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Parenchyma sparing liver resection of the posterior segments: Experiences after randomizing 250 patients to open or laparoscopic resection
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Electronic Poster Abstracts
SYM14-11 FLUORESCENCE-GUIDED LAPAROSCOPIC HEPATECTOMIES L. S. F. Boogerd, H. J. M. Handgraaf, H. D. Lam, C. J. H. van de Velde, A. E. Braat and A. L. Vahrmeijer Leiden University Medical Center, Netherlands Background and technical issue: Laparoscopic surgery deprives surgeons of tactile feedback. Assessment of tumor localization and margins during laparoscopic hepatectomies is therefore limited to inspection and intraoperative ultrasound (IOUS). Recurrence rates after oncologic liver surgery suggest small tumors may remain undetected, underscoring the demand for an accurate additive intraoperative imaging modality. Near-infrared (NIR) fluorescence imaging is an innovative technique enabling realtime intraoperative identification and demarcation of tumors. After administration of indocyanine green (ICG), 24 hours prior to surgery, accumulated ICG in or around liver tumors can be visualized using NIR imaging systems. The aim of the current study was to determine sensitivity of NIR fluorescence imaging for detection of primary hepatic tumors and metastases and to show applicability of this technique during several laparoscopic hepatic procedures. Results: A total of 26 hepatic lesions (including 15 malignant tumors, 1 focal nodular hyperplasia and 10 aspecific lesions), were resected in 12 patients. Of all 16 tumors, sensitivity of preoperative imaging (CT or MRI), visual inspection, IOUS and fluorescence imaging for detection of hepatic tumors was 69%, 44%, 81% and 88%, respectively. Two liver tumors were only identified by fluorescence imaging. Sensitivity of IOUS and fluorescence imaging combined was 100%. Conclusion: This study shows the utility of NIR fluorescence imaging during laparoscopic liver resections. Although only 11/16 tumors were identified by preoperative imaging, all hepatic tumors could be identified by fluorescence imaging and IOUS. Therefore, fluorescence imaging should be applied in every patient undergoing laparoscopic hepatectomy for a malignancy confined to the liver.
SYM14-12 OPTIMIZING SEGMENT 4 HYPERTROPHY FOR BILATERAL HEPATECTOMY e USE OF OUTFLOW MODULATION S. Balzan1,2, V. Gava3, M. Magalhaes1, A. Schwengber1 and M. Dotto1 1 University of Santa Cruz do Sul e UNISC, 2Digestive Surgery, and 3Oncological Surgery, Moinhos de Vento Hospital, Brazil Introduction: Stimulation of hepatic hypertrophy is a useful aid to accomplish hepatic resections when the future liver remnant (FLR) is small. Optimizing hypertrophy of the FLR is challenging when the segment 4 (segment 1) is the only to be preserved. Objective: Description of a method to optimize segment 4 hypertrophy for bilateral hepatectomy in the context of bilobar liver metastases (LM). Method: Four patients with bilobar LM requiring right hepatectomy and left lateral sectionectomy (FLR being only segments 1+4) were managed with a two-stage procedure. The first stage consisted of a right hepatectomy and modulation of the left hepatic vein outflow through reduction of its diameter, with macroscopic congestion of segments 2e3. The second stage consisted of a left lateral sectionectomy six weeks later. Results: After the first stage (right hepatectomy) hypertrophy of non-congested area (segments 4+1) was 23%, 149%, 163% and 203%. Hypertrophy of congested area (segments 2e3) was 15%, 24%, 45% and 120%, respectively. Hypertrophy rate of non-congested segments was more than twice that of congested segments. The patient with minimal hypertrophy after first stage reached a FLR of 0.5% of body weight, developed small-for-size syndrome and died 3 months after the second stage. Another patient developed ascites. Postoperative course was uneventful for the other two patients. Conclusion: After right hepatectomy, modulation of liver outflow allowed maintenance of function in the segments to be resected (segments 2-3) while avoiding their hypertrophy. This strategy optimizes regeneration of FLR and represents an option for bilateral hepatectomy preserving only segment 4.
SYM14-13 PARENCHYMA SPARING LIVER RESECTION OF THE POSTERIOR SEGMENTS: EXPERIENCES AFTER RANDOMIZING 250 PATIENTS TO OPEN OR LAPAROSCOPIC RESECTION
[In vivo fluorescence detection of hepatic tumors]
A. A. Fretland1,2,3, B. Røsok2 and B. Edwin1,2,3 1 The Intervention Centre, 2Department of HPB Surgery, Oslo University Hospital, and 3Institute for Clinical Medicine, University of Oslo, Norway Introduction: Parenchyma Sparing Liver Resection (PSLR) offers improved possibility for repeat resection and is becoming standard treatment for Colorectal Liver
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts Metastases wherever it is technically feasible. However, PSLR can be more demanding then a hemihepatectomy, especially for deep or large tumors, and tumors close to vessels. Performing laparoscopic PLSR increases the level of difficulty even more. In the ongoing Oslo-CoMet study, we have randomized 254 patients to open or laparoscopic parenchyma sparing liver resection. We here present some “tricks of the trade” that we have learned during this experience. Methods: The following maneuvers will be demonstrated in a video presentation: 1. Preoperative planning including 3d reconstruction 2. Patient positioning and trocar placement 3. Mobilization of the liver 4. Intraoperative ultrasound 5. Resection technique 6. Hemostatic tricks including application of TachoSil on a bleeding from the middle hepatic vein. Conclusions: Laparoscopic parenchyma sparing liver resection is safe and feasible, but some tricks of the trade can be useful.
SYM14-14 SIMULTANEOUS IMPLANTATION OF BILATERAL LIVER GRAFTS IN LIVING DONOR LIVER TRANSPLANTATION BY FUSION VENOPLASTY A. Chan1, K. Chok2, S. C. Chan2 and L. Chung Mau2 1 Department of Surgery, University of Hong Kong, Queen Mary Hospital, and 2Department of Surgery, University of Hong Kong, Hong Kong Small-for-size syndrome is a serious complication after living donor liver transplantation (LDLT). LDLT using dual grafts offers an alternative to solve this problem. In case of a right and left liver graft adopted for dual graft LDLT, sequential implantation of the right graft followed by the left graft is the usual approach. However, left hepatic vein and portal vein anastomosis could be challenging when the right subphrenic space is occupied by the right liver graft, and this problem could be avoided by simultaneous implantations of bilateral grafts. In this video, the technique of simultaneous implantation of bilateral living donor liver grafts via fusion venoplasty (FV) in a 59-year old patient with acute liver failure was presented. We performed FV at the backtable to join the right hepatic vein (RHV) and middle hepatic vein (MHV) to create one venous outflow in the right liver graft, the left liver was approximated to the right liver graft at the backtable followed by FV joining the left hepatic vein to the R/MHV venous cuff before anastomosis with the inferior vena cava. The right and left portal veins were then joined together to create one common orifice before anastomosis with the recipient’s main portal vein. The graft right and left hepatic artery were anastomosed with the recipient’s right and left hepatic artery respectively. Biliary reconstruction was performed via a duct-to-duct anastomosis for the right liver graft and a hepaticojejunostomy for the left liver graft.
HPB 2016, 18 (S1), e1ee384
e125
[Bilateral liver grafts after fusion venoplasty]
SYM14-15 PERCUTANEOUS TRANSHEPATIC FEEDING TUBE PLACEMENT: A SINGLE-CENTER EXPERIENCE IN 40 CONSECUTIVE PATIENTS A. Gerritsen1, J. Damstra1, K. P. van Lienden2, O. R. Busch1, T. M. van Gulik1, M. A. Boermeester1, J. S. Laméris2, O. M. van Delden2 and M. G. Besselink1 1 Department of Surgery, and 2Department of Radiology, Academic Medical Center, Netherlands Introduction: Enteral access can be obtained via various routes which all have their specific drawbacks. In a select subset of patients, who also require prolonged percutaneous transhepatic biliary drainage (PTBD), transhepatic feeding tube placement may offer a suitable alternative, but data regarding this technique are lacking. Our aim was to determine the application and feasibility of percutaneous transhepatic feeding tube placement. Methods: We performed a retrospective single-center cohort study in patients with a PTBD catheter undergoing percutaneous transhepatic feeding tube placement (2003e2015). Transhepatic feeding tubes were placed by interventional radiologists alongside a pre-existent PTBD catheter. Results: Overall, 43 patients underwent transhepatic feeding tube placement, of whom 3 were excluded because data were lacking. Indications for PTBD were management of surgical complications (e.g. bile leak, duodenal perforation; n = 28), palliative drainage (n = 5), perioperative biliary decompression (n = 3) or other indications (n = 4). Indications for feeding tube placement were bile restitution (n = 8) or the need for enteral feeding (n = 32) due to severe gastroparesis, duodenal perforation, enterocutaneous fistula, or gastric outlet obstruction. 38 of 40 (95%) initial tube placements were successful. Tube related complications included dislodgement (n = 8), blockage (n = 3), bile leakage (n = 4), cholangitis (n = 1) and bleeding (n = 1) and led to the need for replacement in 9 (23%) patients and removal of the tube in only 1 (3%) patient. Conclusion: Transhepatic feeding tube placement alongside a pre-existent PTBD catheter was safe and successful in this series and may be considered in patients requiring both prolonged PTBD and enteral access.
Electronic Poster Abstracts
SYM14-11 FLUORESCENCE-GUIDED LAPAROSCOPIC HEPATECTOMIES L. S. F. Boogerd, H. J. M. Handgraaf, H. D. Lam, C. J. H. van de Velde, A. E. Braat and A. L. Vahrmeijer Leiden University Medical Center, Netherlands Background and technical issue: Laparoscopic surgery deprives surgeons of tactile feedback. Assessment of tumor localization and margins during laparoscopic hepatectomies is therefore limited to inspection and intraoperative ultrasound (IOUS). Recurrence rates after oncologic liver surgery suggest small tumors may remain undetected, underscoring the demand for an accurate additive intraoperative imaging modality. Near-infrared (NIR) fluorescence imaging is an innovative technique enabling realtime intraoperative identification and demarcation of tumors. After administration of indocyanine green (ICG), 24 hours prior to surgery, accumulated ICG in or around liver tumors can be visualized using NIR imaging systems. The aim of the current study was to determine sensitivity of NIR fluorescence imaging for detection of primary hepatic tumors and metastases and to show applicability of this technique during several laparoscopic hepatic procedures. Results: A total of 26 hepatic lesions (including 15 malignant tumors, 1 focal nodular hyperplasia and 10 aspecific lesions), were resected in 12 patients. Of all 16 tumors, sensitivity of preoperative imaging (CT or MRI), visual inspection, IOUS and fluorescence imaging for detection of hepatic tumors was 69%, 44%, 81% and 88%, respectively. Two liver tumors were only identified by fluorescence imaging. Sensitivity of IOUS and fluorescence imaging combined was 100%. Conclusion: This study shows the utility of NIR fluorescence imaging during laparoscopic liver resections. Although only 11/16 tumors were identified by preoperative imaging, all hepatic tumors could be identified by fluorescence imaging and IOUS. Therefore, fluorescence imaging should be applied in every patient undergoing laparoscopic hepatectomy for a malignancy confined to the liver.
SYM14-12 OPTIMIZING SEGMENT 4 HYPERTROPHY FOR BILATERAL HEPATECTOMY e USE OF OUTFLOW MODULATION S. Balzan1,2, V. Gava3, M. Magalhaes1, A. Schwengber1 and M. Dotto1 1 University of Santa Cruz do Sul e UNISC, 2Digestive Surgery, and 3Oncological Surgery, Moinhos de Vento Hospital, Brazil Introduction: Stimulation of hepatic hypertrophy is a useful aid to accomplish hepatic resections when the future liver remnant (FLR) is small. Optimizing hypertrophy of the FLR is challenging when the segment 4 (segment 1) is the only to be preserved. Objective: Description of a method to optimize segment 4 hypertrophy for bilateral hepatectomy in the context of bilobar liver metastases (LM). Method: Four patients with bilobar LM requiring right hepatectomy and left lateral sectionectomy (FLR being only segments 1+4) were managed with a two-stage procedure. The first stage consisted of a right hepatectomy and modulation of the left hepatic vein outflow through reduction of its diameter, with macroscopic congestion of segments 2e3. The second stage consisted of a left lateral sectionectomy six weeks later. Results: After the first stage (right hepatectomy) hypertrophy of non-congested area (segments 4+1) was 23%, 149%, 163% and 203%. Hypertrophy of congested area (segments 2e3) was 15%, 24%, 45% and 120%, respectively. Hypertrophy rate of non-congested segments was more than twice that of congested segments. The patient with minimal hypertrophy after first stage reached a FLR of 0.5% of body weight, developed small-for-size syndrome and died 3 months after the second stage. Another patient developed ascites. Postoperative course was uneventful for the other two patients. Conclusion: After right hepatectomy, modulation of liver outflow allowed maintenance of function in the segments to be resected (segments 2-3) while avoiding their hypertrophy. This strategy optimizes regeneration of FLR and represents an option for bilateral hepatectomy preserving only segment 4.
SYM14-13 PARENCHYMA SPARING LIVER RESECTION OF THE POSTERIOR SEGMENTS: EXPERIENCES AFTER RANDOMIZING 250 PATIENTS TO OPEN OR LAPAROSCOPIC RESECTION
[In vivo fluorescence detection of hepatic tumors]
A. A. Fretland1,2,3, B. Røsok2 and B. Edwin1,2,3 1 The Intervention Centre, 2Department of HPB Surgery, Oslo University Hospital, and 3Institute for Clinical Medicine, University of Oslo, Norway Introduction: Parenchyma Sparing Liver Resection (PSLR) offers improved possibility for repeat resection and is becoming standard treatment for Colorectal Liver
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts Metastases wherever it is technically feasible. However, PSLR can be more demanding then a hemihepatectomy, especially for deep or large tumors, and tumors close to vessels. Performing laparoscopic PLSR increases the level of difficulty even more. In the ongoing Oslo-CoMet study, we have randomized 254 patients to open or laparoscopic parenchyma sparing liver resection. We here present some “tricks of the trade” that we have learned during this experience. Methods: The following maneuvers will be demonstrated in a video presentation: 1. Preoperative planning including 3d reconstruction 2. Patient positioning and trocar placement 3. Mobilization of the liver 4. Intraoperative ultrasound 5. Resection technique 6. Hemostatic tricks including application of TachoSil on a bleeding from the middle hepatic vein. Conclusions: Laparoscopic parenchyma sparing liver resection is safe and feasible, but some tricks of the trade can be useful.
SYM14-14 SIMULTANEOUS IMPLANTATION OF BILATERAL LIVER GRAFTS IN LIVING DONOR LIVER TRANSPLANTATION BY FUSION VENOPLASTY A. Chan1, K. Chok2, S. C. Chan2 and L. Chung Mau2 1 Department of Surgery, University of Hong Kong, Queen Mary Hospital, and 2Department of Surgery, University of Hong Kong, Hong Kong Small-for-size syndrome is a serious complication after living donor liver transplantation (LDLT). LDLT using dual grafts offers an alternative to solve this problem. In case of a right and left liver graft adopted for dual graft LDLT, sequential implantation of the right graft followed by the left graft is the usual approach. However, left hepatic vein and portal vein anastomosis could be challenging when the right subphrenic space is occupied by the right liver graft, and this problem could be avoided by simultaneous implantations of bilateral grafts. In this video, the technique of simultaneous implantation of bilateral living donor liver grafts via fusion venoplasty (FV) in a 59-year old patient with acute liver failure was presented. We performed FV at the backtable to join the right hepatic vein (RHV) and middle hepatic vein (MHV) to create one venous outflow in the right liver graft, the left liver was approximated to the right liver graft at the backtable followed by FV joining the left hepatic vein to the R/MHV venous cuff before anastomosis with the inferior vena cava. The right and left portal veins were then joined together to create one common orifice before anastomosis with the recipient’s main portal vein. The graft right and left hepatic artery were anastomosed with the recipient’s right and left hepatic artery respectively. Biliary reconstruction was performed via a duct-to-duct anastomosis for the right liver graft and a hepaticojejunostomy for the left liver graft.
HPB 2016, 18 (S1), e1ee384
e125
[Bilateral liver grafts after fusion venoplasty]
SYM14-15 PERCUTANEOUS TRANSHEPATIC FEEDING TUBE PLACEMENT: A SINGLE-CENTER EXPERIENCE IN 40 CONSECUTIVE PATIENTS A. Gerritsen1, J. Damstra1, K. P. van Lienden2, O. R. Busch1, T. M. van Gulik1, M. A. Boermeester1, J. S. Laméris2, O. M. van Delden2 and M. G. Besselink1 1 Department of Surgery, and 2Department of Radiology, Academic Medical Center, Netherlands Introduction: Enteral access can be obtained via various routes which all have their specific drawbacks. In a select subset of patients, who also require prolonged percutaneous transhepatic biliary drainage (PTBD), transhepatic feeding tube placement may offer a suitable alternative, but data regarding this technique are lacking. Our aim was to determine the application and feasibility of percutaneous transhepatic feeding tube placement. Methods: We performed a retrospective single-center cohort study in patients with a PTBD catheter undergoing percutaneous transhepatic feeding tube placement (2003e2015). Transhepatic feeding tubes were placed by interventional radiologists alongside a pre-existent PTBD catheter. Results: Overall, 43 patients underwent transhepatic feeding tube placement, of whom 3 were excluded because data were lacking. Indications for PTBD were management of surgical complications (e.g. bile leak, duodenal perforation; n = 28), palliative drainage (n = 5), perioperative biliary decompression (n = 3) or other indications (n = 4). Indications for feeding tube placement were bile restitution (n = 8) or the need for enteral feeding (n = 32) due to severe gastroparesis, duodenal perforation, enterocutaneous fistula, or gastric outlet obstruction. 38 of 40 (95%) initial tube placements were successful. Tube related complications included dislodgement (n = 8), blockage (n = 3), bile leakage (n = 4), cholangitis (n = 1) and bleeding (n = 1) and led to the need for replacement in 9 (23%) patients and removal of the tube in only 1 (3%) patient. Conclusion: Transhepatic feeding tube placement alongside a pre-existent PTBD catheter was safe and successful in this series and may be considered in patients requiring both prolonged PTBD and enteral access.