The ALPPS procedure for hepatocellular carcinoma larger than 10 centimeters

INTRODUCTION

The only means of achieving long-term survival in hepatocellular carcinoma is complete tumor resection or liver transplantation. Patients with large hepatocellular carcinomas are currently not considered for liver transplantation. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is indicated in selected patients. We present the case of a patient with a huge hepatocellular carcinoma who underwent an ALPPS procedure.

PRESENTATION OF CASE

A 57-year-old man initially presented with a tumor measuring 19cm×10cm in the right lobe of the liver. The liver function was normal and there was no evidence of portal hypertension. The first part of the procedure was performed without mobilizing the liver. The middle hepatic vein was divided during parenchymal transection. The second procedure was performed after 15days. During that procedure the right hepatic artery, right bile duct, and the right hepatic vein were ligated and divided. Liver segments 4-8 with the tumor were removed. The patient developed moderate ascites but recovered after ten days. After 90days, the patient is doing well with no signs of recurrence.

DISCUSSION

Hepatocellular carcinoma is a complicated disease and ALPPS is not considered an optimal treatment option. However, patients with large tumors are not considered for liver transplantation or chemotherapy. Patients with Child-Pugh A liver disease without portal hypertension can benefit from surgical treatment for hepatocellular carcinoma; in some situations, surgery may be considerably better than other forms of treatment.

CONCLUSION

ALPPS should be considered in selected patients with large hepatocellular carcinomas.

PANCREATODUODENECTOMY: BRAZILIAN PRACTICE PATTERNS

Background:

Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative.

Aim:

To understand the Brazilian practice patterns for pancreatoduodenectomy.

Method:

A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery.

Results:

A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube.

Conclusion:

Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.

Isolated caudate lobectomy: Left-sided approach. Case reports

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The options of treatment for caudate tumors are presented.

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Treatment of caudate tumors by left-sided approach is proposal.

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Better results with left-sided approach are discussed.

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Selection of patients with tumors in caudate lobe for left-sided approach is important.

Introduction

The caudate lobe is a distinct liver lobe and surgical resection requires expertise and precise anatomic knowledge. Left-sided approach was described for resection of small tumors originated in the Spiegel lobe but now the procedure has been performed even for tumors more than five centimeters. The aim of this study is to present three cases of tumor of caudate lobe underwent isolated lobectomy by left-sided approach.

Presentation of case

Three patients with metastasis of colorectal cancer, carcinoma hepatocellular and metastasis of neuroendocrine tumor underwent resection. After modified Makuuchi incision, early control of short hepatic e short portal veins before hepatectomy was performed. The operative time was 200, 270 and 230 min respectively. No blood transfusion was used and no postoperative complications were observed. The length of stay was 7, 11 and 5 days respectively.

Discussion

Some approaches have been described to access and resect tumors of the caudate lobe, including the left-sided approach, right-sided approach, combined left- and right-sided approach and the anterior transhepatic approach. For liver resection in patients with malignant disease, parenchymal preservation is important in order to avoid postoperative liver failure or due to the risk of second hepatectomy. In these patients isolated caudate lobectomy is a safe option.

Conclusion

Isolated caudate lobectomy is a feasible procedure. Left-sided approach can be preformed even for tumors larger than 5 cm.

Predictive factors of morbidity in distal pancreatic resections

OBJECTIVE

To evaluate the postoperative morbidity of distal pancreatic resections and to investigate its predictive factors.

METHODS

The study was conducted retrospectively from a prospectively database maintained. From 1994 to 2008, 100 consecutive patients underwent left pancreatic resections. The primary variable of interest was postoperative morbidity, and various other characteristics of the population were simultaneously recorded. Later, for the analysis of predictors of postoperative morbidity, the subgroup of patients who underwent distal pancreatectomy with spleen preservation (n = 65) was separately analyzed with regards to the different techniques of section of the pancreatic parenchyma, as well as to other possible predictors of postoperative morbidity.

RESULTS

Considering all left pancreatic resections performed, the occurrence of overall, relevant and serious complications was 55%, 42% and 20%, respectively. The factors predictive of postoperative morbidity after distal pancreatectomy with spleen preservation were the technique employed for section of the pancreatic parenchyma, age, body mass index and the performance of concomitant abdominal operations.

CONCLUSION

The morbidity associated with pancreatic resections to the left of the superior mesenteric vessels was high. According to the stratification adopted based on the severity of complications, some predictive factors have been identified. Future studies with larger cohorts of patients are needed to confirm these results.

PANCREATODUODENECTOMY DUE TO LIPOMATOUS PSEUDOHYPERTROPHY OF THE PANCREAS

BACKGROUND

Lipomatous pseudohypertrophy of the pancreas, pancreatic lipomatosis, pancreatic steatosis, non-alcoholic fatty pancreatic disease, or fatty pancreas is an extremely rare disease, characterized by the organ enlargement and a localized or diffuse replacement of pancreatic acinar cells by mature adipose tissue, preserving the pancreatic ductal system and islets of Langerhans.

AIMS

To report a rare case of lipomatous pseudohypertrophy of the pancreas in a symptomatic patient and the surgical treatment employed.

METHODS

A 24-year-old male patient with weight loss (10 kilograms in 8 months), hyperglycemia, severe and recurrent acute abdominal pain, epigastric discomfort associated with nausea, vomiting, and jaundice for 40 days. Magnetic resonance imaging was performed, revealing an irregular lipomatous pseudohypertrophy of the pancreas, measuring 6.0 × 5.6 cm in the head, uncinate process, and part of the body of the pancreas. The pancreatic duct dilation was diffuse and irregular, associated with atrophy of the remnant parenchyma, particularly in the tail of the pancreas. The patient underwent pancreatoduodenectomy without total mesopancreas excision followed by pancreatojejunostomy.

RESULTS

The postoperative course was uneventful, the length of stay in the ICU was two days, and the patient was discharged on the seventh postoperative day.

CONCLUSIONS

The disease treatment depends on the signs and symptoms at presentation and a pancreatoduodenectomy is indicated in patients with severe and recurrent abdominal pain.

Factors Associated with Mortality in Patients with Gastric Cancer at a Reference Hospital

Background: Gastric cancer (GC) is the second cause of death by tumor in the world. In Brazil, the survival rate of patients with GC is only five years, due to the low rates of early diagnosis, with about 10 to 15% of the cases. Thus, this study aims to evaluate the factors associated with mortality in CG patients treated at a reference hospital. Method: The study was carried out based on the survey of 96 medical records of patients diagnosed with GC, whose analyzed data were: sex, age, educational level, occupation (socioeconomic level), and risk factors, such as smoking, alcohol consumption, family history of cancer, staging and type of treatment adopted, among other variables. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS-PC) and Kaplan-Meier for survival analysis. Absolute and relative frequencies were calculated for all variables. Results: The sample consisted mainly of male patients with stable union, brown-colored, who lived in the metropolitan region and presented low schooling. In addition, risk factors such as smoking and alcoholism presented a high prevalence in the sample. Regarding mortality, factors such as arterial hypertension (p = 0.1581), diabetes (p = 0.3212), and alcohol consumption (p = 0.6704) were not associated with increased mortality in this study.Conclusion: The clinical and epidemiological profile of patients with GC presented a low degree of tumor differentiation, with predominance of the mixed or unclassifiable subtype. In addition, the majority of the sample was composed of patients living in the metropolitan region and the main form of treatment adopted was surgical intervention in combination with chemotherapy.