Pablo Martí-Cruchaga

Totally laparoscopic Roux-en-Y duct-to-mucosa pancreaticojejunostomy after middle pancreatectomy: a consecutive nine-case series at a single institution.

Objective:To present the results of a series of laparoscopic middle pancreatectomies with roux-en-Y duct-to-mucosa pancreaticojejunostomy. Summary of Background Data:Middle pancreatectomy makes it possible to preserve pancreatic parenchyma in the resection of lesions that traditionally have been treated by distal splenopancreatectomy or cephalic duodenopancreatectomy. The laparoscopic approach could minimize the invasiveness of the procedure and enhance the benefits of middle pancreatectomy. Methods:From March 2005 to October 2007, 9 consecutive patients with benign or low malignant potential lesions in the pancreatic neck or body underwent surgery. Laparoscopic middle pancreatectomy with a roux-en-Y duct-to-mucosa pancreaticojejunostomy was planned on all of them. In the first 2 patients, the pancreas was transected by endostapler; in the last 7, the staple line was reinforced with absorbable polymer membrane. Results:The intervention was concluded laparoscopically in every case except 1 (laparoscopic-assisted) in which pancreaticojejunostomy was performed by means of minilaparotomy. Mortality was 0% and perioperative morbidity was 33%, (fistula of the cephalic stump in the first 2 patients (22%)). The pancreaticojejunostomy fistula rate was 0%. The median postoperative hospital stay was 5 days (range, 3–41). In the last 7 patients, in which pancreas was transected with staple line reinforcement material there were no stump fistulas; morbidity decreased to 14% and the median hospital stay was 4 days (range, 3–30). Conclusions:Laparoscopic middle pancreatectomy is feasible and safe. Duct-to-mucosa pancreaticojejunostomy can be performed safely using this approach. The method of pancreatic transection seems to be decisive in the incidence of cephalic stump fistulas.

Totally laparoscopic right-lobe hepatectomy for adult living donor liver transplantation: useful strategies to enhance safety.

The overriding concern in living donor liver transplantation is donor safety. A totally laparoscopic right hepatectomy without middle hepatic vein for adult living donor liver transplantation is presented. The surgical procedure is described in detail, focusing on relevant technical aspects to enhance donor safety, specifically the hanging maneuver and dynamic fluoroscopy‐controlled bile duct division.

A novel extra-glissonian approach for totally laparoscopic left hepatectomy

IntroductionWe describe a novel extra-glissonian approach (EGA) for totally laparoscopic left hepatectomy. Published techniques for totally laparoscopic left hepatectomy generally involve the selective ligation of the vascular and biliary elements of the left pedicle. The laparoscopic dissection of these structures can be tedious, difficult, and dangerous. The EGA has proven useful in open surgery for major hepatectomies. We feel that this approach could be even more useful in the laparoscopic context.MethodsWe describe an extra-glissonian laparoscopic technique in which the left pedicle is isolated extraparenchymally, detaching the left hilar plate, with particular attention to preserving the branch for segment I. The left portal triad is encircled with a cotton tape and transected with an endostapler. This is performed totally extraparenchymally without damaging the surrounding parenchyma.ResultsThis EGA technique for laparoscopic left hepatectomy follows by laparoscopy the same steps and recommendations that make the EGA safe and effective in open surgery.ConclusionsThe EGA for LLH can be performed as described in open surgery, therefore offering the same advantages.

Laparoscopic limited liver resection decreases morbidity irrespective of the hepatic segment resected.

OBJECTIVES The laparoscopic approach is widely used in abdominal surgery. However, the benefits of laparoscopy in liver surgery have hitherto been insufficiently established. This study sought to investigate these benefits and, in particular, to establish whether or not the laparoscopic approach is beneficial in patients with lesions involving the posterosuperior segments of the liver. METHODS Outcomes in a cohort of patients undergoing mostly minor hepatectomy (50 laparoscopic and 52 open surgery procedures) between January 2000 and December 2010 at the University Clinic of Navarra were analysed. The two groups displayed similar clinical characteristics. RESULTS Patients submitted to laparoscopic liver resection (LLR) had a lower risk for complications [odds ratio (OR) = 0.24, 95% confidence interval (CI) 0.07-0.74; P = 0.013] and shorter hospital stay (OR = 0.08, 95% CI 0.02-0.27; P < 0.001) independently of the presence of classical risk factors for complications. In the cohort of patients with lesions involving posterosuperior liver segments (20 laparoscopic, 21 open procedures), LLR was associated with significantly fewer complications (OR = 0.16, 95% CI 0.04-0.71) and a lower risk for a long hospital stay (OR = 0.1, 95% CI 0.02-0.43). CONCLUSIONS This study confirms that the laparoscopic approach to hepatic resection decreases the risk for post-surgical complications and lengthy hospitalization in patients undergoing minor liver resections. This beneficial effect is observed even in patients with lesions located in segments that require technically difficult resections.

Totally laparoscopic right hepatectomy for living donor liver transplantation. Analysis of a preliminary experience on 5 consecutive cases.

Background The pure laparoscopic approach in right hepatectomy (LRH) for living donor liver transplantation (LDLT) is a controversial issue. Some authors have reported the procedure to be feasible but surgical outcomes and impact on short and long-term morbidity rates are yet to be determined. The aim of this study is to present the results of a preliminary 5 consecutive cases series of LRH for LDLT and to compare it with a successive cohort of open right hepatectomies (ORH) for LDLT. Methods From May 2013 to October 2015, 5 consecutive donors underwent LRH for LDLT in our center. The previous last 10 ORH for LDLT were selected for comparison. Special care was taken to include all adverse events. Each patients complications were graded with the Clavien-Dindo Classification and scored with the Comprehensive Complication Index. Results All 5 consecutive donors completed a pure laparoscopic procedure. All allografts (open and laparoscopically procured) were successfully transplanted with no primary graft failures. Only 2 Clavien-Dindo Grade-I complications occurred in the LRH donors, while ORH donors had 10 Grade I, 2 Grade II and 1 Grade IIIa complications in the short term (<3 months). In the long term (6–12 months follow-up), LRH donors had a significant lower incidence of complications (Comprehensive Complication Index: 1.74; SD, 3891 vs 15.2 SD; 8.618; P = 0.006). Conclusions In our experience, LRH for LDLT is a feasible procedure. Further comparative series may support our preliminary findings of reduced incidence and severity of complications as compared with the open approach.

Laparoscopic resection of the uncinate process of the pancreas: the inframesocolic approach and hanging maneuver of the mesenteric root

BackgroundLaparoscopic pancreatic procedures have increased in recent years. However, only a single case of laparoscopic uncinatectomy has been reported to date, performed through an anterior approach. This video presents a hitherto undescribed laparoscopic inframesocolic approach and also an undescribed maneuver to expose the uncinate process.MethodsA 39-year-old women had a 16-mm insulinoma in the uncinate pancreas. The patient was placed in the supine position with legs apart. A 30º, 5-mm optic was used, and only a 12-mm trocar was needed. The first maneuver moved the major omentum and transverse colon upward to expose the mesenteric root. The duodenum was identified through the peritoneal sheath and mobilized. The superior mesenteric vein was identified and carefully exposed in the vicinity of the uncinate pancreas. To improve the exposure for the uncinatectomy, a hanging maneuver of the mesenteric root was performed with cotton tape. Intraoperative ultrasound identified the tumor and defined the limits of the resection. An inferior pancreaticoduodenal vein was sectioned between clips, and the uncinate process was dissected from the retropancreatic fascia. The transection was performed with a reinforced endostapler. The specimen was dragged into a bag and removed through the 12-mm orifice, which did not have to be enlarged. No drain was left.ResultsThe patient was discharged on postoperative day 3. No early or late surgical complications were observed. At this writing 1 year after the procedure, the patient has lost 35 kg and shows a normal body mass index. She remains asymptomatic with normal blood sugar levels.ConclusionLaparoscopic resection of the uncinate process of the pancreas is feasible and safe. The inframesocolic approach is easy to perform and achieves an optimal exposure that is improved with a hanging maneuver of the mesenteric root.

Pure laparoscopic management of early biliary leakage after liver transplantation: Abdominal lavage and T‐Tube placement

Leakage is the second most frequent biliary complication (after anastomotic strictures) after liver transplantation (LT). Although the therapeutic approach is centerspecific and must be tailored to every patient’s circumstances, endoscopic retrograde cholangiography (ERCP) is usually the therapy of choice and has high success rates. Nevertheless, surgical revision may be indicated, particularly when large defects or severe peritonitis is observed. We present the case of an anastomotic biliary leakage with associated diffuse biliary peritonitis after LT that was successfully treated with a totally laparoscopic approach. It involved thorough abdominal lavage and leakage repair by T-tube placement. Laparoscopic surgery is a widely accepted approach in several surgical fields because it is advantageous in terms of postoperative recovery. In the postoperative course after LT, this minimally invasive approach not only avoids the risks and complications derived from repeated laparotomy but also causes less tissue injury and consequently evokes a minor innate immune response. Because the combination of solid organ transplantation and laparoscopy is one of the medical fields that is still in evolution, we want to contribute to its progress by reporting this case.

Hepatoblastoma en el adulto

Adult hepatoblastoma (AHB) is a very rare tumor, having been described 45 cases up to June 2012. In contrast to HB in infancy (IHB), it has poor prognosis. We present the case of a 37-year-old asymptomatic woman who consulted for a large –12 cm diameter– mass involving segments 5 and 6 of the liver, and alfa-fetoprotein of 1,556,30 UI/mL. A bisegmentectomy was carried out. The microscopic study confirmed the AHB diagnosis, revealing the presence of epithelial cells forming clusters, trabecular patterns and tubules. The patient died on the 10th postoperative month due to progression disease. The Wnt/β-Catenin signaling pathway mutation has been reported and associated with a poor prognosis in IHB. Due to the AHB poor prognosis, seems reasonable to introduce the therapeutic regimens described in children who have a better outcome.

Cirugía laparoscópica hepática y pancreática

El desarrollo de la cirugia laparoscopica incluye tambien los procedimientos mas complejos de la cirugia abdominal como los que afectan al higado y al pancreas. Desde la laparoscopia diagnostica, acompanada de ecografia laparoscopica, hasta las resecciones mayores hepaticas o pancreaticas, el abordaje laparoscopico se ha ido extendiendo y abarca hoy la practica totalidad de los procedimientos quirurgicos en patologia hepatopancreatica. Sin olvidar nunca que el objetivo de la cirugia minimamente invasiva no es un mejor resultado estetico sino la disminucion de las complicaciones postoperatorias, es innegable que el abordaje laparoscopico ha supuesto un gran beneficio para los pacientes en todo tipo de cirugias excepto, por el momento, en el caso de las grandes resecciones como la hepatectomia izquierda o derecha o las resecciones de segmentos VII y VIII. La cirugia pancreatica ha tenido un gran desarrollo con la laparoscopia, especialmente en el campo de la pancreatectomia distal por tumores quisticos y neuroendocrinos, en los que el abordaje de eleccion es laparoscopico. Igualmente juega un importante papel la laparoscopia, junto con la ecolaparoscopia, en la estadificacion de tumores pancreaticos, previa a la cirugia abierta o para indicar el tratamiento adecuado. En los proximos anos, es de esperar que el desarrollo siga siendo exponencial, y, unido a los avances en robotica, permitira asistir todavia a un mayor impacto del abordaje laparoscopico en el campo de la cirugia hepatica y pancreatica.

Screening-detected colorectal cancers show better long-term survival compared with stage-matched symptomatic cancers

PURPOSE the aim of this study was to compare overall and disease-free survival among patients with colorectal cancer detected via a screening program as compared to those with symptomatic cancer. MATERIAL AND METHODS patients diagnosed via colonoscopy (screening group) and those with clinical symptoms (non-screening) were identified from 1995 to 2014. Demographic, clinical, surgical and pathologic variables were recorded. Stage I, II and III cancers were included. Overall and disease-free survival were calculated at five and ten years after tumor resection and survival was calculated by matching both groups for cancers at stage I, II and III. RESULTS two hundred and fifty patients were identified as a result of screening procedures and 1,330 patients presented with symptomatic cancers. There were no significant differences in the baseline characteristics between the two groups. Pathologic stage, degree of differentiation, perineural invasion and lymphovascular invasion were lower in the screening group (p < 0.01). Overall and disease-free survival at five and ten years were higher in the screening group (p < 0.01). However, when the subjects were matched for pathologic stage, significant differences were found between the two groups with regard to stage I and III tumors. Disease-free survival in stage III at five years (79.1 vs 61.7%; p < 0.001) and ten years (79.1% vs 58.5%; p < 0.001) were significantly higher in the screening group. CONCLUSIONS patients with stage I and III tumors that were diagnosed via a screening program have a higher overall and disease-free survival at five and ten years.