Abstract Early cancer diagnosis, new therapies that increased survival of patients, besides the increasingly elderly population are some factors would be associated with possible cancer dissemination in patients under cardiopulmonary bypass (CPB) cardiac surgery. Also, the benefits, and risks, regarding long-term survival, have not yet been established. Therefore, cardiac surgery morbimortality may be superior in patients with cancer disease. Also, immunologic and inflammatory changes secondary to CPB can also increase tumor recurrence. After a brief introduction and CPB immunologic the two main topic subjects included: 1) Combined heart surgery and lung resection and; 2) Possible influence of neoplasia type. After observing the relative literature scarcity, we keep the opinion that “CPB has a modest association with cancer progression” and that “CPB and cancer dissemination should be a logical but unlikely association.”

OBJECTIVE: Transarterial chemoembolization is the treatment of choice for intermediate-stage hepatocellular carcinoma. However, there are no clear data supporting transarterial chemoembolization vs. transarterial embolization or regarding the best chemotherapeutic agent, which may suggest a preponderant role of ischemia over chemotherapeutic action. This study sought to evaluate the radiological response and outcome of transarterial chemoembolization modified by n-butyl cyanoacrylate addition compared to conventional transarterial chemoembolization in hepatocellular carcinoma patients. MATERIALS AND METHODS: A retrospective review identified forty-seven patients who underwent modified chemoembolization and thirty-three who underwent conventional chemoembolization between June 2006 and December 2011. The radiological response was reassessed using the modified Response Evaluation Criteria in Solid Tumors. The sustained complete response, time to progression and overall survival rates were also analyzed. RESULTS: Complete response rates were significantly higher in patients who had undergone modified chemoembolization compared to those who had undergone conventional treatment (61.7% and 24.3%, respectively; p<0.001). The rate of sustained complete response was significantly higher in the modified chemoembolization group compared to the conventional chemoembolization group (median of 236 and 37 days, respectively; p<0.001). Time to progression was significantly higher in the modified chemoembolization group compared to the conventional chemoembolization group (median of 424 and 201 days, respectively; p=0.042). Overall survival rates revealed no difference between patients who received modified chemoembolization and conventional chemoembolization (median of 483 and 399 days, respectively; p=0.316). CONCLUSION: Transarterial chemoembolization modified by n-butyl cyanoacrylate addition was superior to conventional transarterial chemoembolization in terms of the radiological response in the first imaging control. Although the sustained complete response and time to progression rates were higher for the modified chemoembolization group, no differences in overall survival rates were observed.

Contexto Observa-se relativa falta de estudos sobre nitrito (NO2-) exalado como biomarcador de lesão, após transplante de fígado. Objetivo Verificar possíveis diferenças e correlações entre os níveis de nitrito (NO2-), medido no plasma e condensado do exalado pulmonar de pacientes com cirrose e transplante de fígado. Método Sessenta pacientes adultos, masculinos, idades entre 27 e 67 anos, foram divididos em três grupos: grupo controle composto por 15 voluntários saudáveis, grupo cirrose, composto por 15 voluntários e, grupo de transplante, composto por 30 voluntários. As dosagens plasmáticas e do condensado do exalado pulmonar foram realizadas por quimioluminescência. Resultados A análise os valores de NO2- plasmático não mostrou diferença entre os grupos. As comparações entre grupos cirrose e controle, controle e transplantados e cirrose e transplante não foram significativas. As medidas em amostras de condensado do exalado pulmonar entre os três grupos não evidenciaram diferenças estatísticas. Ao comparar as amostras dos grupos controle e cirrótico, controle e transplantado e cirróticos e transplantados, não houve alterações significativas nas concentrações de NO2-. Conclusão Não foram encontradas correlações entre plasma e condensado do exalado pulmonar, sugerindo que o NO exalado reflete mais as condições respiratórias locais de liberação de NO do que a circulação sistêmica.

Context There is a relative lack of studies about exhaled nitrite (NO2-) concentrations in cirrhotic and transplanted patients. Objective Verify possible differences and correlations between the levels of NO2-, measured in plasma and exhaled breath condensate collected from patients with cirrhosis and liver transplant. Method Sixty adult male patients, aged between 27 and 67 years, were subdivided into three groups: a control group comprised of 15 healthy volunteers, a cirrhosis group composed of 15 volunteers, and a transplant group comprised of 30 volunteers. The NO2- concentrations were measured by chemiluminescence. Results 1) The analysis of plasma NO2- held among the three groups showed no statistical significance. 2) The comparison between cirrhotic and control groups, control and transplanted and cirrhotic and transplanted was not statistically significant. 3) The measurements performed on of NO2- exhaled breath condensate among the three groups showed no statistical difference. 4) When comparing the control group samples and cirrhotic, control and transplanted and cirrhotic and transplanted, there was no significant changes in the concentrations of NO2-. Conclusion No correlations were found between plasma and exhaled NO2-, suggesting that the exhaled NO2- is more reflective of local respiratory NO release than the systemic circulation.

PURPOSE: To analyze the intraoperative and immediate postoperative biochemical parameters of patients submitted to orthotopic liver transplantation. METHODS: Forty four consecutive orthotopic liver transplants performed from October 2009 to December 2010 were analyzed. The patients (38 male and eight female) were divided into two groups: group A, survivors, and group B, non-survivors. Fifty percent of group A patients were Chid-Pugh C, 40% Chid-Pugh B and 10% Chid-Pugh A. In group B, 52% of the patients were Chid-Pugh C, 41% Chid-Pugh B, and 17% Chid-Pugh A. All orthotopic liver transplants were performed by the piggy-back technique without a portacaval shunt in an anhepatic phase. ALT, AST, LDH and lactate levels were determined preoperatively, at five, 60 minutes after arterial revascularization of the graft and 24 and 48 hours after the end of the surgery.( or: after the surgery was finished). RESULTS: There were no preoperative clinical differences (Child and Meld) between the two groups. The times of warm and hypothermal ischemia were similar for both groups (p>0.05). Serum aminotransferases levels at five and 60 minutes after arterial revascularization of the graft were similar (p>0.05) for both groups, as also were lactate levels at the time points studied. There was no significant difference in Δ lactate between groups at any time point studied (p>0.05). No significant difference was observed between groups during the first 24 and 48 hours after surgery (p>0.05). CONCLUSION: No significant difference in any of the parameters studied was observed between groups. Under the conditions of the present study and considering the parameters evaluated, no direct relationship was detected between the intraoperative situation and the type of evolution of the patients of the two groups studied.

OBJETIVO: O objetivo do presente estudo é avaliar os níveis do MELD clássico ou puro pós-operatório, alterações dos níveis séricos do lactado e BE, analisando-os como possíveis fatores preditivos do tipo de sobrevida de pacientes submetidos ao transplante ortotópico de fígado (OLT). MÉTODOS: Foram analisados 60 pacientes submetidos ao OLT (técnica de piggy-back) no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto-USP, entre Outubro 2008 e Março de 2012. Foram selecionados os 30 últimos casos de sobreviventes (S) e 30 de não-sobreviventes (NS). Avaliou-se para cada grupo, os valores ALT, AST, de base excess (BE) e lactato sanguíneos em cinco momentos (pré-operatório imediato, no final da isquemia hipotérmica, 5 e 60 minutos após a revascularização arterial e no pós-operatório imediato, quando também foi calculado o MELD pós-operatório. RESULTADOS: Com relação às aminotransferases, houve um aumento máximo após 24 horas de pós-operatório em ambos os grupos S e NS. Houve aumento significativo dos níveis de BE e lactato sanguíneo significativamente maior no grupo NS, sobretudo nos tempos após 5 minutos de reperfusão arterial do enxerto, p<0,05. Não houve diferença significativa entre o MELD pré-operatório em ambos os grupos (p>0,05). O MELD pós-operatório foi maior no grupo NS do que no grupo S (p<0,05). CONCLUSÃO: A análise conjunta do MELD pós-operatório, do BE e do lactato sanguíneo pode ser usada como índice de gravidade da evolução pós-operatória de pacientes submetidos ao OLT.

PURPOSE: The objective of the present study was to evaluate the postoperative levels of classical or pure MELD and changes in lactate or base excess (BE) levels as possible predictive factors of the type of outcome of patients submitted to orthotopic liver trasplantation (OLT). METHODS: The study was conducted on 60 patients submitted to OLT at the University Hospital, Faculty of Medicine of Ribeirão Preto, USP, between October 2008 and March 2012. The 30 latest survivor (S) and non-survivor (NS) cases were selected. All liver transplants were performed using the piggy-back technique. ALT, AST, BE and blood lactate values were determined for each group at five time points (immediate preoperative period, end of hypothermal ischemia, 5 and 60 minutes after arterial revascularization and in the immediate postoperative period, when the postoperative MELD was also calculated. RESULTS: The aminotransferases reached a maximum increase 24 hours after surgery in both the S and NS groups. There was a significantly higher increase in BE and blood lactate in the NS group, especially after 5 minutes of afterial reperfusion of the graft, p<0.05. There was no significant difference in preoperative MELD between groups (p>0.05), while the postoperative MELD was higher in the NS than in the S group (p<0.05) CONCLUSION: Joint analysis of postoperative MELD, BE and blood lactate can be used as an index of severity of the postoperative course of patients submitted to liver transplantation.

OBJETIVO: Analisar parâmetros do pré, intra e pós-operatório imediato de pacientes submetidos ao transplante de fígado. MÉTODOS: Foram analisados 83 transplantes ortotópicos de fígado realizados consecutivamente no período janeiro de 2009 a julho de 2011. Os pacientes foram dividos em dois grupos: A, survivors (MELD entre 16 e 60), e B, non-survivors (MELD entre 14 e 40) sendo que 30,6℅ dos pacientes do grupo A eram CHILD C, 51℅ CHILD B e 18,4℅ CHILD A. No grupo B, 32,1℅ dos pacientes eram CHILD C, 42,9℅ CHILD B, e 25℅ CHILD A. Todos os transplantes ortotópicos de fígado foram feitos com a técnica de piggyback sem "shunt" porto cava. Foram analisados os valores de pressão arterial sistêmica e os níveis séricos de ALT e AST, no pré-operatório, 5, 60 e 1440 minutos após revascularização arterial do enxerto. Avaliaram-se os perfis séricos da ALT e AST durante sete dias de pós-operatorio. RESULTADOS: Verificou-se que em ambos os grupos, os níveis de pressão arterial sistêmica, os tempos de isquemia normotérmica, hipotérmica e de implante do enxerto foram estatisticamente semelhantes (p>0,05). Os níveis séricos (U/L) de ALT e AST nos tempos de 5, 60 e 1440 minutos após a revascularização arterial do enxerto também foram semelhantes nos grupos estudados. Os perfis séricos da ALT e AST foram semelhantes nos dois grupos estudados. CONCLUSÕES: Não se verificou diferença estatisticamente significante entre todos os parâmetros estudados, em ambos os grupos. Nas condições do presente estudo, não se verificou relação direta do intra-operatório com o tipo de evolução (outcome) dos pacientes nos dois grupos estudados.

PURPOSE: To analyze pre-, intra- and immediate postoperative parameters of patients submitted to liver transplantation. METHODS: Eighty-three consecutive orthotopic liver transplants performed from January 2009 to July 2011 were analyzed. The patients were divided into 2 groups: A, survivors (MELD between 9 and 60) and B, non-survivors (MELD between 14 and 40), with 30.6% of group A patients being CHILD C, 51℅ CHILD B and 18,4℅ CHILD A. In group B ,32.1℅ of the patients were CHILD C, 42,9℅ CHILD B, and 25℅ CHILD A. All orthotopic liver transplantations were performed using the piggyback technique without a portacaval shunt. Systemic arterial pressure and serum ALT and AST levels were determined preoperatively and 5, 60 and 1440 minutes after arterial graft revascularization. Serum ALT and AST profiles were evaluated for seven days after surgery. RESULTS: Systemic arterial blood pressure levels, time of hot and hypothermic ischemia and time of graft implant were statistically similar for the two groups (p>0.05). Serum levels (U/L) of ALT and AST at the 5, 60 and 1440 minute time points after arterial revascularization of the graft were also similar for the two groups studied, as also were the serum ALT and AST profiles. CONCLUSIONS: No statistically significant difference in any of the parameters studied was detected between the two groups. Under the conditions of the present study and on the basis of the parameters evaluated, no direct relation was detected between the intraoperative period and the type of patient outcome in the two groups studied.

OBJETIVO: Avaliar as vantagens e desvantagens da oclusão vascular parcial do fígado durante ressecções hepáticas parciais. MÉTODOS: Cento e quatorze pacientes foram submetidos a hepatectomia parcial(ressecção maior versus ressecção menor) com liver partial vascular exclusion (LPVE) sendo utilizada em 57 deles. A idade dos pacientes variou entre 35 e 73 anos e 57% deles eram mulheres. A função mitocondrial foi avaliada por método polarografico avaliada 30 minutos após a ressecção hepática no fígado remanescente, e o perfil das aminotransferase foi determinado antes da cirurgia e durante sete dias de pós-operatório. A EVPH variou de 30 a 60 minutos. Dados foram analisados estatisticamente pelo teste T Student (nível de significância de 5%). RESULTADOS: Nas ressecções hepáticas maiores e menores, a função mitocondrial do fígado remanescente foi semelhante dos dois grupos. O pico máximo de aminotransferases ocorreu as 24 horas de pós-operatório e o perfil enzimático de ALT e AST foi semelhante nos grupos estudados ( minor vs major hepatectomy.) CONCLUSÃO: A EVPH não induziu alterações mitocondriais no tecido hepático em qualquer tipo de cirurgia, e os níveis de aminotransferases foram similares para pacientes hepatectomizados com e sem LPVE.Assim a LPVE foi um procedimento seguro que não induziu alterações significativas típicos de isquemia e reperfusão no fígado remanescente.

PURPOSE: The aim of the present study was to assess the advantages and disadvantages of liver vascular partial exclusion (LVPE) (liver dysfunction due to ischemia) during liver resection in patients submitted to partial hepatectomy. METHODS: A total of 114 patients were submitted to partial hepatectomy (minor versus major resections) with LPVE being used in 57 of them but not in the remaining 57. Patient age ranged from 35 to 73 years and 57 % were women. Mitochondrial function was assessed 30 minutes after liver resection in the remnant liver and serum aminotransferases were determined before surgery and for seven days postoperatively. LPVE time ranged from 30 to 60 minutes. Data were analyzed statistically by the Student T test (5 % level of significance). RESULTS: Mitochondrial function was similar in the minor and major liver resections. The maximum postoperative aminotransferase peak was similar in the groups with and without LPVE. CONCLUSION: LPVE did not induce mitochondrial changes in hepatic tissue in either type of surgery, and aminotransferase levels were similar for patients with and without LPVE. Thus, the results show that LPVE is a safe procedure that does not induce the significant changes typical of ischemia and reperfusion in the liver remnant.

OBJETIVO: O objetivo desse estudo foi analisar as mundanças na quantidade de transfusão necessária com uso do Intraoperative red blood cell salvage (Cell saver), em pacientes submetidos a transplante ortotópico de fígado, doador cadáver. MÉTODOS: Foram avaliados dados de 41 pacientes submetidos a transplante de fígado. O sangramento foi calculado de acordo com débito do aspirador, compressas e captação do Cell saver. A reposição necessária foi avaliada de acordo com a quantidade de transfusão heteróloga e autóloga. Para análise dos dados os pacientes foram dividos em dois grupos: com e sem uso de Cell saver. RESULTADOS: A mediana de idade foi 50 anos e principal indicação de transplante foi cirrose hepática com 35 casos (85,3%). A mediana de sangramento durante o procedimento cirúrgico 8362 + 3994 ml (com cell saver) e 10824 + 7002 ml (sem cell saver) e a mediana de transfusão de concentrado de hemácias heterólogo, durante o período de internação hospitalar 9,6 + 8 unidades (com cell saver) compar 22,3 + 21 unidades (sem cell saver). CONCLUSÃO: Uso de Cell Saver tem um potential para reduzir a quantidade de transfusão heteróloga, dimuindo o risco de transmissão de doenças.

PURPOSE: The aim of this study was to analyse the changes in transfusion requirements, in patients submitted to orthotopic liver transpantation from cadaveric donors, with the use of intraoperative red blood cell salvage (Cell Saver). METHODS: Data from 41 transplants were analysed. Intraoperative blood loss was calculated from the cell salvage, suction and the swabs. The autologous and heterologous transfusions were recorded The red blood salvage was performed using the Cell Saver 5 System (Haemonetics).. For analysis the patients were divided in two groups: one that used the Cell Saver and another that didn't. RESULTS: The median age of the patients was 50 years and the main indication for liver transplantation was cirrhosis (35 cases - 85.3%). The median blood loss was 8362 + 3994 ml (with the Cell Saver) and 10824 + 7002 ml (without the Cell Saver) and the median transfusion of heterologous packed red blood cells was 9,6 + 8 units (with the Cell Saver) compared to 22,3 + 21 units (without the Cell Saver). CONCLUSIONS: The Cells Saver has the potential to reduce the need for heterologous blood transfusion reducing the risks of transmissible diseases.

A introdução da Nutrição Parenteral Total (NPT) despertou uma nova esperança para o tratamento da falência intestina (FI) associada a Síndrome do Intestino Curto (SIC). No entanto, junto com a NPT e o aumento da sobrevida destes pacientes, novos problemas e perguntas emergiram, assim como novas terapêuticas. Tendo em vista esta realidade emergente, o intuito deste artigo é realizar uma revisão dos conceitos atuais e dos tratamentos disponíveis para pacientes com doença hepática associada a FI. A NPT apesar de proporcionar aumento da sobrevida nos pacientes com falência intestinal é fonte potencial de complicações, como: septicemia, hiperglicemia, trombose venosa e doença hepática. Diversas são as hipóteses aventadas para explicar a doença hepática associada a falência intestinal, no entanto, o único tratamento definitivo, com potencial para reverter à doença hepática não cirrótica, é o transplante de intestino delgado. Apesar das indicações do transplante de intestino não estarem totalmente definidas na literatura, a tendência é indicá-lo precocemente em pacientes de alto risco, preservando a integridade hepática e prevenindo a eventual necessidade de transplante de fígado e intestino combinados.

The introduction of the Total Parenteral Nutrition (TPN) has given rise to a new hope in the treatment of intestinal failure (LF) associated with the Short Bowel Syndrome (SBS). However, together with the TPN and the increase of survival of these patients, new problems and questions have emerged, as well as new therapeutical procedures. Taking into consideration this emerging reality, this paper has the purpose to undertake a review of current concepts and available treatments for patients with IF associated-liver disease. Although TPN provides an increase of survival of patients with intestinal failure, it is a potential source of complication such as: septicemia, hyperglycemia, venous thrombosis and liver disease. There are several hypothesis conceived to explain the liver disease associated to intestinal failure, however the only definite treatment as a potential to reverse the non-cirrhotic liver disease is the small intestine transplantation. Despite indications for intestine transplantation are not entirely defined in literature, the trend is its early indication in high-risk patients, preserving the liver integrity and preventing the eventual need of both liver and intestine transplantations altogether.

O sucesso dos transplantes de fígado certamente seria comprometido se a avaliação pré-operatória dos pacientes não fosse realizada de forma adequada. Isto se justifica devido ao reconhecimento de que o sucesso da cirurgia depende, em princípio, do diagnóstico da doença de base, da determinação de sua extensão e do grau de repercussão sistêmica. No final das décadas de setenta a noventa os progressos da hepatologia na identificação das hepatites virais e no manejo da ascite e da síndrome hepatorrenal melhoraram sobremaneira a expectativa de vida do doente portador de doença hepática crônica. Mas, sem dúvida o transplante ortotópico do fígado (TOF) foi o espetacular avanço da hepatologia moderna. Atualmente o transplante é um tratamento eficaz das hepatopatias crônicas, e o índice de sobrevivência global aos 3 anos é ao redor de 80%. É, portanto, uma alternativa de tratamento indicada nos casos terminais, onde a mortalidade com tratamentos conservadores pode atingir até 70% ao final de 12 meses. Neste artigo, os autores comentam aspectos do TOF, relacionados à indicação e a sobrevida.

The success of liver transplantation would be certainly compromised if the pre-operative evaluation was not adequately performed. The success of the liver transplantation depends on the diagnosis of the underlying hepatic disease, the determination of its extension and the degree of systemic repercussion. In the last 30 years, the progress in hepatology, the identification of viral hepatitis and the better management of ascitis and hepatorenal syndrome have increased the life expectancy of patients with chronic liver failure. Undoubtedly, orthotopic liver transplantation represents a great advance in modern hepatology. Nowadays, liver transplantation represents a valid therapeutic option for chronic liver diseases with (and presents) a mean survival rate of about 80% in 3 years. Thus, it is an indicated treatment in situations where the conservative treatment (would) could lead to a (incur) mortality rate as high as 70% in one year. In this article the authors comment (on) various aspects of Orthotopic Liver Transplantation related to indications and survival rates.