ANDRE LUIS MONTAGNINI
Projetos de Pesquisa
Unidades Organizacionais
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
11 resultados
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- The interaction between N-category and N-ratio as a new tool to improve lymph node metastasis staging in gastric cancer: Results of a single cancer center in Brazil(2011) COIMBRA, F. J. F.; COSTA JR., W. L.; MONTAGNINI, A. L.; DINIZ, A. L.; RIBEIRO, H. S. C.; SILVA, M. J. B.; BEGNAMI, M. F. S.Background: Depth of tumor invasion (T-category) and the number of metastatic lymph nodes (N-category) are the most important prognostic factors in patients with gastric cancer. Recently, the ratio between metastatic and dissected lymph nodes (N-ratio) has been established as one. The aim of this study is to evaluate the impact of N-ratio and its interaction with N-category as a prognostic factor in gastric cancer. Methods: This was a retrospective study in which we reviewed clinical and pathological data of 165 patients who had undergone curative surgery at our institution through a 9-year period. The exclusion criteria included metastases, gastric stump tumors and gastrectomy with less than 15 lymph nodes dissected. Results: The median age of the patients was 63 years and most of them were male. Total gastrectomy was the most common procedure and 92.1% of the patients had a D2-lymphadenectomy. Their 5-year overall survival was 57.7%. T-category, N-category, extended gastrectomy, and N-ratio were prognostic factors in overall and disease-free survival in accordance with univariate analysis. In accordance with TNM staging, N1 patients who have had NR1 had 5-year survival in 75.5% whereas in the NR2 group only 33% of the cases had 5-year survival. In the multivariate analysis, the interaction between N-category and N-ratio was an independent prognostic factor. Conclusion: Our findings confirmed the role of N-ratio as prognostic factor of survival in patients with gastric cancer surgically treated with at least 15 lymph nodes dissected. The relationship between N-category and N-ratio is a better predictor than lymph node metastasis staging.
- Liver resection for the treatment of post-cholecystectomy biliary stricture with vascular injury(2015) PERINI, Marcos V.; HERMAN, Paulo; MONTAGNINI, Andre L.; JUKEMURA, Jose; COELHO, Fabricio F.; KRUGER, Jaime A.; BACCHELLA, Telesforo; CECCONELLO, IvanAIM: To report experience with liver resection in a select group of patients with postoperative biliary stricture associated with vascular injury. METHODS: From a prospective database of patients treated for benign biliary strictures at our hospital, cases that underwent liver resections were reviewed. All cases were referred after one or more attempts to repair bile duct injuries following cholecystectomy (open or laparoscopic). Liver resection was indicated in patients with Strasberg E3/E4 (hilar stricture) bile duct lesions associated with vascular damage (arterial and/or portal), ipsilateral liver atrophy/abscess, recurrent attacks of cholangitis, and failure of previous hepaticojejunostomy. RESULTS: Of 148 patients treated for benign biliary strictures, nine (6.1%) underwent liver resection; eight women and one man with a mean age of 38.6 years. Six patients had previously been submitted to open cholecystectomy and three to laparoscopic surgery. The mean number of surgical procedures before definitive treatment was 2.4. All patients had Strasberg E3/E4 injuries, and vascular injury was present in all cases. Eight patients underwent right hepatectomy and one underwent left lateral sectionectomy without mortality. Mean time of follow up was 69.1 mo and after long-term follow up, eight patients are asymptomatic. CONCLUSION: Liver resection is a good therapeutic option for patients with complex postoperative biliary stricture and vascular injury presenting with liver atrophy/abscess in which previous hepaticojejunostomy has failed.
- COMPARING THE ENZYME REPLACEMENT THERAPY COST IN POST PANCREATECTOMY PATIENTS DUE TO PANCREATIC TUMOR AND CHRONIC PANCREATITIS(2016) FRAGOSO, Anna Victoria; PEDROSO, Martha Regina; HERMAN, Paulo; MONTAGNINI, André LuisABSTRACT Background - Among late postoperative complications of pancreatectomy are the exocrine and endocrine pancreatic insufficiencies. The presence of exocrine pancreatic insufficiency imposes, as standard treatment, pancreatic enzyme replacement. Patients with chronic pancreatitis, with intractable pain or any complications with surgical treatment, are likely to present exocrine pancreatic insufficiency or have this condition worsened requiring adequate dose of pancreatic enzymes. Objective - The aim of this study is to compare the required dose of pancreatic enzyme and the enzyme replacement cost in post pancreatectomy patients with and without chronic pancreatitis. Methods - Observational cross-sectional study. In the first half of 2015 patients treated at the clinic of the Department of Gastrointestinal Surgery at Hospital das Clínicas, Universidade de São Paulo, Brazil, who underwent pancreatectomy for at least 6 months and in use of enzyme replacement therapy were included in this series. The study was approved by the Research Ethics Committee. The patients were divided into two groups according to the presence or absence of chronic pancreatitis prior to pancreatic surgery. For this study, P<0.05 was considered statistically significant. Results - The annual cost of the treatment was R$ 2150.5 ± 729.39; R$ 2118.18 ± 731.02 in patients without pancreatitis and R$ 2217.74 ± 736.30 in patients with pancreatitis. Conclusion - There was no statistically significant difference in the cost of treatment of enzyme replacement post pancreatectomy in patients with or without chronic pancreatitis prior to surgical indication.
- Biliary tract schwannoma: A rare cause of obstructive jaundice in a young patient(2012) FONSECA, Gilton Marques; MONTAGNINI, Andre Luis; ROCHA, Manoel de Souza; PATZINA, Rosely Antunes; BERNARDES, Mario Vinicius Angelete Alvarez; CECCONELLO, Ivan; JUKEMURA, JoseSchwannoma is a tumor derived from Schwann cells which usually arises in the upper extremities, trunk, head and neck, retroperitoneum, mediastinum, pelvis, and peritoneum. However, it can arise in the gastrointestinal tract, including biliary tract. We present a 24-year-old male patient with obstructive jaundice, whose investigation with computed tomography abdomen showed focal wall thickening in the common hepatic duct, difficult to differentiate with hilar adenocarcinoma. He was diagnosed intraoperatively schwannoma of common bile duct and treated with local resection. The patient recovered well without signs of recurrence of the lesion after 12 mo. We also reviewed the common bile duct schwannoma related in the literature and evaluated the difficulty in pre and intraoperative differential diagnosis with adenocarcinoma hilar. Resection is the treatment of choice for such cases and the tumor did not recur in any of the resected cases.
- 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.
- Adjuvant chemoradiotherapy after d2-lymphadenectomy for gastric cancer: the role of n-ratio in patient selection. results of a single cancer center(2012) COSTA JR., Wilson L.; COIMBRA, Felipe J. F.; FOGAROLI, Ricardo C.; RIBEIRO, Heber S. C.; DINIZ, Alessandro L.; BEGNAMI, Maria Dirlei F. L.; MELLO, Celso A. L.; FANELLI, Marcelo F.; SILVA, Milton J. B.; FREGNANI, Jose Humberto; MONTAGNINI, Andre L.Background: Adjuvant chemoradiotherapy is part of a multimodality treatment approach in order to improve survival outcomes after surgery for gastric cancer. The aims of this study are to describe the results of gastrectomy and adjuvant chemoradiotherapy in patients treated in a single institution, and to identify prognostic factors that could determine which individuals would benefit from this treatment. Methods: This retrospective study included patients with pathologically confirmed gastric adenocarcinoma who underwent surgical treatment with curative intent in a single cancer center in Brazil, between 1998 and 2008. Among 327 patients treated in this period, 142 were selected. Exclusion criteria were distant metastatic disease (M1), T1N0 tumors, different multimodality treatments and tumors of the gastric stump. Another 10 individuals were lost to follow-up and there were 3 postoperative deaths. The role of several clinical and pathological variables as prognostic factors was determined. Results: D2-lymphadenectomy was performed in 90.8% of the patients, who had 5-year overall and disease-free survival of 58.9% and 55.7%. The interaction of N-category and N-ratio, extended resection and perineural invasion were independent prognostic factors for overall and disease-free survival. Adjuvant chemoradiotherapy was not associated with a significant improvement in survival. Patients with node-positive disease had improved survival with adjuvant chemoradiotherapy, especially when we grouped patients with N1 and N2 tumors and a higher N-ratio. These individuals had worse disease-free (30.3% vs. 48.9%) and overall survival (30.9% vs. 71.4%). Conclusion: N-category and N-ratio interaction, perineural invasion and extended resections were prognostic factors for survival in gastric cancer patients treated with D2-lymphadenectomy, but adjuvant chemoradiotherapy was not. There may be some benefit with this treatment in patients with node-positive disease and higher N-ratio.
- PANCREATODUODENECTOMY: BRAZILIAN PRACTICE PATTERNS(2017) TORRES, Orlando Jorge M; FERNANDES, Eduardo de Souza M; VASQUES, Rodrigo Rodrigues; WAECHTER, Fabio Luís; AMARAL, Paulo Cezar G.; REZENDE, Marcelo Bruno de; COSTA, Roland Montenegro; MONTAGNINI, André LuísABSTRACT Background: Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. Aim: To understand the Brazilian practice patterns for pancreatoduodenectomy. Method: A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. Results: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. Conclusion: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.
- Prognostic significance of epidermal growth factor receptor overexpression in pancreas cancer and nodal metastasis(2015) PERINI, Marcos Vinicius; MONTAGNINI, Andre Luis; COUDRY, Renata; PATZINA, Rosely; PENTEADO, Sonia; ABDO, Emilio Elias; DINIZ, Alessandro; JUKEMURA, Jose; CUNHA, Jose Eduardo Monteiro daBackgroundIdentification of molecular markers in pancreatic adenocarcinoma (PA) has the potential to guide targeted therapy. The objective of this study is to determine the prognostic significance of epidermal growth factor receptor (EGFR) expression (membrane and cytoplasmic) in resected PA and its correlation with lymph node metastasis and survival. MethodsEGFR overexpression was determined by immunohistochemistry, and the pattern of expression was compared between the primary tumour, adjacent normal pancreas and involved lymph nodes. ResultsA total of 88 patients had curative resection. No difference was found in mEGFR overexpression between tumoural and metastatic nodal tissues (P = 0.28). Median overall survival time was 22.9 months. Overall cumulative 1-, 3- and 5-year survival was 48%, 20% and 18%, respectively. In positive mEGFR tumour expression, survival was 46% at 1 year, 8% at 3 years and 0% at 5 years (P < 0.05). Univariate analysis showed that male gender, portal vein (PV) resection, perineural, lymphovascular and peri-pancreatic invasion, positive margins and positive mEGFR expression in tumour tissue had worse survival. Multivariate analysis showed that male gender, PV resection, vascular and perineural invasion remained independent predictors of poor survival. ConclusionPositive mEGFR overexpression is associated with decreased survival; however, it is not an independent prognostic factor.
- Complex biliary stones management: cholangioscopy versus papillary large balloon dilation - a randomized controlled trial(2018) FRANZINI, Tomazo; MOURA, Renata Nobre; BONIFACIO, Priscilla; LUZ, Gustavo Oliveira; SOUZA, Thiago Ferreira de; SANTOS, Marcos Eduardo Lera dos; RODELA, Gustavo Luis; IDE, Edson; HERMAN, Paulo; MONTAGNINI, Andre Luis; D'ALBUQUERQUE, Luiz Augusto Carneiro; SAKAI, Paulo; MOURA, Eduardo Guimaraes Hourneaux deBackground and study aims Endoscopic removal of biliary stones has high success rates, ranging between 85% to 95%. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90% for stones larger than 15mm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80%-90%). However, there is no study comparing these 2 techniques. Patients and methods From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopy+electrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods. Results The mean age was 56 years. 74 (75.5%) patients were female. The initial overall complete stone removal rate was 74.5% (77.1% in group 1 and 72% in group 2, P >0.05). After second session the overall success rate achieved 90.1%. Procedure time was significantly lower in group 2,-25.2min (CI95%-12.48 to -37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events. Conclusion Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.
- LIVER RESECTION IN BRAZIL: A NATIONAL SURVEY(2018) FONSECA, Gilton Marques; JEISMANN, Vagner Birk; KRUGER, Jaime Arthur Pirola; COELHO, Fabricio Ferreira; MONTAGNINI, Andre Luis; HERMAN, PauloBackground: Liver surgery has developed significantly in the past decades. In Brazil, the interest on it has grown significantly, but there is no study regarding its clinical practice. Despite intrinsic limitations, surveys are well suited to descriptive studies and allow understanding the current scenario. Aim: To provide an overview on the current spread of liver surgery in Brazil, focusing on groups' profile, operative techniques and availability of resources. Method: From May to November 2016, was conducted a national survey about liver surgery profile in Brazil composed by 28 questions concerning surgical team characteristics, technical preferences, surgical volume, results and available institutional resources. The survey was sent by e-mail to 84 liver surgery team leaders from different centers including all regions of the country. Results: Forty-three study participants (51.2%), from all Brazilian regions, responded the survey. Most centers have residency/fellowship programs (86%), perform and do laparoscopic procedures (91%); however, laparoscopy is still responsible for a little amount of surgeries (1-9% of laparoscopic procedures over all liver resections in 39.5% of groups). Only seven centers (16.3%) perform more than 50 liver resections/year. Postoperative mortality rate is between 1-3% in 55% of the centers. Conclusion: This is the first depiction of liver surgery in Brazil. It showed a surgical practice aligned with worldwide excellence centers, concentrated on hospitals dedicated to academic practice.