PAULO HERMAN
Projetos de Pesquisa
Unidades Organizacionais
Departamento de Gastroenterologia, Faculdade de Medicina - Docente
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
LIM/37 - Laboratório de Transplante e Cirurgia de Fígado, Hospital das Clínicas, Faculdade de Medicina
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
LIM/37 - Laboratório de Transplante e Cirurgia de Fígado, Hospital das Clínicas, Faculdade de Medicina
9 resultados
Resultados de Busca
Agora exibindo 1 - 9 de 9
- 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.
- BRAZILIAN CONSENSUS ON INCIDENTAL GALLBLADDER CARCINOMA(2020) COIMBRA, Felipe Jose F.; TORRES, Orlando Jorge M.; ALIKHANOV, Ruslan; AGARWAL, Anil; PESSAUX, Patrick; FERNANDES, Eduardo de Souza M.; QUIREZE-JUNIOR, Claudemiro; ARAUJO, Raphael Leonardo C.; GODOY, Andre Luis; WAECHTER, Fabio Luis; RESENDE, Alexandre Prado de; BOFF, Marcio Fernando; COELHO, Gustavo Rego; REZENDE, Marcelo Bruno de; LINHARES, Marcelo Moura; BELOTTO, Marcos; MORAES-JUNIOR, Jose Maria A.; AMARAL, Paulo Cezar G.; PINTO, Rinaldo Danesi; GENZINI, Tercio; LIMA, Agnaldo Soares; RIBEIRO, Heber Salvador C.; RAMOS, Eduardo Jose; ANGHINONI, Marciano; PEREIRA, Lucio Lucas; ENNE, Marcelo; SAMPAIO, Adriano; MONTAGNINI, Andre Luis; DINIZ, Alessandro; JESUS, Victor Hugo Fonseca de; SIROHI, Bhawna; V, Shailesh Shrikhande; PEIXOTO, Renata D. Alpino; KALIL, Antonio Nocchi; JARUFE, Nicolas; SMITH, Martin; HERMAN, PauloBackground: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. Aim: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. Methods: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. Results: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. Conclusions: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.
- Hepatocellular carcinoma in non-alcoholic fatty liver disease (NAFLD) - pathological evidence for a predominance of steatohepatitic inflammatory non-proliferative subtype(2020) CAMPOS, Priscila B. de; OLIVEIRA, Claudia P.; STEFANO, Jose T.; MARTINS-FILHO, Sebastiao N.; CHAGAS, Aline L.; HERMAN, Paulo; D'ALBUQUERQUE, Luiz C.; ALVARES-DA-SILVA, Mario R.; LONGATTO-FILHO, Adhemar; CARRILHO, Flair J.; ALVES, Venancio A. F.Objectives. This study evaluated clinical and pathological aspects of patients with hepatocellular carcinoma (HCC) secondary to non-alcoholic fatty liver disease (NAFLD) and related these factors to immunohistochemical markers representative of the proliferative class. Methods. We evaluated 35 HCC nodules from 21 patients diagnosed with NAFLD undergoing liver resection (n=12) or liver transplantation (n=8) or both (n=1). Demographic, clinical and biochemical data were compared to histological features and to immunohistochemical reactivity for K19 and Ki-67. Results. Cirrhosis was present in 58% of patients. Ages ranged from 50 to 77 years. Sixteen patients (76%) were male and had type 2 diabetes mellitus, 81% had arterial hypertension, and 90% had BMI above 25 kg/m(2). Alpha-fetoprotein levels were normal in 62% of patients. Twenty-five (70%) nodules were diagnosed as ""steatohepatitic HCC"". Only 32% of the nodules presented high levels of Ki-67 (>10%) and/or K19 (>5%), although 63% were poorly differentiated (G.3/G.4) according to Edmondson & Steiner grading system. K19 positivity (>5%) was associated with higher degree of intratumoral inflammation (G.2/G.3), and with fibrosis, both at the center of the tumor and at the tumor front, whereas Ki-67 positivity (>10%) was associated with ballooning of neoplastic cells and occurred in more than 70% in non-cirrhotic patients. Conclusion. NAFLD-related HCC was found in non-cirrhotic patients in 42% of cases, alpha-fetoprotcin level was normal in 63% and ""steatohepatitic HCC"" was the predominant histological type. Immunoexpression of K19 and/or Ki-67 occurred in 32% of the nodules and were associated with intratumoral inflammation and ballooning, suggesting that HCC in MtS may be preferentially ""an inflammatory, non-proliferative subtype of HCC"".
- Laparoscopic Liver Resection: A South American Experience with 2887 Cases(2020) PEKOLJ, J.; SANCHEZ, R. Claria; SALCEDA, J.; MAURETTE, R. J.; SCHELOTTO, P. B.; PIERINI, L.; CANEPA, E.; MORO, M.; STORK, G.; RESIO, N.; NEFFA, J.; CORMACK, L. Mc; QUINONEZ, E.; RAFFIN, G.; OBEIDE, L.; FERNANDEZ, D.; PFAFFEN, G.; SALAS, C.; LINZEY, M.; SCHMIDT, G.; RUIZ, S.; ALVAREZ, F.; BUFFALIZA, J.; MARONI, R.; CAMPI, O.; BERTONA, C.; SANTIBANES, M. de; MAZZA, O.; OLIVEIRA, M. Belotto de; DINIZ, A. L.; OLIVEIRA, M. Enne de; MACHADO, M. A.; KALIL, A. N.; PINTO, R. D.; REZENDE, A. P.; RAMOS, E. J. B.; OLIVEIRA, A. Talvane T.; TORRES, O. J. M.; CASSIS, N. Jarufe; BUCKEL, E.; TORRES, R. Quevedo; CHAPOCHNICK, J.; GARCIA, M. Sanhueza; MUNOZ, C.; CASTRO, G.; LOSADA, H.; SUAREZ, F. Vergara; GUEVARA, O.; DAVILA, D.; PALACIOS, O.; JIMENEZ, A.; POGGI, L.; TORRES, V.; FONSECA, G. M.; KRUGER, J. A. P.; COELHO, F. F.; RUSSO, L.; HERMAN, P.Background Laparoscopic liver resections (LLR) have been increasingly performed in recent years. Most of the available evidence, however, comes from specialized centers in Asia, Europe and USA. Data from South America are limited and based on single-center experiences. To date, no multicenter studies evaluated the results of LLR in South America. The aim of this study was to evaluate the experience and results with LLR in South American centers. Methods From February to November 2019, a survey about LLR was conducted in 61 hepatobiliary centers in South America, composed by 20 questions concerning demographic characteristics, surgical data, and perioperative results. Results Fifty-one (83.6%) centers from seven different countries answered the survey. A total of 2887 LLR were performed, as follows: Argentina (928), Brazil (1326), Chile (322), Colombia (210), Paraguay (9), Peru (75), and Uruguay (8). The first program began in 1997; however, the majority (60.7%) started after 2010. The percentage of LLR over open resections was 28.4% (4.4-84%). Of the total, 76.5% were minor hepatectomies and 23.5% major, including 266 right hepatectomies and 343 left hepatectomies. The conversion rate was 9.7%, overall morbidity 13%, and mortality 0.7%. Conclusions This is the largest study assessing the dissemination and results of LLR in South America. It showed an increasing number of centers performing LLR with the promising perioperative results, aligned with other worldwide excellence centers.
- Fellows perspective of HPB training in Latin America(2020) DOMINGUEZ-ROSADO, Ismael; ESPINOZA, Johana L.; ALVAREZ, Fernando A.; VINTIMILLA, Agustin; QUINTERO, Marco; BARZALLO, David; PEKOLJ, Juan; GONDOLESI, Gabriel; SCHELOTTO, Pablo B.; HERMAN, Paulo; D'ALBUQUERQUE, Luiz A. Carneiro; ANDRAUS, Wellington; PADILLA, Jorge; JARUFE, Nicolas; CHAPA, Oscar; MERCADO, Miguel; CHAN, Carlos; ALSEIDI, AdnanBackground: Currently, no standards for HPB training exist in Latin America. The aim of this work is to evaluate fellows' experience of HPB training and the areas of opportunity to improve. Methods: A 35 points survey was developed and distributed among fellows from dedicated HPB training programs in Latin America. The survey was applied by direct phone call (37%) or web based (63%), to fellows graduated between 2010 and 2014, from 7 different programs. Results: Thirty-nine fellows from Argentina, Brazil, Chile and Mexico were considered with a response rate of 82% (32/39). Most fellows (90%) shared cases with more than one co-fellow. Scrubbing with chief residents ocurred to 60% of fellows; only 14% of fellows noted having a primary surgeon role in more than 70% of cases. Median number of major hepatectomies during training was 15 (1-100), Whipple procedures 6 (1-40), and major bile duct repair 20 (1-80). Limited funding was the main reason to avoid HPB programs outside the country of origin. Conclusion: HPB training in Latin America requires more operative volume and autonomy. Financial burden is the main limitation to pursue training overseas. A multinational fellowship that takes advantage of each center may overcome differences in volume and type of cases.
- Minimally invasive versus open right hepatectomy: comparative study with propensity score matching analysis(2020) DUARTE, Vinicius Campos; COELHO, Fabricio Ferreira; VALVERDE, Alain; DANOUSSOU, Divia; KRUGER, Jaime Arthur Pirola; ZUBER, Kevin; FONSECA, Gilton Marques; JEISMANN, Vagner Birk; HERMAN, Paulo; LUPINACCI, Renato MicelliBackground Minimally invasive liver resections (MILRs) have been increasingly performed in recent years. However, the majority of MILRs are actually minor or limited resections of peripheral lesions. Due to the technical complexity major hepatectomies remain challenging for minimally invasive surgery. The aim of this study was to compare the short and long-term outcomes of patients undergoing minimally invasive right hepatectomies (MIRHs) with contemporary patients undergoing open right hepatectomies (ORHs) Methods Consecutive patients submitted to anatomic right hepatectomies between January 2013 and December 2018 in two tertiary referral centers were studied. Study groups were compared on an intention-to-treat basis after propensity score matching (PSM). Overall survival (OS) analyses were performed for the entire cohort and specific etiologies subgroups Results During study period 178 right hepatectomies were performed. After matching, 37 patients were included in MIRH group and 60 in ORH group. The groups were homogenous for all baseline characteristics. MIRHs had significant lower blood loss (400 ml vs. 500 ml, P = 0.01), lower rate of minor complications (13.5% vs. 35%, P = 0.03) and larger resection margins (10 mm vs. 5 mm, P = 0.03) when compared to ORHs. Additionally, a non-significant decrease in hospital stay (ORH 9 days vs. MIRH 7 days, P = 0.09) was observed. No differences regarding the use of Pringle's maneuver, operative time, overall morbidity or perioperative mortality were observed. OS was similar between the groups (P = 0.13). Similarly, no difference in OS was found in subgroups of patients with primary liver tumors (P = 0.09) and liver metastasis (P = 0.80). Conclusions MIRHs are feasible and safe in experienced hands. Minimally invasive approach was associated with less blood loss, a significant reduction in minor perioperative complications, and did not negatively affect long-term outcomes.
- Preoperative risk score for prediction of long-term outcomes after hepatectomy for intrahepatic cholangiocarcinoma: Report of a collaborative, international-based, external validation study(2020) BRUSTIA, Raffaele; LANGELLA, Serena; KAWAI, Takayuki; FONSECA, Gilton Marques; SCHIELKE, Astrid; COLLI, Fabio; RESENDE, Vivian; FLERES, Francesco; ROULIN, Didier; LEYMAN, Paul; GIACOMONI, Alessandro; GRANGER, Benjamin; FARTOUX, Laetitia; CARLIS, Luciano De; DEMARTINES, Nicolas; SOMMACALE, Daniele; SANCHES, Marcelo Dias; PATRONO, Damiano; DETRY, Olivier; HERMAN, Paulo; OKUMURA, Shinya; FERRERO, Alessandro; SCATTON, OlivierPurpose: A preoperative risk score (PRS) to predict outcome of patients with intrahepatic cholangiocarcinoma treated by liver surgery could be clinically relevant.To assess accuracy for broadly adoption, external validation of predictive models on independent datasets is crucial. The objective of this study was to externally validate the score for prediction of long-term outcomes after liver surgery for intrahepatic cholangiocarcinoma proposed by Sasaki et al. and based on preoperative albumin, neutrophil-to-lymphocytes-ratio, CA19-9 and tumor size. Methods: Patients treated by liver surgery for intrahepatic cholangiocarcinoma at 11 international HPB centers from 2001 to 2018 were included in the external validation cohort. Harrell's c-index and HosmerLemeshow analyses were used to test PRS discrimination and calibration. Kaplan-Meier curve for risk groups as described in the original study were displayed. Results: A total of 355 patients with 174 deaths during the follow-up period (median = 41.7 months, IQR 32.8-50.6) were included. The median PRS value was 14.7 (IQR 10.7-20.6), with normal distribution across the cohort. A Cox regression on PRS covariates found coefficients similar to those of the derivation cohort, except for tumor size. Measures of discrimination estimated by Harrell's c-index was 0.61(95% CI:0.56-0.67) and Hosmer-Lemeshow p = 0.175. The Kaplan-Meyer estimation showed reasonable discrimination across risk groups, with 5years survival rate ranging from 20.1% to 0%. Conclusion: In this external validation cohort, the PRS had mild discrimination and poor calibration performance, similarly to the original publication. Nevertheless, its ability to identify different classes of risk is clinically useful, for a better tailoring of a therapeutic strategy.
- Total laparoscopic vs. open fiver resection: comparative study with propensity score matching analysis(2020) ASSIS, Bruno Silva de; COELHO, Fabricio Ferreira; JEISMANN, Vagner Birk; KRUGER, Jaime Arthur Pirola; FONSECA, Gilton Marques; CECCONELLO, Ivan; HERMAN, PauloBodcground: There have been an increasing number of articles that demonstrate the potential benefits of minimally invasive liver surgery in recent years. Most of the available evidence, however, comes from retrospective observational studies susceptible to bias, especially selection bias. In addition, in many series, several modalities of minimally invasive surgery are included in the same comparison group. Aim: To compare the perioperative results (up to 90 days) of patients submitted to total laparoscopic liver resection with those submitted to open liver resection, matched by propensity score matching (PSM). Method: Consecutive adult patients submitted to liver resection were included. PSM model was constructed using the following variables: age, gender, diagnosis (benign vs. malignant), type of hepatectomy (minor vs. major), and presence of cirrhosis. After matching, the groups were redefined on a 1:1 ratio, by the nearest method. Results: After matching, 120 patients were included in each group. Those undergoing total laparoscopic surgery had shorter operative time (286.8 +/- 133.4 vs. 352.4 +/- 141.5 minutes, p<0.001), shorter ICU stay (1.9 +/- 1.2 vs. 2.5 +/- 2.2days, p=0.031), shorter hospital stay (5.8 +/- 3.9 vs. 9.9 +/- 9.3 days, p<0.001) and a 45% reduction in perioperative complications (19.2 vs. 35%, p=0.008). Conclusion: Total laparoscopic liver resections are safe, feasible and associated with shorter operative time, shorter ICU and hospital stay, and lower rate of perioperative complications.
- Management of Hepatocellular Carcinoma during the COVID-19 Pandemic - Sao Paulo Clinicas Liver Cancer Group Multidisciplinary Consensus Statement(2020) CHAGAS, Aline Lopes; FONSECA, Leonardo Gomes; COELHO, Fabricio Ferreira; SAUD, Lisa Rodrigues Cunha; ABADALA, Edson; ANDRAUS, Wellington; FIORE, Lucas; MOREIRA, Airton Mota; MENEZES, Marcos Roberto; CARNEVALE, Francisco Cesar; TANI, Claudia Megumi; ALENCAR, Regiane S. S. M.; D'ALBUQUERQUE, Luiz Augusto Carneiro; HERMAN, Paulo; CARRILHO, Flair JoseMore than 18 million people in 188 countries have been diagnosed as having coronavirus disease (COVID-19), and COVID-19 has been responsible for more than 600,000 deaths worldwide. Brazil is now the second most affected country globally. Faced with this scenario, various public health measures and changes in the daily routines of hospitals were implemented to stop the pandemic. Patients with hepatocellular carcinoma (HCC) are at an increased risk for severe COVID-19 as they present with two major diseases: cancer and concomitant chronic liver disease. The COVID-19 pandemic can significantly impact the management of HCC patients from diagnosis to treatment strategies. These patients need special attention and assistance at this time, especially since treatment for tumors cannot be delayed in most cases. The aim of this guideline was to standardize the management of HCC patients during the COVID-19 pandemic. This document was developed, on the basis of the best evidence available, by a multidisciplinary team from Instituto do Cancer do Estado de Sao Paulo (ICESP), and Instituto Central of the Hospital das Clinicas da Universidade de Sao Paulo (HC-FMUSP), which are members of the Sao Paulo Cli ' nicas Liver Cancer Group.