Wrapping pancreaticojejunostomy using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a propensity score matching analysis.

BACKGROUND AND OBJECTIVE: It is controversial whether wrapping around the pancreaticojejunostomy (PJ) could reduce the rate of postoperative pancreatic fistula (POPF), especially in laparoscopic pancreaticoduodenectomy (LPD). This study aims to summarize our single-center initial experience in wrapping around PJ using the ligamentum teres hepatis (LTH) and demonstrate the feasibility and safety of this method. METHODS: Patients who underwent LPD applying the procedure of wrapping around the PJ were identified. The cohort was compared to the cohort with standard non-wrapping PJ. A 1:1 propensity score matching (PSM) was performed to compare the early postoperative outcomes of the two cohorts. Risk factors for POPF were determined by using univariate and multivariate logistic regression analysis. RESULTS: Overall, 143 patients were analyzed (LPD without wrapping (n = 91) and LPD with wrapping (n = 52)). After 1:1 PSM, 48 patients in each cohort were selected for further analysis. Bile leakage, DGE, intra-abdominal infection, postoperative hospital stays, harvested lymph nodes, and R0 resection were comparable between the two cohorts. However, the wrapping cohort was associated with significantly less POPF B (1 vs 18, P = 0.003), POPF C (0 vs 8, P = 0.043), and Clavien-Dindo classification level III-V (5 vs 26, P = 0.010). No patients died due to the clinically relevant POPF in the two cohorts. No patients who underwent the LTH wrapping procedure developed complications directly related to the wrapping procedure. After PSM, whether wrapping was an independent risk factor for POPF (OR = 0.202; 95%CI:0.080-0.513; P = 0.001). CONCLUSIONS: Wrapping the LTH around the PJ technique for LPD was safe, efficient, and reproducible with favorable perioperative outcomes in selected patients. However, further validations using high-quality RCTs are still required to confirm the findings of this study.

Favorable Outcome of Repeated Salvage Surgeries for Rare Metastasis to the Ligamentum Teres Hepatis and the Upper Abdominal Wall in a Stage IV Gastric Cancer Patient.

Gastric cancer with peritoneal metastases is typically a devastating diagnosis. Ligamentum teres hepatis (LTH) metastasis is an extremely rare presentation with only four known cases. Herein, we report salvage surgery of successive metastases to the abdominal wall and LTH in a patient originally presenting with advanced gastric cancer with peritoneal metastasis, leading to long-term survival. A 72-year-old man with advanced gastric cancer underwent curative-intent distal gastrectomy with D2 lymph node dissection for gastric outlet obstruction. During this procedure, three small peritoneal metastases were detected in the lesser omentum, the small mesentery, and the mesocolon; however, intraoperative abdominal lavage cytology was negative. We added cytoreductive surgery for peritoneal metastasis. The pathological diagnosis of the gastric cancer was tubular adenocarcinoma with pT4aN1pM1(PER/P1b)CY0 stage IV (Japanese classification of gastric carcinoma/JCGC 15th), or T4N1M1b stage IV (UICC 7th). Post-operative adjuvant chemotherapy with S-1 (TS-1)+cisplatin (CDDP) was administered for 8 months followed by S-1 monotherapy for 4 months. At 28 months after the initial surgery, a follow-up computed tomography (CT) detected a small mass beneath the upper abdominal wall. The ass showed mild avidity on 18F-fluorodeoxyglucose positron-emission (FDG-PET) CT. Salvage resection was performed for diagnosis and treatment, and pathological findings were consistent with primary gastric cancer metastasis. At 49 months after the initial gastrectomy, a new lesion was detected in the LTH with a similar level of avidity on FDG-PET CT as the abdominal wall metastatic lesion. We performed a second salvage surgery for the LTH tumor, which also showed pathology of gastric cancer metastasis. There has been no recurrence up to 1 year after the LTH surgery. With multidisciplinary treatment the patient has survived almost 5 years after the initial gastrectomy. Curative-intent gastrectomy with cytoreductive surgery followed by adjuvant chemotherapy for advanced gastric cancer with localized peritoneal metastasis might have had a survival benefit in our patient. Successive salvage surgeries for oligometastatic lesions in the abdominal wall and the LTH also yielded favorable outcomes.

Ligamentum teres hepatis wrapping of the gastroduodenal artery stump for protection in total laparoscopic pancreaticoduodenectomy: a single-center experience.

OBJECTIVE: Hemorrhage from the stump of the gastroduodenal artery (GDA) is a significant postoperative risk with pancreaticoduodenectomy (PD). Studies have shown that wrapping the GDA stump using the omentum or the falciform ligament can help prevent bleeding. We aimed to determine whether wrapping the GDA stump with the ligamentum teres hepatis (LTH) would reduce postoperative PD hemorrhage. METHODS: We retrospectively reviewed data for 148 patients who underwent laparoscopic pancreatoduodenectomy (LPD) at our hospital from November 2015 to September 2021. We compared perioperative data from 63 LPD patients without wrapping of the GDA (unwrapped group) and 85 whose GDA stumps were wrapped (wrapped group). RESULTS: There were no significant differences in the groups' baseline characteristics. The postoperative GDA stump bleeding incidence was significantly lower in the wrapped group than that in the unwrapped group (7.9% vs. 0, respectively). There was also no significant difference in the incidence of other complications (intra-abdominal infection, postoperative pancreatic fistula (POPF), biliary fistula, and gastrointestinal bleeding). CONCLUSION: Using the LTH to wrap the GDA stump during LPD can reduce bleeding from the GDA stump but not the incidence of other complications.

Predicting portal venous anomalies by left-sided gallbladder or right-sided ligamentum teres hepatis: A large scale, propensity score-matched study.

BACKGROUND: Right-sided ligamentum teres (RSLT) is often associated with portal venous anomalies (PVA) and is regarded as a concerning feature for hepatobiliary intervention. Most studies consider RSLT to be one of the causes of left-sided gallbladder (LGB), leading to the hypothesis that LGB must always be present with RSLT. However, some cases have shown that right-sided gallbladder (RGB) can also be present in livers with RSLT. AIM: To highlight the rare variation that RSLT may not come with LGB and to determine whether ligamentum teres (LT) or gallbladder location is reliable to predict PVA. METHODS: This study retrospectively assessed 8552 contrast-enhanced abdominal computed tomography examinations from 2018 to 2021 [4483 men, 4069 women; mean age, 59.5 ± 16.2 (SD) years]. We defined the surrogate outcome as major PVAs. The cases were divided into 4 subgroups according to gallbladder and LT locations. On one hand, we analyzed PVA prevalence by LT locations using gallbladder location as a controlled variable (n = 36). On the other hand, we controlled LT location and computed PVA prevalence by gallbladder locations (n = 34). Finally, we investigated LT location as an independent factor of PVA by using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). RESULTS: We found 9 cases of RSLT present with RGB. Among the LGB cases, RSLT is associated with significantly higher PVA prevalence than typical LT [80.0% vs 18.2%, P = 0.001; OR = 18, 95% confidence interval (CI): 2.92-110.96]. When RSLT is present, we found no statistically significant difference in PVA prevalence for RGB and LGB cases (88.9 % vs 80.0%, P > 0.99). Both PSM and IPTW yielded balanced cohorts in demographics and gallbladder locations. The RSLT group had a significantly higher PVA prevalence after adjusted by PSM (77.3% vs 4.5%, P < 0.001; OR = 16.27, 95%CI: 2.25-117.53) and IPTW (82.5% vs 4.7%, P < 0.001). CONCLUSION: RSLT doesn't consistently coexist with LGB. RSLT can predict PVA independently while the gallbladder location does not serve as a sufficient predictor.

Primary Solitary Tuberculosis in the Hepatic Round Ligament Detected by 68Ga-FAPI PET/CT.

ABSTRACT: A 45-year-old woman recently complained of abdominal pain, poor appetite, and weight loss. Her serum ferritin, CA199, and CA242 levels were elevated. 68Ga-FAPI PET/CT revealed a subcapsular mass in the liver, which showed a significant FAPI uptake without other abnormal activity. Postoperative pathological examination confirmed tuberculosis in the hepatic round ligament.

Laparoscopic Segmentectomy IV Using Hepatic Round Ligament Approach Combined with Fluorescent Negative Staining Method.

BACKGROUND: Laparoscopic segmentectomy, which maximizes the preservation of the functional hepatic reserve and the possibility for future repeat hepatectomy while ensuring adequate surgical margin, is a feasible alternative to hemihepatectomy for hepatocellular carcinoma (HCC) (Vigano et al. in Ann Surg 270(5):842-851, 2019, Ishizawa et al. in Ann Surg 256(6):959-964, 2012). Herein, we present a video of laparoscopic segmentectomy IV for HCC using hepatic round ligament approach combined with fluorescent negative staining method. PATIENT AND METHODS: A 44-year-old male with history of chronic hepatitis B virus (HBV) infection for 22 months was referred for treatment of a single HCC in segment IV. The procedure was performed according to the following steps: (1) lowering the hilar plate based on Laennec's capsule (Sugioka et al. in J Hepatobiliary Pancreat Sci 24(1):17-23, 2017) after cholecystectomy; (2) cutting the Glisson's pedicles to segment IV along the fissure for the round ligament; (3) the first parenchyma transection was along the falciform ligament, while cutting some deep pedicles to segment IV; (4) clamping the left Glisson's pedicle and using fluorescent negative staining method (Abo et al. in Eur J Surg Oncol 41(2):257-264, 2015, Funamizu et al. in J Hepatobiliary Pancreat Sci, 2021, Xu et al. in Surg Endosc 34(10):4683-4691, 2020); (5) the second parenchyma transection was performed along the boundary of negative fluorescence region to expose the middle hepatic vein (MHV) using a combination of cranial and caudal approaches. RESULTS: The operative time was 190 min, and blood loss during operation was 80 mL. The histopathologic examination showed a solitary HCC, 2.5 cm in diameter, with negative surgical margin and no microvascular invasion. The patient had an uneventful postoperative recovery and was discharged on postoperative day 5. CONCLUSION: The round ligament approach combined with fluorescent negative staining method for laparoscopic anatomic segmentectomy IV is a feasible and effective technique.

Use of the ligamentum teres hepatis for outflow reconstruction during ex vivo liver resection and autotransplantation in patients with hepatic alveolar echinococcosis: A case series of 24 patients.

BACKGROUND: Patients with extensive hepatic alveolar echinococcosis might require ex vivo liver resection and autotransplantation to remove the lesion. Patients with extensive vascular invasion will need reconstruction, but the selection of the proper graft is complicated. This study aimed to investigate the effectiveness and adverse events of using the ligamentum teres hepatis as a vascular replacement graft in ex vivo liver resection and autotransplantation. METHODS: This was a retrospective case series of patients with hepatic alveolar echinococcosis who underwent ex vivo liver resection and autotransplantation between August 2010 and October 2018 and in whom the ligamentum teres hepatis was used to repair the remnant liver. The operative outcomes, recurrence, and survival were examined. RESULTS: Twenty-four patients were included (10 men, 14 women). The anhepatic period was 290 to 672 minutes (median of 450 minutes). The ratio of the remnant liver volume to the standard liver volume was 0.43 to 0.97 (median of 0.71). The blood loss was 1,000 (500-5,000) mL. The postoperative hospital stay was 23 (1-85) days. Of the 24 patients, 3 died after the operation, but those deaths were unrelated to liver vascular complications. CONCLUSION: The ligamentum teres hepatis could be used as a vascular replacement graft in ex vivo liver resection and autotransplantation. It has the advantages of convenient specimen extraction, no donor site injury, and no immunological rejection, which has promising clinical application prospects.

Wrapping the stump of the gastroduodenal artery using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a center's preliminary experience.

BACKGROUND: The present study aims to assess the preliminary outcomes of the effectiveness of wrapping the ligamentum teres hepatis (LTH) around the gastroduodenal artery stump for the prevention of erosion hemorrhage after laparoscopic pancreaticoduodenectomy (LPD). METHODS: We reviewed 247 patients who had undergone LPD between January 2016 and April 2019. The patients were divided into two groups according to whether LTH wrapped the stump of the gastroduodenal artery: group A (119 patients) who underwent the LTH wrapping procedure, and group B (128 patients) who did not undergo the procedure. The perioperative data from the two groups were reviewed to assess the effectiveness of the LTH procedure for the prevention of postpancreatectomy hemorrhage (PPH) and other complications. RESULTS: No differences were observed in the clinical characteristics between the two groups. The data from 247 patients were acceptable for analysis: 119 patients underwent wrapping, and 128 patients did not. The incidence of clinically relevant pancreatic fistula (8.4% vs 3.9%), biliary fistula (2.5% vs 1.6%), intra-abdominal infection (10.1% vs 3.9%) and delayed gastric emptying (13.4% vs 16.4%) showed no significant difference between group A and group B. The 90-day mortality and 90-day reoperation rates (0.8% vs 0.8% and 5.0% vs 3.1%) were also similar between group A and group B. Furthermore, postpancreatectomy hemorrhage of Grade B and C occurred in 0 patients (0.0%) in the wrapping group, which was significantly less frequent than the occurrence in the nonwrapping group (7 patients; 5.5%, P = 0.02). CONCLUSIONS: Wrapping the LTH around the gastroduodenal artery stump after LPD does not reduce the incidence of clinically relevant pancreatic fistula, biliary fistula or delayed gastric emptying. However, this procedure has a trend of reducing the rate of PPH of Grade B and C after LPD and is simple to perform.

Follicular Thyroid Carcinoma Metastases on Round Ligament of Liver.

ABSTRACT: We describe a case of a 69-year-old woman with follicular thyroid cancer of long evolution, with thyroidectomy 20 years before, who had remained clinically stable until now, when she started to present abnormal levels of serum thyroglobulin. An 123I whole-body scan showed a high uptake in the upper right half of her abdomen, and an 18F-FDG PET/CT located this focus at the liver's round ligament. Pathology findings after surgery showed the focus to be a differentiated thyroid cancer metastasis. This is an unusual presentation of differentiated thyroid cancer metastasis.

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy.

BACKGROUND AND PURPOSE: Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy. METHODS: Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed. RESULTS: The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy. CONCLUSIONS: Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

Augmentation of Hiatal Repair with the Ligamentum Teres Hepatis for Intrathoracic Gastric Migration After Bariatric Surgery.

PURPOSE: The augmentation of hiatoplasty (HP) with the ligamentum teres hepatis (LTA) is a new concept for intrathoracic migration of a gastric sleeve or pouch (ITGM). We retrospectively analyzed all cases of hiatal hernia repair in a single center between 2015 and 2019. METHODS: A total of 171 patients underwent 307 hiatal hernia repairs after sleeve gastrectomy (SG) (n = 79), Roux-en-Y gastric bypass (RYGB) (n = 129), and one anastomosis gastric bypass (OAGB) (n = 99). Each hiatal hernia repair was defined as a "case" and assigned to the LTA group or the non-LTA group. The primary outcome was the recurrence of ITGM as detected by endoscopy or CT. RESULTS: The basic characteristics in the LTA group (78 cases) and the non-LTA group (229 cases) were comparable with the exception of the rate of revisional HP (72% vs. 21%), the rate of prior conversion to RYGB (33% vs. 17%), the initial BMI (45.9 ± 8.2 kg/m2 vs. 49.0 ± 8.8 kg/m2), and the follow-up (7 months (1-16) vs. 8 months (1-54)). The ITGM recurrence rate was 15% in the LTA group and 72% in non-LTA group (p < 0.001). Multivariate analysis showed that the length of ITGM and the type of surgical repair were independent risk factors. The addition of LTA to HP lowered the probability of ITGM recurrence by a factor of 0.35 (p = 0.015), but the conversion from SG or OAGB to RYGB did not reduce the risk. CONCLUSIONS: LTA reduces the risk of early ITGM recurrence. The long-term durability, however, needs to be further investigated.

The New Interest of Bariatric Surgeons in the Old Ligamentum Teres Hepatis.

The search for an operation that effectively prevents and treats intrathoracic gastric migration (ITGM) after bariatric surgery has revived a long-forgotten technique: ligamentum teres cardiopexy (LTC) by which a vascularized flap of the teres ligament is wrapped around the distal esophagus. The systematic search of publications in the English language revealed 4 studies (total number of patients 53) in the non-bariatric literature with an unsatisfactory resolution of GERD. There were 5 reports from the bariatric literature with small patient numbers (total 64) and a short follow-up (6-36 months). There were no objective signs of gastric remigration in 93% of investigated patients. Acknowledging the limitations of these preliminary reports, bariatric surgeons are encouraged to further investigate the potentials of LTC in their patients.

A comparison between the mechanical properties of the hepatic round ligament and the portal vein: a clinical implication on surgical reconstruction of the portal and superior mesenteric veins.

Abdominal malignant tumors originated from cancers, such as vater ampulla carcinoma (VAC) and pancreatic cancer (PC), often invades the portal vein (PV) and the superior mesenteric vein (SMV) upon metastasis. Surgical removal of these tumors leads to sacrifice of parts of these vessels that need to be reconstructed with autograft tissues. Current options for the replacement tissue all have their limitations in certain aspects. Therefore, improved interstitial material for the reconstruction with better tissue compatibility is urgently needed. In the present study, we explored the potential of hepatic round ligament (HRL) as a candidate tissue for the task from the biomechanical point of view. We reveal that HRL and PV share similar geometrical parameters in terms of vascular cavity diameter and wall thickness. In addition, they also have similar elastic properties and tissue flexibility and intensity upon increased cavity pressure. Our study strongly supports HRL as potential replacement tissue for PV reconstruction in term of mechanical properties and encourages further biological studies to be performed on these two tissues for further verification.

Primary Hemangiosarcoma of the Falciform Fat in Seven Dogs (2007-2015).

Canine hemangiosarcoma (HSA), a malignant neoplasm of vascular endothelial or bone marrow progenitor cell origin, most often affects the spleen, heart, and liver and typically has an aggressive biologic behavior. Canine HSA arising from the falciform fat/ligament represents a rare anatomic variant, with only two reports in the veterinary literature. In this study, we describe the clinical presentation, treatment, and outcome of seven dogs with primary HSA of the falciform ligament. Histologic grade and mitotic score were not significantly associated with outcome. All dogs had the primary tumor surgically excised except for one diagnosed at necropsy. Median overall survival for all dogs diagnosed prior to necropsy was 339 days, and the 1 yr survival rate was 50%. Four dogs were treated with adjuvant chemotherapy and had a significantly longer median overall survival (394 versus 83 days) than those that did not (P = .018). Dogs with HSA of the falciform ligament may have improved 1 yr survival rates and longer median survival time compared with dogs with HSA in more common visceral locations.

Modified liver hanging maneuver in laparoscopic major hepatectomy: the learning curve and evolution of indications.

BACKGROUND: Laparoscopic major hepatectomy is a technically challenging procedure requiring a steep learning curve. The liver hanging maneuver is a useful technique in liver resection, especially for large or invasive tumors, a relative contraindication of the laparoscopic approach. Therefore, this study aimed to evaluate the learning curve for laparoscopic major hepatectomy using the liver hanging maneuver and extended indications. METHODS: Patients who underwent laparoscopic major hepatectomy using the liver hanging maneuver by a single surgeon from January 2013 and September 2018 were retrospectively reviewed. Our hanging technique involves placing the hanging tape along the inferior vena cava for right-sided hepatectomy or the ligamentum venosum for left-sided hepatectomy. The upper end of the tape was placed at the lateral side of the major hepatic veins. The learning curve for operating time and blood loss was evaluated using the cumulative sum (CUSUM) method. RESULTS: Among 53 patients, 18 underwent right hepatectomy, 26 underwent left hepatectomy, and 9 underwent right posterior sectionectomy. CUSUM analysis showed that operative time and blood loss improved after the 30th laparoscopic major hepatectomy. The 53 consecutive patients were divided into two groups (early, patients 1-30; late, patients 31-53). The median operative time was lower in the late group, but the difference was not statistically significant (270 vs. 245 min, p = 0.261). The median blood loss was also significantly lower in the late group (350 vs. 150 ml, p < 0.001). Large tumors (measuring > 10 cm) and tumors in proximity to major vessels were significantly higher in the late group (0 vs. 17.4%, p = 0.018; 3.3 vs. 21.7%, p = 0.036; respectively). CONCLUSION: This study shows that laparoscopic major hepatectomy using the modified liver hanging maneuver has a learning curve of 30 cases. After procedure standardization, the indications have gradually been extended to large or invasive tumors.

Pancreaticojejunostomy with or without reinforcement after pancreaticoduodenectomy: surgical technique of ligamentum teres hepatis wrap around pancreaticojejunostomy.

In a previous issue of the Journal, Zhong et al. reported a retrospective study that compared the perioperative outcomes of the mesh-reinforced pancreaticojejunostomy with conventional pancreaticojejunostomy. They concluded that mesh-reinforced pancreaticojejunostomy was a safe and effective technique, as it provided a safe anchor site for suture, thus reducing the risk of pancreatic leakage. Considering these encouraging results, we present a further simple technique using ligamentum teres hepatis wrap around pancreatojejunostomy for prevention of postoperative pancreatic fistula after pancreaticoduodenectomy.