VAGNER BIRK JEISMANN
Projetos de Pesquisa
Unidades Organizacionais
Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
24 resultados
Resultados de Busca
Agora exibindo 1 - 10 de 24
- Guidelines for the Treatment of Hepatocellular Adenoma in the Era of Molecular Biology: An Experience-Based Surgeons' Perspective(2021) HERMAN, Paulo; FONSECA, Gilton Marques; KRUGER, Jaime Arthur Pirola; JEISMANN, Vagner Birk; COELHO, Fabricio FerreiraBackground Hepatocellular adenoma (HA) is a rare benign liver tumor with increasing incidence affecting young women. In the last years, much has changed in diagnosis, classification, and treatment, due to the identification of different molecular subtypes. With the evolving knowledge, especially on molecular characteristics of the disease, we are far from a consensus of how to deal with such a multifaceted benign disease Methods In the last 20 years, we have treated 134 patients with HA with a mean age of 28 years, being 126 women. Fifty patients had a history of abdominal pain and 13 patients had an acute episode of pain due to rupture and bleeding. Until 2009, adenomas larger than 4 cm in diameter were resected, regardless of gender. From 2010 to 2016, only adenomas larger than 5 cm were referred for surgical treatment. Since 2016, resection was indicated in all female patients with non-steatotic adenomas larger than 5 cm and all adenomas in men. Results and Discussion One hundred twenty-four patients were submitted to resection, being in 21 major resections. Since 2010, 74% of resections were done laparoscopically. Patients with ruptured adenomas were treated with transarterial embolization. Morbidity rate was 8.1% with no mortality. Authors discuss point-by-point all the aspects and presentations of the disease and the best approach. We proposed a therapeutic guideline based on the best available evidence and in our experience. Conclusions Due to the complexity of the disease, the treatment of HA is one the best examples of an individualized approach.
- Laparoscopic Right Hepatectomy for Cirrhotic Patients: Takasaki's Hilar Control and Caudal Approach(2017) KRUGER, Jaime Arthur Pirola; FONSECA, Gilton Marques; COELHO, Fabricio Ferreira; JEISMANN, Vagner; HERMAN, PauloCirrhotic patients bearing hepatocellular carcinomas (HCC) derive benefits from laparoscopic hepatectomy1 (-) 6 such as reduced bleeding, less overall and liver-specific complications, and fewer adhesions in the case of future reoperation or transplantation.7 (-) 10 Bleeding is concerning in the setting of cirrhosis,11 (-) 15 and adequate inflow control reduces blood loss. The caudal approach is the laparoscopic counterpart of the anterior approach to open surgery. It implies in parenchymal transection initiated from the visceral surface of the liver after limited hepatic mobilization, reducing the risk of increased circulating tumoral cells.16 (-) 18 Venous outflow transection and completion of ligament mobilization are left as last steps. A 46 years-old-male with hepatitis C virus and alcoholic cirrhosis was diagnosed with a 4-cm HCC (right hepatic lobe). Expected future liver remnant was 45 % of his total liver volume. A totally laparoscopic right hepatectomy was performed using six ports, and the specimen was removed through a Pfannenstiel auxiliary incision. A 10-mm 30A degrees scope was used. The pneumoperitoneum pressure was set to 12 mmHg. The right hepatic pedicle, the caudate lobe, and the major hepatic veins were managed with laparoscopic vascular staplers. Surgery was performed with limited liver mobilization and en bloc extrafascial right pedicle control (Takasaki's technique),19 followed by caudal parenchymal transection along the paracaval plane. The operative time was 450 min, and the estimated blood loss was 800 ml (no transfusion was required). The laparoscopic Takasaki technique and caudal approach are feasible procedures in the setting of cirrhosis, resulting in an oncologic adequate intervention with less morbidity.
- Repeat hepatectomy for recurrent colorectal liver metastases: A comparative analysis of short- and long-term results(2022) COSTA, Paulo Figueiredo; COELHO, Fabricio Ferreira; JEISMANN, Vagner Birk; KRUGER, Jaime Arthur Pirola; FONSECA, Gilton Marques; CECCONELLO, Ivan; HERMAN, PauloBackground: Liver recurrence after resection of colorectal liver metastases (CRLM) is frequent. Repeat hepatectomy has been shown to have satisfactory perioperative results. However, the long-term outcomes and the benefits for patients with early recurrence have not been clarified. The aim of this study was to compare the short-and long-term outcomes of patients undergoing single hepatectomy and repeat hepatectomy for CRLM. Additionally, the oncological outcomes of patients with early (& LE; 6 months) and late recurrence who underwent repeat hepatectomy were compared. Methods: Consecutive adult patients undergoing hepatectomy for CRLM between June 20 0 0 and February 2020 were included and divided into two groups: single hepatectomy and repeat hepatectomy. Results: A total of 709 patients were included: 649 in the single hepatectomy group and 60 in the repeat hepatectomy group. Patients in the repeat hepatectomy group underwent more cycles of preoperative chemotherapy [4 (3-6) vs. 3 (2-4), P = 0.003]. Patients in the single hepatectomy group more frequently underwent major hepatectomies (34.5% vs. 16.7%, P = 0.004) and had a greater number of lesions resected (2.9 & PLUSMN; 3.6 vs. 1.9 & PLUSMN; 1.8, P = 0.011). There was no increase in operative time, estimated blood loss, length of hospital stay, complications, or mortality in the repeat hepatectomy group. There were no differences in overall survival ( P = 0.626) and disease-free survival ( P = 0.579) between the two groups. Similarly, for patients underwent repeat hepatectomy, no difference was observed between the early and late recurrence groups in terms of overall survival ( P = 0.771) or disease-free survival ( P = 0.350). Conclusions: Repeat hepatectomy is feasible and safe, with similar short-and long-term outcomes when compared to single hepatectomy. Surgical treatment of early liver recurrence offers similar oncological outcomes to those obtained for late recurrence.
- Laparoscopic vs. open left lateral sectionectomy: An update meta-analysis of randomized and non-randomized controlled trials(2019) MACACARI, Rodrigo Luiz; COELHO, Fabricio Ferreira; BERNARDO, Wanderley Marques; KRUGER, Jaime Arthur Pirola; JEISMANN, Vagner Birk; FONSECA, Gilton Marques; CESCONETTO, Danielle Menezes; CECCONELLO, Ivan; HERMAN, PauloBackground: Left lateral sectionectomy (LLS) is thought to be the anatomical liver resection most suitable for the laparoscopic approach. Despite increasing popularity, comparative analysis of laparoscopic and open LLS are mostly limited to retrospective, underpowered studies with small sample size. Recent population-based studies and prospective trials have generated new data; however, this new body of knowledge has not been submitted systematic reviews or meta-analyses and high quality evidence regarding the actual benefits of minimally invasive LLS is lacking. Methods: Systematic review of studies published until December 31st, 2017 and indexed in Medline, EMBASE, Cochrane Library Central and Scielo/LILACS databases. Randomized controlled trials and observational studies comparing perioperative results of laparoscopic and open LLS were included. Studies with patients submitted to LLS for living donation were excluded. Treatment outcomes, including conversion rates, estimated blood loss, transfusion rates, operative time, length of in-hospital stay, morbidity and mortality rates, were evaluated. Results: The primary search yielded 2838 articles, 23 of which (21 observational studies and 2 randomized controlled trials; 3415 patients) were included in the meta-analysis. Overall conversion rate was 7.4%. Patients submitted to laparoscopic LLS had less blood loss (mean difference, MD = - 119.81 ml, 95% CI = - 127.90, - 111.72, P < .00001, I-2 = 32%, N = 618), lower transfusion rates (4.1% vs. 10.1%; risk difference, RD = - 0.06, 95% CI = - 0.08, - 0.05, P < .00001, I-2 = 13%, N = 2968) and shorter length of in-hospital stay (MD = - 2.02 days, 95% CI = - 2.15, - 1.89, P < .00001, I-2 = 77%, N= 3160) compared to those undergoing open surgery. Marginally decreased overall complication (21.4% vs. 27.5%; RD = -0.03, 95% CI = - 0.06, 0.00, P =. 05, I-2 = 0%, N= 3268) and perioperative mortality (0.3% vs. 1.5%; RD = - 0.01, 95% CI = - 0.02, - 0.00, P =. 01, I-2 = 0%; N= 3332) rates were also observed. Operative time and biliary, cardiac or pulmonary complication rates did not differ significantly between groups. Conclusion: Current evidence supports the safety and feasibility of laparoscopic LLS. The laparoscopic approach is associated with reduced blood loss, lower transfusion rates and shorter length of in-hospital stay and should be considered the gold-standard for LLS.
- Combined liver and multivisceral resections: A comparative analysis of short and long-term outcomes(2020) JUNIOR, Sergio S.; COELHO, Fabricio F.; TUSTUMI, Francisco; CASSENOTE, Alex J. F.; JEISMANN, Vagner B.; FONSECA, Gilton M.; KRUGER, Jaime A. P.; ERNANI, Lucas; CECCONELLO, Ivan; HERMAN, PauloBackground En bloc liver and adjacent organs resections are technically demanding procedures. Few case series and nonmatched comparative studies reported the outcomes of multivisceral liver resections (MLRs). Objectives To compare the short and long-term outcomes of patients submitted MLRs with those submitted to isolated hepatectomies. Methods From a prospective database, a case-matched 1:2 study was performed comparing MLRs and isolated hepatectomy. Additionally, a risk analysis was performed to evaluate the association between MLRs and perioperative morbidity, mortality, and long-term survival. Results Fifty-three MLRs were compared with 106 matched controls. Patients undergoing MLRs had longer operative time (430 [320-525] vs 360 [270-440] minutes,P = .005); higher estimated blood loss (600 [400-800] vs 400 [100-600] mL;P = .011); longer hospital stay (8 [6-14] vs 7 [5-9] days;P = .003); and higher postoperative mortality (9.4% vs 1.9%,P = .042). Number of resected organs was not an independent prognostic factor for perioperative major complications (odds ratio [OR], 1 organ = 1.8 [0.54-6.05]; OR >= 2, organs = 4.0 [0.35-13.84]) or perioperative mortality (OR, 1, organ = 5.2 [0.91-29.51]; OR >= 2, organs = 6.5 [0.52-79.60]). No differences in overall (P = .771) and disease-free survival (P = .28) were observed. Conclusion MLRs are feasible with acceptable morbidity but relatively high perioperative mortality. MLRs did not negatively affect long-term outcomes.
- Prognostic significance of poorly differentiated clusters and tumor budding in colorectal liver metastases(2018) FONSECA, Gilton M.; MELLO, Evandro S. de; FARAJ, Sheila F.; KRUGER, Jaime A. P.; COELHO, Fabricio F.; JEISMANN, Vagner B.; LUPINACCI, Renato M.; CECCONELLO, Ivan; ALVES, Venancio A. F.; PAWLIK, Timothy M.; HERMAN, PauloBackgroundHistomorphological features have been described as prognostic factors after resection of colorectal liver metastases (CLM). The objectives of this study were to assess the prognostic significance of tumor budding (TB) and poorly differentiated clusters (PDC) among CLM, and their association with other prognostic factors. MethodsWe evaluated 229 patients who underwent a first resection of CLM. Slides stained by HE were assessed for TB, PDC, tumor border pattern, peritumoral pseudocapsule, peritumoral, and intratumoral inflammatory infiltrate. Lymphatic and portal invasion were evaluated through D2-40 and CD34 antibody. ResultsFactors independently associated with poor overall survival were nodules>4 (P=0.002), presence of PDC G3 (P=0.007), portal invasion (P=0.005), and absence of tumor pseudocapsule (P=0.006). Factors independently associated with disease-free survival included number of nodules>4 (P<0.001), presence of PDC G3 (P=0.005), infiltrative border (P=0.031), portal invasion (P=0.006), and absent/mild peritumoral inflammatory infiltrate (P=0.002). PDC and TB were also associated with histological factors, as portal invasion (TB), peritumoral inflammatory infiltration (PDC), infiltrative border, and absence of tumor pseudocapsule (TB and PDC). ConclusionsThis is the first study demonstrating PDC as a prognostic factor in CLM. TB was also a prognostic factor, but it was not an independent predictor of survival.
- Treatment of hepatocellular carcinoma with macroscopic vascular invasion: A systematic review and network meta-analysis(2023) TUSTUMI, Francisco; COELHO, Fabricio Ferreira; MAGALHAES, Daniel de Paiva; SILVEIRA JUNIOR, Sergio; JEISMANN, Vagner Birk; FONSECA, Gilton Marques; KRUGER, Jaime Arthur Pirola; D'ALBUQUERQUE, Luiz Augusto Carneiro; HERMAN, PauloBackground: This study aimed to evaluate the outcomes of different treatments for patients with hepatocellular carcinoma (HCC) and macroscopic vascular invasion.Methods: A systematic review and meta-analysis of comparative studies was performed to evaluate various treatment modalities for HCC with macroscopic vascular invasion, including liver resection (LR), liver trans-plantation (LT), transarterial chemoembolization (TACE), transarterial radioembolization (TARE), radiotherapy (RT), radiofrequency ablation (RFA), and antineoplastic systemic therapy (AnST).Results: After applying the selection criteria, 31 studies were included. The surgical resection (SR) group (including LR and LT) had a similar mortality rate to the non-surgical resection (NS) group (RD =-0.01; 95% CI-0.05 to 0.03). The SR group had a higher rate of complications (RD = 0.06; 95% CI 0.00 to 0.12) but a higher 3-year overall survival (OS) rate than the NS group (RD = 0.12; 95% CI 0.05 to 0.20). The network analysis revealed that the overall survival was lower in the AnST group. LT and LR had similar survival benefits. The meta-regression suggested that SR has a greater impact on the survival of patients with impaired liver function.Discussion: Most likely, LT has a significant impact on long-term survival and consequently would be a better option for HCC with macroscopic vascular invasion in patients with impaired liver function. LT and LR offer a higher chance of long-term survival than NS alternatives, although LR and LR are associated with a higher risk of procedure-related complications.
- Infiltrative Tumor Borders in Colorectal Liver Metastasis: Should We Enlarge Margin Size?(2021) JAYME, Vitoria Ramos; FONSECA, Gilton Marques; AMARAL, Isaac Massaud Amim; COELHO, Fabricio Ferreira; KRUGER, Jaime Arthur Pirola; JEISMANN, Vagner Birk; PINHEIRO, Rafael Soares Nunes; MELLO, Evandro Sobroza de; HERMAN, PauloBackground Surgery is the only potentially curative treatment for colorectal cancer liver metastases (CRLMs). Despite an improvement in results following resection, recurrence rates remain high. Many histopathological features have been reported as prognostic factors. Infiltrative borders are known to be associated with worse prognosis; however, margin size has never been evaluated together with the type of tumor border. In the present study, we analyzed the prognosis of patients with resected CRLM according to tumor growth pattern (TGP) and whether a larger margin size would bring any prognostic benefit. Patients and Methods Medical records from a prospective database of 645 patients who underwent hepatic resection for CRLM between January 2004 and December 2019 at a single center were reviewed, and 266 patients were included in the analytic cohort. TGP (pushing or infiltrative) was evaluated regarding the impact in overall and disease-free survival. The impact of margin size (<= or > 1 cm) on survival and hepatic recurrence according to TGP was also evaluated. Results TGP was defined as infiltrative in 182 cases (68.4%) and pushing in 84 patients (31.6%). Patients with infiltrative-type border presented worse overall survival and disease-free survival, as well as higher intrahepatic recurrence (p < 0.05). Larger margin size did not impact the prognosis of patients with infiltrative borders. Conclusions Patients with infiltrative-type border present worse prognosis and higher intrahepatic recurrence. Larger margin size (> 1 cm) does not change the prognosis in patients with infiltrative border, showing that tumor biology is the most important factor for survival.
- Evolution in the surgical management of colorectal liver metastases: Propensity score matching analysis (PSM) on the impact of specialized multidisciplinary care across two institutional eras(2018) KRUGER, Jaime A. P.; FONSECA, Gilton M.; MAKDISSI, Fabio F.; JEISMANN, Vagner B.; COELHO, Fabricio F.; HERMAN, PauloBackground and Objectives: Liver metastases are indicators of advanced disease in patients with colorectal cancer. Liver resection offers the best possibility of long-term survival. Surgical strategies have evolved in complexity in order to offer resection to a greater number of patients, requiring specialized multidisciplinary care. The current paper focused on analyzing outcomes of patients treated after the development of a dedicated cancer center in our institution. Methods: Patients operated on for CLM from our databank were paired through propensity score matching (PSM), and the initial experience of surgery for CLM was compared with the treatment performed after specialized multidisciplinary management. The demographic, oncological, and surgical features were analyzed between groups. Results: Overall, 355 hepatectomies were performed in 336 patients. Patients operated on during the second era of had greater use of preoperative chemotherapy (P<0.001) as well as exposure to more effective oxaliplatin-based regimens (P<0.001). Surgical management also changed, with minor (P=0.002) and non-anatomic (P=0.006) resections preferred over major operations. We also noted an increased number of minimally invasive resections (P<0.001). Conclusion: Treatment in a multidisciplinary cancer center led to changes in oncological and surgical management. Perioperative chemotherapy was frequently employed, and surgeons adopted a conservative approach to liver parenchyma.
- Liver Surgery: Important Considerations for Pre- and Postoperative Imaging(2022) FARIA, Luisa Leitao de; DARCE, George Felipe; BORDINI, Andre Leopoldino; HERMAN, Paulo; JEISMANN, Vagner Birk; OLIVEIRA, Irai Santana de; ORTEGA, Cinthia D.; ROCHA, Manoel de SouzaLiver surgery may be a curative treatment option not only for primary liver neoplasms but also for liver metastases in selected patients. The number of liver surgeries performed worldwide has increased, but surgical morbidity associated with these surgeries remains significant. Therefore, radiologists need to understand the terminology, surgical techniques, resectability and unresectability criteria, and possible postoperative complications as these are part of the decision-making process. Because vascular and biliary variations are common, an adequate preoperative anatomic evaluation determines the best surgical technique, helps identify patients in whom additional surgical steps will be required, and reduces the risk of inadvertent injury. The surgeon must ensure that the future liver remnant is sufficient to maintain adequate function, aided by the radiologist who can provide valuable information such as the presence of steatosis, biliary dilatation, signs of cirrhosis, and portal hypertension, in addition to the volume of the future liver remnant. Postoperative complications must also be understood and evaluated. The most common postoperative complications are vascular (bleeding, thrombosis, and ischemia), biliary (fistulas, bilomas, and strictures), infectious (incisional or deep), those related to liver failure, and even tumor recurrence. An invited commentary byWinslow is available online. (C) RSNA, 2022
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