RESUMO
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.
Assuntos
Neoplasias da Vesícula Biliar , Brasil , Carcinoma , Consenso , Feminino , Humanos , Achados Incidentais , Excisão de Linfonodo , Estadiamento de Neoplasias , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Estudos RetrospectivosRESUMO
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.
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.
Assuntos
Humanos , Feminino , Neoplasias da Vesícula Biliar , Brasil , Carcinoma , Estudos Retrospectivos , Achados Incidentais , Consenso , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Excisão de Linfonodo , Estadiamento de NeoplasiasRESUMO
BACKGROUND: Liver surgery has developed significantly in the past decades. In Brazil, the interest on it has grown significantly, but there is no study regarding its clinical practice. Despite intrinsic limitations, surveys are well suited to descriptive studies and allow understanding the current scenario. AIM: To provide an overview on the current spread of liver surgery in Brazil, focusing on groups´ profile, operative techniques and availability of resources. METHOD: From May to November 2016, was conducted a national survey about liver surgery profile in Brazil composed by 28 questions concerning surgical team characteristics, technical preferences, surgical volume, results and available institutional resources. The survey was sent by e-mail to 84 liver surgery team leaders from different centers including all regions of the country. RESULTS: Forty-three study participants (51.2%), from all Brazilian regions, responded the survey. Most centers have residency/fellowship programs (86%), perform and do laparoscopic procedures (91%); however, laparoscopy is still responsible for a little amount of surgeries (1-9% of laparoscopic procedures over all liver resections in 39.5% of groups). Only seven centers (16.3%) perform more than 50 liver resections/year. Postoperative mortality rate is between 1-3% in 55% of the centers. CONCLUSION: This is the first depiction of liver surgery in Brazil. It showed a surgical practice aligned with worldwide excellence centers, concentrated on hospitals dedicated to academic practice.
Assuntos
Hepatectomia/estatística & dados numéricos , Brasil , Pesquisas sobre Atenção à Saúde , Hepatectomia/métodos , Humanos , Inquéritos e QuestionáriosRESUMO
BACKGROUND AND STUDY AIMS: Endoscopic removal of biliary stones has high success rates, ranging between 85â% to 95â%. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90â% for stones larger than 15âmm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80â%â-â90â%). However, there is no study comparing these 2 techniques. PATIENTS AND METHODS: From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopyâ+âelectrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods. RESULTS: The mean age was 56 years. 74 (75.5â%) patients were female. The initial overall complete stone removal rate was 74.5â% (77.1â% in group 1 and 72â% in group 2, P â>â0.05). After second session the overall success rate achieved 90.1â%. Procedure time was significantly lower in group 2,â-â25.2âmin (CI95â%â-â12.48 to -â37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events. CONCLUSION: Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.
RESUMO
ABSTRACT Background: Liver surgery has developed significantly in the past decades. In Brazil, the interest on it has grown significantly, but there is no study regarding its clinical practice. Despite intrinsic limitations, surveys are well suited to descriptive studies and allow understanding the current scenario. Aim: To provide an overview on the current spread of liver surgery in Brazil, focusing on groups´ profile, operative techniques and availability of resources. Method: From May to November 2016, was conducted a national survey about liver surgery profile in Brazil composed by 28 questions concerning surgical team characteristics, technical preferences, surgical volume, results and available institutional resources. The survey was sent by e-mail to 84 liver surgery team leaders from different centers including all regions of the country. Results: Forty-three study participants (51.2%), from all Brazilian regions, responded the survey. Most centers have residency/fellowship programs (86%), perform and do laparoscopic procedures (91%); however, laparoscopy is still responsible for a little amount of surgeries (1-9% of laparoscopic procedures over all liver resections in 39.5% of groups). Only seven centers (16.3%) perform more than 50 liver resections/year. Postoperative mortality rate is between 1-3% in 55% of the centers. Conclusion: This is the first depiction of liver surgery in Brazil. It showed a surgical practice aligned with worldwide excellence centers, concentrated on hospitals dedicated to academic practice.
RESUMO Racional: A cirurgia hepática se desenvolveu significativamente nas últimas décadas. No Brasil, apesar do crescente interesse pela cirurgia do fígado, não há estudos a respeito da sua prática no país. Assim, foi realizada uma pesquisa do tipo inquérito, apropriada para estudos descritivos, permitindo entender adequadamente o cenário atual nacional. Objetivo: Obter uma visão abrangente da cirurgia hepática no Brasil, com foco no perfil dos grupos, técnicas operatórias e disponibilidade de recursos. Método: De abril a novembro de 2016, foi realizado um inquérito nacional sobre o perfil da cirurgia hepática no Brasil, composta por 28 questões relativas às características das equipes cirúrgicas, preferências técnicas, volume cirúrgico, resultados e disponibilidade de recursos nas instituições. A pesquisa foi enviada por e-mail para 84 cirurgiões hepáticos brasileiros líderes de seus respectivos grupos, abrangendo todas as regiões do país. Resultados: Quarenta e três participantes (51.2%) responderam à pesquisa (42 respostas completas e uma incompleta) de todas as regiões do Brasil. A maioria dos centros tem programa de residência (86%) e faz procedimentos por via laparoscópica (91%); a despeito da laparoscopia corresponder a uma pequena porcentagem das operações (1-9% dos procedimentos são laparoscópicos em 39,5% dos grupos). Apenas sete centros (16.3%) realizam mais do que 50 resecções hepáticas/ano. A taxa de mortalidade pós-operatória é de 1-3% em 55% dos centros. Conclusão: Esta é a primeira avaliação da cirurgia hepática no Brasil e indica que as práticas cirúrgicas estão alinhadas com centros de excelência mundiais, concentradas em hospitais dedicados à prática acadêmica.
Assuntos
Humanos , Hepatectomia/estatística & dados numéricos , Brasil , Inquéritos e Questionários , Pesquisas sobre Atenção à Saúde , Hepatectomia/métodosRESUMO
BACKGROUND: Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. AIM: To understand the Brazilian practice patterns for pancreatoduodenectomy. METHOD: A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. RESULTS: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. CONCLUSION: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.
Assuntos
Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/normas , Padrões de Prática Médica , Brasil , Pesquisas sobre Atenção à Saúde , Humanos , Pancreaticoduodenectomia/métodosRESUMO
ABSTRACT Background: Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. Aim: To understand the Brazilian practice patterns for pancreatoduodenectomy. Method: A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. Results: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. Conclusion: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.
RESUMO Racional: A duodenopancreatectomia é um procedimento cirúrgico tecnicamente desafiador, com uma incidência de complicações pós-operatórias variando de 30% a 61%. O procedimento requer experiência de alto nível, e para minimizar complicações relacionadas à cirurgia uma padronização de alta qualidade é imperativa. Objetivo: Compreender o padrão da prática brasileira para duodenopancreatectomia. Método: Um questionário foi elaborado com a finalidade de obter uma visão geral da prática cirúrgica em câncer do pâncreas, treinamento específico e experiência em duodenopancreatectomia. O questionário foi enviado para cirurgiões com declarado interesse em cirurgia pancreática. Resultados: Um total de 60 questionários foi enviado e 52 retornaram (86,7%). A região sudeste foi a que mais respondeu, com 25 cirurgiões (48,0%). Apenas dois cirurgiões (3,9%), realizaram mais do que 50% das duodenopancreatectomia por videolaparoscopia. O procedimento clássico de Whipple foi realizado por 24 cirurgiões (46,2%) e a linfadenectomia padrão do Grupo Internacional de Estudo em Cirurgia Pancreática foi realizada por 43 cirurgiões (82,7%). Para a reconstrução, a pancreatojejunostomia foi realizada por 49 cirurgiões (94,2%), em alça única por 41 (78,9%), com anastomose do tipo ducto-mucosa por 38 (73,1%). O cateter transanastomose foi realizado por 26 cirurgiões (50%), reconstrução gástrica antecólica por 39 (75%) e enteroanastomose tipo Braun apenas por seis cirurgiões (11,5%). A drenagem abdominal profilática foi realizada por todos os cirurgiões e o uso de análogos da somatostatina por seis cirurgiões (11,5%). Nutrição enteral precoce no pós-operatório foi utilizada de rotina por 22 cirurgiões (42,3%) e 34 cirurgiões (65,4%), usaram sonda nasogástrica de rotina. Conclusão: Heterogeneidade foi observada na prática padrão da duodenopancreatectomia pelos cirurgiões no Brasil e, algumas delas em contraste com evidências estabelecidas na literatura.
Assuntos
Humanos , Neoplasias Pancreáticas/cirurgia , Padrões de Prática Médica , Pancreaticoduodenectomia/normas , Brasil , Pancreaticoduodenectomia/métodos , Pesquisas sobre Atenção à SaúdeRESUMO
BACKGROUND: Among late postoperative complications of pancreatectomy are the exocrine and endocrine pancreatic insufficiencies. The presence of exocrine pancreatic insufficiency imposes, as standard treatment, pancreatic enzyme replacement. Patients with chronic pancreatitis, with intractable pain or any complications with surgical treatment, are likely to present exocrine pancreatic insufficiency or have this condition worsened requiring adequate dose of pancreatic enzymes. OBJECTIVE: The aim of this study is to compare the required dose of pancreatic enzyme and the enzyme replacement cost in post pancreatectomy patients with and without chronic pancreatitis. METHODS: Observational cross-sectional study. In the first half of 2015 patients treated at the clinic of the Department of Gastrointestinal Surgery at Hospital das Clínicas, Universidade de São Paulo, Brazil, who underwent pancreatectomy for at least 6 months and in use of enzyme replacement therapy were included in this series. The study was approved by the Research Ethics Committee. The patients were divided into two groups according to the presence or absence of chronic pancreatitis prior to pancreatic surgery. For this study, P<0.05 was considered statistically significant. RESULTS: The annual cost of the treatment was R$ 2150.5 ± 729.39; R$ 2118.18 ± 731.02 in patients without pancreatitis and R$ 2217.74 ± 736.30 in patients with pancreatitis. CONCLUSION: There was no statistically significant difference in the cost of treatment of enzyme replacement post pancreatectomy in patients with or without chronic pancreatitis prior to surgical indication.