Robotic pancreatic resection. Personal experience with 105 cases.

OBJECTIVE: the first robotic pancreatic resection in Brazil was performed by our team in 2008. Since March 2018, a new policy prompted us to systematically employ the robot in all minimally invasive pancreatic surgery. The aim of this paper is to review our experience with robotic pancreatic resection. METHODS: all patients who underwent robotic pancreatic resection from March 2018 through December 2019 were identified. Descriptive data were collected. Preoperative variables included age, sex, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. RESULTS: 105 patients underwent robotic pancreatectomy. Median age was 60.5 years old. Fifty-five patients were female. 51 patients underwent robotic pancreatoduodenectomies, 34 distal pancreatectomy. Morbidity was 23.8%, mainly related to postoperative pancreatic fistula and one death occurred (mortality of 0.9%). Three patients (2.8%) were converted to open surgery. Four patients had delayed gastric emptying and two presented bleeding. Twenty-four patients had pancreatic fistula that was treated conservatively with late removal of the pancreatic drain. No patient required percutaneous drainage, reintervention or hospital readmission. CONCLUSIONS: the robotic platform is useful for the reconstruction of the alimentary tract after pancreatoduodenectomy or after central pancreatectomy. It may increase the preservation of the spleen during distal pancreatectomies. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency. Robotic resection of the pancreas is safe and feasible for selected patients. It should be performed in specialized centers by surgeons with experience in both open and minimally invasive pancreatic surgery.

Robotic pancreatic resection. Personal experience with 105 cases / Ressecção pancreática robótica. Experiência pessoal com 105 casos

ABSTRACT Objective: the first robotic pancreatic resection in Brazil was performed by our team in 2008. Since March 2018, a new policy prompted us to systematically employ the robot in all minimally invasive pancreatic surgery. The aim of this paper is to review our experience with robotic pancreatic resection. Methods: all patients who underwent robotic pancreatic resection from March 2018 through December 2019 were identified. Descriptive data were collected. Preoperative variables included age, sex, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. Results: 105 patients underwent robotic pancreatectomy. Median age was 60.5 years old. Fifty-five patients were female. 51 patients underwent robotic pancreatoduodenectomies, 34 distal pancreatectomy. Morbidity was 23.8%, mainly related to postoperative pancreatic fistula and one death occurred (mortality of 0.9%). Three patients (2.8%) were converted to open surgery. Four patients had delayed gastric emptying and two presented bleeding. Twenty-four patients had pancreatic fistula that was treated conservatively with late removal of the pancreatic drain. No patient required percutaneous drainage, reintervention or hospital readmission. Conclusions: the robotic platform is useful for the reconstruction of the alimentary tract after pancreatoduodenectomy or after central pancreatectomy. It may increase the preservation of the spleen during distal pancreatectomies. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency. Robotic resection of the pancreas is safe and feasible for selected patients. It should be performed in specialized centers by surgeons with experience in both open and minimally invasive pancreatic surgery.

RESUMO Objetivo: a primeira ressecção pancreática robótica no Brasil foi realizada por nossa equipe em 2008. Desde março de 2018, uma nova política nos levou a empregar sistematicamente o robô em todas cirurgias pancreáticas minimamente invasivas. O objetivo deste artigo é revisar nossa experiência com a ressecção pancreática robótica. Métodos: todos os pacientes submetidos a ressecção pancreática robótica de 2018 a 2019 foram incluídos. Variáveis pré- e intraoperatórias como idade, sexo, indicação, tempo cirúrgico, sangramento, diagnóstico, tamanho do tumor foram analisados. Resultados: 105 pacientes foram submetidos a pancreatectomia robótica. A idade mediana dos pacientes foi de 60,5 anos. 55 pacientes eram do sexo feminino. 51 pacientes foram submetidos a pancreatoduodenectomia, 34 pancreatectomia distal. A morbidade foi de 23,8% e ocorreu um óbito (mortalidade de 0,9%). Três pacientes (2,8%) tiveram a operação convertida para aberta. Quatro pacientes apresentaram retardo no esvaziamento gástrico e dois apresentaram sangramento. Vinte e quatro pacientes apresentaram fístula pancreática tratada de forma conservadora com remoção tardia do dreno pancreático. Nenhum paciente necessitou de drenagem percutânea, reintervenção ou readmissão hospitalar. Conclusões: a plataforma robótica é útil para a reconstrução do trato alimentar após pancreatoduodenectomia ou após pancreatectomia central. Pode aumentar a preservação do baço durante pancreatectomias distais. Técnicas poupadoras de pâncreas, como enucleação, ressecção de processo uncinado e pancreatectomia central, devem ser usadas para evitar insuficiência exócrina e/ou endócrina. A ressecção robótica do pâncreas é segura e viável para pacientes selecionados. Deve ser realizada em centros especializados por cirurgiões com experiência em cirurgia pancreática aberta e minimamente invasiva.

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

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

Reduction of venous pressure during the resection of liver metastases compromises enteric blood flow: IGFBP-1 as a novel biomarker of intestinal barrier injury.

OBJECTIVES: Disruption of the intestinal barrier and bacterial translocation commonly occur when intestinal blood flow is compromised. The aim of this study was to determine whether liver resection induces intestinal damage. METHODS: We investigated intestinal fatty-acid binding protein and insulin-like growth factor binding protein levels in the plasma of patients who underwent liver resection. RESULTS: We show that liver resection is associated with significant intestinal barrier injury, even if the Pringle maneuver is not performed. CONCLUSION: We propose the use of insulin-like growth factor binding protein-1 as a novel biomarker of intestinal damage in such situations.

Reduction of venous pressure during the resection of liver metastases compromises enteric blood flow: IGFBP-1 as a novel biomarker of intestinal barrier injury

OBJECTIVES: Disruption of the intestinal barrier and bacterial translocation commonly occur when intestinal blood flow is compromised. The aim of this study was to determine whether liver resection induces intestinal damage. METHODS: We investigated intestinal fatty-acid binding protein and insulin-like growth factor binding protein levels in the plasma of patients who underwent liver resection. RESULTS: We show that liver resection is associated with significant intestinal barrier injury, even if the Pringle maneuver is not performed. CONCLUSION: We propose the use of insulin-like growth factor binding protein-1 as a novel biomarker of intestinal damage in such situations.

Laparoscopic uncinatectomy: a more conservative approach to the uncinate process of the pancreas / Uncinectomia laparoscópica: uma operação mais conservadora que pode ser a melhor opção para acesso ao processo uncinado do pâncreas

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

RESUMO Racional: A ressecção isolada do processo uncinado do pâncreas é procedimento raramente relatado na literatura, mas consiste em operação adequada para o tratamento de tumores benignos e malignidades não-invasivas de baixo grau do processo uncinado do pâncreas. Objetivo: Detalhar a técnica da uncinectomia laparoscópica e apresentar os resultados iniciais. Método: Paciente é colocado em posição supina com o cirurgião entre as pernas. São utilizados três trocárteres de 5 mm, um de 10 mm e um de 12 mm para realizar a ressecção isolada do processo uncinado. A transecção parenquimatosa é realizada com bisturi harmônico. Tecido absorvível hemostático é implantado sobre a área anteriormente ocupada pelo processo uncinado. Dreno de Waterman é colocado sobre a área de superfície cruenta pancreática. Resultado: Este procedimento foi utilizado em um caso de tumor neuroendócrino de processo uncinado de pâncreas de baixo grau comprovado por biópsia guiada por ultrassonografia endoscópica. Ultrassonografia intra-operatória evidenciou lesão distando alguns milímetros do ducto de Wirsung, e assim optou-se pela realização de uncinectomia laparoscópica. A evolução pós-operatória até recuperação completa foi rápida e sem intercorrências. Conclusão: A uncinectomia por via laparoscópica é procedimento eficaz e seguro em equipes com experiência em cirurgia biliopancreática minimamente invasiva.

Anatomical basis for the intrahepatic glissonian approach during hepatectomies.

BACKGROUND: Anatomical liver resections are based on some basic technical principles such as vascular control, ischemic area delineation to be resected and maximum parenchymal preservation. These aspects are achieved by the intrahepatic glissonian approach, which consists in accessing the pedicles of hepatic segments within the hepatic parenchyma. Small incisions on well-defined anatomical landmarks are performed to approach the pedicles, making dissection of the hilar plate unnecessary. AIM: Analyze parameters in liver anatomy related to intrahepatic surgical technique to glissonians pedicles, to set the normal anatomy related to the procedure and thereby facilitate the attainment of this technique. METHODS: Anatomical parameters related to the intrahepatic glissonian approach were studied in 37 cadavers. Measurements were performed with precision instruments. Data were expressed as mean±standard deviation. The subjects were divided into groups according to gender and liver weight and groups were compared statistically. RESULTS: Twenty-five cadavers were male and 12 female. No statistically significant difference was observed in virtually all parameters when groups were compared. This demonstrates the consistency of the anatomical parameters related to the intrahepatic glissonian approach. CONCLUSION: The results obtained in this study made possible major technical advances in the realization of open and laparoscopic hepatectomies with intrahepatic glissonian approach, and can help surgeons to perform liver resections by this method.

Anatomical basis for the intrahepatic glissonian approach during hepatectomies / Bases anatômicas para o acesso intra-hepático aos pedículos glissonianos durante hepatectomias

BACKGROUND: Anatomical liver resections are based on some basic technical principles such as vascular control, ischemic area delineation to be resected and maximum parenchymal preservation. These aspects are achieved by the intrahepatic glissonian approach, which consists in accessing the pedicles of hepatic segments within the hepatic parenchyma. Small incisions on well-defined anatomical landmarks are performed to approach the pedicles, making dissection of the hilar plate unnecessary. AIM: Analyze parameters in liver anatomy related to intrahepatic surgical technique to glissonians pedicles, to set the normal anatomy related to the procedure and thereby facilitate the attainment of this technique. METHODS: Anatomical parameters related to the intrahepatic glissonian approach were studied in 37 cadavers. Measurements were performed with precision instruments. Data were expressed as mean±standard deviation. The subjects were divided into groups according to gender and liver weight and groups were compared statistically. RESULTS: Twenty-five cadavers were male and 12 female. No statistically significant difference was observed in virtually all parameters when groups were compared. This demonstrates the consistency of the anatomical parameters related to the intrahepatic glissonian approach. CONCLUSION: The results obtained in this study made possible major technical advances in the realization of open and laparoscopic hepatectomies with intrahepatic glissonian approach, and can help surgeons to perform liver resections by this method. .

RACIONAL: Ressecções hepáticas anatômicas são baseadas em alguns princípios técnicos básicos, como o controle vascular, delimitação de área isquêmica a ser ressecada e máxima preservação do parênquima. Isto pode ser obtido pelo acesso intra-hepático aos pedículos glissonianos, que consiste em controle dos pedículos dos segmentos dentro do parênquima hepático. Pequenas incisões ao redor da placa hilar, em marcos anatômicos bem definidos, são utilizadas para acesso aos pedículos, tornando desnecessária a dissecção do hilo hepático. OBJETIVO: Analisar parâmetros da anatomia do fígado relacionada com a técnica cirúrgica da abordagem intra-hepática aos pedículos glissonianos, para definir a anatomia normal relacionada ao procedimento e, assim, facilitar a realização desta técnica. MÉTODOS: Parâmetros anatômicos relacionados à abordagem intra-hepática aos pedículos glissonianos foram estudados em 37 cadáveres. As medições foram realizadas com instrumentos de precisão. Os dados foram expressos em média±desvio-padrão. Os indivíduos foram divididos em grupos de acordo com o sexo e peso do fígado e os grupos foram comparados estatisticamente. RESULTADOS: Vinte e cinco cadáveres eram do sexo masculino e 12 do feminino. Não houve diferença estatisticamente significativa em praticamente todos os parâmetros quando os grupos foram comparados. Isto demonstra a consistência dos parâmetros anatômicos relacionadas com a técnica intra-hepática de acesso glissoniano. CONCLUSÃO: Os resultados obtidos neste estudo possibilitaram grandes avanços técnicos na realização de hepatectomias abertas e laparoscópicas com abordagem intra-hepática aos pedículos glissonianos, e pode ajudar cirurgiões a realizar procedimentos seguros e eficazes por este método. .

Laparoscopic pancreatic resection. From enucleation to pancreatoduodenectomy. 11-year experience.

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

[First single-port laparoscopic liver resection in Brazil]. / Hepatectomia laparoscópica com portal único: experiência pioneira no Brasil.

INTRODUCTION: Since the past decade, minimal access surgery is moving towards minimizing the surgical trauma by reducing numbers and size of the laparoscopic ports . A novel technique with a single-incision laparoscopic approach has been recently described. AIM: To describe the single-port technique for laparoscopic liver resection. TECHNIQUE: A transumbilical 3-cm skin incision is performed and a single-incision advanced access platform is introduced. Operation began with exploration of the abdominal cavity and ultrasound examination of the liver. Intrahepatic Glissonian access for retrieval of portal pedicles from segments 2 and 3 is performed. Vascular endoscopic stapler is used to divide segments 2 and 3 Glissonian pedicle. Liver is transected with harmonic scalpel and left hepatic vein is divided with stapler. Procedure is completed. Surgical specimen is retrieved through the single umbilical incision. No drains are left in place. CONCLUSION: Single port laparoscopic left lateral segmentectomy is feasible and can be safely performed in specialized centers by skilled laparoscopic surgeons.

Laparoscopic paccreatic resection. from enucleaion to pancreatoduodenectomy. 111-year experience / Pancreatectomia laparoscopica. Da enucleacao a duodenopancreatectomia. 11 anos de experiencia

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

Contexto Nossa experiência com ressecção pancreática laparoscópica começou em 2001. No início, a laparoscopia esteve reservada para casos selecionados. Com o aumento da experiência, procedimentos mais complexos, como pancreatectomia central e pancreato duodenectomia, foram realizadas por laparoscopia. Objetivos O objetivo deste trabalho foi rever a experiência de 11 anos com ressecção pancreática laparoscópica. Métodos Foram analisados todos os pacientes submetidos à ressecção pancreática laparoscópica entre 2001 e 2012 e incluídos dados pré-operatórios como idade, sexo e indicação cirúrgica, bem como variáveis intra-operatórias como o tempo operatório, o sangramento e transfusão. O diagnóstico final, o tamanho e a margem foram determinados a partir dos laudos anatomopatológicos. Resultados Desde 2001, 96 pacientes foram submetidos à pancreatectomia laparoscópica. A média de idade foi de 55 anos. Foram 60 homens e 36 mulheres. Oitenta e oito (91,6%) operações foram realizadas por laparoscopia e quatro (4,2%) necessitaram de auxílio da mão e uma robótica. Três pacientes foram convertidos. Quatro necessitaram de transfusão de sangue. O tempo operatório variou de acordo com tipo de operação. A mortalidade foi nula, mas a morbidade foi alta, principalmente devido à fístulas pancreáticas (28,1%). Sessenta e um pacientes foram submetidos à pancreatectomia distal, 18 à enucleação do pâncreas, 7 à duodenopancreatectomia com preservação de piloro, 5 à ressecção do processo uncinado, 3 centrais e duas pancreatectomias totais. Conclusão Ressecção laparoscópica ...

Hepatectomia laparoscópica com portal único: experiência pioneira no Brasil / First single-port laparoscopic liver resection in Brazil

INTRODUÇÃO: Na última década, a cirurgia laparoscópica evoluiu e hoje produz menor trauma graças à redução do número e tamanho dos trocárteres. Recentemente nova técnica com uso de portal único foi descrita. OBJETIVO: Descrever os detalhes de uma segmentectomia lateral esquerda (segmentos 2 e 3) laparoscópica com portal único. TÉCNICA: Portal único com cobertura de gel é introduzido por meio de incisão de 3 cm periumbilical. O procedimento inicia-se com exploração da cavidade com laparoscópio e exame ultra-sonográfico do fígado. É realizado Acesso intra-hepático ao pedículo Glissoniano dos segmentos 2 e 3. O pedículo é seccionado com grampeador com carga vascular. O fígado é seccionado com bisturi harmônico e a veia hepática esquerda é dividida com grampeador. A peça é retirada pelo portal único. A cavidade é revista mas não é deixado dreno. CONCLUSÃO: Segmentectomia lateral esquerda laparoscópica com portal único é procedimento seguro desde que realizado em centros especializados e por equipes com experiência em cirurgia hepática e laparoscopia avançada.

INTRODUCTION: Since the past decade, minimal access surgery is moving towards minimizing the surgical trauma by reducing numbers and size of the laparoscopic ports . A novel technique with a single-incision laparoscopic approach has been recently described. AIM: To describe the single-port technique for laparoscopic liver resection. TECHNIQUE: A transumbilical 3-cm skin incision is performed and a single-incision advanced access platform is introduced. Operation began with exploration of the abdominal cavity and ultrasound examination of the liver. Intrahepatic Glissonian access for retrieval of portal pedicles from segments 2 and 3 is performed. Vascular endoscopic stapler is used to divide segments 2 and 3 Glissonian pedicle. Liver is transected with harmonic scalpel and left hepatic vein is divided with stapler. Procedure is completed. Surgical specimen is retrieved through the single umbilical incision. No drains are left in place. CONCLUSION: Single port laparoscopic left lateral segmentectomy is feasible and can be safely performed in specialized centers by skilled laparoscopic surgeons.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): the Brazilian experience.

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

Ligadura da veia porta associada à bipartição do fígado para hepatectomia em dois estágios (ALPPS): experiência brasileira / Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): the Brazilian experience

RACIONAL: Insuficiência hepática pós-operatória devido à remanescente hepático pequeno tem sido complicação temida em pacientes que são submetidos à ressecção hepática extensa. A ligadura da veia porta associada à bipartição do fígado para hepatectomia em dois estágios (ALPPS) foi desenvolvida recentemente com a finalidade de induzir rápida e significante regeneração do fígado para pacientes em que o tumor é previamente considerado irressecável. OBJETIVO: Apresentar a experiência brasileira com o ALPPS. MÉTODO: Foram analisados 39 pacientes submetidos ao procedimento ALPPS em nove hospitais. Ele foi realizado em duas etapas. A primeira operação consistiu em ligadura do ramo direito da veia porta e bipartição hepática. Na segunda, os ramos direito da artéria hepática, via biliar e veia hepática foram ligados e o lobo hepático direito estendido foi removido. Foram 22 pacientes do sexo masculino (56,4%) e 17 do feminino (43,6%). A média de idade foi 57,3 anos (variando de 20 a 83 anos). RESULTADOS: A indicação mais comum foi metástase hepática em 32 pacientes (82,0%), seguida por colangiocarcinoma em três pacientes (7,7%). Dois morreram neste intervalo e não foram submetidos à segunda operação. O intervalo médio da primeira para a segunda operação foi de 14,1 dias (variando de 5-30 dias). O volume do segmento lateral esquerdo apresentou aumento de 83% (variando de 47-211,9%). Morbidade significante foi observada em 23 pacientes (59,0%). A mortalidade foi de 12,8% (cinco pacientes). CONCLUSÃO: O procedimento ALPPS permite ressecção hepática em pacientes com lesões consideradas previamente irressecáveis por induzir rápida hipertrofia do fígado evitando a insuficiência hepática na maioria dos pacientes. Porém ainda apresenta elevada morbidade e mortalidade.

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

First single-port laparoscopic pancreatectomy in Brazil.

CONTEXT: Pancreatic surgery is an extremely challenging field, and the management of pancreatic diseases continues to evolve. In the past decade, minimal access surgery is moving towards minimizing the surgical trauma by reducing numbers and size of the port. In the last few years, a novel technique with a single-incision laparoscopic approach has been described for several laparoscopic procedures. OBJECTIVES: We present a single-port laparoscopic spleen-preserving distal pancreatectomy. To our knowledge, this is the first single-port pancreatic resection in Brazil and Latin America. METHODS: A 33-year-old woman with neuroendocrine tumor underwent spleen-preserving distal pancreatectomy via single-port approach. A single-incision advanced access platform with gelatin cap, self-retaining sleeve and wound protector was used. RESULTS: Operative time was 174 minutes. Blood loss was minimal, and the patient did not receive a transfusion. The recovery was uneventful, and the patient was discharged on postoperative day 4. CONCLUSIONS: Single-port laparoscopic spleen-preserving distal pancreatectomy is feasible and can be safely performed in specialized centers by skilled laparoscopic surgeons.

Hepatectomia videolaparoscópica: experiência pessoal com 107 casos / Laparoscopic liver resection: personal experience with 107 cases

OBJETIVO: analisar nossa experiência após 107 hepatectomias videolaparoscópicas e discutir a evolução técnica da hepatectomia laparoscópica nos últimos cinco anos. MÉTODOS: entre abril de 2007 e abril de 2012 foram realizadas 107 hepatectomias laparoscópicas em 105 pacientes. A média de idade foi 53,9 anos (17 a 85). Cinquenta e três pacientes eram do sexo masculino. Todas as intervenções foram realizadas pelos autores do trabalho. RESULTADOS: do total de 107 operações, houve necessidade de conversão para a técnica aberta em três casos (2,8%). Dezesseis pacientes (14,9%) apresentaram complicações. Dois pacientes foram a óbito, mortalidade de 1,87%. Um óbito foi decorrente de infarto maciço do miocárdio, sem relação com a hepatectomia laparoscópica, que transcorreu sem intercorrências e não apresentou conversão nem sangramento. O outro óbito foi decorrente de falha do grampeador. Vinte pacientes (18,7%) necessitaram de transfusão sanguínea. O tipo de hepatectomia mais frequente foi a bissegmentectomia, segmentos 2-3, (33 casos), seguida de hepatectomia direita (22 casos). Setenta e duas cirurgias (67,3%) foram realizadas por meio da técnica de acesso Glissoniano. CONCLUSÃO: a divulgação dos resultados é de extrema importância. As dificuldades técnicas, complicações e mesmo mortalidade, inerentes a este complexo tipo de cirurgia, necessitam ser divulgados com clareza. Este procedimento deve ser realizado em centro especializado e por equipe capacitada. A técnica de acesso Glissoniano por via laparoscópica, descrita pela nossa equipe, facilita a realização de hepatectomias anatômicas.

OBJECTIVE: To analyze our experience after 107 laparoscopic hepatectomies and discuss the technical evolution of laparoscopic hepatectomy in the last five years. METHODS: Between April 2007 and April 2012 we performed 107 laparoscopic hepatectomies in 105 patients. The mean age was 53.9 years (17 to 85). Fifty-three patients were male. All interventions were performed by the authors. RESULTS: from the total of 107 operations, there was need for conversion to open technique in three cases (2.8%). Sixteen patients (14.9%) had complications. Two patients died, a mortality of 1.87%. One death was due to massive myocardial infarction, unrelated to the procedure, which was uneventful and showed no conversion or bleeding. The other death was due to failure of the stapler. Twenty patients (18.7%) required blood transfusion. The most frequent type of hepatectomy was bisegmentectomy of segments 2-3, (33 cases), followed by right hepatectomy (22 cases). Seventy-two procedures (67.3%) were performed by the technique of Glissonian access. CONCLUSION: The dissemination of results is of utmost importance. The technical difficulties, complications and even death, inherent in this complex type of surgery, need to be clearly disclosed. This procedure should be performed in a specialized center with knowledgeable staff. The technique of laparoscopic Glissonian access, described by our staff, facilitates the realization of anatomical hepatectomies.

Laparoscopic liver resection: personal experience with 107 cases.

OBJECTIVE: To analyze our experience after 107 laparoscopic hepatectomies and discuss the technical evolution of laparoscopic hepatectomy in the last five years. METHODS: Between April 2007 and April 2012 we performed 107 laparoscopic hepatectomies in 105 patients. The mean age was 53.9 years (17 to 85). Fifty-three patients were male. All interventions were performed by the authors. RESULTS: from the total of 107 operations, there was need for conversion to open technique in three cases (2.8%). Sixteen patients (14.9%) had complications. Two patients died, a mortality of 1.87%. One death was due to massive myocardial infarction, unrelated to the procedure, which was uneventful and showed no conversion or bleeding. The other death was due to failure of the stapler. Twenty patients (18.7%) required blood transfusion. The most frequent type of hepatectomy was bisegmentectomy of segments 2-3, (33 cases), followed by right hepatectomy (22 cases). Seventy-two procedures (67.3%) were performed by the technique of Glissonian access. CONCLUSION: The dissemination of results is of utmost importance. The technical difficulties, complications and even death, inherent in this complex type of surgery, need to be clearly disclosed. This procedure should be performed in a specialized center with knowledgeable staff. The technique of laparoscopic Glissonian access, described by our staff, facilitates the realization of anatomical hepatectomies.

CO2 abdominal insufflation decreases local and systemic inflammatory response in experimental acute pancreatitis.

OBJECTIVES: Acute pancreatitis (AP) is a serious disease that is amplified by an associated systemic inflammatory response. We investigated the effect of CO2 pneumoperitoneum on the local and systemic inflammatory response in AP. METHODS: Acute pancreatitis was induced in Wistar rats by 5% taurocholate intraductal injection. Carbon dioxide pneumoperitoneum was applied for 30 minutes before the induction of AP. Inflammatory parameters were evaluated in the peritoneum (ascites, cell number, and tumor necrosis factor alpha [TNF-alpha]), serum (amylase, TNF-alpha, interleukin-6 [IL-6], and IL-10), pancreas (myeloperoxidase [MPO] activity, cyclo-oxygenase 2 and inducible nitric oxide synthase expression, and histological diagnosis), liver, and lung (mitochondria dysfunction and MPO activity). RESULTS: Abdominal insufflation with CO2 before induction of AP caused a significant decrease in ascites volume, cells, and TNF-alpha in the peritoneal cavity and in serum TNF-alpha and IL-6 but not IL-10 levels. In the pancreas, this treatment reduced MPO activity, acinar and fat necrosis, and the expression of inducible nitric oxide synthase and cyclo-oxygenase 2. There were no significant differences on serum amylase levels, liver mitochondrial function, and pulmonary MPO between groups. CONCLUSIONS: Our data demonstrated that CO2 pneumoperitoneum reduced pancreatic inflammation and attenuated systemic inflammatory response in AP. This article suggests that CO2 pneumoperitoneum plays a critical role on the better outcome in patients undergoing laparoscopic pancreatic surgery.