THERE ARE NO ADVANTAGES BETWEEN LAPAROSCOPIC AND OPEN LIVER RESECTIONS WITHIN AN ENHANCED RECOVERY PROGRAM (ERAS).

BACKGROUND: The use of a successful Enhanced Recovery After Surgery (ERAS) in colorectal surgery favored its application in other organs, and hepatic resections were not excluded from this tendency. Some authors suggest that the laparoscopic approach is a central element to obtain better results. AIM: To compare the laparoscopic vs. open hepatic resections within an ERAS to evaluate if there are any differences between them. METHODS: In a descriptive study 80 hepatic resections that were divided into two groups, regarding to whether they were submitted to laparoscopy or open surgery. Demographic data, those referring to the hepatectomy and the ERAS was analyzed. RESULTS: Forty-seven resections were carried out in open surgery and the rest laparoscopically; in the first group there was only one conversion to open surgery. Of the total, 17 resections were major hepatectomies and in 18 simultaneous resections. There were no differences between procedures regarding hospital stay and number of complications. There was a greater adherence to the ERAS (p=0.046) and a faster ambulation (p=0.001) in the open surgery. CONCLUSION: The procedure, whether open or laparoscopically done in hepatic resections, does not seem to show differences in an ERAS evaluation.

Pure Laparoscopic Anatomic Resection of the Segment 8 Dorsal Area Using the Dorsal Approach of the Right Hepatic Vein.

BACKGROUND: Anatomical resection of segment 8 (s8) is a challenging procedure. S8 can be subdivided into two areas: ventral (s8v) and dorsal (s8d). In the last years, different approaches for performing laparoscopic resection of s8 or any of its subsegments have been described, i.e. the hilar extrafascial approach, transfissural approach for s8v, transparenchymal approach for s8d, and the intrahepatic Glissonean approach. We recently described the dorsal approach of the right hepatic vein (RHV) for anatomical segment 7 resection. This video report describes the approach to a dorsal s8 pedicle using the RHV dorsal approach. METHODS: A 50-year-old woman with a history of morbid obesity and sleep apnea was diagnosed after episodes of hematochezia sigmoid cancer and a 2-cm liver metastases in the s8d, according to vascular reconstruction (Cella Medical Solutions, Murcia, Spain). The surgical technique started with mobilization of the right liver until the root of the RHV was identified and exposed in a craniocaudal fashion and until the s8d Glissonean pedicle was identified and clamped. Indocyanine green counterstaining depicted an intersegmental plane between the s8d and segment 5 and s8v. Transection continued until the anterior fissural vein was exposed at its root, as a landmark of the medial plane. RESULTS: Operative time lasted 265 min. Transection was carried out using the intermittent Pringle maneuver over a period of 81 min. Estimated blood loss was 252 cc. There were no postoperative complications and the patient was discharged on postoperative day 2. CONCLUSIONS: In some cases, the RHV dorsal approach can be used as the landmark for the s8d Glissonean pedicle, allowing anatomical resection of this particular area.

There are no advantages between laparoscopic and open liver resections within an enhanced recovery program (eras) / Não há vantagens entre as ressecções hepáticas laparoscópicas e abertas dentro de um programa de recuperação avançada (eras/acerto)

ABSTRACT Background: The use of a successful Enhanced Recovery After Surgery (ERAS) in colorectal surgery favored its application in other organs, and hepatic resections were not excluded from this tendency. Some authors suggest that the laparoscopic approach is a central element to obtain better results. Aim: To compare the laparoscopic vs. open hepatic resections within an ERAS to evaluate if there are any differences between them. Methods: In a descriptive study 80 hepatic resections that were divided into two groups, regarding to whether they were submitted to laparoscopy or open surgery. Demographic data, those referring to the hepatectomy and the ERAS was analyzed. Results: Forty-seven resections were carried out in open surgery and the rest laparoscopically; in the first group there was only one conversion to open surgery. Of the total, 17 resections were major hepatectomies and in 18 simultaneous resections. There were no differences between procedures regarding hospital stay and number of complications. There was a greater adherence to the ERAS (p=0.046) and a faster ambulation (p=0.001) in the open surgery. Conclusion: The procedure, whether open or laparoscopically done in hepatic resections, does not seem to show differences in an ERAS evaluation.

RESUMO Racional: O uso do protocolo Recuperação Otimizada Após Cirurgia (ERAS/ACERTO) com sucesso na cirurgia colorretal favoreceu a aplicação dele em outros órgãos; as ressecções hepáticas não foram excluídas dessa tendência. Alguns autores sugerem que a abordagem laparoscópica é elemento central para a obtenção de melhores resultados. Objetivo: Comparar as ressecções hepáticas laparoscópicas e abertas dentro de um ACERTO para avaliar se existem diferenças entre as duas técnicas. Métodos: Estudo descritivo comparando 80 ressecções hepáticas divididas em dois grupos, as realizadas por laparoscopia e aquelas por laparotomia. Foram analisados dados demográficos, referentes à hepatectomia e ao ACERTO. Resultados: Foram realizadas 47 ressecções por laparotomia e o restante por laparoscopia; houve apenas uma conversão para laparotomia no grupo da laparoscopia. Do total, 17 ressecções foram hepatectomias maiores e em 18 ressecções simultâneas. Não houve diferenças entre os procedimentos quanto ao tempo de internação e número de complicações. Houve maior adesão ao ACERTO (p=0,046) e deambulação mais rápida (p=0,001) na operação aberta. Conclusão: O procedimento, seja laparotômico ou laparoscópico nas ressecções hepáticas, não parece mostrar diferenças em uma avaliação ERAS/ACERTO.

Laparoscopic two stage hepatectomy: combined Glissonean approach of hepatic pedicles and dorsal approach of right and middle hepatic veins and vascular reconstruction.

Major vascular involvement often constitutes a contraindication to the laparoscopic approach. Lopez-Ben and colleagues described a purely laparoscopic surgical technique consisting of two stages, eight weeks apart, utilizing the caudal view and proximal approach for complete removal of colorectal liver metastases in close proximity to all three hepatic veins.

Evolution of laparoscopic surgery in a high volume hepatobiliary unit: 150 consecutive pure laparoscopic hepatectomies. / Evolución de la cirugía laparoscópica en una unidad hepatobiliar de alto volumen: 150 hepatectomías laparoscópicas consecutivas.

INTRODUCTION: Compared to other surgical areas, laparoscopic liver resection (LLR) has not been widely implemented and currently less than 20% of hepatectomies are performed laparoscopically worldwide. The aim of our study was to evaluate the feasibility, and the ratio of implementation of LLR in our department. METHODS: We analyzed a prospectively maintained database of 749 liver resections performed during the last 10-year period in a single centre. RESULTS: A total of 150 (20%) consecutive pure LLR were performed between 2005 and 2015. In 87% of patients the indication was the presence ofprimary or metastatic liver malignancy. We performed 30 major hepatectomies (20%) and (80%) were minor resections, performed in all liver segments. Twelve patients were operated twice and 2 patients underwent a third LLR. The proportion of LLR increased from 12% in 2011 to 62% in the last year. Conversion rate was 9%. Overall morbidity rate was 36% but only one third were classified as severe. The 90-day mortality rate was 1%. Median hospital stay was 4 days and the rate of readmissions was 6%. CONCLUSIONS: The implementation of LLR has been fast with morbidity and mortality comparable to other published series. In the last 2 years more than half of the hepatectomies are performed laparoscopically in our centre.

[Liver resections as radical surgery for hepatic hydatidosis: results in 50 patients]. / Resultados de las resecciones hepáticas como tratamiento radical de la hidatidosis hepatica en 50 pacientes.

INTRODUCTION: Among several regions in the world hepatic hydatidosis can be considered endemic. Currently there are many available treatments for this disease, been surgery the most effective one. Surgical procedures can be divided in two main groups, radical and non-radical procedures. The goal of this work is to evaluate the morbidity, mortality and percentage of recurrence in patients treated with hepatectomies, comparing them with other publications. MATERIAL AND METHODS: This retrospective study was carried out in a series from Spain and Argentina. We analyzed the following data: sex, age, type of resection, associated surgical gestures, presence of liver disease, operative time, blood transfusion, morbidity, mortality, hospital stay, re-hospitalization, recurrence and follow up. Dindo--Clavien classification was used for complications, and International Hepato-Pancreato-Biliary Association (IHPBA) Brisbane classification for hepatectomies. Mortality was considered until 90 days after surgery. To evaluate the recurence we only included patients followed over 6 months. RESULTS: Indications for liver resections were performed in patients with cysts larger than 5 centimeters, multiple cysts, large cysts, with bile duct communicated or suspicion of this communication. Five patients required blood transfusions (10%) with a median for these 5 patients of 740 ml and 74 ml for the complete series. The median operative time was 186 minutes (range 45 to 1,050 minutes). Median hospital stay was 7.7 days. Monitoring more than 6 months was conducted in 38 patients. CONCLUSIONS: We believe that hepatic hydatid disease is a multifaceted disease and requires more than one therapeutic approach. Hepatectomy with complete resection of the parasite offers the possibility of doing so in a controlled and safe way by experienced hands, ensuring good results in the treatment of this disease.

Pure laparoscopic liver resection reduces surgical site infections and hospital stay. Results of a case-matched control study in 50 patients.

BACKGROUND: Laparoscopic resection is an emerging tool in surgical oncology, but its role in liver tumors is far from being universally accepted. METHODS: We designed a case-matched control study, comparing laparoscopic (LAP) vs. open hepatectomies (OP) performed in the same center during the same period of time. Fifty LAP were performed (34 liver metastases, 7 hepatocellular carcinomas, 2 hydatid cysts, and 5 benign tumors). Cases were compared with 100 OP matched according to: diagnosis, number of lesions, type of resection, age, ASA score, and ECOG performance status. We evaluated intraoperative and postoperative parameters, focusing on morbidity and mortality. RESULTS: Preoperative data were comparable in both groups. Operative features were similar in terms of overall morbidity 18 (36 %) vs. 36 (36 %), p = 1; intraoperative bleeding, 401 (18-2192) vs. 475 (20-2000) mL, p = 0.89; pedicle clamping, 37 (74 %) vs. 88 (88 %), p = 0.55; margin, 0.6 (0-5) vs. 0.65 (0-5) cm, p = 0.94, and mortality p = 0.65 for the LAP and OP groups, respectively. There was a significant decrease in surgical site infections 1 (2 %) vs. 18 (18 %) p = 0.007 in the LAP group. Operative time was longer: 295 (120-600) vs. 200 (70-450) min (p = 0.0001), and hospital stay significantly shorter: 4 (1-60) vs. 7 (3-44) days, p = 0.0001 with less readmissions (0 vs. 7 %) in the LAP. DISCUSSION: In adequately selected patients, laparoscopic hepatectomy is feasible, safe, shortens hospital stay, and decreases surgical site infections.

[Hilar cholangiocarcinoma: The number of positive nodes and positive node/total node ratio is a significant prognostic factor for survival]. / Colangiocarcinoma hiliar: el número de ganglios positivos y la relación ganglios positivos/ganglios totales son un factor pronóstico importante de supervivencia.

INTRODUCTION: Surgical treatment of hilar cholangiocarcinoma remains a challenge. Multiple prognostic factors have been proposed. The number of positive nodes and the ratio between positive lymph node and total lymph node (G+/Gt) are considered by some authors as the most important factor. MATERIAL AND METHODS: We analyzed a series of 58 patients with Klatskin tumors. We evaluated the prognostic factors and survival with emphasis on the prognostic impact of the number of positive nodes and its relation to total lymph nodes. RESULTS: Resectability was 78% with a 5-year survival of 32%. The median number of nodes examined was 9.5. No significant differences were found in several of the proposed prognostic factors. The presence of 2 or more positive nodes or a ratio G+/Gt ≥ 0.2 were found to be poor prognostic factors. CONCLUSION: The relationship between positive lymph nodes and total lymph nodes and the number of positive lymph nodes are important prognostic factors.

Resultados de las resecciones hepáticas como tratamiento radical de la hidatidosis hepatica en 50 pacientes / [Liver resections as radical surgery for hepatic hydatidosis: results in 50 patients].

INTRODUCTION: Among several regions in the world hepatic hydatidosis can be considered endemic. Currently there are many available treatments for this disease, been surgery the most effective one. Surgical procedures can be divided in two main groups, radical and non-radical procedures. The goal of this work is to evaluate the morbidity, mortality and percentage of recurrence in patients treated with hepatectomies, comparing them with other publications. MATERIAL AND METHODS: This retrospective study was carried out in a series from Spain and Argentina. We analyzed the following data: sex, age, type of resection, associated surgical gestures, presence of liver disease, operative time, blood transfusion, morbidity, mortality, hospital stay, re-hospitalization, recurrence and follow up. Dindo--Clavien classification was used for complications, and International Hepato-Pancreato-Biliary Association (IHPBA) Brisbane classification for hepatectomies. Mortality was considered until 90 days after surgery. To evaluate the recurence we only included patients followed over 6 months. RESULTS: Indications for liver resections were performed in patients with cysts larger than 5 centimeters, multiple cysts, large cysts, with bile duct communicated or suspicion of this communication. Five patients required blood transfusions (10

) with a median for these 5 patients of 740 ml and 74 ml for the complete series. The median operative time was 186 minutes (range 45 to 1,050 minutes). Median hospital stay was 7.7 days. Monitoring more than 6 months was conducted in 38 patients. CONCLUSIONS: We believe that hepatic hydatid disease is a multifaceted disease and requires more than one therapeutic approach. Hepatectomy with complete resection of the parasite offers the possibility of doing so in a controlled and safe way by experienced hands, ensuring good results in the treatment of this disease.

Multicentre study of liver metastases from colorectal cancer in pathological livers.

OBJECTIVES: Resection of colorectal cancer (CRC) liver metastases (LM) in pathological liver (PL) patients (with cirrhosis or hepatopathy) is extremely rare. The aim of this study was to perform a multicentre, retrospective analysis of epidemiology, surgical techniques and outcomes in patients with PL who underwent hepatic resection for CRC-LM. METHODS: A retrospective, multicentre questionnaire was distributed to 15 hepatopancreatobiliary surgical units. RESULTS: Only six of 15 (40%) HPB units reported any experience in the surgical resection of CRC-LM in patients with PL. Of the 20 patients identified, 10 had underlying cirrhosis and 10 had chronic hepatopathy. Their median age was 66 years (range: 49-81 years). Thirteen patients were male. Liver dysfunction was known preoperatively in 18 patients. All patients had Child-Pugh class A disease. Six patients had synchronous disease. There were a total of 38 lesions among the 20 patients, distributed at a median of one lesion per patient (range: 1-4 lesions). The median size of the lesions was 3.0 cm (range: 1.5-9.0 cm). Preoperative median carcinoembryonic antigen (CEA) was 32.3 ng/ml (range: 1-184 ng/ml). The surgical procedures performed included: sub-segmentectomy (n= 12); left lateral sectionectomy (n= 6); segmentectomy (n= 4); radiofrequency ablation (n= 3), and exploratory laparotomy (n= 4). Morbidity occurred in four patients (Clavien grades I [n= 1], II [n= 2] and IVa [n= 1]). Mortality was nil. An R0 resection margin was achieved in 15 of 16 patients. Twelve patients did not receive chemotherapy. In resected patients, 10 presented with relapse. The median disease-free and overall survival periods were 12.2 and 22.3 months, respectively. CONCLUSIONS: When feasible, liver resection is the best option for CRC-LM in PL patients.

[Celiac artery stenosis and cephalic duodenopancreatectomy: an undervalued risk?]. / La estenosis del tronco celiaco y duodenopancreatectomía cefálica: ¿un riesgo infravalorado?

INTRODUCTION: Significant celiac trunk or artery stenosis (CAS) is normally asymptomatic. However, when the arteries of the pancreatoduodenal arcade are occluded, it could trigger a visceral ischaemia. The objective of this study is to determine whether preoperative CAS is a risk factor for developing complications in patients subjected to duodenopancreatectomy (DPC). MATERIAL AND METHODS: We have retrospectively analysed 58 consecutive patients subjected to DPC. We have associated significant CAS with post-surgical outcome. In all cases a 16-channel multidetector computed tomography (MDCT) in three hepatic phases was performed. We have reviewed the pre-surgical MDCT focusing on the morphology of the celiac artery (CA), particularly in the presence or absence of significant stenosis (>50%). RESULTS: We found CAS >50% in 13 patients (22%). The overall mortality was 5% (3 patients). Serious complications developed in 16 (28%) patients, 8 (62%) of whom belonged to the group with significant CAS (P=.004). Ten patients (17%) had a pancreatic fistula, 5 (38%) vs. 5 (11%) (P=.036); Fourteen patients (24%) needed new surgery, 7 (54%) vs. 7 (16%) (P=.009); Seven patients (12%) had a haemoperitoneum, 4 (31%) vs. 3 (7%) (P=.038), in the group with and without CAS, respectively. CONCLUSIONS: Significant radiological CAS is a risk factor of serious complications after DPC. The study of the calibre of the superior mesenteric artery (SMA) with MDCT should be routine before a DPC. The correction of a significant CAS should be evaluated preoperatively.

Extra-Glissonian approach in liver resection.

BACKGROUND: In this study we analyzed our most recent experience in the use of the extraglissonian approach to the hilar structures in two circumstances: pedicle transection during major liver resections, and selective clamping in minor hepatectomies. METHODS: The major liver resections study group consisted of 89 cases. Extraglissonian approach and stapler transection of hilar structures was used in 61 (69%). The study group of minor liver resections consisted of 103 cases. Extraglissonian approach and selective clamping was used in 27 cases (26%). RESULTS: In major hepatectomies pedicle stapling and hilar dissection demonstrated a similar operative time (240 vs. 260 min; P = 0.230); no differences were observed in the amount of haemorrhage (800 ml vs. 730 ml; P = 0.699), number of patients transfused (16 vs. 6; P = 0.418) and volume of blood transfused (4 PRC vs. 4 PRC; P = 0.521). Duration of vascular pedicle occlusion was 35 vs. 30 min respectively (P = 0.293). Major complications (grade >or=3a) occurred in 18 (20%) patients and mortality rates (4.9% vs. 3.5%; P = 0.882) were similar for both group. In minor liver resections there were no differences between Pringle and selective clamping in operative time (240 vs. 240 min; P = 0.321), haemorrhage (435 ml vs. 310 ml; P = 0.575), number of patients transfused (18 vs. 7; P = 0.505) and volume blood transfused (4 PRC vs. 3 PRC; P = 0.423). Major complications (grade >or=3a) occurred in 14 (14%) patients, and mortality (2.6% vs. 3.7%; P = 0.719) were similar for both groups. However, the duration of pedicle clamping was significantly longer in the selective clamping group (26 +/- 21 minutes vs. 44 +/- 18 minutes) (P = 0.001). CONCLUSIONS: The extraglissonian approach can be extremely useful in liver surgery. Selective clamping with extraglissonian approach avoids ischemia to the other hemiliver. Selective clamping it is also important from the homodynamic point of view because there is no splanchnic stasis and low fluid replacement.

[Major hepatectomies are safe in patients with cholangiocarcinoma and jaundice]. / Las hepatectomías mayores en pacientes con colangiocarcinoma e ictericia son seguras.

BACKGROUND: Surgical resection is the only possibility of long term survival in patients with Klatskin tumours. However, surgical resection is a challenging problem and hepatic resection is often necessary. OBJECTIVE: The aim of our study was to assess the need for biliary drainage, resection rate and outcome of hilar cholangiocarcinoma in a single tertiary referral centre. PATIENTS AND METHODS: From 2005 to 2008, 26 patients with Klatskin tumours were identified and assessed prospectively with multidetector CT and MR cholangiography in special cases. Seven patients (27%) were deemed to be unresectable in pre-operative staging. A total of 19 surgical procedures were performed, 8 left hepatectomies, 5 right hepatectomies and 6 resections exclusively of the biliary tree. RESULTS: Resection rate was 73%, transfusion rate 53% and preoperative biliary drainage was performed only in 7 cases (37%). Major complications occurred in 11 (58%), including two post-operative deaths (10%). There were no differences in the epidemiological data, when we separately analysed the outcomes of the 9 patients with bilirubin<15 mg/dL and the 10 patients with bilirubin>15 mg/dL. Biliary drainage was required in 6 (67%) patients in the group with low bilirubin levels vs. 1(10%) in the other group (P=0.02). The mean bilirubin level in the jaundiced group was 22.1+/-3.9 vs. 4.7+/-4.3 (P<0.001) in the other group. There were no differences in the postoperative outcome between both groups. CONCLUSION: Resection and survival rates have increased recently but still carries the risk of significant morbidity and mortality. Major hepatectomies in selected patients without percutaneous biliary drainage are safe.

[Results of hepatobiliary and pancreatic surgery according to DRG in a level 2 hospital surgery department during the years 2005-2006]. / Resultados de la cirugía hepatobiliopancreática en un servicio de cirugía de un hospital de segundo nivel según los GRD durante el bienio 2005-2006.

OBJECTIVE: To assess the results of the hepatobiliary and pancreatic surgery of a surgery department during 2005-2006 using the diagnostic related groups. MATERIALS AND METHOD: The data were obtained from the CMBD-HA of the Catalan Health Service. We assessed the frequency, hospital stay and mortality of the surgical procedures. The results were compared with the 63 public hospitals, and the 8 of them belonging to the Catalan Health Institute. RESULTS: In our area, a clear trend is observed in referrals for certain types of complex procedures on the liver, pancreas and biliary system excluding cholecystectomy with or without associated morbidities (7-11%) without exceeding the population percentage (12%). In our centre, the impact on hospital stay is more evident in complex procedures. The total savings in our centre during the years 2005-2006 compared with the XHUP hospitals group were 2212 days of hospital stay with an equivalent cost saving of more than one million euro. The frequency and the results of hospital stay and mortality of laparoscopic and open cholecystectomy were those expected for the population covered by a general hospital. The mortality in complex procedures was half of that of the whole public network or the ICS centres. CONCLUSIONS: In the complex hepatobiliary-pancreatic pathology, the mortality, and cost savings in our centre appear to be the result of, not only the high volume of procedures, but also to specialisation and factors related to the structure of the department, and surgeon training.

[Cephalic duodenopancreatectomy in periampullary tumours. Dissection of the superior mesenteric artery as aninitial approach. Description of the technique and an assessment of our initial experience]. / Duodenopancreatectomía cefálica en tumores periampulares. Disección de la arteria mesentérica superior como abordaje inicial. Descripción de la técnica y evaluación de nuestra experiencia inicial.

INTRODUCTION: Pancreatoduodenectomy (PD) with initial dissection of the superior mesenteric artery (SMA) has been described as a useful technical variant to reduce blood loss and to avoid an unnecessary intervention in those cases with arterial involvement. OBJECTIVES: To analyse the results of two recent technical modifications of PD introduced by our group: initial dissection of SMA and antecolic gastroenterostomy. PATIENTS AND METHOD: Patients were divided into two groups: with and without initial dissection of the SMA. The results were also analysed according to the type of gastric reconstruction. Perioperative and long-term results are compared. RESULTS: The overall mortality was 5%, with no significant differences between the initial SMA dissection and conventional PD. The transfusion rate (p < 0.001), the volume of blood products transfused (p = 0.001), and the overall complication rate were lower (p = 0.01) in the initial SMA dissection group. Also the postoperative hospital stay was significantly lower (p

[Role of intra-operative echography and computed tomography with multiple detectors in the surgery of hepatic metastases: a prospective study]. / Papel de la ecografía intraoperatoria y la tomografía computarizada con multidetectores en la cirugía de las metástasis hepáticas: estudio prospectivo.

OBJECTIVES: To study the performance of the intraoperative ecography in the diagnosis of new liver metastases in the era of computerized tomography (CT) with multidetectors and its impact on the surgical operation. PATIENTS AND METHOD: Between February 2005 and April 2006 patients with resectable liver metastases where studied prospectively in a multidisciplinary meeting (surgeons, radiologist, oncologist). The preoperative CT findings were compared with the intraoperative findings and ultrasound study and the results of the surgical operation. RESULTS: Forty-five candidates for curative surgery had a total of 171 hepatic lesions. CT correctly detected 115 lesions with a sensitivity of 67%, and a positive predictive value of 97%, with a false negative rate of 33% and false positive rate of 2%. In 5 patients intraoperative findings were the cause of changing the surgical procedure, three patients were unresectable (rate of resectability of 93%) and two patients needed a larger hepatic resection. CONCLUSIONS: CT with multidetectors and multidisciplinary meetings are the most important factors in the decision making of surgery of liver metastases with a high resectability rate. Intraoperative ecography is useful for the detection of 10% more liver metastases, but rarely involves a change in the surgical procedure.