JAIME ARTHUR PIROLA KRUGER

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Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas, Faculdade de Medicina - Médico
LIM/37 - Laboratório de Transplante e Cirurgia de Fígado, Hospital das Clínicas, Faculdade de Medicina

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  • article 7 Citação(ões) na Scopus
    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 Ferreira
    Background 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.
  • article 5 Citação(ões) na Scopus
    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, Paulo
    Background: 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.
  • article 36 Citação(ões) na Scopus
    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, Paulo
    Background: 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.
  • article 0 Citação(ões) na Scopus
    The impact of multivisceral liver resection on short- and long-term outcomes of patients with colorectal liver metastasis: A systematic review and meta-analysis
    (2022) SILVEIRA JUNIOR, Sergio; TUSTUMI, Francisco; MAGALHAES, Daniel de Paiva; JEISMANN, Vagner Birk; FONSECA, Gilton Marques; KRUGER, Jaime Arthur Pirola; COELHO, Fabricio Ferreira; HERMAN, Paulo
    The impact of Multivisceral Liver Resection (MLR) on the outcome of patients with Colorectal Liver Metastasis (CRLM) is unclear. The present systematic review aimed to compare patients with CRLM who underwent MLR versus standard hepatectomy regarding short-and long-term outcomes. MLR is a feasible procedure but has a higher risk of major complications. MLR did not negatively affect long-term survival, suggesting that an extended resection is an option for potentially curative treatment for selected patients with CRLM.
  • article 2 Citação(ões) na Scopus
    Preoperative inflammatory markers as prognostic predictors after hepatocellular carcinoma resection: data from a western referral center
    (2022) SILVA, Joao Paulo Maciel; COELHO, Fabricio Ferreira; CASSENOTE, Alex Jones Flores; JEISMANN, Vagner Birk; FONSECA, Gilton Marques; KRUGER, Jaime Arthur Pirola; MEIRA JUNIOR, Jose Donizeti de; NAHAS, Sergio Carlos; HERMAN, Paulo
    Background Recent studies from eastern centers have demonstrate an association between inflammatory response and long-term outcomes after hepatocellular carcinoma (HCC) resection. However, the prognostic impact of inflammatory markers in western patients, with distinct tumor and epidemiologic features, is still unknown. Aim To evaluate the prognostic impact of preoperative neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR), as well as their impact according to tumor size (< 5 cm, 5-10 cm, > 10 cm) in patients undergoing HCC resection with curative intent. Methods Optimal cut-off values for NLR, PLR, and MLR were determined by plotting the receiver operator curves. Overall survival (OS) and disease-free survival (DFS) curves were calculated using the Kaplan-Meier method and compared using the log-rank test. The Cox method was used to identify independent predictors of OS and DFS. Results In total, 161 consecutive adult patients were included. A high NLR (> 1.715) was associated with worse OS (P = 0.018). High NLR (> 2.475; P = 0.047) and PLR (> 100.25; P = 0.028) were predictors of short DFS. In HCC < 5 cm, MLR (> 1.715) was associated with worse OS (P = 0.047). In the multivariate analysis, high PLR was an independent predictor of worse DFS [hazard ratio (HR) 3.029; 95%CI 1.499-6.121; P = 0.002]. Conclusion Inflammatory markers are useful tools to predict long-term outcomes after liver resection in western patients, high NLR was able to stratify subgroups of patients with short OS and DFS, an increased PLR was an independent predictor of short DFS, while high MLR was associated with short OS in patients with early HCC.
  • article 3 Citação(ões) na Scopus
    Two decades of liver resection with a multidisciplinary approach in a single institution: What has changed? Analysis of 1409 cases
    (2022) HERMAN, Paulo; FONSECA, Gilton Marques; COELHO, Fabricio Ferreira; KRUGER, Jaime Arthur Pirola; MAKDISSI, Fabio Ferrari; JEISMANN, Vagner Birk; CARRILHO, Flair Jose; D'ALBUQUERQUE, Luiz Augusto Carneiro; NAHAS, Sergio Carlos
    Objectives: To evaluate results of patients undergoing liver resection in a single center over the past two decades with a particular look at Colorectal Liver Metastasis (CRLM) and Hepatocellular Carcinoma (HCC). Method: Patients were divided into two eras, from 2000 to 2010 (Era 1) and 2011 to 2020 (Era 2). The most frequent diagnosis was CRLM and HCC, with 738 (52.4%) and 227 (16.1%) cases respectively. An evaluation of all liver resection cases and a subgroup analysis of both CRLM and HCC were performed. Preoperative and per operative variables and long-term outcomes were evaluated. Results: 1409 liver resections were performed. In Era 2 the authors observed higher BMI, more: minimally invasive surgeries, Pringle maneuvers, and minor liver resections; and less transfusion, less ICU necessity, and shorter length of hospital stay. Severe complications were observed in 14.7% of patients, and 90-day mortality was 4.2%. Morbidity and mortality between eras were not different. From 738 CRLM resections, in Era 2 there were significantly more patients submitted to neoadjuvant chemotherapy, bilateral metastases, and smaller sizes with significantly less transfusion, the necessity of ICU, and shorter length of hospital stay. More pedicle clamping, minimally invasive surgeries, and minor resections were also observed. From 227 HCC resections, in Era 2 significantly more minimally invasive surgeries, fewer transfusions, less necessity of ICU, and shorter length of hospital stay were observed. OS was not different between eras for CRLM and HCC. Conclusions: Surgical resection in a multidisciplinary environment remains the cornerstone for the curative treatment of primary and metastatic liver tumors.
  • article 1 Citação(ões) na Scopus
    A Combined ""Hanging Liver Maneuver"" and ""Intrahepatic Extra-Glissonian Approach"" for Anatomical Right Hepatectomy: Technique Standardization, Results, and Correlation With Portal Pedicle Anatomy
    (2021) MAKDISSI, Fabio Ferrari; MATTOS, Bruno Vinicius Hortences de; KRUGER, Jaime Arthur Pirola; JEISMANN, Vagner Birk; COELHO, Fabricio Ferreira; HERMAN, Paulo
    Background: The hanging liver maneuver and intrahepatic extra-Glissonian approach are distinct modalities to facilitate safe anatomical liver resections. This study reports a standardized combination of these techniques focusing on safety, results and correlation with portal pedicle anatomy in oncological patients. Method: Combined hanging liver maneuver and intrahepatic extra-Glissonian approach for anatomic right hepatectomy was described stepwise. Portal pedicle anatomy was correlated with the Glissonian approach failure and complications. Clinical characteristics of patients, perioperative outcomes, short and long-term survival rates were analyzed. Results: Thirty colorectal liver metastases patients submitted to the combined approach were evaluated. Anatomical variations of the right portal pedicle were present in 26.6%. Hanging liver maneuver was feasible in 100%, and Glissonian approach in 96.7% despite portal pedicle variations. Mean operative time was 326 min. Mean blood loss was 507 ml. Mean hospital stay was 8 days. There was no 90-day operative mortality and no significant morbidity. Oncological surgical margins were free. Overall and disease-free 5-year survival were 59 and 37%. Conclusion: Regardless of frequent anatomical variations of the right portal pedicle, the hanging liver maneuver, and intrahepatic extra-Glissonian approach can be combined, being useful for anatomical right hepatectomies in a safe and reproducible way in most patients.
  • article 0 Citação(ões) na Scopus
    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, Paulo
    Background: 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.
  • article 6 Citação(ões) na Scopus
    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, Paulo
    Background 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.
  • article
    Feasibility of Right Upper Transversal Hepatectomy in the Absence of an Inferior Right Hepatic Vein: New Insights regarding This Complex Procedure
    (2021) MAKDISSI, Fabio Ferrari; KRUGER, Jaime Arthur Pirola; JEISMANN, Vagner Birk; HERMAN, Paulo
    Background. Right upper transversal hepatectomy (RUTH) is defined as the removal of liver segments 7, 8, and 4A with ligature of the right and middle hepatic veins and is considered one of the most complex techniques of parenchymal-sparing hepatectomies. This procedure can be performed, without venous reconstruction, if collateral veins are present communicating within remnant liver segments to a large inferior right hepatic vein and/or to the left hepatic vein. This venous network could maintain outflow from the inferior right segments (S5, S6) to the left liver when a RUTH is performed, even in the absence of an inferior right hepatic vein. The aim of this study is to present our experience with RUTH without venous reconstruction in patients with and without the presence of an inferior right hepatic vein (IRHV). Methods. Patients submitted to RUTH for treatment of liver metastases were selected from our database. The presence of an IRHV, clinical and surgical characteristics of the patients, immediate outcomes, viability of liver segments 5 and 6, and long-term survival were analyzed. Results. RUTH was successfully performed in four patients. In two patients, IRHV was not present, but intrahepatic communicating veins between proximal right and middle hepatic veins and left hepatic vein were present. No venous reconstructions were performed. Mild congestion of the inferior right segments occurred in the patients where there was no IRHV but no immediate, early, or late complications were observed. Conclusions. RUTH is feasible and can be performed even in the absence of an IRHV, without venous reconstruction. Some degree of congestion of the right inferior liver segments might occur when an IRHV is absent, yet this is not clinically significant when communicating veins are present. Maximum parenchyma preservation might prevent postoperative liver failure and allow repeated resections in case of hepatic recurrence.