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.

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.

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

Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has emerged as an alternative for patients with bilobar colorectal liver metastasis and a small future liver remnant (FLR). In cases of extensive disease, ALPPS can be performed, leaving only one segment of the liver as FLR. We describe a case of monosegmental ALPPS using segment 4 as FLR. In conclusion, ALPPS should be reserved for a selected group of patients. Monosegmental ALPPS is feasible, but should be performed by hepatobiliary surgeons in specialized centers.