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
8 resultados
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- 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.
- 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, PauloBackground: 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.
- 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.
- 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, PauloBackground. 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.
- LAPAROSCOPIC LIVER RESECTION FOR BENIGN TUMORS: THE CURRENT POSITION(2021) HERMAN, Paulo; FONSECA, Gilton Marques; KRUGER, Jaime Arthur Pirola; JEISMANN, Vagner Birk; COELHO, Fabricio FerreiraBACKGROUND: The main indications of the use of laparoscopic liver surgery (LLS), in the early days, were benign liver lesions. As LLS became more popular, indications for malignant diseases outnumbered those for benign ones. This study aims to rule out the indications and results of LLS for the treatment of benign liver tumors. METHODS: Out of 445 LLS performed in a single center, 100 (22.4%) were for benign tumors. The authors discuss the indications for resection and present their perioperative results. RESULTS: In total, 100 patients with benign tumors were evaluated. Specifically, these were as follows: 66 cases of hepatocellular adenomas; 14 cases of biliary mucinous neoplasm; 13 cases of focal nodular hyperplasia; 4 cases of angiomyolipomas; and 3 cases of hemangiomas with a mean size of 7.6 cm (ranging from 3.1 to 19.6 cm). The total morbidity rate was 19%, with 9% classified as Clavien-Dindo grades 3 or 4. No mortality was observed. CONCLUSION: LLS for benign liver tumors is safe and presents excellent results. However, indications for resection are increasingly restricted and should not be performed just because it is a minimally invasive procedure.
- Is There a Role for Locoregional Therapies for Non-colorectal Gastrointestinal Malignancies?(2021) FONSECA, Gilton Marques; BRAGHIROLI, Maria Ignez Freitas Melro; KRUGER, Jaime Arthur Pirola; COELHO, Fabricio Ferreira; HERMAN, Paulo
- 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.
- ASO Visual Abstract: 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