SUMMARY OBJECTIVE: A survey among medical students in a Brazilian public university was performed to investigate the acceptance of organ donation in Brazil, particularly donation after circulatory death (DCD). METHODS: A questionnaire including 26 objectives and Likert scale questions was validated and sent to all medical students of our institution. The answers were analyzed considering the whole set of individuals as well as by dividing the medical students into two groups: less graduated students and more graduated students. RESULTS: From 1050 students, 103 spontaneous answers (9.8%) were retrieved after 3 weeks. A total of 89.3% agreed totally with deceased donor organ donation and 8.7% agreed partially. However, only 50.5% of the students agreed totally and 31.1% agreed partially to living donation. Students revealed that 82.6% know the concept of brain death. On the other hand, 71.8% of them declared not knowing the concept of planned withdrawal of life-sustaining therapy, mainly cardiorespiratory support. A total of 85.4% of students agreed totally with donation after brain death and 11.7% agreed partially. However, when questioned about donation in awaiting circulatory death after a planned withdrawal of life-sustaining therapy, only 18.4% agreed totally and 32% agreed partially. Both groups of less and more graduated students showed similar results. CONCLUSIONS: Our study found a clear lack of information and consequently in acceptance of DCD. Education in the field of end-of-life management may improve not only the acceptance of DCD donation but also the whole understanding of planned withdrawal of life-sustaining therapy.

RESUMO - RACIONAL: O câncer colorretal é a terceira neoplasia mais frequente e metade dos pacientes desenvolvem metástase hepática. O melhor fator prognóstico na metástase hepática de câncer colorretal (MHCCR) é a possibilidade de ressecção com margens livres, porém a maioria permanece irressecável. O racional em realizar transplante hepático (TH) em pacientes portadores de MHCCR está na ampliação do número de pacientes ressecáveis através de uma hepatectomia total. OBJETIVO: Apresentar protocolo brasileiro para realização de transplante hepático em pacientes com MHCCR irressecável. MÉTODO: O protocolo foi realizado por duas instituições com grande volume de ressecções e transplantes hepáticos no Brasil, baseado no trabalho realizado pela Universidade de Oslo. A elaboração foi dividida em 4 etapas. RESULTADO: É apresentada proposta de protocolo para esta doença a ser validada na aplicação clínica. CONCLUSÃO: Foi possível elaborar protocolo de transplante hepático para MHCCR irressecável a fim de uniformizar o tratamento e melhor avaliar os resultados cirúrgicos.

ABSTRACT - BACKGROUND: Colorectal cancer (CRC) is the third most common neoplasm, and half of the patients with CRC develop liver metastasis. The best prognostic factor for colorectal liver metastasis (CRLM) is the possibility of performing a resection with free margins; however, most of them remain unresectable. The justification for performing liver transplantation (LT) in patients with CRLM regards an increase in the number of resectable patients by performing total hepatectomy. AIM: The aim of this study was to provide a Brazilian protocol for LT in patients with unresectable CRLM. METHOD: The protocol was carried out by two Brazilian institutions, which perform a large volume of resections and LTs, based on the study carried out at the University of Oslo. The elaboration of the protocol was conducted in four stages. RESULT: A protocol proposal for this disease is presented, which needs to be validated for clinical use. CONCLUSION: The development of an LT protocol for unresectable CRLM aims to standardize the treatment and to enable a better evaluation of surgical results.

RESUMO Racional: O colangiocarcinoma hilar representa mais da metade de todos os casos de colangiocarcinoma; tem prognóstico reservado e sobrevida global mediana de 12- 24 meses após o diagnóstico. A proposta de realizar transplante hepático surgiu para ampliar a possibilidade de margens livres através de hepatectomia total nos portadores de tumoresirressecáveis com melhor prognóstico. Objetivo: Apresentar protocolo brasileiro para realização de transplante hepático em pacientes com colangiocarcinoma hilar. Método: O protocolo foi realizado por duas instituições com grande volume de ressecções e transplantes hepáticos no Brasil, baseado no trabalho realizado pela MayoClinic. A elaboração foi dividida em quatro etapas. Resultado: É apresentada proposta de protocolo para esta doença a ser validada na aplicação clínica. Conclusão: Foi possível elaborar protocolo de transplante hepático para colangiocarcinoma a fim de uniformizar o tratamento e melhor avaliar os resultados cirúrgicos.

ABSTRACT Background: Hilar cholangiocarcinoma represents more than half of all cholangiocarcinoma cases, having poor prognosis and presenting a median overall survival after diagnosis of 12-24 months. In patients who have unresectable tumors with a better prognosis, the proposal to perform liver transplantation emerged for expanding the possibility of free margins by performing total hepatectomy. Aim: To provide a Brazilian protocol for liver transplantation in patients with hilar cholangiocarcinoma. Method: The protocol was carried out by two Brazilian institutions which perform a large volume of resections and liver transplantations, based on the study carried out at the Mayo Clinic. The elaboration of the protocol was conducted in four stages. Result: A protocol proposal for this disease is presented, which needs to be validated for clinical use. Conclusion: The development of a liver transplantation protocol for cholangiocarcinoma aims not only to standardize the treatment, but also enable a better assessment of the surgical results in the future.

OBJECTIVES: Patients receiving treatment for tuberculosis are at risk of developing acute liver failure due to the hepatotoxicity of antitubercular drugs. We aimed to describe our experience with liver transplantation from deceased donors in this situation. METHODS: We identified patients undergoing transplantation for acute liver failure due to antitubercular drugs in our prospectively maintained database. RESULTS: Of 81 patients undergoing transplantation for acute liver failure, 8 cases were attributed to antitubercular drugs during the period of 2006-2016. Regarding the time of tuberculosis treatment until the onset of jaundice, patients were on antitubercular drugs for a mean of 64.7 days (21-155 days). The model for end-stage liver disease (MELD) score of patients ranged from 32 to 47 (median 38), and seven patients underwent transplantation under vasopressors. The 1-year survival was 50%. Three patients died during the week following transplantation due to septic shock (including a patient with acute liver failure due to hepatic/disseminated tuberculosis), and the remaining patient died 2 months after transplantation due to pulmonary infection. There were 2 cases of mild rejection and 1 case of moderate rejection. Of the surviving patients, all were considered cured of tuberculosis after alternative drugs were given. CONCLUSION: Patients arrived very sick and displayed poor survival after deceased donor transplantation.

RACIONAL: O transplante de fígado é realizado em grandes centros de transplante em todo o mundo como intervenção terapêutica para pacientes com doenças do fígado em fase terminal. OBJETIVO: Analisar os resultados e incidência de transplante de fígado realizado na Universidade de São Paulo e comparar com a do Estado de São Paulo antes e depois da adoção do Modelo para Doença Hepática Estágio Terminal (MELD). MÉTODO: Avaliação do número de transplantes de fígado antes e depois da adoção do escore MELD. Os valores médios e desvios-padrão foram utilizados para analisar variáveis normalmente distribuídas. Os resultados de incidência foram comparados com os do Estado de São Paulo. RESULTADOS: Houve alta prevalência de homens, com predomínio na meia-idade. A principal indicação para o transplante de fígado foi cirrose por hepatite C. A média e as taxas de sobrevivência mediana e sobrevida global em dez e cinco anos, foram semelhantes entre os grupos (p>0,05). A pontuação MELD aumentou ao longo do período de estudo para os pacientes que se submeteram ao transplante de fígado (p>0,05). Houve aumento do número de transplantes de fígado após a adoção do escore MELD na Universidade de São Paulo e no Estado de São Paulo (p<0,001). CONCLUSÃO: A adoção da pontuação MELD levou ao aumento do número de transplantes de fígado realizados em São Paulo.

BACKGROUND: Liver transplantation is performed at large transplant centers worldwide as a therapeutic intervention for patients with end-stage liver diseases. AIM: To analyze the outcomes and incidence of liver transplantation performed at the University of São Paulo and to compare those with the State of São Paulo before and after adoption of the Model for End-Stage Liver Disease (MELD) score. METHOD: Evaluation of the number of liver transplantations before and after adoption of the MELD score. Mean values and standard deviations were used to analyze normally distributed variables. The incidence results were compared with those of the State of São Paulo. RESULTS: There was a high prevalence of male patients, with a predominance of middle-aged. The main indication for liver transplantation was hepatitis C cirrhosis. The mean and median survival rates and overall survival over ten and five years were similar between the groups (p>0.05). The MELD score increased over the course of the study period for patients who underwent liver transplantation (p>0.05). There were an increased number of liver transplants after adoption of the MELD score at this institution and in the State of São Paulo (p<0.001). CONCLUSION: The adoption of the MELD score led to increase the number of liver transplants performed in São Paulo.

INTRODUÇÃO: A trombose de veia porta foi considerada contraindicação ao transplante de fígado no passado em razão da elevada morbi-mortalidade. Diversos avanços permitiram melhora dos resultados. OBJETIVO: Revisão dos avanços e das estratégias cirúrgicas utilizadas para realização do transplante de fígado na vigência de trombose de veia porta. MÉTODO: Revisão da literatura nas bases de dados Medline, Scielo, Lilacs cruzando os descritores: portal vein thrombosis, liver transplantation, vascular complications, jump graft, graft failure, multivisceral transplant. Foram estudados a epidemiologia, fatores de risco, classificação, diagnóstico, estratégias cirúrgicas e resultados. CONCLUSÃO: A trombose de veia porta deixou de ser contraindicação para o transplante hepático. O cirurgião dispõe atualmente de uma série de estratégias para realização do transplante, variando conforme o grau da trombose. Apesar de implicar em maior morbidade e taxas de re-trombose, os resultados do transplante na presença de trombose portal são semelhantes aos observados nas séries habituais.

BACKGROUND: Portal vein thrombosis was considered a contraindication for liver transplantation in the past because of the high morbidity and mortality rates. Many advances made the results better. AIM: Review the advances and surgical strategies for liver transplantation in presence of portal vein thrombosis. METHOD: Survey of publications in Medline, Scielo and Lilacs databases. Headings crossed: portal vein thrombosis, liver transplantation, vascular complications, jump graft, graft failure, multivisceral transplant. Data analyzed were epidemiology, risk factors, classification, diagnosis, surgical strategies and outcomes. CONCLUSION: Portal vein thrombosis is not a contraindication for liver transplantation anymore. There are many strategies to perform the liver transplantation in this condition, depending on portal vein thrombosis grade. Regardless higher morbidity and re-trhombosis rates, the outcomes of liver transplantation in portal vein thrombosis are similar to series without portal vein thrombosis.

Durante o período de janeiro de 1994 a janeiro de 1997 foram submetidos ao método 120 pacientes, sendo 42 do sexo masculino (35%) e 78 do sexo feminino (65%). A idade variou de 16 a 60 anos, com média de 38. Todos apresentavam diagnóstico de colecistite calculosa crônica, sendo selecionados em consultório pelos seguintes critérios: inexistência de quadro inflamatório agudo da vesícula biliar, idade máxima de 60 anos, ausência de suspeita de coledocolitíase e classificação anestésica ASA I e II. A cirurgia era realizada em posição semiginecológica com utilização de três trocartes, sendo a colangiografia realizada de rotina. O tempo cirúrgico variou de 20 a 80 minutos com média de 50 minutos. A colangiografia intra-operatória foi realizada em 105 pacientes (87,5%), demonstrando coledocolitíase em dois (1,9%). Não ocorreram conversões. As complicações pós-operatórias imediatas mais freqüentes foram náuseas em oito casos (6,6%), seguidas de vômitos em dois pacientes (1,6%). A dor foi de pequena intensidade e facilmente controlável com dipirona e antiintlamatórios não-hormonais. Não ocorreram casos de infecção de ferida cirúrgica, mas três pacientes (2,5%) apresentaram hiperemia da incisão umbilical. Todos tiveram condições de alta no mesmo dia da cirurgia. O período de permanência hospitalar foi em média de 10 horas. Não houve necessidade de reinternação em nenhum caso.

The arrival of cholecystectomy by minilaparotomy provided reduction of the hospitalar stay and the discharge on the same day began to be considered and applied with success to some patients. However, it was with the laparoscopic approach that the ambulatory surgery received strong stimulation. The feasibility of cholecystectomy for calculous chronic cholecystitis under laparoscopy in the outpatient ambulatory setting was evaluated in a prospective study. During the period between January 1994 to January 1997,120 patients were operated. Forty-two were male (35%) and 78 female (65%), aging from 16 to 60 at an average of 38. The patients were selected under the following criteria: no accute process, maximum age 60 years, no suspicion of choledocolithiasis and classification ASA I and 11. The surgery was performed in lithotomy position with three trocars. Cholangiography was routine. Surgical time ranged from 20 to 80 minutes with an average of 50. Cholangiography was done in 105 cases (87.5%) confirming choledocolithiasis in two (1.9%). There were no conversions. The most common complications in the imediate postoperative period were: nausea in eight patients (6.6%) with vomiting in two (1.6%). The abdominal pain was little and easily treated with dipiron and nonsteroidal antiinflammatory analgesics. Operatory wound infection was not observed but three patients (2.5%) showed hyperemia in the umbilical incision. All patients were discharged from ambulatory after an average hospitalar stay of ten hours. In conclusion, according to what this study has shown laparoscopic cholecystectomy can perfectly be done in the ambulatory setting without increasing on the complication rates.