Roberto Brusadin

Tourniquet modification of the associating liver partition and portal ligation for staged hepatectomy procedure

In staged liver resections, associating liver partition and portal ligation for staged hepatectomy (ALPPS) achieves sufficient hypertrophy of the future liver remnant (FLR) in 7 days. This is based on portal vein ligation and transection, and on occlusion of intrahepatic collaterals. This article presents a new surgical technique for achieving rapid hypertrophy of the FLR, which also involves adding intrahepatic collateral occlusion to portal vein transection.

Liver transplantation for hilar cholangiocarcinoma

The most appropriate treatment for Klatskin tumor (KT) with a curative intention is multimodal therapy based on achieving resection with tumour-free margins (R0 resections) combined with other types of neoadjuvant or adjuvant treatment (the most important factor affecting KT survival is the possibility of R0 resections, achieving 5-year survival rate of 40%-50%). Thirty to forty percent of patients with KT are inoperable and present a 5-year survival rate of 0%. In irresectable non-disseminated KT patients, using liver transplantation without neoadjuvant treatment, the 5-year survival rate increase to 38%, reaching 50% survival in early stage. In selected cases, with liver transplantation and neoadjuvant treatment (chemotherapy and radiotherapy), the actuarial survival rate is 65% at 5 years and 59% at 10 years. In conclusion, correct staging, neoadjuvant treatment, living donor and priority on the liver transplant waiting list may lead to improved results.

Resección en 2 tiempos de tumores hepáticos perihiliares con torniquete en la cisura umbilical y embolización portal secuencial al cuarto día postoperatorio (ALTPS modificado)

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) achieves the hypertrophy of the future liver remnant in seven days. We achieved the same hypertrophy placing a tourniquet in the parenchimal transection line associating a right portal vein ligation (associating liver tourniquet and right portal vein ligation for staged hepatectomy-ALTPS). In perihiliar tumors a«non touch» technique should be performed. ALPPS y ALTPS do not comply with this technical aspect because a dissection of the hilum is carried out in both procedures during the portal dissection. To avoid this problem we devised a new method called sequential ALTPS. It consists of placing a tourniquet in the umbilical fissure without ligation of the right portal vein during the first stage. Subsequently, on the 4(th) postoperative day we perform a percutaneous right portal vein embolization. We present the first case of this new technique in which we have obtained a hypertrophy of 77% of the future liver remnant seven days after portal vein embolization. In the second stage a right trisectionectomy was performed with inferior vena cava resection with a goretex graft replacement.

Role of 18F-FDG PET/CT vs CT-scan in patients with pulmonary metastases previously operated on for colorectal liver metastases

OBJECTIVE There is currently no conclusive scientific evidence available regarding the role of the 18F-FDG PET/CT for detecting pulmonary metastases from colorectal cancer (PMCRC) in patients operated on for colorectal liver metastases (CRLM). In the follow up of patients who underwent surgery for CRLM, we compare CT-scan and 18F-FDG PET/CT in patients with PMCRC. METHODS We designed the study prospectively performing an 18F-FDG PET/CT on all patients operated on for CRLM where the CT-scan detected PMCRC during the follow up. We included patients who were operated on for PMCRC because the histological findings were taken as a control rather than biopsies. RESULTS Of the 101 pulmonary nodules removed from 57 patients, the CT-scan identified a greater number (89 nodules) than the 18F-FDG PET/CT (75 nodules) (p < 0.001). Sensitivity was greater with the CT-scan (90 vs 76%, respectively) with a lower specificity (50 vs 75%, respectively) than with the 18F-FDG PET/CT. There were no differences between positive-predictive value and negative-predictive value. The 18F-FDG PET/CT detected more pulmonary nodules in four patients (one PMCRC in each of these patients) and more extrapulmonary disease in six patients (four mediastinal lymph nodes, one retroperitoneal lymph node and one liver metastases) that the CT-scan had not detected. CONCLUSION Although CT-scans have a greater capacity to detect PMCRC, the 18F-FDG PET/CT could be useful in the detection of more pulmonary and extrapulmonary disease not identified by the CT-scan. Advances in knowledge: We tried to clarify the utility of 18F-FDG PET/CT in the management of this subpopulation of patients.

Ictericia secundaria a quiste hepático simple con hemorragia intraquística traumática

Simple liver cysts (SLC) are malformations that originate in aberrant bile ducts that have lost their communication with the biliary tree and continue to secrete intraluminal fluid. Most cysts are smaller than 3 cm and are usually asymptomatic. Their incidence increases after the age of 50, with a predominance of women (ratio 1.5:1) and a prevalence of 18% in the adult population. A small percentage of patients present symptoms such as abdominal pain, earlysatiety, nausea and vomiting, all consequences of a mass effect. Due to their large size, physical examination can show evidence of an abdominal mass or hepatomegaly. Complications, such as hemorrhage, rupture or biliary obstruction are uncommon and take place in largesize cysts. Intracystic hemorrhage is rare and normally presents with severe abdominal pain, although it may be asymptomatic. The presence of 2 associated complications, such as intracystic hemorrhage and jaundice due to compression of the intrahepatic bile duct, is a very rare situation, which is why we present the following case. The patient is a 71-year-old woman who came to the emergency department after having an accidental fall with trauma to the right flank of the abdomen, presenting progressive jaundice. The patient’s medical history included: arterial hypertension, type 2 diabetes mellitus, cholecystectomy due to cholelithiasis, IgG lambda multiple myeloma, and ischemic stroke 8 months before. On physical examination, jaundice of the skin and mucous membranes was observed; the abdomen was soft and non-painful, and no masses or enlarged organs were detected. Lab work demonstrated: total bilirubin 16 mg/dL (direct bilirubin 13.7 mg/dL), GOT 276 IU/L, GPT 165 IU/L, GGT 678 IU/L, FA 1.124 IU/L, hematocrit 28.6%, hemoglobin 9.3 g/dL, leukocytes 18 000 (neutrophils 48%), prothrombin activity 100%, Ca 19.9 1036 U/L; CEA and alpha-fetoprotein were normal. Ultrasound revealed a large cystic lesion with dilatation of the intrahepatic bile duct. Computed tomography (Fig. 1) showed evidence of a large SOL in the liver that was cystic in appearance, measuring 12.1 9.4 9.3 cm, which was located in the right lobe and affected segments IV–V. Magnetic resonance (Fig. 2) showed a large cystic mass that, in the hilar region, caused dilatation of the bilobar biliary radicles. Due to suspected malignancy, positron emission tomography was conducted, which showed no metabolic increase in the liver. Serologies for Echinococcus and Entamoeba histolytica were negative. A percutaneous biliary drain was inserted, that resolved the jaundice. Given the suspicion for intracystic hemorrhage and cystadenocarcinoma, the patient was treated surgically through a right subcostal incision. A hepatic cyst was found in segments IV–V, measuring 12 cm in diameter and completely covered by liver parenchyma, while no lesions were observed in the hepatic hilum. The cyst was deroofed and contained abundant old blood. Intraoperative biopsies were taken, which showed no evidence of malignancy and suggested that the lesion was compatible with an SLC. The definitive pathology report defined the mass as an SLC, which coincided with the intraoperative biopsies. Jaundice secondary to obstruction caused by an SLC is uncommon, occurring in cases of large cysts (greater than 10 cm) and close to the porta hepatis. Intracystic hemorrhage is another uncommon complication that requires a differential diagnosis with cystadenocarcinoma. In our case, the size of the cyst, suspicion of intracystic hemorrhage and elevated Ca 19.9 levels led us to consider this possibility. Therefore, it is important to rule out the presence of cystadenoma, cystadenocarcinoma, communication with the biliary tree and other cystic lesions with infectious etiologies before treating the cysts, as the management of most simple cysts is based on a ‘‘wait and see’’ strategy, without requiring

Perforación yatrogénica de la arteria pulmonar por tubo de drenaje pleural

The patient is a 63-year-old male who had undergone splenectomy and had not received pneumococcal vaccination. He was admitted to our hospital with left pneumonia and parapneumonic effusion (empyema). During the insertion of the pleural drainage tube, profuse bleeding was observed, and the tube was clamped. Chest CT (Figs. 1 and 2) showed the tube in the posterior wall of the left pulmonary artery, with no active bleeding. Using thoracotomy, the tube was observed to be perforating the pulmonary parenchyma and entering the posterior wall of the pulmonary artery, where arterial bleeding was identified after careful mobilization of the tube. Hemostasis was achieved with a tobacco pouch suture that encompassed the arterial injury from the drainage tube. The patient presented an uneventful postoperative recovery. c i r e s p . 2 0 1 4 ; 9 2 ( 8 ) : e 4 9

Metástasis hepática y pancreáticas de un tumor fibroso solitario

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