Andrew A. Gumbs

Vascular clamping in liver surgery: physiology, indications and techniques

This article reviews the historical evolution of hepatic vascular clamping and their indications. The anatomic basis for partial and complete vascular clamping will be discussed, as will the rationales of continuous and intermittent vascular clamping.Specific techniques discussed and described include inflow clamping (Pringle maneuver, extra-hepatic selective clamping and intraglissonian clamping) and outflow clamping (total vascular exclusion, hepatic vascular exclusion with preservation of caval flow). The fundamental role of a low Central Venous Pressure during open and laparoscopic hepatectomy is described, as is the difference in their intra-operative measurements. The biological basis for ischemic preconditioning will be elucidated. Although the potential dangers of vascular clamping and the development of modern coagulation devices question the need for systemic clamping; the pre-operative factors and unforseen intra-operative events that mandate the use of hepatic vascular clamping will be highlighted.

Laparoscopic radical cholecystectomy and Roux-en-Y choledochojejunostomy for gallbladder cancer

BackgroundAlthough laparoscopic cholecystectomy was one of the first laparoscopic procedures, gallbladder cancer has been one of the last malignancies tackled with minimally invasive techniques. This video reviews the minimally invasive approaches to preoperatively suspected gallbladder cancer.MethodsLike the standard laparoscopic cholecystectomy, the minimally invasive procedure is performed with four trocars. The surgeon operates with the patient in the French position. A totally laparoscopic radical cholecystectomy including wedge resections of segments IVB and V is undertaken with hepatoduodenal lymphadenectomy and common bile duct excision. The biliary system is reconstructed via a laparoscopic choledochojejunostomy.ResultsSix patients have undergone laparoscopic radical cholecystectomy. Three of these patients were found to have gallbladder cancer according to the final pathology. All the final surgical margins were negative, and the average lymph node retrieval was 3 (range, 1–6).ConclusionThe minimally invasive approach to gallbladder cancer is feasible and safe. It should currently be performed in high-volume centers with expertise in both hepatobiliary and minimally invasive surgery. Larger trials are needed to determine whether either the open or laparoscopic approach offers any advantage.

Importance of Early Splenectomy in Patients with Hepatosplenic T-Cell Lymphoma and Severe Thrombocytopenia

ObjectiveT-cell lymphomas (TCLs) classically have a poorer response to therapy when compared with B-cell lymphomas and account for only 10–15% of all lymphoid malignancies. Hepatosplenic TCLs are a rare subset of this group that usually present with hepatosplenomegaly, B-symptoms, and only rarely with lymphadenopathy.BackgroundThis disease process, also known as gamma/delta (γ/δ) TCL because of the expression of the T-cell receptor γ/δ chain, tends to present in young male patients. Hepatosplenic TCLs have recently gained notoriety because of the realization that patients with long-term treatment of some immunomodulators can develop this potentially fatal disease. These facts are exacerbated by the fact that patients with this disease rarely enjoy remissions of more than brief duration with common chemotherapeutic agents or bone marrow transplants. A novel agent, pralatrexate, has recently been found to have a dramatic activity in this patient population with refractory/relapsed disease. Unfortunately, patients with hepatosplenic TCL often present with thrombocytopenia and this new agent is contraindicated in these patients because of the potential exacerbation of thrombocytopenia with this agent.MethodsBecause of this we attempted a laparoscopic-assisted splenectomy in one patient with grade 4 thrombocytopenia.ResultsPostoperatively the patient’s thrombocytopenia resolved, permitting him to begin treatment with this potentially life-saving agent.ConclusionDue to the lethality of this disease and potential efficacy of new therapies, we believe splenectomy should be considered in patients with hepatosplenic lymphoma in an effort to improve the treatment options and survival of patients with this challenging disease.

Laparoscopic Diagnosis of Annular Pancreas in a Patient with Mucinous Cystoadenoma of the Body of the Pancreas

IntroductionAnnular pancreas (AP) is a rare anomaly due to malrotation of the pancreatic ventral bud during embryologic development. AP has been extensively described in the pediatric population; however, in adults, the incidence has been reported to be only 1 in 22,000 patients with only a few cases presenting with simultaneous mucinous cystadenoma described in the recent literature.Case ReportWe report the case of a 72-year-old female patient with a mucinous cystadenoma, who was found to have a concomitant AP during laparoscopic distal pancreatectomy.DiscussionThe dual presentation of annual pancreas and mucinous cystoadenoma is an infrequent condition and can be managed with minimally invasive techniques; bypass in adults should only be performed in patients with symptomatic duodenal compression or recurrent bouts of pancreatitis.

Abstract B98: Induced pluripotent stem cells from pancreatic ductal adenocarcinoma can recapitulate early developmental stages of cancer.

Pancreatic ductal adenocarcinoma (PDAC) has one of the worst prognoses of any human malignancy. When human PDAC cells are injected into immunodeficient animals, they create tumors of the late stage from which they were derived. We hypothesized that if human pancreatic cancer cells were converted to pluripotency and then allowed to differentiate back into pancreas, the developmental progression would recapitulate early stages of the cancer. To that end, we generated isogenic pairs of induced pluripotent stem (iPS) cell-like lines from epithelial cells of human pancreatic tumors and from histologically normal epithelial cells at the resected pancreatic margins. When injected into immunodeficient mice, at low or high passages, a human pancreatic cancer iPS-like line, but not the corresponding margin iPS-like line, generates pancreatic intraepithelial neoplasia (PanIN) ductal structures that represent the predominant precursor to PDAC. The PanIN-like ducts can be isolated, cultured, and release protein products reflective of PanINs, thereby providing new insights into underlying regulatory networks and potential markers of early diagnosis. These studies demonstrate that iPS technology can be exploited to recapitulate early progression events of a human epithelial cancer. Citation Format: Jungsun Kim, Kenneth S. Zaret, John P. Hoffman, Maximilian . Reichert, Andrew D. Rhim, Ben Z. Stanger, Andrew Gumbs. Induced pluripotent stem cells from pancreatic ductal adenocarcinoma can recapitulate early developmental stages of cancer. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Progress and Challenges; Jun 18-21, 2012; Lake Tahoe, NV. Philadelphia (PA): AACR; Cancer Res 2012;72(12 Suppl):Abstract nr B98.

Cancer of the Gallbladder and Extrahepatic Bile Ducts

Despite the fact that laparoscopic cholecystectomy was one of the first minimally invasive gastrointestinal procedures and currently one of the most common, minimally invasive approach to gallbladder cancer has been limited to incidentally diagnosed T1a lesions. Incidentally diagnosed gallbladder cancers diagnosed on final pathology should be referred to tertiary centers and re-resection should be offered, while patients with unresectable or metastatic disease should be offered palliation. Patients diagnosed with T1b gallbladder cancers or greater are offered laparoscopic re-resection consisting of laparoscopic wedge resection of hepatic segments IVb and V and a laparoscopic hepatoduodenal lymphadenectomy. Although there is no clear survival advantage to primary resection, we have also begun offering patients with preoperatively suspected resectable gallbladder cancer laparoscopic radical cholecystectomy and laparoscopic hepatoduodenal lymph node dissection. The goals of operation are negative margins and a retrieval of, at least, three lymph nodes. When cystic duct margins are positive for malignancy, we perform laparoscopic common bile duct excision with laparoscopic creation of a Roux-en-Y choledochojejunostomy. Expertise in both hepatobiliary and laparoscopic surgery is paramount before embarking on these techniques. These procedures should probably be performed in cancer centers with specialization in minimally invasive techniques. Larger trials are needed to ascertain whether or not there are any advantages to the minimally invasive approach to T1b or greater gallbladder cancer. We describe our indications, workup, and operative technique as we practice it at Fox Chase Cancer Center.

Reply to: 464_126 (2008: 22(12) 2763-2764) Re: Transvaginal laparoscopic cholecystectomy

We thank Dr. Alessiani for his comments and congratulate him for the excellent work done on NOTES in the animal lab. NOTES techniques are in evolution; investigators from all over the world are working on NOTES procedures [1, 2]. We agree that nomenclature is important in communicating about these techniques and believe that if dissection is primarily performed with laparoscopic instruments, then the procedure is laparoscopy. After working in the animal lab, we acquired the necessary skills and experience to translate our work into human NOTES surgery [3]. We are happy that more groups are embracing this interesting technique and we encourage work such as yours in the animal lab before proceeding to the human operating room. References