Marcos Vinicius Perini

Clinical and pathologic prognostic factors for curative resection for pancreatic cancer

BACKGROUND Pancreatic cancer is the fifth leading cause of cancer-related deaths in the world. Operative resection is the only therapeutic option with curative potential for this disease. OBJECTIVE The aim of the present study was to correlate clinical and pathologic parameters with survival in patients submitted to pancreatic resection for pancreatic adenocarcinoma. METHODS Surgical resection with curative intent (R0 and R1 resections) was performed in 65 pancreatic cancer patients between 1990 and 2006. The overall results of surgical treatment were retrospectively analyzed and compared with the clinicopathologic features of these patients. RESULTS Pylorus-preserving pancreatoduodenectomy was performed in 37 patients (56.9%), classic resection in 35.4%, distal pancreatectomy in 4.6% and total pancreatectomy in 3.6%. The inhospital mortality was 5% (three patients). Postoperative complications occurred in 28 patients (43%). Mean survival and five-year survival rate after curative resection were 27 months and 9.0%, respectively. Sex, TNM stage, tumor differentiation, neural invasion, tumor size and involvement of resection margin were significant prognostic factors on univariate analysis. Multivariate analysis showed tumor differentiation and neural invasion as prognostic factors. CONCLUSION Patients with pancreatic cancer, even those with poor prognostic factors should be given the opportunity of surgical resection with curative intent.

Outcomes of cholecystectomy for treatment of acute cholecystitis in octogenarians

The independent influence of advanced age on outcomes in contemporary series treated by early cholecystectomy is undetermined.

Hepatocellular adenoma: an excellent indication for laparoscopic liver resection.

OBJECTIVES Laparoscopic resection for benign liver disease has gained wide acceptance in recent years and hepatocellular adenoma (HA) seems to be an appropriate indication. This study aimed to discuss diagnosis and treatment strategies, and to assess the feasibility, safety and outcomes of pure laparoscopic liver resection (LLR) in a large series of patients with HA. METHODS Of 88 patients who underwent pure LLR, 31 were identified as having HA. Diagnosis was based on radiological evaluation and resections were performed for lesions measuring >5.0 cm. RESULTS The sample included 29 female and two male patients. Their mean age was 33.2 years. A total of 27 patients had a single lesion, one patient had two and one had four lesions. The two remaining patients had liver adenomatosis. Mean tumour size was 7.5 cm. Three right hepatectomies, 17 left lateral sectionectomies and 11 wedge resections or segmentectomies were performed. There was no need for blood transfusion or conversion to open surgery. Postoperative complications occurred in two patients. Mean hospital stay was 3.8 days. CONCLUSIONS Hepatocellular adenoma should be regarded as an excellent indication for pure LLR. Pure LLR is safe and feasible and should be considered the standard of care for the treatment of HA when performed by surgeons with experience in liver and laparoscopic surgery.

Tumor growth pattern as predictor of colorectal liver metastasis recurrence

BACKGROUND Surgical resection is the gold standard therapy for the treatment of colorectal liver metastases (CRM). The aim of this study was to investigate the impact of tumor growth patterns on disease recurrence. METHODS We enrolled 91 patients who underwent CRM resection. Pathological specimens were prospectively evaluated, with particular attention given to tumor growth patterns (infiltrative vs pushing). RESULTS Tumor recurrence was observed in 65 patients (71.4%). According to multivariate analysis, 3 or more lesions (P = .05) and the infiltrative tumor margin type (P = .05) were unique independent risk factors for recurrence. Patients with infiltrative margins had a 5-year disease-free survival rate significantly inferior to patients with pushing margins (20.2% vs 40.5%, P = .05). CONCLUSIONS CRM patients with pushing margins presented superior disease-free survival rates compared with patients with infiltrative margins. Thus, the adoption of the margin pattern can represent a tool for improved selection of patients for adjuvant treatment.

Surgical treatment of the non-complicated gastroesophageal reflux: fundoplication without division of the short gastric vessels

BACKGROUND There is today a significant greater number of laparoscopic antireflux procedures for the surgical treatment of gastroesophageal reflux disease and there are yet controversies about the necessity of division of the short gastric vessels and full mobilization of the gastric fundus to perform an adequate fundoplication. AIM To verify the results of the surgical treatment of non-complicated gastroesophageal reflux disease performing Rossetti modification of the Nissen fundoplication. Patients and Methods - Fourteen patients were operated consecutively and prospectively (mean age 44.07 years); all had erosive esophagitis without Barretts endoscopic signals (grade 3, Savary-Miller) and they were submitted to the Rossetti modification of the Nissen fundoplication. Endoscopy, esophageal manometry and pHmetry were performed before the procedure and around 18 months postoperatively. RESULTS There was no morbidity, transient dysphagia average was 18.42 days; there was no register of dehiscence or displacement of the fundoplication and only one patient revealed a light esophagitis at postoperative endoscopy; the others presented a normal endoscopic view of the distal esophagus. All noticed a marked improvement of preoperative symptoms. Lower esophageal sphincter pressure changed from 5.82 mm Hg (preoperative mean) to 12 mm Hg (postoperative mean); lower esophageal sphincter relaxing pressure, from 0.38 mm Hg to 5.24 mm Hg and DeMeester score, from 16.75 to 0.8. CONCLUSION Rossetti procedure (fundoplication without division of the short gastric vessels) is an effective surgical method to treat gastroesophageal reflux disease.

Half-Pringle Maneuver: A Useful Tool in Laparoscopic Liver Resection

INTRODUCTION Laparoscopic liver resections are becoming a common procedure, and bleeding remains the major concern during parenchymal transection. Total vascular inflow occlusion can be performed, but ischemic reperfusion injuries can lead to postoperative morbidity. On the other hand, hemihepatic inflow occlusion, leading to hemiliver ischemia, decreases the amount of liver parenchyma submitted to reperfusion damage and offers the advantage of reduced blood loss. OBJECTIVE The aim of this work was to describe our experience with laparoscopic the half-Pringle maneuver for segmentar or nonanatomic liver resctions. PATIENTS AND METHODS Eight patients submitted to laparoscopic liver resection in a single tertiary center. RESULTS There were 5 women and 3 men with a mean age of 40.2 years (range, 26-54). Mean tumor size was 4.1 cm (range, 2.6-6.0), and mean hospital stay was 3.1 days (1-5). There were 3 liver adenomas, 2 hepatocellular carcinomas, 1 metastatic melanoma, 1 metastatic colorectal carcinoma, and 1 peripheral colangiocarcinoma. No postoperative complications or mortalities were observed. CONCLUSIONS Results demonstrate that laparoscopic liver resection with the half-Pringle maneuver is feasible and safe and may be included in the technical armamentarium of laparoscopic liver resections for a selected group of patients.

High Mortality Rates After ALPPS: the Devil Is the Indication

Surgical resection with R0 margins still remains the ultimate goal for most liver malignancies [1]. In many cases, a complete margin-free resection represents a challenge especially when lesions might present as giant masses (i.e., hepatocellular carcinoma, intrahepatic cholangiocarcinoma), compromising major vessels, or as bilobar multicentric disease (i.e., metastatic colorectal carcinoma), demanding extended resections. In order to obtain complete resection of tumors that are large, multiple, or oddly located, a great amount of parenchyma is sacrificed, with the greatest concern being the future liver remnant (FLR) and posthepatectomy liver failure [2]. Santibañes and Clavien [3] wrote an elegant editorial enumerating important surgical advances that provided the possibility of curative resection for patients with an extensive tumor load in the liver, such as portal vein embolization, staged liver resection, and the association of both procedures. There is no doubt that these techniques provided a significant advance enabling the treatment of patients with large tumor masses, avoiding a small liver remnant and consequently preventing postoperative liver failure. Recently, an innovative operation combining the principles of these aforementioned strategies has become an alternative approach to increase the FLR in major hepatectomies [3]. The associating liver partition and portal vein ligation for staged hepatectomy—termed as ALPPS—has triggered many and heated debates along recent years. The new concept of in situ liver partition associated to portal vein ligation leading to a fast and significant contralateral parenchyma hypertrophy was first performed by Hans Schlitt in 2007, being the first scientific report by Baumgart et al. in 2011 and popularized by Santibañes and his colleagues [4]. Schnitzbauer et al. [5] in a cooperative experience from 5 German centers with 25 patients showed aspects that should be addressed. In this initial experience, a high morbidity rate (68 %) and a concerning mortality rate (12 %) were reported; on the other hand, an impressive volume growth in a short period of time and low rates of postoperative liver failure were observed. ALPPS is still under evaluation in a stage between exploration and assessment [6]. Indeed, the experience with ALPPS is lacking and we still seek the best indications to perform it. Moreover, regarding the surgical technique itself, the procedure is not well standardized. P. Herman : J. A. P. Krüger (*) :M. V. Perini : F. F. Coelho Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Rua Dr. Enéas de Carvalho Aguiar, 255 9° andar sala 9025, São Paulo, SP CEP 05403-900, Brazil e-mail: jaime.kruger@hc.fm.usp.br

Prognostic significance of epidermal growth factor receptor overexpression in pancreas cancer and nodal metastasis.

Identification of molecular markers in pancreatic adenocarcinoma (PA) has the potential to guide targeted therapy. The objective of this study is to determine the prognostic significance of epidermal growth factor receptor (EGFR) expression (membrane and cytoplasmic) in resected PA and its correlation with lymph node metastasis and survival.

Primary liver leiomyoma: a review of this unusual tumour

Primary liver leiomyoma (PLL) should be considered in the differential diagnosis of liver lesions. A literature review has been completed and two cases are reported. The first is a 45‐year‐old white woman complaining of vague abdominal pain. She was initially evaluated with abdominal ultrasonography (US) that revealed a heterogeneous liver mass measuring 18 cm in greatest diameter. The tumour demonstrated hypointensity on T1‐weighted and hyperintensity on T2‐weighted magnetic resonance imaging. The second case is a 45‐year‐old Asian male who had undergone kidney transplantation 16 years ago for IgA glomerulonephritis and who developed mild, self‐limiting epigastric pain. US showed a 4.3‐cm‐diameter lesion that was predominantly hypoechoic and was either compressing or arising from segment 2 of the liver. Computed tomography showed a well‐circumscribed 4‐cm‐diameter mass that appeared to be arising from segments 2/3 of the liver and was adjacent to the anterior gastric wall. He underwent an uneventful laparoscopic left lateral sectionectomy and discharged on post‐operative day 3. Pathological examination of the resection specimen confirmed the lesion as a PLL in each case. Herein, we report two cases of PLL and review the literature regarding this uncommon disorder.

Focal intrahepatic strictures: a review of diagnosis and management.

INTRODUCTION Focal intrahepatic strictures are becoming more common owing to more prevalent and accurate cross-sectional imaging. However, data relating to their management are lacking. The purpose of the present review was to synthesize the current evidence regarding these lesions and to formulate a strategy for diagnosis and management. METHODS A literature search of relevant terms was performed using Medline. References of papers were subsequently searched to obtain older literature. RESULTS Focal intrahepatic strictures involve segmental hepatic ducts and/or left and right main hepatic ducts during their intrahepatic course. Most patients are asymptomatic while the minority present with vague abdominal pain or recurrent sepsis and only rarely with jaundice. Investigations used to distinguish benign from malignant aetiologies include blood tests (CEA, Ca19.9), imaging studies [ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP) and fluorodeoxyglucose-positron emission tomography (FDG-PET)], endoscopic modalities [endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic ultrasound (EUS)/cholangioscopy] and tissue sampling (brush cytology/biopsy). CONCLUSIONS A focal intrahepatic stricture requires thorough investigation to exclude malignancy even in patients with a history of biliary surgery, hepatolithiasis or parasitic infection. If during the investigative process a diagnosis or suspicion of malignancy is demonstrated then surgical resection should be performed. If all diagnostic modalities suggest a benign aetiology, then cholangioscopy with targeted biopsies should be performed.