Bovine Pericardial Graft for Portomesenteric Reconstruction During Robotic Pancreatoduodenectomy.

BACKGROUND: Minimally invasive pancreatoduodenectomy (PD) is one of the most complex procedures in oncologic surgery. We present a video of robotic portomesenteric reconstruction with bovine pericardial graft during PD. METHODS: A 52-year-old woman was referred with a mass in the head of the pancreas. The tumor was in contact with the portomesenteric axis. The multidisciplinary team decided to perform an upfront resection. The surgery was performed as a pylorus-preserving pancreaticoduodenectomy with lymphadenectomy. The superior mesenteric artery first approach was used to expose the head of the pancreas, so that the entire surgical specimen was attached only through the tumor invasion of the portomesenteric axis. After resection of the invaded portomesenteric axis, its large extension precluded primary reconstruction, so a bovine pericardial graft was used for venous reconstruction. After completion of the venous anastomosis, reconstruction of the digestive tract was performed as usual. RESULTS: Surgical time was 430 min; clamp time was 55 min; and portomesenteric reconstruction took 41 min. Estimated blood loss was 320 mL without transfusion. Pathology confirmed T3N1 ductal adenocarcinoma with free margins. No pancreatic or biliary fistula was observed, and she was discharged on postoperative day 8. A postoperative examination confirmed the patency of the graft. The patient is doing well 6 months after surgery and has no signs of the disease. CONCLUSIONS: A bovine pericardial graft is useful for reconstruction and readily available, eliminating the need to harvest an autologous vein or use synthetic grafts. This procedure can be safely performed with the robotic platform.

HEPATOSPLENIC SCHISTOSOMIASIS-ASSOCIATED CHRONIC PORTAL VEIN THROMBOSIS: RISK FACTOR FOR HEPATOCELLULAR CARCINOMA?

BACKGROUND: Hepatosplenic schistosomiasis is an endemic disease prevalent in tropical countries and is associated with a high incidence of portal vein thrombosis. Inflammatory changes caused by both parasitic infection and portal thrombosis can lead to the development of chronic liver disease with potential carcinogenesis. AIMS: To assess the incidence of portal vein thrombosis and hepatocellular carcinoma in patients with schistosomiasis during long-term follow-up. METHODS: A retrospective study was conducted involving patients with schistosomiasis followed up at our institution between 1990 and 2021. RESULTS: A total of 126 patients with schistosomiasis were evaluated in the study. The mean follow-up time was 16 years (range 5-31). Of the total, 73 (57.9%) patients presented portal vein thrombosis during follow-up. Six (8.1%) of them were diagnosed with hepatocellular carcinoma, all with portal vein thrombosis diagnosed more than ten years before. CONCLUSIONS: The incidence of hepatocellular carcinoma in patients with schistosomiasis and chronic portal vein thrombosis highlights the importance of a systematic long-term follow-up in this group of patients.

A new technique of duodenojejunostomy may reduce the rate of delayed gastric emptying after pylorus-preserving pancreatoduodenectomy: The growth factor technique (with video).

BACKGROUND: Despite various technical modifications, delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy. DGE results in longer hospital stay, higher cost, lower quality of life, and delay of adjuvant therapy. We have developed a modified duodenojejunostomy technique to reduce the incidence of DGE. Here we evaluate our 4-year experience with this technique. METHODS: This study evaluated consecutive patients who underwent pylorus-preserving pancreatoduodenectomy using the growth factor technique. It consists of performing a posterior seromuscular running suture with a zigzag stitch that stretches the jejunum and allows future growth of the anastomosis. This results in a longer jejunal opening. The angles at the edge of the duodenum are cut to accommodate the duodenal opening to the longer jejunum (the growth factor). The anterior seromuscular layer is then performed with interrupted sutures to accommodate the larger anastomosis. These patients were compared with a cohort of patients (n = 103) before the introduction of this new technique using propensity score matching. RESULTS: 134 patients underwent pylorus-preserving pancreatoduodenectomy. Delayed gastric emptying occurred in only three patients (2.2%), one grade B and two grade C. Compared with the 103 patients in the control group with standard technique, the incidence of DGE was significantly higher (11.6%; P = 0.00318). The median hospital stay was also statistically longer in the control group (P = 0.048704). A similar trend was observed in the matched cohort; the proportion of patients who developed DGE was significantly (P = 0.005) lower in the growth factor technique group (2.1% vs. 12.9%). Hospital stay was significantly longer in the standard group (P = 0.008), and patients operated on with the standard technique resumed feeding later than those with the growth factor technique. CONCLUSIONS: This study demonstrated that the new technique of duodenojejunostomy can reduce the incidence and severity of DGE and allow earlier hospital discharge. Comparative studies are still needed to confirm these preliminary results.

Robotic Hepatic Bisegmentectomy (s4b + s5) and Hilar Lymphadenectomy for Incidental Gallbladder Cancer Using Glissonian Approach.

BACKGROUND: Gallbladder carcinoma is a rare cancer with a poor prognosis and the most common biliary tract malignancy. This video shows robotic treatment of a patient with incidental gallbladder cancer diagnosed after laparoscopic cholecystectomy. The operation consisted of a robotic bisegmentectomy (liver segments 4b and 5) using a Glissonian approach and a hilar lymphadenectomy. METHODS: A 73-year-old woman with no relevant history underwent a laparoscopic cholecystectomy at another hospital facility. The pathology revealed a gallbladder carcinoma. The patient was then referred for further treatment. Pathologic revision confirmed T2a carcinoma and staging was negative for distant metastases. The multidisciplinary team decided on a radical resection that will consist of a hilar lymphadenectomy and a frozen section of the cystic stump along the resection of segments 4b and 5. A robotic approach was proposed, and consent was obtained. RESULTS: The operation time was 300 min and was performed 21 days after the cholecystectomy. Estimated blood loss was 120 mL with no transfusions required during or after the procedure. The postoperative recovery was uneventful, and the patient was discharged on the fourth postoperative day. The final pathology showed no residual disease in the liver specimen and no metastases among 16 removed lymph nodes. CONCLUSIONS: The robotic approach is safe and feasible for radical treatment after incidentally discovered gallbladder cancer. The Glissonian approach is useful for anatomic resection of liver segments 4b and 5. This video can help oncologic surgeons to perform this challenging procedure.

Robotic Left Trisectionectomy with Glissonian Approach (with Video).

BACKGROUND: Left hepatic trisectionectomy consists of the removal of liver segments 2, 3, 4, 5, and 8. This difficult surgical procedure may be required when the left liver and right anterior sector (segments 5 and 8) are involved. We present a video of a robotic anatomic left trisectionectomy with Glissonian approach to the left and right anterior sector pedicles. METHODS: A 77-year-old man presented at a routine ultrasound with a large liver mass. Magnetic resonance imaging showed a bulky hepatocellular carcinoma occupying liver segments 2, 3, 4, 5, and 8, with a portal tumor thrombus in the right anterior sector. The patient had multiple comorbidities, including obesity, diabetes, hypertension, and coronariopathy. The multidisciplinary team decided to use immunotherapy with atezolizumab and bevacizumab. After 12 cycles, the patient showed an objective response, and left trisectionectomy was indicated. A robotic approach was proposed and consent was obtained. The Glissonian approach was used for anatomic control of the left and right anterior sector pedicles. RESULTS: The operative time was 390 min with an estimated blood loss of 410 ml, and no transfusion was required during or after the procedure. Recovery was uneventful and the patient was discharged on postoperative day 8. No bile leak was observed, and the drain was removed on postoperative day 8. CONCLUSIONS: Robotic left trisectionectomy is safe and feasible. The Glissonian approach is useful for anatomic left liver trisectionectomy. This video can help gastrointestinal surgeons perform this complex procedure in a minimally invasive manner.

Multiple colorectal liver metastases resection can offer long-term survival: The concept of a chronic neoplastic disease.

BACKGROUND: Resection for colorectal liver metastases has evolved significantly and, currently, there are no limits to the number of resected nodules. This study aimed to evaluate the outcomes and prognostic factors after liver resection for patients with ≥4 colorectal liver metastases, emphasizing long-term survival. METHODS: The study population consisted of 137 patients with ≥4 colorectal liver metastases out of a total of 597 patients with colorectal liver metastases who underwent curative intent liver resection from January 2010 to July 2019 in a single hepatobiliary center. RESULTS: The probability of overall and disease-free survival at 1, 3, and 5 years was 90.8%, 64.5%, 40.6%, and 37.7%, 19.3%, 18.1%, respectively. In a multivariate analysis for overall survival, the size of the largest metastatic nodule was the only unfavorable factor (P = .001). For disease-free survival, complete pathological response was a favorable factor (P = .04), and the following were negative factors: number of nodules ≥7 (P = .034), radiofrequency ablation during surgery (P = .04), positive primary tumor lymph nodes (P = .034), R1 resection (P = .011), and preoperative carcinoembryonic antigen >20 ng/mL (P = .015). After the first and second years of follow-up, 59 patients (45.3%) and 45 patients (34.6%), respectively, were not receiving chemotherapy. After 5 years of follow-up, 21 (16.1%) multimetastatic patients were chemotherapy-free. CONCLUSION: A significant number of patients with multiple colorectal liver metastases will present long-term survival and should not be denied surgery. The long-term survival rates, even in the presence of recurrence, characterize a chronic neoplastic disease.

Hepatosplenic schistosomiasis-associated chronic portal vein thrombosis: risk factor for hepatocellular carcinoma? / Esquistossomose hepatosplênica associada à trombose crônica da veia porta: fator de risco para o carcinoma hepatocelular?

ABSTRACT BACKGROUND: Hepatosplenic schistosomiasis is an endemic disease prevalent in tropical countries and is associated with a high incidence of portal vein thrombosis. Inflammatory changes caused by both parasitic infection and portal thrombosis can lead to the development of chronic liver disease with potential carcinogenesis. AIMS: To assess the incidence of portal vein thrombosis and hepatocellular carcinoma in patients with schistosomiasis during long-term follow-up. METHODS: A retrospective study was conducted involving patients with schistosomiasis followed up at our institution between 1990 and 2021. RESULTS: A total of 126 patients with schistosomiasis were evaluated in the study. The mean follow-up time was 16 years (range 5-31). Of the total, 73 (57.9%) patients presented portal vein thrombosis during follow-up. Six (8.1%) of them were diagnosed with hepatocellular carcinoma, all with portal vein thrombosis diagnosed more than ten years before. CONCLUSIONS: The incidence of hepatocellular carcinoma in patients with schistosomiasis and chronic portal vein thrombosis highlights the importance of a systematic long-term follow-up in this group of patients.

RESUMO RACIONAL: A esquistossomose hepatoesplênica é uma doença endêmica prevalente em países tropicais e está associada a uma alta incidência de trombose da veia porta. Alterações inflamatórias causadas tanto pela infecção parasitária quanto pela trombose portal podem levar ao desenvolvimento de doença hepática crônica com potencial carcinogênico. OBJETIVOS: Avaliar a incidência de trombose da veia porta e carcinoma hepatocelular em pacientes com esquistossomose durante um seguimento de longo prazo. MÉTODOS: Foi realizado estudo retrospectivo envolvendo pacientes com esquistossomose acompanhados em nossa instituição entre 1990 e 2021. RESULTADOS: Um total de 126 pacientes com esquistossomose foram avaliados no estudo. O tempo médio de acompanhamento foi de 16 anos (variando de 5 a 31). Do total, 73 (57,9%) pacientes apresentaram trombose da veia porta durante o seguimento e seis (8,1%) deles foram diagnosticados com carcinoma hepatocelular, todos com trombose da veia porta diagnosticada há mais de 10 anos. CONCLUSÕES: A incidência de carcinoma hepatocelular em pacientes com esquistossomose e trombose da veia porta crônica destaca a importância de um acompanhamento sistemático de longo prazo nesse grupo de pacientes.

Two decades of liver resection with a multidisciplinary approach in a single institution: What has changed? Analysis of 1409 cases.

OBJECTIVES: To evaluate results of patients undergoing liver resection in a single center over the past two decades with a particular look at Colorectal Liver Metastasis (CRLM) and Hepatocellular Carcinoma (HCC). METHOD: Patients were divided into two eras, from 2000 to 2010 (Era 1) and 2011 to 2020 (Era 2). The most frequent diagnosis was CRLM and HCC, with 738 (52.4%) and 227 (16.1%) cases respectively. An evaluation of all liver resection cases and a subgroup analysis of both CRLM and HCC were performed. Preoperative and per operative variables and long-term outcomes were evaluated. RESULTS: 1409 liver resections were performed. In Era 2 the authors observed higher BMI, more: minimally invasive surgeries, Pringle maneuvers, and minor liver resections; and less transfusion, less ICU necessity, and shorter length of hospital stay. Severe complications were observed in 14.7% of patients, and 90-day mortality was 4.2%. Morbidity and mortality between eras were not different. From 738 CRLM resections, in Era 2 there were significantly more patients submitted to neoadjuvant chemotherapy, bilateral metastases, and smaller sizes with significantly less transfusion, the necessity of ICU, and shorter length of hospital stay. More pedicle clamping, minimally invasive surgeries, and minor resections were also observed. From 227 HCC resections, in Era 2 significantly more minimally invasive surgeries, fewer transfusions, less necessity of ICU, and shorter length of hospital stay were observed. OS was not different between eras for CRLM and HCC. CONCLUSIONS: Surgical resection in a multidisciplinary environment remains the cornerstone for the curative treatment of primary and metastatic liver tumors.