RESUMEN
BACKGROUND: Patients with liver tumors that are in contact with the major hepatic veins may require hepatic vein resection to achieve an adequate surgical margin; however, the potential for venous congestion and impaired remnant liver function must be considered. We introduce the anatomy of the hepatic vein related to Laennec's capsule as well as the surgical techniques to overcome these limitations in the laparoscopic approach.1,2 PATIENTS AND METHODS: A patient with hepatocellular carcinoma underwent resection of the paracaval portion of the caudate lobe. A 4.5-cm tumor was located on the hepatic hilum, compressing the middle and right hepatic veins (MHV and RHV). The Laennec's capsule around the hepatic veins consists of cardiac and hepatic layers. In the inter-Laennec approach, the hepatic veins and inferior vena cava were continuously exposed from the root side, during entry into the space between the hepatic and cardiac Laennec's capsules.3,4 Hence, the cardiac Laennec's capsule was preserved on the venous side, and the strength of the hepatic vein walls was maintained without exposing the tumor. Parenchymal transection was performed while preserving the MHV and RHV. RESULTS: The operative time was 331 min, with minimal estimated blood loss. The patient was discharged on postoperative day 6 without complications. A pathological examination revealed the presence of focal capsular invasion; however, the surgical margin was maintained by leaving the hepatic Laennec's capsule on the tumor side. CONCLUSIONS: Understanding the structure of the Laennec's capsule can contribute to the establishment of safe and feasible liver resection techniques.
RESUMEN
PURPOSE: Continuous dissection or simultaneous reconstruction of the hepatic vein (HV) and inferior vena cava (IVC) was achieved under total hepatic vascular exclusion (THVE) with in situ hypothermic isolated hepatic perfusion (HIHP) in two cases. CASE 1: The patient previously underwent liver resections with the right HV for colorectal liver metastasis (CRLM). This time, the CRLM had invaded the left HV and IVC, and five courses of FOLFILI plus ramucirumab were given, resulting in stable disease. Due to expected high HV pressure, liver parenchymal transection was started under THVE. Sub-segmentectomy with patch graft plasty of the IVC and reconstruction of the left HV using a jugular vein graft were performed under THVE and HIHP. This patient died at home 3 months after surgery; the cause of death was unknown. CASE 2: Hepatocellular carcinoma in the caudate lobe was in extensive contact with the roots of three main HVs and the IVC, and pressed the hepatocaval confluence, with high HV pressure expected. In addition, tumor thrombosis extended to both the main portal vein and the common bile duct, resulting in the inability to introduce chemotherapy. After tumor thrombectomy, liver parenchymal transection was started under THVE. Extended left hepatectomy with wedge resection, and primary suture of the right HV and IVC was performed under THVE and HIHP. Recurrence-free and overall survivals were 8 months (lung metastasis) and 31 months, respectively. CONCLUSIONS: In liver resection for liver tumors located in the hepatocaval confluence, THVE with HIHP is useful for ensuring the safety.
Asunto(s)
Carcinoma Hepatocelular , Hepatectomía , Venas Hepáticas , Hipotermia Inducida , Neoplasias Hepáticas , Vena Cava Inferior , Humanos , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/tratamiento farmacológico , Hepatectomía/métodos , Carcinoma Hepatocelular/cirugía , Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/secundario , Carcinoma Hepatocelular/tratamiento farmacológico , Vena Cava Inferior/cirugía , Vena Cava Inferior/patología , Venas Hepáticas/cirugía , Venas Hepáticas/patología , Masculino , Hipotermia Inducida/métodos , Neoplasias Colorrectales/patología , Neoplasias Colorrectales/cirugía , Persona de Mediana Edad , Quimioterapia del Cáncer por Perfusión Regional/métodos , Femenino , Anciano , Pronóstico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéuticoRESUMEN
Laparoscopic ventral and dorsal segmentectomies 8 are an option for parenchymal-sparing liver resection. However, laparoscopic anatomic posterosuperior liver segment resection is technically demanding because of its deep location and the many variations in the segment 8 Glissonean pedicle (G8). In this study, we describe a hepatic vein-guided approach (HVGA) to overcome these limitations. For ventral segmentectomy 8, liver parenchymal transection was initiated at the ventral side of the middle hepatic vein (MHV) and continued exposing it toward the periphery. The G8 ventral branch (G8vent) was identified on the right side of the MHV. Following G8vent dissection, liver parenchymal transection was completed by connecting the demarcation line and G8vent stump. For dorsal segmentectomy 8, the anterior fissure vein (AFV) was exposed peripherally. The G8 dorsal branch (G8dor) was identified on the right side of the AFV. Following G8dor dissection, the right hepatic vein (RHV) was exposed from the root. Liver parenchymal transection was completed by connecting the demarcation line and RHV. Between April 2016 and December 2022, we performed laparoscopic ventral and dorsal segmentectomy 8 in fourteen patients. No complications (Clavien-Dindo classification, Grade ≥ IIIa) were observed. An HVGA is feasible and useful for standardizing safe laparoscopic ventral and dorsal segmentectomies 8.
RESUMEN
Focal nodular hyperplasia (FNH) is a rare benign hepatic tumor which is frequently observed in women of reproductive age, and therapeutic intervention needs to be considered in cases wherein the tumor has a risk of rupture. The laparoscopic approach is beneficial, especially for young women, but is often challenging because the tumor is large and hemorrhagic. Herein, we report a case of large FNH in a 22-year-old woman. The patient was asymptomatic; however, the tumor was approximately 15 cm in diameter and protruded from the liver. Given the risk of rupture, we decided to perform surgical resection. Preoperative transcatheter arterial embolization led to rapid shrinkage of the tumor and control of intraoperative bleeding, which enabled us to safely perform laparoscopic liver resection. The combination of surgical resection with intravascular embolization may be a promising therapeutic option for hypervascular tumors such as FNH.
Asunto(s)
Embolización Terapéutica , Hiperplasia Nodular Focal , Laparoscopía , Neoplasias Hepáticas , Humanos , Femenino , Adulto Joven , Adulto , Hiperplasia Nodular Focal/cirugía , Hiperplasia Nodular Focal/patología , Hígado , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/patologíaRESUMEN
BACKGROUND: Laennec's capsule is the proper membrane covering the entire surface of the liver parenchyma, including around the Glissonean pedicles and hepatic veins. Laennec's capsule around the hepatic veins has been clinically reported to comprise two layers: the hepatic and cardiac Laennec's capsules. However, where the cardiac Laennec's capsule is derived from and the two capsules' separability are still unclear. This study aimed to investigate the anatomy of the two capsules using cadaveric specimens. METHODS: Histopathological examinations of autopsy specimens from four cadavers were conducted. Each specimen was sliced in the longitudinal section to include the pericardium, right hepatic vein (RHV), and inferior vena cava (IVC). Additionally, long-axis specimens of the RHV were obtained to determine the separability of the capsules and to examine the extent to which the capsules extended along the RHV. Laennec's capsule was estimated using elastic fiber staining. RESULTS: The cardiac Laennec's capsule is derived from the pericardium (parietal and visceral) and diaphragm and runs parallel with the IVC and hepatic veins associated with the hepatic Laennec's capsule. The two capsules were separable micro- and macroscopically. The hepatic Laennec's capsule was observed from the root to the peripheral side and the cardiac Laennec's capsule from the root to the middle side of the hepatic vein. CONCLUSIONS: The existence of the two layers of Laennec's capsule around the hepatic veins was confirmed histologically and they were separable. Identification and decollement of these layers would contribute to establishing safe and feasible anatomic liver resection techniques.
Asunto(s)
Venas Hepáticas , Neoplasias Hepáticas , Humanos , Venas Hepáticas/cirugía , Cápsulas , Hepatectomía/métodos , Hígado/cirugía , Hígado/anatomía & histología , Neoplasias Hepáticas/cirugíaRESUMEN
BACKGROUND: The treatment of delayed complications after liver trauma such as bile leakage (BL) and hepatic artery pseudoaneurysms (HAPs) is difficult. The purpose of this study is to investigate the outcomes and management of post-traumatic BL and HAPs. METHODS: We retrospectively evaluated patients diagnosed with blunt liver injury, graded by the American Association for the Surgery of Trauma Liver Injury Scale, who were admitted to our hospital between April 2010 and December 2019. Patient characteristics and treatments were analyzed. RESULTS: A total of 176 patients with blunt liver injury were evaluated. Patients were diagnosed with grade I-II liver injury (n = 127) and with grade III-V injury (n = 49). BL was not observed in patients with grade I-II injury. Eight patients with grade III-V injury developed BL: surgical intervention was not needed for six patients with peripheral bile duct injury, but hepaticojejunostomy was needed for two patients with central bile duct injury. Out of 10 patients with HAPs, only three with grade I-II injury and one with grade III-V were treated conservatively; the rest six with grade III-V injury required transcatheter arterial embolization (TAE). All pseudoaneurysms disappeared. CONCLUSIONS: Severe blunt liver injury causing peripheral bile duct injury can be treated conservatively. In contrast, the central bile duct injury requires surgical treatment. HAPs with grade I-II injury might disappear spontaneously. HAPs with grade III-V injury should be considered TAE.
Asunto(s)
Traumatismos Abdominales , Aneurisma Falso , Enfermedades de los Conductos Biliares , Heridas no Penetrantes , Traumatismos Abdominales/complicaciones , Aneurisma Falso/diagnóstico , Aneurisma Falso/etiología , Aneurisma Falso/terapia , Humanos , Hígado/lesiones , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/terapiaRESUMEN
Whether albumin and bilirubin levels, platelet counts, ALBI, and ALPlat scores could be useful for the assessment of permanent liver functional deterioration after repeat liver resection was examined, and the deterioration after laparoscopic procedure was evaluated. For 657 patients with liver resection of segment or less in whom results of plasma albumin and bilirubin levels and platelet counts before and 3 months after surgery could be retrieved, liver functional indicators were compared before and after surgery. There were 268 patients who underwent open repeat after previous open liver resection, and 224 patients who underwent laparoscopic repeat after laparoscopic liver resection. The background factors, liver functional indicators before and after surgery and their changes were compared between both groups. Plasma levels of albumin (p = 0.006) and total bilirubin (p = 0.01) were decreased, and ALBI score (p = 0.001) indicated worse liver function after surgery. Laparoscopic group had poorer preoperative performance status and liver function. Changes of liver functional values before and after surgery and overall survivals were similar between laparoscopic and open groups. Plasma levels of albumin and bilirubin and ALBI score could be the indicators for permanent liver functional deterioration after liver resection. Laparoscopic group with poorer conditions showed the similar deterioration of liver function and overall survivals to open group.
RESUMEN
BACKGROUND: Laparoscopic left hepatectomy with resection of the Spiegel lobe remains a technically demanding procedure as it is a deep-seated area surrounding the inferior vena cava (IVC). Mobilization of the Spiegel lobe requires safe exposure of the ventral side of the IVC while dissecting the short hepatic veins from the IVC. Additionally, wide space is needed to isolate the left Glissonean pedicle (Glt). We used a modified caudate lobe-first approach to overcome this challenge Maeda (J Hepato-Bil Pancreat Sci 25:335-41, 2018), Li (J Gastrointest Surg 23:1084-5, 2019), Homma (Surg Endosc 33:3851-7, 2019). METHODS: The ischemic area was confirmed after isolating the left and middle hepatic artery and left portal vein. After mobilizing the left lateral section, the Spiegel lobe was divided from the notch, which is the boundary between the caudate lobe and the Spiegel lobe, toward the middle hepatic vein (MHV). The Spiegel lobe was safely detached from the IVC with a short hepatic vein transected with the caudo-dorsal view. The Glt could be easily isolated due to the wide space on the ventral side of the IVC. After dividing the left hepatic duct, the MHV was exposed continuously from the root to the periphery, and parenchymal transection was completed by connecting the demarcation line and MHV. RESULTS: The total operation time was 430 min, and estimated blood loss was minimal. The patient was discharged on postoperative day 6 without complications. CONCLUSIONS: The modified caudate lobe-first approach can be used to safely perform laparoscopic left hepatectomy combined with the Spiegel lobe resection.
RESUMEN
BACKGROUND: The incidence of hepatocellular carcinoma (HCC) requiring surgical treatment in older patients has been continuously increasing. This study aimed to examine the safety and feasibility of performing laparoscopic liver resection (LLR) versus open liver resection (OLR) for HCC in older patients at a Japanese institution. METHODS: Between January 2010 and June 2021, 133 and 145 older patients (aged ≥ 70 years) who were diagnosed with HCC underwent LLR and OLR, respectively. Propensity score matching (PSM) analysis with covariates of baseline characteristics was performed. The intraoperative and postoperative data were evaluated in both groups. RESULTS: After PSM, 75 patients each for LLR and OLR were selected and the data compared. No significant differences in demographic characteristics, clinical data, and operative times were observed between the groups, although less than 10% of cases in each group underwent a major resection. Blood loss (OLR: 370 mL, LLR: 50 mL; P < 0.001) was lower, and the length of postoperative hospital stay (OLR: 12 days, LLR: 7 days; P < 0.001) and time to start of oral intake (OLR: 2 days, LLR: 1 day; P < 0.001) were shorter in the LLR group than in the OLR group. The incidence of complications ≥ Clavien-Dindo class IIIa was similar between the two groups. CONCLUSIONS: LLR, especially minor resections, is safely performed and feasible for selected older patients with HCC.
Asunto(s)
Carcinoma Hepatocelular , Laparoscopía , Neoplasias Hepáticas , Anciano , Carcinoma Hepatocelular/diagnóstico , Hepatectomía/efectos adversos , Humanos , Laparoscopía/efectos adversos , Tiempo de Internación , Neoplasias Hepáticas/diagnóstico , Complicaciones Posoperatorias/etiología , Puntaje de Propensión , Estudios RetrospectivosRESUMEN
BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporarily control bleeding and maintain the cerebral and coronary blood flow in cases in which it is difficult to control hemorrhagic shock. However, the safety and effectiveness of REBOA remains uncertain. OBJECTIVES: This study aimed to estimate the safety and effectiveness of aortic occlusion in patients who undergo REBOA catheter placement. METHODS: We conducted a retrospective study of patients who underwent REBOA catheter placement at Fukuyama City Hospital Emergency Medical Center from August 1, 2008 to March 31, 2020. A propensity score-matching analysis was used to compare 30-day survival between patients who undergo REBOA catheter placement with and without aortic occlusion. RESULTS: Overall, 122 of the 147 who underwent REBOA catheter placement at Fukuyama City Hospital were eligible for inclusion. Thirty-five patients in the Occlusion group and 35 patients in the Nonocclusion group were selected by propensity score matching. According to the 30-day survival rate, the difference between the two groups was not statistically significant (p = 0.288 log-rank test). Moreover, the required treatment, the types and incidence of complications, and other outcomes did not differ according to the presence or absence of aortic occlusion in patients who underwent REBOA catheter placement. CONCLUSION: According to the results of this study, in trauma patients who undergo REBOA catheter placement, the presence of aortic occlusion was not significantly associated with 30-day mortality. Furthermore, the performance of aortic occlusion was not associated with a significant increase in complications.
Asunto(s)
Oclusión con Balón , Procedimientos Endovasculares , Choque Hemorrágico , Aorta , Oclusión con Balón/métodos , Procedimientos Endovasculares/métodos , Humanos , Puntaje de Gravedad del Traumatismo , Resucitación/métodos , Estudios Retrospectivos , Choque Hemorrágico/etiología , Choque Hemorrágico/terapiaRESUMEN
BACKGROUND: Laparoscopic anatomic liver resection is considered highly challenging, especially in segment 8 (S8), owing to the limited angle of the laparoscope and limited manipulation of the surgical instrument1,2. Additionally, resection is technically difficult when approaching the more peripheral branches since the Glissonean pedicle of S8 has several variations3 and is far from the hepatic hilum. The hepatic vein (HV)-guided approach involves entering from the cranial side of the liver while overcoming these difficulties with the unique view and techniques of laparoscopy4,5. We describe laparoscopic anatomic resection of the dorsal part of S8 using the HV-guided approach for hepatocellular carcinoma. METHODS: The drainage vein of segment 8 (V8), which often runs between the ventral and dorsal parts of S86,7, was exposed from the confluence of the middle HV to the periphery. The dorsal Glissonean branch of S8 (G8dor) was identified by deep dissection of the parenchyma on the right side of the V8. The right HV (RHV) was exposed toward the periphery after dissecting the G8dor. Liver parenchymal dissection was completed by connecting the demarcation line and the RHV. RESULTS: The total operation time was 319 min, estimated blood loss was 5 mL, and the patient was discharged on postoperative day 6 with no complications. CONCLUSION: Laparoscopic anatomic resection of the dorsal parts of S8 could be safely performed by exposing the HVs from their roots and using the HVs as a landmark to identify the intrahepatic Glissonean pedicles.
Asunto(s)
Venas Hepáticas , Laparoscopía , Venas Hepáticas/cirugía , Humanos , Hígado/cirugíaRESUMEN
BACKGROUND: Laparoscopic anatomic liver resections of the posterosuperior segments are technically demanding procedures.1-5 The segments are located in a deep-seated area of the liver surrounded by the ribs and the diaphragm, making forceps manipulation difficult. To overcome this limitation, an intrahepatic Glissonean approach and exposure of the hepatic veins from the root side was applied.6-10 The authors describe the technical aspects of performing a bisegmentectomy 7-8. METHODS: Liver parenchymal transection was initiated from the ventral aspect of the root of the middle hepatic vein, which often runs in the intersegmental plane, identifying the Glissonean pedicle of segment 8 (G8). After dissection of the G8, segmentectomy 8 was performed through identification of the ischemic area. After complete mobilization of the right lobe, the Glissonean pedicle of segment 7 (G7), which runs relatively near the liver surface,9, 10 was marked using ultrasonography. After division of the G7, a wide dissection between the caudate lobe and segment 7 was performed and connected to the previously dissected plane from the dorsal side of the right hepatic vein (RHV). Finally, bisegmentectomy 7-8 was performed with RHV resection because of tumor invasion. RESULTS: The operation time was 510 min, and the estimated blood loss was 150 ml. The patient was discharged on postoperative day 10 without any complications. CONCLUSIONS: Application of the intrahepatic Glissonean approach and exposure of the major hepatic veins from their roots using unique laparoscopic principles allows a safe performance of bisegmentectomy 7-8.
Asunto(s)
Laparoscopía , Neoplasias Hepáticas , Hepatectomía , Venas Hepáticas/diagnóstico por imagen , Venas Hepáticas/cirugía , Humanos , Neoplasias Hepáticas/cirugía , Tempo OperativoRESUMEN
BACKGROUND: Laparoscopic anatomic liver resection is technically demanding, given the need to safely isolate the Glissonean pedicles and expose the hepatic veins (HVs) on the liver parenchyma cut surface. Laennec's capsule is observed around the Glissonean pedicles and root of the HVs. However, its existence, particularly on the peripheral side of the HVs, remains controversial. Herein, we describe Laennec's capsule-related histopathological findings around the HVs and a safe laparoscopic left medial sectionectomy utilizing Laennec's capsule. METHODS: The extrahepatic Glissonean approach was performed by connecting Gates II and III, in accordance with Sugioka's Gate theory. Liver parenchymal transection commenced along the demarcation line, which is between the medial and lateral sections, and the G4 was dissected during transection. Subsequently, via the outer-Laennec approach, the middle hepatic vein (MHV) was exposed from the root side in cranial view, while Laennec's capsule was preserved. Parenchymal transection was completed while connecting the MHV with the demarcation line. We obtained the membrane surrounding the HVs and performed histopathological examinations. RESULTS: Six patients underwent laparoscopic left medial sectionectomy from February 2012 to November 2020. There were no cases involving complications (Clavien-Dindo classification; grade II or higher), open-surgery conversion, transfusion, or surgery-related death. The histopathological findings showed Laennec's capsule surrounding both the trunk of the major HVs and the peripheral side of the HVs. CONCLUSIONS: A cranial approach to the major HVs utilizing Laennec's capsule is a feasible and advantageous procedure for laparoscopic left medial sectionectomy. We propose that Laennec's capsule surrounds the entire length of the HVs.
Asunto(s)
Laparoscopía , Neoplasias Hepáticas , Hepatectomía , Venas Hepáticas/cirugía , Humanos , Neoplasias Hepáticas/cirugíaRESUMEN
Less morbidity is considered among the advantages of laparoscopic liver resection (LLR) for HCC patients. However, our previous international, multi-institutional, propensity score-based study of emerging laparoscopic repeat liver resection (LRLR) failed to prove this advantage. We hypothesize that these results may be since the study included complex LRLR cases performed during the procedure's developing stage. To examine it, subgroup analysis based on propensity score were performed, defining the proximity of the tumors to major vessels as the indicator of complex cases. Among 1582 LRLR cases from 42 international high-volume liver surgery centers, 620 cases without the proximity to major vessels (more than 1 cm far from both first-second branches of Glissonian pedicles and major hepatic veins) were selected for this subgroup analysis. A propensity score matching (PSM) analysis was performed based on their patient characteristics, preoperative liver function, tumor characteristics and surgical procedures. One hundred and fifteen of each patient groups of LRLR and open repeat liver resection (ORLR) were earned, and the outcomes were compared. Backgrounds were well-balanced between LRLR and ORLR groups after matching. With comparable operation time and long-term outcome, less blood loss (283.3±823.0 vs. 603.5±664.9 mL, p = 0.001) and less morbidity (8.7 vs. 18.3 %, p = 0.034) were shown in LRLR group than ORLR. Even in its worldwide developing stage, LRLR for HCC patients could be beneficial in blood loss and morbidity for the patients with less complexity in surgery.
RESUMEN
Highlight Kagoura and colleagues report a rare case of paired hepatocellular carcinoma recurrence after hepatectomy with removal of a bile duct tumor thrombosis following endoscopic sphincterotomy. Recurrence is believed to have occurred both at the stump of the hepatic bile duct and at the post-sphincterotomy site of the papilla of Vater.
Asunto(s)
Carcinoma Hepatocelular , Neoplasias Hepáticas , Conductos Biliares , Carcinoma Hepatocelular/diagnóstico por imagen , Carcinoma Hepatocelular/cirugía , Colangiopancreatografia Retrógrada Endoscópica , Hepatectomía/efectos adversos , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/cirugía , Recurrencia Local de Neoplasia/cirugía , Esfinterotomía EndoscópicaRESUMEN
BACKGROUND: Duct-to-mucosa pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) is technically challenging, particularly in cases of soft pancreas with a nondilated main pancreatic duct (MPD). We propose a novel procedure that involves ligating the pancreas in advance to allow for MPD dilation. METHODS: We compared the data of 16 patients who underwent PD followed by PJ with advance ligation (AL) for soft pancreas with a nondilated MPD with that of 17 patients who underwent a conventional procedure (conventional group) without AL at a single institution between January 2015 and April 2017. MPD diameters were assessed using preoperative computed tomography and intraoperative ultrasonography. Pancreatic consistency was judged intraoperatively. The pancreatic parenchyma and MPD were ligated in advance to allow time for MPD dilation. After AL, we divided the pancreatic parenchyma. AL led to MPD dilation and facilitated PJ. RESULTS: There were significantly fewer complications in the AL group than in the conventional group (P=0.005). There were no cases of pancreatitis or death in either group. The mean procedural time for occluding the MPD was 43 min (range, 21-134 min). The median MPD dilation rate after AL was 1.6 (0.9-3.8). CONCLUSIONS: AL is a simple, safe, and useful procedure for facilitating PJ.
RESUMEN
BACKGROUND: A majority of gastrinomas causing Zollinger-Ellison syndrome are located in the duodenum or pancreas. Primary hepatic gastrinomas are rare and difficult to diagnose. We report a rare case of primary hepatic gastrinoma, which could be diagnosed preoperatively. CASE PRESENTATION: A 29-year-old man with a 55-mm tumor in segments 5 and 6 (S 5/6) of the liver was admitted to our hospital. After thorough investigations, he was treated for a suspected inflammatory pseudotumor and advised to undergo routine follow-up. Two years later, he revisited our hospital with a complaint of abdominal pain, vomiting, and diarrhea. Upper gastrointestinal endoscopy revealed multiple duodenal ulcers. His serum gastrin level was 2350 pg/mL (normal: 37-172 pg/mL), suggesting Zollinger-Ellison syndrome. Abdominal computed tomography showed a 78-mm hypervascular tumor with cystic degeneration in the S 5/6 region of the liver, with a potential to increase over time. The tumor showed hypointensity on T2-weighted and hyperintensity on diffusion-weighted abdominal contrast-enhanced magnetic resonance imaging. Somatostatin receptor scintigraphy (SRS) only detected a hepatic tumor. No tumors in the gastrinoma triangle were detected by endoscopic ultrasonography. Hence, selective arterial calcium injection (SACI) test was performed to determine the location of the gastrinoma. The serum gastrin concentration increased from 4620 pg/mL to 23,600 pg/mL at 20 s after calcium gluconate injection into the proper hepatic artery. Conversely, no effect on serum gastrin level was observed after the injection into any other arteries. Extended right hepatic lobectomy and cholecystectomy were performed after percutaneous transhepatic portal vein embolization. A histopathological examination of the liver tumor revealed a gastrinoma. The patient's serum gastrin concentration on postoperative day 1 decreased to 65 pg/mL. CONCLUSION: We report a surgical case of primary hepatic gastrinoma correctly diagnosed preoperatively. The patient underwent extended right hepatic lobectomy, resulting in a histological definitive diagnosis of primary hepatic gastrinoma.
RESUMEN
BACKGROUND: The cranial approach allows easy identification of the major hepatic vein Ome et al. (2020), Honda et al. (2013), Xiao et al. (2016) and Kim (2019) [1-4] and avoids split injury of the hepatic veins (HV) by exposing the HV from the root to the periphery (Honda et al., 2013) [2]. We present the cranial approach to laparoscopic anatomic liver resections of segment 2 (S2) and segment 3 (S3) in two cases of hepatocellular carcinoma (HCC). METHODS: [Laparoscopic segmentectomy 2]After dissection of the S2 Glissonean pedicle, parenchymal transection was initiated to expose the dorsal aspect of the root of the left hepatic vein via parenchymal transection using a cranial approach. The cavitron ultrasonic surgical aspirator (CUSA) was used from the root side towards the peripheral side. The liver parenchymal dissection was completed by dissecting between the demarcation line and the left hepatic vein. [Laparoscopic segmentectomy 3]The liver transection was initiated along the falciform ligament. After the S3 Glissonean pedicle was temporally clamped, the ventral aspect of the root of the left hepatic vein was exposed peripherally. The parenchymal dissection process was completed with the S3 Glissonean pedicle dissection. RESULTS: S2: The operation time was 191 min, the estimated blood loss was 5 ml, and the patient was discharged on postoperative day 5 with no complications. S3: The total operation time was 215 min, the estimated blood loss was 50 ml, and the patient was discharged on postoperative day 9 with no complications. CONCLUSION: The cranial approach is a safe method for laparoscopic anatomic liver resections of segments 2 and 3.
Asunto(s)
Venas Hepáticas/cirugía , Laparoscopía/métodos , Neoplasias Hepáticas/cirugía , Humanos , Hígado/cirugía , Neoplasias Hepáticas/patología , Tempo OperativoRESUMEN
BACKGROUND: Laparoscopic anatomic segmentectomy 8 is a difficult and technically demanding procedure owing to exposure of two major hepatic veins. To safely and accurately perform this procedure, the outer-Laennec approach was developed (Kiguchi et al., 2019) [1], which is based on the structure of Laennec's capsule (Sugioka et al., 2017; Laennec, 1802; Hayashi et al., 2008) [2,3,4]. The capsule comprises two layers: the hepatic and cardiac Laennec's capsules surrounding the major hepatic vein (Kiguchi et al., 2019) [1]. The outer-Laennec approach maintains the strength of the hepatic vein wall, preserving the two layers of Laennec's capsule. We describe a laparoscopic anatomic segmentectomy 8 using the outer-Laennec approach for hepatocellular carcinoma (HCC). METHODS: Parenchymal transection was initiated to expose the root of the middle hepatic vein and right hepatic vein with the cranio-caudal view. The space between the hepatic Laennec's capsule and liver parenchyma was invaded using the outer-Laennec approach. The cavitron ultrasonic surgical aspirator was used from the root side toward the peripheral side to retain the hepatic Laennec's capsule on the vein wall and avoid splitting the bifurcation of the hepatic vein. The parenchymal dissection process was completed by an S8 Glissonean pedicle dissection. RESULTS: The operative time was 296â¯min, and the estimated blood loss was 10â¯mL. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. A pathological examination confirmed that the 2.0-cm mass was HCC with negative margins. CONCLUSION: The outer-Laennec approach is feasible and useful to standardize the safe laparoscopic anatomic segmentectomy 8.