Marcel Autran Cesar Machado

Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka.

OBJECTIVE This review aims to assess the impact of implementing dedicated emergency surgical services, in particular acute care surgery, on clinical outcomes. BACKGROUND The optimal model for delivering high-quality emergency surgical care remains unknown. Acute Care Surgery (ACS) is a health care model combining emergency general surgery, trauma, and critical care. It has been adopted across the United States in the management of surgical emergencies. METHOD A systematic review was performed after PRISMA recommendations using the MEDLINE, Embase, and Psych-Info databases. Studies assessing different care models and institutional factors affecting the delivery of emergency general surgery were included. RESULTS Twenty-seven studies comprising 744,238 patients were included in this review. In studies comparing ACS with traditional practice, mortality and morbidity were improved. Moreover, time to senior review, delays to operating theater, and financial expenditure were often reduced. The elements of ACS models varied but included senior clinicians present onsite during office hours and dedicated to emergency care while on-call. Referrals were made to specialist centers with primary surgical assessments taking place on surgical admissions units rather than in the emergency department. Twenty-four-hour access to dedicated emergency operating rooms was also described. CONCLUSIONS ACS models as well as centralized units and hospitals with dedicated emergency operating rooms, access to radiology and intensive care facilities (ITU) are all factors associated with improved clinical and financial outcomes in the delivery of emergency general surgery. There is, however, no consensus on the elements that constitute an ideal ACS model and how it can be implemented into current surgical practice.

Management of Hepatic Hemangiomas: A 14-Year Experience

Hemangioma is the most common primary tumor of the liver and its diagnosis has become increasingly prevalent. Most of these lesions are asymptomatic and are managed conservatively. Large hemangiomas are often symptomatic and reports of surgical intervention are becoming increasingly frequent. We present our experience, over the last 14 years, with diagnosis and management of 249 liver hemangiomas, with special attention to a conservative strategy. Clinical presentation, diagnosis, treatment, and longterm outcome are analyzed. Of 249 patients, 77 (30.9%) were symptomatic, usually with right abdominal upper quadrant pain. Diagnosis was based on a radiologic algorithm according to the size and characteristics of the tumor; diagnosis by this method was not possible in only one case (0.4 %). Giant hemangiomas (>4 cm) were found in 68 patients (27.3%) and in 16 were larger than 10 cm. Eight patients (3.2%) underwent surgical treatment; indications were incapacitating pain in 6, diagnostic doubt in 1, and stomach compression in 1. No postoperative complications or mortality were observed in this series. Patients who did not undergo surgery (n = 241) did not present any complication related to the hemangioma during long-term follow-up (mean = 78 months). Hemangioma is a benign course disease with easy diagnosis and management. We propose a conservative approach for these lesions. Resection, which can be safely performed, should be reserved for the rare situations such as untreatable pain, diagnostic uncertainty, or compression of adjacent organs.

Prediction of Mortality After ALPPS Stage-1: An Analysis of 320 Patients From the International ALPPS Registry.

OBJECTIVES The aim of this study was to identify predictors of 90-day mortality after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS), available after stage-1, either to omit or delay stage-2. BACKGROUND DATA ALPPS is a two-stage hepatectomy for patients with extensive liver tumors with predicted small liver remnants, which has been criticized for its high mortality rate. Risk factors for mortality are unknown. METHODS Patients in the International Registry undergoing ALPPS from April 2011 to July 2014 were analyzed. Primary outcome was 90-day mortality. Liver function after stage-1 was assessed using the criteria of the International Study Group for Liver Surgery (ISGLS) after stage-1 among others. A multivariable model was used to identify independent predictors of 90-day mortality. RESULTS Three hundred twenty patients registered by 55 centers worldwide were evaluated. Overall 90-day mortality was 8.8% (28/320). The predominant cause for 90-day mortality was postoperative liver failure in 75% of patients. Fourteen percent of patients developed liver failure according to ISGLS criteria already after stage-1 ALPPS. Those and patients with a model of end-stage liver disease (MELD) score more than 10 before stage-2 were at significantly higher risk for 90-day mortality after stage-2 with an odds ratio (OR) 3.9 [confidence interval (CI) 1.4-10.9, P = 0.01] and OR 4.9 (CI 1.9-12.7, P = 0.006), respectively. Other factors, such as size of future liver remnant (FLR) before stage-2 and time between stages, were not predictive. CONCLUSIONS This analysis of the largest cohort of ALPPS patients so far identifies those patients in whom stage-2 ALPPS surgery should be delayed or even denied. These findings may help to make ALPPS safer.

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.

Monosegment ALPPS hepatectomy: Extending resectability by rapid hypertrophy

BACKGROUND Liver remnant function limits major liver resections to generally leave patients with ≥2 Couinaud segments. Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) induces extensive hypertrophy and allows surgeons to perform extreme liver resections. METHODS The international ALPPS registry (NCT01924741; 2011-2014) was screened for novel resection type with only 1 segment remnant. The anatomy of lesions and indications for ALPPS, operative technique, complications, survival, and recurrence were evaluated. RESULTS Among 333 patients, 12 underwent monosegment ALPPS hepatectomies in 6 centers, all for extensive bilobar colorectal liver metastases. All patients were considered unresectable by conventional means, and all had a response to or no progression after chemotherapy before surgery. In 2 patients, the liver remnant consisted of segment 2, in 2 of segment 3, in 6 of segment 4, and in 2 of segment 6. Median time to proceed to stage 2 was 13 days and median hypertrophy of the liver remnant was 160%. There was no mortality. Four patients experienced liver failure, but all recovered. Complications higher than Dindo-Clavien IIIa occurred in 4 patients with no long-term sequelae. At a median follow-up of 14 months, 6 patients are tumor free and 6 patients have developed recurrent metastatic disease. CONCLUSION ALPPS allows systematic liver resections with monosegment remnants, a novelty in liver surgery. Because such resections are difficult to conceive without rapid hypertrophy, we propose to name such resections after the segments constituting the liver remnant rather than the segments removed.

Prognostic Score in Gastric Cancer: The Importance of a Conjoint Analysis of Clinical, Pathologic, and Therapeutic Factors

BackgroundThis study was designed to establish a prognostic score for gastric cancer that takes into account factors related to the tumor, the patient, and the treatment.MethodsTwo hundred thirty patients with gastric adenocarcinoma admitted t o the Department of Abdominal Surgery at Hospital do Câncer A. C. Camargo (São Paulo) and treated by gastrectomy from January 1992 until December 1996 were included in this retrospective cohort. The prognostic score was created according to the variables identified in the multivariate analysis and by using the regression coefficients generated by the Cox regression.ResultsThe 5-year overall survival rate was 44.5%. The final multivariate model identified six variables with a significant and independent effect on survival: sex, weight loss, lymphocyte count, tumor-node-metastasis staging, lymphadenectomy, and lymph node ratio. Patients were divided into four groups according to their scores, as follows: group 1, 0 to 3.0; group 2, 3.5 to 5.5; group 3, 6.0 to 8.5; and group 4, 9.0 to 14.0. The 5-year survival rates were 91.5%, 49.3%, 20.3%, and .0% for the score groups 1, 2, 3, and 4, respectively (P < .001). The score was superior in the assessment of prognosis when compared with tumor-node-metastasis staging alone.ConclusionsIt is possible to create a prognostic score that simultaneously includes factors related to the tumor, patient, and treatment, thus generating a more effective system in predicting the prognosis than the morphology-based staging systems.

Solid serous adenoma of the pancreas: An uncommon but important entity

Serous cystic neoplasms of the pancreas have currently five recognized subtypes: serous microcystic adenoma, serous oligocystic ill-demarcated adenoma, solid serous adenoma, von Hippel-Lindau-associated cystic neoplasm, and serous cystadenocarcinoma. Although these neoplasms are histologically similar they may differ in location, gross appearance and biology. Solid serous adenoma of the pancreas is by far the rarest subtype with only nine cases published thus far. In this review, we will discuss clinical features, imaging characteristics and histopathological findings, considering in particular (1) difficulties in preoperative diagnosis; and (2) relevant immunohistochemical analysis. After analyzing the literature, including one case from our Department, we can conclude that there is enough evidence to support that solid serous adenomas of the pancreas is a solid variant of serous cystadenomas. To date no malignant transformation is reported so far and therefore, to our knowledge, all patients are alive and without recurrence. Incidence is generally around seventh decade of life with no gender preference. Preoperative diagnosis is difficult to establish but magnetic resonance cholangiopancreatography may be useful. Given benign nature of this solid variant conservative surgery is recommended. It is definitively a rare entity but oncologic surgeons should be aware of this neoplasm in order to make a correct preoperative diagnosis that will ultimately result in more conservative surgeries.

Laparoscopic resection of hilar cholangiocarcinoma.

BACKGROUND Surgical resection is the only curative treatment for hilar cholangiocarcinoma. Laparoscopic hepatectomy has been used to treat several types of liver neoplasms. However, technical issues have limited the adoption of laparoscopy for the treatment of hilar cholangiocarcinoma. To date there is only one report of minimally invasive procedure for hilar cholangiocarcinoma in the literature. The present video-assisted procedure shows a laparoscopic resection of hilar cholangiocarcinoma. PATIENT AND METHODS A 43-year-old woman with progressive jaundice due to left-sided hilar cholangiocarcinoma was referred for treatment. The decision was to perform a laparoscopic left hepatectomy with lymphadenectomy and resection of extrahepatic bile ducts. Biliary reconstruction was performed using the hybrid method. RESULTS Operative time was 300 minutes with minimum blood loss and no need for blood transfusion. Recovery was uneventful, and the patient was discharged on postoperative Day 7. Pathology revealed a well-differentiated cholangiocarcinoma with negative lymph nodes and clear surgical margins. The patient is well with no signs of the disease 18 months after the procedure. CONCLUSIONS Laparoscopic left hepatectomy with lymphadenectomy is safe and feasible in selected patients and when performed by surgeons with expertise in liver surgery and minimally invasive techniques. The use of a hybrid method may be needed for biliary reconstruction, especially in cases where position and size of remnant bile ducts may jeopardize the anastomosis. Further studies are still needed to confirm the benefit of this approach over conventional surgery for hilar cholangiocarcinoma.

Postconditioning ameliorates lipid peroxidation in liver ischemia-reperfusion injury in rats

PURPOSE Liver ischemia-reperfusion injury is a phenomenon presents in events like liver resections and transplantation. The restoration of blood flow may leads to local and systemic injury. Several techniques have been developed in order to avoid or ameliorate ischemia-reperfusion injury in clinical situations. The application of a stutter reperfusion after the ischemic event (postconditioning) could alters the hydrodynamics and stimulates endogenous mechanisms that attenuate the reperfusion injury. The present study was designed to evaluate the potential protective effect of postconditioning in a model of ischemia-reperfusion in rats. METHODS Hepatic anterior pedicle of median and left anterolateral segments were exposed and clamped for 1 hour. Two hours later, clamp was released in two different ways: Control Group (n=7): clamp was release straightforward; Postconditioning Group (n=7): clamp was released intermittently. Lipid peroxidation (malondialdehyde) and expression of the glutathione-s-transferase-alpha-3 gene were studied. RESULTS Lipid peroxidation was significantly decreased in ischemic and non-ischemic liver by postconditioning. GST- alpha3 gene was overexpressed in post-conditioned group, but not significantly. CONCLUSION Postconditioning induced hepatoprotection by reducing lipid peroxidation in the ischemic and non-ischemic liver.

Carcinoid tumor of the gallbladder

The carcinoid tumor is a relatively rare type of endocrine tumor, which arises mainly in the gastrointestinal tract. Primary gallbladder and biliary duct system carcinoids comprise less than 1% of all carcinoid tumors arising from any tissue or organ in the body. We describe a case of carcinoid tumor of the gallbladder in a 39-year-old man. There have been only 32 cases described in the literature.