublished experience that patients with the association of poor weight loss after sleeve and difficult to treat GERD will correct their GERD after conversion, but their weight loss results are still marginal even with a well-constructed bypass.
Medically-Necessary, Time Sensitive: (MeNTS) Score
Operating During The COVID-19 Coronavirus Pandemic
“At the University of Chicago, members of the Department of Surgery decided to investigate this issue more precisely. As stay-at-home restrictions in some states are easing, and as non-emergency medical care is being reconsidered, how does one possibly triage the thousands upon thousands of patients whose surgeries were postponed? Instead of the term “elective,” the University of Chicago’s Department of Surgery chose the phrase “Medically-Necessary, Time Sensitive” (MeNTS). This concept can be utilized to better assess the acuity and safety when determining which patients can get to the operating room in as high benefit/low risk manner as possible. And unlike in any recent time in history, risks to healthcare staff as well as risks to the patient from healthcare staff, are now thrown into the equation. The work was published in the April issue of the Journal of the American College of Surgeons.
On March 17, 2020, the American College of Surgeons recommended that all “elective” surgeries be canceled indefinitely. These guidelines were published, stating that only patients with “high acuity” surgical issues, which would include aggressive cancers and severely symptomatic disease, should proceed. Based on the Elective Surgery Acuity Scale (ESAS), most hospitals were strongly encouraged to cancel any surgery that was not high acuity, including slow-growing cancers, orthopedic and spine surgeries, airway surgeries, and any other surgeries for non-cancerous tumors. Heart surgeries for stable cardiac issues were also put on hold. Patients and surgeons waited. Some patients did, indeed undergo non-Covid-19-related surgeries. But most did not. Redeployment is gradually turning to re-entry.
The re-entry process for non-urgent (yet necessary) surgeries is a complicated one. Decisions and timing, based on a given hospital’s number and severity of Covid-19 patients, combined with a given city or state’s current and projected number of Covid-19 cases, how sick those patients will be, and whether or not a second surge may come, involves a fair amount of guesswork. As we have all seen, data manipulation has become a daily sparring match in many arenas. The authors of the study created an objective surgical risk scoring system, in order to help hospitals across this country, as well as others across the world, better identify appropriate timing regarding which surgeries can go ahead sooner rather than later, and why. They factored several variables into their equation, to account for the multiple potential barriers to care, including health and safety of hospital personnel. They created scoring systems based on three factors: Procedure, Disease and Patient Issues.
CALCULATE MeNTS SCORE HERE
The authors of the study created an objective surgical risk scoring system, in order to help hospitals across this country, as well as others across the world, better identify appropriate timing regarding which surgeries can go ahead sooner rather than later, and why. They factored several variables into their equation, to account for the multiple potential barriers to care, including health and safety of hospital personnel. Each patient would receive an overall conglomerate score, based on all of these factors, with the lower risks giving them more favorable scores to proceed with surgery soon, and the higher risks giving patients a higher score, or higher risk regarding proceeding with surgery, meaning it may be safest, for now, to wait.
Dr. Jeffrey Matthews, senior author of the paper, and Department Chair at the University of Chicago, stated that this model is reproducible across hospital systems, in urban, rural, and academic settings. And in the event of potential unpredictable surges of Covid-19 cases, the scoring system “helps prioritize cases not only from the procedure/disease standpoint but also from the pandemic standpoint with respect to available hospital resources such as PPE, blood, ICU beds, and [regular hospital] beds.”
The scoring system is extremely new, and the coming weeks will reveal how patients, surgeons and hospitals are faring as patients without life-and-death emergencies and/or Covid-19 complications gradually begin filling the operating rooms and hospital beds. In addition, and perhaps just as important, the study authors note that creating systems whereby healthcare resources, safety, and impact on outcomes need to be considered more carefully for each patient intervention, the larger impact of each intervention on public health will be better understood: not only for today’s pandemic, but also in future, as yet unknown, global events.”
Source: Nina Shapiro, 2020
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Covid-19 and Digestive Surgery
The current world Covid-19 pandemic has been the most discussed topic in the media and scientific journals. Fear, uncertainty, and lack of knowledge about the disease may be the significant factors that justify such reality. It has been known that the disease presents with a rapidly spreading, it is significantly more severe among the elderly, and it has a substantial global socioeconomic impact. Besides the challenges associated with the unknown, there are other factors, such as the deluge of information. In this regard, the high number of scientific publications, encompassing in vitro, case studies, observational and randomized clinical studies, and even systematic reviews add up to the uncertainty. Such a situation is even worse when considering that most healthcare professionals lack adequate knowledge to critically appraise the scientific method, something that has been previously addressed by some authors. Therefore, it is of utmost importance that expert societies supported by data provided by the World Health Organization and the National Health Department take the lead in spreading trustworthy and reliable information.
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Bariatric Surgery During the COVID-19 Pandemic
Coronavirus disease 2019 (COVID-19) emerged in Wuhan City and rapidly spread throughout China and around the world since December 2019. The World Health Organization (WHO) declared the COVID-19 outbreak a global pandemic on 11 March 2020. Patients with metabolic disorders like cardiovascular diseases, diabetes and obesity may face a greater risk of infection of COVID-19 and it can also greatly affect the development and prognosis of pneumonia.
“A higher cumulative MeNTS score, which can range from 21 to 105, is associated with poorer perioperative patient outcome, increased risk of COVID-19 transmission to the health care team, and/or increased hospital resource utilization. Given the need to maintain OR capacity for trauma, emergency, and highly urgent cases, an upper threshold MeNTS score can be designated by surgical and perioperative leadership based on the immediately anticipated conditions and resources at each institution.”
All elective surgical and endoscopic cases for metabolic and bariatric surgery should be postponed during the pandemic. This minimises risks to both patient and healthcare team, as well as reducing the utilisation of unnecessary resources, such as beds, ventilators and personal protective equipment (PPE). In addition, postponing these services will minimise potential exposure of the COVID-19 virus to unsuspecting healthcare providers and patients. As the long-term effects or complications of COVID-19 are still unknown, metabolic and bariatric surgeries for patients who were diagnosed and recovered from COVID-19 should be evaluated by a multidisciplinary team. Diet and lifestyle modifications should be advised before surgical treatment.
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Many oncological patients with upper gastrointestinal (GI) tract tumours, apart from other symptoms, are malnourished or cachectic at the time of presentation. In these patients feeding plays a crucial role, including as part of palliative treatment. Many studies have proved the benefits of enteral feeding over parenteral if feasible. Depending on the tumour’s location and clinical stage there are several options of enteral feeding aids available. Since the introduction of percutaneous endoscopic gastrostomy (PEG) and its relatively easy application in most patients, older techniques such as open gastrostomy or jejunostomy have rather few indications.
The majority of non-PEG techniques are used in patients with upper digestive tract, head and neck tumours or trauma that renders the PEG technique unfeasible or unsafe for the patient. In these patients, especially with advanced disease requiring neoadjuvant chemotherapy or palliative treatment, open gastrostomy and jejunostomy were the only options of enteral access. Since the first report of laparoscopic jejunostomy by O’Regan et al. in 1990 there have been several publications presenting techniques and outcomes of laparoscopic feeding jejunostomy. Laparoscopic jejunostomy can accompany staging or diagnostic laparoscopy for upper GI malignancy when the disease appears advanced, hence avoiding additional anaesthesia and an operation in the near future.
In this video the author describe the technique of laparoscopic feeding jejunostomy applied during the staging laparoscopy in patient with advanced upper gastrointestinal tract cancer with co-morbid cachexy, requiring enteral feeding and neoadjuvant chemotherapy.
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Basicamente, existem quatro situações que indicam a realização de traqueostomia: prevenção de lesões laringotraqueais pela intubação translaríngea prolongada; desobstrução da via aérea superior, em casos de tumores, corpo estranho ou infecção; acesso à via aérea inferior para aspiração e remoção de secreções; e aquisição de via aérea estável em paciente que necessita de suporte ventilatório prolongado.
A substituição do tubo endotraqueal pela cânula de traqueostomia ainda acrescenta benefícios, proporcionando conforto e segurança do paciente. Algumas sociedades americanas sugerem que a traqueostomia deva ser sempre considerada para pacientes que necessitarão de ventilação mecânica prolongada, ou seja, por mais de 14 dias.
Muitas vezes, a decisão de se realizar uma traqueostomia é tomada pelo julgamento clínico de médicos, principalmente aqueles que trabalham em unidades de terapia intensiva. Isso envolve a análise de múltiplos fatores, tais como as características de cada paciente, o motivo pelo qual ocorreu a intubação, doenças associadas, resposta ao trata-mento e prognóstico individualizado. Embora haja uma tendência de indicação de traqueostomia precoce em pacientes neurocríticos e com trauma grave.
- Diminuição do trabalho respiratório
- Melhora da aspiração das vias aéreas
- Permitir a fonação
- Permitir a alimentação por via oral
- Menor necessidade de sedação
- Redução do risco de pneumonia associada à ventilação
- Diminuição do tempo de ventilação mecânica
- Diminuição do tempo de internação em unidades de terapia
- Redução da mortalidade
Enhanced Recovery After Liver Surgery
The first postoperative fast-track protocols, also called “enhanced recovery after surgery” (ERAS), were instituted by colorectal surgeons almost three decades ago in order to modulate surgical stress and hasten recovery. Since then, the implementation of enhanced recovery programs has had an exponential expansion across most surgical specialties, including gynecology, urology, breast, vascular, and orthopedic surgery.
“Enhanced recovery after liver surgery” (ERLS) was first introduced in 2008 and has incrementally gained acceptance as being an integral part of perioperative care for hepatectomy patients. Several outcome metrics have shown to be improved with the adoption of a multimodal evidencebased strategy in liver surgery, many of which are also shared by other surgical specialties practicing in an enhanced recovery framework.
Improved clinical outcomes such as length of stay, morbidity rates, and hospital costs tend to support implementation of fast-track programs in general, but other metrics specific to liver surgery and to patients with colorectal liver metastases (CLM) further endorse this strategy when managing CLM. The implementation of an ERLS program represents a collaborative approach in which the different team players, including anesthesia, surgery, nutrition, pharmacy, nursing, and most importantly the patient and his/her family, engage actively in the perioperative pathway, in an evidence-based, patient-centered approach. The development of such programs also requires dedicated continuing education for the team members, flexibility in terms of perioperative management and decisionmaking by the health-care providers, support from the hospital administration, and systematic quality control measures to ensure implementation and accurate reporting. This review study the different core elements of ERLS and discuss different outcomes associated with this system-based approach, with an emphasis on oncological patients.
Interference with oncological treatment plans can negatively affect patients’ longterm outcomes but can also be detrimental to quality of life and overall functional status. Patient-reported outcomes (PROs) attempt to capture the patients’ perspective for a given intervention or treatment strategy, which are particularly important in oncological patients. Day et al. reported that the implementation of ERLS was beneficial for patients in terms of functional recovery, and although no significant differences were detected in terms of symptom burden, the impact of ERLS was shown to accelerate functional recovery by returning to baseline interference earlier. This positive effect from ERLS seems more pronounced in patients undergoing open hepatectomy over those already benefiting from minimally invasive surgery.
Ischaemic Preconditioning applied to LIVER SURGERY
The absence of oxygen and nutrients during ischaemia affects all tissues with aerobic metabolism. Ischaemia of these tissues creates a condition which upon the restoration of circulation results in further inflammation and oxidative damage (reperfusion injury). Restoration of blood flow to an ischaemic organ is essential to prevent irreversible tissue injury, however reperfusion of the organ or tissues may result in a local and systemic inflammatory response augmenting tissue injury in excess of that produced by ischaemia alone. This process of organ damage with ischaemia being exacerbated by reperfusion is called ischaemia-reperfusion (IR). Regardless of the disease process, severity of IR injury depends on the length of ischaemic time as well as size and pre-ischaemic condition of the affected tissue. The liver is the largest solid organ in the body, hence liver IR injury can have profound local and systemic consequences, particularly in those with pre-existing liver disease. Liver IR injury is common following liver surgery and transplantation and remains the main cause of morbidity and mortality.
The liver has a dual blood supply from the hepatic artery (20%) and the portal vein (80%). A temporary reduction in blood supply to the liver causes IR injury. This can be due to a systemic reduction or local cessation and restoration of blood flow. Liver resections are performed for primary or secondary tumours of the liver and carry a substantial risk of bleeding especially in patients with chronic liver disease. Significant blood loss is associated with increased transfusion requirements, tumour recurrence, complications and increased morbidity and mortality. Several methods of hepatic vascular control have been described in order to minimise blood loss during elective liver resection. The simplest and most common method is inflow occlusion by applying a tape or vascular clamp across the hepatoduodenal ligament (Pringle Manoeuvre). This occludes both the arterial and portal vein inflow to the liver and leads to a period of warm ischaemia (37 °C) to the liver parenchyma resulting in ‘warm’ IR injury when the temporary inflow occlusion is relieved. In major liver surgery, extensive mobilisation of the liver itself without inflow occlusion results in a significant reduction in hepatic oxygenation.
3. PATOPHYSIOLOGY and RISK FACTORS
A complex cellular and molecular network of hepatocytes, Kupffer cells, liver sinusoidal endothelial cells (LSEC), leukocytes and cytokines play a role in the pathogenesis of IR injury. In general, both warm and cold ischaemia share similar mechanisms of injury. Hepatocyte injury is a predominant feature of warm ischaemia, whilst endothelial cells are more susceptible to cold ischaemic injury. There are currently no proven treatments for liver IR injury. Understanding this complex network is essential in developing therapeutic strategies in prevention and treatment of IR injury. Identifying risk factors for IR injury are extremely important in patient selection for liver surgery and transplantation. The main factors are the donor or patient age, the duration of organ ischaemia, presence or absence of liver steatosis and in transplantation whether the donor organ has been retrieved from a brain dead or cardiac death donor.
4. PREVENTION and TREATMENT
There is currently no accepted treatment for liver IR injury. Several pharmacological agents and surgical techniques have been beneficial in reducing markers of hepatocyte injury in experimental liver IR, however, they are yet to show clinical benefit in human trials. The following is an outline of current and future strategies which may be effective in reducing the detrimental effects of liver IR injury in liver surgery and transplantation.
4.1 SURGICAL STRATEGIES
Inflow occlusion or portal triad clamping (PTC) can be continuous or intermittent; alternating between short periods of inflow occlusion and reperfusion. Intermittent clamping (IC) increases parenchymal tolerance to ischaemia. Hence, prolonged continuous inflow occlusion rather than short intermittent periods results in greater degree of post-operative liver dysfunction. IC permits longer total ischaemia times for more complex resections. Alternating between 15 min of inflow occlusion and 5 min reperfusion cycles can be performed safely for up to 120 min total ischaemia time. There is a potential risk of increased blood loss during the periods of no inflow occlusion. However, these intervals provide an opportunity for the surgeon to check for haemostasis and control small bleeding areas from the cut surface of the liver. The optimal IC cycle times are not clear, although intermittent cycles of up to 30 min inflow occlusion have also been reported with no increase in morbidity, blood loss or liver dysfunction compared to 15 min cycles. IC is particularly beneficial in reducing post-operative liver dysfunction in patients with liver cirrhosis or steatosis.
In liver surgery, IPC ( Ischaemic Preconditioning) involves a short period of ischaemia (10 min) and reperfusion (10 min) intraoperatively by portal triad clamping prior to parenchymal transection during which a longer continuous inflow occlusion is applied to minimise blood loss. It allows continuous ischaemia times of up to 40 min without significant liver dysfunction. However, the protective effect of IPC decreases with increasing age above 60 years old and compared to IC it is less effective in steatotic livers. Moreover, IPC may impair liver regeneration capacity and may not be tolerated by the small remnant liver in those with more complex and extensive liver resections increasing the risk of post-operative hepatic insufficiency.
In order to avoid direct ischaemic insult to the liver by inflow occlusion, remote ischaemic preconditioning (RIPC) has been used. RIPC involves preconditioning a remote organ prior to ischaemia of the target organ. It has been shown to be reduce warm IR injury to the liver in experimental studies. A recent pilot randomised trial of RIPC in patients undergoing major liver resection for colorectal liver metastasis used a tourniquet applied to the right thigh with 10 min cycles of inflation-deflation to induce IR injury to the leg for 60 min. This was performed after general anaesthesia prior to skin incision. A reduction in post-operative transaminases and improved liver function was shown without the use of liver inflow occlusion. These results are promising but require validation in a larger trial addressing clinical outcomes.
5. FUTURE PERSPECTIVES
Hepatic IR injury remains the main cause of morbidity and mortality in liver surgery and transplantation. Despite over two decades of research in this area, therapeutic options to treat or prevent liver IR are limited. This is primarily due to the difficulties in translation of promising agents into human clinical studies. Recent advances in our understanding of the immunological responses and endothelial dysfunction in the pathogenesis of liver IR injury may pave the way for the development of new and more effective and targeted pharmacological agents.
Tumor Markers in HPB Cancers
The “ideal” tumor marker is economical, easy to estimate in easily accessible body fluids like blood or urine, has high sensitivity and specificity, can be used to screen for a cancer, has prognostic and predictive value at diagnosis, and is reliable during treatment and follow-up. It does not exist as of now. Commonly used tumor markers in gastrointestinal, liver, biliary tract, and pancreatic cancers are alpha fetoprotein (AFP), CA19.9, carcinoembryonic antigen (CEA), and chromogranin A (CgA).
Alpha Fetoprotein (AFP)
Alpha fetoprotein (AFP) is a glycoprotein that is produced in the yolk sac and the fetal liver. It is the most commonly used tumor marker for hepatocellular carcinoma (HCC). AFP may be raised in gonadal tumors, gastric cancer, and benign states like pregnancy, viral hepatitis, and cirrhosis caused by hepatitis C. The normal range is 10–20 ng/ml. Values above 400 ng/ml or a steady rise in serial estimation (even if lower than 400 ng/ml) is highly suggestive of HCC in a patient at risk of developing HCC. Persistent elevation of AFP is more significant than fluctuating levels. AFP levels are usually normal in the fibrolamellar variety of HCC. AFP is a heterogeneous molecule with respect to the carbohydrate moiety. Different AFP glycoforms can be separated and characterized by their affinity for lectins. Lectins are carbohydrate-binding proteins.
AFP level >500 ng/ml predicts high recurrence rate after transplantation, and such patients are not listed in the USA. Rise of AFP while on the wait list is also a poor prognostic factor. AFP >1000 ng/ml appears to be related to poor prognostic factors like microvascular invasion, portal vein invasion, bile duct invasion, and intrahepatic metastasis. In 2012 a French paper reported a model that added AFP to Milan criteria which improved prediction of recurrence and survival after liver transplantation for HCC.
CA 19-9 is the abbreviation for carbohydrate antigen or cancer antigen 19-9. This tumor marker belongs to the family of mucinous markers. These have a transmembrane protein skeleton and an extracellular side that has glycosylated oligosaccharides. It is a sialylated Lewis blood group antigen. Mucus glands in the pancreas, biliary tree, salivary glands, stomach, colon, and endometrium physiologically secrete CA 19-9, and this is present in small quantities in serum. Higher levels are observed in inflammatory conditions of the pancreas and biliary tree like acute pancreatitis, biliary obstruction, and cholangitis. Overall mean sensitivity and specificity of serum CA 19-9 for diagnosis of pancreatic cancer are 81% and 90% according to one recent review. This study reported these results using 37 KU/l as cutoff of CA 19-9. Serum CA 19-9 seems to fare very poorly and is unsuitable as a screening modality for pancreatic cancer.
In one of the largest reviews of data, positive predictive value for diagnosis of pancreatic cancer was only 0.9%. Another study from Mumbai used CA 19-9 to predict operability in 49 patients with pancreatic cancer. When CA 19-9 was more than twice the normal (37 U/l), 88% were unresectable. Out of the 29 patients considered resectable after contrast-enhanced CT scan of abdomen, 5 patients were found unresectable at operation due to subcentimeter liver or peritoneal metastasis. All these five patients had CA 19-9 level more than three times the normal limit. These investigators suggest that diagnostic/ staging laparoscopy should be used to avoid a non-therapeutic laparotomy if CA 19-9 is more than thrice the normal limit.
Chromogranin A (CgA)
CgA is an acidic glycoprotein that is ubiquitously present in almost all endocrine and neuroendocrine cells of the human body. They are synthesized in these cells, stored along with other hormones /neurotransmitters in vesicles and released from the cells by exocytosis along with other hormones. The granin family consists of eight different substances of which chromogranin A is the best known and the one in clinical use for several decades now. CgA is thus a universal marker for neuroendocrine cell differentiation and activity. Testing its serum level is a marker of neuroendocrine secretory activity in the body. There are numerous limitations for the use of serum chromogranin A for diagnosis or follow-up of gastroenteropancreatic neuroendocrine tumors (GEP-NETs). However, it still remains the preferred tumor marker in these conditions, as it is widely available and less cumbersome to perform and retains a reasonable sensitivity and specificity provided the clinician applies all necessary recommended precautions in performance of the test and interpretation of the results.
Highest levels of CgA in GEP-NETs are obtained in midgut neuroendocrine tumors, previously termed as “carcinoid tumors.” In ileal carcinoids with liver metastasis, level as high as 200 times upper normal limit is reported. GEP-NETs in MEN-1 syndrome could result in chromogranin A values of about 150 times the upper normal limit. CgA levels in pancreatic NETs are about 60–80 times upper normal limit. CgA is elevated in 100% of gastrinomas and 70% of pancreatic NETs. In gastrinoma, very high levels are reported even in the absence of liver metastasis. CgA level of more than 5000 μg/l was found to be an independent prognostic factor for midgut NETs. Median survival was 33 and 57 months below and above the 5000 μg/l cutoff, respectively. This interpretation of CgA level cannot be generalized to all GEP-NETs. Typical exception of high level without any metastatic disease is gastrinoma as mentioned earlier. CgA level does not correlate with the degree of differentiation of GEP-NETs. Diagnostic accuracy of CgA was 73% in well-differentiated NETs and 50% in poorly differentiated NETs. This is probably related to loss of secretory function of poorly differentiated NETs, where this tumor marker is less reliable. CgA level has been reported to fall after all forms of therapy for GEP-NETs. This could be resection of the tumor, liver transplantation for metastatic disease, radionuclide therapy, or treatment with receptor blockade like everolimus.
Perioperative Fluid Management
In the setting of a normal ejection fraction, fluid is only administered when the expectation is that cardiac output will increase, and vasopressors are utilized if the aforementioned devices show fluid will not increase cardiac output. Excess fluid in certain general surgical cases can cause ileus and bowel edema, and in cardiac cases, it can cause hemodilution. Patients randomized to restricted and liberal fluid resuscitation strategies found a clear linear relationship between total fluids administered (and weight gain) and complications following colorectal surgery including pulmonary edema and tissue-healing complications. Further multiple studies exist demonstrating fewer complications with normovolemia than with liberal strategies of fluid resuscitation.
It must be understood that goal-directed therapy does, in no way, mean reduction in fluid administration. For some procedures, it may be necessary to administer more than anticipated fluid volumes (orthopedics), while for others, the opposite may be true (abdominal). Normovolemia is important to maintain perfusion without volume overload. Thus, the idea behind goaldirected therapy is to maintain zero fluid balance coupled with minimal weight gain or loss. Hypovolemia is associated with reduced circulating blood volume, decreased renal perfusion, altered coagulation, microcirculation compromise, and endothelial dysfunction, among other processes. Hypervolemia is associated with splanchnic edema, decreased pulmonary gas exchange secondary to pulmonary edema, impaired wound healing, anastomotic dehiscence, decreased mobility, altered coagulation, and endothelial dysfunction, amidst others processes.
Classroom: Perioperative Medicine
From a recent Cochrane review, there is no evidence that colloids are superior to crystalloid for resuscitation in patients. Therefore, crystalloid fluids should generally be the primary intravenous fluid during the perioperative course. In cardiac surgery, the utilization of 0.9% normal saline solution was associated with hyperchloremia and poor postoperative outcomes, including higher length of stay and increased mortality.118 Further, a more balanced crystalloid, such as Plasma-Lyte, was associated with improved outcomes in 22,851 surgical patients. In this study, there was a 2.05 odds ratio predictor of mortality with normal saline. Other complications such as acute kidney injury, gastrointestinal complications, major hemorrhage, and major infection were also increased in the group of
patients that were hyperchloremic after normal saline administration. Based on such evidence, it would seem prudent to proceed with a more balanced solution, such as PlasmaLyte, to reduce complications.
Recurrence after Repair of Incisional Hernia
The incidence of recurrence in incisional hernia prosthetic surgery is markedly lower than in direct plasties. Indeed after the autoplasties of the preprosthetic period, the recurrence rate ranged from 35% for ventral hernias. Chevrel and Flament, in 1990, reported on 1,033 patients who had undergone laparotomy. The recurrence rate at 10-year follow-up was 14–24% for patients treated without the use of prostheses but only 8.6% for those in whom a prosthesis was implanted. A similar incidence was reported by Chevrel in 1995: 18.3% recurrence without prostheses, 5.5% with prostheses. Likewise, Wantz, in 1991, noted a recurrence rate of 0–18.5% in prosthetic laparo-alloplasties.
At the European Hernia Society (EHS)-GREPA meeting in 1986, the recurrence rate without prostheses was reported to be between 7.2 and 17% whereas in patients who had been treated with a prosthesis the recurrence was between 1 and 5.8%. A case study published by Flament in 1999 showed a 5.6% recurrence rate for operations with prostheses placed behind the muscles and in front of the fascia, and a 3.6% of such figure consisted of a small-sized lateroprosthetic recurrence. These rates were in contrast to the 26.8% recurrence reported by other surgeons for operations without prostheses.
Studies of recurrence are, of course, influenced by the size of the initial defect and the length of follow-up. Nevertheless, it is beyond dispute that the use of prostheses is associated with a lower rate of recurrence independent of the nature of the incisional hernia. The factors that lead to relapse are recognisable in the original features of the ventral hernia, i.e. combined musculo-aponeurotic parietal involvement, septic complications in the first operation, the nature and appropriateness of treatment, the kind of prosthesis and its position. Also important is whether the surgery was an emergency case and the relation to occlusive phenomena, visceral damage
and whether these problems were addressed at the same time.
Obesity is also an important risk factor for recurrence. In addition to its association with a higher surgical complications rate, related to the high intraabdominal pressure, there are deficits in wound cicatrisation as well as respiratory and metabolic pathologies. In such patients, the laparoscopic approach is very useful to significantly reduce the onset of general and wall complications, and the data concerning recurrence are encouraging, ranging between 1 and 9% in the largest laparoscopic case studies. The important multicentric study of Heniford et al., in 2000, reported a recurrence rate of 3.4% after 23 months. In 2003, the same author, in a study with an average follow-up of 20 months (range 1–96) showed a recurrence rate of 4.7% for different, identifiable causes: intestinal iatrogenic injuries and mesh infection with its removal, insufficient fixation of the prosthesis and abdominal trauma in the first postoperative period.
The incidence of recurrence after laparoscopic treatment may also be related to general patient factors and to the onset of local complications, mistakes in opting for laparoscopic treatment and deficits in implanting and fixing the prosthesis. With respect to the latter, it is very important to allow a large overlap compared to the diameter of the defect. Long-term data analysis, with large case studies, is still needed to obtain detailed information about recurrence, and this is particularly true in the assessment of relatively new techniques.
Management of gallbladder cancer
Gallbladder cancer is uncommon disease, although it is not rare. Indeed, gallbladder cancer is the fifth most common gastrointestinal cancer and the most common biliary tract cancer in the United States. The incidence is 1.2 per 100,000 persons per year. It has historically been considered as an incu-rable malignancy with a dismal prognosis due to its propensity for early in-vasion to liver and dissemination to lymph nodes and peritoneal surfaces. Patients with gallbladder cancer usually present in one of three ways: (1) advanced unresectable cancer; (2) detection of suspicious lesion preoperatively and resectable after staging work-up; (3) incidental finding of cancer during or after cholecystectomy for benign disease.
Although, many studies have suggested improved survival in patients with early gallbladder cancer with radical surgery including en bloc resection of gallbladder fossa and regional lymphadenectomy, its role for those with advanced gallbladder cancer remains controversial. First, patients with more advanced disease often require more extensive resections than early stage tumors, and operative morbidity and mortality rates are higher. Second, the long-term outcomes after resection, in general, tend to be poorer; long-term survival after radical surgery has been reported only for patients with limited local and lymph node spread. Therefore, the indication of radical surgery should be limited to well-selected patients based on thorough preoperative and intra-operative staging and the extent of surgery should be determined based on the area of tumor involvement.
Surgical resection is warranted only for those who with locoregional disease without distant spread. Because of the limited sensitivity of current imaging modalities to detect metastatic lesions of gallbladder cancer, staging laparoscopy prior to proceeding to laparotomy is very useful to assess the
abdomen for evidence of discontinuous liver disease or peritoneal metastasis and to avoid unnecessary laparotomy. Weber et al. reported that 48% of patients with potentially resectable gallbladder cancer on preoperative imaging work-up were spared laparotomy by discovering unresectable disease by laparoscopy. Laparoscopic cholecystectomy should be avoided when a preoperative cancer is suspected because of the risk of violation of the plane between tumor and liver and the risk of port site seeding.
The goal of resection should always be complete extirpation with microscopic negative margins. Tumors beyond T2 are not cured by simple cholecystectomy and as with most of early gallbladder cancer, hepatic resection is always required. The extent of liver resection required depends upon whether involvement of major hepatic vessels, varies from segmental resection of segments IVb and V, at minimum to formal right hemihepatectomy or even right trisectionectomy. The right portal pedicle is at particular risk for advanced tumor located at the neck of gallbladder, and when such involvement is suspected, right hepatectomy is required. Bile duct resection and reconstruction is also required if tumor involved in bile duct. However, bile duct resection is associated with increased perioperative morbidity and it should be performed only if it is necessary to clear tumor; bile duct resection does not necessarily increase the lymph node yield.
Predicting LIVER REMNANT Function
Careful analysis of outcome based on liver remnant volume stratified by underlying liver disease has led to recommendations regarding the safe limits of resection. The liver remnant to be left after resection is termed the future liver remnant (FLR). For patients with normal underlying liver, complications, extended hospital stay, admission to the intensive care unit, and hepatic insufficiency are rare when the standardized FLR is >20% of the TLV. For patients with tumor-related cholestasis or marked underlying liver disease, a 40% liver remnant is necessary to avoid cholestasis, fluid retention, and liver failure. Among patients who have been treated with preoperative systemic chemotherapy for more than 12 weeks, FLR >30% reduces the rate of postoperative liver insufficiency and subsequent mortality.
When the liver remnant is normal or has only mild disease, the volume of liver remnant can be measured directly and accurately with threedimensional computed tomography (CT) volumetry. However, inaccuracy may arise because the liver to be resected is often diseased, particularly in patients with cirrhosis or biliary obstruction. When multiple or large tumors occupy a large volume of the liver to be resected, subtracting tumor volumes from liver volume further decreases accuracy of CT volumetry. The calculated TLV, which has been derived from the association between body surface area (BSA) and liver size, provides a standard estimate of the TLV. The following formula is used:
TLV (cm3) = –794.41 + 1267.28 × BSA (square meters)
Thus, the standardized FLR (sFLR) volume calculation uses the measured FLR volume from CT volumetry as the numerator and the calculated TLV as the denominator: Standardized FLR (sFLR) = measured FLR volume/TLV Calculating the standardized TLV corrects the actual liver volume to the individual patient’s size and provides an individualized estimate of that patient’s postresection liver function. In the event of an inadequate FLR prior to major hepatectomy, preoperative liver preparation may include portal vein embolization (PVE).
Classroom: Principles of Hepatic Surgery
Modern Concepts of Pancreatic Surgery
Operations on the gallbladder and bile ducts are among the surgical procedures most commonly performed by general surgeons. In most hospitals, cholecystectomy is the most frequently performed operation within the abdomen. Pancreatic surgery is less frequent , but because of the close relation between the biliary system and the pancreas, knowledge of pancreatic problems is equally essential to the surgeon. Acute and chronic pancreatitis and cancer of the pancreas are often encountered by surgeons, with apparently increasing frequency; their treatment remains difficult and perplexing. This review demonstrates the modern aspects of pancreatic surgery. Good study.
AULA: PRÍNCIPIOS MODERNOS DA CIRURGIA PANCREÁTICA
Postoperative Delirium in Older Adults
Postoperative delirium is recognized as the most common surgical complication in older adults,occurring in 5% to 50% of older patients after an operation.With more than one-third of all inpatient operations in the United States being performed on patients 65 years or older, it is imperative that clinicians caring for surgical patients understand optimal delirium care. Delirium is a serious complication for older adults because an episode of delirium can initiate a cascade of deleterious clinical events, including other major postoperative complications, prolonged hospitalization, loss of functional independence, reduced cognitive function, and death. The annual cost of delirium in the United States is estimated to be $150 billion. Delirium is particularly compelling as a quality improvement target, because it is preventable in up to 40% of patients; therefore, it is an ideal candidate for preventive interventions targeted to improve the outcomes of older adults in the perioperative setting. Delirium diagnosis and treatment are essential components of optimal surgical care of older adults,yet the topic of delirium is under-represented in surgical teaching.
Postoperative Delirium in Older Adults
7 MOST QUESTIONS ABOUT THE SURGEON PROFESSION
What is a Surgical Profession?
The professions are the means by which the complex services needed by society are organized. A profession has been defined by the American College of Surgeons as: an occupation whose core element is work that is based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning, or the practice of an art founded upon it, is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism and to the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which, in turn, grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.
1. What are the core elements of a profession? All professions are characterized by four core elements: (1) a monopoly over the use of specialized knowledge; (2) in return for that monopoly that we enjoy, relative autonomy in practice and the responsibility of self-regulation; (3) altruistic service to individuals and society; and (4) responsibility for maintaining and expanding professional knowledge and skills.
3.What is professionalism? Professionalism describes the cognitive, moral, and collegial attributes of a professional. Ultimately, it is all the reasons that your mother is proud to say that you are a doctor and a surgeon.
4. Why do physicians need a code of professional conduct? Trust is integral to the practice of surgery. The Code of Professional Conduct clarifies the relationship between the surgical profession and the society it serves. This is often referred to as a social contract. For patients the code of professional conduct crystallizes the commitment of the surgical community toward individual patients and their communities. Trust is built brick by brick.
5. What is the Code of Professional Conduct ? The Code of Professional Conduct takes the general principles of professionalism and applies them to surgical practice. The code is the foundation on which we earn our professional privileges and the trust of patients and the public. It is our job description. During the continuum of the preoperative, intraoperative, and postoperative care surgeons have the responsibility to:
5.1 Serve as effective advocates for our patients’ needs.
5.2 Disclose therapeutic options including their risks and benefits.
5.3 Disclose and resolve any conflict of interest that might influence the decisions of care.
5.4 Be sensitive and respectful of patients, understanding their vulnerability during the perioperative period.
5.5 Fully disclose adverse events and medical errors.
5.6 Acknowledge patients’ psychological, social, cultural and spiritual needs.
5.7 Encompass within our surgical care the special needs of terminally ill patients.
5.8 Acknowledge and support the needs of patients’ families and
5.9 Respect the knowledge, dignity, and perspective of other healthcare professionals.
6. Why do surgeons need their own code of professionalism? A surgical procedure is an extreme experience. We impact our patients physiologically, psychologically, and socially. When patients submit themselves to a surgical experience, they must trust that the surgeon will put their welfare above all other considerations. The written code helps to reinforce these values.
7. What are the fundamental principles of the Code of Professional Conduct and the codes of other professional societies?
7.1 The primacy of patient welfare.
This means that the patient’s interests always come first. Altruism is central to this concept, and it is the surgeon’s altruism that fosters trust in the physician-patient relationship.
7.2 Patient autonomy.
Patients must understand and make their own informed decisions about their treatment. This is tricky. As physicians we must be honest with our patients so that they make educated decisions. At the same time, we must make sure that their decisions are consistent with ethical practices and do not lead to demands for inappropriate care.
7.3 Social justice.
As physicians we must advocate for our individual patients while at the same time promoting the health of the healthcare system as a whole. We must balance our patient’s needs (autonomy) and not misdirect scarce resources that benefit society (social justice).
Cuidados Gerais com a FERIDA PÓS-OPERATÓRIA
A avaliação e os cuidados de feridas pós-operatórias deve ser do domínio de todos os profissionais que atuam na clínica cirúrgica. O conhecimento a cerca dos processos relacionados a cicatrização tecidual é importante tanto nos cuidados como na prevenção de complicações, tais como: infecções e deiscência. Como tal, todos os profissionais médicos, sendo eles cirurgiões ou de outras especialidades, que participam do manejo clínico dos pacientes no período perioperatório devem apreciar a fisiologia da cicatrização de feridas e os princípios de tratamento de feridas pós-operatório. O objetivo deste artigo é atualizar os profissionais médicos de outras especialidades sobre os aspectos importantes do tratamento de feridas pós-operatório através de uma revisão da fisiologia da cicatrização de feridas, os métodos de limpeza e curativo, bem como um guia sobre complicações de feridas pós-operatórias mais prevalentes e como devem ser manejados nesta situação.
Esophagectomy: Anastomotic Complications (Leakage and Stricture)
Esophagectomy can be used to treat several esophageal diseases; it is most commonly used for treatment of esophageal cancer. Esophagectomy is a major procedure that may result in various complications. This article reviews only the important complications resulting from esophageal resection, which are anastomotic complications after esophageal reconstruction (leakage and stricture), delayed emptying or dumping syndrome, reflux, and chylothorax.
Management of POST-HEPATECTOMY complications
Hepatic resection had an impressive growth over time. It has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Management of hepatic resection is challenging. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity and mortality. Especially, complex resections are being increasingly performed in high risk and older patient population. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Common post-hepatectomy complications include venous catheter-related infection, pleural effusion, incisional infection, pulmonary atelectasis or infection, ascites, subphrenic infection, urinary tract infection, intraperitoneal hemorrhage, gastrointestinal tract bleeding, biliary tract hemorrhage, coagulation disorders, bile leakage, and liver failure. These problems are closely related to surgical manipulations, anesthesia, preoperative evaluation and preparation, and postoperative observation and management. The safety profile of hepatectomy probably can be improved if the surgeons and medical staff involved have comprehensive knowledge of the expected complications and expertise in their management.
Classroom: Hepatic Resections
The era of hepatic surgery began with a left lateral hepatic lobectomy performed successfully by Langenbuch in Germany in 1887. Since then, hepatectomy has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity (4.09%-47.7%) and mortality (0.24%-9.7%). This review article focuses on the major postoperative issues after hepatic resection and presents the current management.
The Management of PANCREATIC PSEUDOCYST
Classroom: Principles of Pancreatic Surgery
The pancreatic pseudocyst is a collection of pancreatic secretions contained within a fibrous sac comprised of chronic inflammatory cells and fibroblasts in and adjacent to the pancreas contained by surrounding structures. Why a fibrous sac filled with pancreatic fluid is the source of so much interest, speculation, and emotion amongst surgeons and gastroenterologists is indeed hard to understand. Do we debate so vigorously about bilomas, urinomas, or other abdominal collections of visceral secretions? Perhaps it is because the pancreatic pseudocyst represents a sleeping tiger, which though frequently harmless, still can rise up unexpectedly and attack with its enzymatic claws into adjacent visceral and vascular structures and cause lifethreatening complications.
Another part of the debate and puzzlement about pancreatic pseudocysts is related to confusion about pancreatic pseudocyst definition and nomenclature. The Atlanta classification, developed in 1992, was a pioneering effort in describing and defining morphologic entities in acute pancreatitis. Since then, a working group has been revising this system to incorporate more modern experience into the terminology. In the latest version of this system, pancreatitis is divided into acute interstitial edematous pancreatitis (IEP) and necrotizing pancreatitis (NP), based on the presence of pancreatic tissue necrosis. The fluid collections associated with these two “types” of pancreatitis are also differentiated. Early (<4 weeks into the disease course) peripancreatic fluid collections in IEP are referred to as acute peripancreatic fluid collections (APFC), whereas in NP, they are referred to as postnecrotic peripancreatic fluid collections (PNPFC). Late (>4 weeks) fluid collections in IEP are called pancreatic pseudocysts, and in NP, they are called walled-off pancreatic necrosis (WOPN).
Acute pancreatitis represents a broad spectrum of disease. Although the disease course may smolder, typically an initial inciting event results in organ injury, which sets into play the evolving clinical course. The early phase of disease is marked by the inflammatory mediators from damaged pancreatic tissue, resulting in variable degrees of systemic inflammatory response. The later phase is determined by the morphology of organ injury, specifically with regard to tissue ischemia and necrosis. The outcome of this later phase is often impacted by local or systemic infection. Peripancreatic fluid collections can occur in both the early and the late phases of disease. They presumably occur from injury to or ischemia of the main pancreatic duct or a side branch duct, although some, particularly early on, may be the result of third-space edema fluid. Peripancreatic fluid collections represent a heterogeneous entity.
Review of POSTGASTRECTOMY SYNDROMES
The first postgastrectomy syndrome was noted not long after the first gastrectomy was perfor-med: Billroth reported a case of epigastric pain associated with bilious vomiting as a sequel of gastric surgery in 1885. Several classic treatises exist on the subject; we cannot improve on them and merely provide a few references for the interested reader.
However, the indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. The most marked reduction in the frequency of gastric resection has occurred among patients with peptic ulcer disease. For example, in Olmstead County, Minnesota, the incidence of elective operations on previously unoperated patients declined 8-fold during the 30-year study period between 1956 and 1985 and undoubtedly has declined even further since.
One population-based study concluded that elective surgery for ulcer disease had “virtually disappeared by 1992–1996.” Whereas emergency operations for bleeding and perforation are still encountered, acid-reducing procedures are being performed less frequently in these situations in favor of a damage control approach. Even for gastric cancer, resection rates decreased approximately 20% from 1988 to 2000 in the United States.
An estimated 21,000 new cases of stomach cancer occurred in the United States in 2010, so that the number of cases of gastric resection for cancer is probably less than 15,000 per year in the United States. The virtual disappearance of elective surgery for peptic ulcer has also changed the demographic profile of the postgastrectomy patient: patients who have gastric cancer tend to be older and there is only a slight male preponderance.
These significant changes in the gastric surgery population make it worthwhile to revisit postgastrectomy syndromes. The frequency with which postgastrectomy symptoms/syndromes are found can depend on how hard they are looked for. Loffeld, in a survey of 124 postgastrectomy patients, most of whom had undergone surgery more than 15 years earlier, found that 75% suffered from upper abdominal symptoms, and 1 or more symptoms that indicate dumping were found in 70% of patients who had undergone Billroth-II (B-II) reconstruction.
However, the lack of age-matched and sex-matched controls in this study may have overstated the frequency of symptoms caused by the surgical procedure. Mine and colleagues conducted a large survey of 1153 patients after gastrectomy for cancer and found that 67% reported early dumping and 38% late dumping. By contrast, Pedrazzani and colleagues surveyed 195 patients who underwent subtotal gastrectomy and B-II reconstruction for gastric adenocarcinoma for up to 5 years postoperatively, and concluded that “the incidence of late complications was low and the majority of them recovered within one year after surgery.”
This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient’s long-term follow-up and care.
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Complications of HEMORROIDH SURGERY
Symptomatic hemorrhoids require a number of therapeutic interventions each of which has its own complications. Office-based therapy such as rubber band ligation carries the risk of pain and bleeding, which are self-limited, but also carries the risk of rare complications such as sepsis, which may be life threatening. Operative treatment of hemorrhoids includes conventional hemorrhoidectomy, stapled hemorrhoidectomy, and the use of energy devices. Complications of pain and bleeding are common but self-limited. Late complications such as stenosis and fecal incontinence are rare. Recurrent disease is related to the initial grade and therapeutic approach. Treatment of recurrent hemorrhoids should be individualized based on previous treatments and the grade of disease. Anesthetic complications, especially urinary retention, are common and related to the anesthetic technique. Practitioners should council their patients as to the risks of the various approaches to treating symptomatic hemorrhoids.
Intra Abdominal Infections
With intra-abdominal infection being one of the most common reasons for surgical consultation, understanding the evaluation and management of these processes becomes paramount in the day- to-day practice of the surgeon. The very broad nature of who is affected coupled with the interplay of patient comorbidities and their medications make dealing with intra-abdominal infections a challenge. As with most complex problems in medicine, it is often useful to break them down into simpler and smaller parts. One useful way to categorize intra-abdominal infections is to divide them into those originating from previous abdominal trauma or operations and those presenting in a “virgin” abdomen.
The latter group most commonly includes those patients presenting with specific organ-based infectious processes such as appendicitis, cholecystitis, or diverticulitis. These individual diseases are covered extensively in other chapters and are discussed only superficially in this chapter. The former are those patients who have sustained intra-abdominal trauma or have undergone previous abdominal interventions and are not recovering in the usual expected course. It is this group that taxes diagnostic and clinical skills and may require the most complex medical decision making.
Several factors should come into play once suspicion for an intra-abdominal infection is entertained. These include resuscitation, antibiotic usage, and source control itself. Patients who present with either a suspected or diagnosed intra-abdominal infection should have some form of volume resuscitation. Even without hypotension, there are several reasons why these patients might be volume depleted. These include nausea and vomiting, fluid sequestration within the abdominal cavity or lumen of the bowel, and poor oral intake. As the process progresses, the patient may develop tachypnea, which results in an evaporative fluid loss. By this time, one can often elicit orthostatic hypotension in most patients.
Fluid resuscitation should begin with the administration of isotonic crystalloid and in general be guided by evidence of end organ perfusion (adequate mental status, urine output, correction of acidosis). There is no utility-using colloid such as albumin or hetastarch in these circumstances, and some data suggest a worse outcome. Should the patient present with hypotension or evidence of poor perfusion, a more aggressive approach to volume resuscitation should be employed. Our recommendation is to follow the current surviving sepsis guidelines, which include fluid challenges, monitoring/assessment of filling pressures, and the potential use of pressors and steroids.
KIDNEY INJURY on perioperative period
ACUTE KIDNEY FAILURE_REVIEW ARTICLE
Alterations in renal function are common after surgical emergencies, trauma, and major operations. In these settings, successful recovery of renal function is dependent on prompt diagnosis and protective management strategies. Acute kidney injury (AKI) is characterized by an acute decrease in glomerular filtration rate (GFR). The true incidence of AKI and acute renal failure (ARF) has been difficult to define, given the broad and various definitions used to quantify and study altered renal function. Relatively recent introduction of consensus definitions, such as RIFLE (risk, failure, loss, and end-stage renal failure) criteria and AKIN (Acute Kidney Injury Network) staging, have provided standard definitions to facilitate more uniform outcome reporting. With use of these definitions, recent studies suggest that AKI occurs in up to two thirds of patients in the intensive care unit (ICU). Moreover, increasing severity of AKI is associated with increasing mortality. AKI is also associated with increased morbidity, such as increased hospital length of stay and cost of care, and has been linked to other in-hospital complications, such as increased difficulty in weaning from mechanical ventilation. Preoperative risk factors for development of AKI include older age, emergent surgery, hepatic disease, obesity, high-risk surgery, vascular disease, and chronic obstructive pulmonary disease (COPD). Prompt recognition of AKI facilitates effective treatment. Although the incidence rate of AKI appears to be rising, overall outcomes from AKI are gradually improving.
The reported mortality rate of AKI is 30% to 60%. If RRT is necessary, reported mortality rates are over 50%. The reason for such high mortality is that AKI now usually occurs as part of a spectrum of multiple organ failure, most often associated with severe sepsis or septic shock. The mortality in this setting is often determined by the underlying septic syndrome, rather than by complications of individual organ failure. Of surviving patients of AKI, a significant number have development of chronic renal insufficiency, which necessitates chronic dialysis. The precise rate of development of chronic renal failure varies greatly in the literature, depending on the patient populations. A recent review of AKI estimates that overall, the risk of necessary chronic dialysis is approximately 12%.
Laparoscopic Surgery for Morbid Obesity
The morbid obesity epidemic continues to spread throughout industrialized nations. It is a condition with a heterogeneous etiology, including genetic, psychosocial, and environmental factors. Prevention methods have currently been unable to halt the further spread of this disease. Obesity has been linked to increased healthcare costs, common physiologic derangements, reduced quality of life, and increased overall mortality. More than one third of adults and almost 17% of children in the United States are obese.
Medical therapy that can cause sustained significant weight loss may be years away. Bariatric surgery, when combined with a multidisciplinary team, continues to be the only proven method to achieve sustained weight loss in most patients. Bariatric procedures modify gastrointestinal anatomy and, in some cases, enteric hormone release to reduce caloric intake, reduce absorption, and alter metabolism to achieve weight loss. Currently, the three most common bariatric operations in the United States are Roux-en-Y gastric bypass, adjustable gastric band, and the vertical sleeve gastrectomy.
O termo “gossipiboma” refere-se a uma matriz de matéria têxtil envolvida por reacção de corpo estranho. O termo é derivado do latim “Gossypium”, algodão, e o Swahili “boma”, que significa “esconderijo”. Também conhecida como textiloma, originada de “textilis” (tecer em latim) e “oma” (doença, tumor ou inchaço em grego). O primeiro caso foi descrito por Wilson em 1884. Gossipibomas foram relatados após operações em muitos processos, e em diferentes órgãos e localização. Mas, o local mais comum é o abdominal. Gaze e compressas são os materiais mais comumente retidos após laparotomia. A incidência de gossipibomas é variável e subnotificada, principalmente devido às implicações legais de sua detecção, mas também porque muitos pacientes permanecem assintomáticos. A apresentação clínica é também variável. O tratamento recomendado é a excisão que pretende evitar as complicações que conduzem a taxa de mortalidade entre11-35%.
Ele ocorre entre 1/1000 a 1/1500 nas operações intra-abdominais. A apresentação clínica é variável e depende da localização do corpo estranho e sobre o tipo de reação inflamatória apresentada pela hospedeiro. Podem existir formas agudas e crônicas. A forma aguda tende a apresentar-se com fístulas e abcessos cutâneos, enquanto que a crônica como massa encapsulada (granuloma de corpo estranho) e sintomas inespecíficos. Gossipibomas ocorrem mais comumente após operação abdominal e pélvica. Eles são mais frequentes em pacientes obesos e quando a operação é realizada em emergência. A incidência é maior em nove vezes após operação de emergência, e de quatro em procedimentos não planejados no decorrer de uma intervenção, mudando o que se pretendia realizar. Outros fatores predisponentes incluem operações em campo de batalha, complicações intra-operatórias, tais como perda intensa de sangue, a incapacidade de realizar contagem de materiais cirúrgicos no final do processo, tempo de operação prolongado e as mudanças no pessoal médico e de enfermagem durante o operação.
O tempo entre a operação e aparecimento de manifestações clínicas de Gossipiboma é variável, em particular se o material permanecer estéril. Ele depende da localização do material retido e do tipo de reação orgânica, e foi estimado em entre 10 dias a vários anos. Em patologia, duas reações de corpo estranho pode occorer. A primeira resposta é a produção asséptica de fibrina, o que leva à formação de aderências, material de encapsulamento e à formação de granulomas de corpo estranho. Nesta apresentação, o paciente pode permanecer assintomático por meses ou anos. A segunda resposta é exsudativa, com formação de abcessos, fístulas aos órgãos internos como o estômago, intestino, bexiga, cólon ou vagina, ou também fístula externa para a parede abdominal. Os sintomas dependem do órgão afetado principalmente e podem resultar da compressão, obstrução, síndrome de má absorção, ou crescimento bacteriano. Eles incluem dor abdominal, tumor palpável, náuseas, vômitos, sangramento retal, diarréia, disúria, piúria, hematúria e urgência urinária. Os sintomas sistêmicos como febre, anorexia, anemia e perda de peso também podem occurer. No entanto, a resposta inflamatória e aderências podem formar uma cápsula com o bloqueio omental e órgãos adjacentes, podendo o paciente permanecer assintomático. A falta de sintomas pode dificultar ou retardar o diagnóstico, que muitas vezes é realizado incidentalmente.
O diagnóstico pode ser difícil. Suspeita clínica e o uso de estudos de imagem são importantes, pois é a regra a inexistência ou inespecificidade de sintomas em vários anos após a operação. No pré-operatório pode ser levantada suspeita por meio de estudos radiológicos ou endoscópicos. Muitos casos só são descobertos no intra-operatório. Tomografia computadorizada é o exame complementar de escolha para o diagnóstico e avaliação dessas complicações. Ele fornece informações detalhadas sobre a lesão na maioria dos casos. A aparência pode ser lesão cística espongiforme, cápsula hiperdensa em camadas concêntricas, ou calcificações murais. A presença de gás é indicativa de perfuração do intestino ou à formação de abcessos. Os principais diagnósticos diferenciais são: aderências pós-operatórias, fecalomas, contusões, hematomas, intussuscepção, volvo, tumores e abscessos intracavitários.
Tratamento e Prognóstico
O tratamento de escolha é a remoção cirúrgica que pode ser realizada por laparoscopia ou laparotomia, e visa prevenir complicações. O prognóstico da gossipiboma é variável com taxas de mortalidade de 11 para 35%. Quando a remoção ocorre no período pós-operatório imediato, a morbidade e mortalidade são baixas; no entanto, se o material foi mantido por um longo tempo a remoção pode exigir operação extensa e ter elevado índice de complicações.
Há muitas implicações médico-legais com gossypiboma. Revisão de negligência médica impetradas entre 1988 e 1994 revelou 40 casos de gossipiboma, que representaram 48% de todos os corpos estranhos. Não foi possível determinar se o material esquecimento representou falta de qualidade do cirurgião ou quadro de enfermagem.
A abordagem mais importante é a prevenção. As medidas preventivas necessárias incluem o uso de material têxtil com marcadores radiopacos e contagem minuciosa de materiais cirúrgicos. São recomendadas quatro contagens: na montagem do material, antes da operação, no início do fechamento da cavidade e durante a síntese da pele. Dhillon e Park reforçam a importância da exploração dos quatro quadrantes abdominais no final da operação em todos os casos, mesmo após a contagem das compressas. No caso de contagem incorreta, a menos que o paciente seja considerado instável, a síntese da cavidade não deve ser realizada até que todas elas estejam localizados.
Gossipiboma é um problema médico-legal sério e sua incidência está aparentemente aumentando. Por isso, os meios e métodos nos procedimentos cirúrgicos durante o ato operatório e no contexto geral da sala de operações precisam ser revistos para tomarem-se medidas preventivas. Formação continuada de profissionais da área médica e estrita adesão à técnica operatória são primordiais para a prevenção de gossipiboma.
10 Princípios da RELAÇÃO MÉDICO-PACIENTE
A necessidade de tratamento cirúrgico é algo que sempre tem conotação ameaçadora para o paciente e familiares. A possibilidade de dor, mutilação ou complicações constitui uma ameaça real ou fantasiosa, mesmo em situações desejáveis, como a correção de malformações, o aperfeiçoamento estético, os partos e outras eventualidades nas quais não exista doença. A anestesia em suas várias modalidades é outro evento preocupante. A lembrança de maus resultados vem sempre a mente quando uma intervenção cirúrgica é cogitada. Nos últimos anos, o progresso tecnológico que atingiu a medicina tem sido extremamente exaltado pela mídia. Este fato tem levado a população leiga à falsa impressão de que a medicina e os médicos são capazes de resolver todas as situações. Quando ocorre reversão desta expectativa fala-se em “erro médico”. Para que não se cometa injustiça, este tema deve ser discutido pela sociedade como um todo, e não somente por setores que vêem nele a possibilidade de auferir lucros. Infelizmente, em lugar de uma análise consequente, tem sido comum denegrir a imagem do médico, atribuindo-lhe responsabilidade exclusiva por todas as falhas do sistema de saúde. Os maus resultados profissionais, comuns em todas as profissões, são “imperdoáveis” em medicina, na visão de pessoas que insistem em elevar os médicos à categoria de “infalíveis”, esquecendo-se de que a medicina e os médicos têm compromisso apenas com os meios adotados para a recuperação dos pacientes, e nunca com os resultados. Com o objetivo de fortalecer o relacionamento médico/paciente em clínica cirúrgica e prevenir insatisfações e petições judiciais, seguem-se algumas sugestões que eventualmente podem ser úteis:
1ª. Jamais ceder às pressões de serviços de saúde que visem impor a mentalidade de “linha de produção”, exigindo o “atendimentos” em série dos pacientes. Nessas circunstâncias não sobra tempo para um relacionamento afetivo e efetivo e este é, sem dúvida, o primeiro passo para acusações injustas ou descabidas diante de adversidades;
2ª. Esclarecer ao paciente e ou aos familiares todos os pormenores do ato cirúrgico. As informações devem ser claras, em linguagem simples e acessível, evitando termos técnicos incompreensíveis. Deve-se entrar em detalhes sobre a operação proposta, suas conseqüências e seus riscos; Conduzir com competência o pré-operatório, lembrando que, na avaliação do paciente, é indispensável o exame clínico completo.Os especialistas que se sentirem inseguros em relação ao mesmo devem solicitar o parecer de um clínico ou internista acostumado a fazê-lo; Lembrar que a avaliação do risco cirúrgico é muito mais abrangente do que o simples exame cardiológico. Existem riscos aumentados também em relação aos outros sistemas e aparelhos. Não negligenciar a avaliação psicológica do paciente; Em relação aos exames subsidiários pré-operatórios, lembrar que existe um consenso na literatura médica que vai desde a sua não realização em casos selecionados, até a sua realização fundamentada no exame clínico e em parâmetros como vulto da intervenção, idade e sexo. Em jovens do sexo masculino, sadios, com exame clínico normal, é perfeitamente justificável não realizar exames complementares em intervenções de pequeno e médio porte;
3ª. Nas intervenções com objetivos estéticos, analisar cuidadosamente as expectativas do paciente em relação aos resultados. Verificar senão são excessivamente fantasiosas, em busca somente de ganhos afetivos. Nestes casos, é freqüente que a não consumação dos mesmos se reverta em sentimen-tos negativos em relação ao cirurgião, que pode torna-se o único “culpado”; Jamais garantir resultados ou minimizar o risco. Em relação ao risco, é compreensível que o paciente e familiares não queiram falar ou ouvir sobre o mesmo. Ainda assim, o profissional deve ter habilidade suficiente para abordar o assunto sem atemorizar ou gerar pânico, porém sem omitir a verdade;
4ª. Na avaliação do risco cirúrgico é indispensávela participação do anestesiologista. A esse profissional compete a avaliação do risco anestésico. O tipo de anestesia não deve ser imposto pelo cirurgião e sim discutido como anestesiologista, respeitando sempre sua indicação ou contra-indicação. A avaliação anestesio-lógica nas situações eletivas deve ser realizada em consulta especializada antes da internação hospitalar. É desejável que o paciente conheça, com antecedência,seu anestesiologista; Alertar o paciente sobre a possibilidade de ocorrências imprevisíveis durante a intervenção cirúrgica. Esclarecer que as mesmas poderão alterar o planejamento cirúrgico e exigir mudanças técnicas ou táticas que, por sua vez, poderão implicar novos desdobramentos, como aumento da permanência hospitalar, maior risco ou maiores custos;
5ª. Lembrar que, salvo em situações de emergência e urgência declaradas, é facultado ao cirurgião usar os dispositivos do parágrafo primeiro do artigo 61 do Código de Ética Médica, ou seja, deixar de operar o paciente com o qual não foi possível estabelecer um relacionamento de confiança recíproca. Nesta situação é necessário garantir a transferência do paciente para outro profissional, que deverá ser informado
sobre os detalhes do caso;
6ª. Diante da possibilidade de futuras incompreensões, queixas ou petições, não hesitar em solicitar ao paciente ou a seu responsável legal a assinatura de um “Termo de Consentimento Esclarecido”, que deverá também ser assinado por duas testemunhas não envolvidas no caso;
7ª. Não deixar de preencher corretamente o prontuário ou a ficha clínica do paciente, na qual deverão constar os dados referentes ao exame clínico, aos exames subsidiários, especificando os resultados, o local e data em que foram realizados e aos esclarecimentos prestados;
8ª. Descrever com detalhes o ato cirúrgico. Caso haja material a ser encaminhado para exame anatomopatológico, preencher o laudo de encaminhamento e cientificar-se de que o material foi corretamente acondicionado e identificado;
9ª. Conduzir o pós-operatório anotando as datas e os horários das visitas médicas, bem como todas as providências tomadas. No momento da alta, reavaliar o paciente e registrar as recomendações em relação ao acompanhamento ambulatorial. Estas sugestões se prestam a qualquer tipo de tratamento cirúrgico. O tempo gasto ao adotá-las é altamente recompensado e pode evitar futuros dissabores e danos morais e ou financeiros para o cirurgião e equipe.
10ª.Lembrar que pacientes emocionalmente instáveis,neuróticos ou psicóticos são maus candidatos às intervenções cirúrgicas. Nestes casos impõem-se medidas suporte conduzidas por especialista na área. A apreensão diante das intervenções cirúrgicas é absolutamente normal. Ao contrário, o total destemor deve ser motivo de suspeita a cerca da integridade emocional do paciente;
O aspecto ético na relação médico paciente, acima de valores ou conceitos morais, pressupõe respeito mútuo entre ambas as partes, para que o produto final seja o melhor possível, a manutenção da saúde e da vida. O médico, como qualquer outro profissional, deve seguir preceitos éticos e legais. Não deve, sob pena de processos e punição, incorrer em desvios de conduta como imperícia, imprudência e negligência. Para o bom exercício da medicina é fundamental o bom preparo cognitivo, técnico, afetivo e moral. No caso particular do ato cirúrgico, o cirurgião deve ser eclético, dominar as várias técnicas cirúrgicas e conhecer suas vantagens e desvantagens, para empregar a mais adequada para cada situação em particular e assim melhor beneficiar seus pacientes.
PRINCIPLES OF OSTOMY MANAGEMENT
The creation of a stoma is a technical exercise. Like most undertakings, if done correctly, the stoma will usually function well with minimal complications for the remainder of the ostomate’s life. Conversely, if created poorly, stoma complications are common and can lead to years of misery. Intestinal stomas are in fact enterocutaneous anastomoses and all the principles that apply to creation of any anastomosis (i.e., using healthy intestine, avoiding ischemia and undue tension) are important in stoma creation.
MOST COMMOM POSTOPERATIVE PROBLEMS
Despite good preoperative assessment, surgical and anaesthetic technique and perioperative management, unexpected symptoms or signs arise after operation that may herald a complication. Detecting these early by regular monitoring and surgical review means early treatment can often forestall major deterioration. Managing problems such as pain, fever or collapse requires correct diagnosis then early treatment. Determining the cause can be challenging, particularly if the patient is anxious, in pain or not fully recovered from anaesthesia. It is vital to see and assess the patient and if necessary, arrange investigations, whatever the hour, when deterio-ration suggests potentially serious but often remediable complications. Consider also whether and when to call for senior help.
PREVENTION COMPLICATIONS OF COLON SURGERY
COMPLICATIONS OF COLON SURGERY_REVIEW ARTICLE
Colon surgery represents a high number of patients treated at a department of gastrointestinal surgery and is not limited to colon cancer. It includes other non-neoplastic pathologies such as inflammatory bowel disease, diverticular disease or colonic volvulus. As with any major procedure, colon surgery patients may present serious or even fatal complications. The incidence of postoperative complications from colon surgery has been estimated at between 10% and 30% according to selected series. Preventive measures against surgical complications include selection of an appropriate procedure for the patient as well as good preoperative care, appropriate surgical technique and good postoperative management. When diagnosis has been established, risks for patient should be assessed according to patient’s health conditions and type of surgery accomplished. When the patient meets the surgical requirements, an appropriate course of preoperative care should be carried out including colon wash antibiotics and antithrombotic prophylaxis. Postoperative period will be equivalent to any major abdominal surgery. Typically, it was considered appropriate to wait a few days before initiating feeding in order to protect anastomosis; however, some authors agree that an early oral diet hours after intervention is not associated with a higher risk of anastomotic dehiscence and other complications.
Sleeve Gastrectomy: Complications and Management
SLEEVE GASTRECTOMY COMPLICATIONS_REVIEW ARTICLE
Obesity is a common disease affecting adults and children. The incidence of obesity in worldwide is increasing. Laparoscopic sleeve gastrectomy (LSG) is a relatively new and effective procedure for weight loss. Owing to an increase in the number of bariatric surgical procedures, general surgeons should have an understanding of the complications associated with LSG and an approach for dealing with them. Early postoperative complications following LSG that need to be identified urgently include bleeding, staple line leak and development of an abscess. Delayed complications include strictures, nutritional deficiencies and gastresophageal reflux disease. We discuss the principles involved in the management of each complication.
PERIOPERATIVE FLUID MANAGEMENT IN SURGERY
REVIEW ARTICLE_FLUID MANAGEMENT IN ELECTIVE SURGERY
The purpose of the thesis was to investigate the pathophysiology and functional outcomes of various fluid administration regimens in elective surgical procedures and describe factors of importance in perioperative fluid management. The goal was to create a rational physiologic background on which to design future ran-domized, clinical trials focusing on clinical outcomes aiming to produce evidence-based guidelines for rational perioperative fluid therapy. The main hypothesis of the thesis was thatthe ”liberal” fluid administration regimens seen in daily clinical practice may be detrimental and contribute to increased perioperative morbid-ity primarily due to increased functional demands of the cardi-opulmonary system and gastrointestinal tract as well as de-creased tissue oxygenation (impaired wound healing).
EARLY COMPLICATIONS IN BARIATRIC SURGERY
REVIEW ARTICLE_BARIATRIC SURGERY COMPLICATIONS
The risk of complications and mortality in bariatric surgery is associated with certain factors that are common to other patients and procedures, including age above 65 years, the presence of associated diseases (cardiovascular and pulmonary disease, chronic renal failure, liver cirrhosis, etc.), prior abdominal surgery, and the experience of the surgeon and the institution, especially concerning the ability to make an early diagnosis and address complications. The surgical complications observed in the early postoperative period following surgeries performed to treat severe obesity are similar to those associated with other major surgeries of the gastrointestinal tract. However, given the more frequent occurrence of medical comorbidities (such as diabetes, arterial hypertension, and sleep apnea), as well as the difficulty in making an early diagnosis of the complications (due to limitations of the clinical abdominal workup and imaging methods, such as ultrasonography and computed tomography, particularly in highly obese patients with body mass indices >50 kg/m²), these patients require special attention in the early post operative follow-up. Pulmonary thromboembolism, a complication associated with bariatric surgery, also requires greater attention from the medical team given the high mortality rate associated with this condition. Early diagnosis and appropriate treatment of these complications are directly associated with a greater probability of control.
Princípios da Cirurgia HepatoBiliar
Considera-se que a cirurgia hepática começou após o advento da anestesia e da anti-sepsia. No entanto, muito antes disso, diversos autores já relatavam suas experiências com ressecções do fígado. As primeiras descrições de “cirurgias hepáticas” consistiam no relato de avulsões parciais ou totais de porções do fígado após lesões traumáticas do abdome. O relato de Elliot (1897) exemplifica muito dos temores dos cirurgiões da época: “O fígado (…) é tão friável, tão cheio de vasos e tão evidentemente impossível de ser suturado que parece ser improvável o manejo bem sucedido de grandes lesões de seu parênquima”.
CIRURGIA HEPATOBILIAR_ASPECTOS BÁSICOS
TREATMENT OF POSTOPERATIVE ILEUS
POSTOPERATIVE ILEUS_REVIEW ARTICLE
In systems that try to minimize hospital stay after abdominal surgery, one of the principal limiting factors is the recovery of adequate bowel function, which can delay discharge or lead to readmission. Postoperative ileus (POI) is the term given to the cessation of intestinal function following surgery. Although all surgical procedures put the patient at risk for POI, gastrointestinal tract surgeries in particular are associated with a temporary cessation of intestinal function. The duration of POI varies, lasting from a few hours to several weeks. Prolonged postoperative ileus, also known as pathologic postoperative ileus, can be caused by a myriad of pathologic processes that are treated with limited success by clinical and pharmacologic management. Studies of large administrative databases show that, on average, patients with a diagnosis of POI stay 5 days longer in hospital after abdominal surgery than patients without POI. Over the last decade, substantial efforts have been made to minimize the duration of POI, as there appears to be no associated physiologic benefit, and it is currently the primary factor delaying recovery for most patients. In this review, we define POI, describe the pathogenesis and briefly discuss clinical management before detailing current pharmacologic management options.
Colonoscopia : Quais as principais complicações?
Colonoscopy is a commonly performed procedure for the diagnosis and treatment of a wide range of conditions and symptoms and for the screening and surveillance of colorectal neoplasia. Although up to 33% of patients report at least one minor, transient GI symptom after colonoscopy, serious complications are uncommon. In a 2008 systematic review of 12 studies totaling 57,742 colonoscopies performed for average risk screening, the pooled overall serious adverse event rate was 2.8 per 1000 procedures. The risk of some complications may be higher if the colonoscopy is performed for an indication other than screening. The colorectal cancer miss rate of colonoscopy has been reported to be as high as 6% and the miss rate for adenomas larger than 1 cm is 12% to 17%. Although missed lesions are considered a poor outcome of colonoscopy, they are not a complication of the procedure per se and will not be discussed further in this document. Over 85% of the serious colonoscopy complications are reported in patients undergoing colonoscopy with polypectomy. An analysis of Canadian administrative data, including over 97,000 colonoscopies, found that polypectomy was associated with a 7-fold increase in the risk of bleeding or perforation. However, complication data are often not stratiﬁed by whether or not polypectomy was performed. Therefore, complications of polypectomy are discussed with those of diagnostic colonoscopy. A discussion of the diagnosis and management of all complications of colonoscopy is beyond the scope of this document, although general principles are reviewed.
Câncer de Esôfago
É o tipo de câncer mais associada a quem faz uso de bebidas alcoólicas e é adepto do tabagismo. Mas pode ocorrer também em quem tem refluxo acido do estômago para o esôfago (hérnia hiato e/ou doença do refluxo gastro esofágico). Como todo câncer, seu diagnóstico é tardio, pois não causa dor nem incomodo nas suas fases mais iniciais, e por isso, pedimos aos pacientes, que façam o exame de controle regularmente (endoscopia digestiva alta). O tratamento é um a combinação de radioterapia, quimioterapia e cirurgia, mas que vai ter variações conforme localização no esôfago (medindo entre 26 e 30 centímetros) e o estagio da doença. O esôfago é um tubo musculomembranoso, longo e delgado, que comunica a garganta ao estômago. Ele permite a passagem do alimento ou líquido ingerido até o interior do sistema digestivo, através de contrações musculares. O câncer de esôfago mais freqüente é o carcinoma epidermóide escamoso, responsável por 96% dos casos. Outro tipo de câncer de esôfago, o adenocarcinoma, vem tendo um aumento significativo principalmente em indivíduos com esôfago de Barrett, quando há crescimento anormal de células do tipo colunar para dentro do esôfago.
O câncer de esôfago apresenta uma alta taxa de incidência em países como a China, Japão, Cingapura e Porto Rico. No Brasil, consta entre os dez mais incidentes, segundo dados obtidos dos Registros de Base Populacional existentes, e em 2000 foi o sexto tipo mais mortal, com 5.307 óbitos. De acordo com a Estimativa de Incidência de Câncer no Brasil para 2006, devem ocorrer cerca de 10.580 casos novos deste câncer (7.970 entre os homens e 2.610 entre as mulheres) este ano.
Fatores de Risco/Prevenção
O câncer de esôfago está associado ao alto consumo de bebidas alcoólicas e de produtos derivados do tabaco (tabagismo). Outras condições que podem ser predisponentes para a maior incidência deste tumor são a tilose (espessamento nas palmas das mãos e na planta dos pés), a acalasia, o esôfago de Barrett, lesões cáusticas no esôfago, Síndrome de Plummer-Vinson (deficiência de ferro), agentes infecciosos (papiloma vírus – HPV) e história pessoal de câncer de cabeça e pescoço ou pulmão. Para prevenir o câncer de esôfago é importante adotar uma dieta rica em frutas e legumes, evitar o consumo freqüente de bebidas quentes, alimentos defumados, bebidas alcoólicas e produtos derivados do tabaco. A detecção precoce do câncer de esôfago torna-se muito difícil, pois essa doença não apresenta sintomas específicos. Indivíduos que sofrem de acalasia, tilose, refluxo gastro-esofageano, síndrome de Plummer-Vinson e esôfago de Barrett possuem mais chances de desenvolver o tumor, e por isso devem procurar o médico regularmente para a realização de exames.
O câncer de esôfago na sua fase inicial não apresenta sintomas. Porém, alguns sintomas são característicos como a dificuldade ou dor ao engolir, dor retroesternal, dor torácica, sensação de obstrução à passagem do alimento, náuseas, vômitos e perda do apetite. Na maioria das vezes, a dificuldade de engolir (disfagia) já demonstra a doença em estado avançado. A disfagia progride geralmente de alimentos sólidos até alimentos pastosos e líquidos. A perda de peso pode chegar até 10% do peso corporal.
O diagnóstico é feito através da endoscopia digestiva, de estudos citológicos e de métodos com colorações especiais (azul de toluidina e lugol) para que seja possível se fazer o diagnóstico precoce, fazendo com que as chances de cura atinjam 98%. Na presença de disfagia para alimentos sólidos é necessária a realização de um estudo radiológico contrastado, e também de uma endoscopia com biópsia ou citologia para confirmação. A extensão da doença é muito importante em função do prognóstico, já que esta tem uma agressividade biológica devido ao fato do esôfago não possuir serosa e, com isto, haver infiltração local das estruturas adjacentes, disseminação linfática, cau-sando metástases hematogênicas com grande freqüência.
O paciente pode receber como formas de tratamento a cirurgia, radioterapia, quimioterapia ou a combinação destes três tipos. Para os tumores iniciais pode ser indicada a ressecção endoscópica, no entanto este tipo de tratamento é bastante raro. Na maioria dos casos, a cirurgia é o tratamento utilizado. Dependendo da extensão da doença, o tratamento pode passar a ser unicamente paliativo, através de quimioterapia ou radioterapia. Nos casos de cuidados paliativos, também dispõe-se de dilatações com endoscopia, colocação de próteses auto-expansivas, assim como uso da braquiterapia.
Retromuscular Prefascial Mesh Hernia Repair (Jean RIVES – René STOPPA)
An incisional hernia is usually deﬁned as a chronic postoperative defect of the abdominal wall through which intra-abdominal viscera protrude. Progress in surgical techniques, even with laparoscopic surgery, has not led to the elimination of incisional hernias. On the contrary, the incidence of this complication seems to be increasing as more major and lengthy operations are being performed, especially in elderly patients with concomitant organic disease. The incidence of this condition has been reported to be as high as 11% of all laparotomies. Surgical repair is difﬁcult in the patient with a large abdominal wall defect, especially if the herniated viscera has “lost its right of domain” in the abdominal cavity. It must be remembered that surgical repair of an incisional hernia is not the same thing as closure of a laparotomy. Weakening of the abdominal wall and the consequences of decreased abdominal pressure on diaphragmatic mobility and respiratory function must also be considered. Placement of a prosthetic mesh is essential because without mesh, the recurrence rate is prohibitive, varying from 30% to 60%. The which is the subject of this article, was popularized by Jean Rives and has been used in our department since 1966.
Ethics in Surgery : R.I.S.K.
Renewed public attention is being paid to ethics today. There are governmental ethics commissions, research ethics boards, and corporate ethics committees. Some of these institutional entities are little more than window dressing, whereas others are investigative bodies called into being, for example, on suspicion that financial records have been altered or data have been presented in a deceptive manner. However, many of these groups do important work, and the fact that they have been established at all suggests that we are not as certain as we once were, or thought we were, about where the moral boundaries are and how we would know if we overstepped them. In search of insight and guidance, we turn to ethics. In the professions, which are largely self-regulating, and especially in the medical profession, whose primary purpose is to be responsive to people in need, ethics is at the heart of the enterprise.
Responsibility to the patient in contemporary clinical ethics entails maximal patient participation, as permitted by the patient’s condition, in decisions regarding the course of care. For the surgeon, this means arriving at an accurate diagnosis of the patient’s complaint, making a treatment recommendation based on the best knowledge available, and then talking with the patient about the merits and drawbacks of the recommended course in light of the patient’s life values. For the patient, maximal participation in decision making means having a conversation with the surgeon about the recommendation, why it seems reasonable and desirable, what the alternatives are, if any, and what the probable risks are of accepting the recommendation or pursuing an alternative course.
This view of ethically sound clinical care has evolved over the latter half of the 20th century from a doctor-knows-best ethic that worked reasonably well for both patients and physicians at a time when medical knowledge was limited and most of what medicine could do for patients could be carried in the doctor’s black bag or handled in a small, uncluttered office or operating room. What practical steps can be taken by clinicians to evaluate patient attitudes and behavior relative to the patient’s cultural context so that the physician and patient together can reach mutually desired goals of care? Marjorie Kagawa-Singer and her colleagues at the University of California, Los Angeles, developed a useful tool for ascertaining patients’ levels of cultural influence. It goes by the acronym RISK:
Resources: On what tangible resources can the patient draw, and how readily available are they?
Individual identity and acculturation: What is the context of the patient’s personal circumstances and her degree of integration within her community?
Skills: What skills are available to the patient that allow him to adapt to the demands of the condition?
Knowledge: What can be discerned from a conversation with the patient about the beliefs and customs prevalent in her community and relevant to illness and health, including attitudes about decision making and other issues that may affect the physician-patient relationship.
TRATAMENTO DA TROMBOSE HEMORROIDÁRIA
A doença hemorroidária é uma afecção bastante comum, contudo sua prevalência é subestimada. A taxa de prevalência pode chegar até 20% da população geral. Ocorre mais usualmente nos caucasianos, sexo masculino e a partir da 3a década de vida.
A trombose hemorroidária é uma complicação aguda que ocorre tanto nas hemorróidas externas como internas, caracterizada pela presença de isquemia e trombo nos coxins vasculares submucosos do canal anal. As hemorróidas ocorrem como resultado da degeneração dos tecidos de sustentação e suporte dos coxins vasculares anais. As hemorróidas internas, externas e mistas são diferenciadas por sua origem anatômica no canal anal.
VEJA AQUI ONDE FAZER UMA AVALIAÇÃO ESPECIALIZADA E RECEBER UMA SEGUNDA OPINIÃO
FATORES DE RISCO
Os principais fatores de risco para o desenvolvimento da doença hemorroidária complicada são: dieta Industrializada, Hereditariedade, Constipação intestinal, Obesidade, Gravidez / Pós-parto imediato e Trauma local (Fezes Ressecadas).
Os sintomas mais freqüentes são: dor anal aguda (proctalgia aguda) e constante, tumor anal com ou sem prolapso mucoso, e ás vezes sangramento (hematoquezia) na roupa íntima ou no papel higiênico. A dor tem maior intensidade nas primeiras 72 horas podendo regredir após esse período, assim que o trombo organizar-se, ocorrendo a involução espontânea em 7 a 10 dias. Muitas vezes a dor não é proporcional ao volume da trombose hemorroidária.
VEJA AQUI ONDE FAZER UMA AVALIAÇÃO ESPECIALIZADA E RECEBER UMA SEGUNDA OPINIÃO
Dependendo da extensão da trombose poderá ser clínico ou operatório.
5.1 Tratamento Clínico: Associa-se o uso de analgésicos por via oral, pomada heparinóide aplicada sobre a tumoração, medicamentos mucilaginosos, se houver obstipação intestinal e banhos de assento com água morna.
5.2 Tratamento Operatório: A indicação operatória criteriosa, a anestesia apropriada, a técnica utilizada e os cuidados pós-operatórios adequados, são comemorativos importantes no sucesso do tratamento. Para as tromboses hemorroidárias localizadas preferimos a hemorroidectomia à Milligan-Morgan (técnica aberta) ou Ferguson (técnica fechada) com anestesia local com ou sem sedação endo-venosa; ou a trombectomia, que é a retirada do trombo somente, com anestesia local, em caráter ambulatorial. Para as tromboses hemorroidárias grandes e/ou extensas, preferimos a hemorroidectomia à Milligan-Morgan com anestesia raque e internação por 24 horas .
VEJA AQUI ONDE FAZER UMA AVALIAÇÃO ESPECIALIZADA E RECEBER UMA SEGUNDA OPINIÃO
The operative conduct of the biliary-enteric anastomosis centers around three technical steps: 1) identification of healthy bile duct mucosa proximal to the site of obstruction; 2) preparation of a segment of alimentary tract, most often a Roux-en-Y jejunal limb; and 3) construction of a direct mucosa-to-mucosa anastomosis between these two. Selection of the proper anastomosis is dictated by the indication for biliary decompression and the anatomic location of the biliary obstruction. A right subcostal incision with or without an upper midline extension or left subcostal extension provides adequate exposure for construction of the biliary-enteric anastomosis. Use of retractors capable of upward elevation and cephalad retraction of the costal edges are quite valuable for optimizing visual exposure of the relevant hilar anatomy.
Division of the ligamentum teres and mobilization of the falciform ligament off the anterior surface of the liver also facilitate operative exposure; anterocephalad retraction of the ligamentum teres and division of the bridge of tissue overlying the umbilical fissure are critical for optimal visualization of the vascular inflow and biliary drainage of segments II, III, and IV. Cholecystectomy also exposes the cystic plate, which runs in continuity with the hilar plate. Lowering of the hilar plate permits exposure of the left hepatic duct as it courses along the base of segment IVb. In cases of unilateral hepatic atrophy as a result of long-standing biliary obstruction or preoperative portal vein embolization, it is critical to understand that the normal anatomic relationships of the portal structures are altered. In the more common circumstance of right-sided atrophy, the portal and hilar structures are rotated posteriorly and to the right; as a result, the portal vein, which is typically most posterior, is often encountered first; meticulous dissection is necessary to identify the common bile duct and hepatic duct deep within the porta hepatis.
BILIARY-ENTERIC ANASTOMOSIS_THECNICAL ASPECTS
“de nada adianta um diagnóstico brilhante se o seu tratamento não for compreendido”
Em 2000, o Institute of Medicine dos Estados Unidos da América, publicou o estudo que marcou o cenário mundial na discussão sobre erro no processo de assistência à saúde. O estudo “To Err is Human”. Dentre outras informações, o relatório continha registros de que 44.000 a 98.000 pessoas morriam por ano nos EUA, em decorrência de erros na área da saúde. Dentre estas, 7.000 morte/ano podiam ser atribuídas a erros de medicação, sendo esse número maior que o de pessoas que morriam com câncer de mama, AIDS ou acidentes de veículos. O total dos custos, atribuído aos eventos adversos preveníveis, foi estimado em 17 a 29 bilhões de dólares. Os Princípios da Prescrição Médica Hospitalar na Clínica Cirúrgica são descritos abaixo:
Os itens básicos são:
- Alerta sobre ALERGIAS
- Dieta Oral (Tipos: Liquida restrita, Pastosa, etc…)
- Suporte Nutricional: Enteral ou Parenteral
- Prevenção da Úlcera Gastroduodenal de Stress
- Hidratação Venosa
- Correção dos Distúrbios Hidroeletrolíticos – Hemoderivados
- Antibioticoterapia (Dias de Uso/Dias Previstos)
- Tratamento e Prevenção das NVPO
- Tratamento e Prevenção do TEP
- Medicações de Uso Contínuo
- Fisioterapia Motora e Respiratória
- Glicemia Capilar – Esquema de IR
- Posição do Paciente (Ex. Cabeceira Elevada) e Mudança de Decúbito
- Cuidados com Drenos, Sondas e Ostomias
- Controles dos Sinais Vitais
- Controle da Diurese nas 24h
- Avaliações Especializadas e Interconsultas
- Programação de Exames Complementares ou Procedimentos Cirúrgicos
- Uso Obrigatório de EPIs (Pacientes com HVB, HVC ou HIV)
- Outras Recomendações
Recomendações para um BOA PRESCRIÇÃO
- Identifique alergias e interações medicamentosas.
- Utilize sempre letra legível ou opte pela prescrição digitada;
- Evite o uso de abreviaturas.
- Utilize denominações genéricas. Não utilize fórmulas químicas para nominar os medicamentos e jamais utilize abreviaturas nos nomes dos medicamentos;
- Confira as doses prescritas em fonte de informação atualizada e preferencialmente baseada em evidências;
- Utilize sempre o sistema métrico para expressar as doses desejadas (ml, mg, g, mcg, etc). não utilize medidas imprecisas tais como: “colher de sopa”, “colher de chá”, dentre outras, pois tais unidades de medida acarretam variação de volume e consequentemente de dose;
- Arredonde as doses para o número inteiro mais próximo, quando apropriado. isso deve ser particularmente analisado em prescrições pediátricas;
- Não utilize “vírgula e zero” depois da dose/quantidade, evitando que a prescrição de “5,0” se transforme, em uma leitura rápida, em “50”, ou “0,5” se transforme em “5”, gerando um erro de 10 vezes a dose desejada;
- Verifique se todos os elementos necessários ao adequado cumprimento da prescrição foram escritos;
- Não suprima nenhuma informação de identificação do paciente.
PREVENÇÃO DO TROMBOEMBOLISMO NA CIRURGIA DO CÂNCER DO APARELHO DIGESTIVO
ARTIGO DE REVISÃO_TVP_CÂNCER DO APARELHO DIGESTIVO
Tromboembolismo venoso é complicação frequente após tratamento cirúrgico em geral e, de um modo especial, na condução terapêutica do câncer. A cirurgia do aparelho digestivo tem sido referida como potencialmente indutora desta complicação. Ela tem maior representatividade em determinados segmentos anatômicos e nas condições em que se associam fatores de risco dos pacientes. A prevenção do tromboembolismo é tema de grande importância na prática diária dos cirurgiões. Várias são as formas físicas e medicamentosas que podem ser utilizadas. Nos últimos anos abordagens novas, tanto em relação às manobras físicas como em posologia medicamentosa, têm sido estudadas com boa metodologia. Estes novos enfoques ainda são pouco divulgados e talvez pouco conhecidos pela maioria dos cirurgiões. No câncer a importância desse tema é ainda maior que nas doenças benignas. A Medicina Baseada em Evidências incorpora dados obtidos com base nas mais recentes revisões sistemáticas disponíveis na literatura originando várias formas de contribuições científicas. BOM ESTUDO.
Lesão de Vias Biliares na Colecistectomia: Prevenção e Tratamento
A via laparoscópica tem sido reconhecida como padrão de excelência para a colecistectomias. Phillipe Mouret foi quem primeiro a realizou em 1987, mas outros procedimentos já haviam sido realizados por laparoscopia e foram descritos por ginecologistas. Desenvolvida no final da década de 80 e início dos anos 90, a videolaparoscopia mudou os conceitos de acesso cirúrgico e campo operatório, introduzindo a concepção de “cirurgia minimamente invasiva”.A colecistectomia é um dos procedimentos cirúrgicos mais realizados no mundo. Com o advento da videolaparoscopia, tornou-se uma cirurgia menos traumática, mais estética, com períodos mais curtos de internação. Em contrapartida, observou-se o aumento da incidência de lesões de via biliar extra-hepática quando comparado ao procedimento aberto, fato preocupante devido à morbidade elevada desse tipo de lesão, cuja mortalidade não é desprezível.
PREVENÇÃO DO CÂNCER DO INTESTINO GROSSO
O cólon, incluindo o reto, é o sítio mais freqüente de tumores primários do que qualquer outro órgão do corpo humano. Trata-se do quinto tipo de tumor maligno mais freqüente no Brasil.Segundo dados do Instituto Nacional do Câncer, estima-se que ocorrem no Brasil, cerca de 20.000 casos novos de câncer do intestino grosso (ou colorretal, ou do cólon e do reto) e que cerca de 7.000 brasileiros morrem por conta da doença anualmente. A chance de uma pessoa desenvolver câncer do intestino grosso ao longo de sua vida é de, em média, 1 em 20. O risco de se desenvolver câncer do intestino grosso após os 50 anos é de cerca de 1%.
POR QUE PREVENIR?
O câncer colorretal é um mal silencioso. A maioria dos tumores do intestino grosso não leva a qualquer sintoma até que tenha atingido um tamanho considerável o que diminui as chances de cura. A chance de obter cura para os indivíduos com câncer colorretal e com sintomas é de cerca de 50% e pouco melhorou nos últimos 50 anos apesar dos avanços alcançados no seu diagnóstico e tratamento. Por outro lado, a chance de curar um indivíduo para o qual foi feito diagnóstico de câncer antes de ele desenvolver sintomas é de 80%. Por isso, a melhor forma de se reduzir a chance de morrer de câncer colorretal é através de seu diagnóstico precoce. Só é possível diagnosticar precocemente se praticamos a prevenção, conhecida no meio médico como rastreamento. A maioria dos casos de câncer colorretal se origina a partir de precursores benignos, os pólipos. Se os pólipos forem removidos, o câncer pode ser evitado.
QUEM TEM MAIOR RISCO DE DESENVOLVER CÂNCER COLORRETAL?
Eis os grupos de indivíduos com maior chance de desenvolver câncer do cólon e do reto:
Toda a população com mais de 50 anos;
Os indivíduos com história familiar de:câncer do intestino,pólipos do intestino,câncer do endométrio (útero),câncer de mama, e câncer de ovário.
Os pacientes com doença inflamatória intestinal de longa evolução
De um modo geral, quanto mais jovens forem os antecedentes familiares dos tumores acima relacionados, maior o risco de se ter o tumor.
Existem também evidências acerca do papel das gorduras saturadas na origem do câncer do intestino grosso. A dieta pobre em gordura animal e rica em fibras (legumes, verduras, cereais e frutas) é fator protetor contra o câncer do intestino. Modernamente, a American Society of Cancer elaborou um modelo de dieta rica em frutas, vegetais e fibras e pobre em gorduras para prevenção do câncer colorretal.
Prevenção do câncer colorretal: Recomendações dietéticas
Limitar a ingestão de gordura em 25-30% das calorias diárias. Aumentar a quantidade e variedade de frutas e vegetais (5 porções diárias); Ingerir 20-30 gramas de fibras por dia; Introduzir 3 gramas de carbonato de cálcio por dia.
EXISTE RELAÇÃO COM A CONSTIPAÇÃO?
Nenhuma. Pacientes constipados não têm maior chance de vir a ter câncer do intestino grosso exclusivamente por causa da constipação. No entanto, entende-se que a permanência de carcinógenos (normalmente presentes na dieta) ingeridos por qualquer pessoa em contato com a parede do intestino por mais tempo, como acontece com os indivíduos constipados, pode teoricamente aumentar as chances de transformação maligna. Portanto, uma vez que a melhor forma de tratar a constipação intestinal é através da dieta de fibras, que protege contra o câncer do intestino grosso, pode-se dizer que combater a constipação provavelmente previne o câncer.
COMO SE FAZ A PREVENÇÃO?
Através de exames preventivos. Os exames devem ser solicitados pelo seu médico seja ele generalista ou especialista. Existem diretrizes ou protocolos de sociedades médicas já bem estabelecidos para esse fim. Cabe ao seu médico escolher qual a melhor forma de prevenção para você: ou seja quais exames serão solicitados e com qual freqüência eles devem ser realizados. Os exames que podem ser utilizados são:
a pesquisa de sangue oculto nas fezes,
a retossigmoidoscopia, e
QUEM DEVE FAZER O QUÊ E QUANDO?
Cabe a seu médico e você decidirem qual o melhor programa de prevenção do câncer do intestino grosso para você e sua família. Procure conhecer seus antecedentes familiares de doenças graves. Se você não tem antecedente familiar de câncer do intestino grosso ou pólipos, a prevenção pode começar aos 50 anos de idade. Se você tem mais de 50 anos e nunca preveniu, já é hora de faze-lo. Se você tem um parente próximo que teve câncer do intestino grosso antes dos 50 anos, procure seu médico e fale sobre isso com ele. Sua prevenção deverá ter início antes dos 50 anos e procure saber desde já mais detalhes do caso e se esse seu parente foi o único da família. Se você já fez uma colonoscopia e foram encontrados um ou mais pólipos, a essa altura você já deve saber quando repetir o exame. Se não, procure um GASTROENTEROLOGISTA, CIRURGIÃO DO APARELHO DIGESTIVO OU PROCTOLOGISTA.
Colostomia Temporária: Quando está indicada a cirurgia de reversão?
Apesar de uma diminuição global nas últimas décadas do número de realizações de colostomias temporárias, esta ainda é uma técnica cirúrgica de grande importância no arsenal de opções terapêuticas do CIRURGIÃO DIGESTIVO/COLOPROCTOLOGISTA.
II. EVENTOS ADVERSOS RELACIONADOS
As colostomias, também conhecidas como ostomias, geralmente realizadas em caráter de urgência são desagradáveis para os pacientes e podem trazer uma série de eventos adversos pela sua presença, em especial o risco de infecção de parede abdominal, prolapso (saída) do intestino pela colostomia, oclusão intestinal e as hérnias (enfraquecimento da parede abdominal) para-estomais (ao redor da colostomia), variando a incidência desses eventos adversos em até 60% dos pacientes.
III. RECONSTRUÇÃO DO TRÂNSITO INTESTINAL
Até o momento não se encontra consenso na literatura médica em relação ao tempo ideal de fechamento de uma colostomia temporária. O período clássico de 8 a 12 semanas, encontrado na maioria das publicações, deve ser analisado com grande senso crítico. Os trabalhos científicos especializados identificam taxas de eventos adversos relacionados a cirurgia de fechamento da colostomia ou reconstrução do trânsito intestinal extremamente variadas, com índices que vão de 10% até quase 50% dos casos.
O que podemos identificar a partir destes dados é que as cirurgias de decolostomias (cirurgia de reversão de colostomia) são cirurgias complexas e de difícil comparação entre os casos individuais em virtude da especifidade das indicações clínicas. Contudo os fatores inerentes ao próprio paciente, tais como:
1. idade (acima de 45 anos);
2. comorbidades associadas (presença de Diabetes e Hipertensão Arterial);
3. uso crônico de medicações (tais como Corticóides);
4. grau de desnutrição (Albumina sérica menor que 3,0 g/dl); e
5. doença de base que levou a cirurgia de colostomia exercem influência direta no aumento da morbidade (taxa de eventos adversos) dessas operações.
Desta forma, uma diverticulite aguda complicada, um tumor de cólon obstrutivo, uma lesão colônica por projétil de arma de fogo ou arma branca, ou ainda uma perfuração durante um exame endoscópico provocam, dependendo do paciente, respostas metabólicas e endócrinas variáveis, promovendo também efeitos diversos no processo de cicatrização das feridas no pós-operatórios. Portanto quando da programação das cirurgias de restituição do trânsito intestinal uma das avaliações clínicas de grande importância é a total recuperação do trauma cirúrgico anterior que levou a realização da colostomia que é peculiar de paciente para paciente.
IV. AVALIAÇÃO PRÉ-OPERATÓRIA
A programação do fechamento da colostomia através da cirurgia de DECOLOSTOMIA é realizada pela avaliação do estado clínico atual do paciente, assim também como a condição em que se encontram os segmentos intestinais envolvidos, que são apreciados pelos exames radiológicos contrastados (ENEMA OPACO – TRÂNSITO INTESTINAL) e endoscópicos (COLONOSCOPIA) da porção intestinal a ser reconstruída. Outra avaliação importante é que, do ponto de vista técnico, colostomias feitas em caráter de urgência e a presença de aderências intra-abdominais podem resultar na necessidade de ressecções adicionais de segmentos intestinais.
Os eventos adversos mais comuns da cirurgia de reversão de colostomia são as INFECÇÕES e os VAZAMENTOS DA ANASTOMOSE (FÍSTULAS). Os resultados da cirurgia de reconstrução intestinal segundo Gomes da Silva (2010) foram : tempo operatório médio de 300 minutos (variando de 180 a 720 minutos); a reconstrução do trânsito intestinal foi alcançado em 93% dos casos; a fístula anastomótica ocorreu em 7% e a infecção de sítio cirúrgico em 22%. A taxa de mortalidade, neste estudo foi de 3,4% ocorrendo principalmente por sepse abdominal ocasionada pela fístula. Dentre os fatores relacionados ao insucesso na reconstrução da colostomia a Hartmann observou-se associação significativa com a tentativa prévia de reconstrução (p = 0,007), a utilização prévia de quimioterapia (p = 0,037) e o longo tempo de permanência da colostomia (p = 0,025).
Referências: Fonseca et al. ABCD, 2017. & Silva et al. ABCD, 2010.