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1.
World J Gastroenterol ; 25(28): 3753-3763, 2019 Jul 28.
Artigo em Inglês | MEDLINE | ID: mdl-31391770

RESUMO

Hepatic sinusoidal obstruction syndrome (HSOS) can be caused by the intake of pyrrolizidine alkaloids (PAs). To date, PAs-induced HSOS has not been extensively studied. In view of the difference in etiology of HSOS between the West and China, clinical profiles, imaging findings, treatment, and outcomes of HSOS associated with hematopoietic stem cell transplantation or oxaliplatin might be hardly extrapolated to PAs-induced HSOS. Reactive metabolites derived from PAs form pyrrole-protein adducts that result in toxic destruction of hepatic sinusoidal endothelial cells. PAs-induced HSOS typically manifests as painful hepatomegaly, ascites, and jaundice. Laboratory tests revealed abnormal liver function tests were observed in most of the patients with PAs-induced HSOS. In addition, contrast computed tomography and magnetic resonance imaging scan show that patients with PAs-induced HSOS have distinct imaging features, which reveal that radiological imaging provides an effective noninvasive method for the diagnosis of PAs-induced HSOS. Liver biopsy and histological examination showed that PAs-induced HSOS displayed distinct features in acute and chronic stages. Therapeutic strategies for PAs-induced HSOS include rigorous fluid management, anticoagulant therapy, glucocorticoids, transjugular intrahepatic portosystemic shunt, liver transplantation, etc. The aim of this review is to describe the pathogenesis, clinical profiles, diagnostic criteria, treatment, and outcomes of PAs-induced HSOS.


Assuntos
Veias Hepáticas/patologia , Hepatopatia Veno-Oclusiva/diagnóstico , Plantas Comestíveis/toxicidade , Alcaloides de Pirrolizidina/toxicidade , Anticoagulantes/uso terapêutico , Biópsia , China , Células Endoteliais/patologia , Endotélio Vascular/citologia , Endotélio Vascular/patologia , Hidratação/métodos , Glucocorticoides , Veias Hepáticas/citologia , Veias Hepáticas/diagnóstico por imagem , Hepatopatia Veno-Oclusiva/induzido quimicamente , Hepatopatia Veno-Oclusiva/terapia , Humanos , Fígado/irrigação sanguínea , Fígado/diagnóstico por imagem , Fígado/patologia , Testes de Função Hepática , Transplante de Fígado , Imagem por Ressonância Magnética , Plantas Comestíveis/química , Derivação Portossistêmica Transjugular Intra-Hepática , Tomografia Computadorizada por Raios X , Resultado do Tratamento
2.
BMC Surg ; 19(1): 122, 2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31455319

RESUMO

BACKGROUND: Presence of inferior vena cava tumor thrombosis (IVCTT) is an unfavorable factor to prognosis for patients with hepatocellular carcinoma (HCC). CASE PRESENTATION: Herein we report a case of HCC with IVC tumor thrombosis extending from the right hepatic vein (RHV) to the IVC, but it had not infiltrated the right atrium. Anterior approach right hepatectomy combined with IVC thrombectomy using trans-diaphragmatic IVC occlusion was performed for this patient. The patient is alive with disease-free at 32 months after treatment. A literature review was also performed. This case was demonstrated with the details and concepts of surgery. CONCLUSION: This case suggested that surgical resection of HCC involving the IVC, but still outside the right atrium (RA), could offer satisfactory surgical outcomes in selected patients.


Assuntos
Carcinoma Hepatocelular/cirurgia , Hepatectomia/métodos , Neoplasias Hepáticas/cirurgia , Trombectomia/métodos , Veias Hepáticas/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Veia Cava Inferior/cirurgia , Trombose Venosa/patologia
3.
J Surg Oncol ; 120(4): 654-660, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31309549

RESUMO

Preservation of the future liver remnant (FLR) vascular integrity has always been considered crucial to achieving successful liver growths after major hepatectomies. Most surgeons appeared therefore reluctant to combine stage I of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) with vascular reconstructions. Here we describe a case series, where we combine parenchymal transection and venous in- or outflow reconstruction of the FLR at stage I of ALPPS. In addition, the cold flush of the FLR or delayed portal vein embolization is applied in selected cases.


Assuntos
Hepatectomia/métodos , Veias Hepáticas/cirurgia , Neoplasias Hepáticas/cirurgia , Veia Porta/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Idoso , Seguimentos , Veias Hepáticas/patologia , Humanos , Ligadura , Neoplasias Hepáticas/patologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Veia Porta/patologia , Estudos Retrospectivos
4.
Ann Surg Oncol ; 26(11): 3681, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31183642

RESUMO

BACKGROUND: As defined by Couinaud et al. and Takasaki et al., the dorsal sector (DS) or caudate area is the portion of liver parenchyma located between the retrohepatic inferior vena cava (IVC) and the main hepatic veins confluence.1,2 Its complete resection, usually approached by right- or left-sided liver parenchymotomy, remains technically challenging.3,4 Moreover, these approaches usually fail to properly expose the middle (paracaval portion) and most cranial portion (i.e. behind the hepatic vein confluence) of the DS.5 METHODS: We report the case of a 50-year-old woman presenting with a unique metachronous hepatic metastasis of a colorectal adenocarcinoma. The 40-mm lesion was located behind the confluence of the three main hepatic veins, in front of the IVC, and extended caudally behind the hepatic hilum, thereby occupying the paracaval portion of the DS. The tumor board decision was surgical resection. RESULTS: The procedure included complete anatomic resection of the DS using an anterior transhepatic approach by opening the liver midplane along the Cantlie line. A well-tolerated continuous pedicle and IVC clamping of 30 min was used. The duration of the surgery was 120 min, and the blood loss was 200 mL. The patient was discharged on postoperative day 5. R0 resection was achieved and the patient was free of disease at 1 year post-surgery. CONCLUSION: Anatomic resection of the DS using a transparenchymal anterior approach is a safe and feasible procedure especially suitable for voluminous tumors. It allows the control of all major vascular structures narrowing the lesion, and facilitates an R0 resection.


Assuntos
Adenocarcinoma/cirurgia , Neoplasias Colorretais/cirurgia , Hepatectomia/métodos , Veias Hepáticas/cirurgia , Neoplasias Hepáticas/cirurgia , Veia Cava Inferior/cirurgia , Adenocarcinoma/patologia , Neoplasias Colorretais/patologia , Feminino , Veias Hepáticas/patologia , Humanos , Neoplasias Hepáticas/secundário , Pessoa de Meia-Idade , Prognóstico , Veia Cava Inferior/patologia
5.
Surg Oncol ; 29: 140-141, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31196479

RESUMO

BACKGROUND: Among the laparoscopic anatomical liver resections, the right posterior sectionectomy is highly demanding [1, 2], particularly when exposing the right hepatic vein (RHV). To standardize the procedure, the inter-Laennec approach was developed based on the Laennec's capsule structure, composed of two layers surrounding the RHV. One is derived from the proper membrane (hepatic Laennec's capsule) and the other from the pericardium (cardiac Laennec's capsule) [3]. The inter-Laennec approach is a new strategy to expose the RHV by entering the space between the two layers. Herein, we present the concept and procedure of the inter-Laennec approach. METHODS: The patient with 15-mm metastatic tumor close to the right posterior Glissonean pedicle and RHV was placed in left semi-prone position to obtain a good visual field [4]. After the isolation of the extrahepatic right posterior Glissonean pedicle and mobilization of the right liver, we transected the inferior vena cava ligament that facilitated entry into the inter-Laennec space between the hepatic and cardiac Laennec's capsules. We started the liver parenchyma transection between the right posterior section and caudate lobe, followed by cranio-caudal parenchymal dissection along the inter-Laennec space that safely facilitated the exposure of the RHV and confluences of the V7s. RESULTS: The operative time and estimated blood loss were 538 min and 250 mL, respectively. The surface of the RHV was completely exposed with a whitish and shiny appearance, suggesting it was covered by the cardiac Laennec's capsule. CONCLUSION: The inter-Laennec approach is a feasible procedure to standardize laparoscopic right posterior sectionectomy.


Assuntos
Hepatectomia/métodos , Veias Hepáticas/cirurgia , Laparoscopia/métodos , Neoplasias Hepáticas/cirurgia , Perda Sanguínea Cirúrgica/prevenção & controle , Veias Hepáticas/patologia , Humanos , Neoplasias Hepáticas/secundário , Prognóstico , Decúbito Ventral
6.
Transplant Proc ; 51(5): 1629-1632, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31155207

RESUMO

Thrombosis of the inferior vena cava is a clinical condition with very diverse presentations, ranging from asymptomatic patients to others with severe edema in the legs and lower torso. We report the case of a 27-year-old female patient, previously diagnosed with autoimmune hepatitis, with asymptomatic extensive thrombosis of the inferior vena cava. The thrombus extended from the renal veins up to the emergence of the hepatic veins, causing post-sinusoidal portal hypertension (Budd-Chiari syndrome). The patient underwent an orthotopic cadaveric liver transplant with removal of the retrohepatic vena cava and thrombectomy of blood clots from the infrahepatic vena cava. She initially recovered well from surgery, but on the 8 postoperative day she had a significant increase in hepatic injury markers and was diagnosed with rethrombosis of the inferior vena cava and hepatic veins. A surgical thrombectomy was performed, with an intraoperative finding of chronic thrombus in both renal veins, previously undiagnosed. The thrombectomy was successful, but the patient's hepatic function continued to worsen and a second liver transplant was performed. After the second transplant she underwent several imaging exams that showed no signs of rethrombosis. She was kept on postoperative anticoagulation indefinitely, first with intravenous heparin then with rivaroxaban. An extensive investigation failed to identify any causes of thrombophilia associated with this vast thrombosis. She is currently alive and with good graft function 1 year and 4 months after the second transplant.


Assuntos
Transplante de Fígado , Veia Cava Inferior/patologia , Trombose Venosa/etiologia , Adulto , Feminino , Veias Hepáticas/patologia , Humanos , Recidiva , Veias Renais/patologia , Reoperação , Trombectomia , Trombose/complicações , Trombose/cirurgia
7.
Cardiovasc Intervent Radiol ; 42(9): 1311-1321, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31218407

RESUMO

OBJECTIVE: This retrospective study evaluated interventional treatments (recanalization, balloon dilation, and/or stent placement) for Budd-Chiari syndrome (BCS), caused by combined obstruction of the inferior vena cava (IVC) and hepatic veins (HVs). METHODS: Before and after interventional therapy, patients with BCS (n = 162; asymptomatic 105.2 ± 103.3 mo; follow-up 15 [6-24] mo) underwent imaging studies (color Doppler ultrasound, CT, or MRI), and inferior vena cavography and manometry. Venous lesions were characterized by occlusion features, and presence of thrombosis and peripheral collateral vessels. RESULTS: One, 2, and 3 main HV occlusions were observed, respectively, in 25 (15.4%), 61 (37.7%), and 76 (46.9%) patients. Eighty-three (51.2%), 98 (60.5%), and 104 (64.2%) patients had, respectively, large accessory HVs, venous collaterals formed between the HVs, or venous communicating branches between the HV and the peritoneal veins. The middle, left, and right HV was patent in 32 (19.8%), 35 (21.6%), and 44 (27.2%) patients. Recanalization of both hepatic and caval occlusions was successful in 96% (51/53) of those attempted; recanalization of IVC occlusion was successful in 97% (106/109). Among 157 patients successfully treated, 146 were cured and 11 showed clinical improvement. Clinical symptoms were relieved in 82.4% after the initial intervention, and 94.2% after the second intervention. CONCLUSION: Recanalization and balloon angioplasty was effective for the management of BCS with concurrent HV and IVC occlusions. The majority of patients required only IVC recanalization. The outcome of patients treated only by IVC intervention was similar to that of patients given combined HV and IVC intervention.


Assuntos
Síndrome de Budd-Chiari/cirurgia , Procedimentos Endovasculares/métodos , Veias Hepáticas/patologia , Veias Hepáticas/cirurgia , Veia Cava Inferior/patologia , Veia Cava Inferior/cirurgia , Adolescente , Adulto , Idoso , Angioplastia com Balão/métodos , China , Diagnóstico por Imagem/métodos , Feminino , Veias Hepáticas/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Resultado do Tratamento , Veia Cava Inferior/diagnóstico por imagem , Adulto Jovem
8.
Med Hypotheses ; 126: 109-128, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31010487

RESUMO

Unlike other carcinomas, hepatocellular carcinoma (HCC) metastasizes to distant organs relatively rarely. In contrast, it routinely metastasizes to liver vasculature/liver, affecting portal veins 3-10 times more often than hepatic veins. This portal metastatic predominance is traditionally rationalized within the model of a reverse portal flow, due to accompanying liver cirrhosis. However, this intuitive model is not coherent with facts: 1) reverse portal flow occurs in fewer than 10% of cirrhotic patients, while portal metastasis occurs in 30-100% of HCC cases, and 2) portal vein prevalence of HCC metastasis is also characteristic of HCC in non-cirrhotic livers. Therefore, we must assume that the route for HCC metastatic dissemination is the same as for other carcinomas: systemic dissemination via the draining vessel, i.e., via the hepatic vein. In this light, portal prevalence versus hepatic vein of HCC metastasis appears as a puzzling pattern, particularly in cases when portal HCC metastases have appeared as the sole manifestation of HCC. Considering that other GI carcinomas (colorectal, pancreatic, gastric and small bowel) invariably disseminate via portal vein, but very rarely form portal metastasis, portal prevalence of HCC metastasis appears as a paradox. However, nature does not contradict itself; it is rather our wrong assumptions that create paradoxes. The 'portal paradox' becomes a logical event within the hypothesis that the formation of the unique portal venous system preceded the appearance of liver in evolution of chordates. The analysis suggests that the appearance of the portal venous system, supplying hormones and growth factors of pancreatic family, which includes insulin, glucagon, somatostatin, and pancreatic polypeptide (HGFPF) to midgut diverticulum in the early evolution of chordates (in an Amphioxus-like ancestral animal), promoted differentiation of enterocytes into hepatocytes and their further evolution to the liver of vertebrates. These promotional-dependent interactions are conserved in the vertebrate lineage. I hypothesize that selective homing and proliferation of malignant hepatocytes (i.e., HCC cells) in the portal vein environment are due to a uniquely high concentration of HGFPF in portal blood. HGFPF are also necessary for liver function and renewal and are significantly extracted by hepatocytes from passing blood, creating a concentration gradient of HGFPF between the portal blood and hepatic vein outflow, making post-liver vasculature and remote organs less favorable spaces for HCC growth. It also suggested that the portal vein environment (i.e., HGFPF) promotes the differentiation of more aggressive HCC clones from already-seeded portal metastases, explaining the worse outcome of HCC with the portal metastatic pattern. The analysis also offers new hypothesis on the phylogenetic origin of the hepatic diverticulum of cephalochordates, with certain implications for the modeling of the chordate phylogeny.


Assuntos
Evolução Biológica , Carcinoma Hepatocelular/irrigação sanguínea , Carcinoma Hepatocelular/patologia , Veias Hepáticas/patologia , Neoplasias Hepáticas/irrigação sanguínea , Neoplasias Hepáticas/patologia , Veia Porta/patologia , Animais , Hepatócitos/patologia , História do Século XIX , História do Século XX , Humanos , Anfioxos , Fígado/patologia , Cirrose Hepática/patologia , Neoplasias Hepáticas/secundário , Oncologia/história , Modelos Anatômicos , Modelos Biológicos , Metástase Neoplásica , Obstetrícia/história , Filogenia , Ratos
9.
Ann Surg Oncol ; 26(5): 1465-1473, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30767178

RESUMO

BACKGROUND: Vascular invasion is a major determinant of survival outcomes after curative resection for hepatocellular carcinoma (HCC) patients. This study was designed to investigate the efficacy of postoperative adjuvant transarterial chemoembolization (PA-TACE) in patients with HCC with hepatic vein tumor thrombus (HVTT). METHODS: Data from patients who underwent LR for HCC with HVTT at the Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed. The survival outcomes for patients who underwent PA-TACE after LR were compared with those who underwent LR alone. Propensity score matching (PSM) analysis was performed to match patients in a ratio of 1:1. RESULTS: All included 319 patients who underwent LR for HCC with HVTT, 134 underwent LR alone (the LR group), and 185 patients underwent in adjuvant TACE (the PA-TACE group). PSM matched 107 patients in two groups. The overall survival (OS) and recurrence-free survival (RFS) were significantly better for patients in the PA-TACE group than the LR group (for OS: before PSM, P < 0.001; after PSM, P = 0.004; for RFS: before PSM, P < 0.001; after PSM, P = 0.013), respectively. On subgroup analysis, equivalent acceptable results were obtained in patients with peripheral HVTT (pHVTT) and major HVTT (mHVTT). However, PA-TACE resulted in no survival benefits for patients when the HVTT had extended to the inferior vena cava (IVCTT). CONCLUSIONS: PA-TACE was associated with significantly better survival outcomes than LR alone for patients with HCC and HVTT (pHVTT and mHVTT). There was no survival benefits in patients whose HVTT had extended to form IVCTT.


Assuntos
Carcinoma Hepatocelular/mortalidade , Quimioembolização Terapêutica/mortalidade , Hepatectomia/mortalidade , Veias Hepáticas/cirurgia , Neoplasias Hepáticas/mortalidade , Cuidados Pós-Operatórios , Adjuvantes Imunológicos , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/cirurgia , Feminino , Seguimentos , Veias Hepáticas/patologia , Humanos , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
10.
Ann Surg Oncol ; 26(6): 1859, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30798448

RESUMO

BACKGROUND: More than 40 years ago, patients with tumors infiltrating the confluence of the hepatic veins were deemed unresectable; however, in situ hypothermic perfusion, first described by Fortner et al. (Ann Surg 180(4):644-652, 1974), allowed resection of these tumors. In order to prevent liver ischemia after total vascular exclusion, the liver was flushed with a cooled organ preservation solution. The surgeon was able to resect the tumor and reconstruct the hepatic veins with occlusion of the hepatic inflow and outflow. METHODS: A 55-year-old female suffering from a leiomyosarcoma of the inferior vena cava (IVC) presented to our clinic. Three years ago, the IVC was replaced with a synthetic graft. During the patient's follow-up, a computed tomography (CT) scan revealed three hepatic metastases of the sarcoma. A central metastasis in Segment 8 infiltrated the right hepatic vein (RHV), and two additional metastases were located in the left lateral segments. We used Fortner's technique to resect these tumors. RESULTS: The postoperative course of the patient was prolonged due to a hematoma that partially compressed the new RHV graft. A re-laparotomy was performed and drains were placed. On the 15th postoperative day, the patient was discharged in good health. CONCLUSIONS: Although nowadays patients with these unfortunate tumor locations can, to some extent, be managed non-operatively, surgery remains an option with a chance of cure. Azoulay et al. (Ann Surg 262(1):93-104, 2015) were able to show satisfactory 5-year-survival in 77 patients (30.4%), however 90-day mortality was high (19.5%). Therefore, patients need to be selected carefully. In the era of minimally invasive liver surgery, these old techniques should not vanish from the armamentarium of liver surgeons.


Assuntos
Veias Hepáticas/cirurgia , Hipotermia Induzida , Leiomiossarcoma/cirurgia , Neoplasias Hepáticas/cirurgia , Veia Cava Inferior/cirurgia , Circulação Extracorpórea , Feminino , Hepatectomia , Veias Hepáticas/patologia , Humanos , Leiomiossarcoma/patologia , Neoplasias Hepáticas/secundário , Pessoa de Meia-Idade , Prognóstico , Veia Cava Inferior/patologia
11.
J Surg Oncol ; 119(6): 771-776, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30644109

RESUMO

Incorporation of liver transplant techniques in hepatopancreaticobiliary surgery has created an opportunity for the resection of locally advanced hepatic tumors formerly considered unresectable. A 73-year-old woman presented with cholangiocarcinoma involving inferior vena cava, all three hepatic veins, and right anterior portal pedicle, initially deemed nonoperative. This case demonstrates the first combined application of associating liver partition and portal vein ligation for staged hepatectomy and ex vivo resection to perform an R0. For diseases dependent upon resection, surgical advances and innovations expand the spectrum of interventions through interdisciplinary techniques.


Assuntos
Colangiocarcinoma/cirurgia , Hepatectomia/métodos , Ligadura , Neoplasias Hepáticas/cirurgia , Veia Porta/cirurgia , Idoso , Prótese Vascular , Quimioembolização Terapêutica , Colangiocarcinoma/patologia , Feminino , Veias Hepáticas/patologia , Veias Hepáticas/cirurgia , Humanos , Neoplasias Hepáticas/patologia , Invasividade Neoplásica , Veia Porta/patologia , Veia Cava Inferior/patologia , Veia Cava Inferior/cirurgia
12.
Oncology ; 96(4): 192-199, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30650415

RESUMO

AIM: Prognosis of hepatocellular carcinoma (HCC) with macrovascular invasion (MVI) is extremely poor. However, proper therapeutic strategies have not been established yet. The purpose of this study is to identify the effects of external beam radiation therapy (EBRT) for MVI of HCC. METHODS: We have analyzed and evaluated 80 consecutive patients with HCC with MVI who underwent EBRT, and factors associated with enhanced survival in EBRT were evaluated by univariate and multivariate analysis. RESULTS: The local response rate of radiotherapy for the irradiated MVI was 66.2%. The time to progression of the irradiated MVI was 5.8 months. Univariate and multivariate analyses showed that the higher irradiation dose (over 45 Gy) and the irradiation location (hepatic vein tumor thrombus - HVTT) were significant factors associated with survival benefits of EBRT. The response of EBRT for HVTT was significantly superior to that for portal vein or bile duct tumor thrombus. CONCLUSION: We conclude that a multidisciplinary therapeutic strategy based on EBRT should be proactively selected in the treatment of advanced HCC with MVI.


Assuntos
Ductos Biliares Intra-Hepáticos/efeitos da radiação , Carcinoma Hepatocelular/radioterapia , Veias Hepáticas/efeitos da radiação , Neoplasias Hepáticas/radioterapia , Veia Porta/efeitos da radiação , Dosagem Radioterapêutica , Adulto , Idoso , Idoso de 80 Anos ou mais , Ductos Biliares Intra-Hepáticos/diagnóstico por imagem , Ductos Biliares Intra-Hepáticos/patologia , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Feminino , Veias Hepáticas/diagnóstico por imagem , Veias Hepáticas/patologia , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Veia Porta/diagnóstico por imagem , Veia Porta/patologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
13.
Updates Surg ; 71(1): 67-75, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30255436

RESUMO

The ALPPS is a technique that allows achieving hepatic resection by a rapid future liver remnant hypertrophy. The aim of this study was to report the experience of an Italian center with ALPPS in patients with liver tumors. A retrospective analysis of patients undergoing ALPPS between 2012 and 2017 was performed. Patients' characteristics and disease presentation, increase in future liver remnant (FLR) as well as intraoperative and postoperative short- and long-term outcomes were evaluated. A total of 24 patients underwent the ALPPS procedure: 17 procedures for hepatocarcinoma (HCC), 5 for colorectal liver metastases (CRLM), 1 for cholangiocarcinoma (CC) and 1 for Merkel Cell Carcinoma liver metastasis (MCCLM). Macrovascular invasion (MVI) was recorded in 10 (41.6%) patients: 8 (33.3%) patients with HCC had invasion of portal vein (5), middle hepatic vein (2) and inferior vena cava (1). One patient with CRLM had involvement of middle hepatic vein and one patient with CC had involvement of right portal vein and middle hepatic vein. A p-ALPPS in 14 cases (58.3%), 10 t-ALPPS (41.6%) and hanging maneuver in 19 patients (80%) were performed. Median postoperative stay was 26 days (range 16-68 days). 90-day mortality was 8.3% (two patients, one with CC and one with HCC), 90-day mortality for HCC was 5.8%. After stage 1, we counted 15 complications all of grade I; after stage 2 the number of complications was increased to 37:33 were of grade I and 4 were of grade IV. R0 resection was achieved in all patients with 100% oncology feasibility. After a median follow-up of 10 months (range 2-54), disease recurrence has been recorded in 6 patients with HCC and in 2 with CRLM. Eleven patients died, nine affected by HCC, one by CRLM, and one by CC. 2-years OS and disease-free survival (DFS) for the entire group were 47.3% and 47.5%, respectively. Concerning patients operated on for HCC, the 2-years OS and DFS were 38.5% and 60%, respectively. The ALPPS procedure is an interesting approach for large primary or secondary liver tumor with small FLR above all for large HCC associated with MVI, with acceptable OS and DFS.


Assuntos
Carcinoma Hepatocelular/cirurgia , Hepatectomia/métodos , Neoplasias Hepáticas/cirurgia , Adulto , Idoso , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Intervalo Livre de Doença , Feminino , Veias Hepáticas/patologia , Humanos , Itália , Tempo de Internação , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Veia Porta/patologia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Neoplasias Vasculares/patologia , Veia Cava Inferior
14.
Ann Surg Oncol ; 26(1): 296, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30465224

RESUMO

BACKGROUND: When performing a right hepatectomy, the middle hepatic vein (MHV) should guide the parenchymal transection. MHV hotspots for bleeding can be anticipated when applying the previously developed MHV Roadmap to a minimally invasive approach.1 This video demonstrates application of the MHV Roadmap to perform a safe laparoscopic right hepatectomy. PATIENT: A 44-year-old woman with a solitary and large breast cancer liver metastasis in the right liver was considered for a laparoscopic right hepatectomy following an excellent response to neoadjuvant chemotherapy. The MHV anatomy was reconstructed using automated vascular reconstruction software (Synapse, Fuji) ahead of surgery. TECHNIQUE: With the patient in the French position, the hilar vessels are exposed and the inflow is controlled. Parenchymal transection begins along the demarcation line.2,3 The constant relationship between the portal bifurcation and the V5 ventral and dorsal allows for easy intraparenchymal identification of the MHV. The parenchymal transection is performed in a convex fashion to optimize exposure of the MHV. Using MHV guidance, the parenchymal transection is continued and V8 is safely identified. The operation is completed with division of the anterior fissure and right hepatic vein. CONCLUSION: Outlining the MHV anatomy according to the MHV Roadmap preoperatively helps to anticipate hotspots of bleeding. Guidance along the MHV through the parenchymal transection allows for early identification of tributaries, thereby preventing injury and remnant liver ischemia.


Assuntos
Neoplasias da Mama/cirurgia , Hepatectomia/métodos , Veias Hepáticas/patologia , Laparoscopia/métodos , Neoplasias Hepáticas/cirurgia , Adulto , Neoplasias da Mama/patologia , Feminino , Veias Hepáticas/cirurgia , Humanos , Neoplasias Hepáticas/secundário , Prognóstico
15.
Medicine (Baltimore) ; 97(52): e13873, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30593193

RESUMO

RATIONALE: Autoimmune hepatitis (AIH) is characterised by interface hepatitis. However, some acute cases exhibit atypical centrilobular necrosis with mild portal inflammation. Detailed histological and ultrastructural analyses of acute AIH are limited. PATIENT CONCERNS: A 44-year-old female was admitted to our hospital with jaundice, general fatigue and liver dysfunction. Her transaminase levels were elevated, her immunoglobulin G level was 1735 mg/dL and her anti-nuclear titres were ×80. DIAGNOSIS: AIH was diagnosed, and histochemical examination of a liver biopsy showed the presence of atypical histological features of prominent centrilobular necrosis and central vein and hepatic sinusoidal endotheliitis. Electron microscopy showed that dendritic cells (DCs) and lymphocytes were attached to disrupted liver sinusoidal endothelial cells (LSECs) in hepatic sinusoids and that DCs attached to LSECs via pseudopods in the central vein. INTERVENTIONS AND OUTCOMES: The patient was started on 40 mg/day prednisolone to control the hepatic inflammation. Her aspartate and alanine aminotransferase levels started declining after prednisolone was initiated. Three weeks later, these levels had normalised. The dosage of prednisolone was gradually decreased as liver function improved. The patient remains under observation and continues to receive 2.5 mg prednisolone. LESSONS: An important marker of acute AIH may be the presence of activated DCs in the hepatic sinusoids and central vein.


Assuntos
Capilares/patologia , Células Dendríticas/patologia , Veias Hepáticas/patologia , Hepatite Autoimune/patologia , Adulto , Feminino , Hepatite Autoimune/tratamento farmacológico , Humanos , Fígado/irrigação sanguínea , Prednisolona/uso terapêutico
17.
Transplant Proc ; 50(9): 2630-2635, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30401364

RESUMO

Primary hepatic functional paraganglioma is a rare form of extra-adrenal catecholamine-secreting tumor. Definitive treatment of functioning paraganglioma is challenging because of the critical location of the tumor frequently in close proximity to vital structures and risk of excessive catecholamine release during operative manipulation. We report the multidisciplinary management approach for a case of unresectable primary hepatic functional paraganglioma with invasion into the hepatic veins and suprahepatic vena cava. To our knowledge, this is the first report showing that orthotopic liver transplantation is curative for patients with unresectable primary hepatic paraganglioma. For locally advanced unresectable hepatic paraganglioma that involves the intrapericardial vena cava, a meticulous pre- and intraoperative medical management and transabdominal intrapericardial vascular control of the suprahepatic vena cava during orthotopic liver transplantation allows for complete extirpation of the tumor and achieves optimal outcome.


Assuntos
Neoplasias Hepáticas/cirurgia , Transplante de Fígado/métodos , Paraganglioma/cirurgia , Parede Abdominal/cirurgia , Adolescente , Veias Hepáticas/patologia , Veias Hepáticas/cirurgia , Humanos , Neoplasias Hepáticas/patologia , Masculino , Invasividade Neoplásica , Paraganglioma/patologia , Pericárdio/cirurgia , Veias Cavas/patologia , Veias Cavas/cirurgia
18.
J Dairy Res ; 85(4): 431-438, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30295210

RESUMO

The aim of the present study was to evaluate the potential for diagnosis of fatty liver by means of ultrasonographic measurement of liver and perivisceral adipose tissue as an alternative to blood indicators of lipomobilization and liver biopsy in periparturient high-yielding dairy cows. Thirty cows were enrolled and divided into two groups. The evaluation of body condition score (BCS), non-esterified fatty acids (NEFA), ß-hydroxybutyrate (BHB), liver and perivisceral adipose tissue ultrasonographic measurement and histological liver lipid content (GdL) was performed at 15 ± 5 d prepartum (T0), 10 ± 2 d postpartum (T1), 30 ± 2 d postpartum (T2) and 50 ± 2 d postpartum (T3). Mesenteric fat thickness (the thickness of the perivascular adipose tissue) measured on ultrasound was shown to be an independent determinant of fatty liver. The cut-off of the ultrasonographic evaluation of the liver may be useful as a first and practical approach in identifying fatty liver. In conclusion, a non-invasive and reliable diagnostic method for predicting the risk of fatty liver in high yielding dairy cows has been demonstrated.


Assuntos
Tecido Adiposo/diagnóstico por imagem , Doenças dos Bovinos/diagnóstico por imagem , Fígado Gorduroso/veterinária , Veias Hepáticas/diagnóstico por imagem , Fígado/irrigação sanguínea , Veia Porta/diagnóstico por imagem , Tecido Adiposo/patologia , Animais , Bovinos , Doenças dos Bovinos/metabolismo , Doenças dos Bovinos/patologia , Metabolismo Energético , Ácidos Graxos/metabolismo , Fígado Gorduroso/diagnóstico por imagem , Fígado Gorduroso/patologia , Feminino , Veias Hepáticas/patologia , Lactação/fisiologia , Fígado/metabolismo , Veia Porta/patologia , Período Pós-Parto
19.
Cardiovasc Intervent Radiol ; 41(12): 1885-1891, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30238334

RESUMO

PURPOSE: To compare estimated future remnant liver (FRL) growth following portal vein embolization or liver venous deprivation (LVD) (combined PVE and right hepatic vein embolization), before surgery for a Klatskin tumor in patients who receive intraoperative biliary drainage or before venous interventional radiology. MATERIAL AND METHOD: Six patients underwent LVD and six underwent PVE alone before hepatectomy for a Klatskin tumor. Before embolization, the FRL ratio, prothrombin time and bilirubin levels were similar in both groups. The FRL was determined before and 3 weeks after embolization by enhanced CT. PVE was performed with n-butyl-2-cyanoacrylate, and the right hepatic vein was embolized with vascular plugs during the same procedure. Biliary drainage was performed percutaneously or by endoscopy. Post-hepatectomy liver function and duration of hospital stay were assessed. RESULTS: There were no adverse events. The median FRL ratio was significantly higher following LVD than after PVE 58% (54-71) and 37% (30-44), respectively, p = 0.017. The FRL volume after embolization was 1.6 times higher after LVD than PVE (p = 0.016). Four and five patients were operated in the LVD and PVE groups, respectively. There was a trend toward a shorter median postoperative hospital stay and 90-day mortality in the LVD versus PVE group: 14 versus 44 days, (p = 0.114) and 0 versus two deaths (p = 0.429), respectively. CONCLUSIONS: LVD associated with biliary drainage is safe and results in a better FRL ratio than biliary drainage associated with PVE alone.


Assuntos
Neoplasias dos Ductos Biliares/terapia , Drenagem/métodos , Embolização Terapêutica/métodos , Veias Hepáticas/patologia , Tumor de Klatskin/terapia , Veia Porta/patologia , Cuidados Pré-Operatórios/métodos , Adulto , Idoso , Feminino , Hepatectomia/métodos , Humanos , Testes de Função Hepática , Regeneração Hepática , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
20.
Ann Surg Oncol ; 25(13): 3983, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30206779

RESUMO

BACKGROUND: Hepatocellular carcinoma (HCC) associated with tumor extension in the portal vein, hepatic vein, or inferior vena cava (IVC) is traditionally considered an advanced stage of disease to which palliative radiotherapy or sorafenib chemotherapy is proposed.1,2 Recent studies have shown a significant survival benefit in patients treated with R0 liver resection.3-5 METHODS: We describe the case of a 45-year-old female patient presenting with a voluminous HCC developed in a non-cirrhotic liver with a tumor thrombus obstructing the retrohepatic IVC and the middle hepatic vein termination. Initial treatment included two cycles of selective internal radiation therapy with Yttrium 90 and sorafenib treatment for 1 year. Re-evaluation revealed a significant reduction of the tumor and compensative hypertrophy of the left liver lobe, enabling surgical resection. RESULTS: The procedure included anatomic right hepatic trisectionectomy with caudate lobectomy and retrohepatic IVC graft replacement. Total liver vascular exclusion with intrapericardial IVC control enabled en bloc R0 resection of the tumor and the floating tumor thrombus in the cavo-hepatic venous confluence. Total liver vascular exclusion duration was 20 min, for a total warm liver ischemia of 40 min. The duration of the operation was 240 min and blood loss was 700 mL. The patient was discharged on postoperative day 15 and was free of disease 6 months post-surgery. CONCLUSION: Liver surgery with complex vascular resections for HCC with major vascular invasion should be considered a valid therapeutic option in high-volume hepatobiliary centers.


Assuntos
Carcinoma Hepatocelular/cirurgia , Hepatectomia/métodos , Veias Hepáticas/cirurgia , Neoplasias Hepáticas/cirurgia , Neoplasias Vasculares/cirurgia , Veia Cava Inferior/cirurgia , Carcinoma Hepatocelular/patologia , Feminino , Veias Hepáticas/patologia , Humanos , Neoplasias Hepáticas/patologia , Pessoa de Meia-Idade , Invasividade Neoplásica , Prognóstico , Neoplasias Vasculares/patologia , Veia Cava Inferior/patologia
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