Arquivos Mensais: fevereiro \06\UTC 2014

Management of POST-HEPATECTOMY complications

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Hepatectomia Esquerda – Metástase CR


Hepatic resection had an impressive growth over time. It has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Management of hepatic resection is challenging. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity and mortality. Especially, complex resections are being increasingly performed in high risk and older patient population. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Common post-hepatectomy complications include venous catheter-related infection, pleural effusion, incisional infection, pulmonary atelectasis or infection, ascites, subphrenic infection, urinary tract infection, intraperitoneal hemorrhage, gastrointestinal tract bleeding, biliary tract hemorrhage, coagulation disorders, bile leakage, and liver failure. These problems are closely related to surgical manipulations, anesthesia, preoperative evaluation and preparation, and postoperative observation and management. The safety profile of hepatectomy probably can be improved if the surgeons and medical staff involved have comprehensive knowledge of the expected complications and expertise in their management.

The era of hepatic surgery began with a left lateral hepatic lobectomy performed successfully by Langenbuch in Germany in 1887. Since then, hepatectomy has been widely performed for the treatment of various liver diseases, such as malignant tumors, benign tumors, calculi in the intrahepatic ducts, hydatid disease, and abscesses. Operation on the liver is especially challenging because of its unique anatomic architecture and because of its vital functions. Despite technical advances and high experience of liver resection of specialized centers, it is still burdened by relatively high rates of postoperative morbidity (4.09%-47.7%) and mortality (0.24%-9.7%). This review article focuses on the major postoperative issues after hepatic resection and presents the current management.

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The Management of PANCREATIC PSEUDOCYST

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The pancreatic pseudocyst is a collection of pancreatic secretions contained within a fibrous sac comprised of chronic inflammatory cells and fibroblasts in and adjacent to the pancreas contained by  surrounding structures. Why a fibrous sac filled with pancreatic fluid is the source of so much interest, speculation, and emotion amongst surgeons and gastroenterologists is indeed hard to understand. Do we debate so vigorously about bilomas, urinomas, or other abdominal collections of visceral secretions? Perhaps it is because the pancreatic pseudocyst represents a sleeping tiger, which though frequently harmless, still can rise up unexpectedly and attack with its enzymatic claws into adjacent visceral and vascular structures and cause lifethreatening complications.

Another part of the debate and puzzlement about pancreatic pseudocysts is related to confusion about pancreatic pseudocyst definition and nomenclature. The Atlanta classification, developed in 1992, was a pioneering effort in describing and defining morphologic entities in acute pancreatitis. Since then, a working group has been revising this system to incorporate more modern experience into the terminology. In the latest version of this system, pancreatitis is divided into acute interstitial edematous pancreatitis (IEP) and necrotizing pancreatitis (NP), based on the presence of pancreatic tissue necrosis. The fluid collections associated with these two “types” of pancreatitis are also differentiated. Early (<4 weeks into the disease course) peripancreatic fluid collections in IEP are referred to as acute peripancreatic fluid collections (APFC), whereas in NP, they are referred to as postnecrotic peripancreatic fluid collections (PNPFC). Late (>4 weeks) fluid collections in IEP are called pancreatic pseudocysts, and in NP, they are called walled-off pancreatic necrosis (WOPN). 

Acute pancreatitis represents a broad spectrum of disease. Although the disease course may smolder, typically an initial inciting event results in organ injury, which sets into play the evolving clinical course. The early phase of disease is marked by the inflammatory mediators from damaged pancreatic tissue, resulting in variable degrees of systemic inflammatory response. The later phase is determined by the morphology of organ injury, specifically with regard to tissue ischemia and necrosis. The outcome of this later phase is often impacted by local or systemic infection. Peripancreatic fluid collections can occur in both the early and the late phases of disease. They presumably occur from injury to or ischemia of the main pancreatic duct or a side branch duct, although some, particularly early on, may be the result of third-space edema fluid. Peripancreatic fluid collections represent a heterogeneous entity.

THE CURRENT MANAGEMENT OF PANCREATIC PSEUDOCYST

POSTGASTRECTOMY SYNDROMES

GASTRECTOMY_OZIMOGAMA

The first postgastrectomy syndrome was noted not long after the first gastrectomy was performed: Billroth reported a case of epigastric pain associated with bilious vomiting as a sequel of gastric surgery in 1885. Several classic treatises exist on the subject; we cannot improve on them and merely provide a few references for the interested reader.

However, the indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. The most marked reduction in the frequency of gastric resection has occurred among patients with peptic ulcer disease. For example, in Olmstead County, Minnesota, the incidence of elective operations on previously unoperated patients declined 8-fold during the 30-year study period between 1956 and 1985 and undoubtedly has declined even further since.

One population-based study concluded that elective surgery for ulcer disease had “virtually disappeared by 1992–1996.” Whereas emergency operations for bleeding and perforation are still encountered, acid-reducing procedures are being performed less frequently in these situations in favor of a damage control approach. Even for gastric cancer, resection rates decreased approximately 20% from 1988 to 2000 in the United States.

An estimated 21,000 new cases of stomach cancer occurred in the United States in 2010, so that the number of cases of gastric resection for cancer is probably less than 15,000 per year in the United States. The virtual disappearance of elective surgery for peptic ulcer has also changed the demographic profile of the postgastrectomy patient: patients who have gastric cancer tend to be older and there is only a slight male preponderance.

These significant changes in the gastric surgery population make it worthwhile to revisit postgastrectomy syndromes. The frequency with which postgastrectomy symptoms/syndromes are found can depend on how hard they are looked for. Loffeld, in a survey of 124 postgastrectomy patients, most of whom had undergone surgery more than 15 years earlier, found that 75% suffered from upper abdominal symptoms, and 1 or more symptoms that indicate dumping were found in 70% of patients who had undergone Billroth-II (B-II) reconstruction.

However, the lack of age-matched and sex-matched controls in this study may have overstated the frequency of symptoms caused by the surgical procedure. Mine and colleagues conducted a large survey of 1153 patients after gastrectomy for cancer and found that 67% reported early dumping and 38% late dumping. By contrast, Pedrazzani and colleagues surveyed 195 patients who underwent subtotal gastrectomy and B-II reconstruction for gastric adenocarcinoma for up to 5 years postoperatively, and concluded that “the incidence of late complications was low and the majority of them recovered within one year after surgery.”

This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient’s long-term follow-up and care.

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