Thoracic epidural analgesia and immediate extubation for less than 10 kg infants undergoing living donor liver transplantation: A report of two successful cases.

BACKGROUND: Perioperative pain management in small infants weighing <10 kg undergoing liver transplantation is challenging. The use of TEA in this setting has not been reported, as well as its potential role to facilitate IE, ie, in the OR. METHODS: We describe here the use of TEA in two small infants who had IE after a LDLT procedure. RESULTS: TEA was successfully performed and IE was achieved in both cases. Postoperative analgesia assessment in the OR was satisfactory according to the FLACC pain scale, with scores of 2 and 3 for each patient, respectively. There were no major complications in the postoperative period, and the two children were discharged home uneventfully. CONCLUSIONS: The use of TEA and its influence on IE rate and other perioperative outcomes should be more explored in small infants undergoing LDLT.

Variation in complications and mortality following ALPPS at early-adopting centers.

BACKGROUND: Various, often conflicting, estimates for post-operative morbidity and mortality following ALPPS have been reported in the literature, suggesting that considerable center-level variation exists. Some of this variation may be related to center volume and experience. METHODS: Using data from seventeen centers who were early adopters of the ALPPS technique, we estimated the variation, by center, in standardized 90-day mortality and comprehensive complication index (CCI) for patients treated between 2012 and 2018. RESULTS: We estimated that center-specific 90-day mortality following treatment with ALPPS varied from 4.2% (95% CI: 0.8, 9.9) to 29.1% (95% CI: 13.9, 50.9), and that center-specific CCI following treatment with ALPPS varied from 17.0 (95% CI: 7.5, 26.5) to 49.8 (95% CI: 38.1, 61.8). Declines in estimated 90-day mortality and CCI were observed over time, and almost all individual centers followed this trend. Patients treated at centers with a higher number of ALPPS cases performed over the prior year had a lower risk of post-operative mortality. CONCLUSION: Despite considerable center-level variation in ALPPS outcomes, perioperative outcomes following ALPPS have improved over time and treatment at higher volume centers results in a lower risk of 90-day mortality. Morbidity and mortality remain concerningly high at some centers.

Monosegmental ALPPS after Bilateral Hepatectomy.

Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has emerged as an alternative for patients with bilobar colorectal liver metastasis and a small future liver remnant (FLR). In cases of extensive disease, ALPPS can be performed, leaving only one segment of the liver as FLR. We describe a case of monosegmental ALPPS using segment 4 as FLR. In conclusion, ALPPS should be reserved for a selected group of patients. Monosegmental ALPPS is feasible, but should be performed by hepatobiliary surgeons in specialized centers.

ALPPS as a salvage procedure after insufficient future liver remnant hypertrophy following portal vein occlusion.

BACKGROUND: A minimum future liver remnant (FLR) of 30% is required to avoid post hepatectomy liver failure (PHLF). Portal vein occlusion (PVO) is the main strategy to induce hypertrophy of the FLR, but some patients will not reach sufficient FLR hypertrophy to enable resection. Recently ALPPS has emerged as a "Salvage Procedure" for PVO failure. The aim of this study was to report the short term outcomes of ALPPS following PVO failure. METHODS: A retrospective analysis of patients enrolled within the international ALPPS Registry between October 2012 and November 2015 (NCT01924741) was performed. Patients with documented PVO failure were included. The outcomes reported included feasibility, FLR growth rate and safety of ALPPS. Complications were recorded as per Clavien-Dindo classification. RESULTS: From 510 patients enrolled in the Registry there were 22 patients with previous PVO failure. Two patients were excluded due to missing data and twenty patients were analysed. All of them completed the proposed ALPPS with a medium FLR increase of 88% (23-115%) between two stages and no 90-day mortality. CONCLUSION: In experienced centers, ALPPS following PVO failure is feasible and safe. The FLR hypertrophy was similar to other ALPPS series. ALPPS is a potential rescue strategy after PVO failure.

ACUTE CHOLECYSTITIS IN HIGH-RISK PATIENTS. SURGICAL, RADIOLOGICAL, OR ENDOSCOPIC TREATMENT? BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER.

Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

RE-HEPATECTOMY MEANS MORE MORBIDITY? A MULTICENTRIC ANALYSIS.

AIM: Colorectal cancer generally metastasizes to the liver. Surgical resection of liver metastasis, which is associated with systemic chemotherapy, is potentially curative, but many patients will present recurrence. In selected patients, repeated hepatectomy is feasible and improves overall survival. This study aimed to analyze patients with colorectal liver metastasis (CRLM) submitted to hepatectomy in three centers from Rio de Janeiro, over the past 10 years, by comparing the morbidity of first hepatectomy and re-hepatectomy. METHODS: From June 2009 to July 2020, 192 patients with CRLM underwent liver resection with curative intent in three hospitals from Rio de Janeiro Federal Health System. The data from patients, surgeries, and outcomes were collected from a prospectively maintained database. Patients submitted to first and re-hepatectomies were classified as Group 1 and Group 2, respectively. Data from groups were compared and value of p<0.05 was considered significant. RESULTS: Among 192 patients, 16 were excluded. Of the remaining 176 patients, 148 were included in Group 1 and 28 were included in Group 2. Fifty-five (37.2%) patients in Group 1 and 13 (46.5%) in Group 2 presented postoperative complications. Comparing Groups 1 and 2, we found no statistical difference between the cases of postoperative complications (p=0.834), number of minor (p=0.266) or major (p=0.695) complications, and deaths (p=0.407). CONCLUSIONS: No differences were recorded in morbidity or mortality between patients submitted to first and re-hepatectomies for CRLM, which reinforces that re-hepatectomy can be performed with outcomes comparable to first hepatectomy.

Undifferentiated Embryonal Sarcoma of the Liver Involving All Major Hepatic Veins Treated by Left Extended Trisectionectomy.

Introduction: Over the past few years, liver surgery has been in constant evolution and gained many improvements that helped surgeons push limits further. A complex procedure such as left extended trisectionectomy, as described by Makuuchi in 1987, may be performed in selected cases. Aim: Describe a case of successful resection of a huge bilobar liver sarcoma involving all hepatic veins from a young female patient, in which the blood outflow was preserved through an inferior right hepatic vein, leaving only segment 6 as liver remnant. Case Report. A 19-year-old female with a 3-month history of abdominal pain, vomiting, and weight loss was referred for our evaluation. CT scan and MRI revealed a heterogeneous and bulky expansive hepatic lesion, sparing only segment 6, with an estimated volume of 530 cm3, corresponding to a 1.2 FLR/BW ratio. The tumor involved the three major hepatic veins, but an inferior right hepatic vein was present, draining the spared segment 6. She was submitted to a left trisectionectomy extended to the caudate lobe and segment 7, including resection of all hepatic veins and lymphadenectomy of the hepatic pedicle. She was discharged on the 7th postoperative day without complications. The histopathological and immunohistochemical analysis demonstrated an undifferentiated embryonal sarcoma of the liver. Conclusion: Inferior right hepatic vein-preserving left extended trisectionectomy is a safe and feasible procedure that should be performed by a hepatobiliary team experienced in major complex hepatectomies.

EXTERNAL PRINGLE MANEUVER IN LAPAROSCOPIC LIVER RESECTION: A SAFE, CHEAP AND REPRODUCIBLE WAY TO PERFORM IT.

BACKGROUND: Tourniquet for right hepatectomy tightened and secured with forceps (arrow). Laparoscopic liver resection is performed worldwide. Hemorrhage is a major complication and bleeding control during hepatotomy is an important concern. Pringle maneuver remains the standard inflow occlusion technique. AIM: Describe an extracorporeal, efficient, fast, cheap and reproducible way to execute the Pringle maneuver in laparoscopic surgery, using a chest tube. METHODS: From January 2014 to March 2020, our team performed 398 hepatectomies, 63 by laparoscopy. We systematically encircle the hepatoduodenal ligament and prepare a tourniquet to perform Pringle maneuver. In laparoscopy, we use a 24 Fr chest tube, which is inserted in the abdominal cavity through a small incision. We thread the cotton tape through the tube, pulling it out through the external end, outside the abdomen. To perform the tourniquet, we just need to push the tube as we hold the tape, clamping both with one forceps. RESULTS: The 24 Fr chest tube is firm and works perfectly to occlude blood inflow as the cotton band is tightened. It has an internal diameter of 5,5 mm, sufficient for a laparoscopic grasper pass through it to catch the cotton band, and an external diameter of 8 mm, which allows to be inserted in the abdomen through a tiny incision. The cost of this tube and the cotton band is less than US$ 1. No complications related to the method were identified in our patients. CONCLUSIONS: The extracorporeal Pringle maneuver presented here is a safe, cheap and reproducible method, that can be used for bleeding control in laparoscopic liver surgery.

Hepatic artery reconstruction in pediatric living donor liver transplantation under 10 kg, without microscope use.

Arterial reconstructions are pivotal, particularly in pediatric LDLT. We describe microsurgical reconstruction technique with 6x loupes and the clinical course of the first 23 less than 10 kg recipients in an initial LDLT program at a developing country. From March 2002 to October 2008, 286 liver transplantation were performed in 279 patients at our unit. There were 73 children and 206 adults. Among the children, 23 weighing less than 10 kg were recipients from living donors. Arterial reconstructions were with end-to-end interrupted suture using a 6x magnification loupe, according to the untied suture technique. All patients were prospectively followed by color Doppler ultrasound protocol. In our initial experience there were no arterial complications. With mean 24 months of follow-up, 19 patients (82%) are alive with good graft function. Hepatic artery in LDLT can be safely reconstructed with microsurgical techniques without microscope using, with 6x loupe magnification, and can achieve good results in patients under 10 kg.

Is there any difference between right hepatectomy and left lateral sectionectomy for living donors? as much you cut, as much you hurt?

BACKGROUND: The worldwide rising demand for cadaveric donors in liver transplantation is an important incentive for the development of alternative transplantation options, such as living donors. A precise evaluation of surgical complications is, therefore, considered to be an important issue in this setting. AIM: Present a retrospective analysis of 126 living donors hepatectomies undertaken at our centre. METHODS: From December 2002 to August 2009, 126 living donors were submitted to hepatectomy. Donors' complications were stratified according to Clavien's scoring system to compare the morbidity of right hepatectomy (RH) (Group 1) and left lateral sectionectomy (LLS) (Group 2). RESULTS: Thirty-nine complications were observed in 35 patients. Sixty LLS, 3 left (LH) and 63 RH were performed. The complications were classified as: Clavien grade 1-11 (28.2%), grade 2-12 (30.7%), grade 3A-13 (33.3%), grade 3B-2 (5.1%) and grade 4A-1 (2.5%). When Group 1 (63 patients) and Group 2 (60 patients) were compared, there was no significant difference between the number of complications: 20 (31%) and 14 (23%), respectively (P > 0.3). CONCLUSIONS: Hepatectomy for living donor liver transplantation (LDLT) was a safe procedure, regardless of the type of liver resection undertaken. We found no difference in morbidity between RH and LLS, which suggests that complications may occur despite the amount of liver retrieved.

BRAZILIAN CONSENSUS ON INCIDENTAL GALLBLADDER CARCINOMA.

BACKGROUND: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. AIM: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. METHODS: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. RESULTS: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. CONCLUSIONS: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

Protamine sulphate for treatment of severe post-reperfusion coagulopathy in pediatric liver transplantation.

In this case report, we describe a child with biliary atresia who underwent a living LDLT and developed severe coagulopathy after reperfusion of the graft. The ROTEM analysis strongly suggested the presence of either a heparin effect or severe deficiency of coagulation factors. The former diagnosis was supported by a subsequent in-vitro HEPTEM. A small dose of protamine sulphate was then administered, which promptly restored hemostasis. The remainder of the procedure was uneventful.

Acute cholecystitis in high-risk patients. surgical, radiological, or endoscopic treatment? brazilian college of digestive surgery position paper / Colecistite aguda em pacientes de alto risco. tratamento cirúrgico, radiológico ou endoscópico? posicionamento do colégio brasileiro de cirurgia digestiva

ABSTRACT Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

RESUMO A colecistite aguda (CA) é um processo inflamatório agudo da vesícula biliar que pode estar associado a complicações potencialmente graves, como empiema, gangrena, perfuração da vesícula biliar e sepse. O tratamento padrão para a CA é a colecistectomia laparoscópica. No entanto, para um pequeno grupo de pacientes com CA, o risco de colecistectomia laparoscópica pode ser muito alto, principalmente em idosos com doenças graves associadas. Nestes pacientes críticos, a colecistectomia percutânea ou a drenagem endoscópica da vesícula biliar guiada por ultrassom podem ser uma opção terapêutica temporária, como ponte para a colecistectomia. O objetivo deste artigo de posicionamento do Colégio Brasileiro de Cirurgia Digestiva é apresentar novos avanços no tratamento da CA em pacientes cirúrgicos de alto risco, para auxiliar cirurgiões, endoscopistas e clínicos a selecionar o melhor tratamento para os seus pacientes. A eficácia, segurança, vantagens, desvantagens e resultados de cada procedimento são discutidos. As principais conclusões são: a) Pacientes com CA e risco cirúrgico elevado devem ser tratados preferencialmente em hospitais terciários onde a experiência e os recursos cirúrgicos, radiológicos e endoscópicos estão disponíveis. b) A modalidade de tratamento ideal para pacientes com elevado risco cirúrgico, deve ser individualizada, com base nas condições clínicas e na experiência disponível. c) A colecistectomia laparoscópica continua sendo uma excelente opção de tratamento, principalmente em hospitais em que a drenagem da vesícula biliar percutânea ou endoscópica não está disponível. d) A colecistostomia percutânea e a drenagem endoscópica da vesícula biliar devem ser realizadas apenas em hospitais bem equipados e com radiologista intervencionista e/ou endoscopista experientes. e) O cateter de colecistostomia deve ser removido após a resolução da CA. No entanto, em pacientes que não têm condição clínica para realizar colecistectomia, o cateter pode ser mantido por um período prolongado ou mesmo definitivamente. f) Se o cateter de colecistostomia for mantido por longo período de tempo podem ocorrer várias complicações, como sangramento, fístula biliar, obstrução, dor no local de inserção, remoção acidental do cateter e CA recorrente. g) O tempo de espera ideal entre a colecistostomia e a colecistectomia ainda não foi estabelecido, e vai desde imediatamente após a melhoria clínica, até meses após. h) Longos períodos de espera entre colecistostomia e colecistectomia podem estar associados a novos episódios de CA, múltiplas readmissões hospitalares e aumento dos custos. Finalmente, ao selecionar a melhor opção de tratamento, outros aspectos também devem ser considerados, como custos, disponibilidade dos procedimentos no centro médico e o desejo do paciente. O paciente e sua família devem ser completamente informados sobre todas as opções de tratamento, para que possam ajudar a tomar a decisão final.

Re-hepatectomy means more morbidity? a multicentric analysis / Re-hepatectomia significa maior morbidade? uma análise multicêntrica

ABSTRACT - BACKGROUND: Colorectal cancer generally metastasizes to the liver. Surgical resection of liver metastasis, which is associated with systemic chemotherapy, is potentially curative, but many patients will present recurrence. In selected patients, repeated hepatectomy is feasible and improves overall survival. AIM: This study aimed to analyze patients with colorectal liver metastasis (CRLM) submitted to hepatectomy in three centers from Rio de Janeiro, over the past 10 years, by comparing the morbidity of first hepatectomy and re-hepatectomy. METHODS: From June 2009 to July 2020, 192 patients with CRLM underwent liver resection with curative intent in three hospitals from Rio de Janeiro Federal Health System. The data from patients, surgeries, and outcomes were collected from a prospectively maintained database. Patients submitted to first and re-hepatectomies were classified as Group 1 and Group 2, respectively. Data from groups were compared and value of p<0.05 was considered significant. RESULTS: Among 192 patients, 16 were excluded. Of the remaining 176 patients, 148 were included in Group 1 and 28 were included in Group 2. Fifty-five (37.2%) patients in Group 1 and 13 (46.5%) in Group 2 presented postoperative complications. Comparing Groups 1 and 2, we found no statistical difference between the cases of postoperative complications (p=0.834), number of minor (p=0.266) or major (p=0.695) complications, and deaths (p=0.407). CONCLUSIONS: No differences were recorded in morbidity or mortality between patients submitted to first and re-hepatectomies for CRLM, which reinforces that re-hepatectomy can be performed with outcomes comparable to first hepatectomy.

RESUMO - RACIONAL: O câncer colorretal geralmente metastatiza para o fígado. Hepatectomia associada à quimioterapia sistêmica é potencialmente curativa para metástases hepáticas colorretais, entretanto, muitos pacientes apresentarão recidiva após a cirurgia. Em casos selecionados, a re-hepatectomia é viável, com relatos de melhora na sobrevida global. OBJETIVO: Analisar pacientes com metástase hepática colorretal operados em três centros do Rio de Janeiro, nos últimos 10 anos, comparando as morbidades da primeira hepatectomia e da re-hepectomia. MÉTODOS: De junho de 2009 a julho de 2020, 192 pacientes com metástase hepática colorretal foram submetidos à hepatectomia em três hospitais do Rio de Janeiro. Os dados dos pacientes, cirurgias e desfechos foram coletados de um banco de dados mantido prospectivamente. Pacientes submetidos à primeira hepatectomia e re-hepatectomia foram classificados como Grupo 1 e Grupo 2, respectivamente. Os dados dos grupos foram comparados e o valor de p<0,05 foi considerado significativo. RESULTADOS: Dentre 192 pacientes, dezesseis foram excluídos. Dos 176 pacientes restantes, 148 e 28 foram incluídos dos Grupos 1 e 2, respectivamente. Cinquenta e cinco (37,2%) pacientes no Grupo 1 e treze (46,5%) no Grupo 2 apresentaram complicações pós-operatórias. Comparando os Grupos 1 e 2, não foi observada diferença estatística entre o número de pacientes com complicações pós-operatórias (p = 0,834), complicações menores (p = 0,266) ou maiores (p = 0,695) e óbitos (p = 0,407). CONCLUSÕES: Não foram registradas diferenças na morbidade ou mortalidade entre os pacientes submetidos à primeira ou à re-hepatectomia em pacientes com metástase hepática colorretal, o que sustenta que a re-hepatectomia pode ser realizada com resultados comparáveis à primeira hepatectomia.

External pringle maneuver in laparoscopic liver resection: a safe, cheap and reproducible way to perform it / Manobra de pringle extracorpórea em ressecções hepáticas laparoscópicas: maneira segura, barata e reproduzível de realizá-la

ABSTRACT Background: Laparoscopic liver resection is performed worldwide. Hemorrhage is a major complication and bleeding control during hepatotomy is an important concern. Pringle maneuver remains the standard inflow occlusion technique. Aim: Describe an extracorporeal, efficient, fast, cheap and reproducible way to execute the Pringle maneuver in laparoscopic surgery, using a chest tube. Methods: From January 2014 to March 2020, our team performed 398 hepatectomies, 63 by laparoscopy. We systematically encircle the hepatoduodenal ligament and prepare a tourniquet to perform Pringle maneuver. In laparoscopy, we use a 24 Fr chest tube, which is inserted in the abdominal cavity through a small incision. We thread the cotton tape through the tube, pulling it out through the external end, outside the abdomen. To perform the tourniquet, we just need to push the tube as we hold the tape, clamping both with one forceps. Results: The 24 Fr chest tube is firm and works perfectly to occlude blood inflow as the cotton band is tightened. It has an internal diameter of 5,5 mm, sufficient for a laparoscopic grasper pass through it to catch the cotton band, and an external diameter of 8 mm, which allows to be inserted in the abdomen through a tiny incision. The cost of this tube and the cotton band is less than US$ 1. No complications related to the method were identified in our patients. Conclusions: The extracorporeal Pringle maneuver presented here is a safe, cheap and reproducible method, that can be used for bleeding control in laparoscopic liver surgery.

RESUMO Racional: Ressecções hepáticas laparoscópicas são realizadas em todo mundo. A hemorragia é complicação grave e o controle do sangramento durante a hepatotomia é preocupação importante. A manobra de Pringle continua sendo a técnica padrão de oclusão do influxo sanguíneo. Objetivo: Descrever uma maneira eficiente, rápida, barata e reproduzível de executar a manobra de Pringle extracorpórea, em operação laparoscópica, utilizando um dreno de tórax. Métodos: De janeiro/2014 a março/2020, realizamos 398 hepatectomias, 63 por laparoscopia. Nós sistematicamente laçamos o ligamento hepatoduodenal e preparamos um torniquete para a manobra de Pringle. Na laparoscopia, usamos um dreno de tórax 24 Fr, inserido na cavidade abdominal através de uma pequena incisão. Passamos a fita de algodão através do tubo, puxando-a pela extremidade externa, fora do abdome. Para apertar o torniquete, basta pressionar o tubo enquanto seguramos a fita, prendendo ambos com uma pinça. Resultados: O dreno de tórax 24 Fr é firme e funciona perfeitamente para ocluir influxo de sangue, à medida que apertamos o torniquete. Tem diâmetro interno de 5,5 mm, suficiente para passar uma pinça laparoscópica e puxar a fita de algodão, e um diâmetro externo de 8 mm, permitindo a inserção no abdome através de uma pequena incisão. O custo do tubo e fita é inferior a US$ 1, valor insignificante. Não foram identificadas complicações relacionadas ao método em nossos pacientes. Conclusões: A manobra extracorpórea de Pringle apresentada aqui é método seguro, barato e reproduzível, que pode ser utilizado para o controle do sangramento em hepatectomias laparoscópicas.

Brazilian consensus on incidental gallbladder carcinoma / Consenso brasileiro de carcinoma incidental de vesícula biliar

ABSTRACT Background: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. Aim: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. Methods: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. Results: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. Conclusions: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

RESUMO Racional: Carcinoma incidental da vesícula biliar é definido como uma neoplasia descoberta por exame histológico após colecistectomia videolaparoscópica. É potencialmente uma doença curável. Entretanto algumas questões relacionadas ao seu manuseio permanecem controversas e uma estratégia definida está associada com melhor prognóstico. Objetivo: Desenvolver o primeiro consenso baseado em evidências para o manuseio de pacientes com carcinoma incidental da vesícula biliar no Brasil. Métodos: Dezesseis questões foram selecionadas e para responder as questões e 36 membros das sociedades brasileiras e internacionais foram incluídos. As recomendações foram baseadas em evidências da literatura atual. Um relatório final foi enviado para os membros do painel para avaliação de concordância. Resultados: Avaliação intraoperatória da peça cirúrgica, uso de bolsas para retirar a peça cirúrgica e exame histopatológico de rotina, foram recomendados. Avaliação pré-operatória completa é necessária e deve ser realizada assim que o estadiamento final esteja disponível. Avaliação da margem do ducto cístico e biópsia de rotina do linfonodo 16b1 são recomendadas. Quimioterapia deve ser considerada e quimioradioterapia indicada se a margem cirúrgica microscópica seja positiva. Os portais devem ser ressecados excepcionalmente. O estadiamento laparoscópico antes da operação é recomendado, mas o tratamento radical por abordagem minimamente invasiva deve ser realizado apenas em centros especializados em cirurgia hepatopancreatobiliar minimamente invasiva. A extensão da ressecção hepática é aceitável até que seja alcançada a ressecção R0. A linfadenectomia padrão é indicada para tumores iguais ou superiores a T2, mas a ressecção da via biliar não é recomendada de rotina. Conclusões: Recomendações seguras foram preparadas para carcinoma incidental da vesícula biliar, destacando os mais frequentes tópicos do trabalho diário do cirurgião do aparelho digestivo e hepatopancreatobiliar.

Portal vein embolization using an adapted hysterosalpingography catheter.

BACKGROUND: Portal vein embolization is an accepted procedure that provides hypertrophy of the future remnant liver in order to reduce post-hepatectomy complications. AIM: To present a series submitted to portal vein embolization using an adapted hysterosalpingography catheter via transileocolic route. METHODS: Were performed right portal branch embolization in 19 patients using hysterosalpingography catheter. For embolizing the vessel, was used Gelfoam(r) powder with absolute alcohol solution. Indications for hepatectomy were colorectal liver metastases in all cases. RESULTS: An adequate growth of the future remnant liver was achieved in 15 patients (78.9%) and second time hepatectomy could be done in 14 (73.7%). In one patient (5.2%), tumor progression prevented surgery. One patient presented acute renal failure after portal embolization. CONCLUSIONS: The hysterosalpingography catheter is easy to handle and can be introduced into the portal vein with a wire guide. There were no major post-embolization complication. Its use is safe, cheap and effective.

Right gastroepiploic artery as an alternative for arterial reconstruction in living donor liver transplantation.

Background. An adequate blood flow is directly related to graft survival in living donor liver transplantation. However, in some cases, unfavorable conditions prevent the use of the hepatic artery for arterial reconstruction. Herein, we report a case in which the recipient right gastroepiploic artery was used as an option for arterial reconstruction in adult-to-adult living donor liver transplantation. Case Report. A 62-year-old woman, with cirrhosis due to hepatitis B associated with hepatocellular carcinoma, was submitted to living donor liver transplantation. During surgery, thrombosis of the hepatic artery with intimal dissection until the celiac trunk was observed, which precluded its use in arterial reconstruction. We decided to use the right gastroepiploic artery for arterial revascularization of the liver graft. Despite the discrepancy in size between donor hepatic artery and recipient right gastroepiploic artery, anastomosis was performed successfully. Conclusions. The use of the right gastroepiploic artery as an alternative for arterial revascularization of the liver graft in living donor liver transplantation should always be considered when the hepatic artery of the recipient cannot be used. For performing this type of procedure, familiarity with microsurgical techniques by the surgical team is necessary.