JAIME ARTHUR PIROLA KRUGER
Projetos de Pesquisa
Unidades Organizacionais
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
LIM/37 - Laboratório de Transplante e Cirurgia de Fígado, Hospital das Clínicas, Faculdade de Medicina
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- 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.
- 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, PauloThe 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 Serous Cystadenocarcinoma of the Pancreas Presenting with Liver Metastases: Case Report and Literature Review(2016) PERINI, Marcos Vinicius; LIMA, Fabiana Roberto; FRENK, Nathan Elie; LEDO FILHO, Hilton Muniz; COELHO, Fabricio Ferreira; KRUGER, Jaime Arthur; ROCHA, Manoel de Souza; HERMAN, PauloSerous cystic neoplasms of the pancreas are usually benign. Malignant serous cystic neoplasm is a rare clinical entity. We report a case of a 45-year-old man presenting with metastatic liver lesions on ultrasound. Computed tomography scan showed a hypervascular solid lesion arising in the pancreatic body and invading the celiac axis and portal vein with liver metastases. Ultrasound-guided liver biopsy diagnosed a serous cystic neoplasm, indistinguishable from serous cystadenoma. Based on clinical, radiological and pathological correlation, the diagnosis of cystadenocarcinoma was established. There are few reported cases of malignant serous cystic neoplasms in which malignancy was confirmed. Although rare in males, cystadenocarcinoma should be considered in the differential diagnosis of patients presenting with a pancreatic mass and liver metastasis.- 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.
- Preoperative strategies to improve resectability for hepatocellular carcinoma: a systematic review and meta-analysis(2018) TUSTUMI, Francisco; ERNANI, Lucas; COELHO, Fabricio F.; BERNARDO, Wanderley M.; JUNIOR, Sergio S.; KRUGER, Jaime A. P.; FONSECA, Gilton M.; JEISMANN, Vagner B.; CECCONELLO, Ivan; HERMAN, PauloBackground: Preoperative strategies to increase the future liver remnant are useful methods to improve resectability rates for patients with hepatocellular carcinoma (HCC). The aim of this study was to perform a systematic review and meta-analysis of the main strategies used for this purpose. Methods: A systematic review was performed in PubMed, EMBASE, Cochrane and Scielo/LILACS. The procedures included for analysis were portal vein embolization or ligation (PVE/PVL), sequential trans-arterial embolization and PVE (TACE + PVE), radioembolization (RE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Perioperative morbidity and mortality, post-hepatectomy liver failure (PHLF), and survival rates were evaluated. Results: A total of 46 studies were included in the systematic review (1284 patients). Resection rate was higher in TACE + PVE (90%; N = 315) when compared to PVE/PVL (75%; N = 254; P = < 0.001) and similar to ALPPS (84%; N = 43; P = 0.374) and RE (100%; N = 28; P = 0.14). ALPPS was associated with higher PHLF and perioperative mortality rates when compared to PVE/PVL and TACE + PVE. ALPPS and RE showed higher risk of major complications than PVE/PVL and TACE + PVE. Conclusion: Preoperative strategies to increase liver volume are effective in achieving resectability of HCC. TACE + PVE is as safe as PVL/PVE providing higher OS. ALPPS is associated with a higher risk of PHLF, major complications, and mortality. RE despite the small experience seems to present similar resection rate and OS as TACE + PVE with higher rate of major complications.
- Histopathological prognostic factors for colorectal liver metastases: A systematic review and meta-analysis of observational studies(2021) OLIVEIRA, Cassio Virgilio Cavalcante de; FONSECA, Gilton Marques; KRUGER, Jaime Arthur Pirola; MELLO, Evandro Sobroza de; COELHO, Fabricio Ferreira; HERMAN, PauloIntroduction. Resection is the mainstay of treatment for colorectal liver metastases (CRLMs). Many different histopathological factors related to the primary colorectal tumour have been well studied; however, histopathological prognostic factors related to CRLMs are still under evaluation. Objective. To identify histopathological factors related to overall survival (OS) and disease-free survival (DFS) in patients with resected CRLMs. Methods. A systematic review was performed with the following databases up to August 2020: PubMed, EMBASE, Web of Science, SciELO, and LILACS. The GRADE approach was used to rate the overall certainty of evidence by outcome. Results. Thirty-three studies including 4,641 patients were eligible. We found very low certainty evidence that the following histopathological prognostic factors are associated with a statistically significant decrease in OS: presence of portal vein invasion (HR, 410.50 [95% CI, 0.37 to 0.68]; I-2=0%), presence of perineural invasion (HR, 0.55 [95% CI, 420.36 to 0.83]; I-2=0%), absence of pseudocapsule (HR, 0.41 [CI 95%, 0.29 to 0.57], p<0.00001; I-2=0%), presence of satellite nodules (OR, 0.45 [95% CI, 0.26 to 0.80]; I-2=0%), and the absence of peritumoural inflammatory infiltrate (OR, 0.20 [95% CI, 0.08 to 0.54]; I-2=0%). Outcome data on DFS were scarce, except for tumour borders, which did not present a significant impact, precluding the meta-analysis. Conclusion. Of the histopathological prognostic factors studied, low- to moderate-certainty evidence shows that vascular invasion, perineural invasion, absence of pseudocapsule, presence of satellite nodules, and absence of peritumoral inflammatory infiltrate are associated with shorter overall survival in CRLMs.
- Laparoscopy-assisted versus open and pure laparoscopic approach for liver resection and living donor hepatectomy: a systematic review and meta-analysis(2018) COELHO, Fabricio F.; BERNARDO, Wanderley M.; KRUGER, Jaime A. P.; JEISMANN, Vagner B.; FONSECA, Gilton M.; MACACARI, Rodrigo L.; CESCONETTO, Danielle M.; D'ALBUQUERQUE, Luiz A. C.; CECCONELLO, Ivan; HERMAN, PauloBackground: Laparoscopy-assisted (hybrid) liver surgery is considered a minimally invasive technique, however there are doubts regarding loss of the benefits of laparoscopy due to the use of an auxiliary incision. The aim of this study was to compare perioperative results of hybrid vs. open and hybrid vs. pure laparoscopic approach to liver resection for focal lesions and living donation. Methods: A systematic review was performed in Medline, EMBASE, Cochrane Library Central and LILACS databases. Perioperative outcomes were analyzed. Results: 21 studies were included. Hybrid vs. open: operative time was lower in open group (mean difference [MD] = 34 min; 95% CI: 22-47; P < 0.001; N = 669). Hybrid technique was associated with a reduction in operative blood loss [MD = -43 ml; 95% CI: -74-(-13); P = 0.005, N = 1738]; shorter hospital stay [MD = -1.9 days; 95% CI: -3.2-(-0.5); P = 0.008; N = 833] and lower morbidity [risk difference (RD) = -0.05; 95% CI: -0.10-(-0.01); P = 0.010; N = 1359]. Hybrid vs. pure laparoscopic: There was no difference regarding blood loss, transfusion rate, hospital stay and morbimortality. Discussion: Hybrid technique had perioperative outcomes that were more in keeping with pure laparoscopic outcomes than open surgery. Hybrid liver surgery should be considered a minimally invasive approach.
- Pathological factors and prognosis of resected liver metastases of colorectal carcinoma: implications and proposal for a pathological reporting protocol(2018) FONSECA, Gilton M.; HERMAN, Paulo; FARAJ, Sheila F.; KRUGER, Jaime A. P.; COELHO, Fabricio F.; JEISMANN, Vagner B.; CECCONELLO, Ivan; ALVES, Venancio A. F.; PAWLIK, Timothy M.; MELLO, Evandro S. deColorectal cancer is a leading cause of death worldwide. The liver is the most common site of distant metastases, and surgery is the only potentially curative treatment, although the recurrence rate following surgery is high. In order to define prognosis after surgery, many histopathological features have been identified in the primary tumour. In turn, pathologists routinely report specific findings to guide oncologists on the decision to recommend adjuvant therapy. In general, the pathological report of resected colorectal liver metastases is limited to confirmation of the malignancy and details regarding the margin status. Most pathological reports of a liver resection for colorectal liver metastasis lack information on other important features that have been reported to be independent prognostic factors. We herein review the evidence to support a more detailed pathological report of the resected liver specimen, with attention to: the number and size of liver metastases; margin size; the presence of lymphatic, vascular, perineural and biliary invasion; mucinous pattern; tumour growth pattern; the presence of a tumour pseudocapsule; and the pathological response to neoadjuvant chemotherapy. In addition, we propose a new protocol for the evaluation of colorectal liver metastasis resection specimens.
- Management of variceal hemorrhage: current concepts(2014) COELHO, Fabricio Ferreira; PERINI, Marcos Vinícius; KRUGER, Jaime Arthur Pirola; FONSECA, Gilton Marques; ARAÚJO, Raphael Leonardo Cunha de; MAKDISSI, Fábio Ferrari; LUPINACCI, Renato Micelli; HERMAN, PauloINTRODUCTION: The treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades. AIM: To review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients. METHODS: Survey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis. CONCLUSION: Pre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.
- Brazilian Landscape of Hepatocellular Carcinoma(2023) FONSECA, Leonardo G.; CHEN, Andre T. C.; OLIVEIRA, Irai S. de; CHAGAS, Aline L.; KRUGER, Jaime A. P.; CARRILHO, Flair J.The incidence of hepatocellular carcinoma (HCC) is expected to increase in the coming years, and strategies to mitigate the burden of this disease are needed in different regions. Geographic variations in epidemiology and risk factors, such as viral hepatitis and metabolic disease, pose challenges in adopting programs for early detection programs and management of patients with HCC. Brazil, like other countries, has high economic and social inequality, with heterogeneous access to health care. Viral hepatitis is themain risk factor but there is growing awareness of fatty liver disease. Risk factor monitoring and screening programs are unmet priorities because patients are often diagnosed at later stages. Advances in the management of patients with HCC have been made in recent years, including new tools for selecting patients for liver transplantation, sophisticated surgical techniques, and new systemic agents. High-volume academic centers often achieve favorable results through the adoption and application of established treatments, but this is not a reality in most regions of Brazil, because of disparities in wealth and resources. As HCC management requires a coordinated and multidisciplinary team, the role of local referral centers in decentralizing access to treatments and promoting health education in different regions should be encouraged and supported.