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Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers' practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.
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OBJECTIVE: To evaluate perioperative outcomes, safety and feasibility of video-assisted resection for primary and secondary liver lesions. METHODS: From a prospective database, we analyzed the perioperative results (up to 90 days) of 25 consecutive patients undergoing video-assisted resections in the period between June 2007 and June 2013. RESULTS: The mean age was 53.4 years (23-73) and 16 (64%) patients were female. Of the total, 84% were suffering from malignant diseases. We performed 33 resections (1 to 4 nodules per patient). The procedures performed were non-anatomical resections (n = 26), segmentectomy (n = 1), 2/3 bisegmentectomy (n = 1), 6/7 bisegmentectomy (n = 1), left hepatectomy (n = 2) and right hepatectomy (n = 2). The procedures contemplated postero-superior segments in 66.7%, requiring multiple or larger resections. The average operating time was 226 minutes (80-420), and anesthesia time, 360 minutes (200-630). The average size of resected nodes was 3.2 cm (0.8 to 10) and the surgical margins were free in all the analyzed specimens. Eight percent of patients needed blood transfusion and no case was converted to open surgery. The length of stay was 6.5 days (3-16). Postoperative complications occurred in 20% of patients, with no perioperative mortality. CONCLUSION: The video-assisted liver resection is feasible and safe and should be part of the liver surgeon armamentarium for resection of primary and secondary liver lesions.
Assuntos
Hepatectomia , Neoplasias Hepáticas/cirurgia , Cirurgia Vídeoassistida , Adulto , Idoso , Feminino , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Objective: To evaluate perioperative outcomes, safety and feasibility of video-assisted resection for primary and secondary liver lesions. Methods : From a prospective database, we analyzed the perioperative results (up to 90 days) of 25 consecutive patients undergoing video-assisted resections in the period between June 2007 and June 2013. Results : The mean age was 53.4 years (23-73) and 16 (64%) patients were female. Of the total, 84% were suffering from malignant diseases. We performed 33 resections (1 to 4 nodules per patient). The procedures performed were non-anatomical resections (n = 26), segmentectomy (n = 1), 2/3 bisegmentectomy (n = 1), 6/7 bisegmentectomy (n = 1), left hepatectomy (n = 2) and right hepatectomy (n = 2). The procedures contemplated postero-superior segments in 66.7%, requiring multiple or larger resections. The average operating time was 226 minutes (80-420), and anesthesia time, 360 minutes (200-630). The average size of resected nodes was 3.2 cm (0.8 to 10) and the surgical margins were free in all the analyzed specimens. Eight percent of patients needed blood transfusion and no case was converted to open surgery. The length of stay was 6.5 days (3-16). Postoperative complications occurred in 20% of patients, with no perioperative mortality. Conclusion : The video-assisted liver resection is feasible and safe and should be part of the liver surgeon armamentarium for resection of primary and secondary liver lesions.
Objetivo: avaliar os resultados perioperatórios, segurança e exequibilidade das ressecções videoassistidas para lesões hepáticas primárias e secundárias. Métodos: a partir de um banco de dados prospectivo, foram analisados os resultados perioperatórios (até 90 dias) de 25 pacientes consecutivos submetidos à ressecções videoassistidas, no período entre junho de 2007 e junho de 2013. Resultados: a média de idade foi 53,4 anos (23 a 73 anos), sendo 16 (64%) pacientes do sexo feminino. Do total, 84% eram portadores de patologias malignas. Foram realizadas 33 ressecções (1 a 4 nódulos por paciente). Os procedimentos realizados foram: ressecções não regradas (n=26), segmentectomia (n=1), bissegmentectomia 2/3 (n=1), bissegmentectomia 6/7 (n=1), hepatectomia esquerda (n=2), hepatectomia direita (n=2). Do total, 66,7% dos procedimentos foram em segmentos póstero-superiores, necessitaram de resecções múltiplas ou ressecções maiores. O tempo médio de operação foi 226 minutos (80-420 min) e o tempo de anestesia de 360 minutos (200-630 min). O tamanho médio dos nódulos ressecados foi 3,2cm (0,8 a 10 cm) e as margens cirúrgicas foram livres em todos os espécimes analisados. Foram transfundidos 8% dos pacientes e nenhum caso foi convertido. O tempo de internação foi 6,5 dias (3 a 16 dias). Complicações pós-operatórias ocorreram em 20% dos pacientes, não havendo mortalidade perioperatória. Conclusão: a ressecção hepática videoassistida é exequível e segura, devendo fazer parte do armamentário do cirurgião de fígado para ressecções de lesões hepáticas primárias e secundárias.
Assuntos
Humanos , Masculino , Feminino , Adulto , Idoso , Adulto Jovem , Cirurgia Vídeoassistida , Hepatectomia , Neoplasias Hepáticas/cirurgia , Estudos Prospectivos , Resultado do Tratamento , Laparoscopia , Pessoa de Meia-IdadeAssuntos
Neoplasias Colorretais/mortalidade , Hepatectomia/mortalidade , Neoplasias Hepáticas/mortalidade , Veia Porta/cirurgia , Adulto , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Feminino , Seguimentos , Humanos , Ligadura , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Veia Porta/patologia , Prognóstico , Taxa de SobrevidaRESUMO
BACKGROUND: Identification 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. METHODS: EGFR overexpression was determined by immunohistochemistry, and the pattern of expression was compared between the primary tumour, adjacent normal pancreas and involved lymph nodes. RESULTS: A 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. CONCLUSION: Positive mEGFR overexpression is associated with decreased survival; however, it is not an independent prognostic factor.
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Adenocarcinoma/cirurgia , Biomarcadores Tumorais/metabolismo , Receptores ErbB/metabolismo , Pancreatectomia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia , Adenocarcinoma/metabolismo , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Imuno-Histoquímica , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Neoplasias Pancreáticas/metabolismo , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Prognóstico , Análise de Sobrevida , Resultado do TratamentoRESUMO
AIM: To propose a less invasive surgical treatment for schistosomal portal hypertension. METHODS: Ten consecutive patients with hepatosplenic schistosomiasis and portal hypertension with a history of upper gastrointestinal hemorrhage from esophageal varices rupture were evaluated in this study. Patients were subjected to a small supraumbilical laparotomy with the ligature of the splenic artery and left gastric vein. During the procedure, direct portal vein pressure before and after the ligatures was measured. Upper gastrointestinal endoscopy was performed at the 30(th) postoperative day, when esophageal varices diameter were measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings. RESULTS: There was no intra-operative mortality and all patients had confirmed histologic diagnoses of schistosomal portal hypertension. During the immediate postoperative period, two of the ten patients had complications, one characterized by a splenic infarction, and the other by an incision hematoma. Mean hospitalization time was 4.1 d (range: 2-7 d). Pre- and post-operative liver function tests did not show any significant changes. During endoscopy thirty days after surgery, a decrease in variceal diameters was observed in seven patients. During the follow-up period (57-72 mo), endoscopic therapy was performed and seven patients had their varices eradicated. Considering the late postoperative evaluation, nine patients had a decrease in variceal diameters. A mean of 3.9 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence at the late postoperative period, which was controlled with endoscopic banding in one patient due to variceal rupture and presented as secondary to congestive gastropathy in the other patient. Both bleeding episodes were of minor degree with no hemodynamic consequences or need for blood transfusion. CONCLUSION: Ligature of the splenic artery and left gastric vein with supraumbilical laparotomy is a promising and less invasive method for treating presinusoidal schistosomiasis portal hypertension.
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Endoscopia , Hipertensão Portal/cirurgia , Pressão na Veia Porta , Esquistossomose/parasitologia , Artéria Esplênica/cirurgia , Adulto , Idoso , Varizes Esofágicas e Gástricas/parasitologia , Feminino , Hemorragia Gastrointestinal/parasitologia , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/parasitologia , Hipertensão Portal/fisiopatologia , Tempo de Internação , Ligadura , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Esquistossomose/complicações , Esquistossomose/diagnóstico , Artéria Esplênica/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare disease with an indolent behavior. Its prognosis is better than that of patients with hepatocellular carcinoma. The authors present their experience with resection of FLHCC. METHODS: Twenty-one patients with FLHCC were treated at our institution between 1990 and 2012. Of these patients, 14 were subjected to resection of the tumor. Patient demographics, medical history, results of imaging studies and laboratory tests, surgical data, and pathologic findings were evaluated. RESULTS: The median age of the patients at the diagnosis of the tumor was 20 years and 14 patients were female. None of the patients had tumor-associated chronic liver disease or cirrhosis. The mean tumor size was 12.8 cm (range 6-19) and 18 patients had a single liver nodule. Fourteen patients were subjected to hepatectomy and six of them had lymph node metastases resected. Pathologic evaluation revealed that 5 (35.7%) patients had major vascular invasion. Tumor recurrence was seen in 8 patients (66.7%), during a follow-up. The median survival time for patients who were subjected to resection was 36 months. The 5-year overall survival rate and disease free survival rate were 28.0% and 8.5%, respectively. Univariate analysis showed that vascular invasion was the only variable associated with the disease free survival rate. CONCLUSIONS: Despite an aggressive treatment, patients with FLHCC presented unexpected low survival rates. It seems that an underestimated malignant behavior is attributed to this disease, and that the forms of adjuvant treatment should be urgently evaluated.
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Carcinoma Hepatocelular/secundário , Carcinoma Hepatocelular/cirurgia , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Adolescente , Adulto , Vasos Sanguíneos/patologia , Carcinoma Hepatocelular/patologia , Intervalo Livre de Doença , Feminino , Hepatectomia , Humanos , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia , Taxa de Sobrevida , Carga Tumoral , Adulto JovemRESUMO
INTRODUCTION: Minimally invasive laparoscopic liver surgery is being performed with increased frequency. Lesions located on the anterior and lateral liver segments are easier to approach through laparoscopy. On the other hand, laparoscopic access to posterior and superior segments is less frequent and technically demanding. AIM: Technical description for laparoscopic transthoracic access employed on hepatic wedge resection. TECHNIQUE: Laparoscopic transthoracic hepatic wedge resection on segment 8. CONCLUSION: Transthoracic approach allows access to the posterior and superior segments of the liver, and should be considered for oddly located tumors and in patients with numerous previous abdominal interventions. .
INTRODUÇÃO: As ressecções hepáticas minimamente invasivas vêm sendo realizadas com frequência crescente. O fígado é facilmente abordável através de laparoscopia para o tratamento de lesões localizadas nos segmentos anteriores e laterais; porém, o acesso aos segmentos posteriores é infrequente e tecnicamente difícil. OBJETIVO: Descrever a técnica empregada no acesso laparoscópico transtorácico para realização de ressecção hepática. TÉCNICA: Ressecção hepática em cunha no segmento 8 do fígado realizada através de laparoscopia com auxílio de portais transtorácicos. CONCLUSÃO: A abordagem transtorácica permite o acesso à parte posterior e aos segmentos superiores do fígado; deve ser considerada para tumores localizados excentricamente, e em pacientes com numerosas intervenções abdominais anteriores. .
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Idoso , Humanos , Masculino , Hepatectomia/métodos , Laparoscopia/métodos , Neoplasias Hepáticas/cirurgia , TóraxRESUMO
INTRODUCTION: The treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades. AIM: To review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients. METHODS: Survey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis. CONCLUSION: Pre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, ...
INTRODUÇÃO: O tratamento da hipertensão portal é complexo e a definição da melhor estratégia depende da causa subjacente (cirrose vs. Esquistossomose), da condição clínica e do momento em que é realizado (episódio agudo de hemorragia ou como profilaxia pré-primária, primária ou secundária). Com o advento de novas opções medicamentosas e o desenvolvimento da endoscopia e radiologia intervencionista, o tratamento da hipertensão portal tem sofrido grande transformação nas últimas décadas. OBJETIVO: Avaliar os avanços e as estratégias empregadas no tratamento emergencial e eletivo da hemorragia varicosa em pacientes cirróticos e esquistossomóticos. MÉTODO: Revisão bibliográfica nas bases de dados PubMed, Embase, Lilacs, SciELO e Cochrane até junho de 2013, com os descritores: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pré-primary prophylaxis. CONCLUSÃO: Com relação à profilaxia pré-primária não existem estratégias específicas; a melhor recomendação é tratamento da doença de base. A proflaxia primária em pacientes cirróticos deve ser feita com betabloqueadores ou terapêutica endoscópica com ligadura elástica. Existe controvérsia quanto à efetividade da profilaxia primária em pacientes esquistossomóticos; quando indicada, faz-se com betabloqueadores ou terapêutica endoscópica nas varizes de maior risco. O tratamento do sangramento agudo é o com melhor sistematização e mais alto nível de evidência; a associação de drogas vasoconstritoras e terapia endoscópica ...
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Humanos , Hemorragia Gastrointestinal/terapia , Tratamento de Emergência , Varizes Esofágicas e Gástricas/complicações , Hemorragia Gastrointestinal/etiologia , Cirrose Hepática/complicações , Esquistossomose/complicaçõesRESUMO
INTRODUCTION: The treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades. AIM: To review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients. METHODS: Survey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis. CONCLUSION: Pre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.