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Surgical Management of PANCREATIC CANCER

INTRODUCTION

Pancreatic ductal adenocarcinoma (PDAC) carries one of the poorest overall prognosis of all human malignancies. The 5-year survival in patients with PDAC, for all stages, remains as low as 6–7%. The low survival rate is attributed to several factors, of which the two most important are aggressive tumor biology and late stage at which most patients are diagnosed. Only 10–20% of patients are eligible for resection at presentation, 30–40% are unresectable/locally advanced, and 50–60% are metastatic. Pancreatic cancer without distant metastasis can be divided into three categories: resectable, borderline resectable, and locally advanced. In absence of metastatic disease, the most important factor for improving survival and possibly offer cure is to achieve a margin-negative resection. Even after potential curative resection, most patients develop recurrences eventually, and 5-year survival of completely resected patients is only up to 25%. The aggressive tumor biology and its inherent resistance to chemotherapy and radiotherapy contributes to early recurrence and metastasis.

SURGICAL ADVANCES

Pancreatic cancer surgery has evolved over the past few decades and remains the cornerstone of treatment of resectable and borderline resectable tumors. Advances in modern imaging give precise information on disease extension and vascular involvement that aids in surgical planning in order to achieve a margin-negative resection.

SURGICAL TECHNIQUES

Surgical techniques for pancreatic cancer include pancreaticoduodenectomy, distal pancreatectomy with splenectomy, and total pancreatectomy. Standard lymphadenectomy for pancreatoduodenectomy should include removal of lymph node stations 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a, 14b, 17a, and 17b. Involvement of superior mesenteric vein (SMV)/portal vein(PV) was previously considered as a contraindication for resection. However, curative resection along with SMV/PV with vascular reconstruction has now become a standard practice in specialized high-volume centers. To improve margin-negative resections, specially in borderline resectable tumors with proximity to vascular structures, SMA first approach was proposed as a new modification of standard pancreatico-duodenectomy. In a systematic review, SMA first approach was shown to be associated with better perioperative outcomes, such as blood loss, transfusion requirements, pancreatic fistula, delayed gastric emptying, and reduced local and metastatic recurrence rates. In case of arterial involvement, there is no good evidence at present to justify arterial resections for right-sided pancreatic tumors. However, the modified Appleby procedure, which includes en bloc removal of celiac axis with or without arterial reconstruction, when used in appropriately selected patients, offers margin negative resection with survival benefit for locally advanced pancreatic body and tail tumors and should be performed in high-volume centers. Most evidence does not support advantage of more extended resections such as removal of the para-aortic lymph nodes and nerve plexus and multivisceral resections routinely. Such extended resections are associated with compromised quality of life because of associated higher perioperative morbidity and intractable diarrhea. However, in highly selected patients, with preserved performance status and stable or nonprogressive disease on neoadjuvant treatment, such extended resections can provide survival advantage over palliative treatments. Radical surgery in the presence of oligometastatic disease has also been reported to prolong survival in highly selected patients.

Surgical Management

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Adverse events in SURGERY

The surgical domain can be seen as more complex and high risk in its delivery of care than other non-interventional specialities. It is therefore not surprising that in the majority of studies of adverse events in healthcare, at least 50% occurred within the surgical domain and the majority of these in the operating theatre. Furthermore, at least half of these adverse events were also deemed preventable. Just as the multiple studies in the developed world have similar figures for adverse events in hospitalised patients across all specialities, there appears to be a similar rate of harm in surgery. A review of 14 studies, incorporating more than 16000 surgical patients, quoted an adverse event occurring in 14.4% of surgical patients. This was not simply minor harm; a full 3.6% of these adverse events were fatal, 10% severe and 34% moderately harmful. Gawande, a surgeon from Boston, made one of the first attempts to clarify the source of these adverse events.

This paper pioneered the concept that the majority of these adverse events were not due to lack of technical expertise or surgical skill on the part of the surgeon, finding instead that ‘systems factors’ were the main contributing factor in 86% of adverse events. The most common system factors quoted were related to the people involved and how they were functioning in their environment. Communication breakdown was a factor in 43% of incidents, individual cognitive factors (such as decision-making) were cited in 86%, with excessive workload, fatigue and the design or ergonomics of the environment also contributing.

These findings were confirmed in the systematic review of surgical adverse events, where it was found that errors in what were described as ‘nonoperative management’ were implicated in 8.32% of the study population versus only 2.5% contributed to by technical surgical error. In accordance with other high-risk industries, such as commercial aviation, the majority of these adverse events are therefore not caused by failures of technical skill on the part of the individual surgeon, but rather lie within the wider healthcare team, environment and system. Lapses and errors in communication, teamworking, leadership, situational awareness or decision-making all feature highly in post-hoc analysis of surgical adverse events. This knowledge of error causation has been prominent and acknowledged in most other high-risk industries for many years, but it is only recently that healthcare has appreciated this.

Hepatocellular ADENOMA

Benign liver tumours are common and are frequently found coincidentally. Most benign liver lesions are asymptomatic, although larger lesions can cause non-specific complaints such as vague abdominal pain. Although rare, some of the benign lesions, e.g. large hepatic adenomas, can cause complications such as rupture or bleeding. Asymptomatic lesions are often managed conservatively by observation. Surgical resection can be performed for symptomatic lesions or when there is a risk of malignant transformation. The type of resection is variable, from small, simple, peripheral resections or enucleations, to large resections or even liver transplantation for severe polycystic liver disease.

General Considerations
Hepatocellular adenomas (HCA) are rare benign hepatic neoplasms in otherwise normal livers with a prevalence of around 0.04% on abdominal imaging. HCAs are predominantly found in women of child-bearing age (2nd to 4th decade) with a history of oral contraceptive use; they occur less frequently in men. The association between oral contraceptive usage and HCA is strong and the risk for a HCA increases if an oral contraceptive with high hormonal potency is used, and if it is used for over 20 months. Long-term users of oral contraceptives have an estimated annual incidence of HCA of 3–4 per 100000. More recently, an increase in incidence in men has been reported, probably related to the increase in obesity, which is reported as another risk factor for developing HCA. In addition, anabolic steroid usage by body builders and metabolic disorders such as diabetes mellitus or glycogen storage disease type I are associated with HCAs. HCAs in men are generally smaller but have a higher risk of developing into a malignancy. In the majority of patients, only one HCA is found, but in a minority of patients more than 10 lesions have been described (also referred to as liver adenomatosis).

Clinical presentation
Small HCAs are often asymptomatic and found on abdominal imaging being undertaken for other purposes, during abdominal surgery or at autopsy. Some patients present with abdominal discomfort, fullness or (right upper quadrant) pain due to an abdominal mass. It is not uncommon that the initial symptoms of a HCA are acute onset of abdominal pain and hypovolaemic shock due to intraperitoneal rupture. In a series of patients who underwent resection, bleeding was reported in up to 25%. The risk of rupture is related to the size of the adenoma. Exophytic lesions (protruding from the liver) have a higher chance of bleeding compared to intrahepatic or subcapsular lesions (67% vs 11% and 19%, respectively, P<0.001). Lesions in segments II and III are also at higher risk of bleeding compared to lesions in the right liver (35% vs 19%, P = 0.049).

Management

There is no guideline for the treatment of HCAs, although there are general agreements. In men, all lesions should be considered for surgical resection independent of size, given the high risk of malignant transformation, while taking into account comorbidity and location of the lesion. Resection should also be considered in patients with HCAs due to a metabolic disorder. In women, lesions <5 cm can be observed with sequential imaging after cessation of oral contraceptive treatment. In larger tumours, treatment strategies vary. Some clinicians have proposed non-surgical management if hormone therapy is stopped and patients are followed up with serial radiological examinations. The time period of waiting is still under debate, however recent studies indicate that a waiting period of longer than 6 months could be justified.

Conventional Left Hepatectomy

More recently, the subtypes of the Bordeaux classification of HCA have been studied related to their risk of complications. Some groups report that percutaneous core needle biopsy is of limited value because the therapeutic strategy is based primarily on patient sex and tumour size. Others report a different therapeutic approach based on subtype. Thomeer et al. concluded that there was no evidence to support the use of subtype classification in the stratification and management of individual patients related to risk of bleeding. Size still remains the most important feature to predict those at risk of bleeding during follow-up. However, malignant transformation does seem to be related to differences in subtypes. β-catenin-mutated HCAs trigger a potent mitogenic signalling pathway that is prominent in HCC. Cases of inflammatory HCAs can also show activation of the β-catenin pathway with a risk of developing malignancy. Therefore, β-catenin-mutated and inflammatory HCAs are prone to malignant degeneration, and particularly if >5cm. In these circumstances, invasive treatment should be considered.

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Liver Uptake on Cadaveric Donors for Transplant

Since the initial descriptions of orthotopic liver transplantation (OLT) in the 1960s, both the number of patients receiving transplants and the indications for the procedure have increased significantly. OLT represents the only treatment modality for many patients with a diverse spectrum of disease, with the predominant common factor end-stage liver failure. Advances in perioperative care of the donor and recipient, organ preservation methods, and surgical techniques have resulted in a 5 year overall survival of 78% for all recipients (Kim et al, 2015).

OPERATIVE TECHNIQUES
The first published description of human liver transplantation was by Starzl and colleagues in 1963 at the University of Colorado. In this seminal paper, the dismal outcomes of three OLT recipients were described, including one intraoperative death from uncorrectable coagulopathy and two survivors of 7 and 22 days. In addition to the pioneering conceptual framework and implementation of LT, the advanced techniques included grafts from non–heart-beating donors, venovenous bypass in the recipients, choledochocholedochostomy, and coagulation monitoring by using thromboelastography (TEG). Many of these concepts remain or have reentered the realm of LT more than 40 years after their initial description. Based largely on the initial body of work by Starzl and colleagues, this section describes the surgical procedures commonly used worlwide.

Liver Uptake on Cadaveric Donors for Transplant

The typical deceased donor has had a catastrophic head injury or an intracerebral bleed, with brain death but without multisystem organ failure. Electrolyte imbalance and hepatic steatosis in the donor are predictors of graft nonfunction. A “donor risk index” has been derived to assess the likelihood of good graft function. Key adverse factors include older donor age (especially >60 years of age), use of a split or partial graft, and a non–heart-beating donor, from which the organs are harvested after the donor’s cardiac output ceases, in contrast to the more typical deceased donation in which the organs are harvested prior to cardiovascular collapse. Use of non–heart-beating donors is associated with reduced rates of long-term graft survival and increased risk of biliary complications, which correlate with the duration of “warm ischemia” after cardiovascular collapse and before retrieval of the organ. With the critical shortage of deceased organ donors, expansion of the donor pool has included acceptance of donors 70 years of age and older for selected recipients. Prior to hepatectomy, the harvesting team makes a visual and, if necessary, histologic assessment of the donor organ. Particular attention is paid to anatomic variants in the hepatic artery that may complicate the graft arterial anastomosis in the recipient. Once donor circulation is interrupted, the organ is rapidly infused with a cold preservation solution (e.g., University of Wisconsin, histidine-tryptophan-ketoglutarate, or Institut Georges Lopez solution). Donor iliac arteries and veins are also retrieved in case vascular grafting is required. After its arrival at the recipient institution, further vascular dissection, with arterial reconstruction if necessary, is performed before implantation.

Future Perspectives

Major challenges remain in LT, including the shortage of donor organs, threat of recurrent disease, and morbidity associated with lifelong therapeutic immunosuppression. Nevertheless, the availability of LT has transformed the lives of patients with advancing liver disease and their health care providers from an ultimately futile effort to manage the complications of cirrhosis into a life-prolonging and life-enhancing intervention.

Necrotizing Gallstone Pancreatitis

The AGA recently published a Clinical Practice Update reviewing the best available evidence on pancreatic necrosis, regardless of cause. The update provides 15 best practice advice points that include the need for multidisciplinary care coordination and referral to a tertiary-care center as appropriate. The update describes supportive care, avoidance of prophylactic antibiotics, and optimization of nutrition. In addition, there is an included algorithm for the management of pancreatic necrosis requiring debridement. Debridement within the early acute phase of pancreatitis (within the first 2–4 weeks) should be avoided if possible secondary to increased morbidity and mortality. Intervention in the late phase (> 2–4 weeks) is indicated for patients with infected necrosis or persistent organ dysfunction and failure to thrive. Multiple approaches are available for the management of infected necrosis, including but not limited to percutaneous, endoscopic, or laparoscopic transgastric, or open debridement. In addition, a combination approach using percutaneous drainage followed by videoscopic retroperitoneal debridement or step-up approach can also be used. Since the publication of a multicenter RCT (PANTER) in 2010, the step-up approach for necrotizing pancreatitis has been increasingly used.

Necrotizing Gallstone Pancreatitis

The step-up approach or video-assisted retroperitoneal debridement (VARD) is a minimally invasive technique that begins with percutaneous drain placement for necrotizing pancreatitis followed by a minimally invasive retroperitoneal necrosectomy. Patients who underwent the step-up approach versus open necrosectomy had less multiple-organ failure, incisional hernias, and newonset diabetes, but no difference in mortality. The 2020 AGA Clinical Practice Update on the management of pancreatic necrosis suggests that best practice is that ‘‘minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity’’. However, the update also notes that open necrosectomy still has a role in the modern management of acute necrotizing pancreatitis, particularly for cases whereby less invasive techniques are not feasible.

Pancreatic Surgery

POPF after Distal Pancreatectomy

Minimally Invasive Versus Open Techniques

Despite advances in laparoscopic and robotic approaches, the vast majority of distal pancreatectomies continue to be performed via an open approach. Recent retrospective data have demonstrated that minimally invasive distal pancreatectomy is associated with decreased blood loss and shorter hospital stays than open pancreatectomy. A large recent study utilizing the Nationwide Inpatient Sample database suggested, first, that the minimally invasive approach is becoming more widely utilized, increasing from 2.4 to 7.3 % over a study period from 1998 to 2009. Second, that study reported that the minimally invasive approach was associated with decreased length of stay as well as decreased incidence of infectious complications, bleeding complications, and blood transfusions. This population-based study echoes conclusions drawn by a large multi-institutional study performed several years previously. Drawing on a combined patient sample of 667 patients, with 24 % initially attempted laparoscopically, the authors were able to demonstrate lower overall complication rate, decreased blood loss, and shorter hospital stays among patients undergoing laparoscopic approach via a multivariate analysis.

Clockwise Approach

Notably, there was no significant difference in the pancreatic leak rate between the open and laparoscopic approaches, although there was a nonsignificant trend favoring the laparoscopic approach. More recently, the robotic approach has generated significant interest as a technique for performing distal pancreatectomy. Retrospective analysis has suggested that the robotic approach is well suited for pancreatectomy. Fistula rates, however, remain a concern. A retrospective review of patients undergoing robotic pancreatic operations included 83 patients who underwent distal pancreatectomy. About 27 % were identified as having a ISPGF type A pancreatic leak; 12 and 4.8 % were identified as having a grade B or C leak, respectively.

Identifying Risk Factors

For pancreaticoduodenectomy (PTD) , a fistula risk score has been recently developed that has been shown to be highly predictive of POPF. This score assigns points based on gland texture, gland pathology, duct diameter, and intraoperative blood loss. In general, high blood loss, soft gland texture, and smaller duct diameter confer increased risk of POPF, whereas pancreatic adenocarcinoma and pancreatitis as the indication for PTD confer protection for the development of pancreatic fistula versus other diagnoses. Also of note, higher fistula risk scores correlated with greater incidence of clinically relevant (ISGPF grade B or C) fistula. The adaptation of this risk score to patients undergoing distal pancreatectomy is yet to be validated; however, at least one published study indicates that this scoring system may have limitations in the setting of distal pancreatectomy. In that study, risk factors for pancreatic fistula after stapled gland transection in patients undergoing distal pancreatectomy were examined, and in a multivariate analysis, only the presence of diabetes and the use of a 4.1-mm staple cartridge were associated with increased risk of pancreatic fistula formation.

LAPAROSCOPIC DISTAL PANCREATECTOMY

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PhD THESIS (Ozimo Gama, MD)

COMPARATIVE STUDY BETWEEN THE SLEEVE GASTRECTOMY AND GASTRIC PLICATION IN OBESE RATS

INTRODUCTION: Obesity results from a prolonged imbalance between energy intake and energy expenditure. Studies with experimental models of bariatric surgery provided a fundamental contribution to the understanding of morphological and functional changes in obesity and after bariatric surgery. The restrictive bariatric surgery techniques currently used are gastric banding, sleeve gastrectomy and the gastric plication. The latter is considered an experimental technique and has therefore not yet enough studies that shed light on the postoperative rates of weight loss, surgical complications, resolution of comorbidities and the mechanisms responsible for weight loss. The aim of this study was to conduct a comparative study in rats with cafeteria diet-induced, between gastric plication and sleeve gastrectomy in variation late postoperative in body weight ,plasma biochemistry and gross and microscopic alterations gastric effects obesity.

MATERIAL AND METHOD: 28 male Wistar rats were randomized into three groups after induction period of obesity by cafeteria diet and underwent sleeve gastrectomy (GV group), gastric plication (GP group) and sham operation (control group). The animals were assessed daily postoperatively and the variables were recorded: (initial seven days, 14 and 21 days) body weight and presence of complications until day 21 postoperatively, when they were euthanized and evaluated: biochemistry (glucose, insulin, HDL, total cholesterol, triglycerides, AST, ALT and serum ghrelin), degree of intra-abdominal adhesions, resistance testing will air insufflation in the stomach and microscopic evaluation of the gastric mucosa.

RESULTS: In relation to body weight variation of animals GV group (initial weight: 318 ± 7.89 g / Final weight: 213 ± 9.03g) was significantly decreased (p<0.05) at 21 post-surgery day compared to the GP group (initial weight: 314.11 ± 20.79 g / final weight: 239.16 ± 14.71 g) and control (initial weight: 315.16±17.54g / final weight: 317.91±16.06 g). The animals in the GV group had a significant decrease (p<0.001) in blood glucose, insulin, transaminases, serum HDL and ghrelin compared to animals in GP and control. Was also significantly lower the burst pressure of the stomach in the GV group, the insufflation test the atmospheric air in relation to the GP and control groups. The GP and GV groups showed even different histological grade of inflammation
(subacute inflammation) and control group (chronic inflammation).

CONCLUSIONS: The sleeve gastrectomy is more effective than gastric plication weight loss, metabolic control and reduction of serum ghrelin in obesity rats, and presents the same rates of postoperative complications (adhesions, deaths and grade inflammation).

KEYWORDS: 1. Obesity; 2. Bariatric Surgery; 3.Wistar rats.

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.

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Critical View Of Safety

Steven Strasberg, 2017

“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. 

Critical View of Safety (Mindset)

Mirizzi’s Syndrome

INTRODUCTION

First described by Pablo Mirizzi in 1948 as “functional hepatic syndrome”, Mirizzi’s syndrome was initially thought to be the result of a “physiologic sphincter” of the hepatic duct. It is now understood to be a result of mechanical obstruction of the common hepatic duct secondary to an impacted stone in the gallbladder neck, Hartmann’s pouch, or the cystic duct. The syndrome is very uncommon in Western populations with a reported prevalence of 0.05%-5.7% in large modern series of patients undergoing biliary surgery. With chronic stone impaction, inflammation and recurrent cholangitis can develop with subsequent erosion into the common bile duct (CBD) and resultant biliobiliary fistula between the gallbladder and CBD.

CLASSIFICATION

The syndrome encompasses a spectrum of disease. Broadly speaking, Mirizzi’s syndrome can be grouped into two major categories: (1) external compression of the CBD without a fistula (Type 1), and (2) erosion into the CBD causing a cholecystobiliary fistula (Type II-IV). Csendes classification is currently being used to reflect the above classification. Retrospective studies have identified an association between Mirizzi’s syndrome and gallbladder cancer, with an incidence as high as 28%, relative to an incidence of 1-2% in patients with uncomplicated gallstone disease. As with other malignant processes of the biliary tract, biliary stasis and chronic inflammation have been suggested to play a role. In general, it is difficult to distinguish benign Mirizzi’s syndrome from a neoplastic process preoperatively, although older patient age, significantly elevated Ca 19-9, and imaging features suggestive of invasion into the liver or a mass filling the gallbladder should raise suspicion for malignancy.

CLINICAL FINDS
The most common presenting symptoms are right upper quadrant pain, jaundice, nausea/vomiting, and fever. This spectrum of findings overlaps with several other pathologic processes of the hepatobiliary tract, making preoperative diagnosis difficult. Additionally, the clinical picture may be complicated by the concurrent presence of acute cholecystitis, pancreatitis, or even gallstone ileus. Mirizzi’s syndrome should be suspected in any patient presenting with right upper quadrant pain and abnormal liver enzymes (particularly elevated bilirubin and alkaline phosphatase) or imaging suggestive of an impacted stone. Three findings on imaging together suggest a diagnosis of Mirizzi’s: 1) dilation of the biliary system above the level of the gallbladder neck, 2) the presence of a stone impacted in the gallbladder neck, and 3) an abrupt change to a normal width of the common duct below the level of the stone. Such findings should prompt further imaging to better define the biliary tree, either indirectly though magnetic resonance cholangiopancreatography (MRCP), or directly through endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). No imaging modality is entirely sensitive for Mirizzi’s syndrome and the key is to maintain a high index of suspicion.

MANAGEMENT

Management of Mirizzi’s syndrome depends on the degree of fistula. In Type I disease, laparoscopic cholecystectomy is usually achievable, either total (classic) or subtotal, depending on the specific intraoperative findings. If the view of safety can be attained with the critical structures isolated, a classic cholecystectomy may be performed. If the view of safety cannot be achieved due to inflammation or adhesions, the gallbladder is taken down retrograde and opened near the cystic duct orifice. All stones are removed, including any impacted stones, and the cystic duct orifice is examined for the presence of bile to determine whether it is patent. If the cystic duct is patent, it should be ligated (if possible), or the remnant gallbladder should be sutured closed over it (choledochoplasty). An external closed suction drain may be left in the gallbladder fossa and removed the following day if drainage is non-bilious. More commonly, the cystic duct is obliterated, and a subtotal cholecystectomy with removal of all stones is sufficient.

Management of Mirizzi’s syndrome in the presence of a biliobiliary fistula is more complex. If the fistula involves <1/3 of the CBD circumference (Type II), options include primary repair using absorbable suture, closure over a T-tube, or choledochoplasty using the remnant gallbladder. The last approach is preferable to maintain the diameter of the CBD and minimize the risk of subsequent stricture but requires that sufficient gallbladder remnant be available to allow closure. In the presence of a more extensive fistula (Type III or IV), bilioenteric anastomosis is usually the best option.

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.

GERD AFTER SLEEVE GASTRECTOMY

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.

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Causas de conversão da VIDEOCOLECISTECTOMIA

OZIMO_GAMA_CIRURGIÃO_DIGESTIVOEstima-se que atualmente 90% das colecistectomias sejam realizadas pela técnica laparoscópica, percentual este atingido nos Estados Unidos da América no ano de 1992. Os motivos para tal preferência na escolha da técnica cirúrgica aplicada são claros: menor dor no pós-operatório, recuperação pós-cirúrgica mais rápida, menor número de dias de trabalho perdidos e menor tempo de permanência hospitalar. A colecistectomia laparoscópica foi claramente estabelecida como padrão-ouro para o tratamento cirúrgico da litíase biliar, no entanto 2 a 15% das colecistectomias vídeolaparoscópicas necessitam de conversão para cirurgia convencional, sendo as razões mais comuns a inabilidade para se identificar corretamente a anatomia, suspeita de lesão da árvore biliar e sangramento. A identificação dos fatores associados a um maior índice de conversão possibilita à equipe cirúrgica estimar o grau de dificuldade do procedimento, preparando melhor o paciente para o risco de conversão e permitindo a participação de um cirurgião mais experiente num procedimento de maior risco.

Relacionados ao Paciente: 1. Obesidade (IMC > 35), 2. Sexo Masculino, 3. Idade > 65 anos, 4. Diabetes Mellitus e 5. ASA > 2.

Relacionadas a Doença: 1. Colecistite Aguda, 2. Líquido Pericolecístico, 3. Pós – CPRE, 4. Síndrome de Mirizzi e 5. Edema da parede da vesícula > 5 mm.

Relacionadas a Cirurgia: 1. Hemorragia, 2. Aderências firmes, 3. Anatomia obscura, 4. Fístulas internas e 5. Cirurgia abdominal prévia.

Management of POST-HEPATECTOMY complications

HEPATECTOMY_OZIMOGAMA

Hepatectomia Esquerda – Metástase CR


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.

REVIEW_ARTICLE_HEPATECTOMY_COMPLICATIONS

Complications of HEMORROIDH SURGERY

Hemorroidectomia_DrOzimoGama

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.

HEMORRHOID SURGERY COMPLICATIONS_REVIEW

Lymph Node Dissection in Gastric Adenocarcinoma

LINFATICOS GASTRICOS

Extent of lymph node dissection has been an area of controversy in gastric adenocarcinoma for many years. Some surgeons believe that cancer metastasizes through a stepwise progression, and an extensive lymphadenectomy is necessary to improve survival and/or cure the patient. Other physicians argue that extensive ly-mphadenectomies only add pe-rioperative morbidity and mor-tality and do not improve survival. Asian countries have been performing extended lymphadenectomies routinely for many years with promising survival data, although Western countries have not been able to reproduce those results. Much of the controversy surrounding lymphadenectomies started in the 1980s when Japanese studies reported superior survival rates matched stage for stage, compared to the United States. This was theorized to be secondary to the more extensive lymphadenectomy performed in Japan compared to the United States

Resultado de imagem para gastric cancer linfadenectomy d2

A United Kingdom study randomized 400 patients to either a D1 or a D2 lymph node dissection. Those patients with tumors in the upper or middle third of the stomach underwent a distal pancreaticosplenectomy to obtain retropancreatic and splenic hilar nodes. While the 5-year survival rates were not statistically significant between the two groups, on multivariate analyses it was noted that those patients in the D2 group that did not undergo the distal pancreaticosplenectomy had an increased survival compared with the D1 group. A trial in the Netherlands randomized 380 gastric cancer patients to a D1 lymphadenectomy and 331 patients to a D2 lymphadenectomy. Similar to the United Kingdom study, there was not a significant difference in survival between the two groups, even when followed out to 11 years. There was a significant increase in postoperative complications in the D2 group compared with the D1 group (43 % vs. 25 %, respectively) as well as mortality (10 % vs. 4 %, respectively).

The data from these two studies suggest that a pancreaticosplenectomy performed to harvest lymph nodes seems to only add morbidity and mortality while not improving survival. One concern raised about the prior two studies was the variation in surgical technique and lack of standardization of surgeon experience. A Taiwanese study accounted for this by performing the study at a single institution with three surgeons, each of whom had completed at least 25 D3 lymph node dissections prior to the study. Patients with gastric cancer were randomized to a D1 lymph node dissection (defined as resection of perigastric lymph nodes along the lesser and greater curves of the stomach) or a D3 lymph node dissection (defined as resection of additional lymph nodes surrounding the splenic, common hepatic, left gastric arteries, nodes in the hepatoduodenal ligament, and retropancreatic lymph nodes). There was an overall 5-year survival benefit with the D3 group of 60 % compared with the D1 group of 54 %. A Japanese study evaluated a more aggressive lymph node dissection and randomized patients to a D2 dissection or a para-aortic lymph node dissection (PAND). There was no significant difference in 5-year survival between the two groups with a trend toward an increase in complications in the PAND group. Multiple studies have shown that the number of positive lymph nodes is a significant predictor of survival. Current AJCC guidelines stipulate that at least 15 lymph nodes are needed for pathologic examination to obtain adequate staging.

Laparoscopic techniques have become an integral part of surgical practice over the past several decades. For gastric cancer, multiple retrospective studies have reported the advantages of laparoscopic gastrectomy (LG) over open gastrectomy (OG). A recent meta-analysis of 15 nonrandomized comparative studies has also shown that although LG had a longer operative time than OG, it was associated with lower intraoperative blood loss, overall complication rate, fewer wound-related complications, quicker recovery of gastrointestinal motility with shorter time to first flatus and oral intake, and shorter hospital stayA randomized prospective trial comparing laparoscopic assisted with open subtotal gastrectomy reported that LG had a significantly lower blood loss (229 ± 144 ml versus 391 ± 136 ml; P< 0.001), shorter time to resumption of oral intake (5.1 ± 0.5 days versus 7.4 ± 2 days; P< 0.001), and earlier discharge from hospital (10.3 ± 3.6 days versus 14.5 ± 4.6 days; P< 0.001). 

BILIARY-ENTERIC ANASTOMOSIS



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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.

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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

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