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Aproximadamente metade dos pacientes portadores de câncer colorretal apresenta metástases hepáticas durante a evolução de sua doença que afetam diretamente o prognóstico e são diretamente responsáveis por 2/3 dos óbitos relacionados à doença. Nas últimas duas décadas o tratamento das metástases hepáticas de câncer colorretal (MHCCR) proporcionou ganho expressivo na sobrevida quando todas as opções terapêuticas são colocadas à disposição do paciente. Nesse contexto, o tratamento cirúrgico persiste como a única possibilidade de cura com índices de sobrevida em cinco anos de 25 a 58%. No entanto, apenas 1/4 dos pacientes tem doença ressecável ao diagnóstico. Por essa razão, um dos pontos fundamentais no manejo atual dos pacientes com MHCCR é o desenvolvimento de estratégias que possibilitem a ressecção completa das lesões hepáticas. O advento e aperfeiçoamento dos métodos ablativos expandiram as possibilidades da terapêutica cirúrgica, além disto, o surgimento de novos esquemas quimioterápicos e a introdução das terapias-alvo proporcionou altas taxas de resposta e alteraram definitivamente o manejo destes pacientes. O tratamento multimodal e a utilização da experiência de diversas especialidades médicas permitiram que o tratamento das MHCCR se aproximasse cada vez mais do tratamento ideal, ou seja, individualizado. Baseado em uma extensa revisão da literatura e na experiência de alguns dos centros especializados mais importantes do Brasil, o Clube do Fígado de São Paulo iniciou um trabalho de discussão multi-institucional que resultou nas recomendações que se seguem. Essas recomendações, no entanto, não visam ser absolutas, mas sim ferramentas úteis no processo de decisão terapêutica desse grupo complexo de pacientes. Approximately half of patients with colorectal cancer present with liver metastases during the course of their disease, which directly affect prognosis and is responsible for two thirds of deaths related to the disease. In the last two decades the treatment of liver metastases from colorectal cancer (CRCLM) provided significant gain in survival when all treatment options are available to the patient. In this context, surgical treatment remains as the only chance of cure, with five-year survival rates of 25-58%. However, only 1/4 of the patients have resectable disease at diagnosis. For this reason, one of the key points in the current management of patients with CRCLM is the development of strategies that facilitate complete resection of liver lesions. The advent and refinement of ablative methods have expanded the possibilities of surgical therapy. The emergence of new chemotherapy regimens and the introduction of targeted therapies has provided high response rates and has permanently altered the management of these patients. The multimodal therapy and the involvement of different medical specialties has increasingly enabled CRCLM treatment to approached the ideal treatment, i.e., an individualized one. Based on an extensive review of literature and on experience from some of the most important specialized centers of Brazil, the São Paulo Liver Club began a process of multi-institutional discussions that resulted in the recommendations that follow. These recommendations, however, are not intended to be absolute, but useful tools in the therapeutic decision process for this complex group of patients.

Approximately 50% of the patients with a colorectal tumor develop liver metastasis, for which hepatectomy is the standard care. Several prognostic factors have been discussed, among which is the surgical margin. This is a recurring issue, since no consensus exists as to the minimum required distance between the metastatic nodule and the liver transection line.To evaluate the surgical margins in liver resections for colorectal metastases and their correlation with local recurrence and survival.A retrospective study based on the review of the medical records of 91 patients who underwent resection of liver metastases of colorectal cancer. A histopathological review was performed of all the cases; the smallest surgical margin was verified, and the late outcome of recurrence and survival was evaluated.No statistical difference was found in recurrence rates and overall survival between the patients with negative or positive margins (R0 versus R1); likewise, there was no statistical difference between subcentimeter margins and those greater than 1 cm. The disease-free survival of the patients with microscopically positive margins was significantly worse than that of the patients with negative margins. The uni- and multivariate analyses did not establish the surgical margin (R1, narrow or less than 1 cm) as a risk factor for recurrence.The resections of liver metastases with negative margins, independently of the margin width, had no impact on tumor recurrence (intra- or extrahepatic) or patient survival.

As many as 25 % of colorectal cancer (CRC) patients have liver metastases at presentation. However, the optimal strategy for resectable synchronous colorectal liver metastasis remains controversial. Despite the increasing use of laparoscopy in colorectal and liver resections, combined laparoscopic resection of the primary CRC and synchronous liver metastasis is rarely performed. The potential benefits of this approach are the possibility to perform a radical operation with small incisions, earlier recovery, and reduction in costs. The aim of this study was to review the literature on feasibility and short-term results of simultaneous laparoscopic resection. We conducted a systematic search of all articles published until February 2013. Search terms included: hepatectomy [Mesh], “liver resection,” laparoscopy [Mesh], hand-assisted laparoscopy [Mesh], surgical procedures, minimally invasive [Mesh], colectomy [Mesh], colorectal neoplasms [Mesh], and “colorectal resections.” No randomized trials are available. All data have been reported as case reports, case series, or case–control studies. Thirty-nine minimally invasive simultaneous resections were identified in 14 different articles. There were 9 (23 %) major hepatic resections. The most performed liver resection was left lateral sectionectomy in 26 (67 %) patients. Colorectal resections included low rectal resections with total mesorectal excision, right and left hemicolectomies, and anterior resections. Despite the lack of high-quality evidence, the laparoscopic combined procedure appeared to be feasible and safe, even with major hepatectomies. Good patient selection and refined surgical technique are the keys to successful simultaneous resection. Simultaneous left lateral sectionectomy associated with colorectal resection should be routinely proposed.

Aim The aim of this study was to determine the incidence and prognostic factors of postoperative liver failure in patients submitted to liver resection for colorectal metastases. Method Patients with CLM who underwent hepatectomy from 1998 to 2009 were included in retrospective analysis. Postoperative liver failure was defined using either the 50–50 criteria or the peak of serum bilirubin level above 7 mg/dL independently. Results Two hundred and nine (209) procedures were performed in 170 patients. 120 surgeries were preceded by chemotherapy within six months. The overall morbidity rate was 53.1% and 90-day mortality was 2.3%. Postoperative liver failure occurred in 10% of all procedures, accounting for a mortality rate of 9.5% among this group of patients. In multivariate analysis, extent of liver resection, need of blood transfusion and more than eight preoperative chemotherapy cycles were independent prognostic factors of postoperative liver insufficiency. This complication was not related with the chemotherapy regimen used. Conclusion We conclude that postoperative liver failure has a relatively low incidence (10%) after CLM resection, but a remarkable impact on postoperative mortality rate. The amount of liver resected, the need of blood transfusion and extended preoperative chemotherapy are independent predictors of its occurrence and this knowledge can be used to prevent postoperative liver failure in a multidisciplinary approach.

Inferior vena cava leiomyosarcoma is a rare tumor with a recent increase in incidence. The authors describe 2 cases and discuss clinical features, diagnosis, and treatment. With recent advances in imaging methods and surgical procedures an early diagnosis and radical resection might be possible, leading to a better prognosis or even the cure of the disease.

Benign liver tumors, due to its relative easeness its imaging identification, have their incidence increasing in population in recent years, becoming frequent in the clinical picture and often a challenge for clinicians and surgeons. Doctors began to face dilemmas related to diagnosis in asymptomatic patients with liver nodules.Update the knowledge of hepatic adenomas due to the crescent diagnosis seen in the recent years.Was performed a literature review consulting Medline/PubMed, SciELO, Embase, Lilacs database with the following descriptors: hepatic adenoma, surgery, medical treatment, diagnosis, pathophysiology and molecular biology.The diagnosis of incidental asymptomatic lesions is a major dilemma in clinical practice because it brings intense distress for patients and their families, and often become a challenge for the physician or surgeon. Injury is of particular interest because it can provide both benign evolution or potentially lethal complications. Recently, its resection is no more mandatory; currently, more individualized treatment are required, aiming less morbidity. In light of new advances in molecular biology, the physician who diagnoses the lesion must identify the potential unfavorable evolution, and recognize cases who need more aggressive medical management.

RACIONAL: Tromboembolismo venoso é complicação frequente após tratamento cirúrgico em geral e, de um modo especial, na condução terapêutica do câncer. A cirurgia do aparelho digestivo tem sido referida como potencialmente indutora desta complicação. Os pacientes com câncer digestivo, têm risco substancialmente aumentado de iniciarem ou de terem recorrência de processo tromboembólico. OBJETIVO: Oferecer aos cirurgiões que atuam na cirurgia digestiva e geral orientação segura sobre como efetuar a tromboprofilaxia dos pacientes que necessitam de operações no tratamento de doenças malignas digestivas. MÉTODOS: A Diretriz foi baseada a partir da elaboração de 15 questões clínicas relevantes e relacionadas ao risco, tratamento e prognóstico do paciente submetido ao tratamento cirúrgico do câncer do aparelho digestivo. Elas focaram tanto os eventos tromboembólicos associados às operações quanto os aspectos relacionados à sua profilaxia. As questões foram estruturadas por meio do P.I.C.O. (Paciente, Intervenção ou Indicador, Comparação e Outcome), permitindo gerar estratégias de busca da evidência nas principais bases primárias de informação científica (Medline/Pubmed, Embase, Lilacs/Scielo, Cochrane Library, Premedline via OVID). Também foi realizada busca manual da evidência e de teses (BDTD e IBICT). A evidência recuperada foi selecionada a partir da avaliação crítica utilizando instrumentos (escores) discriminatórios de acordo com a categoria da questão: risco, terapêutica e prognóstico (JADAD para Ensaios Clínicos Randomizados e New Castle Otawa Scale para estudos não randômicos). Após definir os estudos potenciais para sustento das recomendações, eles foram selecionados pela força da evidência e grau de recomendação segundo a classificação de Oxford, incluindo a evidência disponível de maior força. RESULTADOS: Foram avaliados 53.555 trabalhos pelo título e/ou resumo. Deste total foram selecionados (1ª seleção) 478 trabalhos avaliados pelo texto completo. A partir deles, para sustentar as recomendações, foram incluídos neste consenso 132 trabalhos. As 15 perguntas formuladas puderam ser respondidas com artigos com grau de evidência correspondentes à 31 A, 130 B, 1 C e 0 D. CONCLUSÃO: Esta revisão possibilitou elaborar orientação segura para a profilaxia do tromboembolismo nas operações sobre o câncer do aparelho digestivo, abordando os tópicos mais frequentes do quotidiano do trabalho dos cirurgiões gerais e do aparelho digestivo. BACKGROUND: The venous thromboembolism is a common complication after surgical treatment in general and, in particular, on the therapeutic management on cancer. Surgery of the digestive tract has been reported to induce this complication. Patients with digestive cancer have substantial increased risk of initial or recurrent thromboembolism. AIM: To provide to surgeons working in digestive surgery and general surgery guidance on how to make safe thromboprophylaxis for patients requiring operations in the treatment of their gastrointestinal malignancies. METHODS: The guideline was based on 15 relevant clinical issues and related to the risk factors, treatment and prognosis of the patient undergoing surgical treatment of cancer on digestive tract. They focused thromboembolic events associated with operations and thromboprophylaxis. The questions were structured using the PICO (Patient, Intervention or Indicator, Comparison and Outcome), allowing strategies to generate evidence on the main primary bases of scientific information (Medline / Pubmed, Embase, Lilacs / Scielo, Cochrane Library, PreMedline via OVID). Evidence manual search was also conducted (BDTD and IBICT). The evidence was recovered from the selected critical evaluation using discriminatory instruments (scores) according to the category of the question: risk, prognosis and therapy (JADAD Randomized Clinical Trials and New Castle Ottawa Scale for studies not randomized). After defining potential studies to support the recommendations, they were selected by the strength of evidence and grade of recommendation according to the classification of Oxford, including the available evidence of greater strength. RESULTS: A total of 53,555 papers by title and / or abstract related to issue were found. Of this total were selected (1st selection) 478 studies that were evaluated as full-text. From them to support the recommendations were included in the consensus 132 papers. The 15 questions could be answered with evidence grade of articles with 31 A, 130 B, 1 C and 0 D. CONCLUSION: It was possible to prepare safe recommendations as guidance for thromboembolism prophylaxis in operations on the digestive tract malignancies, addressing the most frequent topics of everyday work of digestive and general surgeons.

The venous thromboembolism is a common complication after surgical treatment in general and, in particular, on the therapeutic management on cancer. Surgery of the digestive tract has been reported to induce this complication. Patients with digestive cancer have substantial increased risk of initial or recurrent thromboembolism.To provide to surgeons working in digestive surgery and general surgery guidance on how to make safe thromboprophylaxis for patients requiring operations in the treatment of their gastrointestinal malignancies.The guideline was based on 15 relevant clinical issues and related to the risk factors, treatment and prognosis of the patient undergoing surgical treatment of cancer on digestive tract. They focused thromboembolic events associated with operations and thromboprophylaxis. The questions were structured using the PICO (Patient, Intervention or Indicator, Comparison and Outcome), allowing strategies to generate evidence on the main primary bases of scientific information (Medline / Pubmed, Embase, Lilacs / Scielo, Cochrane Library, PreMedline via OVID). Evidence manual search was also conducted (BDTD and IBICT). The evidence was recovered from the selected critical evaluation using discriminatory instruments (scores) according to the category of the question: risk, prognosis and therapy (JADAD Randomized Clinical Trials and New Castle Ottawa Scale for studies not randomized). After defining potential studies to support the recommendations, they were selected by the strength of evidence and grade of recommendation according to the classification of Oxford, including the available evidence of greater strength.A total of 53,555 papers by title and / or abstract related to issue were found. Of this total were selected (1st selection) 478 studies that were evaluated as full-text. From them to support the recommendations were included in the consensus 132 papers. The 15 questions could be answered with evidence grade of articles with 31 A, 130 B, 1 C and 0 D.It was possible to prepare safe recommendations as guidance for thromboembolism prophylaxis in operations on the digestive tract malignancies, addressing the most frequent topics of everyday work of digestive and general surgeons.

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.To present the Brazilian experience with ALPPS approach.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).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).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/AIMS Liver resection is the only curative therapy for metastatic colorectal cancer. However, recurrence occurs in the majority of the cases. Hilar lymph node metastases occur with a high frequency but the methodology for its detection and the impact on the outcome of patients undergoing hepatectomy is still unknown. METHODOLOGY Twenty-six patients submitted to partial liver resection and systematic lymphadenectomy were studied prospectively. Lymph nodes considered negative by hematoxylin and eosin (H&E) staining were analyzed by serial sectioning and immunohistochemistry (IHC) with anti-human pancytokeratin antibody AE1/AE3. Recurrence-free and overall survivals were compared among LN groups. RESULTS The mean number of dissected lymph nodes were 6.3 per patient. H&E showed microscopic involvement of LN in 2 patients and 3 patients had metastases identified only by IHC. The median follow-up was 39.3 months. Sixteen patients (61.5%) recurred after liver resection and although no statistical difference in survival was demonstrated there was a trend towards shorter recurrence-free survival among microscopic positive LN. CONCLUSIONS Microscopic LN metastases may have impact in the outcome of patients submitted to curative hepatectomy. A better definition of micrometastases to LN is warranted, as though the potential benefit of hilar lymphadenectomy and chemotherapy selection by hilar lymph node status.

Approximately half of patients with colorectal cancer present with liver metastases during the course of their disease, which directly affect prognosis and is responsible for two thirds of deaths related to the disease. In the last two decades the treatment of liver metastases from colorectal cancer (CRCLM) provided significant gain in survival when all treatment options are available to the patient. In this context, surgical treatment remains as the only chance of cure, with five-year survival rates of 25-58%. However, only 1/4 of the patients have resectable disease at diagnosis. For this reason, one of the key points in the current management of patients with CRCLM is the development of strategies that facilitate complete resection of liver lesions. The advent and refinement of ablative methods have expanded the possibilities of surgical therapy. The emergence of new chemotherapy regimens and the introduction of targeted therapies has provided high response rates and has permanently altered the management of these patients. The multimodal therapy and the involvement of different medical specialties has increasingly enabled CRCLM treatment to approached the ideal treatment, i.e., an individualized one. Based on an extensive review of literature and on experience from some of the most important specialized centers of Brazil, the São Paulo Liver Club began a process of multi-institutional discussions that resulted in the recommendations that follow. These recommendations, however, are not intended to be absolute, but useful tools in the therapeutic decision process for this complex group of patients.

Background: The use of stapling devices for performing gastrointestinal anastomosis has gained wide acceptance in the last decade. Linear cutting devices have been used routinely during gastrointestinal operations in our hospital since 1992. However, we still have shortage of stapling devices due to cost reduction politics. Methods: We propose a modification of the standard technique in order to reduce the number of devices used. Our technique employs a single stapled including the section of the jejunum and the side-to-side jejunoanastomosis. Results: We have used this technique for 1 year without complications related to the stapled anastomosis. Conclusions: This technique may reduce the time of reconstruction of Roux-en-Y anastomosis without interfering in its final result. This modified technique may be useful in hospitals with reduced economic resources. © 2002 Excerpta Medica Inc. All rights reserved.

INTRODUÇÃO: Atualmente, as ressecções hepáticas podem ser realizadas com taxas aceitáveis de morbimortalidade. Em centros especializados, mortalidade ao redor de 1% pode ser alcançada, mesmo em fígados previamente submetidos à quimioterapia por longo prazo. Com o objetivo de reduzir essas taxas, novas estratégias têm sido empregadas, como a embolização portal, ablação por radiofrequência, re-hepatectomias ressecções vasculares com reconstrução e hepatectomias em dois tempos. MÉTODO: Foi realizada revisão de literatura nos sites de pesquisa PubMed, Bireme e Scielo, com os descritores "hepatectomias parciais, metástases, neoplasia colorretal, radiofrequência e embolização". Selecionaram-se, principalmente, os estudos de aplicação de técnicas e procedimentos cirúrgicos no tratamento das metástases hepáticas. CONCLUSÃO: Sobrevida ao redor de 50% em cinco anos podem ser conseguidas em casos selecionados quando equipe multidisciplinar está envolvida no tratamento. Com a melhora na técnica operatória, poupando-se parênquima hepático, e com o advento de novos agentes quimioterápicos, lesões metastáticas hepáticas irressecáveis podem se tornar ressecáveis e a sobrevida a longo prazo pode ser alcançada. INTRODUCTION: Nowadays, liver resections can be performed with acceptable morbi-mortality rates. In specialized centers, mortality as low as 1% can be achieved, even with the advent of new hepatotoxic chemotherapy regimens. In order to reduce morbidity and mortality, newer strategies can be undertaken, such as portal vein embolization, radiofrequency ablation techniques, re-hepatectomies, major vascular resections and two stages hepatectomies. METHOD: Literature review was conducted on sites search PubMed, BIREME, SciELO, with the headings "partial hepatectomy, hepatic metastases, colorectal cancer, radiofrequency and embolization". Were selected mainly studies with the application of techniques and surgical procedures in the treatment of liver metastasis. CONCLUSION: Survival rates as good as 50% in 5y can be achieved in selected cases when a multidisciplinary team is involved. Better surgical techniques, with parenchimal sparing strategies and the advent of neoadjuvant chemotherapy can turn unresectable liver lesions to resectable and increase survival rates

Made available in DSpace on 2022-04-28T18:56:52Z (GMT). No. of bitstreams: 0 Previous issue date: 2011-03-01 Laparoscopic approaches have been increasingly used in patients with colorectal or liver cancer. Simultaneous colectomy and hepatectomy are considered safe techniques and present similar oncological results regardless of the location of the primary tumor when there are fewer than four liver metastases, since there is no increase in morbidity or decrease in survival. The development of laparoscopic techniques and materials has made the combined resection of the colon and liver a very attractive option. The aim of this study is to demonstrate the synchronous resection of the sigmoid tumor and single liver metastasis treated by purely laparoscopic colectomy and liver left lateral sectorectomy. Surgery of the Liver and Portal Hypertension Department of Gastroenterology São Paulo State University - USP, São Paulo - SP Surgical Clinics Francisco Morato de Oliveira State Public Servers Hospital, São Paulo - SP Surgery of the Liver and Portal Hypertension Department of Gastroenterology São Paulo State University - USP, São Paulo - SP

Hepatectomy is the only possible option for cure in any treatment strategy of colorectal liver metastases, and several studies have shown good results, with five-year survival rates ranging from 27 to 56%. Several clinical and pathological predictive factors for survival after liver resection have been studied and the metastatic involvement of the hepatic hilum lymph nodes indicates a poor long-term prognosis. Despite variable results, some authors have reported a not-insignificant improvement in survival rate in liver-metastasis patients with hilar-lymph-node involvement who undergo combined liver resection and lymphadenectomy. Due to the low rates of morbidity and mortality for liverresection surgery, several specialized centers perform liver resections combined with lymphadenectomy in selected cases. It should be noted that the therapeutic value of systemic lymphadenectomy is not yet entirely understood, and only controlled studies comparing groups with and without lymphadenectomy can fully resolve the issue. In any case, hilar lymph node dissection has been shown to be a useful tool for improving the accuracy of extrahepatic disease staging, regardless of its impact on survival. The authors review the incidence and the clinical impact of hilar lymph node metastases, and analyses the possible beneficial role of systematic lymphadenectomy in patients who have undergone liver resection for colorectal-cancer metastases.

RACIONAL: Sabe-se que tanto a leucopenia quanto a plaquetopenia têm relação direta com a esplenomegalia, mas não existem estudos correlacionando de forma direta ou precisa o tamanho do baço com o número de plaquetas. Ainda há controvérsia se a plaquetopenia observada em pacientes com doenças hepáticas crônicas está mais relacionada à esplenomegalia ou à própria hipertensão portal. OBJETIVO: Correlacionar o nível sérico das plaquetas nos períodos pré e pós-operatório imediato com peso e volume do baço em pacientes portadores da forma hepatoesplênica da esquistossomose com indicação para tratamento cirúrgico da hipertensão portal. MÉTODO: Foram analisados os prontuários de pacientes portadores da forma hepatoesplênica da esquistossomose mansônica submetidos a tratamento cirúrgico da hipertensão portal. Foram incluídos portadores com a doença confirmada pelo diagnóstico anatomopatológico da biópsia hepática realizada no período intra-operatório. Foram excluídos todos os doentes que apresentavam antecedentes de etilismo crônico, hepatite viral, evidências clínico-laboratoriais de insuficiência hepática ou alterações histopatológicas compatíveis com cirrose hepática. Foram avaliados: o tamanho e volume do baço; o nível sérico de plaquetas; o número de plaquetas. RESULTADOS: Foram identificados 141 pacientes que preenchiam os critérios de inclusão do total de 160 prontuários analisados. A idade média foi de 39,03 ± 12,74 anos (15 a 74 anos), sendo 84 homens (59,5%) e 57 mulheres (40,5%). O peso médio do baço foi de 966,27 ± 464,61 g (120 a 2700 g). O volume elíptico médio foi de 966,68 ± 499,12 cm3 (236,13 a 2782,36 cm³. Houve correlação estatisticamente significativa entre o peso e o volume elíptico do baço (p

Esophagogastric devascularization and splenectomy (EGDS) is the most performed operation for prophylaxis of esophageal varices bleeding recurrence in hepatosplenic schistosomiasis. Lower rebleeding rates are obtained through the association of postoperative endoscopic treatment; however, there is a dearth of studies showing long-term results. Clinical, laboratory, and endoscopic data of 97 patients submitted to EGDS with at least 5 years of follow-up, were analyzed. The mean follow-up was 116.4 months. Bleeding recurrence occurred in 24.7% of patients; however, this percentage was 14.6% when only variceal hemorrhage was considered. Bleeding recurrence occurred in four patients even after endoscopic evaluation demonstrated esophageal varices eradication. In the late follow-up we observed normalization of anemia, leukopenia, thrombocytopenia, hyperbilirubinemia, and a prothrombin activity time increase. No clinical or laboratory hepatic insufficiency was observed. The EGDS procedure with postoperative endoscopic treatment led to good clinical results and avoided hemorrhagic recurrence in 75.3% of schistosomal patients. There was improvement of laboratory measures of hepatic function, as well as correction of hypersplenism. Variceal hemorrhagic recurrence may occur even when esophageal varices eradication is reached.

AIM: To evaluate the long-term results of liver resection for the treatment of primary intrahepatic lithiasis. Prognostic factors, especially the impact of bilioenteric anastomosis on recurrence of symptoms were assessed. METHODS: Forty one patients with intrahepatic stones and parenchyma fibrosis/atrophy and/or biliary stenosis were submitted to liver resection. Resection was associated with a Roux-en-Y hepaticojejunostomy in all patients with bilateral stones and in those with unilateral disease and dilation of the extrahepatic biliary duct (> 2 cm). Late results and risk factors for recurrence of symptoms or stones were evaluated. RESULTS: There was no operative mortality. After a mean follow-up of 50.3 mo, good late results were observed in 82.9% of patients; all patients submitted to liver resection alone and 58.8% of those submitted to liver resection and hepaticojejunostomy were free of symptoms (P = 0.0006). Patients with unilateral and bilateral disease showed good late results in 94.1% and 28.6%, respectively (P < 0.001). CONCLUSION: Recurrence of symptoms in patients with hepaticojejunostomy showed that this may not be the ideal solution. Further studies are needed to establish the best treatment for patients with bilateral stones or unilateral disease and a dilated extrahepatic duct.

Laparoscopic approaches have been increasingly used in patients with colorectal or liver cancer. Simultaneous colectomy and hepatectomy are considered safe techniques and present similar oncological results regardless of the location of the primary tumor when there are fewer than four liver metastases, since there is no increase in morbidity or decrease in survival. The development of laparoscopic techniques and materials has made the combined resection of the colon and liver a very attractive option. The aim of this study is to demonstrate the synchronous resection of the sigmoid tumor and single liver metastasis treated by purely laparoscopic colectomy and liver left lateral sectorectomy.

Recent advances in laparoscopic devices and experience with advanced techniques have increased the indications for laparoscopic liver.The aim of this work was to present a video with technical aspects of a pure laparoscopic left hemihepatectomy (segments 2, 3, and 4) by using the intrahepatic Glissonian approach and control of venous outflow without hilar dissection or the Pringle maneuver.A 63-year-old woman with a 5-cm solitary liver metastasis was referred for treatment. Four trocars were used. The left lobe was pulled upward and the lesser omentum was divided, exposing Arantius' ligament. This ligament is a useful landmark for the identification of the main left Glissonian pedicle. A small anterior incision was made in front of the hilum, and a large clamp was introduced behind the Arantius' ligament toward the anterior incision, allowing control of the left main sheath. Ischemic discoloration of the left liver was achieved and marked with cautery. The vascular clamp was replaced by a stapler. If ischemic delineation was coincident with a previously marked area, the stapler was fired. The left hepatic vein was dissected and encircled. Parenchymal transection and vascular control of the hepatic veins were accomplished with a Harmonic scalpel and an endoscopic stapling device, as appropriate. All these steps were performed without the Pringle maneuver and without hand assistance.Operative time was 220 minutes with minimum blood loss. Hospital stay was 4 days. Pathology showed free surgical margins. The patient is alive with no signs of recurrence 18 months after the operation.Totally laparoscopic left hemihepatectomy is safe and feasible in selected patients and should be considered for patients with benign or malignant liver neoplasms. The described technique, with the use of the intrahepatic Glissonian approach and control of venous outflow, may facilitate laparoscopic left hemihepatectomy by reducing the technical difficulties in pedicle control and may decrease bleeding during liver transection.

BACKGROUND: Schistosomiasis is an important public health issue in more than 70 countries around the world. About 600 million people are at risk to acquire the parasite and there are 200 million infected worldwide. AIM: To evaluate the characteristics of schistosomal portal hypertension individuals who underwent previous esophageal varices bleeding treated in a tertiary hospital. METHODS: The records of 155 patients were evaluated and clinical, laboratorial, endoscopic, epidemiological features and hemorrhagic event severity were analyzed to individualize this population. RESULTS: Mean age was 37.2 years and no clinical signs of hepatic failure were observed. Serum laboratory tests to evaluate liver function were normal or slightly alter. Anemia was present in 70 %, leucopenia in 75 % and thrombocytopenia in 86 % of the patients. At endoscopic evaluation varices were classified as grade III and IV in 91.3 %; red spots were observed in 40.3 % and congestive gastropathy in 13.6 %. Patients presented a mean of 2.8 previous episodes of variceal hemorrhage and, in 75 % with hemodynamic instability. CONCLUSIONS: Patients with schistosomal portal hypertension and history of upper digestive bleeding from esophageal varices are young individuals, without either clinical or laboratorial evidence of liver dysfunction, that present high morbidity due to the severity of the acute event of bleeding. RACIONAL: Esquistossomose é importante doença na saúde pública envolvendo mais de 70 países. Cerca de 600 milhões de pessoas estão em áreas de risco para adquirir a doença e em torno de 200 milhões estão por ela infectados. OBJETIVO: Avaliar as características da hipertensão porta esquistossomótica em indivíduos que se submeteram previamente a tratamento de varizes esofágicas hemorrágicas em hospital terciário. MÉTODOS: Os prontuários de 155 pacientes foram avaliados analisando-se aspectos clínicos, laboratoriais, endoscópicos, epidemiológicos e intensidade de eventos hemorrágicos. RESULTADOS: A idade média foi de 37.2 anos e não havia sinais clínicos de insuficiência hepática. Análises séricas para avaliação da função hepática foram normais ou levemente alteradas. Anemia estava presente em 70 %, leucopenia em 75 % e trombocitopenia em 86 %. Na endoscopia as varizes foram classificadas em graus III e V em 91.3 %; red spots foram vistos em 40.3 % e gastropatia congestiva em 13.6 %. Os pacientes apresentaram média de 2.8 prévios episódios de hemorragia por varizes e em 75 % havia instabilidade hemodinâmica. Conclusões - Pacientes com hipertensão porta esquistossomótica e histórico de sangramento digestivo alto por varizes esofágicas são jovens, sem evidências laboratoriais de alteração hepática importante e apresentam alta morbidade, devido à severidade do evento hemorrágico.

INTRODUÇÃO: As ressecções hepáticas representam umas das últimas fronteiras vencidas pela cirurgia videolaparoscópica. Apesar da complexidade do procedimento, da demanda de grande incorporação de tecnologia e necessidade de experiência em cirurgia hepática e laparoscópica, a indicação do método tem crescido de forma expressiva nos últimos anos. OBJETIVO: Realizar análise crítica do método, baseada nos trabalhos existentes na literatura, ressaltando o estado atual de suas indicações, exequibilidade, segurança, resultados e aspectos técnicos primordiais. MÉTODO: Foram identificados e analisados os trabalhos pertinentes nas bases de dados LILACS e PUBMED até dezembro de 2009, utilizando-se os descritores "liver resection", "laparoscopic" e "liver surgery". Não foram encontrados trabalhos prospectivos e randomizados sobre o tema, sendo os dados disponíveis provenientes de série de casos, estudos caso-controle e alguns estudos multicêntricos e metanálises. CONCLUSÃO: A hepatectomia por videolaparoscopia é hoje operação segura e factível, mesmo para as ressecções hepáticas maiores, com baixo índice de morbimortalidade. O método pode ser utilizado para lesões malignas sem prejuízo dos princípios oncológicos e com vantagens nos pacientes com cirrose ou disfunção hepática. A melhor indicação recai sobre as lesões benignas, em especial o adenoma hepatocelular. Em mãos experientes e casos selecionados, como as lesões benignas localizadas nos segmentos anterolaterais hepáticos, principalmente no segmento lateral esquerdo, a ressecção videolaparoscópica pode ser considerada hoje como tratamento padrão. INTRODUCTION: Hepatic resection is the last frontier to be surpassed by laparoscopic surgery. Although a highly complex procedure, the need of advanced technology and experience in both laparoscopic and hepatic surgery, the indications and number of cases done worldwide had a major growth in the last few years. AIM: Critically analyze the technique, based on published articles and acquired experience with more than 50 laparoscopic hepatic resections. Indications, feasibility, safety, and basic technical aspects are outlined. METHODS: Original published studies were identified by searching the Lilacs and Medline databases (up to December 2009) using the keywords "liver resection", "laparoscopic" and "liver surgery". It was not found any prospective randomized trial, so all data came from case series, case-control studies, and meta-analysis. CONCLUSION: Laparoscopic liver resection is safe and feasible even for major resections, with low morbidity and mortality rates. Laparoscopic approach is considered to be oncologically similar to its open counterpart and may have some advantage in cirrhotic patients. Benign lesions, especially hepatocellular adenoma, remains the best indication. In experienced centers the laparoscopic approach may be considered the standard of care for benign antero-lateral located lesions, and for left lateral sectorectomy.

Upper gastrointestinal (GI) bleeding is a common complication of portal hypertension in cirrhotic patients, and hepatocellular carcinoma (HCC) is the most common tumor in cirrhotic livers. Bleeding from tumor erosion into the GI tract is very rare. A patient with HCC and gastric tumor invasion was described and the previously reported cases were reviewed.A patient with upper GI bleeding was treated in a tertiary hospital.A cirrhotic patient with a HCC invading the stomach leading to upper GI bleeding was treated by left lateral segmentectomy and sub-total gastrectomy. The bleeding was controlled and a good surgical outcome was achieved.HCC with gastric invasion should be differentially diagnosed from upper GI bleeding in cirrhotic patients. Bleeding can be controlled and symptomatic relief marked in selected cases.

Acinar cell carcinomas are uncommon malignant tumors of the pancreas, accounting for 1-2% of all the cases of exocrine pancreatic tumor. Some authors have estimated acinar cell tumors to be as aggressive as ductal adenocarcinoma of the pancreas whereas other series showed acinar cell tumors to have a favorable clinical outcome. This discrepancy in prognosis may be related to the cellular components of the tumor.With the aim to evaluate the possible relationship between the presence of neuroendocrine differentiation and behavior of these tumors, the authors reviewed all patients presenting acinar cell carcinoma of the pancreas in the last 5 years with emphasis in the immunohistochemical evaluation.Four patients presented neuroendocrine differentiation on immunohistochemical evaluation and had a more benign outcome. Two patients without neuroendocrine component had a disseminated disease at presentation. This data suggests that this tumor is less aggressive than ductal adenocarcinoma and even with nodal involvement, long-term survival after complete resection can be achieved.It is possible that the absence of neuroendocrine component may be related to a less favorable outcome and adjuvant therapy may be necessary. Due to the rarity of this pancreatic tumor, this relationship remains to be confirmed with a multicentric study including a larger number of patients.

Portal vein thrombosis is the most frequent complication after esophagogastric devascularization and splenectomy for hepatosplenic schistosomosis.To evaluate portal vein thrombosis in 155 patients with schistosomal portal hypertension submitted to esophagogastric devascularization and splenectomy.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.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.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.

Solitary fibrous tumor of the liver is extremely rare, with only 38 cases reported in the literature. We present one case of a SFT originating from the caudate lobe of the liver, treated by surgical resection and review the previous reported cases.

Background Progress in liver surgery has enabled hepatectomy with concomitant venous resection for liver malignancies involving the inferior vena cava (IVC). The authors describe an alternative technique for IVC reconstruction without the need of graft. Methods Parenchymal transection is performed from anterior surface of the liver down to the anterior or left lateral surface of the IVC using combination of two techniques reported elsewhere. IVC is clamped above and below the tumor and the liver in continuity with an invaded segment of IVC is removed en bloc. A transverse anastomosis of IVC is performed starting with running suture on the posterior wall followed by the anterior wall. Results This approach has been successfully employed in eight consecutive patients with IVC involvement. The procedures performed were 5 right hepatectomies, 1 right posterior sectionectomy, 1 right trisectionectomy, and 1 left trisectionectomy. Two patients needed total vascular exclusion (TVE) for 11 and 10 min, respectively. Blood transfusion was necessary in three patients. Pathologic surgical margins were free in all cases. No postoperative mortality was observed. Conclusion This technique of IVC reconstruction precludes the use of graft and minimizes the use of TVE decreasing ischemic damage to the remnant liver. J. Surg. Oncol. 2007;96:73–76. © 2007 Wiley-Liss, Inc.

We present a case of a patient with hypersplenism secondary to portal hypertension due to hepato-splenic schistosomiasis, which was accompanied by severe and refractory thrombocytopenia. We performed spleen ablation and measured the total spleen and ablated volumes with contrast-enhanced computed tomography and volumetry. No major complications occurred, thrombocytopenia was resolved, and platelet levels remained stable, which allowed for early treatment of the patient’s underlying disease. Previous work has shown that splenic radiofrequency ablation is an attractive alternative treatment for hypersplenism induced by liver cirrhosis. We aimed to contribute to the currently sparse literature evaluating the role of radiofrequency ablation (RFA) in the management of hypersplenism. We conclude that splenic RFA appears to be a viable and promising option for the treatment of hypersplenism.

Background Parenchymal transection is the most important step of liver resection, and during this phase, blood loss may lead to morbidity and mortality. Liver parenchyma can be transected by different ways such as finger fracture, clamp crushing, or instrument-based techniques. Methods A simple and cost-efficient method has been developed for liver transection using a technique based on silk crushing of the liver substance. Results We have successfully employed this technique in 278 consecutive liver resections from July 2001 to March 2006. The average duration of hepatic transection varied according to the type of liver resection: 22 min (range 15–42), 19 min (range 11–37), and 12 min (range 7–21) for right hepatectomy, left hepatectomy, and bisegmentectomy 2-3, respectively. The mean transection speed was 6.9 ± 2.3 cm2/min. Blood transfusions were necessary in 42 patients (15.1%), and there were three operative deaths (1.1%). Morbidity rate was 20.9% (58 patients). Conclusions This technique allows a safe and quick liver transection without the use of expensive hemostatic devices, and also precludes the use of inflow occlusion maneuvers. We recommend the use of this technique in centers with low economic resources. J. Surg. Oncol. 2007;95:86–89. © 2006 Wiley-Liss, Inc.

In the last few years there has been expanding use of hepatic resection for non-colorectal metastases. The purpose of this study is to evaluate the experience of liver resection for patients with metastatic melanoma.Eighteen patients with metastatic melanoma were explored for possible surgical resection. All patients fitted the following criteria: absence of extra-hepatic disease after evaluation with CT/MRI and FDG-PET scans; disease-free interval longer than 24 months after the resection of the primary melanoma; presumed completely resectable lesions; absence of clinical co-morbidities.Liver resection was performed in 10 patients; 8 out of 18 presented with irresectable tumors and/or peritoneal metastases and were not operated. One patient presented with postoperative biliary fistula and was conservatively managed. No other complications or postoperative mortality were observed. After a mean follow-up of 25.4 months, 5 patients are alive and without evidence of recurrence. Overall median survival was 22 months; overall survival and disease-free survival were 70% and 50% respectively.Resection of liver metastases from melanoma in a selected group of patients may increase survival. Exploratory laparoscopy should be included in the preoperative armamentarium of diagnostic tools.

Despite the advances during the last years, liver resection remains as one of the last frontiers in laparoscopic surgery. Published data include case reports and evaluations of small series of patients and are seen with skepticism by many surgeons. Laparoscopic liver resection is a long and hazardous and long procedure and experience in liver and laparoscopic surgery and an adequate equipment are needed. A critical analysis of the indications, technical aspects and the method was performed.We can conclude that laparoscopic liver resection is safe, feasible and can be considered as an excellent choice for selected cases. There is no doubt that video-laparoscopic liver resection is a reality and should be part of liver surgeon's therapeutic armamentarium.

Twenty-five to 50% of the patients with hepatic metastases are potential candidates for curative surgery. Intraoperative ultrasound has been employed to guide the surgery.To evaluate this method in liver surgeries and compare it to other imaging methods.Thirty-five patients (20 females, with median age of 56 years) with hepatic metastases were prospectively studied between February 2001 and July 2003. Patients had as primary tumors: colorectal cancer (24), neuroendocrine tumors (3), renal cell carcinoma (2), melanoma (2), others (4). Each patient was submitted to at least: computed tomography (30), ultrasonography (14) and magnetic resonance imaging (8). Intraoperative ultrasound was performed in all patients in order to detect liver nodules. The number and location of liver lesions were compared to preoperative results.Intraoperative ultrasound was useful in 23 (65.6%) of the 35 surgeries and changed the planned surgical strategy in 9 (25.7%). There was a statistical significant correlation between the mean number of nodules identified by ultrasonography, computed tomography, magnetic resonance imaging and intraoperative ultrasound. We found no statistical difference between magnetic resonance imaging and intraoperative ultrasound in identifying hepatic nodules. Fifty-five nodules were submitted to histological evaluation, the gold standard method and 52/55 (94.5%) were identified by intraoperative ultrasound. Intraoperative ultrasound identified 91.6% of the smaller than 1.5 cm lesions, ultrasonography identified 15.0% of them, computed tomography 33.3% and magnetic resonance imaging 66.6%.Intraoperative ultrasound is crucial in the evaluation and decision making in hepatic surgery. Intraoperative ultrasound presents the highest sensibility in the detection of hepatic nodules compared to other imaging methods, especially for small lesions.

RACIONAL: Vinte e cinco a 50% dos pacientes com metástases hepáticas são potenciais candidatos à cirurgia curativa. A ultra-sonografia intra-operatória tem sido usada com grande acurácia para orientar a ressecção das lesões hepáticas. OBJETIVO: Avaliar em nosso meio a importância desse método nas cirurgias hepáticas e comparar seus achados com os dos métodos de imagem pré-operatórios. PACIENTES E MÉTODOS: Estudou-se prospectivamente 35 pacientes com metástases hepáticas e indicação cirúrgica, com os seguintes tumores primários: cólon (24), tumor neuroendócrino (3), carcinoma de células renais e melanoma (2) e outros (4). A idade mediana foi de 56 anos, sendo 20 pacientes do sexo feminino. Os pacientes foram submetidos a pelo menos um exame entre tomografia computadorizada (30), ultra-sonografia (14) e ressonância magnética (8). RESULTADOS: A ultra-sonografia intra-operatória foi útil em 23 (65,6%) das 35 cirurgias, e mudou o plano cirúrgico em 9 (25,7%) pacientes. Houve correlação estatisticamente significativa entre o número de nódulos identificados por ultra-sonografia percutânea do abdome, tomografia computadorizada e ressonância magnética, e a ultra-sonografia intra-operatória, sendo que a média de nódulos por paciente encontrados pela ressonância magnética (2,6) e pela ultra-sonografia intraoperatória (3,0) não mostrou diferença estatisticamente significativa. Cinqüenta e cinco nódulos foram submetidos a análise anatomopatológica, considerada padrão-ouro para o cálculo de sensibilidade da ultra-sonografia intra-operatória, sendo que 52 (94,5%) foram identificados pela ultra-sonografia intra-operatória. Dos nódulos menores que 1,5 cm, a ultra-sonografia detectou 15,0%, a tomografia computadorizada 33,3%, a ressonância magnética 66,6% e a ultra-sonografia intra-operatória 91,6%. CONCLUSÕES: A ultra-sonografia intra-operatória é útil na avaliação e conduta intra-operatórias durante as ressecções de metástases hepáticas, especialmente em pacientes com nódulos pequenos. BACKGROUND: Twenty-five to 50% of the patients with hepatic metastases are potential candidates for curative surgery. Intraoperative ultrasound has been employed to guide the surgery. AIM: To evaluate this method in liver surgeries and compare it to other imaging methods. PATIENTS AND METHODS: Thirty-five patients (20 females, with median age of 56 years) with hepatic metastases were prospectively studied between February 2001 and July 2003. Patients had as primary tumors: colorectal cancer (24), neuroendocrine tumors (3), renal cell carcinoma (2), melanoma (2), others (4). Each patient was submitted to at least: computed tomography (30), ultrasonography (14) and magnetic resonance imaging (8). Intraoperative ultrasound was performed in all patients in order to detect liver nodules. The number and location of liver lesions were compared to preoperative results. RESULTS: Intraoperative ultrasound was useful in 23 (65.6%) of the 35 surgeries and changed the planned surgical strategy in 9 (25.7%). There was a statistical significant correlation between the mean number of nodules identified by ultrasonography, computed tomography, magnetic resonance imaging and intraoperative ultrasound. We found no statistical difference between magnetic resonance imaging and intraoperative ultrasound in identifying hepatic nodules. Fifty-five nodules were submitted to histological evaluation, the gold standard method and 52/55 (94.5%) were identified by intraoperative ultrasound. Intraoperative ultrasound identified 91,6% of the smaller than 1.5 cm lesions, ultrasonography identified 15,0% of them, computed tomography 33.3% and magnetic resonance imaging 66,6%. CONCLUSIONS: Intraoperative ultrasound is crucial in the evaluation and decision making in hepatic surgery. Intraoperative ultrasound presents the highest sensibility in the detection of hepatic nodules compared to other imaging methods, especially for small lesions.

Pharyngolaryngoesophagectomy is the gold standard treatment for the majority of larynx, pharynx and cervical esophagus advanced tumours. Reconstruction of these pharyngoesophageal defects is complex, and implicates additional time, morbity and mortality to the procedure. Gastric pull up and pharyngogastrostomy with hand sewing technique is the commonest way of doing it. The authors describe a modified technique to execute it using a stapler device.

Portal vein thrombosis is a frequent postoperative complication after esophagogastric devascularization with splenectomy. The aim of this study was to analyze biochemical, hematological, coagulation blood tests and intraoperative portal vein hemodynamics after surgical treatment of hepatosplenic Mansonic schistosomal portal hypertension.Forty patients with hepatosplenic schistosomiasis with indication for surgical treatment were prospectively studied. All patients underwent routine pre- and postoperative biochemical, hematologic, coagulation blood tests and intraoperative portal hemodynamic evaluation (portal pressure and portal flow) before and after esophagogastric devascularization and splenectomy using a 4-F thermodilution catheter introduced inside the portal vein.Portal vein thrombosis, diagnosed by routine postoperative Doppler ultrasonography was found in 22 patients (55%). It was partial in nineteen and total in three. In patients with postoperative portal thrombosis, we observed a reduction in portal flow of 971 +/- 592 mL/min (42 +/- 16%) at the end of the surgery, while this reduction was of 720 +/- 644mL/ min (33 +/- 30%) in those with postoperative pervious portal vein (p = 0.245). The decrease in portal pressure was the same in both groups: 7.2 +/- 3.0 mmHg (23 +/- 10%) and 7.6 +/- 3.8 mmHg (27 +/- 14%) with and without thrombosis respectively (p=0.759). There was also no significant difference between patients with and without portal vein thrombosis regarding pre- and postoperative hemoglobin level or platelet levels, coagulation tests, portal vein diameter and spleen's weight.Portal vein thrombosis was observed in 55% of the patients but this complication did not show any correlation with the decrease in portal flow or pressure or with biochemical, hematologic, coagulation blood tests, portal vein diameter or spleen's weight.

Cystic neoplasms are an uncommon group among pancreatic tumors. These lesions are seen more frequently in recent surgical practice, probably because of advances in diagnostic and surgical techniques. Total tumor resection provides the best chance of cure and may remove the risk of malignant transformation of the cystadenomas, particularly of the mucinous type. Minimally invasive techniques have been revolutionary and provide clinical evidence of decreased morbidity and comparable efficacy to traditional, open surgery. However, laparoscopic pancreatic resection is not an established treatment for tumors of the pancreas.The authors present their initial experience with laparoscopic distal pancreatectomy for pancreatic cystadenomas.Three female patients (mean age, 55 years) underwent laparoscopic pancreatic resection between September 2001 and December 2003.Laparoscopic pancreatic resection was successfully performed in all patients. Operative time varied between 4 and 6 hours. Intraoperative bleeding was minimal. Due to a thick pancreas, the application of vascular endoscopic stapler was difficult in one patient. Two patients presented postoperative pancreatic leakage with spontaneous resolution.Resection of the pancreas can be safely performed via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.

Among several liver resection techniques, the use of stapler in the portal pedicles is an interesting option.To describe the technique of liver resection using a vascular stapling device.A total of eight patients underwent hepatic resections with stapling techniques. The authors have used intrahepatic approach glissonian pedicles with the application of a vascular stapler device in all cases. Liver parenchyma and hepatic veins were transected as usual.There were no deaths. No complications directly attributable to stapler ligations of portal pedicles were observed.Stapling techniques can be helpful in hepatic resection procedures. The vascular stapler may significantly reduce glissonian pedicle section time.

Background: The current study sought to evaluate the results of liver resection as the treatment for unilateral non-oriental primary intrahepatic lithiasis (PHIL). Methods: Twenty-seven symptomatic patients (mean age 42 years) were submitted to liver resection; the indications were parenchymal fibrosis/atrophy in 22 and biliary stenosis in 5. Resection was associated with a Roux-en-Y hepaticojejunostomy in patients with a significant degree of dilation of the extrahepatic biliary duct. Results: There was no operative mortality and the morbidity rate was 7.4% (2 patients with biliary fistula). After a median follow-up of 41.2 months, the overall rate of good results was 92.6%. All patients submitted to liver resection alone presented good late results, while 80% of those with associated hepaticojejunostomy did not have complications (P .12). Late complications were observed in 2 patients (7.4%): 1 with a liver abscess and 1 with cholangitis and recurrent stones. There was no mortality during long-term follow-up. Conclusions: Liver resection showed low incidence of complications and good long-term results. None of the patients with unilateral disease without associated extrahepatic bile duct dilation presented complications and they were considered cured. We believe that resection indications should be expanded and the procedure should be indicated as routine in patients with unilateral PHIL even in the absence of parenchymal fibrosis/atrophy or biliary stenosis. © 2006 Excerpta Medica Inc. All rights reserved.

OBJETIVO: Discutir as indicações e resultados da meso-hepatectomia (hepatectomia central), um procedimento raro, trabalhoso e desafiador. MÉTODO: Estudo de três pacientes portadores de hepatopatia e diagnóstico de tumor de localização central no parênquima hepático, submetidos à meso-hepatectomia. Para realização do procedimento, empregou-se a abordagem glissoniana aos pedículos dos segmentos a serem ressecados, sem clampeamento do hilo hepático. RESULTADOS: Apenas um paciente necessitou de transfusão de glóbulos durante a operação. O tempo médio da operação foi de quatro horas. Não se observaram complicações pósoperatórias e o tempo médio de internação foi de seis dias. CONCLUSÕES: A meso-hepatectomia é um procedimento que apesar de trabalhoso pode ser padronizado e realizado com segurança em pacientes com tumores centrais e hepatopatia associada. A preservação do parênquima, tem papel importante na boa evolução dos pacientes e, o acesso glissoniano, é um procedimento útil, tanto do ponto de vista técnico como para evitar a isquemia do parênquima remanescente. BACKGROUND: To evaluate the indications and results of mesohepatectomy, a rare and challenging procedure. METHODS: Study of three patients with central liver tumours and an associated parenchimal disfunction were submitted to mesohepatectomy. During resection, a glissonian approach to segmental liver pedicles was employed, avoiding hepatic hilum clamping. RESULTS: Only one patient received blood transfusion during the operation. Median operative time was four hours. There were no postoperative complications and the mean hospital discharge was at the sixth day. CONCLUSIONS: Mesohepatectomy is a technically demanding procedure that can be standardized and safely performed in patients with central liver tumours and associated liver disease. Parenchimal preservation represents an important role for patients' good outcome and the glissonian approach is a usefull procedure for central resection and to avoid liver ischemia.

The main cause of portal hypertension in Brazil is the hepato-splenic form of mansonic schistosomiasis and the most employed technique for the surgical approach of this disease is the esophagogastric devascularization with splenectomy, generally associated to postoperative endoscopical esophageal varices sclerotherapy. The hemodynamic alterations after surgical treatment and its possible influence on the outcome are not well established.To evaluate the immediate impact of esophagogastric devascularization with splenectomy upon portal pressure as well as the results of the surgical treatment on digestive hemorrhage recurrence and on esophageal varices.Nineteen patients with mean age of 37.9 years and portal hypertension and previous episodes of digestive hemorrhage caused by esophageal varices rupture due to hepato-splenic schistosomiasis were studied. None of the patients had received any treatment prior to the surgery and underwent to elective esophagogastric devascularization with splenectomy. Portal pressure was assessed at the beginning and at the end of esophagogastric devascularization with splenectomy through portal vein catheterization with a polyethylene catheter introduced through a jejunal branch vein. All patients were submitted to digestive endoscopy before and after the surgery, in order to classify the size of esophageal varices after esophagogastric devascularization with splenectomy according to Palmer's classification.In all patients the portal pressure had diminished with a mean decrease of 31.3% after esophagogastric devascularization with splenectomy. In the postoperative endoscopic follow-up (1 month), the esophageal varices showed a statistically significant reduction in their size, when compared to the pre-surgical measurements.These results have demonstrated that the esophagogastric devascularization with splenectomy promotes immediate decrease in the portal pressure and a consequent reduction in the esophageal varices size. We also observed that the risk of mortality and severe complications related to this technique is not insignificant.

Despite accumulated experience and advancing techniques for laparoscopic hepatectomy, surgeons still face challenging resections that require specific and innovative intraoperative maneuvers [1–3]. The right posterior sectionectomy presents special concerns about its location, the extensive transection area, and the difficult access to the pedicle [4, 5]. The intrahepatic Glissonian approach allows safe en masse control of the portal structures without prolonged dissection [2]. Its association with the half-Pringle maneuver results in less bleeding during parenchymal transection [1, 6]. A 34-year-old woman was referred for treatment of an 8-cm hepatocellular adenoma located at segments 6 and 7. She was placed in a semi-supine position, and six ports were located in a distribution that resembled a Makuuchi incision. The right liver was mobilized, and preparation for an anatomic Glissonian approach was performed. A vascular clamp was placed to ensure that full control of the right posterior pedicle was possible. Then a vascular stapler replaced it, with division of the right posterior Glissonian pedicle. A vascular clamp was inserted from the inferior right-flank 5-mm trocar for performance of a half-Pringle maneuver of the right pedicle to minimize blood loss during parenchymal transection. The liver parenchyma was transected with a harmonic scalpel and a vascular stapler. The right hepatic vein was divided intraparenchymally with a vascular stapler. The specimen was extracted through a Pfannenstiel incision. The total surgical time was 210 min, and the estimated blood loss was 200 ml. No blood transfusion was required. The recovery was uneventful, and hospital discharge occurred on postoperative day 5. Pathology confirmed the diagnosis of an hepatocellular adenoma. Technical issues initially hindered the development of laparoscopic liver resections [7–10]. Surgeons were concerned about hemostasis, bleeding control, safe and effective parenchymal transection, adequate visualization, and the feasibility of working on deeper regions of the liver. During the past decade, many limitations were overcome, but lesions located on the posterosuperior liver are still considered tough to beat [5, 11]. Large series and extensive reviews [12–14] show that resections located on the posterior segments still are infrequent. Limited access to the portal triad, difficult pedicle control, and a large transection area and its anatomic location, attached to the diaphragm and retroperitoneum and hidden from the surgeon’s view, makes such resections defying. The authors’ team has performed 97 laparoscopic hepatectomies, including resection of 6 lesions in the right posterior sector. In their series, half-pedicle clamping was used for 12 patients, and they adopt such a maneuver as an inflow control when operating on peripheric lesions with difficult vascular control (e.g., enucleations or posterosuperiorly located segmentectomies). This technique is safe and useful because it reduces liver ischemic aggression, a very important issue with diseased livers (e.g., steatosis, steatohepatitis, prolonged chemotherapy, cirrhosis) [6, 15]. In their series, the authors applied the Glissonian intrahepatic approach in 7 cases (2 left hepatectomies and 5 right hepatectomies). They understand that laparoscopy applies perfectly to oddly (posterosuperior) located tumors and that right posterior sectionectomy can be accomplished safely. In fact, they share the opinion of other specialized hepatobiliary centers, believing that this may be the preferred approach [16].