PARTIAL HEPATECTOMY USING LINEAR CUTTER STAPLER: ARE THERE ADVANTAGES?

BACKGROUND: Morbidity of liver resections is related to intraoperative bleeding and postoperative biliary fistulas. The Endo-GIA stapler (EG) in liver resections is well established, but its cost is high, limiting its use. The linear cutting stapler (LCS) is a lower cost device. AIMS: To report open liver resections, using LCS for transection of the liver parenchyma and en bloc stapling of vessels and bile ducts. METHODS: Ten patients were included in the study. Four patients with severe abdominal pain had benign liver tumors (three adenomas and one focal nodular hyperplasia). Among the remaining six patients, four underwent liver resection for the treatment of colorectal liver metastases, three of which had undergone preoperative chemotherapy. The other two cases were one patient with metastasis from a testicular teratoma and the other with metastasis from a gastrointestinal neuroectodermal tumor. RESULTS: The average length of stay was five days (range 4-7 days). Of the seven patients who underwent resections of segments II/III, two presented postoperative complications: one developed a seroma and the other a collection of abdominal fluid who underwent percutaneous drainage, antibiotic therapy, and blood transfusion. Furthermore, the three patients who underwent major resections had postoperative complications: two developed anemia and received blood transfusions and one had biloma and underwent percutaneous drainage and antibiotic therapy. CONCLUSIONS: The use of the linear stapler in hepatectomies was efficient and at lower costs, making it suitable for use whenever EG is not available. The size of the LCS stapler shaft is more suitable for en bloc transection of the left lateral segment of the liver, which is thinner than the right one. Further studies are needed to evaluate the safety of LCS for large liver resections and resections of tumors located in the right hepatic lobe.

Partial hepatectomy using linear cutter stapler: are there advantages? / Hepatectomia parcial empregando grampeador linear cortante: há vantagens?

ABSTRACT BACKGROUND: Morbidity of liver resections is related to intraoperative bleeding and postoperative biliary fistulas. The Endo-GIA stapler (EG) in liver resections is well established, but its cost is high, limiting its use. The linear cutting stapler (LCS) is a lower cost device. AIMS: To report open liver resections, using LCS for transection of the liver parenchyma and en bloc stapling of vessels and bile ducts. METHODS: Ten patients were included in the study. Four patients with severe abdominal pain had benign liver tumors (three adenomas and one focal nodular hyperplasia). Among the remaining six patients, four underwent liver resection for the treatment of colorectal liver metastases, three of which had undergone preoperative chemotherapy. The other two cases were one patient with metastasis from a testicular teratoma and the other with metastasis from a gastrointestinal neuroectodermal tumor. RESULTS: The average length of stay was five days (range 4-7 days). Of the seven patients who underwent resections of segments II/III, two presented postoperative complications: one developed a seroma and the other a collection of abdominal fluid who underwent percutaneous drainage, antibiotic therapy, and blood transfusion. Furthermore, the three patients who underwent major resections had postoperative complications: two developed anemia and received blood transfusions and one had biloma and underwent percutaneous drainage and antibiotic therapy. CONCLUSIONS: The use of the linear stapler in hepatectomies was efficient and at lower costs, making it suitable for use whenever EG is not available. The size of the LCS stapler shaft is more suitable for en bloc transection of the left lateral segment of the liver, which is thinner than the right one. Further studies are needed to evaluate the safety of LCS for large liver resections and resections of tumors located in the right hepatic lobe.

RESUMO RACIONAL: A morbidade das ressecções hepáticas está relacionada a sangramento intraoperatório e fístulas biliares pós-operatórias. O grampeador Endo-GIA (EG) em ressecções hepáticas está bem estabelecido, mas o seu custo é elevado, limitando seu uso. O grampeador de corte linear (LCS) é um dispositivo com menor custo. OBJETIVOS: Relatar ressecções hepáticas abertas, empregando o LCS para transecção do parênquima hepático e grampeamento em bloco de vasos e ductos biliares. MÉTODOS: Dez pacientes foram incluídos no estudo. Quatro pacientes com dor abdominal importante apresentavam tumores hepáticos benignos (três adenomas e um hiperplasia nodular focal). Dentre os demais seis pacientes, quatro foram submetidos à ressecção hepática para o tratamento de metástases hepáticas colorretais, sendo que três deles haviam sido submetidos à quimioterapia pré-operatória. Os dois outros casos foram um paciente com metástase de teratoma testicular e o outro com metástase de tumor neuroectodérmico gastrointestinal. RESULTADOS: O tempo médio de internação foi de 5 dias (variação=4-7 dias). Dos sete pacientes submetidos a ressecções dos segmentos II/III, dois apresentaram complicações pós-operatórias: um paciente desenvolveu seroma e o outro uma coleção de fluido abdominal submetido a drenagem percutânea, antibioticoterapia e transfusão de sangue. Além disso, os três pacientes submetidos a ressecções maiores tiveram complicações pós-operatórias: dois pacientes desenvolveram anemia e receberam transfusões de sangue e um paciente apresentou biloma e foi submetido a drenagem percutânea e antibioticoterapia. CONCLUSÕES: O emprego do grampeador linear nas hepatectomias foi eficiente e a custos mais baixos, tornando-o adequado para uso sempre que EG não estiver disponível O tamanho da haste do grampeador LCS é mais adequado para a transecção em bloco do segmento lateral esquerdo do fígado, que é mais fino que o direito. Novos estudos são necessários para avaliar a segurança do LCS para grandes ressecções hepáticas e ressecções de tumores localizados no lobo hepático direito.

Elastic Fibers Density: a New Parameter of Improvement of NAFLD in Bariatric Surgery Patients.

PURPOSE: Obesity is a major risk factor for nonalcoholic fatty liver disease (NAFLD), affecting 25% of the worldwide population. Weight loss through bariatric surgery can improve much of the liver steatosis, inflammation, and fibrosis. However, it is not known whether there is reversal of the elastic fiber deposition process, triggered by hepatic damage and related to worse prognosis. MATERIALS AND METHODS: Individuals submitted to bariatric surgery at our institution, from March 2016 to June 2017, with intraoperative liver biopsy confirming NAFLD were approached. Those who consented were submitted to a second liver biopsy 1 year later and were included. Specimens were sliced and stained with hematoxylin-eosin and Sirius red for histological assessment according to Brunt's criteria and with orcein for digital analysis morphometrics using ImageJ®. Quantification of elastic fibers was accomplished by corrected integrated density. RESULTS: Thirty-seven patients were included. Body mass index, metabolic markers, NAFLD activity score, and fibrosis improved 1 year after the procedure. The elastic fiber density showed a significant decrease: 239.3 × 103 absorbance micrometer2 (141.08-645.32) to 74.62 × 103 absorbance micrometer2 (57.42-145.17), p = 0.007. CONCLUSION: Liver elastic fiber density decreases with the reversal of NAFLD through weight loss.

Are Noninvasive Methods Comparable to Liver Biopsy in Postoperative Patients After Roux-en-Y Gastric Bypass?

INTRODUCTION: Transient tissue elastography (TTE) may estimate the degree of hepatic fibrosis in patients with obesity, but the method has restrictions that are mainly related to patients' BMI. PURPOSE: To compare the results of the evaluation of hepatic fibrosis by biochemical methods and TTE with those determined by liver biopsy in patients after RYGB. METHODS: This was a cross-sectional study involving patient data, TTE, and liver biopsy 1 year after RYGB. RESULTS: Of the 94 selected patients, 33 underwent TTE and liver biopsy. The average weight of patients was 84.4 ± 15.4 kg. The mean APRI was 0.2 ± 0.1, and 36 patients (97.3%) were classified as F0-F1. The average NFS was - 2.0 ± 1.0, with 25 patients (67%) classified as F0-F1 and 12 patients (32.4%) classified as F2. The agreement rate between Fibroscan and liver biopsy was 80.0%. Histological analysis revealed regression of inflammatory changes in all patients: 26 patients (72.2%) had some degree of non-alcoholic steatohepatitis (NAS ≥ 5), and after surgery, no patient presented inflammation upon biopsy. Nine patients (24.3%) had fibrosis at surgery, and only two (5.4%) still had fibrosis 1 year later (p < 0.008). CONCLUSIONS: The use of APRI and Fibroscan is promising, but more studies are needed to evaluate patients with an advanced degree of NAFLD and confirm the entire spectrum of the disease.