RESUMO
OBJECTIVE: Several studies have investigated the correlation between the effects of different surgical treatments and laboratory exams for schistosomal portal hypertension, especially concerning portal system thrombosis. The etiopathogenic factors of this thrombosis are not fully understood. In this study, the correlation between surgical treatment for schistosomal portal hypertension and the occurrence of postoperative portal system thrombosis was investigated. METHODS: A total of 61 patients who underwent surgical treatment for schistosomal portal hypertension were distributed into four groups: Patients in Group 1 (n=12) underwent portal variceal disconnection associated with splenic artery ligation and spleen preservation. Patients in Group 2 (n=20) underwent portal variceal disconnection and total splenectomy. Patients in Group 3 (n=20) underwent portal variceal disconnection with subtotal splenectomy, preserving the upper splenic pole supplied by the splenogastric vessels. Patients in Group 4 (n=9) underwent portal variceal disconnection with total splenectomy and autogenous splenic implants on the greater omentum. Late postoperative portal vein thrombosis was diagnosed using Doppler ultrasound. RESULTS: Over the 10-year follow-up, portal vein thrombosis occurred in 26 operated patients (42.6%), with no significant difference observed among the four surgical groups (p=0.217). Most of the thrombi only partially occluded the portal system veins. All the patients presented with a thrombus inside the portal vein. There was no difference in hematological and biochemical tests between groups with or without portal vein thrombosis. CONCLUSIONS: Portal vein thrombosis is often observed in the late postoperative period, irrespective of the surgical treatment employed, and is not associated with patient characteristics or any hematological and biochemical tests.
Assuntos
Hipertensão Portal , Veia Porta , Esplenectomia , Trombose Venosa , Humanos , Hipertensão Portal/cirurgia , Hipertensão Portal/etiologia , Feminino , Masculino , Esplenectomia/efeitos adversos , Esplenectomia/métodos , Veia Porta/cirurgia , Veia Porta/diagnóstico por imagem , Adulto , Pessoa de Meia-Idade , Trombose Venosa/etiologia , Trombose Venosa/cirurgia , Trombose Venosa/diagnóstico por imagem , Resultado do Tratamento , Adulto Jovem , Esquistossomose/cirurgia , Esquistossomose/complicações , Seguimentos , Complicações Pós-Operatórias , Ligadura/métodos , Varizes Esofágicas e Gástricas/cirurgia , Varizes Esofágicas e Gástricas/etiologia , Adolescente , Ultrassonografia DopplerAssuntos
Pancreaticoduodenectomia , Pericárdio , Procedimentos Cirúrgicos Robóticos , Humanos , Pancreaticoduodenectomia/métodos , Pancreaticoduodenectomia/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Pericárdio/transplante , Animais , Bovinos , Procedimentos de Cirurgia Plástica/métodos , Veia Porta/cirurgia , Neoplasias Pancreáticas/cirurgia , Anastomose Cirúrgica/métodosRESUMO
ALPPS enables complete tumor resection in a shorter interval and a larger number of patients than classic two-stage hepatectomies. However, there is little evidence regarding long-term outcomes in patients with colorectal liver metastases (CLM). This study aims to evaluate the short and long-term outcomes of ALPPS in patients with CRM. Single-cohort, prospective, observational study. Patients with unresectable CLM due to insufficient liver remnant who underwent ALPPS between June 2011 and June 2021 were included. Of 32 patients treated, 21 were male (66%) and the median age was 56 years (range = 29-81). Both stages were completed in 30 patients (93.7%), with an R0 rate of 75% (24/32). Major morbidity was 37.5% and the mortality nil. Median overall survival (OS) and recurrence-free survival (RFS) were 28.1 and 8.8 months, respectively. The 1-3, and 5-year OS was 86%, 45%, and 21%, and RFS was 42%, 14%, and 14%, respectively. The only independent risk factor associated with poor RFS (5.7 vs 11.6 months; p = 0.038) and OS (15 vs 37 months; p = 0.009) was not receiving adjuvant chemotherapy. KRAS mutation was associated with worse OS from disease diagnosis (24.3 vs. 38.9 months; p = 0.025). ALPPS is associated with favorable oncological outcomes, comparable to traditional strategies to increase resectability in patients with CLM and high tumor burden. Our results suggest for the first time that adjuvant chemotherapy is independently associated with better short- and long-term outcomes after ALPPS. Selection of patients with KRAS mutations should be performed with caution, as this could affect oncological outcomes.
Assuntos
Neoplasias Colorretais , Hepatectomia , Neoplasias Hepáticas , Humanos , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/mortalidade , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/tratamento farmacológico , Pessoa de Meia-Idade , Hepatectomia/métodos , Masculino , Feminino , Idoso , Quimioterapia Adjuvante , Estudos Prospectivos , Adulto , Idoso de 80 Anos ou mais , Resultado do Tratamento , Veia Porta/cirurgia , Taxa de Sobrevida , Ligadura/métodos , Fatores de TempoRESUMO
BACKGROUND: Endovascular management of portal vein thrombosis (PVT) is challenging. Transsplenic access (TSA) is growing as an access option to the portal system but with higher rates of bleeding complications. The aim of this article is to evaluate the efficacy and safety of transsplenic portal vein recanalization (PVR) using a metallic stent after pediatric liver transplantation. MATERIALS AND METHODS: This is a retrospective review of 15 patients with chronic PVT who underwent PVR via TSA between February 2016 and December 2020. Two children who had undergone catheterization of a mesenteric vein tributary by minilaparotomy were excluded from the patency analysis but included in the splenic access analysis. The technical and clinical success of PVR and complications related to the procedure via TSA were evaluated. RESULTS: Thirteen children with PVT were treated primarily using the TSA. The mean age was 4.1 years (range, 1.5-13.7 years), and the most common clinical presentation was hypersplenism (60%). Technically successful PVR was performed in 11/13 (84.6%) children, and clinical success was achieved in 9/11 (81.8%) children. No major complications were observed, and one child presented moderate pain in the TSA (from a total of 17 TSA). The median follow-up was 48.2 months. The median primary patency was 9.9 months. Primary patency in the first 4 years was 75%, and primary assisted patency was 100% in the follow-up period. CONCLUSIONS: Transsplenic PVR is a safe and effective method for the treatment of PVT after pediatric liver transplantation.
Assuntos
Hepatopatias , Transplante de Fígado , Trombose Venosa , Humanos , Criança , Pré-Escolar , Transplante de Fígado/efeitos adversos , Veia Porta/cirurgia , Resultado do Tratamento , Hepatopatias/complicações , Trombose Venosa/etiologia , Trombose Venosa/cirurgia , Estudos RetrospectivosAssuntos
Embolização Terapêutica , Neoplasias Hepáticas , Humanos , Veia Porta/cirurgia , Fígado/irrigação sanguínea , Hepatectomia/métodos , Embolização Terapêutica/métodos , Procedimentos Cirúrgicos Vasculares , Ligadura/métodos , Neoplasias Hepáticas/cirurgia , Regeneração Hepática , Resultado do TratamentoRESUMO
BACKGROUND: The incidence of portal vein thrombosis (PVT) at the time of liver transplantation (LT) may be variable and underestimated. Therefore, preoperative diagnosis and stratification of its extension is so relevant for adequate surgical planning. Revascularization of the portal vein graft becomes essential for graft and patient survival after LT. Early stages of PVT may be managed with eversion thrombectomy and end-to-end anastomoses. However, severe PVT (grades 3 and 4) poses significant challenges for patients requiring LT, resulting in more complex surgeries and higher complication rates. To address these complexities, various surgical techniques have been developed, including collateral alternative vessel utilization, renoportal anastomoses, mesoportal jump graft placement, cavoportal hemitranspositions, portal vein arterialization, or even multivisceral transplantation. PURPOSE: We herein describe the preoperative surgical planning as well as the different surgical strategies possible to treat portal vein thrombosis during LT. CONCLUSION: A comprehensive preoperative evaluation of PVT is crucial for accurately assessing its extent and severity. This information is vital for proper surgical planning, which ultimately prepares both the surgeon and the patient for potentially complex procedures during LT. The surgical alternatives presented in this technical report offer promising solutions for treating PVT during LT, making it a viable option for selected patients.
Assuntos
Hepatopatias , Transplante de Fígado , Trombose Venosa , Humanos , Adulto , Transplante de Fígado/métodos , Veia Porta/cirurgia , Hepatopatias/complicações , Anastomose Cirúrgica/efeitos adversos , Trombose Venosa/etiologia , Trombose Venosa/cirurgiaRESUMO
BACKGROUND: Minimally invasive pancreatoduodenectomy (PD) is one of the most complex procedures in oncologic surgery. We present a video of robotic portomesenteric reconstruction with bovine pericardial graft during PD. METHODS: A 52-year-old woman was referred with a mass in the head of the pancreas. The tumor was in contact with the portomesenteric axis. The multidisciplinary team decided to perform an upfront resection. The surgery was performed as a pylorus-preserving pancreaticoduodenectomy with lymphadenectomy. The superior mesenteric artery first approach was used to expose the head of the pancreas, so that the entire surgical specimen was attached only through the tumor invasion of the portomesenteric axis. After resection of the invaded portomesenteric axis, its large extension precluded primary reconstruction, so a bovine pericardial graft was used for venous reconstruction. After completion of the venous anastomosis, reconstruction of the digestive tract was performed as usual. RESULTS: Surgical time was 430 min; clamp time was 55 min; and portomesenteric reconstruction took 41 min. Estimated blood loss was 320 mL without transfusion. Pathology confirmed T3N1 ductal adenocarcinoma with free margins. No pancreatic or biliary fistula was observed, and she was discharged on postoperative day 8. A postoperative examination confirmed the patency of the graft. The patient is doing well 6 months after surgery and has no signs of the disease. CONCLUSIONS: A bovine pericardial graft is useful for reconstruction and readily available, eliminating the need to harvest an autologous vein or use synthetic grafts. This procedure can be safely performed with the robotic platform.
Assuntos
Neoplasias Pancreáticas , Procedimentos Cirúrgicos Robóticos , Feminino , Humanos , Bovinos , Animais , Pessoa de Meia-Idade , Pancreaticoduodenectomia/métodos , Neoplasias Pancreáticas/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Veia Porta/cirurgia , Pâncreas/cirurgiaRESUMO
BACKGROUND: The management of complex, intra- and extrahepatic portal vein thrombosis (PVT) after liver transplantation (LT) is challenging. Although most of the patients remain asymptomatic or oligosymptomatic in the chronic setting, some of them may develop severe portal hypertension and related complications, notably gastrointestinal (GI) bleeding. In the emergency scenario, clinical and endoscopic treatments as well as intensive support constitute the bases of conservative management, while more definitive treatment options such as surgical shunting and retransplantation are related to high morbidity rates. Transjugular intrahepatic portosystemic shunt (TIPS) was largely considered of limited role due to technical difficulties arising from extensive PVT. Recently, however, new minimally invasive image-guided techniques emerged, allowing portal vein recanalization and TIPS creation simultaneously (TIPS-PVR), even in complex PVT pretransplant patients. METHODS: Herein, we describe a novel indication for TIPS-PVR in a post-LT adolescent presenting with life-threatening, refractory GI bleeding. RESULTS: The patient presented with complete resolution of the hemorrhagic condition after the procedure, with no deterioration of hepatic function or hepatic encephalopathy. Follow-up Doppler ultrasound after TIPS-PVR showed normal hepatopetal venous flow within the stents, and no evidence of complications, including intraperitoneal or peri splenic bleeding. CONCLUSIONS: This report describes the feasibility of TIPS-PVR in the post-LT scenario complicated by extensive PVT. In this case, a complete resolution of the life-threatening GI bleeding was achieved, with no major complications. Other patients with complex chronic PVT might benefit from the use of the described technique, but further studies are required to determine the correct timing and indications of the procedure, eventually before the occurrence of life-threatening complications.
Assuntos
Varizes Esofágicas e Gástricas , Transplante de Fígado , Derivação Portossistêmica Transjugular Intra-Hepática , Trombose Venosa , Humanos , Adolescente , Veia Porta/cirurgia , Transplante de Fígado/efeitos adversos , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/cirurgia , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/cirurgia , Trombose Venosa/cirurgia , Trombose Venosa/complicações , Resultado do TratamentoRESUMO
BACKGROUND: Inflammatory myofibroblastic tumors (IMTs) of the liver are rare neoplasms. These tumors are difficult to distinguish from other neoplasms by radiological examination, have uncertain evolution, and there is no consensus on the treatment of these lesions. Hilar tumors can involve the portal vein, hepatic artery, bile duct, and spread to the branches of the portal triad, causing obstructive symptoms, occlusive phlebitis, and portal hypertension. Thus, liver transplantation (LT) is an excellent alternative for locally advanced hilar tumors, since it ensures complete tumor resection with free margins. METHODS/RESULTS: We present a literature review and a case report showing a 3-year-old boy with liver IMT invading the hepatic hilum and inferior vena cava, who underwent a successful living donor liver transplantation that required portal vein and vena cava replacement. CONCLUSION: The incidence of hilar IMTs is low and there is no well-established standard treatment. Liver transplantation for a hilar tumor with vascular invasion was acceptable in this case because the radically of the surgery was the key for the cure, and because the tumor was benign in nature.
Assuntos
Neoplasias dos Ductos Biliares , Transplante de Fígado , Masculino , Humanos , Pré-Escolar , Hepatectomia , Doadores Vivos , Fígado/cirurgia , Artéria Hepática/cirurgia , Veia Porta/cirurgia , Veia Porta/patologiaRESUMO
BACKGROUND: Portal vein occlusion shortly before extended hepatic resections has hepatoprotective properties, but its molecular effects have not been elucidated. We characterized the impact of regenerative preconditioning by portal vein embolization (PVE) on hepatic energy metabolism and cytokine expression. MATERIALS AND METHODS: About 90% hepatectomies were performed in normal pigs (Control) and in pigs that underwent a PVE 24 h before the surgery (n = 10/group). Blood biochemistry and coagulation, liver damage, liver function (ICG), hepatic content of adenine nucleotides, and hepatic expression of inflammatory mediators (RT-PCR and WB) were determined before the hepatectomy, 15 min, and 24 h later. RESULTS: All PVE and hepatectomies were successfully accomplished. The 90% hepatectomy resulted in: Immediate reduction of ATP, leading to persistent decreases of energy load and ATP/ADP ratio up to the 24-h time-point; and pro-inflammatory expression profile of cytokines in the remnant liver. Prior performance of PVE attenuated the bioenergetic alterations and prevented many of the changes in hepatic cytokine expression. CONCLUSIONS: Regenerative preconditioning by PVE improved hepatic energy metabolism and modulated inflammatory mediators in the remnant liver in pigs undergoing major hepatectomies, potentially contributing to its hepatoprotective effects.
INTRODUCCIÓN: la oclusión de la vena porta precoz antes de hepatectomías extendidas tiene propiedades hepatoprotectoras, pero sus efectos moleculares no se han aclarado. Caracterizamos el impacto del preacondicionamiento regenerativo por embolización de la vena porta (PVE) sobre el metabolismo energético hepático y la expresión de citocinas. MATERIALES Y MÉTODOS: Realizamos hepatectomías del 90% en cerdos (Control) y en cerdos sometidos a PVE 24 horas antes de la cirugía (n = 10/grupo). La bioquímica y la coagulación, el daño hepático, la función hepática (ICG), los nucleótidos de adenina y la expresión de mediadores inflamatorios (RT-PCR y WB) fueron determinado antes de la hepatectomía, quince minutos y 24 horas después. RESULTADOS: Las PVE y las hepatectomías se realizaron con éxito. La hepatectomía del 90% resultó en: una reducción del ATP, lo que disminuye la carga energética y la relación ATP/ADP a las 24 horas; y en la expresión de citocinas proinflamatorias. La realización previa de PVE atenuó las alteraciones bioenergéticas y evitó muchos de los cambios en la expresión de citocinas. CONCLUSIONES: El preacondicionamiento regenerativo con PVE mejoró el metabolismo energético y moduló los mediadores inflamatorios en el hígado remanente en cerdos sometidos a hepatectomías subtotales, contribuyendo potencialmente a sus efectos hepatoprotectores.