Publications by authors named "Delcio Matos"

77 Publications

INTERVENTIONS FOR THE TREATMENT OF IRRITABLE BOWEL SYNDROME: A REVIEW OF COCHRANE SYSTEMATIC REVIEWS.

Arq Gastroenterol 2021 Jan-Mar;58(1):120-126

Universidade Metropolitana de Santos (UNIMES), Departamento de Medicina, Santos, SP, Brasil.

Background: Irritable bowel syndrome (IBS) is a complex gastrointestinal disorder, whose understanding is relatively uncertain, and the treatment guidance decision still represents a challenge.

Objective: To identify and critically appraise systematic reviews (SRs) published in the Cochrane Database of SRs (CDSR) on the effects of interventions (pharmacological and non-pharmacological) for the treatment of IBS.

Methods: The search was conducted at the Cochrane Library in May 2020. The methodological quality of the SRs was evaluated by the AMSTAR-2 tool.

Results: Eight SRs with moderate to high quality were included, which addressed the treatments: (a) pharmacological: volume agents, antispasmodics, antidepressants and tegaserod; and (b) non-pharmacological: homeopathy, acupuncture, phytotherapy, biofeedback, psychological interventions and hypnotherapy. The results were favorable to antispasmodic drugs and antidepressants regarding the improvement of clinical symptoms. There was no difference between volume agents or tegaserod when compared to placebo. Acupuncture and homeopathy showed a little improvement in symptoms compared to placebo, but the certainty of this evidence was considered low to very low. Psychological interventions seem to improve the overall assessment of the patient and relief symptoms such as abdominal pain. However, there was no long-term follow-up of these patients. The results of the other treatments were considered uncertain due to the high risk of bias.

Conclusion: Considering the low quality of the studies included in the SRs, pharmacological treatment with antispasmodics and antidepressants seems to be beneficial for patients with IBS. Among non-pharmacological interventions, psychological interventions seem to be beneficial. However, further clinical trials are recommended with greater methodological rigor to prove these findings.
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http://dx.doi.org/10.1590/S0004-2803.202100000-20DOI Listing
April 2021

Metalloproteinases and colorectal cancer. Correlation of gene expression and clinical-pathological parameters.

Acta Cir Bras 2020 14;35(7):e202000707. Epub 2020 Aug 14.

Department of Surgery, UNIFESP, Sao Paulo, SP, Brazil.

Purpose: To analyze gene and protein expression of metalloproteinases 1, 2, 9, 11 and 16 and their correlation with clinicopathological variables in colorectal adenocarcinoma.

Methods: A retrospective study of 114 patients with colorectal adenocarcinoma treated surgically in the period 2006 to 2008 in Hospital de Câncer de Barretos - Fundação Pio XII. The evaluation of gene expression was performed by RT-PCR, and protein by immunohistochemistry. The analysis of gene expression was classified as overexpressed genes and poorly expressed (fold change of approximately 2, p<0.05). The positivity of the markers in the immunohistochemical study was performed by semi-quantitative analysis. The tissue of TMA (Tissue Microarray) was done by two independent pathologists.

Results: The gene expression validated by immuno - histochemical was MMP-1(p= 0.00 and 1.57 fold change) and MMP - 2 (p= 0.01 and - 1.84 to fold change) when correlated with the histological types mucinous and adenocarcinoma NOS, MMP9 (p=0.01 and fold change of 1.13) and MMP-16 (p=0.03 and 1.61 fold change) when compared with the histological types villous and adenocarcinoma NOS, MMP - 11 statistically significant in relation to male (p = 0.04 and 1.65 fold change).

Conclusions: The MMPs 1, 2, 9, 11 and 16 gene and protein expression with statistical significance in at least one of the clinicopathological variables studied. Thus, we conclude that these MMPs have potential as a prognostic factor in colorectal adenocarcinoma.
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http://dx.doi.org/10.1590/s0102-865020200070000007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433662PMC
October 2020

Immunoexpression of TS, p53, COX2, EGFR, MSH6 and MLH1 biomarkers and its correlation with degree of differentiation, tumor staging and prognostic factors in colorectal adenocarcinoma: a retrospective longitudinal study.

Sao Paulo Med J 2019 May;137(1):33-38

MD, MSc, PhD. Associate Professor, Department of Surgery, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.

Background: There are cases of colorectal tumors that, although small, show more aggressive evolution than large tumors. This motivated us to study whether there are any proteins capable of alerting about these changes. The aim here was to correlate the immunoexpression of the TS, p53, COX2, EGFR, MSH6 and MLH1 biomarkers in tumors in patients with colorectal adenocarcinoma, with the degree of cell differentiation, tumor staging and clinical-pathological prognostic factors.

Design And Setting: Retrospective observational study at a public tertiary-level hospital.

Methods: We analyzed tissue-microarray paraffin blocks of tumor tissues that had been resected from 107 patients. We used Fisher's exact test to study associations between tumor differentiation/staging and the immunoexpression of biomarkers. We also used Kaplan-Meier estimation, the log-rank test and the adjusted Cox regression model to investigate the patients' overall survival (in months) according to biomarkers and disease-free interval.

Results: The degree of tumor differentiation and tumor staging were not associated with the biomarkers, except in cases of patients in stages III or IV, in which there was a correlation with MLH1 expression (P=0.021). Patient survival and disease-free interval were not associated with the biomarkers.

Conclusion: There were no associations between the degree of tumor differentiation, staging, length of survival or disease-free interval and the immunoexpression of the TS, p53, COX2, EGFR or MSH6 tumor markers. In advanced cases of colorectal adenocarcinoma (stages III and IV), there was a higher percentage of MLH1-negative results.
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http://dx.doi.org/10.1590/1516-3180.2018.0270071218DOI Listing
May 2019

Inborn-like errors of metabolism are determinants of breast cancer risk, clinical response and survival: a study of human biochemical individuality.

Oncotarget 2018 Aug 3;9(60):31664-31681. Epub 2018 Aug 3.

Fleury Laboratories, São Paulo, Brazil.

Breast cancer remains a leading cause of morbidity and mortality worldwide yet methods for early detection remain elusive. We describe the discovery and validation of biochemical signatures measured by mass spectrometry, performed upon blood samples from patients and controls that accurately identify (>95%) the presence of clinical breast cancer. Targeted quantitative MS/MS conducted upon 1225 individuals, including patients with breast and other cancers, normal controls as well as individuals with a variety of metabolic disorders provide a biochemical phenotype that accurately identifies the presence of breast cancer and predicts response and survival following the administration of neoadjuvant chemotherapy. The metabolic changes identified are consistent with inborn-like errors of metabolism and define a continuum from normal controls to elevated risk to invasive breast cancer. Similar results were observed in other adenocarcinomas but were not found in squamous cell cancers or hematologic neoplasms. The findings describe a new early detection platform for breast cancer and support a role for pre-existing, inborn-like errors of metabolism in the process of breast carcinogenesis that may also extend to other glandular malignancies. Statement of Significance: Findings provide a powerful tool for early detection and the assessment of prognosis in breast cancer and define a novel concept of breast carcinogenesis that characterizes malignant transformation as the clinical manifestation of underlying metabolic insufficiencies.
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http://dx.doi.org/10.18632/oncotarget.25839DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6114970PMC
August 2018

Prevalence of cubital tunnel syndrome among dock workers, Saint Sebastian, São Paulo, Brazil.

Rev Bras Med Trab 2018 1;16(3):270-276. Epub 2018 Sep 1.

Universidade Metropolitana de Santos - Santos (SP), Brazil.

Background: Ports play a substantial role in the Brazilian economy.Despite the large number of port workers, few studies report that the most common musculoskeletal disorders among them involve the upper limbs, including carpal tunnel syndrome, rotator cuff syndrome, cervicalgia and cubital tunnel syndrome.The latter is a neuritis caused by compression of the ulnar nerve at the cubital tunnel (CuTS) on the elbow.

Objective: To estimate the prevalence of a suggestive diagnosis of CuTS among port workers.

Method: Seventy-two independent port workers registered with the Labor Management Organ (Órgão Gestor de Mão de Obra - OGMO), Port of Saint Sebastian, were evaluated based on a semi-structured questionnaire and clinical examination, including investigation of pain on palpation of the middle area of the elbow and two maneuvers specific for CuTS, namely, the pressure provocation and maximal flexion tests.

Results: The average age of the participants was 48.49 years old, and their average length in the job 23.13 years.Suggestive diagnosis of CuTS was established for five participants.In only two cases elbow pain had begun before, and in three after starting work at the port.

Conclusion: The prevalence of a suggestive diagnosis of CuTS was 6.9%, and was higher among the participants with longer length in the job (over one year).
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http://dx.doi.org/10.5327/Z1679443520180265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104821PMC
September 2018

HNF4A expression as a potential diagnostic tool to discriminate primary gastric cancer from breast cancer metastasis in a Brazilian cohort.

Diagn Pathol 2017 Jun 5;12(1):43. Epub 2017 Jun 5.

Departamento de Cirurgia, Gastroenterologia Cirúrgica, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.

Background: Among the many challenges in cancer diagnosis is the early distinction between metastatic cancer and a secondary tumor. This difficulty stems from the lack of markers that offer high sensitivity and specificity and can be easily applied in routine laboratory work. An example of this challenge is distinguishing gastric metastases originating from breast cancer from a gastric primary tumor. Hepatocyte nuclear factor 4 alpha (HNF4A) has been suggested as a potential marker in these cases. The aim of this study was to analyze the expression of HNF4A, estrogen receptor (ER), progesterone receptor (PR) and gross cystic disease fluid protein 15 (GCDFP-15) in a Brazilian cohort.

Methods: We performed immunohistochemistry analysis of HNF4A, ER, PR and GCDFP-15 in 126 patients divided into three cohorts: primary breast cancer, primary gastric cancer and both types of tumors.

Results: Our data confirmed the sensitivity and specificity of the HNF4A marker compared to other currently used clinical markers.

Conclusion: HNF4A alone could be a gold standard marker for distinguishing primary gastric cancer from breast metastasis, thus validating its potential clinical use, especially in populations with high genetic diversity.
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http://dx.doi.org/10.1186/s13000-017-0635-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5460322PMC
June 2017

Genetic and Immunohistochemical Expression of Integrins ITGAV, ITGA6, and ITGA3 As Prognostic Factor for Colorectal Cancer: Models for Global and Disease-Free Survival.

PLoS One 2015 16;10(12):e0144333. Epub 2015 Dec 16.

Postgraduate Program in Interdisciplinary Surgery Science, Federal University of São Paulo UNIFESP-Escola Paulista de Medicina, São Paulo, Brazil.

Objective: To evaluate the relationship between the expression profiles of 84 extracellular matrix (ECM) genes and the prognosis of patients with colorectal cancer (CRC).

Methods: This retrospective study included 114 patients with stage I-IV CRC who underwent primary tumour resection. Quantitative real-time PCR and immunohistochemistry assays were conducted using primary tumour samples. Kaplan-Meier survival curves were also generated to identify differences in global survival (GS) and disease-free survival (DFS) for the hypo- or hyperexpression status of each marker. The log-rank test was used to verify whether the differences were significant. Stepwise Cox regression models were also used to identify the risk factors associated with GS and DFS in a multivariate mode, and then were used to score the risk of death associated with each marker, either independently or in association.

Results: In the univariate analyses, significant differences in GS in relation to the expression profiles of ITGAV (p = 0.001), ITGA3 (p = 0.002), ITGA6 (p = 0.001), SPARC (p = 0.036), MMP9 (p = 0.034), and MMP16 (p = 0.038) were observed. For DFS, significant differences were observed in associated with ITGAV (p = 0.004) and ITGA3 (p = 0.001). However, only the ITGAV and ITGA6 gene markers for GS (hazard ratio (HR) = 3.209, 95% confidence interval (CI) = 1.412-7.293, p = 0.005 and HR = 3.105, 95% CI = 1.367-7.055, p = 0.007, respectively), and ITGA3 for DFS (HR = 3.806, 95% CI = 1.573-9.209, p = 0.003), remained in the final Cox regression models. A scoring system was developed to evaluate the risk of patient death based on the number of markers for the components of the final GS model. Scores of 0, 1, or 2 were associated with the following mean survival rates [CI]: 47.162 [44.613-49.711], 39.717 [35.471-43.964], 30.197 [24.030-36.327], respectively.

Conclusions: Multivariate mathematical models demonstrated an association between hyperexpression of the ITGAV and ITGA6 integrins and GS, and also between the ITGA3 integrin and DFS, in patients with colorectal tumours. A risk scoring system based on detected hyperexpression of 0, 1, or 2 markers (e.g., ITGAV and/or ITGA6) was also found to accurately correlate with the GS curves generated for the present cohort.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0144333PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4682960PMC
June 2016

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances.

Cochrane Database Syst Rev 2015 May 22(5):CD008096. Epub 2015 May 22.

Department of Gastroenterological Surgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil.

Background: A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

Objectives: To evaluate the effectiveness and safety of PEG compared with NGT for adults with swallowing disturbances.

Search Methods: We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to January 2014, and contacted the main authors in the subject area. There was no language restriction in the search.

Selection Criteria: We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment).

Data Collection And Analysis: We used standard methodological procedures expected by The Cochrane Collaboration. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%.

Main Results: We included 11 randomised controlled studies with 735 participants which produced 16 meta-analyses of outcome data. Meta-analysis indicated that the primary outcome of intervention failure, occurred in lower proportion of participants with PEG compared to NGT (RR 0.18, 95% CI 0.05 to 0.59, eight studies, 408 participants, low quality evidence) and this difference was statistically significant. For this outcome, we also subgrouped the studies by endoscopic gastrostomy technique into pull, and push and not reported. We observed a significant difference favouring PEG in the pull subgroup (RR 0.07, 95% CI 0.01 to 0.35, three studies, 90 participants). Thepush subgroup contained only one clinical trial and the result favoured PEG (RR 0.05, 95% CI 0.00 to 0.74, one study, 33 participants) techniques. We found no statistically significant difference in cases where the technique was not reported (RR 0.43, 95% CI 0.13 to 1.44, four studies, 285 participants).There was no statistically significant difference between the groups for meta-analyses of the secondary outcomes of mortality (RR 0.86, 95% CI 0.58 to 1.28, 644 participants, nine studies, very low quality evidence), overall reports of any adverse event at any follow-up time point (ITT analysis, RR 0.83, 95% CI 0.51 to 1.34), 597 participants, 6 studies, moderate quality evidence), specific adverse events including pneumonia (aspiration) (RR 0.70, 95% CI 0.46 to 1.06, 645 participants, seven studies, low quality evidence), or for the meta- analyses of the secondary outcome of nutritional status including weight change from baseline, and mid-arm circumference at endpoint, although there was evidence in favour of PEG for meta-analyses of mid-arm circumference change from baseline (MD 1.16, 95% CI 1.01 to 1.31, 115 participants, two studies), and levels of serum albumin were higher in the PEG group (MD 6.03, 95% CI 2.31 to 9.74, 107 participants).For meta-analyses of the secondary outcomes of time on enteral nutrition, there was no statistically significant difference (MD 14.48, 95% CI -2.74 to 31.71; 119 participants, two studies). For meta-analyses of quality of life measures (EuroQol) outcomes in two studies with 133 participants, for inconvenience (RR 0.03, 95% CI 0.00 to 0.29), discomfort (RR 0.03, 95% CI 0.00 to 0.29), altered body image (RR 0.01, 95% CI 0.00 to 0.18; P = 0.001) and social activities (RR 0.01, 95% CI 0.00 to 0.18) the intervention favoured PEG, that is, fewer participants found the intervention of PEG to be inconvenient, uncomfortable or interfered with social activities. However, there were no significant differences between the groups for pain, ease of learning to use, or the secondary outcome of length of hospital stay (two studies, 381 participants).

Authors' Conclusions: PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure may be more effective and safe compared with NGT. There is no significant difference in mortality rates between comparison groups, or in adverse events, including pneumonia related to aspiration. Future studies should include details of participant demographics including underlying disease, age and gender, and the gastrostomy technique.
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http://dx.doi.org/10.1002/14651858.CD008096.pub4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464742PMC
May 2015

Risk factors associated with outcome in liver retransplantation: multicentric study.

Hepatogastroenterology 2015 Mar-Apr;62(138):341-5

Background/aims: To externally validate the predictive mathematical model of survival designed by Linhares et al. (2006).

Methodology: This retrospective study was conducted on 217 individuals submitted to liver retransplantation from January 2000 to December 2008 in four European centers. The following variables were obtained on the recipient: age, creatinine, urgency of retransplantation and time between transplantation and retransplantation. The Kaplan-Meier survival curve and ROC curve were used to validate the mathematical model.

Results: The present results showed a similar pattern of survival compared to the study of Linhares et al. (2006) concerning the biological variations, when survival curves were compared for each of the four variables analyzed between both samples. When compared, the areas below the ROC curve (aROC) of derivation (0.733) and validation samples (0.593) presented significant difference (p = 0.005), revealing low relationship of sensitivity and specificity between the two curves. Similarity was observed in Kaplan-Meier survival curves.

Conclusion: This study allowed external validation by the Kaplan-Meier survival curves of the predictive mathematical model of survival in liver retransplantation proposed by Linhares et al. (2006). However, validation through the ROC curve, the aROC, evidenced weak discrimination ability.
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June 2015

CT colonography: the value of this method in the view of specialists.

Radiol Bras 2014 May-Jun;47(3):135-40

Professor, Department of Imaging Diagnosis, Escola Paulista de Medicina - Universidade Federal de São Paulo (EPM-Unifesp), MD, Laboratório Fleury-São Paulo, São Paulo, SP, Brazil.

Objective: To map the view of surgeons on the role played by computed tomography colonography (CTC).

Materials And Methods: An electronic questionnaire was sent to members of the Brazilian College of Surgeons. The questionnaire consisted of 16 multiple-choice questions about demographics and general knowledge about CTC.

Results: The authors obtained 144 responses; 90.3% of the specialists were men, 60% with less than 30 years from graduation, 77.1% were gastrointestinal surgeons, 22.9% were general surgeons, 53.5% were involved in academic activity, and 59.7% had their professional activity in cities with more than 500,000 inhabitants. As regards the knowledge about CTC, 84.7% of the respondents knew the method, 70.8% knew how it is performed, 56.9% reported knowing the bowel preparation used for the procedure, 31.3% used the method, and 53.5% knew some CTC service in their city. About half of the respondents did not know the precise indication of the method. The method is most frequently known and used by professionals working in cities with more than 500,000 inhabitants (p < 0.005). There was a tendency of a more frequent use of the method by the professionals pursuing an academic career.

Conclusion: Despite its infrequent use in Brazil, CTC is a well known method, particularly in large urban centers and in the academic environment.
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http://dx.doi.org/10.1590/0100-3984.2013.1837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4337144PMC
March 2015

An evaluation of the protective effect of an infusion of chilled glucose solution on thermal injury of the bile ducts caused by radiofrequency ablation of the liver.

Acta Cir Bras 2015 Jan;30(1):34-45

Department of Surgery, UNIFESP, Sao Paulo, SP, Brazil.

Purpose: To evaluate the protective effects of chilling the bile ducts with cold (5°C) 5% glucose solution (GS) during radiofrequency (RF) administration.

Methods: Twenty male pigs (3 mos. old; 25-30 kg) were subjected to RF delivery with chilling (experimental group, N=10) or without chilling (control group, N=10). Half of the animals in each group were euthanized immediately after the operation, and half were euthanized one week later. The following histological variables in relation to the bile ducts were evaluated by a pathologist (blind examiner): degenerative changes to the epithelium; epithelial necrosis; ulceration, regenerative changes of the epithelium; polymorphonuclear neutrophil infiltration; and thermal effects.

Results: The experimental group (88 bile ducts examined) showed reduced thermal damage relative to the control group (86 bile ducts examined) as demonstrated by significant differences in the following histopathological parameters: epithelial detachment of biliary epithelium (84.1% vs. 59.3%; p<0.006); elongation/palisade arrangement of nuclei (65.1% vs. 87.5%; p<0.001); pseudo-goblet cells (32.9% vs. 56.8%; p<0.001).

Conclusion: Infusion of 5% glucose solution (5°C) has a protective effect on bile ducts subjected to heat (95-110°C, 12 min) from radiofrequency thermal ablation device.
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http://dx.doi.org/10.1590/S0102-86502015001000005DOI Listing
January 2015

Using computed tomography colonography in patients at high risk of colorectal cancer - a prospective study in a university hospital in South America.

Clinics (Sao Paulo) 2014 Nov;69(11):723-30

Division of Abdominal Imaging, Department of Diagnostic Imaging, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil.

Objectives: The purpose of our study was to report the results of the implementation of computed tomography colonography in a university hospital setting serving a Brazilian population at high risk of colorectal cancer.

Methods: After creating a computed tomography colonography service in our institution, 85 patients at high risk of colorectal cancer underwent computed tomography colonography followed by a same-day optical colonoscopy from September 2010 to May 2012. The overall accuracy of computed tomography colonography in the detection of lesions ≥6 mm was compared to that of optical colonoscopy (direct comparison). All colonic segments were evaluated using quality imaging (amount of liquid and solid residual feces and luminal distension). To assess patient acceptance and preference, a questionnaire was completed before and after the computed tomography colonography and optical colonoscopy. Fisher's exact test was used to measure the correlations between colonic distension, discomfort during the exam, exam preference and interpretation confidence.

Results: Thirteen carcinomas and twenty-two lesions ≥6 mm were characterized. The sensitivity, specificity and accuracy of computed tomography colonography were 100%, 98.2% and 98.6%, respectively. Computed tomography colonography was the preferred method of investigation for 85% of patients. The preparation was reported to cause only mild discomfort for 97.6% of patients. According to the questionnaires, there was no significant relationship between colonic distension and discomfort (p>0.05). Most patients (89%) achieved excellent bowel preparation. There was a statistically significant correlation between the confidence perceived in reading the computed tomography colonography and the quality of the preparation in each colonic segment (p≤0.001). The average effective radiation dose per exam was 7.8 mSv.

Conclusion: It was possible to institute an efficient computed tomography colonography service at a university hospital that primarily assists patients from the public health system, with high accuracy, good acceptance and effective radiation doses. Our results seem to be comparable to other centers of excellence and fall within acceptable published guidelines, showing that a successful computed tomography colonography program can be reproduced in a South American population screened in a university hospital.
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http://dx.doi.org/10.6061/clinics/2014(11)03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255077PMC
November 2014

Overexpression of the ITGAV gene is associated with progression and spread of colorectal cancer.

Anticancer Res 2014 Oct;34(10):5599-607

Department of Surgery, São Paulo Federal University, São Paulo, Brazil.

Background/aim: The interaction of neoplastic cells with the extracellular matrix is a critical event for the initiation of cancer invasion and metastasis. We evaluated the relationship between the expression of SPARC, ITGAV, THBS1 and VCAM-1 genes of extracellular matrix in the progression and dissemination of colorectal cancer (CRC).

Patients And Methods: Adult patients (N=114) underwent resection of CRC. Gene expression in CRC was determined by quantitative real-time polymerase chain reaction (PCR). Protein expression was analyzed by immunohistochemistry (IHC). Correlation with pathway-related molecules (p53, Bcl-2, Ki-67, EGFR and VEGF) was assessed.

Results: Tumors with perineural invasion showed overexpression (p=0.028) of the ITGAV gene with regard to cancers without perineural invasion and validation of the result through IHC expression of the corresponding proteins, was significant for the expression of ITGAV protein (p=0.001).

Conclusion: The overexpression of ITGAV gene was associated with higher progression and spread of CRC via perineural invasion.
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October 2014

Association between human Papillomavirus and colorectal adenocarcinoma and its influence on tumor staging and degree of cell differentiation.

Arq Bras Cir Dig 2014 Jul-Sep;27(3):172-6

Federal University of São Paulo, São Paulo, SP, Brazil.

Background: Colorectal cancer is one of the most common types of neoplasia among the worldwide adult population. Among neoplasms of the gastrointestinal tract, it is ranked second in relation to prevalence and mortality, but its etiology is only known in around 5% of the cases. It is believed that 15% of malignant diseases are related to viral oncogenesis.

Aim: To correlate the presence of HPV with the staging and degree of cell differentiation among patients with colorectal adenocarcinoma.

Methods: A retrospective case-control study was conducted on 144 patients divided between a test group of 79 cases of colorectal cancer and a control group to analyze 144 patients aged 25 to 85 years (mean, 57.85 years; standard deviation, 15.27 years and median, 58 years). Eighty-six patients (59.7%) were male. For both groups, tissue samples from paraffin blocks were subjected to DNA extraction followed by the polymerase chain reaction using generic and specific primers for HPV 16 and 18. Dot blot hybridization was also performed with the aim of identifying HPV DNA.

Results: The groups were shown to be homogenous regarding sex, age and site of HPV findings in the samples analyzed. Out of the 41 patients with HPV, 36 (45.6%) were in the cases and five (7.7%) were in the control group (p<0.001). All the HPV cases observed comprised HPV 16, and HPV 18 was not shown in any of the cases studied. There were no significant differences in comparisons of sex, age and site regarding the presence of HPV in either of the groups. It was not observe any significant difference in relation to staging or degree of cell differentiation among the patients with colorectal cancer.

Conclusion: Human papillomavirus type 16 is present in individuals with colorectal carcinoma. However, its presence was unrelated to staging or degree of differentiation.
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http://dx.doi.org/10.1590/s0102-67202014000300003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676375PMC
May 2015

Effect of the celexoxib in microscopic changes of the esophageal mucosal of rats induced by esofagojejunostomy.

Rev Col Bras Cir 2014 May-Jun;41(3):193-7

Department of Morphology, Universidade Federal de Alagoas.

Objective: To evaluate the protective effect of celecoxib in the esophageal mucosa in rats undergoing esofagojejunostomy.

Methods: Sixty male Wistar rats from the vivarium of the University of Health Sciences of Alagoas were used for the experiment. The animals were divided into four groups: Group I, 15 rats undergoing esofagojejunostomy with the use of celecoxib postoperatively; Group II, 15 rats undergoing esofagojejunostomy without the use of celecoxib; Group III, 15 rats undergoing celiotomy with bowel manipulation; and Group IV, 15 rats without surgery and using celecoxib. The observation period was 90 days. After the death of the animals, the distal segment of the esophagus was resected and sent for microscopic analysis.

Results: esofagojejunostomy caused macroscopic and microscopic esophagitis. Esophagitis was equal in both groups I and II. In groups III and IV esophageal lesions were not developed.

Conclusions: celecoxib had neither protective nor inducing effect on esophagitis, but had a protective effect on dysplasia of the animals of group I.
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http://dx.doi.org/10.1590/s0100-69912014000300010DOI Listing
July 2016

Expression profiling using a cDNA array and immunohistochemistry for the extracellular matrix genes FN-1, ITGA-3, ITGB-5, MMP-2, and MMP-9 in colorectal carcinoma progression and dissemination.

ScientificWorldJournal 2014 4;2014:102541. Epub 2014 Mar 4.

Postgraduate Program in Interdisciplinary Surgery Science, UNIFESP-Escola Paulista de Medicina, São Paulo, SP 04023-062, Brazil.

Colorectal cancer dissemination depends on extracellular matrix genes related to remodeling and degradation of the matrix structure. This investigation intended to evaluate the association between FN-1, ITGA-3, ITGB-5, MMP-2, and MMP-9 gene and protein expression levels in tumor tissue with clinical and histopathological neoplastic parameters of cancer dissemination. The expression associations between ECM molecules and selected epithelial markers EGFR, VEGF, Bcl2, P53, and KI-67 have also been examined in 114 patients with colorectal cancer who underwent primary tumor resection. Quantitative real-time PCR and immunohistochemistry tissue microarray methods were performed in samples from the primary tumors. The gene expression results showed that the ITGA-3 and ITGB-5 genes were overexpressed in tumors with lymph node and distant metastasis (III/IV-stage tumors compared with I/II tumors). The MMP-2 gene showed significant overexpression in mucinous type tumors, and MMP-9 was overexpressed in villous adenocarcinoma histologic type tumors. The ECM genes MMP9 and ITGA-3 have shown a significant expression correlation with EGFR epithelial marker. The overexpression of the matrix extracellular genes ITGA-3 and ITGB-5 is associated with advanced stage tumors, and the genes MMP-2 and MMP-9 are overexpressed in mucinous and villous adenocarcinoma type tumors, respectively. The epithelial marker EGFR overactivity has been shown to be associated with the ECM genes MMP-9 and ITGA-3 expression.
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http://dx.doi.org/10.1155/2014/102541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3967625PMC
January 2015

Comparison of the morbidity, weight loss, and relative costs between robotic and laparoscopic sleeve gastrectomy for the treatment of obesity in Brazil.

Obes Surg 2014 Sep;24(9):1420-4

Background: In recent years, there has been renewed interest in using robotics in bariatric surgery for the treatment of morbid obesity. However, the high cost of a robotic surgical system has hindered its widespread use in developing countries. This study aims to compare the rate of morbidity, weight loss, and relative costs between laparoscopic (LSG) and robotic-assisted sleeve gastrectomy (RSG) performed for the treatment of obesity in a single center in Brazil.

Methods: From January 2011 to March 2013, 48 severely obese patients underwent either LSG or RSG at our institution and were prospectively followed up for 12 months. Patients were free to choose either approach and were informed of any extra costs that may be incurred.

Results: Thirty-two patients underwent LSG and 16 patients, RSG. No significant differences were observed between LSG and RSG groups regarding age, sex, BMI, incidence of comorbidities, duration of surgery, and length of hospital stay. Also, there were no significant between-group differences in BMI values evaluated at 6 and 12 months after surgery. Surgical costs were almost twice as high and total hospital costs were approximately 50 % higher in the robotic approach compared to the laparoscopic approach.

Conclusion: Both RSG and LSG had excellent and similar post-operative clinical outcomes. However, the much higher costs of purchasing and maintaining the robotic system are still precluding the use of RSG as a routine approach in the treatment of morbid obesity in Brazil.
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http://dx.doi.org/10.1007/s11695-014-1239-5DOI Listing
September 2014

Intravenous versus inhalational anaesthesia for paediatric outpatient surgery.

Cochrane Database Syst Rev 2014 Feb 7(2):CD009015. Epub 2014 Feb 7.

Department of Surgery/ Discipline of Anesthesiology, Universidade Federal de São Paulo, Rua Napoleão de Barros 715 - 5th floor, São Paulo, São Paulo, Brazil, 04024002.

Background: Ambulatory or outpatient anaesthesia is performed in patients who are discharged on the same day as their surgery. Perioperative complications such as postoperative nausea and vomiting (PONV), postoperative behavioural disturbances and cardiorespiratory complications should be minimized in ambulatory anaesthesia. The choice of anaesthetic agents and techniques can influence the occurrence of these complications and thus delay in discharge.

Objectives: The objective of this review was to evaluate the risk of complications (the risk of postoperative nausea and vomiting (PONV), admission or readmission to hospital, postoperative behavioural disturbances and perioperative respiratory and cardiovascular complications) and recovery times (time to discharge from recovery ward and time to discharge from hospital) comparing the use of intravenous to inhalational anaesthesia for paediatric outpatient surgery.

Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 8); MEDLINE (1948 to 1 October 2013); EMBASE (1974 to 1 October 2013); Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) (1982 to 1 October 2013). We also handsearched relevant journals and searched the reference lists of the articles identified.

Selection Criteria: We included randomized controlled trials comparing paediatric outpatient surgery using intravenous versus inhalational anaesthesia.

Data Collection And Analysis: Two review authors independently assessed trial quality and extracted the data. When necessary, we requested additional information and clarification of published data from the authors of individual trials.

Main Results: We included 16 trials that involved 900 children in this review. Half of all the studies did not describe the generation of randomized sequence and most studies did not describe adequate allocation sequence concealment. The included studies showed variability in the types and combinations of drugs and the duration of anaesthesia, limiting the meta-analysis and interpretation of the results.For the induction and maintenance of anaesthesia there was a significant difference favouring intravenous anaesthesia with propofol; the incidence of PONV was 32.6% for sevoflurane and 16.1% for propofol (odds ratio (OR) 2.96; 95% confidence interval (CI) 1.35 to 6.49, four studies, 176 children, low quality evidence). The risk of postoperative behavioural disturbances also favoured intravenous anaesthesiaas the incidence was 24.7% for sevoflurane and 11.5% for propofol (OR 2.67; 95% CI 1.14 to 6.23, four studies, 176 children, very low quality evidence). There were no differences between groups in the risk of intraoperative and postoperative respiratory and cardiovascular complications (OR 0.75; 95% CI 0.27 to 2.13, three studies,130 children, very low quality evidence) and there was no difference in the time to recovery from anaesthesia and discharge from hospital. These results should be interpreted with caution due to heterogeneity between studies in the type and duration of operations, types of reported complications and the high risk of bias in almost all studies. Two studies (105 participants) compared halothane to propofol and showed heterogeneity in duration of anaesthesia and in the type of ambulatory procedure. For the risk of PONV the results of the studies were conflicting, and for the risks of intraoperative and postoperative complications there were no significant differences between the groups.For the maintenance of anaesthesia there was a significant difference favouring anaesthesia with propofol, with or without nitrous oxide (N2O), when compared to thiopentone and halothane + N2O (OR 3.23; 95% CI 1.49 to 7.02, four studies, 176 children, low quality evidence; and OR 7.44; 95% CI 2.60 to 21.26, two studies, 87 children, low quality evidence), respectively. For the time to discharge from the recovery room, there were no significant differences between groups. The studies were performed with different ambulatory surgeries and a high risk of bias.Four studies (250 participants) compared the induction of anaesthesia by the inhalational or intravenous route, with inhalational anaesthesia for maintenance, and found no significant differences between groups in all outcomes (the risk of PONV, behavioural disturbances, respiratory and cardiovascular complications and time to discharge from recovery room). Meta-analysis was not done in this comparison because of significant clinical heterogeneity.Readmission to hospital was not reported in any of the included studies. No other adverse effects were reported.

Authors' Conclusions: There is insufficient evidence to determine whether intravenous anaesthesia with propofol for induction and maintenance of anaesthesia in paediatric outpatients undergoing surgery reduces the risk of postoperative nausea and vomiting and the risk of behavioural disturbances compared with inhaled anaesthesia. This evidence is of poor quality. More high-quality studies are needed to compare the different types of anaesthesia in different subsets of children undergoing ambulatory surgery.
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http://dx.doi.org/10.1002/14651858.CD009015.pub2DOI Listing
February 2014

Analysis of differentially expressed genes in colorectal adenocarcinoma with versus without metastasis by three-dimensional oligonucleotide microarray.

Int J Clin Exp Pathol 2014 15;7(1):255-63. Epub 2013 Dec 15.

UNIFESP - EPM (Federal University Of Sao Paulo), Escola Paulista de Medicina São Paulo, Brasil.

Background: Our objective was to examine how the gene expression profile of tumor tissue correlates with lymph node metastasis in patients with advanced colorectal adenocarcinoma (CRAC).

Methods: We studied 36 patients (20 men and 16 women, 22-90 years of age) treated for CRAC (classifications of T2, T3, or T4; histological grade of G1 or G2). Amplified tumor mRNA samples were exposed to 20,000 human sequence probes and digitized images of the hybridized samples were analyzed.

Results: On average, 2389 probes were detected above the background, with an average correlation R value of 0.19 between data from different patient groups (with or without lymph node invasion, colon or rectal, with or without angio-lymphatic invasion, with or without recurrence). Lymph node metastasis had a statistically significant signature according to Significance Analysis of Microarrays (SAM) and parametric t-tests, with a false discovery rate (FDR)=0.1% and p=0.001, respectively. Cross-correlation of these two tests identified 102 transcripts as being potentially related to node metastases, with fold changes in the range of 2.182-12.960.

Conclusion: We identified 102 differentially expressed genes related to the presence of lymph node metastases in patients with advanced colorectal cancer.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3885480PMC
September 2014

Expression of integrin genes and proteins in progression and dissemination of colorectal adenocarcinoma.

BMC Clin Pathol 2013 24;13:16. Epub 2013 May 24.

Interdisciplinary Surgery, Federal University of São Paulo, São Paulo, SP, Brazil.

Background: This study aimed to evaluate the relationship between the expression levels of selected integrin genes and proteins and cell differentiation, TNM stage, histological type and other variables potentially associated with the progression and dissemination of colorectal carcinoma (CRC).

Methods: A total of 114 patients (63 men and 51 women) were treated for CRC between 2006 and 2009, including 25 (21.9%) TNM I, 39 (34.2%) TNM II, 34 (29.8%) TNM III, and 16 (14.1%) TNM IV. Regarding grade, 91 (79.8%) were grade II, 14 (12.2%) were grade III and nine (7.8%) were grade I. Reverse-transcription polymerase chain reaction (RT-PCR) and tissue microarray (TMA) methods were used to examine the expression levels of the genes ITGAV, ITGA3, ITGA5, ITGB5, and ITGA6, and their proteins, respectively.

Results: In relation to TNM staging, ITGB5 and ITGA3 were over-expressed in stages III versus I. These results were confirmed by TMA analysis. In terms of age, ITGA5 was under-expressed according to RT-PCR, but over-expressed by TMA in patients over 60 years, while ITGA5 gene and protein levels were increased in mucinous carcinomas. In addition ITGAV gene and protein levels were elevated in tumors with neural invasion, and ITGA6 gene and protein were over-expressed in cases with venous invasion. All these results were significant at P < 0.05.

Conclusion: The results of this study suggest that over-expression of some integrins is associated with TNM III stage, increased risk of vascular and neural invasion, and mucinous histology in patients with CRC.
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http://dx.doi.org/10.1186/1472-6890-13-16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671190PMC
May 2014

Evaluation of breathing exercise in hormonal and immunological responses in patients undergoing abdominal surgery.

Acta Cir Bras 2013 May;28(5):385-90

Department of Surgery, Federal University of Triangulo Mineiro, Uberaba-MG, Brazil.

Purpose: To evaluate the effects of sustained deep inspiration in the prevention of postoperative pulmonary complications, the hormonal and immunological responses in patients submitted to abdominal surgery.

Methods: This randomized clinical trial study included 75 patients submitted to abdominal surgery, of which 36 were randomly allocated in the experimental group and underwent sustained deep inspiration during five seconds, in three sets of ten repetitions per day. The others 39 patients were allocated in the control group and were not submitted to any breathing exercise. The following parameters were measured preoperatively, 24h and 48h postoperatively: chest x-ray, serum ACTH, cortisol, IL-4, IL-10, TNF-α, forced expiratory volume in first second (FEV1), forced expiratory flow 25-75% (FEF 25-75), forced vital capacity (FVC), paO2 and paCO2.

Results: Mean serum cortisol in patients of the experimental and control groups before surgery were 12.8 mcg/dl (4.6-50) and 10.48 mcg/dl (1-29.1), respectively (p=0.414). The experimental group had significantly increase in serum cortisol levels, 23.6 mcg/dl (9.3-45.8), especially 24h postoperatively (p=0.049).

Conclusion: Sustained deep inspiration in patients submitted to abdominal surgery determined important changes in serum cortisol, however, without significantly influence the postoperative pulmonary complications and the endocrine and immune responses.
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http://dx.doi.org/10.1590/s0102-86502013000500011DOI Listing
May 2013

Effects of preoperative irradiation using fractioned electron beam on the healing process of colocolonic anastomosis in rats undergoing early and late surgical intervention.

Acta Cir Bras 2013 Jan;28(1):72-7

Postgraduate Program in Surgical Gastroenterology, UNIFESP, Sao Paulo, Brasil.

Purpose: To investigate the effects of preoperative fractioned irradiation using an electron beam on the healing process of colocolonic anastomoses in rats that underwent early and late surgical intervention.

Methods: Thirty Wistar rats, distributed as follows: group A (surgery only), group B (fractionated irradiation for 30 days (if), surgery seven days after the end of it), group C (if for 30 days, and surgery after 30 days of termination). On the seventh postoperative day the anastomotic segment analysis was taken, using tension tests, histology and collagen deposition evaluation by computerized analysis.

Results: Regarding the tension resistance of the anastomosis, there were no statistical differences (p=0.42). However, a significant increase in cells number in the inflammatory infiltrate in the group with a longer interval between surgery and pre op radiation (p<0.05). The collagen concentration had no significant variance.

Conclusion: The irradiation in divided doses increased local inflammatory cellularity when the surgery was performed later. This result did not affect the increase of complications, nor on the local concentration of collagen, achieving similar clinical outcomes.
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http://dx.doi.org/10.1590/s0102-86502013000100012DOI Listing
January 2013

Relationship between the expression of the extracellular matrix genes SPARC, SPP1, FN1, ITGA5 and ITGAV and clinicopathological parameters of tumor progression and colorectal cancer dissemination.

Oncology 2013 31;84(2):81-91. Epub 2012 Oct 31.

Postgraduate Program in Interdisciplinary Surgery, Federal University of São Paulo, São Paulo, Brazil.

Objective: To evaluate the relationship between the expression of the extracellular matrix (ECM) genes SPARC, SPP1, FN1, ITGA5 and ITGAV and the histopathologic parameters of neoplastic progression and colorectal carcinoma (CRC) dissemination.

Methods: A retrospective study was conducted in 114 patients with stage I-IV CRC who underwent primary tumor resection. Quantitative real-time PCR and immunohistochemistry (IHC) assays were performed in samples obtained from the primary tumors. The correlation between the expression of these markers and the expression of p53, Bcl-2, Ki67, epidermal growth factor receptor (EGFR) and vascular endothelial growth factor was assessed with the Spearman coefficient (r).

Results: The ITGAV gene was found to be significantly amplified in tumors with positive perineural invasion (p = 0.028). Expression of the SPARC, SPP1, FN1, ITGA5 and ITGAV genes did not correlate with TNM staging. A direct relationship between ITGAV and EGFR expression (r = 0.774; p < 0.001) was observed by IHC.

Conclusions: ECM gene expression did not correlate with classical prognostic factors for CRC, but overexpression of the ITGAV gene and protein was correlated with an increased risk of perineural invasion. The relationship between ITGAV and EGFR expression suggests the possibility of crosstalk in this signal pathway.
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http://dx.doi.org/10.1159/000343436DOI Listing
February 2013

Evaluation of the clinical and inflammatory responses in exclusively NOTES transvaginal cholecystectomy versus laparoscopic routes: an experimental study in swine.

Surg Endosc 2012 Nov 23;26(11):3232-44. Epub 2012 Jun 23.

Department of Surgery, Maranhão Federal University (UFMA), São Luís, Maranhão, Brazil.

Background: The aim of this study was to evaluate the clinical and inflammatory responses to surgical trauma caused by the natural orifice transluminal endoscopic surgery (NOTES) transvaginal endoscopic procedure compared with those of the laparoscopic route.

Methods: Twenty-one female swine were divided into three groups of seven animals and subjected to cholecystectomy using laparoscopic, laparotomic, and exclusively NOTES transvaginal routes. A group of five animals served as a control. The animals were monitored during surgery to evaluate anesthetic/surgical time and the presence of complications, which were evaluated after surgery with respect to roaming time, feeding, and the presence of clinical occurrence Measurements of TNF-α, IL-1β, IL-6, CRP, IFN-γ were obtained before and after surgery, on the second and seventh postoperative days, and when the animals were killed and necropsied.

Results: All procedures were successfully completed as proposed in each group. Perioperative complications consisted of only gallbladder perforation and hepatic bleeding. The anesthetic/surgical time was longer in the NOTES vaginal group (p < 0.001). The postanesthetic recovery time, roaming, nutrition, and clinical evolution were similar in all groups. IL-1β and IL-6 were undetectable in all groups. Levels of TNF-α, CRP, and IFN-γ were similar among the groups. However, the evolution of the inflammatory process, measured as the difference between the peak dose and the basal dose of IFN-γ, was lower in the NOTES group than in the laparotomy group. In the necropsy findings, only adhesions were found, with no difference among the groups.

Conclusions: The entirely NOTES transvaginal cholecystectomy was feasible and safe. The surgical time was greater for the NOTES vaginal route. The inflammatory response was similar among the groups based on the levels of CRP and IFN-γ. However, the evolution of the inflammatory process seems to have been shorter in the vaginal NOTES group than in the laparotomy group as demonstrated by the difference between the peak and basal doses of IFN-γ.
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http://dx.doi.org/10.1007/s00464-012-2329-xDOI Listing
November 2012

Relationship between the preoperative body mass index and the resolution of metabolic syndrome following Roux-en-Y gastric bypass.

Metab Syndr Relat Disord 2012 Aug 30;10(4):292-6. Epub 2012 Apr 30.

Department of Surgical Gastroenterology, Federal University of São Paulo-Paulista School of Medicine, São Paulo, Brazil.

Background: The increased prevalence of overweight and obesity has reached alarming proportions worldwide and has serious health implications, including an association with an increase in metabolic syndrome. Among the methods to control metabolic syndrome, bariatric surgery plays an important role and can provide a significant improvement in the components of metabolic syndrome.

Objective: The aim of this study was to determine the relationship between the preoperative body mass index (BMI) and the postoperative resolution of metabolic syndrome [using the National Cholesterol Education Program (NCEP ATP III criteria)] in patients undergoing Roux-en-Y gastric bypass (RYGB).

Methods: Retrospective analysis of a consecutive series of cases, stratified by BMI into three groups (group 1, BMI <40 kg/m(2), group 2, BMI 40-49.9 kg/m(2), and group 3, BMI 50 ≥ kg/m(2)) consisting of both sexes between 20 and 60 years of age. The cohort consisted of 149 patients undergoing RYGB. Anthropometric, biochemical, and clinical evaluations were performed preoperatively and then at 30 and 180 days postoperatively.

Results: The average age was 40 years, and the patients were predominately female (72%). At the end of the study period, all groups showed a significant reduction in metabolic syndrome compared with preoperative levels. Logistic regression showed a higher percentage of metabolic syndrome in patients in group 3 after 180 days.

Conclusion: There was significant resolution of metabolic syndrome in all groups, independently of the preoperative BMI. However, in group 3 (BMI ≥ 50 kg/m(2)), 22% of individuals still presented with metabolic syndrome at 180 days postoperatively (P=0.03).
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http://dx.doi.org/10.1089/met.2012.0014DOI Listing
August 2012

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances.

Cochrane Database Syst Rev 2012 Mar 14(3):CD008096. Epub 2012 Mar 14.

Gastroenterological Surgery, UNIFESP - Escola Paulista deMedicina, São Paulo, Brazil.

Background: A number of conditions compromise the passage of food along the digestive tract. Nasogastric tube (NGT) feeding is a classic, time-proven technique, although its prolonged use can lead to complications such as lesions to the nasal wing, chronic sinusitis, gastro-oesophageal reflux, and aspiration pneumonia. Another method of infusion, percutaneous endoscopy gastrostomy (PEG), is generally used when there is a need for enteral nutrition for a longer time period. There is a high demand for PEG in patients with swallowing disorders, although there is no consistent evidence about its effectiveness and safety as compared to NGT.

Objectives: To evaluate the effectiveness and safety of PEG as compared to NGT for adults with swallowing disturbances, by updating our previous Cochrane review.

Search Methods: We searched The Cochrane Library, MEDLINE, EMBASE, and LILACS from inception to September 2011, as well as contacting main authors in the subject area. There was no language restriction in the search.

Selection Criteria: We planned to include randomised controlled trials comparing PEG versus NGT for adults with swallowing disturbances or dysphagia and indications for nutritional support, with any underlying diseases. The primary outcome was intervention failure (e.g. feeding interruption, blocking or leakage of the tube, no adherence to treatment).

Data Collection And Analysis: Review authors performed selection, data extraction and evaluation of methodological quality of studies. For dichotomous and continuous variables, we used risk ratio (RR) and mean difference (MD), respectively with the random-effects statistical model and 95% confidence interval (CI). We assumed statistical heterogeneity when I² > 50%.

Main Results: We included nine randomised controlled studies. We did not identify new eligible studies published after our previous review literature search date (August 2009). Intervention failure occurred in 19/156 patients in the PEG group and 63/158 patients in the NGT group (RR 0.24, 95%CI 0.08 to 0.76, P = 0.01) in favour of PEG. There was no statistically significant difference between comparison groups in complications (RR 1.00, 95%CI 0.91 to 1.11, P = 0.93).

Authors' Conclusions: PEG was associated with a lower probability of intervention failure, suggesting the endoscopic procedure is more effective and safe as compared to NGT. There is no significant difference of mortality rates between comparison groups, and pneumonia irrespective of underlying disease (medical diagnosis). Future studies should include previously planned and executed follow-up periods, the gastrostomy technique, and the experience of the professionals to allow more detailed subgroup analysis.
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http://dx.doi.org/10.1002/14651858.CD008096.pub3DOI Listing
March 2012

Accuracy of preoperative biopsies compared with surgical specimens in the diagnosis of colorectal adenocarcinoma.

Int J Surg Pathol 2012 Aug 13;20(4):355-9. Epub 2012 Mar 13.

Paulista Medical School, Universidade Federal de São Paulo, São Paulo, Brazil.

Objective: Since the first data from a patient with colorectal adenocarcinoma are obtained by biopsy, this study evaluated the accuracy of diagnosis by biopsy as compared with the diagnostic potential of the surgical specimen, considering the histological type, grade of differentiation, and immunohistochemical expression of p53.

Methods: The specimens were obtained from 80 patients assisted at Hospital São Paulo. The biopsy and surgical specimen sections were stained by hematoxylin-eosin and immunohistochemistry and compared by 3 pathologists blinded to the evaluations.

Results: The accuracy for the histological types was 88%. The grade of differentiation presented an accuracy of 70% with Kappa = .48. The expression of protein p53 exhibited an accuracy of 68% with Kappa = .22.

Conclusion: The preoperative biopsy of colorectal adenocarcinoma presented good accuracy compared with histopathological examination of the surgical specimen, but with weak to moderate effective degree of agreement between the results.
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http://dx.doi.org/10.1177/1066896912437412DOI Listing
August 2012

Stapled versus handsewn methods for colorectal anastomosis surgery.

Cochrane Database Syst Rev 2012 Feb 15(2):CD003144. Epub 2012 Feb 15.

Interdisciplinary Surgical Science Program,UNIFESP-Escola Paulista deMedicina, São Paulo, Brazil.

Background: Previous systematic reviews comparing stapled and handsewn colorectal anastomosis that are available in the medical literature have not shown either technique to be superior. An update of this systematic review was performed to find out if there are any data that properly answer this question.

Objectives: To compare the safety and effectiveness of stapled and handsewn colorectal anastomosis surgery. The following primary hypothesis was tested: the stapled technique is more effective because it decreases the level of complications.

Search Methods: A computerized search was performed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE according to the strategies of the Colorectal Cancer Group of The Cochrane Collaboration. There were no limits upon language, date or other criteria. A revised search strategy was performed for this updated version of the review May 2011.

Selection Criteria: All randomised controlled trials (RCTs) in which stapled and handsewn colorectal anastomosis techniques were compared. Participants were adult patients undergoing elective colorectal anastomosis surgery. The interventions were endoluminal circular stapler and handsewn colorectal anastomosis surgery. Outcomes considered were a) mortality; b) overall anastomotic dehiscence; c) clinical anastomotic dehiscence; d) radiological anastomotic dehiscence; e) stricture; f) anastomotic haemorrhage; g) reoperation; h) wound infection; i) anastomosis duration; and j) hospital stay.

Data Collection And Analysis: Data were independently analysed by the two review authors (CBN, SASL) and cross-checked. The methodological quality of each trial was assessed by the same two authors. After searching the literature for this update, no study was added to those in the previous version of this review. Details of randomizations (generation and concealment), blinding, whether an intention-to-treat analysis was done or not, and the number of patients lost to follow-up were recorded. The analysis of the risk of bias was updated according to the software Review Manager 5.1. The results of each RCT were summarized on an intention-to-treat basis in 2 x 2 tables for each outcome. External validity was defined by the characteristics of the participants, interventions and the outcomes. The RCTs were stratified according to the level of colorectal anastomosis. The risk difference (RD) method (random-effects model) and number needed to treat (NNT) for dichotomous outcome measures and weighted mean differences (WMD) for continuous outcomes measures, with the corresponding 95% confidence intervals (CI), were presented in this review. Statistical heterogeneity was evaluated using a funnel plot and the Chi(2) test.

Main Results: Of the 1233 patients enrolled in nine identified trials, 622 were treated with staples and 611 with manual suture. The following main results were obtained. a) Mortality, result based on 901 patients: RD -0.6%, 95% CI -2.8% to +1.6%. b) Overall dehiscence, result based on 1233 patients: RD 0.2%, 95% CI -5.0% to +5.3%. c) Clinical anastomotic dehiscence, result based on 1233 patients: RD -1.4%, 95% CI -5.2 to +2.3%. d) Radiological anastomotic dehiscence, result based on 825 patients: RD 1.2%, 95% CI -4.8% to +7.3%. e) Stricture, result based on 1042 patients: RD 4.6%, 95% CI 1.2% to 8.1%; NNT 17, 95% CI 12 to 31. f) Anastomotic haemorrhage, result based on 662 patients: RD 2.7%, 95% CI -0.1% to +5.5%. g) Reoperation, result based on 544 patients: RD 3.9%, 95% CI 0.3% to 7.4%. h) Wound infection, result based on 567 patients: RD 1.0%, 95% CI -2.2% to +4.3%. i) Anastomosis duration, result based on one study (159 patients): WMD -7.6 minutes, 95% CI -12.9 to -2.2 minutes. j) Hospital stay, result based on one study (159 patients): WMD 2.0 days, 95% CI -3.27 to +7.2 days.

Authors' Conclusions: The evidence found was insufficient to demonstrate any superiority of stapled over handsewn techniques in colorectal anastomosis surgery, regardless of the level of anastomosis. There were no randomised clinical trials comparing these two types of anastomosis in elective conditions in the last decade. The relevance of this research question has possibly lost its strength where elective surgery is concerned. However, in risk situations, such as emergency surgery, trauma and inflammatory bowel disease, new clinical trials are needed.
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http://dx.doi.org/10.1002/14651858.CD003144.pub2DOI Listing
February 2012

Liver re-transplantation: internal validation of a predictive mathematical model of survival.

Hepatogastroenterology 2012 Jun;59(116):1230-3

Department of Surgical Gastroeneterology, Federal University of Sao Paulo, Sao Paulo, Brazil.

Background/aims: Because of the worse results from re-transplantation, a model for determining the long-term survival has been previously developed. Its effectiveness had to be tested and validated, as proposed in this study, using a different sample population than the one used to build it.

Methodology: Age, recipient creatinine, urgency of re-transplantation, interval between primary liver transplant and re-transplantation (RETx) of 92 patients that received first liver RETx, from a different sample of patients, in a different time period than those used to develop the initial model. The proposed mathematical model was used to predict survival at six months after undergoing liver RETx. We compared the areas under the ROC curves (AROC) corresponding to the two independent samples (derivation and validation samples). By the log-rank technique, the survival curves were also compared and classified into tertiles according to the risk scores of the original model: high risk (>32), medium risk (24-32) and low risk (<24).

Results: Age, creatinine, time between primary liver transplant and re-transplantation and the urgency with which patients were enrolled, had comparable survival curves among the derivation and validation samples. When comparing the AROC of the derivation (0.733) and validation (0.741) samples, there was no statistically significant difference (p=0.915), therefore sensitivity and specificity ratios between the two are similar.

Conclusions: This study made it possible to internally validate the original model for predicting survival at six months after undergoing liver RETx, although an external validation still needs to be done.
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http://dx.doi.org/10.5754/hge11719DOI Listing
June 2012

Co-expression of monocarboxylate transporter 1 (MCT1) and its chaperone (CD147) is associated with low survival in patients with gastrointestinal stromal tumors (GISTs).

J Bioenerg Biomembr 2012 Feb 27;44(1):171-8. Epub 2012 Jan 27.

Departments of Digestive Surgery and Pathology and Centre for Researcher Support, Barretos Cancer Hospital, Pio XII Foundation, Barretos, São Paulo, Brazil.

Monocarboxylate transporters (MCTs) have been described to play an important role in cancer, but to date there are no reports on the significance of MCT expression in gastrointestinal stromal tumors (GISTs). The aim of the present work was to assess the value of MCT expression, as well as co-expression with the MCT chaperone CD147 in GISTs and evaluate their clinical-pathological significance. We analyzed the immunohistochemical expression of MCT1, MCT2, MCT4 and CD147 in a series of 64 GISTs molecularly characterized for KIT, PDGFRA and BRAF mutations. MCT1, MCT2 and MCT4 were highly expressed in GISTs. CD147 expression was associated with mutated KIT (p = 0.039), as well as a progressive increase in Fletcher's Risk of Malignancy (p = 0.020). Importantly, co-expression of MCT1 with CD147 was associated with low patient's overall survival (p = 0.037). These findings suggest that co-expression of MCT1 with its chaperone CD147 is involved in GISTs aggressiveness, pointing to a contribution of cancer cell metabolic adaptations in GIST development and/or progression.
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http://dx.doi.org/10.1007/s10863-012-9408-5DOI Listing
February 2012
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