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ABSTRACT BACKGROUND: Hepatosplenic schistosomiasis is an endemic disease prevalent in tropical countries and is associated with a high incidence of portal vein thrombosis. Inflammatory changes caused by both parasitic infection and portal thrombosis can lead to the development of chronic liver disease with potential carcinogenesis. AIMS: To assess the incidence of portal vein thrombosis and hepatocellular carcinoma in patients with schistosomiasis during long-term follow-up. METHODS: A retrospective study was conducted involving patients with schistosomiasis followed up at our institution between 1990 and 2021. RESULTS: A total of 126 patients with schistosomiasis were evaluated in the study. The mean follow-up time was 16 years (range 5–31). Of the total, 73 (57.9%) patients presented portal vein thrombosis during follow-up. Six (8.1%) of them were diagnosed with hepatocellular carcinoma, all with portal vein thrombosis diagnosed more than ten years before. CONCLUSIONS: The incidence of hepatocellular carcinoma in patients with schistosomiasis and chronic portal vein thrombosis highlights the importance of a systematic long-term follow-up in this group of patients.

RESUMO RACIONAL: A esquistossomose hepatoesplênica é uma doença endêmica prevalente em países tropicais e está associada a uma alta incidência de trombose da veia porta. Alterações inflamatórias causadas tanto pela infecção parasitária quanto pela trombose portal podem levar ao desenvolvimento de doença hepática crônica com potencial carcinogênico. OBJETIVOS: Avaliar a incidência de trombose da veia porta e carcinoma hepatocelular em pacientes com esquistossomose durante um seguimento de longo prazo. MÉTODOS: Foi realizado estudo retrospectivo envolvendo pacientes com esquistossomose acompanhados em nossa instituição entre 1990 e 2021. RESULTADOS: Um total de 126 pacientes com esquistossomose foram avaliados no estudo. O tempo médio de acompanhamento foi de 16 anos (variando de 5 a 31). Do total, 73 (57,9%) pacientes apresentaram trombose da veia porta durante o seguimento e seis (8,1%) deles foram diagnosticados com carcinoma hepatocelular, todos com trombose da veia porta diagnosticada há mais de 10 anos. CONCLUSÕES: A incidência de carcinoma hepatocelular em pacientes com esquistossomose e trombose da veia porta crônica destaca a importância de um acompanhamento sistemático de longo prazo nesse grupo de pacientes.

https://doi.org/10.1590/0102-672020230045e1763

What factors influence the quality of local governments' digital transparency? Evidence from the Brazilian case
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Herman, Fellipe

; Marques, Francisco Paulo Jamil

; Miola, Edna

Opinião Pública

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sep 2022, Volume 28 N. 3 Pages 857 - 884

This article investigates the factors associated with the quality of transparency of the websites of Brazilian local governments. We also question the extent to which external control institutions have pressured municipal governments to improve their online transparency. Through multiple regression models, we discuss whether and how socio-demographic, political, and economic variables are relevant to explain the differences in e-transparency in 5,563 cities. The results show that, despite an institutionalization process of public transparency led by federal regulatory evolution, experiences at the local level remain heterogeneous. Population size, GDP per capita, education levels, and voter turnout are statistically important to explain the quality of e-transparency experiences. The main conclusion is that external regulators play a crucial role in shaping digital transparency due to the possibility of imposing legal penalties. Effective use of digital media to foster democratic practices involves pressure from external monitoring agencies willing to challenge a bureaucratic culture resistant to openness.

Résumé L'article étudie les facteurs associés à la qualité de la transparence sur les sites Web des gouvernements locaux au Brésil. Nous nous demandons également dans quelle mesure les institutions de contrôle externes ont fait pression sur les municipalités pour améliorer la transparence en ligne. Grâce à des modèles de régression multiple, nous discutons si et comment les variables sociodémographiques, politiques et économiques sont pertinentes pour expliquer les différences de transparence électronique dans 5 563 villes. Malgré un processus d'institutionnalisation de la transparence publique conduit par l'évolution de la réglementation fédérale, les résultats montrent que les expériences au niveau local restent hétérogènes. La taille de la population, le PIB par habitant, le niveau d'éducation et la participation électorale sont statistiquement importants pour expliquer la qualité des expériences de transparence électronique. La principale conclusion est que les régulateurs externes jouent un rôle crucial dans l'élaboration de la transparence numérique en raison de la possibilité d'imposer des sanctions légales. Une utilisation efficace des médias numériques pour favoriser les pratiques démocratiques implique alors la pression d'agences de contrôle externes prêtes à remettre en question une culture bureaucratique résistante à l'ouverture.

Resumen El artículo investiga los factores asociados con la calidad de la transparencia en los sitios web de los gobiernos locales en Brasil. También cuestionamos hasta qué punto las instituciones de control externo han presionado a los municipios para mejorar la transparencia en línea. A través de modelos de regresión múltiple, discutimos si y de qué manera las variables sociodemográficas, políticas y económicas son relevantes para explicar las diferencias en la transparencia electrónica en 5.563 ciudades. A pesar de un proceso de institucionalización de la transparencia pública liderado por la evolución regulatoria federal, los resultados muestran que las experiencias a nivel local siguen siendo heterogéneas. El tamaño de la población, el PIB per cápita, el nivel de educación y la participación electoral son estadísticamente importantes para explicar la calidad de las experiencias de transparencia electrónica. La principal conclusión es que los reguladores externos juegan un papel crucial en la configuración de la transparencia digital debido a la posibilidad de imponer sanciones legales. Un uso eficaz de los medios digitales para fomentar prácticas democráticas implica entonces la presión de agencias de monitoreo externas dispuestas a desafiar una cultura burocrática resistente a la apertura.

Resumo O artigo investiga que fatores estão associados à qualidade da transparência em sites de governos locais no Brasil. Também questiona em que medida instituições de controle externo têm pressionado os municípios a melhorarem os recursos de transparência online. Por meio de modelos de regressão múltipla, discute de que modo variáveis sociodemográficas, políticas e econômicas são relevantes para explicar as diferenças na transparência digital em 5.563 cidades. Apesar de haver um processo de institucionalização da transparência pública liderado pela evolução da regulamentação federal, os resultados mostram que as experiências em nível local permanecem heterogêneas. Tamanho da população, PIB per capita, nível de educação e a participação eleitoral são estatisticamente importantes para explicar a qualidade das experiências de transparência digital. Conclui-se que agentes reguladores externos desempenham papel crucial na qualidade da transparência digital devido à possibilidade de impor penalidades legais. Uma utilização eficaz dos media digitais para promover práticas democráticas envolve a pressão de agências externas de monitoramento dispostas a desafiar uma cultura burocrática resistente à abertura.

https://doi.org/10.1590/1807-01912022283857

COMBINED “HANGING LIVER MANEUVER” AND “INTRAHEPATIC EXTRA-GLISSONIAN APPROACH” FOR ANATOMICAL RIGHT HEPATECTOMY: TECHNIQUE STANDARDIZATION (VIDEO)
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MAKDISSI, Fabio Ferrari

; FONSECA, Gilton Marques

; KRUGER, Jaime Arthur Pirola

; JEISMANN, Vagner Birk

; COELHO, Fabricio Ferreira

; HERMAN, Paulo

Arquivos de Gastroenterologia

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jun 2022, Volume 59 N. 2 Pages 319 - 320

Abstract: En | Text: En | PDF: En

https://doi.org/10.1590/s0004-2803.202202000-57

Two decades of liver resection with a multidisciplinary approach in a single institution: What has changed? Analysis of 1409 cases
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Herman, Paulo

; Fonseca, Gilton Marques

; Coelho, Fabricio Ferreira

; Kruger, Jaime Arthur Pirola

; Makdissi, Fabio Ferrari

; Jeismann, Vagner Birk

; Carrilho, Flair José

; D’Albuquerque, Luiz Augusto Carneiro

; Nahas, Sergio Carlos

Clinics

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2022, Volume 77 elocation 100088

Abstract: En | Text: En | PDF: En

Abstract Objectives: To evaluate results of patients undergoing liver resection in a single center over the past two decades with a particular look at Colorectal Liver Metastasis (CRLM) and Hepatocellular Carcinoma (HCC). Method: Patients were divided into two eras, from 2000 to 2010 (Era 1) and 2011 to 2020 (Era 2). The most frequent diagnosis was CRLM and HCC, with 738 (52.4%) and 227 (16.1%) cases respectively. An evaluation of all liver resection cases and a subgroup analysis of both CRLM and HCC were performed. Preoperative and per operative variables and long-term outcomes were evaluated. Results: 1409 liver resections were performed. In Era 2 the authors observed higher BMI, more: minimally invasive surgeries, Pringle maneuvers, and minor liver resections; and less transfusion, less ICU necessity, and shorter length of hospital stay. Severe complications were observed in 14.7% of patients, and 90-day mortality was 4.2%. Morbidity and mortality between eras were not different. From 738 CRLM resections, in Era 2 there were significantly more patients submitted to neoadjuvant chemotherapy, bilateral metastases, and smaller sizes with significantly less transfusion, the necessity of ICU, and shorter length of hospital stay. More pedicle clamping, minimally invasive surgeries, and minor resections were also observed. From 227 HCC resections, in Era 2 significantly more minimally invasive surgeries, fewer transfusions, less necessity of ICU, and shorter length of hospital stay were observed. OS was not different between eras for CRLM and HCC. Conclusions: Surgical resection in a multidisciplinary environment remains the cornerstone for the curative treatment of primary and metastatic liver tumors.

https://doi.org/10.1016/j.clinsp.2022.100088

The impact of multivisceral liver resection on short- and long-term outcomes of patients with colorectal liver metastasis: A systematic review and meta-analysis
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Silveira Junior, Sergio

; Tustumi, Francisco

; Magalhães, Daniel de Paiva

; Jeismann, Vagner Birk

; Fonseca, Gilton Marques

; Kruger, Jaime Arthur Pirola

; Coelho, Fabricio Ferreira

; Herman, Paulo

Clinics

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2022, Volume 77 elocation 100099

Abstract: En | Text: En | PDF: En

Abstract The impact of Multivisceral Liver Resection (MLR) on the outcome of patients with Colorectal Liver Metastasis (CRLM) is unclear. The present systematic review aimed to compare patients with CRLM who underwent MLR versus standard hepatectomy regarding short- and long-term outcomes. MLR is a feasible procedure but has a higher risk of major complications. MLR did not negatively affect long-term survival, suggesting that an extended resection is an option for potentially curative treatment for selected patients with CRLM.

https://doi.org/10.1016/j.clinsp.2022.100099

Hepatocellular carcinoma (HCC) in patients with Non-Alcoholic Fatty Liver Disease (NAFLD): screening, treatment and survival analysis in a Brazilian series
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Alencar, Regiane Saraiva de Souza Melo

; Oliveira, Claudia P.

; Chagas, Aline Lopes

; Fonseca, Leonardo Gomes da

; Maccali, Claudia

; Saud, Lisa Rodrigues da Cunha

; Xerfan, Mariana Pinheiro

; Stefano, Jose Tadeu

; Herman, Paulo

; D'Albuquerque, Luiz Augusto Carneiro

; Alves, Venâncio Avancini Ferreira

; Carrilho, Flair Jose

Clinics

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2022, Volume 77 elocation 100097

Abstract: En | Text: En | PDF: En

Abstract Objective: The aim of the present study was to evaluate the clinical features, Hepatocellular Carcinoma (HCC) screening, treatment modalities, and Overall Survival (OS) in a series of Non-Alcoholic Fatty Liver Disease-Related Hepatocellular Carcinoma (NAFLD-HCC) Brazilian patients. Methods: This was a cross-sectional study at the Instituto do Cancer do Estado de São Paulo, at the Faculdade de Medicina da Universidade de São Paulo with the approval of the local research ethics committee. NAFLD patients with HCC diagnosed, from May 2010 to May 2019, were included. Results: A total of 131 patients were included. Risk factors for NAFLD were present in 94.7% of the patients. Only 29% of patients were in the HCC screening program before diagnosis. HCC treatment was performed in 84.7% of patients. Cumulative survival at the end of the first year was 72%, second-year 52%, and fifth-year 32%. HCC screening before diagnosis was not significantly associated with higher cumulative survival. The independent factors associated with shorter general survival were BCLC C-D, p < 0.001, and the size of the largest nodule > 42 mm, p = 0.039. Conclusions: Although the efficacy of screening in our population regarding overall survival was hampered due to the sample size (29% had screening), BCLC stages C‒D and the size of the largest nodule larger than 42 mm were identified as independent factors of worse prognosis.

https://doi.org/10.1016/j.clinsp.2022.100097

PROTOCOLO DE TRANSPLANTE HEPÁTICO PARA METÁSTASE COLORRETAL IRRESSECÁVEL
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ERNANI, Lucas

; FERNANDES, Eduardo de Souza Martins

; MARTINO, Rodrigo Bronze de

; COELHO, Fabricio Ferreira

; MELLO, Felipe Pedreira Tavares de

; ANDRADE, Ronaldo

; PIMENTEL, Leandro Savattone

; HADDAD, Luciana Bertocco de Paiva

; HERMAN, Paulo

; ANDRAUS, Wellington

; D’ALBUQUERQUE, Luiz Augusto Carneiro

ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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2021, Volume 34 N. 4 elocation e1625

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO - RACIONAL: O câncer colorretal é a terceira neoplasia mais frequente e metade dos pacientes desenvolvem metástase hepática. O melhor fator prognóstico na metástase hepática de câncer colorretal (MHCCR) é a possibilidade de ressecção com margens livres, porém a maioria permanece irressecável. O racional em realizar transplante hepático (TH) em pacientes portadores de MHCCR está na ampliação do número de pacientes ressecáveis através de uma hepatectomia total. OBJETIVO: Apresentar protocolo brasileiro para realização de transplante hepático em pacientes com MHCCR irressecável. MÉTODO: O protocolo foi realizado por duas instituições com grande volume de ressecções e transplantes hepáticos no Brasil, baseado no trabalho realizado pela Universidade de Oslo. A elaboração foi dividida em 4 etapas. RESULTADO: É apresentada proposta de protocolo para esta doença a ser validada na aplicação clínica. CONCLUSÃO: Foi possível elaborar protocolo de transplante hepático para MHCCR irressecável a fim de uniformizar o tratamento e melhor avaliar os resultados cirúrgicos.

ABSTRACT - BACKGROUND: Colorectal cancer (CRC) is the third most common neoplasm, and half of the patients with CRC develop liver metastasis. The best prognostic factor for colorectal liver metastasis (CRLM) is the possibility of performing a resection with free margins; however, most of them remain unresectable. The justification for performing liver transplantation (LT) in patients with CRLM regards an increase in the number of resectable patients by performing total hepatectomy. AIM: The aim of this study was to provide a Brazilian protocol for LT in patients with unresectable CRLM. METHOD: The protocol was carried out by two Brazilian institutions, which perform a large volume of resections and LTs, based on the study carried out at the University of Oslo. The elaboration of the protocol was conducted in four stages. RESULT: A protocol proposal for this disease is presented, which needs to be validated for clinical use. CONCLUSION: The development of an LT protocol for unresectable CRLM aims to standardize the treatment and to enable a better evaluation of surgical results.

https://doi.org/10.1590/0102-672020210002e1625

RESSECÇÃO LAPAROSCÓPICA DE TUMORES BENIGNOS DO FÍGADO: POSIÇÃO ATUAL
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HERMAN, Paulo

; FONSECA, Gilton Marques

; KRUGER, Jaime Arthur Pirola

; JEISMANN, Vagner Birk

; COELHO, Fabricio Ferreira

ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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2021, Volume 34 N. 4 elocation e1641

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO - RACIONAL: As principais indicações das hepatectomias video-laparoscópicas (HVL), inicialmente, eram nas lesões hepáticas benignas. À medida que a HVL se tornou mais popular, as indicações de doenças malignas superaram as de doenças benignas. Este estudo teve como objetivo discutir as indicações e resultados da HVL para o tratamento de tumores hepáticos benignos. MÉTODOS: De 445 HVL realizadas em um único centro, 100 (22,4%) foram para tumores benignos. Os autores discutem as indicações para ressecção e apresentam seus resultados perioperatórios. RESULTADOS: No total, 100 pacientes com tumores benignos foram avaliados, a saber: 66 casos de adenomas hepatocelulares; 14 de neoplasia mucinosa biliar; 13 de hiperplasia nodular focal; 4 de angiomiolipomas; e 3 de hemangiomas. O tamanho médio das lesões foi de 7,6 cm (3,1 a 19,6 cm). A taxa de morbidade total foi de 19%, sendo 9% classificados como Clavien-Dindo 3 ou 4 e não foi observada mortalidade. CONCLUSÃO: A HVL para tumores hepáticos benignos é segura e apresenta excelentes resultados. No entanto, as indicações para cirurgia são cada vez mais restritas, não sendo recomendável indicar a ressecção somente por se tratar de procedimento minimamente invasivo.

ABSTRACT - BACKGROUND: The main indications of the use of laparoscopic liver surgery (LLS), in the early days, were benign liver lesions. As LLS became more popular, indications for malignant diseases outnumbered those for benign ones. This study aims to rule out the indications and results of LLS for the treatment of benign liver tumors. METHODS: Out of 445 LLS performed in a single center, 100 (22.4%) were for benign tumors. The authors discuss the indications for resection and present their perioperative results. RESULTS: In total, 100 patients with benign tumors were evaluated. Specifically, these were as follows: 66 cases of hepatocellular adenomas; 14 cases of biliary mucinous neoplasm; 13 cases of focal nodular hyperplasia; 4 cases of angiomyolipomas; and 3 cases of hemangiomas with a mean size of 7.6 cm (ranging from 3.1 to 19.6 cm). The total morbidity rate was 19%, with 9% classified as Clavien-Dindo grades 3 or 4. No mortality was observed. CONCLUSION: LLS for benign liver tumors is safe and presents excellent results. However, indications for resection are increasingly restricted and should not be performed just because it is a minimally invasive procedure.

https://doi.org/10.1590/0102-672020210002e1641

Safety and effectiveness of mycophenolate mofetil associated with tacrolimus for liver transplantation immunosuppression: a systematic review and meta-analysis of randomized controlled trials
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Tustumi, Francisco

; Miranda Neto, Antonio Afonso de

; Silveira Júnior, Sérgio

; Fernandes, Felipe Alexandre

; Silva, Miller Barreto de Brito e

; Ernani, Lucas

; Nacif, Lucas Souto

; Coelho, Fabricio Ferreira

; Andraus, Wellington

; Bernardo, Wanderley Marques

; Herman, Paulo

; Carneiro-D’Albuquerque, Luiz Augusto

Clinics

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2021, Volume 76 elocation e2597

Abstract: En | Text: En | PDF: En

A combination of immunosuppressants may improve outcomes due to the synergistic effect of their different action mechanisms. Currently, there is no consensus regarding the best immunosuppressive protocol after liver transplantation. This review aimed to evaluate the effectiveness and safety of tacrolimus associated with mycophenolate mofetil (MMF) in patients undergoing liver transplantation. We performed a systematic review and meta-analysis of randomized clinical trials. Eight randomized trials were included. The proportion of patients with at least one adverse event related to the immunosuppression scheme with tacrolimus associated with MMF was 39.9%. The tacrolimus with MMF immunosuppression regimen was superior in preventing acute cellular rejection compared with that of tacrolimus alone (risk difference [RD]=-0.11; p =0.001). The tacrolimus plus MMF regimen showed no difference in the risk of adverse events compared to that of tacrolimus alone (RD=0.7; p=0.66) and cyclosporine plus MMF (RD=-0.7; p=0.37). Patients undergoing liver transplantation who received tacrolimus plus MMF had similar adverse events when compared to patients receiving other evaluated immunosuppressive regimens and had a lower risk of acute rejection than those receiving in the monodrug tacrolimus regimen.

https://doi.org/10.6061/clinics/2021/e2597 395 downloads

10.

DOES THE DROP IN PORTAL PRESSURE AFTER ESOPHAGOGASTRIC DEVASCULARIZATION AND SPLENECTOMY INFLUENCE THE VARIATION OF VARICEAL CALIBERS AND THE REBLEEDING RATES IN SCHISTOSOMIASIS IN LATE FOLLOW-UP?
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SILVA-NETO, Walter de Biase

; QUIRESE, Claudemiro

; MOURA, Eduardo Guimarães Horneaux de

; COELHO, Fabricio Ferreira

; HERMAN, Paulo

ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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2021, Volume 34 N. 2 elocation e1581

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO Racional: O tratamento de escolha para pacientes com hipertensão portal esquistossomótica com sangramento de varizes é a desconexão ázigo-portal mais esplenectomia (DAPE) associada à terapia endoscópica. Porém, estudos mostram aumento do calibre das varizes em alguns pacientes durante o seguimento em longo prazo. Objetivo: Avaliar o impacto da DAPE e tratamento endoscópico pós-operatório no comportamento das varizes esofágicas e recidiva hemorrágica, de pacientes esquistossomóticos. Métodos: Foram estudados 36 pacientes com seguimento superior a cinco anos, distribuídos em dois grupos: queda da pressão portal abaixo de 30% e acima de 30% comparados com o calibre das varizes esofágicas no pós-operatório precoce e tardio além do índice de recidiva hemorrágica. Resultados: Após a DAPE houve diminuição significativa no calibre das varizes esofágicas que, durante o seguimento aumentaram de calibre e foram controladas com tratamento endoscópico. A queda da pressão portal não influenciou significativamente o comportamento do calibre das varizes no pós-operatório precoce nem tardio nem os índices de recidiva hemorrágica. Conclusão: A queda na pressão portal não influenciou significativamente a variação dos calibres das varizes ao comparar os diâmetros pré e pós-operatórios precoces ou tardios. A comparação entre a queda de pressão do portal e as taxas de ressangramento também não foi significativa.

ABSTRACT Background: The treatment of choice for patients with schistosomiasis with previous episode of varices is bleeding esophagogastric devascularization and splenectomy (EGDS) in association with postoperative endoscopic therapy. However, studies have shown varices recurrence especially after long-term follow-up. Aim: To assess the impact on behavior of esophageal varices and bleeding recurrence after post-operative endoscopic treatment of patients submitted to EGDS. Methods: Thirty-six patients submitted to EGDS were followed for more than five years. They were divided into two groups, according to the portal pressure drop, more or less than 30%, and compared with the behavior of esophageal varices and the rate of bleeding recurrence. Results: A significant reduction on the early and late post-operative varices caliber when compared the pre-operative data was observed despite an increase in diameter during follow-up that was controlled by endoscopic therapy. Conclusion: The drop in portal pressure did not significantly influence the variation of variceal calibers when comparing pre-operative and early or late post-operative diameters. The comparison between the portal pressure drop and the rebleeding rates was also not significant.

https://doi.org/10.1590/0102-672020210002e1581 304 downloads

11.

WILLIAM ABRÃO SAAD: IN MEMORIAN TO THE GRAND MASTER OF HEPATIC SURGERY!
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RIBEIRO-JR, Marcelo A. F.

; HERMAN, Paulo

; D`ALBUQUERQUE, Luiz Augusto Carneiro

; COELHO, Fabrício F.

; CHAIB, Eleazar

; ANDRAUS, Welington

; CECONELLO, Ivan

; SAAD JUNIOR, William Abrão

; NAHAS, Sérgio C.

ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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2021, Volume 34 N. 3 elocation e1588

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

https://doi.org/10.1590/0102-672020210003e1588

12.

PROTOCOL FOR LIVER TRANSPLANTATION IN HILAR CHOLANGIOCARCINOMA
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ERNANI, Lucas

; MARTINO, Rodrigo Bronze de

; ANDRAUS, Wellington

; FERNANDES, Eduardo de Souza Martins

; MELLO, Felipe Pedreira Tavares de

; ANDRADE, Ronaldo

; PIMENTEL, Leandro Savattone

; HADDAD, Luciana Bertocco de Paiva

; COELHO, Fabricio Ferreira

; HERMAN, Paulo

; D’ALBUQUERQUE, Luiz Augusto Carneiro

ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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2021, Volume 34 N. 3 elocation e1618

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO Racional: O colangiocarcinoma hilar representa mais da metade de todos os casos de colangiocarcinoma; tem prognóstico reservado e sobrevida global mediana de 12- 24 meses após o diagnóstico. A proposta de realizar transplante hepático surgiu para ampliar a possibilidade de margens livres através de hepatectomia total nos portadores de tumoresirressecáveis com melhor prognóstico. Objetivo: Apresentar protocolo brasileiro para realização de transplante hepático em pacientes com colangiocarcinoma hilar. Método: O protocolo foi realizado por duas instituições com grande volume de ressecções e transplantes hepáticos no Brasil, baseado no trabalho realizado pela MayoClinic. A elaboração foi dividida em quatro etapas. Resultado: É apresentada proposta de protocolo para esta doença a ser validada na aplicação clínica. Conclusão: Foi possível elaborar protocolo de transplante hepático para colangiocarcinoma a fim de uniformizar o tratamento e melhor avaliar os resultados cirúrgicos.

ABSTRACT Background: Hilar cholangiocarcinoma represents more than half of all cholangiocarcinoma cases, having poor prognosis and presenting a median overall survival after diagnosis of 12-24 months. In patients who have unresectable tumors with a better prognosis, the proposal to perform liver transplantation emerged for expanding the possibility of free margins by performing total hepatectomy. Aim: To provide a Brazilian protocol for liver transplantation in patients with hilar cholangiocarcinoma. Method: The protocol was carried out by two Brazilian institutions which perform a large volume of resections and liver transplantations, based on the study carried out at the Mayo Clinic. The elaboration of the protocol was conducted in four stages. Result: A protocol proposal for this disease is presented, which needs to be validated for clinical use. Conclusion: The development of a liver transplantation protocol for cholangiocarcinoma aims not only to standardize the treatment, but also enable a better assessment of the surgical results in the future.

https://doi.org/10.1590/0102-672020210002e1618

13.

Management of Hepatocellular Carcinoma during the COVID-19 Pandemic - São Paulo Clínicas Liver Cancer Group Multidisciplinary Consensus Statement
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Chagas, Aline Lopes

; da Fonseca, Leonardo Gomes

; Coelho, Fabricio Ferreira

; da Cunha Saud, Lisa Rodrigues

; Abdala, Edson

; Andraus, Wellington

; Fiore, Lucas

; Moreira, Airton Mota

; Menezes, Marcos Roberto

; Carnevale, Francisco César

; Tani, Claudia Megumi

; Alencar, Regiane S.S.M

; D'Albuquerque, Luiz Augusto Carneiro

; Herman, Paulo

; Carrilho, Flair José

Clinics

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2020, Volume 75 elocation e2192

Abstract: En | Text: En | PDF: En

More than 18 million people in 188 countries have been diagnosed as having coronavirus disease (COVID-19), and COVID-19 has been responsible for more than 600,000 deaths worldwide. Brazil is now the second most affected country globally. Faced with this scenario, various public health measures and changes in the daily routines of hospitals were implemented to stop the pandemic. Patients with hepatocellular carcinoma (HCC) are at an increased risk for severe COVID-19 as they present with two major diseases: cancer and concomitant chronic liver disease. The COVID-19 pandemic can significantly impact the management of HCC patients from diagnosis to treatment strategies. These patients need special attention and assistance at this time, especially since treatment for tumors cannot be delayed in most cases. The aim of this guideline was to standardize the management of HCC patients during the COVID-19 pandemic. This document was developed, on the basis of the best evidence available, by a multidisciplinary team from Instituto do Câncer do Estado de São Paulo (ICESP), and Instituto Central of the Hospital das Clínicas da Universidade de São Paulo (HC-FMUSP), which are members of the São Paulo Clínicas Liver Cancer Group.

https://doi.org/10.6061/clinics/2020/e2192 361 downloads

14.

BRAZILIAN CONSENSUS ON INCIDENTAL GALLBLADDER CARCINOMA
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COIMBRA, Felipe Jose F

; TORRES, Orlando Jorge M

; ALIKHANOV, Ruslan

; AGARWAL, Anil

; PESSAUX, Patrick

; FERNANDES, Eduardo de Souza M

; QUIREZE-JUNIOR, Claudemiro

; ARAUJO, Raphael Leonardo C

; GODOY, André Luis

; WAECHTER, Fabio Luis

; RESENDE, Alexandre Prado de

; BOFF, Marcio Fernando

; COELHO, Gustavo Rego

; REZENDE, Marcelo Bruno de

; LINHARES, Marcelo Moura

; BELOTTO, Marcos

; MORAES-JUNIOR, Jose Maria A

; AMARAL, Paulo Cezar G

; PINTO, Rinaldo Danesi

; GENZINI, Tercio

; LIMA, Agnaldo Soares

; RIBEIRO, Heber Salvador C

; RAMOS, Eduardo José

; ANGHINONI, Marciano

; PEREIRA, Lucio Lucas

; ENNE, Marcelo

; SAMPAIO, Adriano

; MONTAGNINI, André Luis

; DINIZ, Alessandro

; JESUS, Victor Hugo Fonseca de

; SIROHI, Bhawna

; SHRIKHANDE, Shailesh V

; PEIXOTO, Renata D`Alpino

; KALIL, Antonio Nocchi

; JARUFE, Nicolas

; SMITH, Martin

; HERMAN, Paulo

ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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2020, Volume 33 N. 1 elocation e1496

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO Racional: Carcinoma incidental da vesícula biliar é definido como uma neoplasia descoberta por exame histológico após colecistectomia videolaparoscópica. É potencialmente uma doença curável. Entretanto algumas questões relacionadas ao seu manuseio permanecem controversas e uma estratégia definida está associada com melhor prognóstico. Objetivo: Desenvolver o primeiro consenso baseado em evidências para o manuseio de pacientes com carcinoma incidental da vesícula biliar no Brasil. Métodos: Dezesseis questões foram selecionadas e para responder as questões e 36 membros das sociedades brasileiras e internacionais foram incluídos. As recomendações foram baseadas em evidências da literatura atual. Um relatório final foi enviado para os membros do painel para avaliação de concordância. Resultados: Avaliação intraoperatória da peça cirúrgica, uso de bolsas para retirar a peça cirúrgica e exame histopatológico de rotina, foram recomendados. Avaliação pré-operatória completa é necessária e deve ser realizada assim que o estadiamento final esteja disponível. Avaliação da margem do ducto cístico e biópsia de rotina do linfonodo 16b1 são recomendadas. Quimioterapia deve ser considerada e quimioradioterapia indicada se a margem cirúrgica microscópica seja positiva. Os portais devem ser ressecados excepcionalmente. O estadiamento laparoscópico antes da operação é recomendado, mas o tratamento radical por abordagem minimamente invasiva deve ser realizado apenas em centros especializados em cirurgia hepatopancreatobiliar minimamente invasiva. A extensão da ressecção hepática é aceitável até que seja alcançada a ressecção R0. A linfadenectomia padrão é indicada para tumores iguais ou superiores a T2, mas a ressecção da via biliar não é recomendada de rotina. Conclusões: Recomendações seguras foram preparadas para carcinoma incidental da vesícula biliar, destacando os mais frequentes tópicos do trabalho diário do cirurgião do aparelho digestivo e hepatopancreatobiliar.

ABSTRACT Background: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. Aim: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. Methods: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. Results: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. Conclusions: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

https://doi.org/10.1590/0102-672020190001e1496 2194 downloads

15.

Total laparoscopic vs. open liver resection: comparative study with propensity score matching analysis
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ASSIS, Bruno Silva de

; COELHO, Fabricio Ferreira

; JEISMANN, Vagner Birk

; KRUGER, Jaime Arthur Pirola

; FONSECA, Gilton Marques

; CECCONELLO, Ivan

; HERMAN, Paulo

ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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2020, Volume 33 N. 1 elocation e1494

Abstract: Pt En | Text: Pt En | PDF: Pt | PDF: En

RESUMO Racional: Com a disseminação da cirurgia hepática minimamente invasiva tem-se observado nos últimos anos número crescente de trabalhos que demonstram seus potencias benefícios. No entanto, a maior parte da evidência disponível provém de estudos observacionais retrospectivos sujeitos a vieses, em especial, os de seleção. Além disso, em muitas casuísticas são incluídas no mesmo grupo diversas modalidades de operações minimamente invasivas. Objetivo: Comparar os resultados perioperatórios (até 90 dias) de pacientes submetidos a ressecções hepáticas totalmente laparoscópicas com pacientes contemporâneos por cirurgias abertas, pareados por pontuação de propensão (propensity score matching PSM), submetidos a ressecções hepáticas convencionais. Método: Foram estudados pacientes adultos consecutivos submetidos à ressecção hepática. Para homogeneização dos grupos foi utilizado pareamento por pontuação de propensão, utilizando a variável idade, gênero, tipo de doença (benigna vs. maligna), tipo de hepatectomia (maior vs. menor) e presença de cirrose. A partir disto, os grupos foram redefinidos com proporção 1:1, pelo método nearest. Resultado: Após o pareamento foram incluídos 120 pacientes em cada grupo. Os submetidos à operação totalmente laparoscópica apresentaram menor tempo cirúrgico (286,8±133,4 vs. 352,4±141,5 min, p<0,001), menor tempo de internação em unidade de terapia intensiva (1,9±1,2 vs. 2,5±2,2dias, p=0,031), menor tempo de internação hospitalar (5,8±3,9 vs. 9,9±9,3dias, p<0,001) e redução de 45% nas complicações perioperatórias (19,2 vs. 35%, p=0,008). Conclusão: As ressecções hepáticas totalmente laparoscópicas são exequíveis, seguras e associadas à menor tempo operatório, menor tempo de internação em unidade de terapia intensiva e internação hospitalar, além de diminuição nas complicações perioperatórias.

ABSTRACT Background: There have been an increasing number of articles that demonstrate the potential benefits of minimally invasive liver surgery in recent years. Most of the available evidence, however, comes from retrospective observational studies susceptible to bias, especially selection bias. In addition, in many series, several modalities of minimally invasive surgery are included in the same comparison group. Aim: To compare the perioperative results (up to 90 days) of patients submitted to total laparoscopic liver resection with those submitted to open liver resection, matched by propensity score matching (PSM). Method: Consecutive adult patients submitted to liver resection were included. PSM model was constructed using the following variables: age, gender, diagnosis (benign vs. malignant), type of hepatectomy (minor vs. major), and presence of cirrhosis. After matching, the groups were redefined on a 1:1 ratio, by the nearest method. Results: After matching, 120 patients were included in each group. Those undergoing total laparoscopic surgery had shorter operative time (286.8±133.4 vs. 352.4±141.5 minutes, p<0.001), shorter ICU stay (1.9±1.2 vs. 2.5±2.2days, p=0.031), shorter hospital stay (5.8±3.9 vs. 9.9±9.3 days, p<0.001) and a 45% reduction in perioperative complications (19.2 vs. 35%, p=0.008). Conclusion: Total laparoscopic liver resections are safe, feasible and associated with shorter operative time, shorter ICU and hospital stay, and lower rate of perioperative complications.

https://doi.org/10.1590/0102-672020190001e1494 1207 downloads

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