RESUMO

Pancreatoduodenectomy is the most appropriate technique for the treatment of periampullary tumors. In the past, this procedure was associated with high mortality and morbidity, but with improvements in patient selection, anesthesia, and surgical technique, mortality has decreased to less than 5%. However, morbidity remains increased due to various complications such as delayed gastric emptying, bleeding, abdominal collections, and abscesses, most of which are related to the pancreatojejunostomy leak. Clinically relevant postoperative pancreatic fistula is the most dangerous and is related to other complications including mortality. The incidence of postoperative pancreatic fistula ranges from 5-30%. Various techniques have been developed to reduce the severity of pancreatic fistulas, from the use of an isolated jejunal loop for pancreatojejunostomy to binding and invagination anastomoses. Even total pancreatectomy has been considered to avoid pancreatic fistula, but the late effects of this procedure are unacceptable, especially in relatively young patients. Recent studies on the main techniques of pancreatojejunostomy concluded that duct-to-mucosa anastomosis is advisable, but no technique eliminates the risk of pancreatic fistula. The purpose of this study is to highlight technical details and tips that may reduce the severity of pancreatic fistula after pancreatojejunostomy during open or minimally invasive pancreatoduodenectomy.

Assuntos

Fístula Pancreática , Pancreaticoduodenectomia , Pancreaticojejunostomia , Complicações Pós-Operatórias , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Fístula Pancreática/prevenção & controle , Fístula Pancreática/etiologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/efeitos adversos , Pancreaticojejunostomia/métodos , Pancreaticojejunostomia/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/etiologia , Índice de Gravidade de Doença

RESUMO

BACKGROUND: Left hepatic trisectionectomy consists of the removal of liver segments 2, 3, 4, 5, and 8. This difficult surgical procedure may be required when the left liver and right anterior sector (segments 5 and 8) are involved. We present a video of a robotic anatomic left trisectionectomy with Glissonian approach to the left and right anterior sector pedicles. METHODS: A 77-year-old man presented at a routine ultrasound with a large liver mass. Magnetic resonance imaging showed a bulky hepatocellular carcinoma occupying liver segments 2, 3, 4, 5, and 8, with a portal tumor thrombus in the right anterior sector. The patient had multiple comorbidities, including obesity, diabetes, hypertension, and coronariopathy. The multidisciplinary team decided to use immunotherapy with atezolizumab and bevacizumab. After 12 cycles, the patient showed an objective response, and left trisectionectomy was indicated. A robotic approach was proposed and consent was obtained. The Glissonian approach was used for anatomic control of the left and right anterior sector pedicles. RESULTS: The operative time was 390 min with an estimated blood loss of 410 ml, and no transfusion was required during or after the procedure. Recovery was uneventful and the patient was discharged on postoperative day 8. No bile leak was observed, and the drain was removed on postoperative day 8. CONCLUSIONS: Robotic left trisectionectomy is safe and feasible. The Glissonian approach is useful for anatomic left liver trisectionectomy. This video can help gastrointestinal surgeons perform this complex procedure in a minimally invasive manner.

Assuntos

Carcinoma Hepatocelular , Neoplasias Hepáticas , Procedimentos Cirúrgicos Robóticos , Masculino , Humanos , Idoso , Hepatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias Hepáticas/cirurgia , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/cirurgia

RESUMO

BACKGROUND: Low-grade lesions may benefit from pancreatic-sparing techniques. Resection of the uncinate process is rarely performed and reported due to its complexity that requires careful patient selection and accurate knowledge of the pancreatic anatomy. This study describes relevant anatomical elements to safely perform this complex operation in the minimally invasive setting. METHODS: In this study, consecutive patients undergoing resection of the uncinate process of the pancreas were studied. Patients undergoing open approach were used for comparison. Preoperative and intraoperative variables were recorded, and the diagnosis and tumor size were determined from the pathology reports. Immediate postoperative results and hospital stay were analyzed. Follow-up was used to assess long-term complications and endocrine and exocrine functions. RESULTS: Twenty-nine patients underwent resection of the uncinate process. The median age was 57 years. There were 21 males and eight females. Twenty patients underwent minimally invasive resection (14 laparoscopic and six by robotic approach) and nine were operated by open approach. A clinically relevant postoperative pancreatic fistula was observed in one patient (3.4%). Biochemical leakage was present in 44.8% of our patients. Mean follow-up was 62 months (3-147). Two patients needed reoperation during follow-up. No patient presented exocrine or endocrine insufficiency during late follow-up. CONCLUSION: Minimally invasive resection of the uncinate process of the pancreas is a complex but a feasible procedure that preserves the pancreatic endocrine and exocrine functions. This pancreas-sparing procedure is an interesting alternative to pancreaticoduodenectomy in selected patients.

Assuntos

Laparoscopia , Neoplasias Pancreáticas , Masculino , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias Pancreáticas/cirurgia , Neoplasias Pancreáticas/patologia , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Pâncreas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Fístula Pancreática/cirurgia , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Complicações Pós-Operatórias/cirurgia

RESUMO

BACKGROUND: Hepatectomy is the standard treatment for colorectal liver metastases. However, the high recurrence rate is a persistent problem that occurs in up to 65% of patients. Repeat hepatectomy is a feasible treatment and may offer favorable surviva but is technically demanding so minimally invasive repeat hepatectomy has been used in a few patients. Colorectal liver metastases are different from hepatocellular carcinoma and rarely present with macroscopic portal vein tumoral thrombus. To the best of our knowledge, minimally invasive approaches for this rare condition have not yet been reported. METHOD: We present here a video of a robotic right hepatectomy in a patient with single colorectal liver metastasis and macroscopic tumor thrombi in the right portal vein. A 61-year-old woman underwent open resection of a transverse colon cancer (T3N0M0) in December 2015. In March 2019, she underwent nonanatomical resection of a liver metastases located in segment 6 also via an open approach. She then underwent adjuvant chemotherapy. However, in September 2020, she presented with a local recurrence and a tumor thrombus in the right portal vein. She was then referred to us for treatment and a multidisciplinary team decided on upfront liver resection due to the risk of left portal vein progression. Liver volumetry showed future liver remnant of 52.5%. Right hepatectomy with portal vein thrombectomy was indicated. A robotic approach was proposed, and consent was obtained. RESULTS: The Da Vinci system was used. The operation began with the division of adhesions from previous laparotomies. Intraoperative ultrasound was performed to locate the tumor and to confirm the portal vein invasion. Hepatic hilum was carefully dissected. The replaced right hepatic artery from the superior mesenteric artery was ligated and divided. The common bile duct was dissected and encircled with a vessel loop. The portal vein was dissected, and an enlarged right portal vein with a protruding tumoral thrombus was seen. The left portal vein and portal vein trunk were then temporarily clamped. The right portal vein was carefully transected with robotic scissors being careful not to displace the thrombus. A minimum stump was left to safely suture the portal vein. The portal vein was then closed with a running 5-0 prolene suture. The portal vein clamping was then released, and a patent anastomosis with no leakage was observed. Right liver ischemic discoloration was seen and confirmed with fluorescence imaging after indocyanine green injection. A future line of transection was marked along ischemic area. The liver was divided using bipolar forceps under saline irrigation until it was detached from the retrohepatic vena cava. A right hepatic vein was divided with a stapler to complete the right hepatectomy. The surgical specimen was removed through a suprapubic incision, and the abdominal cavity was drained with a closed-suction drain. The total operative time was 270 min with no transfusion. Pathology conformed the diagnosis with free surgical margins. CONCLUSION: Robotic right hepatectomy with tumor thrombectomy is feasible and safe even in the presence of lobar portal vein invasion. This video may help HPB surgeons perform this complex procedure.

Assuntos

Neoplasias do Colo , Laparoscopia , Neoplasias Hepáticas , Procedimentos Cirúrgicos Robóticos , Feminino , Hepatectomia , Humanos , Neoplasias Hepáticas/cirurgia , Pessoa de Meia-Idade , Veia Porta/cirurgia , Trombectomia

Assuntos

Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Carcinoma Ductal Pancreático/cirurgia , Humanos , Pâncreas/diagnóstico por imagem , Pâncreas/cirurgia , Pancreatectomia , Ductos Pancreáticos/diagnóstico por imagem , Ductos Pancreáticos/cirurgia , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/cirurgia

RESUMO

BACKGROUND Hyperammonemic encephalopathy is a potentially fatal condition that may progress to irreversible neuronal damage and is usually associated with liver failure or portosystemic shunting. However, other less common conditions can lead to hyperammonemia in adults, such as fibrolamellar hepatocellular carcinoma. Clinical awareness of hyperammonemic encephalopathy in patients with normal liver function is paramount to timely diagnosis, but understanding the underlying physiopathology is decisive to initiate adequate treatment for complete recovery. CASE REPORT A 31-year-old male with fibrolamellar carcinoma and peritoneal carcinomatosis presented with rapid onset hyperammonemic encephalopathy. Despite usual treatment for hepatic encephalopathy, his hyperammonemia was aggravated. A physiopathological pathway to encephalopathy resulting from hepatocellular dysfunction or portosystemic shunting was suspected and proper treatment was initiated, which resulted in complete remission of encephalopathy. Thus, we propose there is a physiopathology path to hyperammonemic encephalopathy in non-cirrhotic patients with fibrolamellar carcinoma independent of ornithine transcarbamylase (OTC) mutation. An ornithine metabolism imbalance resulting from overexpression of Aurora Kinase A as a result of a single, recurrent heterozygous deletion on chromosome 19, common to all fibrolamellar carcinomas, can lead to a c-Myc and ornithine decarboxylase overexpression that results in ornithine transcarboxylase dysfunction with urea cycle disorder and subsequent hyperammonemia. CONCLUSIONS The identification of a physiopathological pathway allowed adequate medical treatment and full patient recovery from severe hyperammonemic encephalopathy.

Assuntos

Encefalopatias Metabólicas/etiologia , Carcinoma Hepatocelular/complicações , Carcinoma Hepatocelular/fisiopatologia , Hiperamonemia/etiologia , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/fisiopatologia , Adulto , Humanos , Masculino , Ornitina Carbamoiltransferase

RESUMO

BACKGROUND: Laparoscopic ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) has previously been reported but has been the authors' default option since 2015 in patients with small future liver remnant. METHODS: A retrospective analysis of all consecutive patients undergoing ALPPS at a single referral center was performed using a prospective database from July 2011 to June 2016. Feasibility was studied by assessing conversions. The 90-day mortality and complications were analyzed using a Dindo-Clavien score and the comprehensive complication index. Operative time, blood loss, volumetric growth, and hospital stay were examined. The CUSUM analysis was performed. RESULTS: ALPPS was performed in 30 patients, 10 of whom underwent a laparoscopic approach. There was no mortality and no complication grade ≥3A observed in laparoscopic ALPPS. In open ALPPS, 10 of 20 patients experienced complications grade ≥3A (p = 0.006) and one patient died. Liver failure was not observed after laparoscopic ALPPS, but two patients in the open ALPPS group developed complications that precluded the second stage. The total hospital stay was shorter in the laparoscopic ALPPS group. CONCLUSION: Laparoscopic ALPPS is feasible as the default procedure for patients with very small FLR, and it is not inferior to the open approach. Surgeons experienced with complex laparoscopy should be encouraged to use a laparoscopic approach to ALPPS.

Assuntos

Hepatectomia/métodos , Laparoscopia , Fígado/cirurgia , Veia Porta/cirurgia , Adulto , Idoso , Perda Sanguínea Cirúrgica , Brasil , Bases de Dados Factuais , Estudos de Viabilidade , Feminino , Hepatectomia/efeitos adversos , Hepatectomia/mortalidade , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/mortalidade , Tempo de Internação , Ligadura , Fígado/diagnóstico por imagem , Fígado/fisiopatologia , Regeneração Hepática , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Tamanho do Órgão , Seleção de Pacientes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento

RESUMO

Surgical resection is the treatment of choice for malignant liver tumours. Nevertheless, surgical approach to tumours located close to the confluence of the hepatic veins is a challenging issue. Trisectionectomies are considered the first curative option for treatment of these tumours. However, those procedures are associated with high morbidity and mortality rates primarily due to post-operative liver failure. Thus, maximal preservation of functional liver parenchyma should always be attempted. We describe the isolated resection of Segment 8 for the treatment of a tumour involving the right hepatic vein and in contact with the middle hepatic vein and retrohepatic vena cava with immediate reconstruction of the right hepatic vein with a vascular graft. This is the first time this type of reconstruction was performed, and it allowed to preserve all but one of the hepatic segments with normal venous outflow. This innovative technique is a fast and safe method to reconstruct hepatic veins.

RESUMO

Modern liver techniques allowed the development of segment-based anatomical liver resections. Nevertheless, there is still a place for nonanatomical liver resections. However, in some cases, there is a need for enucleation of deep located liver tumors. The main problem with enucleation of a liver tumor deeply located in the middle of the liver is the control of bleeding resulting from the rupture of small or medium vessels. The authors describe a simple way to control the bleeding without the use of any special instrument or material. This technique can also be used to control bleeding from penetrating liver injury.

RESUMO

Laparoscopic distal pancreatectomies became more common in the past few years as a safe and effective treatment option for benign and low-grade malignant tumors of the body and tail of the pancreas. Adequate exposure and wide operative field are crucial to perform this procedure, and this is achieved by retraction of the stomach with an angled liver retractor or a grasper through a subxiphoid trocar, that is usually used only to this purpose. We developed an innovative technique to retract the stomach during laparoscopic distal pancreatectomies that provides excellent operative field and frees the subxiphoid trocar to be used in other tasks during the surgery.