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BACKGROUND: Acute kidney injury (AKI) has serious consequences on the prognosis of patients undergoing liver transplantation. Recently, artificial neural network (ANN) was reported to have better predictive ability than the classical logistic regression (LR) for this postoperative outcome. AIM: To identify the risk factors of AKI after deceased-donor liver transplantation (DDLT) and compare the prediction performance of ANN with that of LR for this complication. METHODS: Adult patients with no evidence of end-stage kidney dysfunction (KD) who underwent the first DDLT according to model for end-stage liver disease (MELD) score allocation system was evaluated. AKI was defined according to the International Club of Ascites criteria, and potential predictors of postoperative AKI were identified by LR. The prediction performance of both ANN and LR was tested. RESULTS: The incidence of AKI was 60.6% (n = 88/145) and the following predictors were identified by LR: MELD score > 25 (odds ratio [OR] = 1.999), preoperative kidney dysfunction (OR = 1.279), extended criteria donors (OR = 1.191), intraoperative arterial hypotension (OR = 1.935), intraoperative massive blood transfusion (MBT) (OR = 1.830), and postoperative serum lactate (SL) (OR = 2.001). The area under the receiver-operating characteristic curve was best for ANN (0.81, 95% confidence interval [CI]: 0.75-0.83) than for LR (0.71, 95%CI: 0.67-0.76). The root-mean-square error and mean absolute error in the ANN model were 0.47 and 0.38, respectively. CONCLUSION: The severity of liver disease, pre-existing kidney dysfunction, marginal grafts, hemodynamic instability, MBT, and SL are predictors of postoperative AKI, and ANN has better prediction performance than LR in this scenario.
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OBJECTIVE: The aim of this study was to determine the prospective capacity and impact of donor risk index, preallocation survival outcomes following liver transplant, donor model for end-stage liver disease, and balance of risk on patients' 30-day survival after liver transplantation. METHODS: We prospectively analyzed patient survival in a multicentric observational cohort of adult liver transplantation through the year of 2019 at the state of Paraná, Brazil. The receiver operating characteristic curve, the area under the curve, and the best cutoff point (i.e., the Youden's index) were estimated to analyze the prognostic value of each index. RESULTS: In total, 252 liver transplants were included with an average model for end-stage liver disease score of 21.17 and a 30-day survival of 79.76%. The donor risk index was the only prognostic variable with no relation to patients' 30-day mortality model for end-stage liver disease and donor model for end-stage liver disease have no prognostic value on receiver operating characteristic curve, but preallocation survival outcomes following liver transplant, survival outcomes following liver transplant, and balance of risk presented good relationship with this observation. The cutoff value was estimated in 11-12 points for balance of risk and 9-12 for preallocation survival outcomes following liver transplant and survival outcomes following liver transplant. The 30-day survival for the group of transplants with scores up to 12 points (n=172) in all the three indexes was 87.79%, and for those transplants with scores higher than 12 it was 36.36%. CONCLUSIONS: The 30-day survival is 79.76%, and balance of risk, survival outcomes following liver transplant, and preallocation survival outcomes following liver transplant are the good prognostic indexes. The cutoff value of 12 points has clinical usefulness to predict the post-liver transplantation results.
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Enfermedad Hepática en Estado Terminal , Trasplante de Hígado , Enfermedad Hepática en Estado Terminal/cirugía , Humanos , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Donantes de TejidosRESUMEN
AIM: To identify risk factors for the occurrence of acute kidney injury (AKI) in the postoperative period of partial hepatectomies. METHODS: Retrospective analysis of 446 consecutive resections in 405 patients, analyzing clinical characteristics, preoperative laboratory data, intraoperative data, and postoperative laboratory data and clinical evolution. Adopting the International Club of Ascites criteria for the definition of AKI, potential predictors of AKI by logistic regression were identified. RESULTS: Of the total 446 partial liver resections, postoperative AKI occurred in 80 cases (17.9%). Identified predictors of AKI were: Non-dialytic chronic kidney injury (CKI), biliary obstruction, the Model for End-Stage Liver Disease (MELD) score, the extent of hepatic resection, the occurrence of intraoperative hemodynamic instability, post-hepatectomy haemorrhage, and postoperative sepsis. CONCLUSION: The MELD score, the presence of non-dialytic CKI and biliary obstruction in the preoperative period, and perioperative hemodynamics instability, bleeding, and sepsis are risk factors for the occurrence of AKI in patients that underwent partial hepatectomy.
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Currently, partial hepatectomy is the treatment of choice for a wide variety of liver and biliary conditions. Among the possible complications of partial hepatectomy, acute kidney injury (AKI) should be considered as an important cause of increased morbidity and postoperative mortality. Difficulties in the data analysis related to postoperative AKI after liver resections are mainly due to the multiplicity of factors to be considered in the surgical patients, moreover, there is no consensus of the exact definition of AKI after liver resection in the literature, which hampers comparison and analysis of the scarce data published on the subject. Despite this multiplicity of risk factors for postoperative AKI after partial hepatectomy, there are main factors that clearly contribute to its occurrence. First factor relates to large blood losses with renal hypoperfusion during the operation, second factor relates to the occurrence of post-hepatectomy liver failure with consequent distributive circulatory changes and hepatorenal syndrome. Eventually, patients can have more than one factor contributing to post-operative AKI, and frequently these combinations of acute insults can be aggravated by sepsis or exposure to nephrotoxic drugs.
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BACKGROUND: Surgical resection is considered the standard therapy in the treatment of liver metastases from colorectal cancer (CRCLM); however, most patients experience tumor recurrence after curative hepatic resection. The objective was to determine potential prognostic factors for tumor recurrence after an initial hepatectomy for CRCLM. METHODS: A study population of 101 patients who had undergone a first curative hepatectomy for CRCLM was retrospectively analyzed. Selected biological tumor markers, and clinical and pathological features were then tested by Cox regression. RESULTS: Synchronous liver metastases occurred in 38 patients (37.6%) and 63 patients (62.3%) presented with metachronous liver metastases. In a median follow-up time of 68 months, recurrence was observed in 64 patients (63.3%). The 5-year cumulative risk of recurrence was 56.7%. The median survival after recurrence was 24.5 months (range 1 to 41 months) and 5-year cumulative overall survival was 31.8%. Of all variables tested by Cox regression, intra- and extrahepatic resectable disease, CEA levels≥50 ng/mL and bilobar liver disease remained significant as predictors of recurrence in the multivariate analysis. CONCLUSIONS: Independent risk factors for recurrence after an initial hepatectomy for CRCLM, such as intra- and extrahepatic resectable disease, CEA levels≥50 ng/mL and bilobar liver disease, can eventually help in making decisions in this very complex scenario.
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Neoplasias Colorrectales/patología , Hepatectomía/mortalidad , Neoplasias Hepáticas/secundario , Recurrencia Local de Neoplasia/patología , Adulto , Anciano , Biomarcadores de Tumor/análisis , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/cirugía , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/cirugía , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/mortalidad , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
BACKGROUND: Conventional axillary lymph node dissection (ALND) has recently become less radical. The treatment morbidity effects of reduced ALND aggressiveness are unknown. This article investigates the prevalence of the main complications of ALND: lymphedema, range-of-motion restriction, and arm paresthesia and pain. METHODS: This cross-sectional study included 200 women with invasive breast cancer who underwent breast-conserving surgery (82.5%, n = 165) or mastectomy (17.5%, n = 35) with ALND from 2007 to 2011. Arm perimetry was used to assess lymphedema, defined as a difference >2 cm in the upper arm circumference between the nonsurgical and surgical arms. Range-of-motion restriction was assessed by evaluating the degree of arm abduction. Paresthesia was measured in the inner and proximal arm regions. Arm pain was assessed by directly questioning the patients and defined as either present or absent. RESULTS: The average (±SD) time between ALND and morbidity evaluation was 35 ± 18 months (range, 7-60 months). The average dissected lymph node number per patient was 14 ± 4 (range, 6-30 lymph nodes). Only 3.5% (n = 7) of the patients presented with lymphedema. Single-incision approaches to breast tumor and ALND (P = 0.04) and the presence of a postoperative seroma (P = 0.02) were associated with lymphedema in univariate analysis. Paresthesia was the most frequent side effect observed (53% of patients, n = 106). This complication was associated with increased age (P < 0.0001) and a larger dissected lymph node number (P = 0.01) in univariate and multivariate analysis. Additionally, 24% (n = 48) of patients had noticeable limited arm abduction. Among the patients, 27.5% (n = 55) experienced sporadic arm pain corresponding to the surgically treated armpit. In multivariate analysis, the pain risk was 1.9-fold higher in patients who underwent ALND corresponding to their dominant arm (95% CI, 1.0-3.7, P = 0.04). CONCLUSION: Conventional ALND in breast cancer patients can result in unwanted complications. However, the current lymphedema prevalence is lower than that of the other analyzed side effects.
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Neoplasias de la Mama/cirugía , Escisión del Ganglio Linfático/efectos adversos , Mastectomía Segmentaria/efectos adversos , Mastectomía/efectos adversos , Morbilidad , Dolor Postoperatorio/etiología , Parestesia/etiología , Axila , Neoplasias de la Mama/complicaciones , Neoplasias de la Mama/secundario , Estudios Transversales , Femenino , Estudios de Seguimiento , Humanos , Metástasis Linfática , Linfedema/diagnóstico , Linfedema/etiología , Persona de Mediana Edad , Dolor Postoperatorio/diagnóstico , Parestesia/diagnóstico , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Pronóstico , Rango del Movimiento ArticularRESUMEN
OBJETIVO: Avaliar as indicações, sobrevida e fatores prognósticos da esofagogastrectomia com linfadenectomia em dois campos no câncer do esôfago torácico. MÉTODOS: Foram avaliados 111 pacientes retrospectivamente no período de janeiro de 1990 a dezembro de 2001 sendo 83 homens e 29 mulheres. A idade média dos pacientes foi 55,1 anos (variando entre 35-79). A linfadenectomia em dois campos foi parcial (Standard) em 34 pacientes(30,6 por cento) e ampliada em 77(69,4 por cento). RESULTADOS: A média de linfonodos dissecados foi de 22,6(variando entre 4 e 50). A doença R0 ocorreu em 53 pacientes(47,7 por cento) a doença residual microscópica (R1) em 57 (52,3 por cento) e a doença residual R2 em um paciente(0,9 por cento). A recidiva ocorreu em 32 pacientes (28,8 por cento) sendo em sete (6,3 por cento) cervical, 17 (15,3 por cento) locorregional e 19 (17,1 por cento) sistêmica. A morbidade e mortalidade pós-operatória foram de 31,5 por cento e 9 por cento respectivamente, sem diferença significativa em relação á extensão da linfadenectomia mediastinal. A sobrevida global dos 111 pacientes em cinco anos foi de 48,4 por cento, sem diferença significativa na sobrevida em relação á extensão da linfadenectomia, porém, houve aumento significativo na sobrevida livre de doença a favor dos paciente submetidos a linfadenectomia mediastinal ampliada(p=0,01). A ausência de doença residual (R0), comprometimento linfonodal (pN0) e o número de linfonodos comprometidos inferior a quatro, indicaram bom prognóstico. CONCLUSÃO: A esofagogastrectomia com linfadenectomia em dois campos apresentou um impacto positivo na taxa de sobrevida em cinco anos nos pacientes com câncer do esôfago torácico, particularmente em relação aos pacientes com ECIII. A linfadenectomia mediastinal ampliada aumentou significativamente a sobrevida livre de doença.
BACKGROUND: To evaluate the indication, survival and prognostic factors of esophagogastrectomy with two-field lymphadenectomy in thoracic esophageal carcinoma. METHODS: From January 1990 to December 2001, 111 patients were retrospectively analyzed. There were 83 men and 29 women. Median age was 55,1 years (range 35-79). Partial( standard) mediastinal lymphadenectomy was performed in 34 patients (30,6 percent) and extended lymphadenectomy in 77(69,4 percent). RESULTS: The median number of dissected lymph node was 22,6(range 4-50). No residual disease(R0) was found in 53 patients(47,7 percent), microscopic residual disease(R1) in 57(52,3 percent and macroscopic residual disease(R2) in 1(0,9 percent). Recurrence occurred in 32 patients(28,8 percent): cervical in 7(6,3 percent), locoregional in 17(15,3 percent) and distant in 19(17,1 percent). Operative morbity and mortality were 31,55 and 9 percent respectively with no significant difference between partial(standard) and extended mediastinal lymphadenectomy. The overall 5-year survival rate was 48,4 percent, with no significant diference with respect to the extension of the mediastinal lymphadenectomy. However there was a significant diference in disease-free survival rate in favor of patientes who underwent extended mediastinal lymphadenectomy (0,01). No residual disease(RO), no regional lymph node involvement(pN0) and number of positive lymph node less than 4 were identified as good prognostic factors. CONCLUSION: The esophagogastrectomy with two-field lymphadenectomy had a positive impact in 5-year survival rate in patients with thoracic esophageal carcinoma particularly in ECIII patients. Extended mediastinal lymphadenectomy improved the disease-free survival.
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Objetivo - Comparar os resultados da colecístectomía videolaparoscópica em pacientes submetidos a algum procedimento abdominal prévio (cirurgia elou radioterapia) com os resultados obtidos em pacientes sem história de procedimento abdominal Método - Estudo retrospectivo de 44 colecistectomías videolaparoscópícas consecutivas, não randomizadas, realizadas no Serviço de Cirurgia Abdominal do Hospital Erasto Gaertner num período de cinco anos. Resultados - Dos pacientes analisados, 32 (72,7 por cento) eram do sexo feminino e 12 (27,3 por cento) do sexo masculino, com média de idade de 49,6 anos, sendo que 25 (56,8 por cento) pacientes não tinham história de procedimento abdominal e 19 pacientes (43,2 por cento) foram submetidos a algum procedimento abdominal prévio. Não houve diferença entre os grupos no tempo cirúrgico (p=0,36), dificuldades técnicas (p=0,95), extravasa- mento de bile na cavidade (p=0,82), taxa de conversão (p=0,43), taxa de lesões iatrogê- nicas (p=0,35) e tempo médio de internamente (p=0,38). Conclusão - O procedimento abdominal prévio não teve interferência nos resultados da colecistectomia videolaparoscópica realizada em pacientes portadores de colelitíase.(au)
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Humanos , Masculino , Femenino , Abdomen , Colelitiasis , Colecistectomía Laparoscópica/métodos , Cirugía General , Complicaciones PosoperatoriasRESUMEN
O último século foi de extraordinária evolução na apresentação clínica, no entendimento biológico e no manejo do câncer de mama. Estudos clínicos randomizados demonstraram claramente que procedimentos cirúrgicos menos radicais são tão efetivos como aqueles desenvolvidos na virada do século, como a mastectomia radical. Este estudo foi realizado com o objetivo de demonstrar a evolução do tratamento cirúrgico do câncer de mama na instituição no que se refere à radicalidade cirúrgica. Através da correlação da modalidade cirúrgica e do período que este tratamento foi realizado com o estádio clínico da doença, relatando também os índices de recidiva local, foi possível caracterizar três décadas distintas no que se refere à radicalidade cirúrgica do tratamento do câncer de mama no Hospital Erasto Gaertner
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Humanos , Femenino , Persona de Mediana Edad , Neoplasias de la Mama , Ensayos Clínicos como Asunto , Mastectomía Radical Modificada , Mastectomía Radical , Mastectomía Segmentaria , Recurrencia Local de Neoplasia , Estadificación de Neoplasias , Estudios RetrospectivosRESUMEN
Este livro aborda os seguintes itens: avaliação pré-operatória, avaliação nutricional em pacientes com câncer, preparo pré-operatório, rotinas para cirurgia torácica, rotinas para tumores cutâneos e melanoma, rotinas para cirurgia de cabeça e pescoço, rotinas para oncologia clínica, rotinas para cirurgia abdominal, rotinas para ginecologia e mama, emergências oncológicas, tratamento da dor no paciente oncológico.
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Humanos , Masculino , Femenino , Cirugía General , Oncología Médica , Servicio de Oncología en HospitalRESUMEN
Objetivos: a antibiótico-profilaxia das cirurgias de tumores malignos da cabeça e do pescoço, pode ser considerada complexa. Apesar de relatos da literatura não demonstrarem diferenças significativas na ocorrência de infecção pós-operatória, antes de mudar-se o tempo de vigência do antibiótico profilático (cefazolina) de 72 para 24 horas instituiu-se um protocolo, de forma prospectiva e randomizada, com a intenção de se avaliar a repercussão desta mudança no ambiente específico do Serviço de Cirurgia da Cabeça e do Pescoço do Hospital Erasto Gaertner. Material e métodos: no período de dezembro de 1993 até agosto/1998, com 93 casos, foi realizado o protocolo direcionado para as pelveglossomandibulectomias (PGM) e para as laringectomias totais (LAR), estratificando-as de forma equivalente, obedecendo-se critérios de elegibilidade e também critérios definindo a existência de infecção.Resultados: até o momento os casos estão assim distribuídos: 45 PGM e 48 LAR. Dos incluídos no grupo de 24 horas (39 casos), 10 por cento evoluíram com infecção e dos incluídos no grupo de 72 horas (54 casos), 22 por cento infectaram. Conclusão: não se percebeu piora nos índices de ocorrência de infecção pós-operatória no braço 24 horas, sendo indicada a sua utilização. Novo estudo semelhante está sendo executado, comparando-se agora o tempo de oito horas com o de 24 horas.
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Masculino , Femenino , Humanos , Profilaxis Antibiótica , Antibacterianos/uso terapéutico , Cefazolina , Infección de la Herida Quirúrgica/tratamiento farmacológico , Neoplasias de Cabeza y Cuello/cirugíaRESUMEN
A antibiótico-profilaxia das cirurgias de tumores malignos da cabeça e do pescoço, pode ser considerada complexa. Com a intençäo de se avaliar a incidência de infecçäo de ferida cirúrgica, no ambiente específico do Hospital Erasto Gaertner, e sua relaçäo com o tempo de antibiótico-profilaxia, foram correlacionados os índices de infecçäo com o tempo de vigência do antibiótico profilático (cefazolina): 8 ou 24 horas. Num período de 24 meses, 49 pacientes foram analisados, conforme protocolo direcionado para pelviglossomandibulectomias (PGM) e laringectomias totais (LGT). Obedecendo-se a critérios de elegibilidade, os pacientes foram classificados conforme a ocorrência de infecäo da ferida operatória em presente ou ausente. Neste período, foram realizadas 24 PGM e 25 LGT. Dos pacientes incluídos no grupo de oito horas (n=20), 25 por cento evoluíram com infecçäo e dos incluídos no grupo de 24 horas (n=29), 27,5 por cento infectaram. Como näo houve diferença significativa (p>0,05) nos índices de infecç-o de ferida operatória em ambos os grupos de pacientes, os autores propöes a realizaçäo de estudos mais amplos para possível confirmaçäo dos resultados aqui apresentados
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Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Cirugía General , Adolescente , Profilaxis Antibiótica , Infecciones , Neoplasias de Cabeza y Cuello/cirugía , Periodo PosoperatorioRESUMEN
O cistossarcomona Phyllodes da mama é um tumor raro, representando menos de 1% dos tumores de mama, contudo é o sarcoma que mais freqüentemente acomete o órgão. Trata-se de neoplasia fibroepitelial que ainda representa um desafio para patologistas e cirurgiões. O tumor, apesar da nomenclatura, nem sempre apresenta cistos ou comporta-se como um sarcoma, sendo microscopicamente similar a um fibroadenoma. Poucas séries foram publicadas com número adequado de pacientes para que se possam tomar decisões inequívocas no manejo desta doença. Relatamos um caso de uma paciente de 53 anos, portadora de cistossarcoma Phyllodes de mama com metástases para os gânglios axilares, bem como revisamos as informações disponíveis na literatura referante aos casos de disseminação linfonodal da doença.
The cystosarcoma Phyllodes of the breast is a rare tumor, accouting for less than 1% of the breast tumors, however, it represents the most common sarcoma of the breast. The cystosarcoma Phyllodes is fibroepitelial neoplasm that represents a challenge for pathologists and surgeons. The tumor, besides the nomenclature, not always presents with cysts or behave like a sarcoma, simulating a fibroadenoma on the histology. Few trials have been published with significant number of patients to make unmistaken decisions about the management of this disease. This article describe the case of a 53 years old patient with cystosarcoma Phyllodes of the breast metastatic to lymph nodes, rewing the literature data about the nodal spread of this disease.