The development of surgical techniques, chemotherapy, biological agents, and multidisciplinary approaches have made patients with unresectable. colorectal liver metastases eligible for surgery. Many strategies have been developed to allow patients for surgical resection (percutaneous portal vein embolization, liver venous deprivation, parenchyma-sparing liver surgery, reverse strategy, associating liver partition and portal vein ligation for staged hepatectomy, and liver transplantation), the only form of disease control and curative treatment.

ABSTRACT Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient’s desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

Introduction. Over the past few years, liver surgery has been in constant evolution and gained many improvements that helped surgeons push limits further. A complex procedure such as left extended trisectionectomy, as described by Makuuchi in 1987, may be performed in selected cases. Aim. Describe a case of successful resection of a huge bilobar liver sarcoma involving all hepatic veins from a young female patient, in which the blood outflow was preserved through an inferior right hepatic vein, leaving only segment 6 as liver remnant. Case Report. A 19-year-old female with a 3-month history of abdominal pain, vomiting, and weight loss was referred for our evaluation. CT scan and MRI revealed a heterogeneous and bulky expansive hepatic lesion, sparing only segment 6, with an estimated volume of 530 cm(3), corresponding to a 1.2 FLR/BW ratio. The tumor involved the three major hepatic veins, but an inferior right hepatic vein was present, draining the spared segment 6. She was submitted to a left trisectionectomy extended to the caudate lobe and segment 7, including resection of all hepatic veins and lymphadenectomy of the hepatic pedicle. She was discharged on the 7th postoperative day without complications. The histopathological and immunohistochemical analysis demonstrated an undifferentiated embryonal sarcoma of the liver. Conclusion. Inferior right hepatic vein-preserving left extended trisectionectomy is a safe and feasible procedure that should be performed by a hepatobiliary team experienced in major complex hepatectomies.

ABSTRACT - BACKGROUND: Colorectal cancer generally metastasizes to the liver. Surgical resection of liver metastasis, which is associated with systemic chemotherapy, is potentially curative, but many patients will present recurrence. In selected patients, repeated hepatectomy is feasible and improves overall survival. AIM: This study aimed to analyze patients with colorectal liver metastasis (CRLM) submitted to hepatectomy in three centers from Rio de Janeiro, over the past 10 years, by comparing the morbidity of first hepatectomy and re-hepatectomy. METHODS: From June 2009 to July 2020, 192 patients with CRLM underwent liver resection with curative intent in three hospitals from Rio de Janeiro Federal Health System. The data from patients, surgeries, and outcomes were collected from a prospectively maintained database. Patients submitted to first and re-hepatectomies were classified as Group 1 and Group 2, respectively. Data from groups were compared and value of p<0.05 was considered significant. RESULTS: Among 192 patients, 16 were excluded. Of the remaining 176 patients, 148 were included in Group 1 and 28 were included in Group 2. Fifty-five (37.2%) patients in Group 1 and 13 (46.5%) in Group 2 presented postoperative complications. Comparing Groups 1 and 2, we found no statistical difference between the cases of postoperative complications (p=0.834), number of minor (p=0.266) or major (p=0.695) complications, and deaths (p=0.407). CONCLUSIONS: No differences were recorded in morbidity or mortality between patients submitted to first and re-hepatectomies for CRLM, which reinforces that re-hepatectomy can be performed with outcomes comparable to first hepatectomy.

Perioperative pain management in small infants weighing <10 kg undergoing liver transplantation is challenging. The use of TEA in this setting has not been reported, as well as its potential role to facilitate IE, ie, in the OR.

Malignant liver tumors can directly invade the inferior vena cava (IVC) due to anatomical proximity.In such cases, hepatectomy combined to IVC resection may be required to achieve negative surgical margins (1,2) .This approach becomes more common, due to progress in surgical techniques and perioperative management (3,4) .Herein, we present a case of a 42-year-old woman with a 23 cm hypervascular liver mass located on the right liver, extended to segments one and four, encompassing completely the IVC circumference, near the root of the left hepatic vein (LHV) (FI-GURE 1).Preoperative diagnosis was between liver cell adenoma or hepatocellular carcinoma (HCC).Patient was taken to surgery, which was performed through a bilateral subcostal incision with

Background: Residual gallbladder is the remnant part of the gallbladder not resected during subtotal cholecystectomy.This technique is used mostly in cholecystitis cases, to avoid biliary injury.In some patients, the residual gallbladder may become symptomatic causing symptoms related to gallstone problems, such as symptomatic cholelithiasis, choledocholithiasis and gallstone pancreatitis.Case Report: Herein, we describe the two patients, a 52-year-old man and a 67-year-old woman, respectively submitted to cholecystectomy 16 months and 24 years before, who presented mainly abdominal pain after eating.Abdominal ultrasonography identified the remnant gallbladder in the first case.Second patient was wrongly treated for gastritis for one year, until residual gallbladder was confirmed by magnetic resonance cholangio-pancreatography. Patients underwent surgical treatment, with good results.Conclusion: Symptomatic residual gallbladder should be suspected in patients previously submitted to cholecystectomy, presenting symptoms suggestive of biliary colic.Symptoms may arise many years after the index surgery.Since this is a rare condition, a high grade of suspicion is required and imaging exams are important to confirm diagnosis.Caution is necessary during surgery, due to adhesions to the hepatic pedicle and common bile duct injury risk.

A ressecção hepática se tornou mais segura nos últimos anos, com taxas de mortalidade menores do que 5% em grandes centros. Porém, a incidência da fistula biliar não mudou, variando de 4%-15%. O presente estudo tem como objetivo avaliar se o uso sistemático do teste de biliostasia durante ressecções hepáticas reduz a incidência de fístula biliar no pós operatório.

As hepatobiliary surgeons, we read with great interest the article written by Dixon et al, in which an awesome revision of the future liver remnant (FLR) management was carried out. In cases that a major hepatectomy is needed, but the FLR is small, achieving an adequate hypertrophy of this part of the liver is an issue that concerns every liver surgeon since we are dealing more and more with aggressive liver surgery for malignancy. As described in the thorough article, portal vein embolization (PVE) is the method of choice to promote hypertrophy of the FLR, but in some cases, when an inadequate growth occurs, some other techniques, such as hepatic vein embolization or the associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure, may be used to stimulate more hypertrophy. We were pleased to see that our article was cited to show that a robust growth of the FLR can be reached by salvage ALPPS, when PVE fails to achieve a satisfactory hypertrophy. However, we noticed that the median degree of hypertrophy promoted by ALPPS was not corrected cited in the article. As we published (summary at table 3), compared to the standard liver volume (SLV), the median FLR volume after PVE and prior to ALPPS procedure was 23%. After the first stage of ALPPS, the median FLR/SLV ratio was 41%, meaning that we could observe an impressive median degree of hypertrophy of 88%, instead of the 18% miscited in the article. We believe that this mistake was due to a misinterpretation of math and proportional relationship between growth of the FLR between stages 1 and 2. We fully agree with the author that the role of ALPPS in the management of small FLR is not well defined, and this surgery should be indicated very criteriously, even though its potential to stimulate hypertrophy of the FLR is well known.

Simple liver cysts are congenital or acquired benign cysts formations and are commonly found incidentally. It has a prevalence of 3-5% in ultrasound studies and 18-24% in CT scans. Frequently asymptomatic, liver cysts may be associated with symptoms in 1016% of patients. Hemoperitoneum is a far rare complication. Herein, we report a case presented at the emergency room with acute hemorrhagic rupture of a liver cyst.

ABSTRACT Background: Incidental gallbladder cancer is defined as a cancer discovered by histological examination after cholecystectomy. It is a potentially curable disease. However, some questions related to their management remain controversial and a defined strategy is associated with better prognosis. Aim: To develop the first evidence-based consensus for management of patients with incidental gallbladder cancer in Brazil. Methods: Sixteen questions were selected, and 36 Brazilian and International members were included to the answer them. The statements were based on current evident literature. The final report was sent to the members of the panel for agreement assessment. Results: Intraoperative evaluation of the specimen, use of retrieval bags and routine histopathology is recommended. Complete preoperative evaluation is necessary and the reoperation should be performed once final staging is available. Evaluation of the cystic duct margin and routine 16b1 lymph node biopsy is recommended. Chemotherapy should be considered and chemoradiation therapy if microscopically positive surgical margins. Port site should be resected exceptionally. Staging laparoscopy before reoperation is recommended, but minimally invasive radical approach only in specialized minimally invasive hepatopancreatobiliary centers. The extent of liver resection is acceptable if R0 resection is achieved. Standard lymph node dissection is required for T2 tumors and above, but common bile duct resection is not recommended routinely. Conclusions: It was possible to prepare safe recommendations as guidance for incidental gallbladder carcinoma, addressing the most frequent topics of everyday work of digestive and general surgeons.

BACKGROUND:Various, often conflicting, estimates for post-operative morbidity and mortality following ALPPS have been reported in the literature, suggesting that considerable center-level variation exists. Some of this variation may be related to center volume and experience.METHODS:Using data from seventeen centers who were early adopters of the ALPPS technique, we estimated the variation, by center, in standardized 90-day mortality and comprehensive complication index (CCI) for patients treated between 2012 and 2018.RESULTS:We estimated that center-specific 90-day mortality following treatment with ALPPS varied from 4.2% (95% CI: 0.8, 9.9) to 29.1% (95% CI: 13.9, 50.9), and that center-specific CCI following treatment with ALPPS varied from 17.0 (95% CI: 7.5, 26.5) to 49.8 (95% CI: 38.1, 61.8). Declines in estimated 90-day mortality and CCI were observed over time, and almost all individual centers followed this trend. Patients treated at centers with a higher number of ALPPS cases performed over the prior year had a lower risk of post-operative mortality.CONCLUSION:Despite considerable center-level variation in ALPPS outcomes, perioperative outcomes following ALPPS have improved over time and treatment at higher volume centers results in a lower risk of 90-day mortality. Morbidity and mortality remain concerningly high at some centers.

Colorectal liver metastasis (CRLM) is the most common lesion diagnosed in the liver worldwide and new therapies have been proposed over the last decades. On the leading edge of these therapies, radiofrequency ablation (RFA) has been increasingly applied for treatment these lesions. The procedure can be done by percutaneous approach guided by CT, or during open or laparoscopic surgery. Although findings in preliminary reports suggest that this procedure is both safe and effective, only a few studies have been published. We present a 69-year-old female, previously submitted to two hepatic resections and one RFA for treatment of CRLM, who developed an abdominal wall recurrence due to neoplastic seeding after RFA procedure. In the published literature thus far, some risk factors have been associated with neoplastic seeding following RFA, like subcapsular location, multiple electrode placements, multiple RFA treatments and poor tumor differentiation grade. Technical features like access through normal liver substance and tract needle ablation may play a role in mitigating the risk of this complication. Although it seems to be a safe procedure, only a few retrospective papers have been published its rare complications and outcomes. Nevertheless, patients with localized disease may benefit from surgical resection.

Background: Liver resection is the only potentially curative treatment for liver tumors. Billiary fistulas remains a major concern in hepatectomies and its incidences has not changed over the past few decades. Many methods have been suggested to prevent bile leakage without a significance acceptance. Aim: Assess whether the systematic use of the bile leakage test during liver resections reduces the incidence of biliary fistula in the postoperative period. Materials and Methods: From December 2016 to February 2020, sixty-two hepatectomies performed using bile leakage test were prospectively analyzed to compare the incidence of biliary fistula in patients that had a negative bile leak test (group A) and patients that had a positive test (group B). The bile leak test was performed after liver transection, by injection of 10 mL of saline solution in the cystic duct, through a cholangiography catheter followed by 10 ml of air twice. Leaking points were sutured with 5-0 monofilament polypropylene. Results: Twenty-seven patients (46%) were allocated to group A and thirty-two patients (54%) were allocated to group B. Three patients were excluded from analysis. Three patients (5%) evolved with biliary fistula in the postoperative period, two from the group A and one from group B, with no significant difference (p = 0.45). Conclusion: In conclusion, the bile leakage test proposed in the present study proved to be safe, with no complications related to the test. Even though there was no significant difference in the number of patients that evolved with fistula between the analyzed groups, results suggest that the majority of patients with a positive test may have benefited from the exam and did not developed biliary fistula. Further studies, with a larger group of patients, are necessary to corroborate this statement.

ABSTRACT Background: Laparoscopic liver resection is performed worldwide. Hemorrhage is a major complication and bleeding control during hepatotomy is an important concern. Pringle maneuver remains the standard inflow occlusion technique. Aim: Describe an extracorporeal, efficient, fast, cheap and reproducible way to execute the Pringle maneuver in laparoscopic surgery, using a chest tube. Methods: From January 2014 to March 2020, our team performed 398 hepatectomies, 63 by laparoscopy. We systematically encircle the hepatoduodenal ligament and prepare a tourniquet to perform Pringle maneuver. In laparoscopy, we use a 24 Fr chest tube, which is inserted in the abdominal cavity through a small incision. We thread the cotton tape through the tube, pulling it out through the external end, outside the abdomen. To perform the tourniquet, we just need to push the tube as we hold the tape, clamping both with one forceps. Results: The 24 Fr chest tube is firm and works perfectly to occlude blood inflow as the cotton band is tightened. It has an internal diameter of 5,5 mm, sufficient for a laparoscopic grasper pass through it to catch the cotton band, and an external diameter of 8 mm, which allows to be inserted in the abdomen through a tiny incision. The cost of this tube and the cotton band is less than US$ 1. No complications related to the method were identified in our patients. Conclusions: The extracorporeal Pringle maneuver presented here is a safe, cheap and reproducible method, that can be used for bleeding control in laparoscopic liver surgery.

Background: Hepatocellular adenoma is a rare liver tumor that may require surgical treatment in cases of hemorrhage or suspicion of malignant lesions. Aim: To analyze data from patients who underwent hepatectomy for hepatocellular adenoma (HCA) in Rio de Janeiro, Brazil. Methods: From January 2005 to March 2019, sixty-nine patients with HCA underwent hepatectomy at centers in Rio de Janeiro. They were included in the analysis patients undergoing hepatectomy with pathological diagnosis of hepatocellular adenoma and excluded patients with hepatectomy with anatomopathological diagnosis other than hepatocellular adenoma, mainly nodular focal hyperplasia. Data related to patients, tumor and surgery were analyzed retrospectively. Results: Sixty patients (87%) were female and nine were male. Among women, 83% had a history of contraceptive use; among men, only one had an androgen intake history. Overall mean age was 36.4 years (15 - 49), with men older than women (33.9 ± 8.14 years vs. 40.4 ± 6.27 years; P = 0.02). Forty one patients reported abdominal pain, associated or not to other symptoms; 32% had an episode of hemorrhage; 28 were asymptomatic with an incidental radiological finding. In total, 45 patients presented only one lesion and overall mean size was 8.1 cm (2 - 31); tumors were larger among men (mean size 12.9 ± 9.86 cm vs. 7.7 ± 4.58 cm; P = 0.009). Twenty one surgeries were laparoscopic. Hepatocellular carcinoma (HCC) was identified in three specimens and the incidence was higher among men (22.2% vs. 1.6%; P = 0.042) and in tumors larger than 20 cm (66.6% vs. 0.02%). There was no perioperative mortality. Two of the three patients with HCC died with extrahepatic recurrence; the remaining patient is well after 36 months. Overall mean follow-up time was 14.2 months (2 - 76). Conclusion: Male patients with HCA were older and had larger tumors when compared to females. Incidence of HCC was higher among men and in lesions larger than 20 cm. Male patients with HCA should be treated more aggressively than females.

1Professor of Surgery Department, Antonio Pedro University Hospital, Fluminense Federal University, Niterói, Brazil 2Hepatobiliary Surgery, Ipanema Federal Hospital, Health Ministry, Rio de Janeiro, Brazil 3Hepatobiliary Surgery, Bonsucesso Federal Hospital, Health Ministry, Rio de Janeiro, Brazil 4Antonio Pedro University Hospital, Fluminense Federal University, Niterói, Brazil 5Nacional Cancer Institute, Rio de Janeiro, Brazil 6Equipe Multidisciplinar Hepatobiliar, Brazil *Address for Correspondence: Reinaldo Fernandes, Professor of Surgery Department, Antonio Pedro University Hospital, Fluminense Federal University, Niteroi, Brazil, Tel: +55-212-629-9025; ORCID iD: https://orcid.org/0000-0001-8759-2552; E-mail: rei.fernandes.jr@gmail.com

Background: A minimum future liver remnant (FLR) of 30% is required to avoid post hepatectomy liver failure (PHLF). Portal vein occlusion (PVO) is the main strategy to induce hypertrophy of the FLR, but some patients will not reach sufficient FLR hypertrophy to enable resection. Recently ALPPS has emerged as a "Salvage Procedure" for PVO failure. The aim of this study was to report the short term outcomes of ALPPS following PVO failure. Methods: A retrospective analysis of patients enrolled within the international ALPPS Registry between October 2012 and November 2015 (NCT01924741) was performed. Patients with documented PVO failure were included. The outcomes reported included feasibility, FLR growth rate and safety of ALPPS. Complications were recorded as per Clavien-Dindo classification. Results: From 510 patients enrolled in the Registry there were 22 patients with previous PVO failure. Two patients were excluded due to missing data and twenty patients were analysed. All of them completed the proposed ALPPS with a medium FLR increase of 88% (23-115%) between two stages and no 90-day mortality. Conclusion: In experienced centers, ALPPS following PVO failure is feasible and safe. The FLR hypertrophy was similar to other ALPPS series. ALPPS is a potential rescue strategy after PVO failure.