Eduardo de Souza Martins Fernandes

Ligadura da veia porta associada à bipartição do fígado para hepatectomia em dois estágios (ALPPS): experiência brasileira

RACIONAL: Insuficiencia hepatica pos-operatoria devido a remanescente hepatico pequeno tem sido complicacao temida em pacientes que sao submetidos a resseccao hepatica extensa. A ligadura da veia porta associada a biparticao do figado para hepatectomia em dois estagios (ALPPS) foi desenvolvida recentemente com a finalidade de induzir rapida e significante regeneracao do figado para pacientes em que o tumor e previamente considerado irressecavel. OBJETIVO: Apresentar a experiencia brasileira com o ALPPS. METODO: Foram analisados 39 pacientes submetidos ao procedimento ALPPS em nove hospitais. Ele foi realizado em duas etapas. A primeira operacao consistiu em ligadura do ramo direito da veia porta e biparticao hepatica. Na segunda, os ramos direito da arteria hepatica, via biliar e veia hepatica foram ligados e o lobo hepatico direito estendido foi removido. Foram 22 pacientes do sexo masculino (56,4%) e 17 do feminino (43,6%). A media de idade foi 57,3 anos (variando de 20 a 83 anos). RESULTADOS: A indicacao mais comum foi metastase hepatica em 32 pacientes (82,0%), seguida por colangiocarcinoma em tres pacientes (7,7%). Dois morreram neste intervalo e nao foram submetidos a segunda operacao. O intervalo medio da primeira para a segunda operacao foi de 14,1 dias (variando de 5-30 dias). O volume do segmento lateral esquerdo apresentou aumento de 83% (variando de 47-211,9%). Morbidade significante foi observada em 23 pacientes (59,0%). A mortalidade foi de 12,8% (cinco pacientes). CONCLUSAO: O procedimento ALPPS permite resseccao hepatica em pacientes com lesoes consideradas previamente irressecaveis por induzir rapida hipertrofia do figado evitando a insuficiencia hepatica na maioria dos pacientes. Porem ainda apresenta elevada morbidade e mortalidade.

Risk factors for long‐term mortality in a large cohort of patients wait‐listed for liver transplantation in Brazil

Liver donor shortage and long waiting times are observed in many liver transplant programs worldwide. The aim of this study was to evaluate the wait list in a developing country, before and after the introduction of the MELD scoring system. In addition, the MELD score ability to predict mortality in this setting was assessed. A single‐center retrospective study of patients wait‐listed for liver transplantation between 1997 and 2010 was undertaken. There were 1339 and 762 patients on the list in pre‐MELD and MELD era, respectively. A competitive risk analysis was performed to assess age, gender, disease diagnosis, serum sodium, MELD, Child‐Pugh, ABO type, and body mass index. Also, MELD score predictive ability at 3, 6, 12, and 24 months after list enrollment was evaluated. The overall mortality rates on waiting list were 31.0% and 28.1% (P = 0.16), and the median waiting times were 412 and 952 days (P < 0.001), in pre and MELD eras, respectively. The competitive risk analysis yielded the following significant P values for both eras: HCC (0.03 and <0.001), MELD (<0.001 and 0.002), sodium level (0.002 and <0.001), and Child‐Pugh (0.02 and <0.001). The MELD mortality predictions at 3, 6, 12, and 24 months were similar. In conclusion, in a liver transplant program with long waiting times, the MELD system introduction did not improve mortality rate. In either pre and MELD eras, HCC diagnosis, serum sodium, Child‐Pugh, and MELD were significant predictors of prognosis. Short‐ and long‐term MELD based mortality predictions were similarly accurate. Strategies for increasing the liver donor pool should be implemented to improve mortality. Liver Transpl 17:1013–1020, 2011.

THE LARGEST WESTERN EXPERIENCE WITH HEPATOPANCREATODUODENECTOMY: LESSONS LEARNED WITH 35 CASES.

Background: Hepatopancreatoduodenectomy is one of the most complex abdominal operations mainly indicated in advanced biliary carcinoma. Aim: To present 10-year experience performing this operation in advanced malignant tumors. Methods: This is a retrospective descriptive study. From 2004 to 2014, 35 hepatopancreatoduodenectomies were performed in three different institutions. The most common indication was advanced biliary carcinoma in 24 patients (68.5%). Results: Eighteen patients had gallbladder cancer, eight Klatskin tumors, five neuroendocrine tumors with liver metastasis, one colorectal metastasis invading the pancreatic head, one intraductal papillary mucinous neoplasm with liver metastasis, one gastric cancer recurrence with liver involvement and one ocular melanoma with pancreatic head and right liver lobe metastasis. All patients were submitted to pancreatoduodenectomy with a liver resection as follows: eight right trisectionectomies, five right lobectomies, four left lobectomies, 18 central lobectomies (IVb, V and VIII). The overall mortality was 34.2% (12/35) and the overall morbidity rate was 97.4%. Conclusion: Very high mortality is seen when major liver resection is performed with pancreatoduodenectomy, including right lobectomy and trisectionectomy. Liver failure in combination with a pancreatic leak is invariably lethal. Efforts to ensure a remnant liver over 40-50% of the total liver volume are the key to obtain patient survival.

ALPPS: PAST, PRESENT AND FUTURE

Complete tumor resection in the liver is the only chance to obtain long-term survival in patients with hepatic tumor or metastasis from other primary cancers. In patients with a large load of tumor within the liver, multiple strategies have been employed to improve resection, especially when a small liver remnant is expected. Staged hepatectomies, in which the surgeon perform partial resection in one side of the liver, and after four to six weeks proceed with the resection of the other side, and strategies to induce hypertrophy of the future liver remnant that include percutaneous portal vein embolization or intraoperative portal vein ligation, have also been largely employed by specialized liver surgery teams. Hans Schlitt from Regensburg, Germany developed a new procedure, called liver bi-partition, for the first time by chance, in 2007. Planning to perform an extended right hepatectomy in a patient with hilar cholangiocarcinoma being the future cholestatic liver remnant too small to sustain the patient postoperatively he decided to perform intraoperatively only a selective hepatico-jejunostomy on the left biliary system, dividing the liver parenchyma along the falciform ligament, thereby completely devascularizing segment 4. Finally, the right portal vein was ligated to induce hypertrophy on segments 2 and 3. On the 8th postoperative day was performed a CT scan and observed a huge hypertrophy of the remnant liver. Recently, de Santibanes and Clavien2 proposed the acronym “ALPPS” for Associating Liver Partition and Portal vein Ligation for Staged hepatectomy. The ALPPS procedure has become an advance that represents an important tool to surgically induce fast liver hypertrophy.1,2,3 Despite an initial worldwide enthusiasm, the initially reported high mortality rates of 12% by Schnitzbauer et al. 7 and 12.8 % by Torres et al.8, triggered an intense debate about the safety of this procedure. Several modifications to the originally described ALPPS technique have been reported and careful patient selection became mandatory. The strict selection of patients, not only regarding the cause of the disease but, patients status performance and technical aspects, lead a few groups to perform ALPPS with low or even no mortality.7,8 ALPPS became a controversial issue in liver surgery being a subject of debate in many surgical meetings. In last February, the first international consensus meeting on ALPPS, organized by Karl Oldhafer and Thomas Van Gulik, took place in Hamburg, Germany. Liver surgeons from all over the world with experience in ALPPS and many critics of the procedure were present. Five experienced surgeons in ALPPS technique represented Brazil. In that meeting, several issues were discussed as the indications for ALPPS, technical aspects, hypertrophy, laparoscopy, morbidity, Klatskin tumor, hepatocellular carcinoma, portal vein embolization and two-stage hepatectomy. At the end of the meeting, some recommendations were elaborated. All patients with indication for ALPPS should be discussed in a multidisciplinary meeting. Inclusion criteria are patients with extensive bilobar colorectal liver metastases, needing an extended hepatectomy, a feasible R0 resection, a predicted future liver remnant <30%, no evidence of extrahepatic disease and complete or partial response to systemic chemotherapy. ALPPS should be mainly indicated for patients that have to undergo a right trisectionectomy. ALPPS is indicated in selected patients with hepatocellular carcinoma and cholangiocarcinoma, but the procedure has higher mortality than for colorectal liver metastases. Others indications included findings during surgical exploration; so, is necessary to decide intraoperatively in cases with unexpected tumor extension in the future liver remnant or when the future liver remnant volume is adequate but with a macroscopically diseased parenchyma. Failure of portal vein embolization or portal vein ligation, as a rescue surgery has been considered one of the best indication for ALPPS. It is an alternative to conventional two-stage hepatectomy and, comparing with portal vein embolization or portal vein ligation, can lead to a significant and quick growth of the future liver remnant. Age over 60 years, presence of jaundice/cholestasis and additional procedures like pancreaticoduodenectomy are associated with higher morbidity and mortality.6 The ALPPS technical aspects group recommended that the middle hepatic artery and middle hepatic vein, if not involved by tumor, should be preserved during the liver partition to avoid ischemic injury and to decrease congestion of the segment8. There is no evidence to support coverage of the partition area of the liver in order to decrease adhesions or avoid bile leaks. Ligation of the bile duct in the deportalized liver during the first stage in an attempt to induce hypertrophy of the future liver remnant should be avoided, because ALPPS morbidity is attributed in many cases to biliary leak and the resulting septic complications. Atypical resections of additional metastases (1-3) in the future liver remnant should be performed during the first stage. Use of a loop surrounding hilar structures and hepatic veins during the first surgery, are useful tools for the second stage of the procedure. An interval of 7-14 days between both procedures in patients with stable condition is also recommended. The short interval to reoperation for ALPPS and the earlier removal of tumor burden improves oncologic outcomes as patients complete the second stage (R0 resection) in more than 90% of the cases (compared to 70% in staged hepatectomies). Partial partition of the liver during the first stage (named p-ALPPS) has become an interesting option to decrease morbidity after the first stage. This partial partition in the first stage requires more liver transection and liver mobilization during the second stage making it more complex. Partial ALPPS needs to be explored and compared with the classical ALPPS; no recommendations can be given at this moment. Correlation between volume and function is difficult not only in ALPPS but for all extended liver resections. Functional

Propranolol improves endothelial dysfunction in advanced cirrhosis: the ‘endothelial exhaustion’ hypothesis

We read with interest the recent work of Leithead and coworkers about the use of non-selective β-blockers (NSBBs) in patients in the transplant waiting list. They studied 322 patients, among those 117 had refractory ascites and observed higher survival rate in those using NSBB, including the ones with refractory ascites (HR mortality=0.35; confidence interval (CI) 95%: 0.14 to 0.86).1 However, the use of NSBB has been a polemic issue since the hypothesis proposed by Krag and coworkers suggesting the existence of a ‘therapeutic window’, according to which NSBB would not be beneficial to patients in early or end-stage cirrhosis with refractory ascites, when it would impair the compensatory cardiac output increase, worsening organ perfusion in decompensated cirrhosis.2 Considering current controversies about the use of propranolol (PPL) in advanced cirrhosis, and its possible deleterious effect on haemodynamic and organ perfusion, we have investigated the endothelial function in patients with …

I BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 2: APPROACH TO RESECTABLE METASTASES

Background: Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients. Aim: In the second module of this consensus, management of resectable liver metastases was discussed. Method: Concept of synchronous and metachronous metastases was determined, and both scenarius were discussed separately according its prognostic and therapeutic peculiarities. Results: Special attention was given to the missing metastases due to systemic preoperative treatment response, with emphasis in strategies to avoid its reccurrence and how to manage disappeared lesions. Conclusion: Were presented validated ressectional strategies, to be taken into account in clinical practice.

PANCREATODUODENECTOMY: BRAZILIAN PRACTICE PATTERNS

ABSTRACT Background: Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. Aim: To understand the Brazilian practice patterns for pancreatoduodenectomy. Method: A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. Results: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. Conclusion: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.

Right hepatectomy due to hepatolithiasis caused by endoclip migration after laparoscopic cholecystectomy: a case report

Abstract Complications related to cholecystectomy occur in <3% of patients. Endoclip migration after laparoscopic cholecystectomy with hepatolithiasis is an extremely rare complication. We report a case of hepatolithiasis secondary to endoclip migration after laparoscopic cholecystectomy treated successfully via right hepatectomy. A 35-year-old female presented with upper abdominal pain, fever and vomiting 9 years after laparoscopic cholecystectomy for chronic calculus cholecystitis. Laboratory investigation revealed gamma-glutamyl transpeptidase of 550 U/L and alkaline phosphatase of 350 U/L. Magnetic resonance cholangiopancreatography revealed a dilated intrahepatic bile duct in segment 6 filled with stones. After preoperative evaluation, a right hepatectomy was performed using the intermittent Pringle maneuver. The postoperative recovery was uneventful and the patient was well after 4 months of follow-up. Although rare, endoclip migration should be considered in patients presenting with intrahepatic lithiasis even many years after laparoscopic cholecystectomy. Liver resection may be necessary in cases of failure of endoscopic extraction.

Anterior transhepatic approach for total caudate lobectomy including spigelian lobe, paracaval portion and caudate process: A Brazilian experience

Nowadays, because of the infiltration of cholangiocarcinoma to he parenchyma and/or bile ducts of the caudate lobe, the incluion of caudate lobe combined with a major hepatectomy remains he gold standard approach for a resectable hilar cholangiocarcioma. Since the last years of the 20th century, some authors have egun to report isolated caudate lobe resection for hepatocellular arcinoma (HCC), in order to achieve a radical surgery by sparing t the same time hepatic parenchyma [1] . Moreover, caudate lobe an be an uncommon site of metastatic involvement. Without any oubt, caudate lobectomy is a very demanding procedure, mainly ecause of the deep and complex location of the caudate lobe beween major vessels. Hepatectomies performed for tumors located n this dangerous area may lead to massive hemorrage that can e difficult to control. In this setting, the so called anterior tranhepatic approach provides a very good exposure to the surgical eld. At our institution, between January 2011 and December 2017, our patients (two females and two males), were submitted to isoated complete caudate lobectomy using an anterior transhepatic pproach. Two patients were affected by HCC, one by fibrolamelar HCC and one by a metastasis from a previous renal cell carcioma. All patients had a normal liver function (Child A). Informed onsent was obtained from the patients for publication of this reort and any accompanying images. The characteristics of the paients are summarized in Table 1 . All cases were carefully evaluted with a CT scan completed with liver volumetry and virtual epatectomy. All patients underwent isolated complete caudate reection through anterior transhepatic approach ( Fig. 1 ). The mean ge of patients was 56 years, ranging from 28 to 74 years. The four ndications were, respectively: fibrolamellar HCC, HCC in a nonirrhotic liver affected by non-alcholic steatohepatitis, HCC in HCVelated cirrhotic liver with mild portal hypertension, and metastais from a bilateral renal cell carcinoma in a patient who was preiously submitted to bilateral nephrectomy (hemodialysis 4 times a eek). Mean tumor size was 5.4 cm (4.1–6.7). We decided to perorm the anterior transhepatic approach for total caudectomy in hese very selected cases due to the size and position of these umors. Conventional extesive major hepatectomies cause signifiant risk of morbidity and mortality due to posthepatectomy liver ailure. Pringle’s maneuver was used routinely, if needed. From a echnical point of view, in the first two cases middle hepatic vein emained attached to the left lobe: we found mild congestion in ight anterior sector during intraoperative Doppler ultrasound, but o related complication was observed postoperatively. In the sec-

De Mello's Single Incision for Combined Liver-kidney Transplantation, Keeping the Kidney Retroperitoneal: A Case Report

The combined liver-kidney transplantation (cLKT) is the procedure of choice for patients with end-stage liver and kidney disease. In cLKT we can usually accommodate the grafts in two different ways, varying the kidney placement. The retroperitoneal kidney implant has some advantages, such as the easy access or avoiding vascular complications. We propose a new single incision, not yet reported, maintaining an extraperitoneal kidney, with excellent surgical field for cLKT and possible reduction of the impact of wound complications.