Tiago Basseres

Laparoscopic Pancreatoduodenectomy in 50 Consecutive Patients with No Mortality: A Single-Center Experience

BACKGROUND Laparoscopic pancreatic surgery has gradually expanded to include pancreatoduodenectomy (PD). This study presents data regarding the efficacy of laparoscopic PD in a single center. METHODS This was a single-cohort, prospective observational study. From March 2012 to September 2015, 50 consecutive patients underwent laparoscopic PD using a five-trocar technique. Reconstruction of the digestive tract was performed with double jejunal loop technique whenever feasible. Patients with radiological signs of portal vein invasion were operated by open approach. RESULTS Twenty-seven women and 23 men with a median age of 63 years (range 23-76) underwent laparoscopic PD. Five patients underwent total pancreatectomy. All, but 1 patient (previous bariatric operation), underwent pylorus-preserving resection. Reconstruction was performed with double jejunal loop in all cases except in 5 cases of total pancreatectomy. Conversion was required in 3 patients (6%) as a result of difficult dissection (two cases) and unsuspected portal vein invasion (1 patient). Median operative time was 420 minutes (range 360-660), and the 90-day mortality was nil. Pancreatic fistula occurred in 13 patients (26%). There was one grade C (reoperated), one grade B (percutaneous drainage), and all remaining were grade A (conservative treatment). Other complications included port site bleeding (n = 1), biliary fistula (n = 2), and delayed gastric emptying (n = 2). Mean hospital stay was 8.4 days (range 5-31). CONCLUSIONS Laparoscopic PD is feasible and safe, but is technically demanding and may be reserved to highly skilled laparoscopic surgeons with proper training in high-volume centers. Isolated pancreatic anastomosis may be useful to decrease the severity of postoperative pancreatic fistulas. Therefore, it could be a good option in patients with a high risk for developing postoperative pancreatic, as well as by less-experienced surgeons.

A Proposed Physiopathological Pathway to Hyperammonemic Encephalopathy in a Non-Cirrhotic Patient with Fibrolamellar Hepatocellular Carcinoma without Ornithine Transcarbamylase (OTC) Mutation

Patient: Male, 31 Final Diagnosis: Fibrolamellar hepatocellular carcinoma Symptoms: Encephalopathy Medication:— Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Hyperammonemic encephalopathy is a potentially fatal condition that may progress to irreversible neuronal damage and is usually associated with liver failure or portosystemic shunting. However, other less common conditions can lead to hyperammonemia in adults, such as fibrolamellar hepatocellular carcinoma. Clinical awareness of hyperammonemic encephalopathy in patients with normal liver function is paramount to timely diagnosis, but understanding the underlying physiopathology is decisive to initiate adequate treatment for complete recovery. Case Report: A 31-year-old male with fibrolamellar carcinoma and peritoneal carcinomatosis presented with rapid onset hyperammonemic encephalopathy. Despite usual treatment for hepatic encephalopathy, his hyperammonemia was aggravated. A physiopathological pathway to encephalopathy resulting from hepatocellular dysfunction or portosystemic shunting was suspected and proper treatment was initiated, which resulted in complete remission of encephalopathy. Thus, we propose there is a physiopathology path to hyperammonemic encephalopathy in non-cirrhotic patients with fibrolamellar carcinoma independent of ornithine transcarbamylase (OTC) mutation. An ornithine metabolism imbalance resulting from overexpression of Aurora Kinase A as a result of a single, recurrent heterozygous deletion on chromosome 19, common to all fibrolamellar carcinomas, can lead to a c-Myc and ornithine decarboxylase overexpression that results in ornithine transcarboxylase dysfunction with urea cycle disorder and subsequent hyperammonemia. Conclusions: The identification of a physiopathological pathway allowed adequate medical treatment and full patient recovery from severe hyperammonemic encephalopathy.

Extended laparoscopic liver resection: initial experience and review of the literature

Background: Laparoscopic extended liver resections have been limited to very few centers with only few cases reported so far. The aim with this study was to perform a comprehensive analysis of our experience with extended laparoscopic liver surgery using a prospective database. Methods: In this study, consecutive patients undergoing extended laparoscopic liver surgery by this team between 2007 and 2016 were studied. The primary endpoint was safety of the procedure. Secondary endpoints were conversion rates, operative times, blood loss, need for transfusions, and hospital length of stay. Results: Between 2007 and 2016, 23 extended laparoscopic liver resections were performed at our institution. Of these, 12 (52%) were performed as a second stage in a staged liver resection and 11 (48%) were performed during one-stage resection with or without preoperative portal vein embolization. There were 13 women and 10 men with mean age of 56.3 years old [22–73]. The main indication for liver resection was col-orectal liver metastases. Two patients required conversion to open surgery, one due to hemorrhage and one due to technical difficulties. Blood loss was significant in 6 patients with need for transfusion. The mean operative time was 245 minutes. Median hospital stay was 7 days. Significant complications occurred in six patients (26.1%). No 90-day mortality was observed. Conclusions: This observational study shows that laparoscopic ex-tended liver resections are safe and feasible. Adequate analysis of quality and volume of the future liver remnant (FLR) is essential. Complications, operative times, hospital stay and blood loss were comparable to open extended liver resections.

First totally laparoscopic ALPPS procedure with selective hepatic artery clamping: Case report of a new technique.

Background:ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) is a new surgical approach for the treatment of liver tumors. It is indicated in cases where the future liver remnant is not sufficient to maintain postoperative liver function. We report a totally laparoscopic ALPPS with selective hepatic artery clamping. Pneumoperitoneum itself results in up to 53% of portal vein flow and selective hepatic artery clamping can reduce blood loss while maintaining hepatocellular function. Therefore, the combination of both techniques may result in effective control of bleeding with no damage in the liver function that may have direct impact in the result of ALPPS procedure. Methods:A 65-year-old man with colorectal liver metastases in all liver segments, except liver segment 1 (S1), were evaluated as unresectable. He underwent chemotherapy with objective response and multidisciplinary board decided for ALPPS procedure. First stage was performed entirely by laparoscopy and consisted of enucleation of metastases from segments 2 and 3, ligation of the right portal vein and liver splitting under selective common hepatic artery clamping. The second stage was done 3 weeks later and consisted of laparoscopic right trisectionectomy by laparoscopy. Results:Operative time was 250 and 200 minutes, respectively. Estimated blood loss was 150 and 100 mL. There was no need for transfusion or hospitalization in intensive care. He was discharged on the 3rd and 5th postoperative day, respectively. Recovery was uneventful after both stages and patient did not present any sign of liver failure. Elevation of liver enzymes was minimal. Computerized tomography (CT) scan before second stage showed a liver hypertrophy of 53%, sFLR was 0.37 before second stage, or 33% of the total liver volume. CT scan shows no residual liver disease and optimum liver regeneration. Patient is well with no evidence of the disease 11 months after the procedure. Conclusions:Totally laparoscopic ALPPS is a feasible and safe approach for selected patients with liver tumors. The hypertrophy of the remaining liver was adequate and sequential procedures were performed without morbidity and no mortality. Selective hepatic artery clamping seems to be an interesting solution to decrease intraoperative blood loss without the harsh effect of Pringle maneuver.

Laparoscopic pylorus-preserving pancreatoduodenectomy. Roux-en-y reconstruction with isolated pancreatic drainage (with video)

Please cite this article in press as: Machado MA, et al. Laparoscopic pylorus-preserving pancreatoduodenectomy. Roux-en-y reconstruction with isolated pancreatic drainage (with video). Journal of Visceral Surgery (2016), http://dx.doi.org/10.1016/j.jviscsurg.2016.02.005

Enucleation of liver tumors: you do not have to feel blue about it

Enucleation of hepatic tumors is a low-morbidity technique with adequate oncological results that is useful in many clinical settings. Compared with anatomical liver resections, it offers the advantage of maximal hepatic parenchymal preservation. However, some technical adversities may occur during the enucleation of liver tumors, such as difficulty in finding the lesions by intraoperative ultrasonography after hepatic transection or further visually spotting the tumor within the parenchyma if a first specimen is retracted not containing the lesion. We describe an innovative technique that overcomes these possible adversities and makes the enucleation of liver tumors easier and more precise.

Endoscopic ultrasound-guided treatment of pancreatic fluid collections with lumen apposing metallic stents: lessons learned

Pancreatic fluid collections are common pancreatitis complications that frequently require drainage. Endoscopic ultrasound-guided placement of expandable lumen apposing metallic stents has recently emerged as an effective and less invasive treatment option. It is associated with less morbidity, lower costs, and faster clinical recovery than other therapeutic modalities. Nevertheless, this procedure may result in severe complications such as bleeding, buried stent syndrome, and prosthesis dislodgement (with perforation and peritoneal leakage). We performed 108 EUS-guided drainages with lumen apposing metallic stents for the treatment of pancreatic fluid collections with 8 complications and only two cases that required urgent surgical procedures resulting in one fatality. We present this two severe complications submitted to surgical treatment and discuss potential signs of alarm that must be taken under consideration before choosing a treatment modality.

How to Improve Visualization During Laparoscopic Surgery in Jaundice Patients The Yellow Balance

Dear Editor: Recent technological advancements have led to the introduction of high-quality cameras in laparoscopic surgery. The better view achieved with this new equipment along with the use of a high-definition monitor improved the quality of vision resulting in better precision of surgical performance. The longer the surgical procedure the greater the need for better visualization. In patients with jaundice, the visualization of the surgical field may be impaired by the tainting of the tissues by the accumulation of bilirubin. The yellowish pigmentation of the tissue may make it difficult to identify the anatomical structures and its margins may appear blurred. In order to overcome this problem, we have used a simple trick. At the beginning of the procedure we use the white balance adjustment from the camera using a white pad as a reference. As we enter the abdominal cavity with the laparoscope we can see the abdominal cavity tainted by the yellow pigment from hyperbilirubinemia (Figure 1A). We then perform a “white” balance using a yellow pad to adjust the color of the video, the so-called “yellow balance.” Another way to do it is to use the patient’s skin (Figure 1B and C), if the patient is Caucasian. The appearance of the abdominal cavity returns to was to be expected in a nonjaundiced 681890 SRIXXX10.1177/1553350616681890Surgical InnovationMachado et al letter2016

LAPAROSCOPIC UNCINATECTOMY: A MORE CONSERVATIVE APPROACH TO THE UNCINATE PROCESS OF THE PANCREAS

ABSTRACT Background: The isolate resection of the uncinate process of the pancreas is a rarely described procedure but is an adequate surgery to treat benign and low grade malignancies of the uncinate process of the pancreas. Aim: To detail laparoscopic uncinatectomy technique and present the initial results. Method: Patient is placed in supine position with the surgeon between legs. Three 5-mm, one 10-mm and one 12-mm trocars were used to perform the isolated resection of the uncinate process of the pancreas. Parenchymal transection is performed with harmonic scalpel. A hemostatic absorbable tissue is deployed over the area previously occupied by the uncinate process. A Waterman drain is placed. Result: This procedure was applied to an asymptomatic 62-year-old male with biopsy proven low grade neuroendocrine tumor of the pancreatic uncinate process. A laparoscopic pancreaticoduodenectomy was proposed. During the initial surgical evaluation, intraoperative sonography was performed and disclosed that the lesion was a few millimeters away from the Wirsung. The option was to perform a laparoscopic uncinatectomy. Postoperative period until full recovery was swift and uneventful. Conclusion: Laparoscopic uncinatectomy is a safe and efficient procedure when performed by surgical teams with large experience in minimally invasive biliopancreatic procedures.

A novel technique for hepatic vein reconstruction during hepatectomy

Surgical resection is the treatment of choice for malignant liver tumours. Nevertheless, surgical approach to tumours located close to the confluence of the hepatic veins is a challenging issue. Trisectionectomies are considered the first curative option for treatment of these tumours. However, those procedures are associated with high morbidity and mortality rates primarily due to post-operative liver failure. Thus, maximal preservation of functional liver parenchyma should always be attempted. We describe the isolated resection of Segment 8 for the treatment of a tumour involving the right hepatic vein and in contact with the middle hepatic vein and retrohepatic vena cava with immediate reconstruction of the right hepatic vein with a vascular graft. This is the first time this type of reconstruction was performed, and it allowed to preserve all but one of the hepatic segments with normal venous outflow. This innovative technique is a fast and safe method to reconstruct hepatic veins.