Claudio Brandi

Hepatic artery reconstruction first for the treatment of hilar cholangiocarcinoma bismuth type IIIB with contralateral arterial invasion: a novel technical strategy

BACKGROUND En-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure. METHODS The authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed. RESULTS In both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months. CONCLUSIONS This new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.

Surgical strategies for restoring liver arterial perfusion in pancreatic resections

BackgroundHepatic perfusion failure represents an important risk factor for severe complications and death after pancreatic resections. Arterial reconstruction could be required during pancreatic surgery because of tumor infiltration, benign strictures, or as a consequence of accidental arterial injury during dissection. All these situations can be faced with a certain frequency in high-volume pancreatic centers, where surgeons must be aware of the different alternatives to deal with these intricate scenarios.PurposeWe herein describe the preoperative surgical planning as well as different surgical strategies for the restoration of arterial perfusion of the liver in pancreatic resections.ConclusionA thorough preoperative evaluation is essential for planning pancreatic surgery and preparing the surgeon and patient for potentially high complex procedures. The various therapeutic alternatives presented in this technical report might represent a good solution for selected patients with no other potentially curative option than surgery.

Hernia obturatriz: una entidad con baja prevalencia pero alta mortalidad. Abordaje laparoscópico. A propósito de un caso

Introduccion: La hernia obturatriz es una entidad poco frecuente, cuya incidencia oscila entre 0.05 % y el 1.5 %, con una morbimortalidad cercana al 40 %. Caso clinico: Mujer de 85 anos, que comienza con nauseas, vomitos y distension abdominal. Se realiza radiografia de abdomen y tomografia computarizada (tac), donde se observa hernia obturatriz izquierda. Se decide laparoscopia exploradora. Se reduce la hernia y se coloca malla de polipropileno preperitoneal. Discusion: La hernia obturatriz es una entidad poco frecuente, que se presenta en mujeres ancianas, multiparas y desnutridas. Su diagnostico suele ser tardio, por lo que es una entidad con alta mortalidad, cercana al 40 %. La tomografia computarizada es el metodo diagnostico por eleccion, y el abordaje laparoscopico, el tratamiento de primera opcion. Conclusion: El objetivo principal en estos pacientes es realizar un diagnostico precoz y poder, de esa manera, disminuir los indices de mortalidad. Ante la sospecha clinica, se solicitara tomografia computarizada de abdomen y pelvis, con la idea de no demorar la intervencion quirurgica.