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Laparoscopic two-stage-hepatectomy: Laparoscopic colectomy with intraoperative portal-vein phenolization on patients with predicted insufficient liver remnant. Strategy safer than ALPPS and cheaper than portal vein embolization
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Electronic Poster Abstracts
looking for a replaced right hepatic artery arising from SMA. We continue dissection toward the right wall of the SMA in order to identify the superior and inferior Pancreaticoduodenal Artery. In case of suspicion of SMA involvement a fresh-frozen section exanimation of the arterial sheath could be performed. Conclusion: Our approach has many advantages in order to assess resectability of the tumour as detect peritoneal carcinomatosis, hepatic metastases and perform para-aortic lymph nodes sampling and SMA approach. This avoids unnecessary laparotomy for patients not suitable for surgery and giving a prompt access to chemotherapy to advantages of laparoscopy.
SYM14-07 THE SOFT PANCREAS: PANCREATOGASTROPEXY WITH PANCREATICOGASTROSTOMY MINIMIZES PANCREATIC FISTULA RATE POST PANCREATODUODENECTOMY E. C. -Y. Ip, R. C. Gandy, A. Ling and K. Haghighi Prince of Wales Hospital, Australia Introduction: Despite significant pancreatic fistulae associated morbidity and mortality, there is no consensus on the ideal pancreatic-enteric anastomosis particularly with softtextured pancreases. Objective: To review incidence of pancreatic fistulae, morbidity and mortality associated with a surgeon’s modified pancreaticogastrostomy (PG) technique. Methodology: All PG anastomoses by a single surgeon (KSH) between January2007 and September2015 were identified. The anastomois was a two-layer tension-free technique between the pancreatic cut surface, duct and posterior gastric wall. To minimize movement and tension at the anastomotic surface, the anterior pancreatic body capsule and posterior gastric wall are fixated with sutures. Two-layers of sutures are then placed between the superior and inferior cut pancreatic parenchymal surface and duct to approximate to the gastrostomy via duct-to-gastrostomy and parenchyma-to-gastrostomy sutures. Lastly, the pancreas was gently invaginated into the gastrostomy with further fixating sutures between the parenchyma adjacent to the cut surface and the peri-gastrostomy serosa. An operative video will be presented as part of this presentation. Results: 108 modified PG anastomoses were performed, including 37.9% (n = 41) for extended PD and 1.8% (n = 2) for non-continuous organ resection with PD respectively. 31.5% (n = 34) underwent vascular reconstruction. Postoperatively, 1.9% (n = 2) of patients experienced Grade A fistulae with no Grade B or C fistulae observed. Low morbidity and no 90-day mortality was reported. Conclusion: A low incidence of Grade A pancreatic fistulae was experienced with the modified PG technique. An anastomosis involving fixating both pancreatic body to posterior stomach and peri-pancreatic cut surface to perigastrostomy may be a solution in soft pancreases.
SYM14-08 LAPAROSCOPIC TWO-STAGEHEPATECTOMY: LAPAROSCOPIC COLECTOMY WITH INTRAOPERATIVE PORTAL-VEIN PHENOLIZATION ON PATIENTS WITH PREDICTED INSUFFICIENT LIVER REMNANT. STRATEGY SAFER THAN ALPPS AND CHEAPER THAN PORTAL VEIN EMBOLIZATION D. Davila1, S. Lopez-Ben2, J. P. Aristizabal1,3, J. Bernal4 and O. Palacios1 1 Hepato-Pancreato-Biliary Surgery, Clinica CES, Colombia, 2Hepato-Pancreato-Biliary Surgery, Hospital Dr Josep Trueta de Girona, Spain, 3Anaesthesia Department, and 4Gastrointestinal Surgery, Clinica CES, Colombia Initially unresectable liver metastases may turn resectable by several approaches. Two-stage hepatectomy combined with chemotherapy may allow long-term remission even in patients with multilobar metastastatic disease. Selective portal vein embolization is a standard practice for this approach; unfortunately this procedure demands time and expensive resources. We propose an innovative full-laparoscopic approach that combines colectomy with primary anastomosis, portal vein ligation, and subsequent liver remnant hypertrophy for a second-stage permanent extended liver resection. During the first stage hepatectomy and immediately after laparoscopic colectomy but before resecting/ablating small metastases on the remnant lobe, we selectively ligate laparoscopically the portal vein branch we want to occlude above its bifurcation from the main portal vein. Through a Fogarty catheterÔ inserted in such portal vein branch (Figure 1), 20 millilitres of absolute phenol are infused to cause phlebitis of the interlobular arterio-venous shunts, enhancing thus compensatory hypertrophy of the desired lobule in three to four weeks. During this time the patient is on chemotherapy. Afterwards, during the second stage, a vessel loop left in the first stage around bile duct and artery from the lobule to be resected facilitates the laparoscopic major hepatectomy.
[Figure 1] With this technique, we were been able to increase Future Liver Remnant/Body Weight ratio from 0.49 to 0.67 in three weeks, allowing a subsequent safer major hepatectomy without liver dysfunction and delay of colectomy or chemotherapy, avoiding a full cut surface in the first HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts stage (seen in pure ALPPS) that could lead to bleeding or bile leak and could impair liver regeneration.
SYM14-09 SUPRAMESOCOLIC ACCESS THE LIGAMENT OF TREITZ DURING MINIMALLY INVASIVE PANCREATODUODENECTOMY R. Jureidini1, T. Bacchella1, G. N. Namur1, T. C. Ribeiro1, U. Ribeiro Junior2, L. M. Rios3 and I. Cecconello4 1 Gastroenterology e Pancreatic and Biliary Surgery Division, 2Gastroenterology e Instituto do Cancer do Estado de Sao Paulo, University of Sao Paulo, 3University of Sao Paulo/Medical School, and 4Gastroenterology, University of Sao Paulo, Brazil Introduction: The technique of minimaly invasive pancreatoduodenectomy is not yet standartazed. In an attempt to avoid colonic manipulation and possible bowel perforation due to excessive intestinal loops manipulation during minimally invasive procedure, we have developed a new technique to expose and dissect proximal jejunal and Treitz’s ligament through a window at the transverse mesocolon on the left avascular area of mid colic artery. This window is also used to bring first jejunal loop for pancreatojejunoanastomosis without tensioning mesenteric vessels. This maneuver can be easily reproduced and facilitates mesoduodenun and first jejunal loop transection. The safety and facility of this new technique was observed in 15 total laparoscopic pancreatoduodenectomies performed at our University and is a useful tool for this complex procedure.
[Opening mesocolon to acces ligament of treiz]
HPB 2016, 18 (S1), e1ee384
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SYM14-10 RADICAL RESECTION OF RETROPERITONEAL LIPOLYMPHATIC LAYER (RRRLLL) FOR PANCREATIC HEAD CANCER: A NEW STRATEGY IN PANCREATICODUODENECTOMY S. Y. Peng1, J. -T. Li1, R. Y. Qin2, Y. B. Liu3, D. F. Hong4, J. W. Wang5, M. Wang2, W. G. Wu3, C. Y. Huang6, Z. J. Tan7 and Y. Q. Yu1 1 Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, 2Department of Biliary and Pancreas, Tongji Hospital, The Huazhong University of Science and Technology School of Medicine, 3 Department of Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 4Department of Hepato-Pancreato-Biliary, Zhejiang Provincial People’s Hospital, 5Department of Surgical Oncology, Second Affiliated Hospital, Zhejiang University School of Medicine, 6Department of Surgery, Yuebei People’s Hospital, Shantou University School of Medicine, and 7Department of Surgery, Guangdong Province Traditional Chinese Medical Hospital, Guangzhou University of Chinese Medicine, China Introduction: The significance of extended radical lympadenectomy for pancreas cancer is still controvertible. Although several articles considered it useless, many scholars are still trying to improve it and making progress. We propose a new method to perform the extended radical lympadenectomy. It is named Radical Resection of Retroperitoneal Lipo-Lymphatic Layer (RRRLLL), and is very promising. Methods: From January 2012 to February 2015, 133 patients with pancreatic head adenocarcinoma underwent RRRLLL in PD, surgical technique and clinical perioperative results were analyzed. The most striking characteristics of RRRLLL are 1. All the important vessels including SMA、SMV、 PV、SV、IMA、IMV、HA、CA、SA are isolated and taped before the RLLL is performed. 2. Transection on the left side of RLLL is carried out bundle by bundle. Thus the manipulation become safe, rapid, less blood loss and less traumatic. Results: 133 patients underwent RRRLLL in pancreaticoduodenectomy. The mean operation time was 288 min., mean blood loss 454 ml. 39 patients underwent resection and/or repair of PV or SMV. 31 cases with postoperative complications (23.3%) and no mortality. The incidence rates of postoperative bleeding, pancreatic leakage, biliary leakage, delayed gastric emptying and diarrhea, were 3.0%, 4.5%, 3.0%, 3.8%, and 1.5% respectively. Conclusion: RRRLLL depicts a definite area of resection for PD. It is relatively easy and rapid to perform. This updated concept of PD is promising in terms of its effectiveness and safety. Further study is required to confirm its radicalness.
Electronic Poster Abstracts
looking for a replaced right hepatic artery arising from SMA. We continue dissection toward the right wall of the SMA in order to identify the superior and inferior Pancreaticoduodenal Artery. In case of suspicion of SMA involvement a fresh-frozen section exanimation of the arterial sheath could be performed. Conclusion: Our approach has many advantages in order to assess resectability of the tumour as detect peritoneal carcinomatosis, hepatic metastases and perform para-aortic lymph nodes sampling and SMA approach. This avoids unnecessary laparotomy for patients not suitable for surgery and giving a prompt access to chemotherapy to advantages of laparoscopy.
SYM14-07 THE SOFT PANCREAS: PANCREATOGASTROPEXY WITH PANCREATICOGASTROSTOMY MINIMIZES PANCREATIC FISTULA RATE POST PANCREATODUODENECTOMY E. C. -Y. Ip, R. C. Gandy, A. Ling and K. Haghighi Prince of Wales Hospital, Australia Introduction: Despite significant pancreatic fistulae associated morbidity and mortality, there is no consensus on the ideal pancreatic-enteric anastomosis particularly with softtextured pancreases. Objective: To review incidence of pancreatic fistulae, morbidity and mortality associated with a surgeon’s modified pancreaticogastrostomy (PG) technique. Methodology: All PG anastomoses by a single surgeon (KSH) between January2007 and September2015 were identified. The anastomois was a two-layer tension-free technique between the pancreatic cut surface, duct and posterior gastric wall. To minimize movement and tension at the anastomotic surface, the anterior pancreatic body capsule and posterior gastric wall are fixated with sutures. Two-layers of sutures are then placed between the superior and inferior cut pancreatic parenchymal surface and duct to approximate to the gastrostomy via duct-to-gastrostomy and parenchyma-to-gastrostomy sutures. Lastly, the pancreas was gently invaginated into the gastrostomy with further fixating sutures between the parenchyma adjacent to the cut surface and the peri-gastrostomy serosa. An operative video will be presented as part of this presentation. Results: 108 modified PG anastomoses were performed, including 37.9% (n = 41) for extended PD and 1.8% (n = 2) for non-continuous organ resection with PD respectively. 31.5% (n = 34) underwent vascular reconstruction. Postoperatively, 1.9% (n = 2) of patients experienced Grade A fistulae with no Grade B or C fistulae observed. Low morbidity and no 90-day mortality was reported. Conclusion: A low incidence of Grade A pancreatic fistulae was experienced with the modified PG technique. An anastomosis involving fixating both pancreatic body to posterior stomach and peri-pancreatic cut surface to perigastrostomy may be a solution in soft pancreases.
SYM14-08 LAPAROSCOPIC TWO-STAGEHEPATECTOMY: LAPAROSCOPIC COLECTOMY WITH INTRAOPERATIVE PORTAL-VEIN PHENOLIZATION ON PATIENTS WITH PREDICTED INSUFFICIENT LIVER REMNANT. STRATEGY SAFER THAN ALPPS AND CHEAPER THAN PORTAL VEIN EMBOLIZATION D. Davila1, S. Lopez-Ben2, J. P. Aristizabal1,3, J. Bernal4 and O. Palacios1 1 Hepato-Pancreato-Biliary Surgery, Clinica CES, Colombia, 2Hepato-Pancreato-Biliary Surgery, Hospital Dr Josep Trueta de Girona, Spain, 3Anaesthesia Department, and 4Gastrointestinal Surgery, Clinica CES, Colombia Initially unresectable liver metastases may turn resectable by several approaches. Two-stage hepatectomy combined with chemotherapy may allow long-term remission even in patients with multilobar metastastatic disease. Selective portal vein embolization is a standard practice for this approach; unfortunately this procedure demands time and expensive resources. We propose an innovative full-laparoscopic approach that combines colectomy with primary anastomosis, portal vein ligation, and subsequent liver remnant hypertrophy for a second-stage permanent extended liver resection. During the first stage hepatectomy and immediately after laparoscopic colectomy but before resecting/ablating small metastases on the remnant lobe, we selectively ligate laparoscopically the portal vein branch we want to occlude above its bifurcation from the main portal vein. Through a Fogarty catheterÔ inserted in such portal vein branch (Figure 1), 20 millilitres of absolute phenol are infused to cause phlebitis of the interlobular arterio-venous shunts, enhancing thus compensatory hypertrophy of the desired lobule in three to four weeks. During this time the patient is on chemotherapy. Afterwards, during the second stage, a vessel loop left in the first stage around bile duct and artery from the lobule to be resected facilitates the laparoscopic major hepatectomy.
[Figure 1] With this technique, we were been able to increase Future Liver Remnant/Body Weight ratio from 0.49 to 0.67 in three weeks, allowing a subsequent safer major hepatectomy without liver dysfunction and delay of colectomy or chemotherapy, avoiding a full cut surface in the first HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts stage (seen in pure ALPPS) that could lead to bleeding or bile leak and could impair liver regeneration.
SYM14-09 SUPRAMESOCOLIC ACCESS THE LIGAMENT OF TREITZ DURING MINIMALLY INVASIVE PANCREATODUODENECTOMY R. Jureidini1, T. Bacchella1, G. N. Namur1, T. C. Ribeiro1, U. Ribeiro Junior2, L. M. Rios3 and I. Cecconello4 1 Gastroenterology e Pancreatic and Biliary Surgery Division, 2Gastroenterology e Instituto do Cancer do Estado de Sao Paulo, University of Sao Paulo, 3University of Sao Paulo/Medical School, and 4Gastroenterology, University of Sao Paulo, Brazil Introduction: The technique of minimaly invasive pancreatoduodenectomy is not yet standartazed. In an attempt to avoid colonic manipulation and possible bowel perforation due to excessive intestinal loops manipulation during minimally invasive procedure, we have developed a new technique to expose and dissect proximal jejunal and Treitz’s ligament through a window at the transverse mesocolon on the left avascular area of mid colic artery. This window is also used to bring first jejunal loop for pancreatojejunoanastomosis without tensioning mesenteric vessels. This maneuver can be easily reproduced and facilitates mesoduodenun and first jejunal loop transection. The safety and facility of this new technique was observed in 15 total laparoscopic pancreatoduodenectomies performed at our University and is a useful tool for this complex procedure.
[Opening mesocolon to acces ligament of treiz]
HPB 2016, 18 (S1), e1ee384
e123
SYM14-10 RADICAL RESECTION OF RETROPERITONEAL LIPOLYMPHATIC LAYER (RRRLLL) FOR PANCREATIC HEAD CANCER: A NEW STRATEGY IN PANCREATICODUODENECTOMY S. Y. Peng1, J. -T. Li1, R. Y. Qin2, Y. B. Liu3, D. F. Hong4, J. W. Wang5, M. Wang2, W. G. Wu3, C. Y. Huang6, Z. J. Tan7 and Y. Q. Yu1 1 Department of Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, 2Department of Biliary and Pancreas, Tongji Hospital, The Huazhong University of Science and Technology School of Medicine, 3 Department of Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 4Department of Hepato-Pancreato-Biliary, Zhejiang Provincial People’s Hospital, 5Department of Surgical Oncology, Second Affiliated Hospital, Zhejiang University School of Medicine, 6Department of Surgery, Yuebei People’s Hospital, Shantou University School of Medicine, and 7Department of Surgery, Guangdong Province Traditional Chinese Medical Hospital, Guangzhou University of Chinese Medicine, China Introduction: The significance of extended radical lympadenectomy for pancreas cancer is still controvertible. Although several articles considered it useless, many scholars are still trying to improve it and making progress. We propose a new method to perform the extended radical lympadenectomy. It is named Radical Resection of Retroperitoneal Lipo-Lymphatic Layer (RRRLLL), and is very promising. Methods: From January 2012 to February 2015, 133 patients with pancreatic head adenocarcinoma underwent RRRLLL in PD, surgical technique and clinical perioperative results were analyzed. The most striking characteristics of RRRLLL are 1. All the important vessels including SMA、SMV、 PV、SV、IMA、IMV、HA、CA、SA are isolated and taped before the RLLL is performed. 2. Transection on the left side of RLLL is carried out bundle by bundle. Thus the manipulation become safe, rapid, less blood loss and less traumatic. Results: 133 patients underwent RRRLLL in pancreaticoduodenectomy. The mean operation time was 288 min., mean blood loss 454 ml. 39 patients underwent resection and/or repair of PV or SMV. 31 cases with postoperative complications (23.3%) and no mortality. The incidence rates of postoperative bleeding, pancreatic leakage, biliary leakage, delayed gastric emptying and diarrhea, were 3.0%, 4.5%, 3.0%, 3.8%, and 1.5% respectively. Conclusion: RRRLLL depicts a definite area of resection for PD. It is relatively easy and rapid to perform. This updated concept of PD is promising in terms of its effectiveness and safety. Further study is required to confirm its radicalness.