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Liver partition and portal vein ligation in staged hepatectomy (ALPPS) as a savage procedure after failed portal embolization in colorectal liver metastases
Electronic Poster Abstracts Method: Laparoscopic Glissonian approach and extracorporeal control of Glissonian pedicle make it easy and safe dissection of parenchyma and pedicle control. Hepatectomy including bile duct exploration by using combination of Glissonian approach followed by individual dissection could help bile duct exploration easy without bleeding. If IHD stone was located in the main bifurcation, bile duct exploration should be required. Glissonian approach made identification of left pedicle more easy. After isolation of left pedicle, individual dissection of hepatic artery and left portal vein was easy and safe. After dissection of liver parenchyma using Glissonian approach, bile duct exploration with ligation of left hepatic artery and portal vein performed. Result: This combination method has the advantages of Glissonian approach such as, short operation time and easy approach of hilum. Moreover, it makes bloodless and safe bile duct exploration in hilar type IHD stone. Conclusion: Combination of Glissonian approach and individual dissection is useful method in laparoscopic liver resection requiring bile duct exploration.
EP01D-069 BISEGMENTECTOMY 7e8: A SAFE AND EFFECTIVE ALTERNATIVE TO RIGHT HEPATECTOMY J. D. Kim and D. L. Choi Department of Surgery, Daegu Catholic University College of Medicine, Republic of Korea Introduction: A lesion in segment 7e8 and infiltrating the RHV is usually an indication for right hepatectomy. However, if there is the presence of a small remnant liver, steatotic or cirrhotic liver, parenchymal sparing liver resection should be considered in order to prevent postoperative liver failure. Methods: We present two cases of or bisegmentectomy 7e 8 and this resection could be considered as an safe alternative to right hepatectomy without postoperative morbidity and long-term tumor recurrence. Results: The first case was a 57-year-old woman with hepatitis B related liver cirrhosis was referred for management to hepatocellular carcinoma (HCC). Dynamic CT scan demonstrated large HCC infiltrating right hepatic vein at segment 7 and 8. The second case was 57year-old woman was also referred for hepatitis B related liver cirrhosis with HCC which was demonstrated 2 cm sized HCC at segment 7 and 8. We planned to perform bisegmentectomy 7-8 instead to right hepatectomy because of small remnant left liver volime and the presence of large inferior right hepatic vein in both cases. After complete resection, no congestion on segment 5, 6 was encountered. Postoperative courses in two patients were uneventful and these patients were discharged on postoperative 8th and 10th day. Abdominal CT scan after hepatectomy showed neither congestion nor atrophy at segment 6 and there was no tumor recurrence. Conclusion: The bisegmentectomy 7e8 should be a safe alternative to right hepatectomy in the selected patients. Moreover, it can provide the curative resection without unnecessary sacrifice of functional parenchyma with minimal morbidity.
HPB 2016, 18 (S1), e1ee384
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EP01D-070 CASE REPORT: LIVER TRANSPLANT OWING TO MASSIVE POLYCYSTIC LIVER DISEASE REPRESENTING 30% OF BODY VOLUME: ARTERIAL RECONSTRUCTION USING GRAFT AORTOILIAC OF DONOR A. A. Barbiere Bonatelli1, E. C. Ataide1, I. D. F. Santana Ferreira Boin2, C. A. Fazzio Escanhoela3, P. Turine Neto1, M. Silva Garcia1, P. V. Barreto Guimarães4 and S. Reges Perales1 1 Gastrocirurgia, 2Universade de Campinas e Unicamp, 3 Patologia, and 4Cirurgia Geral, Universade de Campinas e Unicamp, Brazil The Polycystic Liver disease is caused by genetic changes that lead to formation of multiple hepatic cysts, and may be associated with renal cysts disease. The symptoms are usually small, but large cysts may cause abdominal pain, increased abdominal size and even abdominal compartment syndrome, which is indication for liver transplant. Herein, we present a case of a 37 years old female, weight of 50kilograms with family history of polycystic liver disease. She received the diagnosed in 2010 by abdominal routine ultrasound and during next 4 years she had showed increased liver volume due to cysts became greater. On July of 2015 she was submitted to liver transplant owing to abdominal compartment syndrome. The liver explant extended over pelvis and weighed 7 kilograms in context of polycystic disease with serous content. The patient had hepatic artery thrombosis on the 5th postoperative day being submitted to retransplantation. The procedure realized was the Standard technique by arterial reconstruction using graft aortoiliac of donorto communicating the aorta of receptor with the donor celiac trunk. She showed kidney failure requiring dialysis postoperatively, but control tests observed normal liver flow. She was discharged on 33th postoperative day without need of dialysis and using immunosuppressants.
EP01D-071 LIVER PARTITION AND PORTAL VEIN LIGATION IN STAGED HEPATECTOMY (ALPPS) AS A SAVAGE PROCEDURE AFTER FAILED PORTAL EMBOLIZATION IN COLORECTAL LIVER METASTASES A. E. Padilla Rosciano1, H. N. Lopez Basave1, G. Miranda Devora2, M. G. Serna Thome3, S. L. Lino Silva3 and A. Herrera Gomez2 1 Gastrointestinal and HPB Tumors, 2Surgical Oncology, and 3National Cancer Institute, Mexico Background: Portal vein embolization (PVE) is indicated when future liver remnant (FLR) is smaller than 30% after chemotherapy, one major concern with PVE is the growth rate is usually slow and there is risk of tumor progression or the growth of FLR might be insufficient and a large number of patients will never be resected, the ALPPS could be an option for rescue in failing PVE.
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Electronic Poster Abstracts
Case report: A 45 years-old female with sigmoid cancer and synchronous multiple liver metastases received neoadjuvant chemotherapy (8 cycles FOLFOX) followed by primary resection. CT volumetry revealed small FLR 234 ml, 23% of total liver volume, percutaneous PVE was performed, CT (Week 4) after embolization showed partial patency of the right vein considering failure to PVE. We performed ALPPS, during first stage, the liver was partitioned and right portal vein ligated, right hepatic artery, duct and vein were secured with loops CT on postoperative day 10 showed increase of 234 to 659 ml .FLR increase from 23% to 60%. The second stage of ALPPS was on postoperative day 12 completing the right hepatectomy without complications. The patient was discharged 7 days after second step. Is alive and disease free 8 months after surgery. Discussion: The mortality rate is higher in ALPPS compared to PVE. ALPPS seems offer more liver resection with increase mortality. The role of ALPPS is not clear, maybe it is most suitable for colorectal liver metastases failing to PVE. Conclusions: ALPPS could be the only option in patients failing to PVE.
of the cystic fluid under direct vision. Unroofing with the ultrasound scalpel allows quick dissection, safe coagulation of small vessels and bile ducts as well as ablation of the fluid-producing epithelial cyst lining. Fibrin glue seals the raw liver surface and further prevents bile leakage and haemorrhage. Wide-bore closed-suction fluted drain avoids accumulation of ascitic fluid and ensures complete evacuation of the collection and collapse of the opened cystic cavities.
Figure
EP01D-072 LAPAROSCOPIC EXCISION OF LARGE, SOLITARY NON-PARASITIC HEPATIC CYSTS: A REPORT OF TWO CASES C. Kosmidis1,2, C. Efthimiadis1, D. Chourmouzi3, A. Ioannidis1, N. Varsamis1, E. Georgakoudi4 and G. Anthimidis1 1 Department of Surgery, Interbalkan European Medical Center, 2Faculty of Medicine, Associate Professor of Surgery, Aristotelian University of Thessaloniki, 3Department of Radiology, Interbalkan European Medical Center, and 4Faculty of Medicine, Aristotelian University of Thessaloniki, Greece Introduction: Solitary non-parasitic hepatic cysts, also known as simple cysts, are treated in case of enlargement or presence of symptoms and complications. We present two cases of patients treated with laparoscopic excision of large, symptomatic simple hepatic cysts. Methods: The first patient was an 80 year-old female with symptoms of gastric obstruction. Workout revealed a solitary hepatic cyst, measuring 17 cm in diameter. The stomach was compressed between the cyst and the spleen. The second patient was a 70-year old female with a history of a simple hepatic cyst which enlarged and caused epigastric pain. Both patients were treated with laparoscopic aspiration and unroofing, using ultrasound scissors. Fibrin glue was spread over the cut liver surface and a closed-suction fluted drain (30 F) was left in place. Results: Excessive fluid loss through the drain tube was not encountered. Clinical course was uncomplicated and both patients were discharged on the second postoperative day. Follow up after six months and one year revealed no signs of recurrence. Conclusion: Laparoscopic intervention in cases of large, solitary, non-parasitic hepatic cysts enables safe aspiration
EP01D-073 PORTAL EMBOLIZATION AS TREATMENT IN PATIENT WITH PREOPERATIVE HEPATOCELLULAR CARCINOMA J. C. Cavalcante Jr., M. F. C. Medeiros, N. R. D. A. Neto, J. O. d. O. Tavares, D. R. Costa, D. F. Ferro, A. C. P. Pontes and J. Batista Neto Oncologic Surgery, University Hospital of Alagoas, Brazil Introduction: Liver malignancy have increased in incidence over the decades, and the liver is a common site of metastases. In recent decades, improvements in surgical techniques, increased understanding of liver anatomy and advances in perioperative care have resulted in improvements in mortality. Case report: Men, 71, complaining of abdominal discomfort. Upper abdominal CT scan that showed a mass in the right lobe of the liver, occupying segments V, VI, VII, VIII, 1 3 6 11.6 13 cm in their largest diameter, without involvement of other segments. Biopsy diagnosed with well-differentiated hepatocellular carcinoma was performed. Conducting right portal vein embolization in order to increase the residual liver volume for subsequent hepatectomy. Patient underwent embolization and portal vein chemoembolization of the right hepatic artery was discharged on POD 50. It was accompanied with rescanned after 30 days, which showed growth of 28.9% of the FFR. Hospitalized for 40 days to carry out the right hepatectomy was discharged in 110 days, and outpatient follow-up. Conclusions: The preoperative embolization portal vein yielded growth of residual liver 28.9% hepatectomy sufficient to allow safety.
HPB 2016, 18 (S1), e1ee384
EP01D-069 BISEGMENTECTOMY 7e8: A SAFE AND EFFECTIVE ALTERNATIVE TO RIGHT HEPATECTOMY J. D. Kim and D. L. Choi Department of Surgery, Daegu Catholic University College of Medicine, Republic of Korea Introduction: A lesion in segment 7e8 and infiltrating the RHV is usually an indication for right hepatectomy. However, if there is the presence of a small remnant liver, steatotic or cirrhotic liver, parenchymal sparing liver resection should be considered in order to prevent postoperative liver failure. Methods: We present two cases of or bisegmentectomy 7e 8 and this resection could be considered as an safe alternative to right hepatectomy without postoperative morbidity and long-term tumor recurrence. Results: The first case was a 57-year-old woman with hepatitis B related liver cirrhosis was referred for management to hepatocellular carcinoma (HCC). Dynamic CT scan demonstrated large HCC infiltrating right hepatic vein at segment 7 and 8. The second case was 57year-old woman was also referred for hepatitis B related liver cirrhosis with HCC which was demonstrated 2 cm sized HCC at segment 7 and 8. We planned to perform bisegmentectomy 7-8 instead to right hepatectomy because of small remnant left liver volime and the presence of large inferior right hepatic vein in both cases. After complete resection, no congestion on segment 5, 6 was encountered. Postoperative courses in two patients were uneventful and these patients were discharged on postoperative 8th and 10th day. Abdominal CT scan after hepatectomy showed neither congestion nor atrophy at segment 6 and there was no tumor recurrence. Conclusion: The bisegmentectomy 7e8 should be a safe alternative to right hepatectomy in the selected patients. Moreover, it can provide the curative resection without unnecessary sacrifice of functional parenchyma with minimal morbidity.
HPB 2016, 18 (S1), e1ee384
e285
EP01D-070 CASE REPORT: LIVER TRANSPLANT OWING TO MASSIVE POLYCYSTIC LIVER DISEASE REPRESENTING 30% OF BODY VOLUME: ARTERIAL RECONSTRUCTION USING GRAFT AORTOILIAC OF DONOR A. A. Barbiere Bonatelli1, E. C. Ataide1, I. D. F. Santana Ferreira Boin2, C. A. Fazzio Escanhoela3, P. Turine Neto1, M. Silva Garcia1, P. V. Barreto Guimarães4 and S. Reges Perales1 1 Gastrocirurgia, 2Universade de Campinas e Unicamp, 3 Patologia, and 4Cirurgia Geral, Universade de Campinas e Unicamp, Brazil The Polycystic Liver disease is caused by genetic changes that lead to formation of multiple hepatic cysts, and may be associated with renal cysts disease. The symptoms are usually small, but large cysts may cause abdominal pain, increased abdominal size and even abdominal compartment syndrome, which is indication for liver transplant. Herein, we present a case of a 37 years old female, weight of 50kilograms with family history of polycystic liver disease. She received the diagnosed in 2010 by abdominal routine ultrasound and during next 4 years she had showed increased liver volume due to cysts became greater. On July of 2015 she was submitted to liver transplant owing to abdominal compartment syndrome. The liver explant extended over pelvis and weighed 7 kilograms in context of polycystic disease with serous content. The patient had hepatic artery thrombosis on the 5th postoperative day being submitted to retransplantation. The procedure realized was the Standard technique by arterial reconstruction using graft aortoiliac of donorto communicating the aorta of receptor with the donor celiac trunk. She showed kidney failure requiring dialysis postoperatively, but control tests observed normal liver flow. She was discharged on 33th postoperative day without need of dialysis and using immunosuppressants.
EP01D-071 LIVER PARTITION AND PORTAL VEIN LIGATION IN STAGED HEPATECTOMY (ALPPS) AS A SAVAGE PROCEDURE AFTER FAILED PORTAL EMBOLIZATION IN COLORECTAL LIVER METASTASES A. E. Padilla Rosciano1, H. N. Lopez Basave1, G. Miranda Devora2, M. G. Serna Thome3, S. L. Lino Silva3 and A. Herrera Gomez2 1 Gastrointestinal and HPB Tumors, 2Surgical Oncology, and 3National Cancer Institute, Mexico Background: Portal vein embolization (PVE) is indicated when future liver remnant (FLR) is smaller than 30% after chemotherapy, one major concern with PVE is the growth rate is usually slow and there is risk of tumor progression or the growth of FLR might be insufficient and a large number of patients will never be resected, the ALPPS could be an option for rescue in failing PVE.
e286
Electronic Poster Abstracts
Case report: A 45 years-old female with sigmoid cancer and synchronous multiple liver metastases received neoadjuvant chemotherapy (8 cycles FOLFOX) followed by primary resection. CT volumetry revealed small FLR 234 ml, 23% of total liver volume, percutaneous PVE was performed, CT (Week 4) after embolization showed partial patency of the right vein considering failure to PVE. We performed ALPPS, during first stage, the liver was partitioned and right portal vein ligated, right hepatic artery, duct and vein were secured with loops CT on postoperative day 10 showed increase of 234 to 659 ml .FLR increase from 23% to 60%. The second stage of ALPPS was on postoperative day 12 completing the right hepatectomy without complications. The patient was discharged 7 days after second step. Is alive and disease free 8 months after surgery. Discussion: The mortality rate is higher in ALPPS compared to PVE. ALPPS seems offer more liver resection with increase mortality. The role of ALPPS is not clear, maybe it is most suitable for colorectal liver metastases failing to PVE. Conclusions: ALPPS could be the only option in patients failing to PVE.
of the cystic fluid under direct vision. Unroofing with the ultrasound scalpel allows quick dissection, safe coagulation of small vessels and bile ducts as well as ablation of the fluid-producing epithelial cyst lining. Fibrin glue seals the raw liver surface and further prevents bile leakage and haemorrhage. Wide-bore closed-suction fluted drain avoids accumulation of ascitic fluid and ensures complete evacuation of the collection and collapse of the opened cystic cavities.
Figure
EP01D-072 LAPAROSCOPIC EXCISION OF LARGE, SOLITARY NON-PARASITIC HEPATIC CYSTS: A REPORT OF TWO CASES C. Kosmidis1,2, C. Efthimiadis1, D. Chourmouzi3, A. Ioannidis1, N. Varsamis1, E. Georgakoudi4 and G. Anthimidis1 1 Department of Surgery, Interbalkan European Medical Center, 2Faculty of Medicine, Associate Professor of Surgery, Aristotelian University of Thessaloniki, 3Department of Radiology, Interbalkan European Medical Center, and 4Faculty of Medicine, Aristotelian University of Thessaloniki, Greece Introduction: Solitary non-parasitic hepatic cysts, also known as simple cysts, are treated in case of enlargement or presence of symptoms and complications. We present two cases of patients treated with laparoscopic excision of large, symptomatic simple hepatic cysts. Methods: The first patient was an 80 year-old female with symptoms of gastric obstruction. Workout revealed a solitary hepatic cyst, measuring 17 cm in diameter. The stomach was compressed between the cyst and the spleen. The second patient was a 70-year old female with a history of a simple hepatic cyst which enlarged and caused epigastric pain. Both patients were treated with laparoscopic aspiration and unroofing, using ultrasound scissors. Fibrin glue was spread over the cut liver surface and a closed-suction fluted drain (30 F) was left in place. Results: Excessive fluid loss through the drain tube was not encountered. Clinical course was uncomplicated and both patients were discharged on the second postoperative day. Follow up after six months and one year revealed no signs of recurrence. Conclusion: Laparoscopic intervention in cases of large, solitary, non-parasitic hepatic cysts enables safe aspiration
EP01D-073 PORTAL EMBOLIZATION AS TREATMENT IN PATIENT WITH PREOPERATIVE HEPATOCELLULAR CARCINOMA J. C. Cavalcante Jr., M. F. C. Medeiros, N. R. D. A. Neto, J. O. d. O. Tavares, D. R. Costa, D. F. Ferro, A. C. P. Pontes and J. Batista Neto Oncologic Surgery, University Hospital of Alagoas, Brazil Introduction: Liver malignancy have increased in incidence over the decades, and the liver is a common site of metastases. In recent decades, improvements in surgical techniques, increased understanding of liver anatomy and advances in perioperative care have resulted in improvements in mortality. Case report: Men, 71, complaining of abdominal discomfort. Upper abdominal CT scan that showed a mass in the right lobe of the liver, occupying segments V, VI, VII, VIII, 1 3 6 11.6 13 cm in their largest diameter, without involvement of other segments. Biopsy diagnosed with well-differentiated hepatocellular carcinoma was performed. Conducting right portal vein embolization in order to increase the residual liver volume for subsequent hepatectomy. Patient underwent embolization and portal vein chemoembolization of the right hepatic artery was discharged on POD 50. It was accompanied with rescanned after 30 days, which showed growth of 28.9% of the FFR. Hospitalized for 40 days to carry out the right hepatectomy was discharged in 110 days, and outpatient follow-up. Conclusions: The preoperative embolization portal vein yielded growth of residual liver 28.9% hepatectomy sufficient to allow safety.
HPB 2016, 18 (S1), e1ee384