SUMMARY OBJECTIVE: To analyze abdominal drain on the first postoperative day and evaluate its predictive nature for the diagnosis of Pancreatic Fistula exclusion, seeking to establish a cutoff point from which lower values demonstrate safety in excluding the possibility of this complication. METHODS: From August 2017 to June 2020, data from 48 patients undergoing pancreatic resection were collected and analyzed from a prospective cohort. The patients were divided into two groups, one group consisting of patients who did not develop PF (Group A), and the other composed of patients who developed PF (Group B). The receiver operation characteristic curve was constructed, and cutoff points were evaluated by calculating sensitivity and specificity. RESULTS: Group A brought 30 patients together (62.5%) and Group B brought 18 patients together (37.5%). The 444 U/L value was the most satisfactory cutoff point for the receiver operation characteristic curve (CI 0.690–0.941), with a sensitivity of 94.4% and a specificity of 60%, thus being able to select 18 of 30 patients who did not succumb to PF. CONCLUSIONS: Abdominal drain on the first postoperative day can be used as a predictive factor in the diagnosis of PF exclusion (CI 0.690–0.941), with the value of 444 U/L being the best performance cutoff point.

RESUMO Objetivo Avaliar os fatores epidemiológicos e funcionais pós operatórios dos pacientes operados por duplicação de polegar. Métodos Essa é uma série retrospectiva de casos em que foram avaliados 20 pacientes (23 polegares), operados entre janeiro de 2012 e dezembro de 2016, no Hospital Menino Jesus/ SP. Foram estudados fatores epidemiológicos e clínicos, dentre os quais o score funcional de Tada. Resultados Das 34 crianças operadas, apenas 20 compareceram para avaliação funcional. Dos casos operados, 60% eram Wassel tipo 4. Todos os casos avaliados obtiveram resultado funcional bom (Tada maior ou igual a 5), com score médio de 6,65. A técnica cirúrgica mais utilizada foi a ressecção do polegar radial com reconstrução do ligamento colateral radial, presente em 47,8% das vezes. Conclusão A correção cirúrgica da duplicação de polegar cursa com bons resultados, desde que se atente para as anormalidades osteoligamentares e tendíneas. Nível de Evidência IV; Série de casos.

ABSTRACT Objective To evaluate postoperative epidemiological and functional factors in patients operated to treat duplicate thumb. Methods This retrospective case series evaluated 20 patients (23 thumbs) treated from January 2012 to December 2016 at our service. Epidemiological and clinical factors were studied, including Tada score. Results Of the 34 children who were treated surgically, only 20 appeared for the functional evaluation and were included in the study. Of the operated cases, 60% were Wassel type 4. All evaluated cases had good functional results (Tada score ≥5, mean score: 6.65). The most frequently used surgical technique was resection of the radial thumb with reconstruction of the radial collateral ligament (47.8% of cases). Conclusion Surgical correction of duplicated thumb yields good results, as long as attention is paid to abnormalities in bones, ligaments, and tendons. Level of Evidence IV; Case series.

Abstract Purpose: To evaluate the behavior of arterial circulation and testicular volume in patients submitted to conventional inguinal hernia repair without the use of a synthetic prosthesis to reinforce the posterior wall. Methods: A prospective observational clinical trial was performed on 26 male patients with unilateral inguinal hernia types I and II by the Nyhus classification, who underwent surgical correction using the modified Bassini technique. Bilateral Doppler ultrasonography was performed preoperatively, at the third and at the sixth postoperative month. The studied variables were: systolic peak velocity (SPV), diastolic peak velocity (DPV), resistance index (RI), pulsatility index (PI) and testicular volume. Results: There were no statistically significant changes over time in the variables studied on the operated side: SPV (p = 0.916), DPV (p = 0.304), RI (p = 0.879), PI (p = 0.475), and testicular volume (p = 0.100). The variables on the control side also did not change statistically until the sixth postoperative month: SPV (p = 0.784), DPV (p = 0.446), RI (p = 0.672), PI (p = 0.607), and testicular volume (p = 0.413). Conclusion: Surgical correction of the inguinal hernia without the use of a prosthesis does not cause alterations in vascularization and testicular volume in the first six months postoperatively.

Abstract Purpose: To analyze the use of this sponge in pediatric patients undergoing split-liver transplantation. Methods: Retrospective study, including 35 pediatric patients undergoing split-liver transplantation, divided into two groups according to the use of the sponge: 18 patients in Group A (no sponge) and 17 in Group B (with sponge). Results: The characteristics of recipients and donors were similar. We observed greater number of reoperation due to bleeding in the wound area in Group A (10 patients - 55.5%) than in Group B (3 patients - 17.6%); p = 0.035. The median volume of red blood cells transfused in Group A was significantly higher (73.4 ± 102.38 mL/kg) than that in Group B (35.1 ± 41.67 mL/kg); p = 0.048. Regarding bile leak there was no statistical difference. Conclusion: The use of the human fibrinogen and thrombin sponge, required lower volume of red blood cell transfusion and presented lower reoperation rates due to bleeding in the wound area.

ABSTRACT PURPOSE: To describe an animal model for acute liver failure by intraperitoneal d-galactosamine injections in rats and to define when is the best time to intervene through King's College and Clichy´s criteria evaluation. METHODS: Sixty-one Wistar female rats were distributed into three groups: group 1 (11 rats received 1.4 g/kg of d-galactosamine intraperitoneally and were observed until they died); group 2 (44 rats received a dose of 1.4 g/kg of d-galactosamine and blood and histological samples were collected for analysis at 12 , 24, 48 , 72 and 120 hours after the injection); and the control group as well (6 rats) . RESULTS: Twelve hours after applying d-galactosamine, AST/ALT, bilirubin, factor V, PT and INR were already altered. The peak was reached at 48 hours. INR > 6.5 was found 12 hours after the injection and factor V < 30% after 24 hours. All the laboratory variables presented statistical differences, except urea (p = 0.758). There were statistical differences among all the histological variables analyzed. CONCLUSION: King's College and Clichy´s criteria were fulfilled 12 hours after the d-galactosamine injection and this time may represent the best time to intervene in this acute liver failure animal model.

RESUMO Racional: A neoplasia sólida pseudopapilar é tumor raro de pâncreas de tratamento cirúrgico. No entanto, sua causa ainda gera discussões. Objetivo: Analisar os dados clínicos, do diagnóstico e do tratamento da dessa neoplasia. Métodos: Estudo retrospectivo com dados médicos de pacientes tratados entre janeiro de 1997 a julho de 2015. Resultados: Foram identificados 17 casos. A maioria era de mulheres (94,11%) e a média de idade foi de 32,88 anos. A principal queixa era massa abdominal (47,05%). A localização mais frequente era no corpo/cauda do pâncreas (72,22%) e a operação mais realizada foi a pancreatectomia corpocaudal com esplenectomia (64,70%). Nenhum caso apresentou metástase no momento do diagnóstico. Operação conservadora de parênquima pancreático foi realizada em apenas três casos. A taxa de complicações no pós-operatório foi de 35,29% e a principal complicação foi fístula pancreática (29,41%). Nenhum paciente realizou adjuvância no seguimento. Conclusões: A mais comum apresentação clínica da neoplasia sólida pseudopapilar é de massa abdominal. Ela é de tratamento cirúrgico e pancreatectomia corpocaudal com esplenectomia é o procedimento mais realizado para seu tratamento.

ABSTRACT Background: The solid pseudopapillary neoplasm is a rare tumor of the pancreas. However, it´s etiology still maintain discussions. Aim: To analyze it´s clinical data, diagnosis and treatment. Methods: A retrospective study of medical records of all patients treated from January 1997 until July 2015. Results: Were identified 17 cases. Most patients were women (94.11%) and the average age was 32.88 years. The main complaint was abdominal mass (47.05%). The most frequent location was in the body/tail of the pancreas (72.22%) and the most frequently performed surgery was distal pancreatectomy with splenectomy (64.70%). No patient had metastases at diagnosis. Conservative surgery for pancreatic parenchyma was performed in only three cases. The rate of complications in the postoperative period was 35.29% and the main complication was pancreatic fistula (29.41%). No patient underwent adjuvant treatment. Conclusions: The treatment is surgical and the most common clinical presentation is abdominal mass. Distal pancreatectomy with splenectomy was the most frequently performed surgery for its treatment.

Objetivo Determinar a sobrevida global dos pacientes com câncer pancreático avançado e avaliar fatores com impacto prognóstico em um centro de câncer privado.Métodos Foram coletados retrospectivamente os dados do Registro de Câncer do Hospital Israelita Albert Einstein. Os pacientes incluídos apresentaram câncer metastático ao diagnóstico ou em estádio mais precoce com recorrência subsequente. Os casos de tumores neuroendócrinos foram excluídos.Resultados Foram avaliados 65 pacientes, incluindo 63 com adenocarcinoma. A sobrevida global mediana dos pacientes em todos os estádios foi 20,7 meses (IC95%: 15,6-25,7), enquanto a sobrevida global de doença metastática foi de 13,3 meses. Entre os 33 casos com câncer em estádio IV, não houve evidência de associação estatisticamente significativa entre a sobrevida mediana e CA19-9 ao diagnóstico (p=0,212), localização do tumor (p=0,482), primeiro tratamento realizado (p=0,337), invasão vasculo-linfática (p=0,286) e idade (p=0,152). No entanto, o número de linhas de quimioterapia foi significativamente associado com a sobrevida (log-rankp=0,013), com uma sobrevida mediana estimada de 10,2 meses para os pacientes que receberam até duas linhas de tratamento e de 23,5 meses para os que receberam mais de duas linhas.Conclusão A sobrevida dos pacientes tratados foi maior do que o relatado na literatura. O único fator estatisticamente significativo relacionado à maior sobrevida foi maior número de linhas de quimioterapia recebidas. Acreditamos que o nível socioeconômico dos pacientes pesquisados neste estudo, assim como seu maior acesso a opções de tratamento, pode ter influenciado em sua sobrevivência global.

Objective To determine the overall survival of patients with advanced pancreatic cancer and evaluate factors that impact prognosis in a private cancer center.Methods Data from the Hospital Cancer Registry at Hospital Israelita Albert Einstein were retrospectively collected. The patients enrolled had metastatic cancer at diagnosis or earlier staging and subsequent recurrence. Cases of neuroendocrine tumors were excluded.Results A total of 65 patients were evaluated, including 63 with adenocarcinoma. The median overall survival for patients in all stages was 20.7 months (95%CI: 15.6-25.7), while the overall survival of metastatic disease was 13.3 months. Among the 33 cases with stage IV cancer, there was no evidence of a statistically significant association between median survival and CA19-9 dosage (p=0.212), tumor location (p=0.482), first treatment performed (p=0.337), lymphovascular invasion (p=0.286), and age (p=0.152). However, the number of lines of chemotherapy was significantly associated with survival (log-rank p=0.013), with an estimated median survival of 10.2 months for patients who received up to two lines of treatment and 23.5 months for those receiving more than two lines of chemotherapy.Conclusion The survival of patients treated was longer than that reported in the literature. The only statistically significant factor related to increased survival was higher number of lines of chemotherapy received. We believe that the higher socioeconomic status of patients surveyed in this study, as well as their greater access to treatment options, may have influenced their overall survival.

PURPOSE:To evaluate the protective effects of chilling the bile ducts with cold (5°C) 5% glucose solution (GS) during radiofrequency (RF) administration.METHODS:Twenty male pigs (3 mos. old; 25-30 kg) were subjected to RF delivery with chilling (experimental group, N=10) or without chilling (control group, N=10). Half of the animals in each group were euthanized immediately after the operation, and half were euthanized one week later. The following histological variables in relation to the bile ducts were evaluated by a pathologist (blind examiner): degenerative changes to the epithelium; epithelial necrosis; ulceration, regenerative changes of the epithelium; polymorphonuclear neutrophil infiltration; and thermal effects.RESULTS: The experimental group (88 bile ducts examined) showed reduced thermal damage relative to the control group (86 bile ducts examined) as demonstrated by significant differences in the following histopathological parameters: epithelial detachment of biliary epithelium (84.1% vs. 59.3%; p<0.006); elongation/palisade arrangement of nuclei (65.1% vs. 87.5%; p<0.001); pseudo-goblet cells (32.9% vs. 56.8%; p<0.001).CONCLUSION: Infusion of 5% glucose solution (5°C) has a protective effect on bile ducts subjected to heat (95-110°C, 12 min) from radiofrequency thermal ablation device.

RACIONAL: O carcinoma de vesícula biliar apresenta mau prognóstico. O tratamento de escolha é a ressecção cirúrgica que está associado à alta morbimortalidade. O melhor conhecimento de fatores prognósticos pode resultar em melhor seleção dos doentes para o tratamento cirúrgico e multimodal. OBJETIVOS: Avaliar a imunoexpressão tecidual das proteínas P53, E-caderina, Cox-2 e EGFR e correlacionar com a sobrevida do adenocarcinoma de vesícula biliar ressecado. MÉTODO: Os dados clínicos, laboratoriais, cirúrgicos e anatomopatológicos de uma série de doentes operados por adenocarcinoma de vesicula biliar foram coletados. A casuística total foi de 42 doentes. A mediana de idade foi de 72 anos (35-87). Foram sete homens e 35 mulheres. A distribuição da lesão de acordo com TNM foi a seguinte: T1 (n=2), T2 (n=5), T3 (n=31), T4 (n=4). Vinte três doentes realizaram ressecção radical (R0) enquanto 19 operação paliativa (R1-R2). Um bloco de tissue microarray foi confeccionado com tecido neoplásico de cada doente. para avaliação da imunoexpressão das proteínas P53, E-Caderina, COX-2 e EGFR. Esses achados foram correlacionados com prognóstico final dos doentes. RESULTADOS: A sobrevida estimada em cinco anos foi de 28%. A mediana de sobrevida global foi de oito meses. Apenas a imunoexpressão da proteína EGFR foi considerada variável independente no prognóstico dos doentes. CONCLUSÃO: Pior prognóstico teve relação com a imunoexpressão aumentada da proteína EGFR no tecido tumoral.

BACKGROUND: Gallbladder carcinoma presents a dismal prognosis. Choice treatment is surgical resection that is associated a high levels of both morbidity and mortality. Best knowledgement of prognostic factors may result a better selection of patients either for surgical or multimodal treatment. AIM: To evaluate tecidual immunoexpression of P53, E-cadherin, Cox-2, and EGFR proteins and to correlate these findings with resected gallbladder adenocarcinoma survival. METHODS: Clinical, laboratorial, surgical, and anatomopathological reports of a series of gallbladder adenocarcinoma patients were collected by individualized questionary. Total sample was 42 patients. Median of age was 72 years (35-87). There were seven men and 35 women. Lesion distribuition in according TNM state was the following: T1 (n=2), T2 (n=5), T3 (n=31), T4 (n=4). Twenty-three patients underwent radical resection (R0), while 19 palliative surgery (R1-R2). A block of tissue microarray with neoplasic tissue of each patient was confected. It was performed evaluation of P53, E-Caderine, COX-2, and EGFR proteins imunoexpression. These findings were correlated with overall survival. RESULTS: Five-year survival was 28%. The median of global survival was eight months. Only immunoexpression of EGFR protein was considered independent variable at multivariated analysis. CONCLUSION: Final prognosis was influenced by over-expression of EGFR protein in tumoral tissue.

ContextoA ocorrência de disfagia grave após fundoplicatura total laparoscópica representa atualmente um importante fator associado à perda da qualidade de vida em pacientes submetidos a esta modalidade de tratamento para doença do refluxo gastroesofágico.ObjetivosComparar a incidência e avaliar as possíveis causas da disfagia grave pós-operatória em pacientes submetidos à fundoplicatura total laparoscópica (FTL) sem liberação dos vasos gástricos curtos utilizando apenas a parede gástrica anterior (FTL à Rossetti) ou as paredes gástricas anterior e posterior (FTL à Nissen).MétodosAnálise de dados de 289 pacientes submetidos à FTL sem liberação dos vasos gástricos curtos no período de janeiro de 2004 a janeiro de 2012, com acompanhamento mínimo de 6 meses. Os pacientes foram divididos em Grupo 1 (FTL à Rossetti – n = 160) e Grupo 2 (FTL à Nissen – n = 129).ResultadosA incidência global de disfagia grave pós-operatória foi de 3,11%, sendo 4,37% no grupo 1 e 1,55% no grupo 2 (P = 0.169). A necessidade de tratamento cirúrgico da disfagia foi de 2,5% no grupo 1 e 0,78% no grupo 2 (P = 0.264). Em todos os pacientes reoperados após FTL à Rossetti foram observadas distorções das válvulas que podem responder pela ocorrência de disfagia, ao passo que no paciente submetido à reoperação após FTL à Nissen nenhuma alteração foi observada.ConclusõesA incidência global de disfagia grave pós-operatória não apresentou diferença entre as duas técnicas relatadas. A FTL à Rossetti foi associada a distorções estruturais das válvulas que podem justificar a disfagia, fato não observado após FTL à Nissen.

ContextThe occurrence of severe dysphagia after laparoscopic total fundoplication is currently an important factor associated with loss of quality of life in patients undergoing this modality of treatment for gastroesophageal reflux disease.ObjectivesCompare the incidence and evaluate the causes of severe postoperative dysphagia in patients undergoing laparoscopic total fundoplication (LTF) without short gastric vessels division, using the anterior gastric wall (Rossetti LTF) or anterior and posterior gastric walls (Nissen LTF).MethodsAnalysis of the data of 289 patients submitted to LTF without short gastric vessels division from January 2004 to January 2012, with a minimum follow-up of 6 months. Patients were divided in Group 1 (Rossetti LTF – n = 160) and Group 2 (Nissen LTF – n = 129).ResultsThe overall incidence of severe postoperative dysphagia was 3.11% (4.37% in group 1 and 1.55% in group 2; P = 0.169). The need for surgical treatment of dysphagia was 2.5% in group 1 and 0.78% in group 2 (= 0.264). Distortions of the fundoplication were identified as possible causes of the dysphagia in all patients taken to redo fundoplication after Rossetti LTF. No wrap distortion was seen in redo fundoplication after Nissen LTF.ConclusionsThe overall incidence of severe postoperative dysphagia did not differ on the reported techniques. Only Rossetti LTF was associated with structural distortion of the fundoplication that could justify the dysphagia.

PURPOSE: To compare the efficacy of different types of solutions (Belzer or Euro-Collins) for the preservation of rat pancreas during cold ischemia.METHODS: Thirty Wistar rats were divided into three groups according to the perfusion or storage solution: Group E (perfusion and storage in Euro-Collins solution); Group B (perfusion and storage in Belzer solution) and Group BE (Perfusion in Belzer solution and storage in Euro-Collins solution). After perfusion, the pancreas was excised and stored at 4˚C for 18 hours. Amylase was measured at 6, 12 and 18h, and histological analysis of the pancreas was performed after 18h of cold storage.RESULTS: Amylase was elevated and comparable in Groups E and BE after 12 and 18 hours of ischemia (p<0.05). In the exocrine pancreas, histological differences in the amount of necrosis (p=0.049), lymphocytic infiltrate (p<0.001) and neutrophilic infiltrate (p=0.004) were observed, with more favorable features present in Group B. In the endocrine pancreas, Group B showed less edema (p<0.001), but other parameters were similar among all groups.CONCLUSION: The Euro-Collins solution is inferior to the Belzer solution for the preservation of rat pancreas during cold ischemia.

PURPOSE: To evaluate of postoperative adhesion prevention and inflammatory response to polypropylene mesh, coated with reabsorbable hydrogel of polyethylene glycol (Coseal®) in contact with small bowel in an experimental model in rabbits. METHODS: Twenty female rabbits underwent laparotomy to implant two polypropylene meshes, 2x1cm, in the right and left flanks. The right mesh was protected with Coseal® spray (Group 1) and the left mesh received no treatment after implantation (Group 2). Thirty days after implantation, the rabbits underwent laparoscopy for adhesion analysis; the prosthesis were removed en bloc with the adjacent tissue for microscopic analysis of inflammation. Statistical analysis used the Mann-Whitney test. RESULTS: There was adhesion formation in five meshes (36%) from Group 1 and in 14 meshes (100%) from Group 2, with statistical significance (p<0.01). There were no differences in the inflammatory response, fibrosis, foreign body reaction, presence of collagen and type of inflammatory cells between the two groups. CONCLUSION: Polypropylene mesh coated with Coseal® showed a significantly lower rate of adhesion formation when compared with uncoated meshes, without interfering with inflammatory response.

PURPOSE: To investigate if the ethyl-pyruvate solution could reduce mortality in AP and/or diminish the acute lung injury. METHODS: Forty male rats, weighing between 270 to 330 grams were operated. An experimental model of severe AP by injection of 0.1ml/100g of 2.5% sodium taurocholate into the bilio-pancreatic duct was utilized. The rats were divided into two groups of ten animals each: CT - control (treatment with 50ml/kg of Ringer's solution, intraperitoneal) and EP (treatment with 50ml/kg of Ringer ethyl- pyruvate solution, intra-peritoneal), three hours following AP induction. After six hours, a new infusion of the treatment solution was performed in each group. Two hours later, the animals were killed and the pulmonary parenchyma was resected for biomolecular analysis, consisting of: interleukin, myeloperoxidase, MDA, nitric oxide, metalloproteinases and heat shock protein. In the second part of the experiment, another, 20 rats were randomly divided into EP and CT groups, in order to evaluate a survival comparison between the two groups. RESULTS: There were no significant differences in IL-1B,IL-10, MMP-9, HSP70, nitric oxide, MPO, MDA (lipidic peroxidation) concerning both groups. The levels of IL-6 were significantly diminished in the EP group. Furthermore, the MMP-2 levels were also reduced in the EP group (p<0.05). The animals from the EP treatment groups had improved survival, when compared to control group (p<0.05). CONCLUSION: The ethyl-pyruvate diminishes acute lung injury inflammatory response in acute pancreatitis and ameliorates survival when compared to control group, in the experimental model of necrotizing acute pancreatitis.

OBJETIVO: Avaliar os resultados do Protocolo de Atendimento de pacientes com diagnóstico de pancreatite aguda grave. MÉTODOS: Foram analisados, consecutivamente, a partir de janeiro de 2002, idade, sexo, etiologia, tempo de internação, tipo de tratamento e mortalidade de 37 pacientes portadores de pancreatite aguda grave. RESULTADOS: A idade dos pacientes variou de 20 a 88 anos (média de 50 anos); 27% foram do sexo feminino e 73% do masculino. O tempo médio global de internação foi 47 dias. Treze pacientes foram tratados cirurgicamente; a média de operações realizadas foi duas por paciente. Ocorreram seis óbitos dentre os pacientes submetidos ao tratamento cirúrgico (46%) e dois óbitos no grupo submetido somente ao tratamento clínico (8,3%). A mortalidade global foi 21% CONCLUSÃO: Após a modificação na forma de abordagem dos pacientes com pancreatite aguda grave, houve diminuição da mortalidade e uma tendência para a conduta expectante.

OBJECTIVE: To evaluate the results of the Protocol for treatment of patients with severe acute pancreatitis. METHODS: We consecutively analyzed age, gender, etiology, length of hospital stay, type of treatment and mortality of 37 patients with severe acute pancreatitis from January 2002. RESULTS: The patients' ages ranged from 20 to 88 years (average 50 years), 27% were female and 73% male. Mean overall hospital stay was 47 days. Thirteen patients were treated surgically, the average operations per patient was two. There were six deaths among patients undergoing surgical treatment (46%) and two deaths in the group submitted to medical treatment alone (8.3%). The overall mortality was 21%. CONCLUSION: After modification in the form of management of patients with severe acute pancreatitis, there was a decrease in mortality and a trend for conservative management.