BACKGROUND:Right superior liver resection or bisegmentectomy 7-8 is defined as the anatomical removal of segments 7 and 8 of the liver. According to recent reports, this type of resection requires the presence of a large accessory right inferior hepatic vein to drain the remaining segment 6. However, anatomic studies have shown that segment 6 has multiple veins presenting several anastomosis with the surrounding hepatic veins. Therefore, the maintenance of the veins from segment 5 that ultimately drain into the middle hepatic vein can be enough to assure venous drainage of both segments.METHODS:Describe an alternative technique for bisegmentectomy 7-8 using intrahepatic glissonian access in patients with absence of a large inferior right hepatic vein.RESULTS:The technique was successfully performed in four consecutive patients without immediate or long-term venous or venous related complications.CONCLUSIONS:Bisegmentectomy 7-8 may increase resectability rate in patients with bilateral lesions and may also enhance the opportunity to perform repeated resections in cases of tumor recurrence. Our study confirms the anatomical assumption that bisegmentectomy 7-8 did not result in segmental outflow block even in the absence of a thick inferior right hepatic vein and therefore should be performed more often than reported so far. The absence of this vein should not be a straightforward indication for right hepatectomy in cases where a liver-sparing procedure such as bisegmentectomy 7-8 can be safely employed.

Background: The current study sought to evaluate the results of liver resection as the treatment for unilateral non-oriental primary intrahepatic lithiasis (PHIL).Methods: Twenty-seven symptomatic patients (mean age 42 years) were submitted to liver resection; the indications were parenchymal fibrosis/atrophy in 22 and biliary stenosis in 5. Resection was associated with a Roux-en-Y hepaticojejunostomy in patients with a significant degree of dilation of the extrahepatic biliary duct.Results: There was no operative mortality and the morbidity rate was 7.4% (2 patients with biliary fistula). After a median follow-up of 41.2 months, the overall rate of good results was 92.6%. All patients submitted to liver resection alone presented good late results, while 80% of those with associated hepaticojejunostomy did not have complications (P = .12). Late complications were observed in 2 patients (7.4%): 1 with a liver abscess and I with cholangitis and recurrent stones. There was no mortality during long-term follow-up.Conclusions: Liver resection showed low incidence of complications and good long-term results. None of the patients with unilateral disease without associated extrahepatic bile duct dilation presented complications and they were considered cured. We believe that resection indications should be expanded and the procedure should be indicated as routine in patients with unilateral PHIL even in the absence of parenchymal fibrosis/atrophy or biliary stenosis. (c) 2006 Excerpta Medica Inc. All rights reserved.

Rat intestinal transplantation is an optimal model for research; nevertheless, it requires a complex and difficult microsurgical technique (1–5). We have recently developed a simplified rat model for intestinal transplantation using portal cuff anastomosis to overcome these technical difficulties (Fig. 1A). Preoperative procedures, anesthesia and laparotomy are performed as previously described (1– 4). In the donor operation, middle and descending colons are isolated from small bowel and ascending colon. Superior mesenteric vein is dissected and encircled. Splenic and pyloric veins are divided and portal vein is dissected up to hepatic hilum. Abdominal aorta is dissected and celiac trunk, right renal artery and lumbar branches are divided. Aorta is clamped at the diaphragm, tied below the mesenteric artery and this arterial segment is resected allowing a long aortomesenteric conduit. Entire small bowel, cecum and ascending colon are harvested on a vascular pedicle consisting of right colonic vessels, aortomesenteric conduit and portal vein. The graft is flushed and stored in cold preservation solution. Polyethylene catheter is used to create the cuff as described elsewhere (5). In this modified technique, the vein is introduced into the cuff and everted, covering the outer wall and fixed with three equidistant stitches (Fig. 1B). In the recipient, the superior mesenteric vein is exposed, and a segment between the first and second jejunal branch is dissected and prepared for cuff anastomosis. Eventually, the second jejunal branches and the right colonic vein may be divided in order to increase this segment. The graft is implanted in the recipient with an end-to-side aortoaorta anastomosis as previously described (1–5). The dissected segment of mesenteric vein is isolated between clamps to insert the portal cuff and a 6-0 suture is used to fix the cuff into recipient’s mesenteric vein. The clamps are released and immediate graft reperfusion is observed. The recipient jejunum, ileum, cecum, and ascending colon are removed en bloc. Finally, anastomosis between the graft and the remaining intestine restores the digestive tract (Fig. 1A). The present model offers many possibilities for intestinal transplantation research with the following advantages: reconstitutes the natural and physiologic portal graft drainage; the portal cuff anastomosis is performed within few minutes without bleeding or venous thrombosis. This alternative technique avoids recipient visceral ischemia and hemodynamic instability because there is no obstruction on inferior vena cava and portal vein. Furthermore, it maintains grafts ileocecal valve and preserves the extrinsic enervation along the mesenteric-aortic segment that may improve bowel movement. This modified technique can be easily performed within two hours after a short period of training (8 3 week) and may reach excellent success rates. This rat model may surmount technical obstacles precluding microsurgical techniques and may ultimately spread this model in centers with low technical resources.

BACKGROUND:Hepatic epithelioid hemangioendothelioma is a rare malignant tumor of vascular origin with frequent multifocal appearance. Liver resection may cause tumor spread. Liver transplantation has been indicated for unresectable nodules. We hypothesized that adjuvant interferon treatment is effective to prevent metastasis after liver resection. We report a case of multifocal hepatic epithelioid hemangioendothelioma successfully treated with interferon pulse therapy and bilobar hepatic resection.METHODOLOGY:CT scan and magnetic resonance imaging diagnosed three nodules in the liver (segments IV, VI and VII). Histopathology and specific immunostaining of a percutaneous nodule biopsy confirmed the diagnosis of hepatic epithelioid hemangioendothelioma. The treatment protocol included daily interferon alpha 2b 9 weeks before and 1 week after resection of liver segments IV, VI and VII.RESULTS:The postoperative outcome was complicated by a self-limited biliary fistula. The patient remains tumor free at 3 years after liver resection and currently enjoys excellent health.CONCLUSION:Interferon pulse therapy and hepatic resection was a good option to treat multifocal bilobar hepatic epithelioid hemangioendothelioma; it may prevent metastasis dissemination.

Pancreaticoduodenectomy is the only curative treatment for pancreatic head tumors. The possibility to achieve a potentially curative surgical treatment is limited to patients in which a complete tumor resection can be performed with free surgical margins. In a small number of patients with localized pancreatic cancer, negative margins are only accomplished with portal vein resection. Pancreaticoduodenectomy is often avoided in these patients due to the mistaken concept that venous resection may be followed by higher mortality and carries poorer survival. Actually, these patients present the same survival rate as patients similarly staged in whom portal vein resection was not performed. Therefore, venous resection is worthwhile. The authors describe an alternative technique for venous reconstruction after resection of a long segment of portal or superior mesenteric vein. The use of a venous graft as proposed in this study is feasible, easy to perform, and may simplify the venous reconstruction even in extensive mesentericoportal venous resection. J. Surg. Oncol. 2004;88:52–54. Copyright © 2004 Wiley‐Liss, Inc.

Laparoscopic hepatectomy has been recently proposed for the treatment of liver tumors, however there is a lack of experimental models to study surgical technique and the metabolic reactions after this procedure. The dog is an important animal for research but the laparoscopic hepatectomy model is not well established in this animal. We describe the surgical laparoscopic technique of left liver segmentectomy in the dog and the preliminary results of this procedure. Female dogs weighting more then 15 kg were used. Four transversal abdominal incisions (two of 1 cm and two of 0.5 cm) were made for the introduction of the video camera and the other laparoscopic instruments. The liver was inspected and the left lobe was mobilized through incision of the left triangular hepatic ligament. The vascular pedicle corresponding to the left medial lobe (corresponding to segment II) was identified, dissected, and clamped, delimiting a correspondent ischemic area. The hepatic parenchyma was divided according to the previous delimitation with minimum bleeding. The segment of the liver was then removed through an enlarged abdominal incision. The incisions were closed by continuous suture. The mean time of the procedure was forty minutes. We observed normal clinical evolution without any sign of complications due to the hepatic resection, and normal augmentation of body weight on follow-up of more than 3 months. Left hepatectomy in the dog is a viable procedure and may serve for surgical training and development of research projects in this field.

HYPOTHESIS:Anatomical resection of the left liver segments are rarely mentioned in the literature. We describe an anatomical access to the left liver segments' pedicles without hilar dissection.DESIGN:Original surgical technique.PATIENTS AND METHODS:This technique was used in 26 consecutive resections involving left liver segments between July 2001 and December 2003. There were 15 men and 11 women with mean age of 57.1 years. Eleven patients had liver metastasis, 8 had primary liver cancer, 6 had benign lesions, and 1 had gallbladder cancer. The technique consists of small liver incisions according to anatomical landmarks such as the Arantius and round ligaments. In a systematized way, it was possible to reach every glissonian sheath of segments II, III, and IV.RESULTS:Liver resection was feasible using the proposed technique in every patient of this series, and the Pringle maneuver was not required in any patient. Intraoperative blood loss was minimal in all cases, and 23 patients did not require blood transfusion. There was no postoperative death.CONCLUSIONS:This operative procedure allows easy, fast access for anatomical resection of the left liver segments. It is useful for performing controlled hepatectomies without clamping the main hepatic pedicle and may facilitate the recognition of all left liver segment sheaths, with excellent immediate results.

The shortage of donor organs and the long waiting lists have increased the need to better select liver transplant candidates using predictors of success. We reviewed the results of 29 liver transplantations performed from January 2002 to February 2003 analyzing the correlations with early mortality (30 days) of patient data, pretransplant laboratory data, warm ischemia time, intraoperations blood unit transfusions, and postoperative complications of prolonged mechanical ventilation, dialysis, and infection. Overall early mortality was 27.6% and 44% in fulminant hepatic failure (n = 9), there were four retransplants with one death, and two intraoperative deaths. Only pretransplant bilirubin (P = .045) and postoperative lactate levels (P = .002) were significantly different between alive versus dead patients. In this small population bilirubin was more related to death than the MELD score. Lactate levels, nonspecific predictor of death in shock syndromes were probably related to septic complications.

Laparoscopic splenectomy is becoming the gold standard technique for the treatment of hematological disorders of the spleen. Hemostasis is a fundamental step during laparoscopic splenectomy leading some authors to develop several techniques to control splenic vessels such as hand assistance, preoperative splenic artery embolization, and the use of vascular linear staplers. However, intraoperative bleeding is usually due to inadequate exposure of the hilar splenic vessels itself. The authors describe a standardized technique for the exposure of splenic pedicle using an endoscopic triangular retractor. We have been used this technique in 16 consecutive laparoscopic splenectomies with minimal blood loss. The present technique may increase the safety of laparoscopic splenectomy with adequate exposure of the splenic hilum reducing the conversion rate and intraoperative blood loss.

Biliary complications have been reported in 9% to 34% of liver transplant patients. Although most centers seem to prefer a duct-to-duct anastomosis without a T-tube when feasible, the best method of biliary reconstruction remains controversial. The aim of this study was to review our experience on reconstruction of the biliary tract without drainage. Forty-one patients underwent 45 liver transplants over two periods. Forty patients underwent 15 liver transplants from October 1992 to March 1995; and 27 underwent 30 liver transplants from January 2002 to February 2003. Our standard biliary reconstruction was an end-to-end anastomosis without drain. The overall actuarial survival was 72.7% at 1 year, 64.7% at 3 years, and 56.6% at 5 years. The mean follow-up was 23 months. Eight patients (22.2%) developed biliary tract complications: five patients papillary dysfunction (13.9%); two, biliary stricture (5.5%); and one, biliary sludge without evidence of stricture (2.8%). Papillary dysfunction represented 62.5% of all complications. Biliary reconstruction without drainage may be routinely performed since the complications are only those not related to the T-tube.

HYPOTHESIS The indications for segmental liver resections are increasing. This type of procedure can be performed by deep wedge transparenchymal transection or by the intrahepatic approach, reaching the portal pedicle through the hilar plate. We devised a systematized way to perform such an operation. DESIGN Original surgical technique. PATIENTS AND METHODS Fourteen consecutive patients (8 men and 6 women; mean age, 55 years) underwent right segmental liver resections between July 1, 2001, and July 31, 2002. Seven patients had liver metastasis, 3 had primary liver cancer, 3 had benign lesions, and 1 had gallbladder cancer. The surgery was performed by making 3 small incisions around the hilar plate. With a standardized method, the right posterior and anterior sheaths were reached by combining these incisions. RESULTS Right segmental liver resection was feasible with the proposed technique in all patients. Intraoperative blood loss was minimal in all cases, and 11 patients did not require blood transfusion. There was no postoperative death. CONCLUSIONS This operative procedure standardizes the intrahepatic approach to the right portal pedicle for right segmental resections. It may reduce bleeding at the site of hilar plate incisions and the need for main hepatic pedicle clamping and may facilitate the recognition of right posterior and anterior sheaths, with excellent immediate results.

Alimentary tract duplications are rare congenital malformations that may be found anywhere from mouth to anus. They usually share a common smooth muscle wall and blood supply with the adjacent bowel. Some duplications are asymptomatic but most cause problems in early childhood. Gastric duplications account for 2% to 7% of all gastrointestinal duplications. The management of gastric duplication is essentially surgical. The treatment of choice is the complete excision of the gastric duplication without violation of the gastric lumen whenever possible. The authors report an unusual case of gastroesophageal junction duplication completely removed by laparoscopy. To our knowledge, this is the first case of gastric duplication successfully treated by laparoscopy in English literature. Laparoscopic resection may be added to the surgical armamentarium in the treatment of alimentary tract duplications.

Background: The use of stapling devices for performing gastrointestinal anastomosis has gained wide acceptance in the last decade. Linear cutting devices have been used routinely during gastrointestinal operations in our hospital since 1992. However, we still have shortage of stapling devices due to cost reduction politics.Methods: We propose a modification of the standard technique in order to reduce the number of devices used. Our technique employs a single stapled including the section of the jejunum and the side-to-side jejunoanastomosis.Results: We have used this technique for 1 year without complications related to the stapled anastomosis.Conclusions: This technique may reduce the time of reconstruction of Roux-en-Y anastomosis without interfering in its final result. This modified technique may be useful in hospitals with reduced economic resources. (C) 2002 Excerpta Medica Inc. All rights reserved.

Journal of Surgical OncologyVolume 78, Issue 2 p. 148-150 Short Communication Modified technique for esophagojejunostomy after total gastrectomy Marcel Autran C. Machado MD, Marcel Autran C. Machado MD Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.A.C.M., P.H., A.L.M., M.L.V.C. work as the staff surgeonsSearch for more papers by this authorPaulo Herman MD, Paulo Herman MD Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.A.C.M., P.H., A.L.M., M.L.V.C. work as the staff surgeonsSearch for more papers by this authorAndré L. Montagnini MD, André L. Montagnini MD Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.A.C.M., P.H., A.L.M., M.L.V.C. work as the staff surgeonsSearch for more papers by this authorMarcelo L. V. Costa MD, Marcelo L. V. Costa MD Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.A.C.M., P.H., A.L.M., M.L.V.C. work as the staff surgeonsSearch for more papers by this authorMarcel C. C. Machado MD, Corresponding Author Marcel C. C. Machado MD [email protected] Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.C.C.M. works as the Head of the Department.Al. Casa Branca 438 # 101-01408-001, São Paulo, Brazil. Fax: 55-11-253-0670.Search for more papers by this author Marcel Autran C. Machado MD, Marcel Autran C. Machado MD Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.A.C.M., P.H., A.L.M., M.L.V.C. work as the staff surgeonsSearch for more papers by this authorPaulo Herman MD, Paulo Herman MD Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.A.C.M., P.H., A.L.M., M.L.V.C. work as the staff surgeonsSearch for more papers by this authorAndré L. Montagnini MD, André L. Montagnini MD Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.A.C.M., P.H., A.L.M., M.L.V.C. work as the staff surgeonsSearch for more papers by this authorMarcelo L. V. Costa MD, Marcelo L. V. Costa MD Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.A.C.M., P.H., A.L.M., M.L.V.C. work as the staff surgeonsSearch for more papers by this authorMarcel C. C. Machado MD, Corresponding Author Marcel C. C. Machado MD [email protected] Department of Abdominal Surgery, Cancer Hospital, São Paulo, Brazil M.C.C.M. works as the Head of the Department.Al. Casa Branca 438 # 101-01408-001, São Paulo, Brazil. Fax: 55-11-253-0670.Search for more papers by this author First published: 25 September 2001 https://doi.org/10.1002/jso.1138Citations: 2 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. REFERENCES 1 Lawrence W Jr.: Reconstruction after total gastrectomy: what is preferred technique? J Surg Oncol 1996; 62: 215– 220. 2 Ikeda Y, Minagawa S, Koyanagi N, et al.: Esophagojejunostomy with manual single layer suturing after a total gastrectomy for gastric cancer. J Surg Oncol 1997; 66: 127– 129. 3 Matsushita K, Sugiyama A, Saito H, et al.: A modified stapling technique for esophagojejunostomy after total orproximal gastrectomy. J Am Coll Surg 1997; 184: 513– 517. 4 Ceraudo E, Degano G, Santarelli E, et al.: Esophago-jejunal anastomosis after total gastrectomy with circular suturing: using a personal method. Minerva Chir 1995; 50(12): 1115– 1117. 5 Elhomsy G, Varaei K, Matta W: Trans-sutural mechanical anastomosis in esophagogastric surgery. Apropos of 25 cases. J Chir 1994; 131: 546– 548. 6 Guerra JP, Silva MH, dos Santos JG: An improved technique for a stapled transabdominal esophagojejunostomy. Am J Surg 1997; 174: 61– 62. 7 Fujimoto S, Takahashi M, Endoh F, et al.: Stapled or manual suturing in esophagojejunostomy after total gastrectomy: a comparison of outcome in 379 patients. Am J Surg 1991; 162: 256– 259. 8 Pol B, Le Treut YP, Hardwigsen J, et al.: Mechanically stapled esophagojejunostomy. Results of a prospective series of 176 cases. Hepatogastroenterology 1997; 44: 458– 466. Citing Literature Volume78, Issue2October 2001Pages 148-150 ReferencesRelatedInformation