Fábio Luiz Waechter

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.

É possível diminuir o sangramento em hepatectomias sem a realização de exclusão vascular total ou parcial?: Resultados do uso de radiofrequência bipolar com agulhas resfriadas

BACKGROUND: Although the resection is the chosen procedure in the therapeutic treatment of liver malign lesions, the bleeding represents a factor of morbidity with a great impact in the hepatic surgery. With the means of minimizing this complication, several technological options have been utilized, being radiofrequency more recently among them, allowing the procedure to be realized with smaller incisions, without the need of vascular clamping, with minimum hepatic dissection, or bleeding. AIM: To present the results of the use of a new technique of hepatic parenchyma resection through parallel needles of bipolar radiofrequency developed by the authors themselves, verifying the impact in the trans-operation bleeding of patients subjected to hepatectomies. METHODS: Sixty patients were submitted to hepatic resection through the use of bipolar radiofrequency. The pre-operation bleeding was evaluated through the medication of the collected volume in the vacuum and by the weight difference in the compresses utilized during the procedure. All cases were monitored in their hepatocitary function through laboratory tests during the first week of the post-operation. RESULTS: The hepatic resections were realized with the mean of 87 minutes, mean incision size of 14 cm and mean bleeding of 58 ml. None of the patients received blood transfusion or derivatives. Central venous catheters were not utilized. All patients obtained fast anesthetic recuperation, leaving the recuperation room to the ward in less than 12 hours. The post-operation drainage was noted down until the drain removal occurring in all patients. The mean hospitalization time was of 3,2 days. After the elevation peak of the hepatic function tests in the first three days, all patients presented regression of them in a one month. CONCLUSION: It is possible, feasible and valid to use radiofrequency needle to perform hepatectomy, even larger ones, reducing bleeding.

AMBULATORY LAPAROSCOPIC CHOLECYSTECTOMY IS SAFE AND COST-EFFECTIVE: a Brazilian single center experience

BACKGROUND - Laparoscopic cholecystectomy is the treatment of choice for gallstone disease, and has been perfomed as an outpatient surgery in many Institutions over the last few years. OBJECTIVE - This is a retrospective study of a single center in Brazil, that aims to analyze the outcomes of 200 cases of ambulatory laparoscopic cholecystectomy performed by the same Hepato-Pancreato-Biliary team, evaluating the safety and cost-effectiveness of the method. METHODS - Two hundred consecutive patients who underwent elective laparoscopic cholecystectomy were retrospectively analyzed; some of them underwent additional procedures, as liver biopsies and abdominal hernias repair. RESULTS - From a total of 200 cases, the outpatient surgery protocol could not be carried out in 22 (11%). Twenty one (95.5%) patients remained hospitalized for 1 day and 1 (4.5%) patient remained hospitalized for 2 days. From the 178 patients who underwent ambulatory laparoscopic cholecystectomy, 3 (1.7 %) patients returned to the emergency room before the review appointment. Hospital cost was on average 35% lower for the ambulatory group. CONCLUSION - With appropriate selection criteria, ambulatory laparoscopic cholecystectomy is feasible, safe and effective; readmission rate is low, as well as complications related to the method. Cost savings and patient satisfaction support its adoption. Other studies are necessary to recommend this procedure as standard practice in Brazil.

Estenoses biliares benignas: reparação e resultados com o uso de silastic transhepático transanastomótico

BACKGROUND: The medical advances is not always related to homogeneous good results for all the patients. This is the case of laparoscopic cholecystectomy, whose advantages are largely recognized in the medical literature. However, this operation most dreaded complication, iatrogenic major bile duct injury, is rising in the last years, despite the learning curve, and stabilized in a level higher than that experienced in open cholecystectomy. Among the features which can bring to this event a good outcome is the use of transhepatic transanastomotic tubes in association with the corrective hepaticojejunostomy. AIM: To report a 20 years experience on biliary reconstruction of bile duct injuries with the use of transhepatic transanastomotic tubes. METHODS: Data were analysed from 338 patients who underwent operation for major bile duct injuries between January 1988 and December 2009. RESULTS: All the 338 patients were submitted to Roux-en-Y hepaticojejunostomy (Hepp-Couinaud approach) or distinct cholangiojejunostomies, all with the use of transhepatic transanastomotic silastic tubes. A successful long-term result was achieved in 240 (92,9%) of 338 patients, including those who required subsequent procedures. CONCLUSION: Benign bile duct strictures near the hepatic duct confluence remains a surgical challenge. The use of silastic transhepatic transanastomotic tubes in high biliary tract reconstruction is an option which can provides a successful repair of bile duct injuries with low complication rates.

Early Drain Amylase Value Predicts the Occurrence of Pancreatic Fistula After Pancreaticoduodenectomy.

To the Editor: We read with special interest the article by Ven Fong et al published on August 2015. We believe that this study is a cornerstone in pancreatic surgery, bringing a new concept that can greatly contribute to postoperative care in patients undergoing pancreaticoduodenectomy (PD). Surgical resection remains the treatment of choice for patients with periampullary tumors, representing the only chance to obtain long-term survival. Nowadays, with improvements in surgical expertise, anesthesia and postoperative care, this procedure can be accomplished with a mortality rate of less than 5%. Pancreatic fistula (PF), especially that one of clinical relevance, is a major complication after PD, affecting up to one-third of patients. Early prediction of its occurrence is of considerable interest; its exclusion in the early postoperative days enables the treatment of patients under fast-track protocol, which includes mobilization and removal of abdominal drains, rapid evolution of oral feeding, shorter length of hospital stay, and cost savings. This idea is important because the occurrence of PF changes the surveillance of patients, carrying a high percentage of major complications (bleeding, abdominal abscess, need for invasive procedures, or reoperation), often requiring interruption of enteral nutrition, maintenance of drains, use of antibiotics, and close monitoring of 7

Utilização das hepatectomias centrais nas cirurgias hepatobiliares

The treatment of hepatobiliary diseases by central hepatectomies has been one of the most important challenges in surgical technique at the end of this century. Although different techniques were used in the last decades, only recently they have been carried out safely, drastically reducing the morbidity and mortality rates, and thus providing favorable results in treating different hepatic diseases. Whether the liver does or not present chronic liver disease, the integration of related multiple-disciplinary teams in this type of surgery and disease has allowed complex ablations, sometimes bordering on the limit of the possibility of life.Based on the principle of maintaining a viable remaining hepatocyte mass and function, the morphological and functional study of the liver during the preoperative period requires the frequent use of techniques to transplant liver segments, both for vascular reconstruction and for the reduction and conservation of the liver mass. Thus, the resection of any part of the liver with a minimum use of blood products has proved feasible with thorough knowledge of the anatomy of the liver, and the use of echography during surgery. Different central hepatectomy techniques are, thus, presented, discussing indications and surgical details of each of them.

Primitive Neuroectodermal Tumor of the Pancreas: A Case Report and Review of the Literature.

Primitive neuroectodermal tumors (PNETs) are presented as rare malignant neoplasms. In unusual cases, those neoplasms may arise in solid organs containing neuroendocrine cells, such as the pancreas. Herein the case of a 28-year-old patient that underwent gastroduodenopancreatectomy after the diagnosis of a huge mass (PNET) located in both head and body of the pancreas is reported. This is the 19th case of pancreatic PNET reported in literature.

FIRST BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 1: PRE-TREATMENT EVALUATION

Background : Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients with these tumors. Aim : In this module, was contextualized the clinical situations and parameterized epidemiological data and results of the various treatment modalities established. Method: Was realized deep discussion on detecting and staging metastatic colorectal cancer, as well as employment of imaging methods in the evaluation of response to instituted systemic therapy. Results : The next step was based on the definition of which patients would have their metastases considered resectable and how to expand the amount of patients elegible for modalities with curative intent. Conclusion : Were presented clinical, pathological and molecular prognostic factors, validated to be taken into account in clinical practice.

Síndrome de Mirizzi em associação com níveis séricos de CA 19-9 superiores a 20.000U/ml: é possível?

Mulher de 83 anos foi atendida com historia de ictericia progressiva, coluria, hipocolia, prurido, dor em abdome superior e emagrecimento. Ao exame fisico apresentava-se icterica com discreta dor a palpacao do hipocondrio direito, sem evidencia de massas palpaveis. Os exames laboratoriais da admissao foram: bilirrubina total=26, bilirrubina direta=15,8, gama glutamil-transferase=829, fosfatase alcalina=518, transaminase glutâmico-oxalacetica=115, transaminase glutâmico-piruvica=92, hemoglobina=12,7, tempo de protrombina=89%, antigeno carboidrato 19-9=24.480. Destes, destaca-se o CA 19-9 de 24.480 U/mL. Tomografia computadorizada de abdome evidenciou dilatacao importante das vias biliares intra e extra-hepaticas e do segmento proximal do ducto hepatico comum (Figura 1). Observou-se tambem aparente compressao do hepatocoledoco pela vesicula biliar que se encontrava moderadamente distendida, com paredes espessadas, e provavel imagem de calculo na sua regiao infundibular medindo cerca de 2,0 cm. Ressalte-se que a possibilidade de neoplasia em via biliar nao podia ser afastada.A paciente em foi submetida a laparotomia exploradora, na qual foi evidenciado processo inflamatorio intenso no triângulo de Calot, com presenca de fistula entre a vesicula biliar - que apresentava-se escleroatrofica -, e o hepatocoledoco. Iniciou-se pela abertura da vesicula, onde foi identificado calculo unico de 2,3 cm no infundibulo, realizada biopsia da parede do coledoco e exploracao da via biliar a procura de outros calculos, que nao foram encontrados. Realizou-se coledocostomia com colocacao de dreno de Kehr e colangiografia de controle pelo dreno. Observou-se passagem do contraste para o duodeno e ausencia de lesoes ou calculos. A biopsia hepatica revelou reacao portal de padrao biliar com septos porta-porta, sugestivo de obstrucao de grandes ductos. Biopsias do coledoco/ducto hepatico/vesicula biliar nao revelaram malignidade, sendo compativeis com inflamacao aguda e cronica e edema, confirmando o diagnostico de sindrome de Mirizzi.A paciente evoluiu bem no pos-operatorio. Colangiografia no 9o dia foi normal. Houve normalizacao dos marcadores de colestase e decrescimo significativo do nivel serico do Ca 19-9 para 355,9 U/mL. No seguimento de tres anos, a paciente permanecia viva em bom estado geral sem evidencia de doenca maligna e com niveis sericos de CA 19-9 dentro da normalidade.

Características construtivas e funcionais das agulhas de radiofrequência bipolares resfriadas para reduzir o sangramento nas ressecções hepáticas

Background - To reduce bleeding in liver resection various technological options have been disclosed, among them the radiofrequency. The intent of the various methods is to avoid vascular clamping, less liver dissection and minimize bleeding. Aim - To present a new technique of parallel bipolar radiofrequency needles developed by the authors and the technical details. Methods - The needle system has two parallel electrodes (18 gauge each) of 25 cm in length, separated by a distance of 1.5 cm, and only distal 4 cm dissipate energy generated by a bipolar electrocautery. These needles are cooled by an internal cooling system for continuous flow of cold sterile distilled water at 0oC, whose temperature is maintained through the presence of sterile distilled water ice. The operation is performed under general anesthesia and is not used central venous catheters during or after the procedure. The incisions may be right subcostal and median supra-umbilical. Results - The inical use in liver resection showed an average 87 minutes operation time, average size of abdominal incision of 14 cm and 58 ml of blood loss during surgery. No patient in the inical group received transfusion of blood or blood products. Conclusion - The bipolar radiofrequency cooled needles are viable and reduce bleeding in liver resection. ABCDDV/785