Rodrigo C. Surjan

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

Treatment of advanced hepatocellular carcinoma with very low levels of amplitude-modulated electromagnetic fields.

Background:Therapeutic options for patients with advanced hepatocellular carcinoma (HCC) are limited. There is emerging evidence that the growth of cancer cells may be altered by very low levels of electromagnetic fields modulated at specific frequencies.Methods:A single-group, open-label, phase I/II study was performed to assess the safety and effectiveness of the intrabuccal administration of very low levels of electromagnetic fields amplitude modulated at HCC-specific frequencies in 41 patients with advanced HCC and limited therapeutic options. Three-daily 60-min outpatient treatments were administered until disease progression or death. Imaging studies were performed every 8 weeks. The primary efficacy end point was progression-free survival ⩾6 months. Secondary efficacy end points were progression-free survival and overall survival.Results:Treatment was well tolerated and there were no NCI grade 2, 3 or 4 toxicities. In all, 14 patients (34.1%) had stable disease for more than 6 months. Median progression-free survival was 4.4 months (95% CI 2.1–5.3) and median overall survival was 6.7 months (95% CI 3.0–10.2). There were three partial and one near complete responses.Conclusion:Treatment with intrabuccally administered amplitude-modulated electromagnetic fields is safe, well tolerated, and shows evidence of antitumour effects in patients with advanced HCC.

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.

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.

LAPAROSCOPIC PANCREATIC RESECTION. FROM ENUCLEATION TO PANCREATODUODENECTOMY. 11-YEAR EXPERIENCE

CONTEXT Our experience with laparoscopic pancreatic resection began in 2001. During initial experience, laparoscopy was reserved for selected cases. With increasing experience more complex laparoscopic procedures such as central pancreatectomy and pancreatoduodenectomies were performed. OBJECTIVES The aim of this paper is to review our personal experience with laparoscopic pancreatic resection over 11-year period. METHODS All patients who underwent laparoscopic pancreatic resection from 2001 through 2012 were reviewed. Preoperative data included age, gender, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. Diagnosis, tumor size, margin status were determined from final pathology reports. RESULTS Since 2001, 96 patients underwent laparoscopic pancreatectomy. Median age was 55 years old. 60 patients were female and 36 male. Of these, 88 (91.6%) were performed totally laparoscopic; 4 (4.2%) needed hand-assistance, 1 robotic assistance. Three patients were converted. Four patients needed blood transfusion. Operative time varied according type of operation. Mortality was nil but morbidity was high, mainly due to pancreatic fistula (28.1%). Sixty-one patients underwent distal pancreatectomy, 18 underwent pancreatic enucleation, 7 pylorus-preserving pancreatoduodenectomies, 5 uncinate process resection, 3 central and 2 total pancreatectomies. CONCLUSIONS Laparoscopic resection of the pancreas is a reality. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency that could be detrimental to the patients quality of life. Laparoscopic pancreatoduodenectomy is a safe operation but should be performed in specialized centers by highly skilled laparoscopic surgeons.

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.

Intrahepatic Glissonian Approach for Laparoscopic Right Trisectionectomy

A 22-year-old woman with a giant angiomyolipoma was referred for surgical treatment. The patient was placedin aleft semilateral decubitus position with the surgeon between the patient’s legs. Five trocars (three 12 and two 5mm) were used. The pneumoperitoneum is established at a pressure of 12mm Hg. Round and falciform ligaments are taken down close to the abdominal wall in order to facilitate left-liver fixation at the end of the procedure. The falciform and coronary ligaments are divided by using laparoscopic coagulation shears (Harmonic Scalpel LCS; Ethicon Endo-Surgery Industries, Cincinnati, OH)toexpose thesuprahepaticinferiorvenacava. After cholecystectomy, the right hepatic artery is ligated, resulting in an ischemic delineation of the right liver. Due to previous right-portal-vein embolization in this patient, the hepatic pedicle was not fully dissected. The right liver is then fully mobilized, and the inferior vena cava is dissected. A large inferior right hepatic vein arising from segment 6 is ligated and divided between metallic clips. Another accessory right hepatic vein from segment 7 (middle-right hepatic vein) is divided with a vascular endoscopic stapler. The right hepatic vein is finally encircled, and downward retraction permits the safe application of a vascular endoscopic stapler. The stapler is fired, leaving three lines of metallic clips. With this maneuver, the anterior surface of the retrohepatic vena cava is completely exposed. The main trunk, including the middle and left hepatic veins, is now the only venous drainage of the liver. It is encircled and traction or temporary clamping permits complete outflow control of the liver, minimizing bleeding during liver transection. At this time, the intrahepatic access to the main right Glissonian pedicle is achieved with two small incisions: An incision is performed on the right portion of the caudate lobe and another anterior incisionismadeinfrontofthehilum.Anendoscopicvascular

Iliac-hepatic arterial bypass for compromised collateral flow during modified Appleby operation for advanced pancreatic cancer

Involvement of the celiac trunk and common hepatic artery are two of the most common forms of vascular invasion by tumours of the distal pancreas, and until recently this finding was considered a contra-indication to resection. We described a modified Appleby operation for locally advanced distal pancreatic cancer with compromised hepatic collateral flow that needed hepatic arterial revascularization, successfully accomplished by left external iliac-hepatic arterial bypass with Dacron prosthesis. Patient recovery was uneventful and he was discharged on the 10th postoperative day. Postoperative angio-CT disclosed a patent arterial bypass. Patient is well and asymptomatic 13 months after operation. At the time of this writing, postoperative CT scan showed no evidence of disease and CA 19-9 level is normal. There is a well established rationale to perform extended resection of pancreatic carcinomas that compromise vascular structures. Modified Appleby procedure can safely be performed, has oncological advantages to palliative procedures and provides relief of pain but is reserved for selected patients. Preservation of hepatic arterial flow has utmost importance to avoid hepatobiliary complications as liver necrosis, liver abscess, gallbladder necrosis or cholecystitis. In this case, hepatic revascularization was particularly challenging, but was successfully accomplished by left external iliac--hepatic arterial bypass. To our knowledge this type of arterial bypass has never been described so far in the English literature and its description may be important for surgeons dealing with advanced pancreatic cancer.

Hepatectomia direita por videolaparoscopia

The first application of laparoscopic liver surgery consisted of wedge liver biopsies or resection of peripheral lesions, mostly benign. More recently, reports of anatomic left and right hepatectomy have been seen in the literature. Expertise in some centers has evolved to such an extent that even living related donor hepatectomy has been performed. The aim of this paper is to report a laparoscopic right hepatectomy and describe in detail the surgical technique employed. To our knowledge this is the first case performed in Brazil totally laparoscopically. The surgery followed four distinct phases: complete mobilization of the liver; hilum dissection with encircling of right portal vein and right hepatic artery, caval dissection using linear vascular stapler to divide right hepatic vein and parenchymal transection with harmonic shears and firings of linear staplers are used to divide segmental 5 and 8 branches of middle hepatic vein. The liver specimen was removed by Pfannenstiel incision. Intraoperative blood loss was estimated in 120 ml with no need for blood transfusion. Hospital stay was 5 days. Laparoscopic right hepatectomy is feasible, technically demanding but can be safely accomplished by surgeons who have experience in advanced laparoscopic procedures and open hepatic surgery. In Brazil laparoscopic liver surgery is still in its first years and there is a lack of technical description of this complex procedure.

Intrahepatic Glissonian Approach for Single-Port Laparoscopic Liver Resection

BACKGROUND Minimal access surgery is moving toward reduced size and fewer ports. The aim of this article is to describe our experience with the intrahepatic Glissonian approach for single-port laparoscopic left lateral sectionectomy. SUBJECTS AND METHODS We have performed this procedure on 8 consecutive patients. A transumbilical incision is performed, and a single-incision platform is introduced. The operation begins with ultrasound examination of the liver. Intrahepatic Glissonian access of the portal pedicle from segments 2 and 3 is performed, and the pedicle is divided with a stapler. The liver is transected, and the left hepatic vein is divided with a stapler. A surgical specimen is retrieved through the single umbilical incision. No drains are left in place. RESULTS The median operative time was 68 minutes, and there was minimal bleeding. The median hospital stay was 1 day. Six patients were operated on for liver adenoma. There was no morbidity or mortality. During follow-up (median, 12 months), no patient developed incisional hernia. The cosmetic appearance of the incision was excellent in all cases. CONCLUSIONS Single-port laparoscopic left lateral sectionectomy is feasible and can be safely performed in specialized centers.