Marcel Autran C. Machado

Hepatic Adenoma and Focal Nodular Hyperplasia: Differential Diagnosis and Treatment

The diagnosis of benign hepatic tumors as hepatic adenoma (HA) and focal nodular hyperplasia (FNH) remains a challenge for clinicians and surgeons. The importance of differentiating between these lesions is based on the fact that HA must be surgically resected and FNH can be only observed. A series of 23 female patients with benign liver tumors (13 FNH, 10 HA) were evaluated, and a radiologic diagnostic algorithm was employed with the aim of establishing preoperative criteria for the differential diagnosis. All patients were submitted to surgical biopsy or hepatic resection to confirm the diagnosis. Based only on clinical and laboratory data, distinction was not possible. According to the investigative algorithm, the diagnosis was correct in 82.6% of the cases; but even with the development of imaging methods, which were used in combination, the differentiation was not possible in four patients. For FNH cases scintigraphy presented a sensitivity of 38.4% and specificity of 100%, whereas for HA the sensitivity reached 60% and specificity 85.7%. Magnetic resonance imaging, employed when scintigraphic findings were not typical, presented sensitivities of 71.4% and 80% and specificities of 100% and 100% for FNH and HA, respectively. Preoperative diagnosis of FNH was possible in 10 of 13 (76.9%) patients and was confirmed by histology in all of them. In one case, FNH was misdiagnosed as HA. The diagnosis of HA was possible in 9 of 10 (90%) adenoma cases. Surgical biopsy remains the best method for the differential diagnosis between HA and FNH and must be performed in all doubtful cases. Surgical resection is the treatment of choice for all patients with adenoma and can be performed safely. With the evolution of imaging methods it seems that the preoperative diagnosis of FNH may be considered reliable, thereby avoiding unnecessary surgical resection.

Intrahepatic Glissonian approach for laparoscopic right segmental liver resections.

BACKGROUND Experience with laparoscopic procedures and recent advances in laparoscopic devices have created an evolving interest in the application of these techniques to liver resection. However, laparoscopic liver resection has not been widely developed and anatomical segmental liver resection is not currently performed due to difficulty to control segmental Glissonean pedicles laparoscopically. METHODS Seven consecutive patients underwent laparoscopic liver resection using an intrahepatic Glissonian approach from April 2007 to September 2007. Three patients underwent laparoscopic bisegmentectomy 6-7 and 4 patients underwent laparoscopic right hemihepatectomy. RESULTS Blood transfusion was required in 1 patient. Mean operation time was 460 minutes (range 300-630 minutes). The median hospital stay was 5 days (range 3-8 days). One patient developed bile leakage that was treated conservatively. No patient had postoperative signs of liver failure. No postoperative mortality was observed. CONCLUSIONS The main advantage over other techniques is the possibility to gain a rapid and precise access to the right posterior and anterior sheaths facilitating right hemihepatectomy, and right anterior and posterior sectionectomies. We believe that the described technique facilitates laparoscopic liver resection by reducing the technical difficulties in pedicle control and may increase the development of segment-based laparoscopic liver resections.

Totally Laparoscopic ALPPS Is Feasible and May Be Worthwhile

W e read with great interest the article by Schnitzbauer and colleagues1 and the excellent editorial by de Santibañes and Clavien in the March 2012 issue of Annals of Surgery.2 The acronym proposed by Santibañes and Clavien was a breakthrough and, from now on, different procedures using the same principle can be agglutinated under the same acronym-–ALPPS, Associating Liver Partition and Portal vein ligation for Staged hepatectomy. Our interest in reading the technique description and its results in this article relates to the fact that we had the opportunity to perform 8 similar cases using the same principles but with some variations in technique and we can now study them as a unique procedure. Another point of interest and concern is the use of a plastic bag around the liver as a solution to avoid adhesions and facilitate the second stage. We believe that this maneuver can be hazardous because sometimes the second stage needs to be postponed because of clinical complications or insufficient hypertrophy of the remnant liver. In some occasions, the second stage may never occur and the patient will need a reoperation to remove the bag. With this in mind, we have used a different strategy—laparoscopy, which we would like to share with the readers. It is common knowledge that laparoscopy may reduce adhesions.3 Our previous experience with 2-stage laparoscopic liver resection4 showed that laparoscopic rehepatectomy has been greatly facilitated by the lack of adhesions, and it has been possible to use the same trocar incisions.4 Therefore, in our last case, we decided to perform the associating liver partition and portal vein

An Alternative Technique in the Treatment of Celiac Axis Stenosis Diagnosed During Pancreaticoduodenectomy

Celiac compression is usually a benign condition, but when surgery necessitates division of collaterals from the superior mesenteric artery, it may cause life-threatening celiac organ ischemia. Celiac axis obstruction is found in 12.5% to 49.7% of patients during abdominal angiography. In such patients, the arterial blood supply to the stomach, spleen, and liver is sustained through extraordinarily welldeveloped pathways in the pancreas. Though collateral pathways may be sacrificed during pancreaticoduodenectomy, only a small proportion of patients develop hepatic, gastric and splenic ischemia during the procedure. If the appropriate angiographic studies have not been obtained before pancreatic resection, a test occlusion of the gastroduodenal artery, as recommended by Bull et al. [2], should precede its ligation. The hepatic arteries are palpated before and after the test occlusion. In the occasional patient in whom the pulse diminishes during occlusion or if there is evidence of upper abdominal visceral ischemia, revascularization of the celiac circulation may be required. Reestablishment of the celiac circulation may be accomplished by the use of a vein graft between the aorta and the celiac tributaries. This article describes an alternative technique for revascularization of the celiac circulation without the use of a venous graft.

Laparoscopic resection of gastric duplication: successful treatment of a rare entity.

Alimentary tract duplications are rare congenital malformations that may be found anywhere from mouth to anus. They usually share a common smooth muscle wall and blood supply with the adjacent bowel. Some duplications are asymptomatic but most cause problems in early childhood. Gastric duplications account for 2% to 7% of all gastrointestinal duplications. The management of gastric duplication is essentially surgical. The treatment of choice is the complete excision of the gastric duplication without violation of the gastric lumen whenever possible. The authors report an unusual case of gastroesophageal junction duplication completely removed by laparoscopy. To our knowledge, this is the first case of gastric duplication successfully treated by laparoscopy in English literature. Laparoscopic resection may be added to the surgical armamentarium in the treatment of alimentary tract duplications.

Laparoscopic central pancreatectomy: a review of 51 cases.

Background: Central pancreatectomy is an alternative technique for benign or low-grade malignant tumors. Laparoscopic central pancreatectomy has been rarely performed, with only 48 cases reported in the English literature. The aim of this paper was to review all published cases together with 3 cases from our institution. Methods: All published articles indexed on PubMed were included. Terms used were “laparoscopic central pancreatectomy” or “laparoscopic middle pancreatectomy.” Variables studied were the operative time, the type of reconstruction, indications, the use of robotic or hand assistance, blood loss, transfusion, pancreatic fistula, hospital stay, follow-up, development of exocrine and/or endocrine insufficiency, morbidity, and mortality. Results: A total of 51 patients were identified. Twenty-one patients underwent total laparoscopy (41.2%), 27 required robotic assistance (52.9%), one required hand assistance (1.9%), and there were 2 conversions. In 18 cases (35.3%), pancreatic reconstruction involved a Roux-en-Y pancreatojejunostomy, and in 32 cases, pancreatogastrostomy (62.7%). The mean operative time was 356 minutes. Blood loss was minimal in most cases, and only 1 patient required blood transfusion (1.9%). Mortality was nil, but morbidity was high, mainly because of pancreatic fistula (46%). The mean hospital stay was 13.8 days. All patients underwent laparoscopic central pancreatectomy for benign or low-grade neoplasms. The mean follow-up duration was 19.6 months (range, 2 to 48 mo). No patient presented exocrine or endocrine insufficiency. Conclusions: Laparoscopic central pancreatectomy is a feasible and useful technique for the removal of tumors located in the neck of the pancreas. There are very few centers performing this operation, and therefore, a literature review was necessary to identify its indications and technical possibilities, and to promote its use.

Hemihepatic ischemia for laparoscopic liver resection.

Laparoscopic hepatectomy has been recently proposed for the treatment of liver tumors. However, because of technical difficulties such as control of hemorrhage from the transection plane and large intrahepatic veins, laparoscopic hepatectomy has not been widely developed. The technique of hemihepatic ischemia has been used by the authors in conventional liver resection over the past 10 years with reduced splanchnic congestion and excellent hemostatic control. To minimize both intraoperative bleeding and circulatory and biochemical disturbances due to the interruption of blood flow to the liver, the authors describe a new technique combining hemihepatic ischemia and laparoscopic liver resection.

Trombose de veia porta após desconexão ázigo-portal e esplenectomia em pacientes esquistossomóticos: Qual a real importância?

CONTEXT: Portal vein thrombosis is the most frequent complication after esophagogastric devascularization and splenectomy for hepatosplenic schistosomosis. OBJECTIVE: To evaluate portal vein thrombosis in 155 patients with schistosomal portal hypertension submitted to esophagogastric devascularization and splenectomy. METHODS: We retrospectively analyzed not only the incidence and predictive factors of this complication, but also clinical, laboratorial, endoscopic and Doppler sonography outcome of these patients. RESULTS: Postoperative portal thrombosis was observed in 52.3% of the patients (partial in 45.8% and total in 6.5%). Postoperative diarrhea was more frequent in patients with portal vein thrombosis. Fever was a frequent postoperative symptom (70%) but occurred in a higher percentage when total portal vein thrombosis was present (100%). Superior mesenteric vein thrombosis occurred in four patients (2.6%) and was associated with total thrombosis of the portal vein. There was no statistical difference between patients with and without portal vein thrombosis according to clinical and endoscopic parameters during late follow-up. It was not possible to identify any predictive factor for the occurrence of this complication. CONCLUSIONS: Portal vein thrombosis is an early and frequent event after esophagogastric devascularization and splenectomy, usually partial with benign outcome and low morbidity. Total portal vein thrombosis is more frequently associated with a high morbidity complication, the superior mesenteric vein thrombosis. Long-term survival was not influenced by either partial or total portal thrombosis.

Unusual case of pentastomiasis mimicking liver tumor

Pentastomiasis is a rare zoonotic disease. Almost all recorded cases of human pentastomiasis had been incidental findings at autopsy. We report an unusual case of human pentastomiasis mimicking liver tumor successfully treated by liver resection. This clinical presentation is uncommon and it was probably caused by a pentastomid that exited its cyst and migrated to the liver causing an infarct that was mistaken as a primary liver tumor. Diagnosis could not be made before the surgery. This is the first reported case of human pentastomiasis in Brazil.

Laparoscopic Pylorus-Preserving Pancreatoduodenectomy with Double Jejunal Loop Reconstruction: An Old Trick for a New Dog

BACKGROUND Pancreatoduodenectomy is an established procedure for the treatment of benign and malignant diseases located at the pancreatic head and periampullary region. In order to decrease morbidity and mortality, we devised a unique technique using two different jejunal loops to avoid activation of pancreatic juice by biliary secretion and therefore reduce the severity of pancreatic fistula. This technique has been used for open pancreatoduodenectomy worldwide but to date has never been described for laparoscopic pancreatoduodenectomy. This article reports the technique of laparoscopic pylorus-preserving pancreatoduodenectomy with two jejunal loops for reconstruction of the alimentary tract. MATERIALS AND METHODS After pancreatic head resection, retrocolic end-to-side pancreaticojejunostomy with duct-to-mucosa anastomosis is performed. The jejunal loop is divided with a stapler, and side-to-side jejunojejunostomy is performed with the stapler, leaving a 40-cm jejunal loop for retrocolic hepaticojejunostomy. Finally, end-to-side duodenojejunostomy is performed in an antecolic fashion. RESULTS This technique has been successfully used in 3 consecutive patients with pancreatic head tumors: 2 patients underwent hand-assisted laparoscopic pylorus-preserving pancreatoduodenectomy, and 1 patient underwent totally laparoscopic pylorus-preserving pancreatoduodenectomy. One patient presented a Grade A pancreatic fistula that was managed conservatively. One patient received blood transfusion. Mean operative time was 9 hours. Mean hospital stay was 7 days. No postoperative mortality was observed. CONCLUSIONS Laparoscopic pylorus-preserving pancreatoduodenectomy with double jejunal loop reconstruction is feasible and may be useful to decrease morbidity and mortality after pancreatoduodenectomy. This operation is challenging and may be reserved for highly skilled laparoscopic surgeons.