Surgical approach for hepatic caudate lobectomy: Review of 401 cases.
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Carcinoma, Hepatocellular↗
Biomedical subjects
Ivan Cecconello
Publications and source records attributed to Ivan Cecconello.
Rhabdomyolysis after gastric bypass: severity and outcome patterns.
BACKGROUND: Rhabdomyolysis (RML) is a recently recognized complication of bariatric operations, but it is not known whether creatine kinase (CK) levels along with clinical markers are able to define the course and outcome. METHODS: Bariatric patients (n=324) were reviewed retrospectively. Substantially elevated plasma CK after operation was identified in 4.9% (16/324). The affected population was divided into Group I (n=11, 68.8%) with CK 1050-8000 IU/L and no conspicuous muscle pain, weakness or swelling, and Group II (n=5, 31.2%) displaying CK >8000 IU/L and severe pain and dysfunction. The main outcome measures were CK concentration, frequency of renal failure, need for hemodialysis and mortality. RESULTS: Group I subjects compared to Group II were younger (37.7 +/- 10.9 vs 44.0 +/- 5.5 years, P<0.05) and predominantly females (72.7% vs 40.0%, P<0.05). Peak CK values were definitely lower (2811 +/- 952 vs 28136 +/- 19000 IU/L, P<0.001), and none progressed to renal failure (0% vs 40.0%, P<0.05). No difference was detected regarding preoperative BMI (50.8 +/- 8.1 vs 54.6 +/- 7.0 kg/m(2), NS), duration of operation (5.3 +/- 1.6 vs 5.6 +/- 2.1 hours, NS) or types of anesthetic drugs (basically fentanyl, nitrogen oxide and halothane/isoflurane). CONCLUSIONS: 1) Demographic features, nominally gender and age, were different between the two degrees of RML; 2) Renal failure and hemodialysis were a danger only in patients with massive CK elevation and muscle pain; 3) Moderate CK increase was very well tolerated and rarely entailed major clinical symptoms; 4) Early diagnosis, fluid replenishment and general supportive therapy probably contributed to avert mortality.
Adult↗
Computerized baropodometry in obese patients.
BACKGROUND: Few studies have investigated the influence of obesity on the structural and functional performance of the feet, and its potential implications for the musculoskeletal system. Computerized baropodometric analysis (CPA) is a new investigation for the center of pressure, plantar surface area and plantar pressure while standing on the platform of a specialized apparatus. CPA is relevant to gait and posture, and may be important as well for postoperative musculoskeletal disorders. We investigated the biomechanical dysfunctions of foot pressure by means of CPA in bariatric and non-bariatric subjects. METHODS: Subjects (n=67, 71.6% females, age 40.8 +/- 13.8 years, BMI 31.4 +/- 11.0 kg/m(2)) included obese (BMI 30.0-60.0 kg/m(2), n=27), overweight (BMI 25.0-29.9 kg/m(2), n=12) and normal-weight controls (BMI 20.0-24.9 kg/m(2), n=28) of equivalent age and gender. Variables included center of pressure location, plantar ground contact area and pressure, and pressure patterns (maximum and average) in different regions of the foot, during quiet standing on the platform of the baropodometer. RESULTS: A significant increase was detected for peak pressure on forefoot and plantar ground contact area in the obese group, compared to control and overweight cases, during quiet standing. CONCLUSION: Excessive forefoot pressure and enlarged support area were a consequence of obesity, mirroring the efforts of the obese subject to acquire a wider and stronger support base. Although this is originally a physiological change, it may result in maladaptative and degenerative musculoskeletal consequences. Re-education exercises may be advised, in combination with bariatric surgery in the morbidly obese, aiming at restoration of normal gait and posture, as well as at minimization of stress damage to bones and joints in the axial skeleton.
Adult↗
Origin of adenocarcinoma in Barrett's esophagus: p53 and Ki67 expression and histopathologic background.
UNLABELLED: Barrett's esophagus is the substitution of squamous epithelium of the distal esophagus by columnar epithelium. Intestinal metaplasia in Barrett's esophagus is considered to be the main risk factor for the development of adenocarcinoma. Diffuse adenocarcinoma and Barrett's esophagus without intestinal metaplasia are rare, and reports on the subject are scarce. PURPOSE AND METHOD: To estimate the prevalence of adenocarcinoma in 297 patients with Barrett's esophagus, during the period of 1990 to 2002, and in 13 patients undergoing surgery, to conduct detailed macroscopic and microscopic analysis, with performance of immunohistochemical tests for p53 and Ki67, correlating the type of tumor with its adjacent epithelium. RESULTS: In our patients with Barrett's esophagus, there was a prevalence of 5.7% of adenocarcinoma. The tumors developed only when the Barrett's esophagus segment was long (>3.0 cm). Tumors were located close to the squamous-columnar junction. The histological study revealed 2 patients (15.4%) with Barrett's esophagus adjacent to a tumor with gastric metaplasia without the presence of intestinal metaplasia. Tumors were classified according to Nakamura's classification (23% differentiated pattern, and 77% undifferentiated pattern) and to Lauren's classification (61% intestinal and 39% diffuse). The difference is due to the migration of microtubular and foveolar tumors of undifferentiated (gastric) pattern in Nakamuras classification to the Lauren's intestinal type. The immunohistochemical test for Ki67 was strongly positive in all the patients, thus evidencing intense cell proliferation in both the columnar epithelium and tumor. Expression of p53 was negative in 67% of the adjacent columnar epithelia and 42% of the tumors, without any correlation between the tissue types. CONCLUSION: Adenocarcinoma develops from mixed columnar epithelium, either intestinal or gastric, showing both the gastric and the intestinal patterns; thus, tumors can also grow in columnar epithelium without intestinal metaplasia. Barrett's esophagus should be followed up for the possibility of progression to malignancy, especially when the segment is longer than 3 cm.
Adenocarcinoma↗
Cardiaplasty and Roux-en-Y partial gastrectomy (Serra-Dória procedure) for reoperation of achalasia.
BACKGROUND: After cardiomyotomy for the treatment of megaesophagus, recurrence of symptoms occur in up to 15% of the patients, but only some require a reoperation. AIM: To evaluate the results of reoperation -- cardioplasty with Roux-en-Y partial gastrectomy, a technique proposed by Serra-Dória. CASUISTIC AND METHODS: Twenty patients with achalasia previously treated by cardiomyotomy, were retrospectively studied. The etiology of symptoms recurrence was reflux esophagitis in nine (45.0%) patients, healing of the myotomy in five (25.0%), end staging megaesophagus in five (25.0%) and incomplete myotomy in one (5%). Intra and postoperative complications were analyzed. The patients were studied by clinical (dysphagia, regurgitation, heartburn and weight gain), radiological and endoscopic evaluation, in the pre- and postoperative period. RESULTS: Five (25.0%) patients had complications in the immediate postoperative period. No deaths were observed. Dysphagia improved in all the patients. Regurgitation and heartburn almost disappeared in the whole group. Weight was maintained or increased in 64.7% of the patients. Radiological studies showed a decrease in the caliber of the esophagus in 53.0%, while the remaining patients maintained the pre-operative diameter. Endoscopy, performed during the late postoperative period in 17 patients, showed that 6 among the 9 with reflux esophagitis improved; 2 among the 8 with a normal esophagus during the preoperative period, developed esophagitis. CONCLUSIONS: The Serra-Dória procedure for the treatment of megaesophagus in patients who had already undergone cardiomyotomy and whose symptoms recurred, presented a low morbidity and no mortality. It offered a significant relief of symptoms with a decrease of the caliber of the esophagus in several patients. The patients also improved with regards to reflux esophagitis. In some cases reflux was still present after surgery. Others with normal esophagus in the preoperative period developed esophagitis.
Adolescent↗
Anatomic study of gastric vascularization and its relationship to cervical gastroplasty.
The aim of this study was to perform an anatomic study of the stomach and its vascularization, evaluating the frequency of communication between the right gastroepiploic artery (RGEA) and the left gastroepiploic artery (LGEA), as well as their relationship to the length of the stomach without extramural (direct) vascularization in cervical gastroplasty. Forty-two fresh human cadaveric specimens were studied, and the presence of communication between the RGEA and the LGEA was observed in 26 of the dissected stomachs (61.9%). When communication was present (group 1), to a total length of 49.60 cm of greater curvature length, it was verified that approximately 16.48 cm of this curvature lacked direct extramural vascularization (33.20%). When there was non-communication (group 2), to a greater curvature length of approximately 45.41 cm, it was found that 18.96 cm of this curvature (gastric fundus) lacked direct extramural vascular perfusion (41.76%). Results obtained in both groups were tested for statistically significant differences by the Pearson correlation test (P<0.05). A P value of 0.05 or less was considered statistically significant. It can be concluded that the presence of communication between the RGEA and the LGEA increases extramural vascularization in the great gastric curvature.
Adult↗
Reflux esophagitis and ectopic columnar epithelium (Barrett's esophagus) in the esophageal stump after cervical gastroplasty.
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Barrett Esophagus↗
Molecular aspects of esophageal squamous cell carcinoma carcinogenesis.
BACKGROUND: The development of human esophageal cancer is a multistep, progressive process. An early indicator of this process is an increased proliferation of esophageal epithelial cells morphologically including basal cell hyperplasia, dysplasia, carcinoma in situ and advanced esophageal squamous cell carcinoma. The process of tumorigenesis at cellular level is related to disorders of the control of cell proliferation and differentiation and controlled cell death (apoptosis). Most of cancer cells contain genetic alterations related to the control of these processes, including transcription factors and apoptosis related proteins. AIM: In this review, the current knowledge of the genetic profile of this subtype of esophageal tumor is discussed, focusing on the potential of the development of novel tools for clinical management of esophageal squamous cell carcinoma. CONCLUSIONS: The advances in the field of molecular biology have let us to deeper our knowledge of the process of carcinogenesis of esophagus. Ideally, this knowledge should be translated in benefits for patients suffering from cancer. Thus, better understanding of molecular alterations during carcinogenesis is expected to improve tumor control and prevention and also may lead to better disease management.
Apoptosis↗
[Barrett's esophagus: new diagnostic tools].
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Barrett Esophagus↗
[Megaesophagus microbiota and carcinogenesis].
BACKGROUND: The risk of development of spin cell carcinoma of the esophagus is 33 times higher in patients with chagasic achalasia. It is possible that the production of N-nitroso compounds in the esophageal lumen by of bacterial action in the stasis liquid that reduce nitrates from diet into nitrites may play a role in this process. AIM: To analyze qualitatively and quantitatively the microbiota in chagasic megaesophagus with special attention to bacteria capable of transforming nitto reduction. PATIENTS: Fifteen patients (six men and nine women) were prospectively studied, with ages varying from 28 to 73 years. Patients were divided into three sub-groups according to Rezende et al. classification of esophageal dilation (grade I, grade II and grade III). METHOD: The sample collection was performed using a method specially developed to avoid contamination with microorganisms of the oral cavity and oropharynx, using a Levine catheter n 14 and a 7,5 oro-traqueal tube. RESULTS: Ninety three point three percent of the cultures were positive, with great bacterial variability and predominance of a variety of aerobic Gram-positive and anaerobic bacteria. The bacterial concentrations were generally more elevated in grade III in comparison to grade I and grade II. Among the microorganisms found, Staphylococcus sp, Corynebacterium sp, Peptostreptococcus sp e a Veillonella sp were those with the capability of nitrate reduction. CONCLUSION: It was concluded that patients with megaesophagus present some bacteria in the esophageal lumen that are able to reduce nitrates intro nitrites, an important step in the formation of N-nitroso compounds.
Adult↗
Brazilian consensus on gastroesophageal reflux disease: proposals for assessment, classification, and management.
The Brazilian Consensus on Gastroesophageal Reflux Disease considers gastroesophageal reflux disease to be a chronic disorder related to the retrograde flow of gastroduodenal contents into the esophagus and/or adjacent organs, resulting in a variable spectrum of symptoms, with or without tissue damage. Considering the limitations of classifications currently in use, a new classification is proposed that combines three criteria-clinical, endoscopic, and pH-metric-providing a comprehensive and more complete characterization of the disease. The diagnosis begins with the presence of heartburn, acid regurgitation, and alarm manifestations (dysphagia, odynophagia, weight loss, GI bleeding, nausea and/or vomiting, and family history of cancer). Also, atypical esophageal, pulmonary, otorhinolaryngological, and oral symptoms may occur. Endoscopy is the first approach, particularly in patients over 40 yr of age and in those with alarm symptoms. Other exams are considered in particular cases, such as contrast radiological examination, scyntigraphy, manometry, and prolonged pH measurement. The clinical treatment encompasses behavioral modifications in lifestyle and pharmacological measures. Proton pump inhibitors in manufacturers' recommended doses are indicated, with doubling of the dose in more severe cases of esophagitis. The minimum time of administration is 6 wk. Patients who do not respond to medical treatment, including those with atypical manifestations, should be considered for surgical treatment. Of the complications of gastroesophageal reflux disease, Barrett's esophagus presents a potential development of adenocarcinoma; biopsies should be performed, independent of Barrett's esophagus extent or location. In this regard the designation "short Barrett's" is not important in terms of management and prognosis.
Biopsy, Needle↗
Megaesophagus microbiota: a qualitative and quantitative analysis.
Bacterial overgrowth in the esophageal lumen in patients with megaesophagus can be the cause of recurring pulmonary infections, infectious complications due to surgical or endoscopic procedures, and the development of dysplasia of the esophageal mucosa and cancer. Despite this, esophageal microbiota in the megaesophagus have never been studied. The aim of this study was to analyze qualitatively and quantitatively the microbiota in chagasic megaesophagus in comparison to the normal esophagus. Twenty-five patients (10 men and 15 women), ranging in age from 24 to 74 years (mean years), were prospectively studied from March to September 2000. Fifteen patients with chagasic megaesophagus were divided into three subgroups (n = 5 patients in each) according to the grade of esophageal dilation: MG1 = megaesophagus grade I; MG2 = megaesophagus grade II; and MG3 = megaesophagus grade III. Another group of 10 patients without esophageal disease served as a control group. Samples were collected using a method especially developed to avoid contamination with microorganisms of the oral cavity and oropharynx. In the control group, 40% of the cultures were positive with the genus Streptococcus predominating and concentrations varying from 10(1) to 10(2) colony-forming units/ml. In the megaesophagus group, 93.3% of the cultures were positive, with great variability in the bacteria and a predominance of various aerobic gram-positive bacteria (Streptococcus was most common) and anaerobic bacteria (Veillonella was most frequent) in concentrations that ranged from 10(1) to 10(5) colony-forming units/ml. The bacterial concentrations were generally more elevated in MG3 patients in comparison to MG1 and MG2 patients and the control group (P < 0.05). It was concluded that patients with megaesophagus have a variety of microbiota consisting mostly of aerobic gram-positive and anaerobic bacteria, in concentrations that varied according to the degree of esophageal dilation.
Adult↗
Economic study in surgical patients of a new model of nutrition therapy integrating hospital and home vs the conventional hospital model.
BACKGROUND: Dehospitalization is a trend in the health sector justified by humanitarian and socials aspects for the patient and relatives. From the financing institutions' perspective, whether government or third party, the positive results arise from an optimization of hospital bed use and favorable cost-benefit ratio. The "integrated home-hospital" model was created with the purpose of optimization of resources without detriment to the patients' nutritional care. The objective of this study was an economic evaluation regarding nutrition therapy of the integrated hospital-home model in comparison with an exclusively hospital model. METHODS: A retrospective controlled study, paired (age, sex, disease, and surgical procedure), was performed on 56 digestive surgery patients divided into 2 groups: study (SG; n = 30) and control (CG; n = 26). The data collected included total expenses with hospitalization, nutritional benefits, minimization cost analysis, cost-effectiveness ratio analysis, cost-benefit ratio analysis, hospital length of stay, and hospital-bed optimization. RESULTS: The patients from the SG achieved the same nutritional benefits as those in the CG, but with expenses 3 times lower (median Brazil Reals (R)$3237.18 vs R$8647.93; p < .05). The new model resulted in economic benefit to the institution, as shown by the cost-effectiveness ratio, mainly resulting from the savings of the days of hospitalization avoided. The cost-benefit ratio showed an important savings per patient for the institution (US $3100). CONCLUSIONS: The home-hospital model also reduced length of hospital stay 2.7 times and optimized the hospital bed usage, as it promoted higher hospital-bed rotation (3 times greater).
Cost-Benefit Analysis↗
Lugol staining and histological evaluation of esophageal mucosa in achalasia.
BACKGROUND/AIMS: Esophageal cancer in achalasia is often diagnosed in the advanced stage, which makes for a poor prognosis. Therefore, the aim of this study was to evaluate the macroscopic and histological features of the esophageal mucosa in order to improve the early detection of cancer. METHODOLOGY: We studied the macroscopic features of esophageal mucosa using Lugol's solution and compared them with histological analysis of the entire mucosa in 20 esophagectomy specimens resected for achalasia. Intraepithelial neoplasia, when detected, was selected for DNA ploidy analysis through static cytometry. RESULTS: Macroscopically, the mucosa showed opacification and/or diffuse irregularities in 19 specimens. Advanced squamous cell carcinoma was diagnosed in 2 cases. Using Lugol, the esophageal mucosa acquired irregular brownish color. Clear unstained areas were circumscribed in 5 esophagi. They were macroscopically defined as ulcer, neoplasia (2 cases) and mucosal irregularities (2 cases). The histological analysis showed ulcer, squamous cell carcinoma (2 cases), Barrett's esophagus and esophagitis, respectively. The histological study of the stained mucosa revealed minute foci of DNA aneuploid intraepithelial neoplasia in 4 cases. CONCLUSIONS: Macroscopic examination using Lugol failed to identify minute foci of early carcinoma. The stained mucosa does not exclude the esophageal cancer risk in achalasia.
Adolescent↗