GILTON MARQUES FONSECA
Projetos de Pesquisa
Unidades Organizacionais
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
52 resultados
Resultados de Busca
Agora exibindo 1 - 10 de 52
- 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.
- Laparoscopic Right Hepatectomy for Cirrhotic Patients: Takasaki's Hilar Control and Caudal Approach(2017) KRUGER, Jaime Arthur Pirola; FONSECA, Gilton Marques; COELHO, Fabricio Ferreira; JEISMANN, Vagner; HERMAN, PauloCirrhotic patients bearing hepatocellular carcinomas (HCC) derive benefits from laparoscopic hepatectomy1 (-) 6 such as reduced bleeding, less overall and liver-specific complications, and fewer adhesions in the case of future reoperation or transplantation.7 (-) 10 Bleeding is concerning in the setting of cirrhosis,11 (-) 15 and adequate inflow control reduces blood loss. The caudal approach is the laparoscopic counterpart of the anterior approach to open surgery. It implies in parenchymal transection initiated from the visceral surface of the liver after limited hepatic mobilization, reducing the risk of increased circulating tumoral cells.16 (-) 18 Venous outflow transection and completion of ligament mobilization are left as last steps. A 46 years-old-male with hepatitis C virus and alcoholic cirrhosis was diagnosed with a 4-cm HCC (right hepatic lobe). Expected future liver remnant was 45 % of his total liver volume. A totally laparoscopic right hepatectomy was performed using six ports, and the specimen was removed through a Pfannenstiel auxiliary incision. A 10-mm 30A degrees scope was used. The pneumoperitoneum pressure was set to 12 mmHg. The right hepatic pedicle, the caudate lobe, and the major hepatic veins were managed with laparoscopic vascular staplers. Surgery was performed with limited liver mobilization and en bloc extrafascial right pedicle control (Takasaki's technique),19 followed by caudal parenchymal transection along the paracaval plane. The operative time was 450 min, and the estimated blood loss was 800 ml (no transfusion was required). The laparoscopic Takasaki technique and caudal approach are feasible procedures in the setting of cirrhosis, resulting in an oncologic adequate intervention with less morbidity.
- 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, PauloBackground: 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.
- 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.
- 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.
- Prognostic significance of poorly differentiated clusters and tumor budding in colorectal liver metastases(2018) FONSECA, Gilton M.; MELLO, Evandro S. de; FARAJ, Sheila F.; KRUGER, Jaime A. P.; COELHO, Fabricio F.; JEISMANN, Vagner B.; LUPINACCI, Renato M.; CECCONELLO, Ivan; ALVES, Venancio A. F.; PAWLIK, Timothy M.; HERMAN, PauloBackgroundHistomorphological features have been described as prognostic factors after resection of colorectal liver metastases (CLM). The objectives of this study were to assess the prognostic significance of tumor budding (TB) and poorly differentiated clusters (PDC) among CLM, and their association with other prognostic factors. MethodsWe evaluated 229 patients who underwent a first resection of CLM. Slides stained by HE were assessed for TB, PDC, tumor border pattern, peritumoral pseudocapsule, peritumoral, and intratumoral inflammatory infiltrate. Lymphatic and portal invasion were evaluated through D2-40 and CD34 antibody. ResultsFactors independently associated with poor overall survival were nodules>4 (P=0.002), presence of PDC G3 (P=0.007), portal invasion (P=0.005), and absence of tumor pseudocapsule (P=0.006). Factors independently associated with disease-free survival included number of nodules>4 (P<0.001), presence of PDC G3 (P=0.005), infiltrative border (P=0.031), portal invasion (P=0.006), and absent/mild peritumoral inflammatory infiltrate (P=0.002). PDC and TB were also associated with histological factors, as portal invasion (TB), peritumoral inflammatory infiltration (PDC), infiltrative border, and absence of tumor pseudocapsule (TB and PDC). ConclusionsThis is the first study demonstrating PDC as a prognostic factor in CLM. TB was also a prognostic factor, but it was not an independent predictor of survival.
- HEPATOSPLENIC SCHISTOSOMIASIS-ASSOCIATED CHRONIC PORTAL VEIN THROMBOSIS: RISK FACTOR FOR HEPATOCELLULAR CARCINOMA?(2023) DARCE, George Felipe Bezerra; MAKDISSI, Fabio Ferrari; ANDO, Sabrina de Mello; FONSECA, Gilton Marques; KRUGER, Jaime Arthur Pirola; COELHO, Fabricio Ferreira; ROCHA, Manoel de Souza; HERMAN, PauloBACKGROUND: Hepatosplenic schistosomiasis is an endemic disease prevalent in tropical countries and is associated with a high incidence of portal vein thrombosis. Inflammatory changes caused by both parasitic infection and portal thrombosis can lead to the development of chronic liver disease with potential carcinogenesis. AIMS: To assess the incidence of portal vein thrombosis and hepatocellular carcinoma in patients with schistosomiasis during long-term follow-up. METHODS: A retrospective study was conducted involving patients with schistosomiasis followed up at our institution between 1990 and 2021. RESULTS: A total of 126 patients with schistosomiasis were evaluated in the study. The mean follow-up time was 16 years (range 5-31). Of the total, 73 (57.9%) patients presented portal vein thrombosis during follow-up. Six (8.1%) of them were diagnosed with hepatocellular carcinoma, all with portal vein thrombosis diagnosed more than ten years before. CONCLUSIONS: The incidence of hepatocellular carcinoma in patients with schistosomiasis and chronic portal vein thrombosis highlights the importance of a systematic long-term follow-up in this group of patients.
- Laparoscopic Resection of Hepatocellular Carcinoma: When, Why, and How? A Single-Center Experience(2014) HERMAN, Paulo; PERINI, Marcos Vinicius; COELHO, Fabricio Ferreira; KRUGER, Jaime Arthur Pirolla; LUPINACCI, Renato Micelli; FONSECA, Gilton Marques; LOPES, Felipe de Lucena Moreira; CECCONELLO, IvanPurpose: The aim of this study was to evaluate short- and intermediate-term results of laparoscopic liver resection in selected patients with hepatocellular carcinoma (HCC). Patients and Methods: Eighty-five patients with HCC were subjected to liver resection between February 2007 and January 2013. From these, 30 (35.2%) were subjected to laparoscopic liver resection and were retrospectively analyzed. Special emphasis was given to the indication criteria and to surgical results. Results: There were 21 males and 9 females with a mean age of 57.4 years. Patients were subjected to 10 nonanatomic and 20 anatomic resections. Two patients were subjected to hand-assisted procedures (right posterior sectionectomies); all other patients were subjected to totally laparoscopic procedures. Conversion to open surgery was necessary in 4 patients (13.3%). Postoperative complications were observed in 12 patients (40%), and the mortality rate was 3.3%. Mean overall survival was 29.8 months, with 3-year overall and disease-free survival rates of 76% and 58%, respectively. Conclusions: Laparoscopic treatment of selected patients with HCC is safe and feasible and can lead to good short- and intermediate-term results.
- 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.
- Primary liposarcoma of the pancreas: A review illustrated by findings from a recent case(2016) MACHADO, Marcel Cerqueira Cesar; FONSECA, Gilton Marques; MEIRELLES, Luciana Rodrigues de; ZACCHI, Flavia Fernandes Silva; BEZERRA, Regis Otaviano FrancaLiposarcoma is the most common soft tissue sarcoma and accounts for 15%-20% of all mesenchymal malignancies. The tumor occurs most frequently in limbs and retroperitoneum, with only rare instances of visceral location reported. Pancreas is a very rare site of primary liposarcoma, with a total of seven cases reported since 1979 and only four of those in the English literature. We review the literature specific for primary liposarcoma of the pancreas and discuss radiological and pathological aspects of this rare tumor type as well as emerging options of treatment. The review is illustrated by findings of a recent case of a dedifferentiated liposarcoma of the pancreas coupled with undifferentiated pleomorphic sarcoma, including the first description of this rare tumor by magnetic resonance imaging. The patient was successfully treated with distal pancreatectomy and splenectomy, followed by adjuvant chemotherapy and radiotherapy. At the 5-year follow-up, the patient showed no signs of recurrence.