Search

Background: Hepatectomies promote considerable amount of blood loss and the need to administrate blood products, which are directly linked to higher morbimortality rates. The blood-conserving hepatectomy (BCH) is a modification of the selective vascular occlusion technique. It could be a surgical maneuver in order to avoid or to reduce the blood products utilization in the perioperative period., Aim: To evaluate in rats the BCH effects on the hematocrit (HT) variation, hemoglobin serum concentration (HB), and on liver regeneration., Methods: Twelve Wistar rats were divided into two groups: control (n=6) and intervention (n=6). The ones in the control group had their livers partially removed according to the Higgins and Anderson technique, while the rats in the treatment group were submitted to BCH technique. HT and HB levels were measured at day D0, D1 and D7. The rate between the liver and rat weights was calculated in D0 and D7. Liver regeneration was quantitatively and qualitatively evaluated., Results: The HT and HB levels were lower in the control group as of D1 onwards, reaching an 18% gap at D7 (p=0.01 and p=0.008, respectively); BCH resulted in the preservation of HT and HB levels to the intervention group rats. BCH did not alter liver regeneration in rats., Conclusion: The BCH led to beneficial effects over the postoperative HT and serum HB levels with no setbacks to liver regeneration. These data are the necessary proof of evidence for translational research into the surgical practice. A) Unresected liver; B) liver appearance after the partial hepatectomy (1=vena cava; 2=portal vein; 3=hepatic vein; 4=biliary drainage; 5=hepatic artery).

Objective: To analyze the influence of portal vein ligation in hepatic regeneration by immunohistochemical criteria., Methods: Ten pigs divided into two groups of five animals underwent hepatectomy in two stages, and the groups were differentiated by ligation or not of the left portal vein tributary, which is responsible for vascularization of the left lateral and medial lobes of the pig liver. Five days after the procedure, the animals underwent liver biopsies for further analysis of histological and immunohistochemical with marker Ki67., Results: The group submitted to hepatectomy with vascular ligation showed an increase of approximately 4% of hepatocytes in regeneration status, as well as a greater presence of Kupffer and inflammatory cells as compared to control., Conclusion: As a result of positive cell replication observed through the Ki67 marker, we can suspect that the ligation of a tributary of the portal vein associated with liver resection promoted a greater stimulus of liver regeneration when compared to liver resection alone., Objetivo: Analisar a influência da ligadura da tributária da veia porta no estímulo regenerativo hepático por meio de critérios imuno-histoquímicos., Métodos: Dez suínos, divididos em dois grupos de cinco animais, foram submetidos à hepatectomia em dois estágios, sendo que os grupos foram diferenciados pela ligadura ou não da tributária da veia porta, responsável pela vascularização dos lobos lateral e medial esquerdos do fígado do suíno. Cinco dias após o procedimento, os animais foram reabordados para retirada de amostras hepáticas para posterior análise de histológica e imunoistoquímica com o marcador Ki67., Resultados: O grupo submetido à hepatectomia com ligadura vascular apresentou incremento de 4% aproximadamente de hepatócitos em processo de regeneração, bem como grande número de células de Kupffer e células inflamatórias, quando comparado ao controle., Conclusão: Em virtude da análise positiva da replicação celular observada por meio do marcador Ki67, pode-se observar que a ligadura de uma tributária da veia porta promoveu um maior estímulo de regeneração hepática, efeito observado com menor intensidade no grupo submetido apenas à ressecção hepática.

Background: Partial portal vein ligation causes an increase in portal pressure that remains stable even after the appearance of collateral circulation, with functional adaptation to prolonged decrease in portal blood flow., Aim: To assess whether different constriction rates produced by partial ligation of the vein interfere with the results of this experimental model in rats., Methods: Three groups of five rats each were used; in group 1 (sham-operated), dissection and measurement of portal vein diameters were performed. Portal hypertension was induced by partial portal vein ligation, reducing its size to 0.9 mm in the remaining 10 animals, regardless of the initial diameter of the veins. Five animals with portal hypertension (group 2) underwent reoperation after 15 days and the rats in group 3 after 30 days. The calculation of the constriction rate was performed using a specific mathematical formula (1 - π r 2 / π R2) x 100% and the statistical analysis with the Student t test., Results: The initial diameter of the animal's portal vein was 2.06 mm, with an average constriction rate of the 55.88%; although the diameter of the veins and the constriction rate in group 2 were lower than in group 3 (2.06 mm - 55,25% and 2.08 mm - 56.51%, respectively), portal hypertension was induced in all rats and no significant macroscopic differences were found between the animals that were reoperated after 15 days and after 30 days respectively, being the shorter period considered enough for the evaluation. Comparing the initial diameter of the vein and the rate of constriction performed in groups 2 and 3, no statistic significance was found (p>0.05)., Conclusion: Pre-hepatic portal hypertension in rat can be induced by the reduction of the portal vein diameter to 0.9 mm, regardless the initial diameter of the vein and the vessel constriction rate.

Background: Due to their complexity and risks, mesenteric-portal axis resection and reconstruction during the pancreatectomy procedure were not recommended back in the early nineties. However, as per technical improvements and the reduction in morbidity and mortality rates, they have been routinely indicated in large medical centers., Aim: To show results from cases of patients subjected to mesenteric-portal axis resection during pancreatectomy., Method: Patients subjected to mesenteric-portal axis resection during pancreatectomy were prospectively and consecutively assessed. The procedure was indicated according to anatomical criteria defined by imaging exams or intraoperative assessment., Results: Ten patients, half of them were male, with mean age of 55.7 years (40-76) were included. The most frequent underlying diseases were pancreatic adenocarcinoma and Frantz tumor. The circumferential resection of the portal vein associated with the superior mesenteric vein with splenic vein ligature (4 cases=40%) and the primary anastomosis of the vascular stumps (5 cases=50%) were, respectively, the most performed types of vascular resection and reconstruction. Surgery time ranged from 480 to 600 minutes (average=556 minutes) and postoperative hospitalization time ranged from 9 to 114 days (average=34.8 days). Morbidity rate was 60%, and clinical pancreatic fistula (grade B and C) was the most common complication (3 cases=30%). Mortality rate was 10% (1 case)., Conclusion: Mesenteric-portal axis resection is a valid technical procedure. It should be taken into account after a clinical assessment that included not only the patients' clinical condition but also the technical and anatomical conditions of the mesenteric-portal axis tumor infiltration as well as life expectancy based on the patient's cancer prognosis.

Resection of the confluence of the superior mesenteric and portal veins has been performed most frequently in the treatment of adenocarcinoma of the pancreas, in view of the reported positive results, but it can also be used in cases of benign pancreatic neolpasias when they are strongly adhered to the mesenteric-portal trunk. Nevertheless, there is no study on the best type of venous grafts for reconstruction of the mesenteric-portal trunk when required. The choice of graft depends on the preference of the surgeon or the institution. This technical note critically discusses the use of the splenic vein as an option for mesenteric-portal trunk reconstruction after gastroduodenopancreatectomy.

Background: Pressure increase in the portal venous system, caused by reduction of blood supply to the liver, develops collateral circulation of splanchnic vessel that reaches the venous system of superior vena cava. The spleen works as an auxiliary capacitance system which compensates the increase in portal pressure that may cause splenomegaly., Aim: To reproduce experimental model of pre-hepatic portal hypertension by reducing the caliber of the vein, allowing the study of alterations in the rat's spleen in this situation., Methods: Fifteen Wistar rats were divided into three groups of five. All animals were operated, being the first five used as control (group 1) and reoperated after 15 days (sham-operated), along with five other animals had portal hypertension induced (group 2). The last five animals, also with portal hypertension were reoperated after 30 days (group 3). Prehepatic portal hypertension was caused in experimental animals by partial ligation of portal vein in hepatic hilum. The spleen was measured during the first and second operations, allowing the calculation of its volume in the three groups studied using specific mathematical formula., Results: No macroscopic changes in spleen were significant when compared the animals reoperated after 15 days (group 2) to the ones after 30 days (group 3), being 15 days considered enough for the evaluation of effects on spleen after partial ligation. Although the volume of spleens studied in groups 2 and 3 have increased after the first operation - ranging on average from 0.5417 cm(3) to 0.6345 cm(3) at reoperation with increase of approximately 17% in volume between the first and second phase - the rsults were not statistically significant (p> 0.05)., Conclusion: There was no statistically significant increase in the spleen volume after partial ligation of the portal vein when comparing the calculated volume in the first operation to the volume found at reoperation. There was no difference when comparing the spleen volumes of the animals reoperated after 15 days and the ones reoperated after 30 days.

Background: Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. To induce rapid and significant hepatic hypertrophy, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients which tumor is previously considered unresectable., Aim: To present the Brazilian experience with ALPPS approach., Method: Were analyzed 39 patients who underwent hepatic resection using ALPPS in nine hospitals. The procedure was performed in two steps. The first operation was portal vein ligation and in situ splitting. In the second operation the right hepatic artery, right bile duct and the right hepatic vein were isolated and ligated. The extended right lobe was removed. There were 22 male (56.4%) and 17 female (43.6%). At the time of the first operation, the median age was 57.3 years (range: 20-83 years)., Results: The most common indication was liver metastasis in 32 patients (82.0%), followed by cholangiocarcinoma in three (7.7%). Two patients died (5.2%) during this period and did not undergo the second operation. The mean interval between the first and the second operation was 14.1 days (range: 5-30 days). The volume of the left lateral segment of the liver increased 83% (range 47-211.9%). Significant morbidity after ALPPS was seen in 23 patients (59.0%). The mortality rate was 12.8% (five patients)., Conclusion: The ALPPS approach can enable resection in patients with lesions previously considered unresectable. It induces rapid liver hypertrophy avoiding liver failure in most patients. However still has high morbidity and mortality.

Background: Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a new approach for patient which tumor is previously considered unresectable., Aim: To present ALPPS as an innovative surgical technique of two-staged hepatectomy for the treatment of patients with marginally resectable or initially nonresectable primary and metastatic liver tumors., Technique: The procedure is performed in two steps. The first consists on ligation of the right portal vein branch. Subsequently, total or nearly total parenchyma dissection along the falciform ligament is performed, including the middle hepatic vein. A plastic bag is used to cover the right extended lobe, and the abdomen is drained and closed. The second one is performed after a computer tomography, six to 12 days interval. After laparotomy, the plastic bag is removed. The right artery, right bile duct and the right hepatic vein are divided. The extended right lobe is removed. Drain is placed at the resection surface, and the abdomen is closed., Conclusion: The associating of liver partition and portal vein ligation can enable curative resection of liver metastasis in patients with lesions previously considered unresectable.

Context: Portal vein thrombosis is the most frequent complication after esophagogastric devascularization and splenectomy for hepatosplenic schistosomosis., Objective: To evaluate portal vein thrombosis in 155 patients with schistosomal portal hypertension submitted to esophagogastric devascularization and splenectomy., Methods: We retrospectively analyzed not only the incidence and predictive factors of this complication, but also clinical, laboratorial, endoscopic and Doppler sonography outcome of these patients., Results: Postoperative portal thrombosis was observed in 52.3% of the patients (partial in 45.8% and total in 6.5%). Postoperative diarrhea was more frequent in patients with portal vein thrombosis. Fever was a frequent postoperative symptom (70%) but occurred in a higher percentage when total portal vein thrombosis was present (100%). Superior mesenteric vein thrombosis occurred in four patients (2.6%) and was associated with total thrombosis of the portal vein. There was no statistical difference between patients with and without portal vein thrombosis according to clinical and endoscopic parameters during late follow-up. It was not possible to identify any predictive factor for the occurrence of this complication., Conclusions: Portal vein thrombosis is an early and frequent event after esophagogastric devascularization and splenectomy, usually partial with benign outcome and low morbidity. Total portal vein thrombosis is more frequently associated with a high morbidity complication, the superior mesenteric vein thrombosis. Long-term survival was not influenced by either partial or total portal thrombosis.

Background: The study compared the preoperative portal vein congestion index estimated by Doppler ultrasound and the postoperative portal vein thrombosis of patients submitted to esophagogastric devascularization and splenectomy (EDS)., Methods: 65 patients with portal hypertension due to schistosomiasis and previous gastrointestinal bleeding submitted to EDS were divided into two groups: GROUP A (28 patients without postoperative portal vein thrombosis) and GROUP B (37 patients with postoperative portal vein thrombosis). The following parameters of preoperative Doppler ultrasound of the portal vein were analyzed: diameter, area, mean blood flow velocity and blood flow, whereupon the congestion index was calculated., Results: The diameter, area and blood flow of the portal vein were greater in group B (mean of 1.52 cm; 1.77 cm(2) and 2533.12 ml / min) than in group A (mean of 1.33 cm; 1.44 cm(2) and 1609.03 ml / min) with p = 0.03; 0.03 and 0.04 respectively. Difference of the congestion index was not statistically significant between the two groups (p = 0.07)., Conclusions: The portal vein congestion index at the preoperative of EDS estimated by Doppler ultrasound was not predictive of portal vein thrombosis in the postoperative of patients with portal hypertension due to schistosomiasis.

Background: Esophagogastric devascularization with splenectomy has been used for the treatment of upper digestive bleeding due to esophagic varices in hepatoportal mansoni's schistosomic portal hypertension. Nevertheless, early portal thrombosis has hampered this surgical technique (13.3% and 53.2%), compromising the good results on the hemorrhagic side. Supposing that portal circulatory changes, due to the surgical treatment, may play an important role in this kind of complication, our objective was to identify the hemodynamic facilitating factors. Portal hemodynamic aspects, identified by ultra-sonographic Doppler study, from two groups of patients: non-operated upon and splenectomized with esophagogastric devascularization in late post-operatory phase (in excess of 6 moths), with portal hypertension due to mansoni hepatoesplenic portal hypertension and in similar clinical conditions, were compared., Method: Fifty eight ambulatorial patients were studied, all had portal hypertension caused by mansoni's hepatosplenic schistosomiasis and previous bouts of digestive bleeding. They were divided in two groups: A--29 followed clinically/endoscopically, and group B--29 previously submitted to esophagogastric devascularization with splenectomy. In all was measured the diameter and mean flow velocity in the portal vein and its right and left branches by ultra-sonographic Doppler study. The results were submitted to statistical analysis for inter- and intra-group comparison., Results: Group A (non-operated): the portal vein diameter was greater than the right and left branches (10.6 +/- 2.9, 8.0 +/- 1.8, 9.1 +/- 2.6 cm), the mean flow velocities in the portal vein and its branches were similar (15.62 +/- 6.17, 14.92 +/- 5.33, 16.12 +/- 4.18 cm/seg). Group B (operated): the diameter and mean flow velocity in all vessels were reduced (8.8 +/- 1.7, 5.2 +/- 1.2, 7.5 +/- 2.2 cm/12.53 +/- 2.60, 8.86 +/- 1.75, 9.69 +/- 3.75 cm/seg)., Conclusions: After esophagogastric devascularization with splenectomy, there was a reduction of the diameter and mean flow velocity in the portal vein, its right and left branches.

The consequence of an acute mesenteric venous thrombosis following porta-azygos disconnection for the treatment of bleeding esophageal varices due to mansonian schistosomiasis has not been well defined in the literature. The clinical manifestations reported were fever, spasmodic abdominal pain associated with food intake. We treated three patients with thrombosis of the portal-mesenteric trunk following porta-azygos disconnection and adopted a conservative clinical approach in two patients while one had to have a surgical small bowel ressection.

The authors studied 30 patients with bleeding from esophageal varices due to portal hypertension. They underwent the disconnection of portal and azygos veins and splenectomy. The immediate postoperative complications were: portal thrombosis in four patients (13.3%); subphrenic abscess in two (6.6%); pulmonary embolism in one (3.3%) and esophageal perforation in one (3.3%). The manifestations of portal thrombosis were ascites, and fever (without leukocytosis). One patient with portal thrombosis who had intractable ascite was submitted to peritoneovenous shunting.