Laparoscopic pancreatic resection without advanced laparoscopic devices.

BACKGROUND/AIMS: Laparoscopic pancreatic resection has been slow to develop because of the high degree of technical difficulty and generally expensive laparoscopic devices required. We evaluate our experience with laparoscopic resections for pancreatic pathologies without expensive and advanced laparoscopic devices. METHODOLOGY: A prospective evaluation was carried out of consecutive laparoscopic pancreatic resections performed between July 2003-June 2011. RESULTS: Laparoscopic pancreatic resections were attempted in 13 and performed in 10 patients: 6 laparoscopic spleen-preserving distal pancreatectomy and 4 laparoscopic enucleation. Pathological diagnoses: four insulinomas, two serous cystadenoma, two pancreatic pseudocyst, one microcystic serous cystadenoma, two non-functioning neuroendocrine tumors, one leiomyosarcoma, and one case of solid-pseudopapillary tumor. In the laparoscopic operations the mean operative time was 195min and no blood transfusions were required. The mean postoperative hospital stay was 4.7 days. There were three pancreatic fistulas. No patients required a second operation. There were no deaths. Follow-up was available for all patients. CONCLUSIONS: Laparoscopic pancreatic resection is feasible and relatively safe without advanced laparoscopic devices. As with open resections, pancreatic fistula is the dominant morbidity. The best indications for a laparoscopic approach are benign pancreatic tumors that are not inside the neck of the pancreas and do not require pancreaticoenteric reconstruction.

Pharmacological preconditioning using intraportal infusion of L-arginine protects against hepatic ischemia reperfusion injury.

OBJECTIVE: The present study examined the effects of intraportal infusion of L-arginine on ischemia/reperfusion injury (I/RI) in pig livers, by observing changes in the liver function, liver cell morphology, and changes in the mitochondrial ultrastructure. BACKGROUND: The involvement of the nitric oxide (NO) pathway in the reperfusion-ischemic phenomenon is complex and not fully understood. Likewise, little is known about the possible benefit of intraportal infusion of L-arginine (substrate for the NO synthesis) on liver I/RI. METHODS: A pig model consisting of 90 min of hepatic ischemia and 180 min of reperfusion was employed. Eighteen female hybrid pigs were randomly divided into three groups: sham-operated, non-preconditioned, and pharmacologically preconditioned group (intraportal infusion of L-arginine 400 mg/kg) 10 min before being subjected to ischemia and reperfusion. Serum concentrations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), thiobarbituric acid reactive substances (TBARS), and the bile flow were measured. Liver biopsies were taken 180 min after reperfusion for histology, caspase-3 immunohistochemistry, and ultrastructural examination of mitochondria. RESULTS: In the pharmacologically preconditioned group, we observed increased bile flow (P < 0.01) and improved serum AST levels (P < 0.01) relative to the non-preconditioned group. Serum concentrations of TBARS did not differ between the groups. Sinusoidal congestion (P = 0.02) was more evident in the non-preconditioned group than in the sham operated group. Infiltrating PMNs (P = 0.01) were more evident in the non-preconditioned group than in the sham and pharmacologically preconditioned group. The pharmacologically preconditioned group showed an approximately 2.5-fold decrease in caspase-3 activity relative to the non-preconditioned group (P < 0.01). Notably, damage to the mitochondrial ultrastructure in the pharmacologically preconditioned group was reduced relative to the other groups (P < 0.01). CONCLUSIONS: Pharmacological preconditioning with intraportal L-arginine provided protection against hepatic I/RI in early phases of the reperfusion period. The mechanisms underlying the protective effect may include preservation of the mitochondrial structure and inhibition of caspase-3 activity.

Ischemic preconditioning protects the pig liver by preserving the mitochondrial structure and downregulating caspase-3 activity.

BACKGROUND DATA: The beneficial effects of ischemic preconditioning (IPC) on hepatic ischemia-reperfusion injury (I/RI) have been described. However, the way in which IPC causes the changes in mitochondrial ultrastructure seen in hepatic I/RI is not well understood. OBJECTIVE: The objective of the present study was to determine whether IPC protects the liver from changes in mitochondrial structure and caspase 3 activity in the early phase of post-ischemic injury. METHODS: A pig model consisting of 90 min of hepatic ischemia and 180 min of reperfusion was employed. Eighteen female pigs were randomly divided into three groups: sham-operated, non-preconditioned, and ischemic preconditioned (10 min ischemia followed by 10 min reperfusion). Serum concentrations of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and thiobarbituric acid reactive substances (TBARS), as well as bile flow, were measured. Liver biopsies were taken after reperfusion for histological, immunohistochemical (anti-caspase 3), and ultrastructural examinations. RESULTS: The IPC procedure increased bile flow (p < 0.01), reduced serum AST level (p < 0.01), and reduced serum concentration of TBARS at 180 min of reperfusion (p = 0.05). Ischemic-preconditioned liver cells had less caspase 3 activity than the non-preconditioning group (p < 0.01), and changes in mitochondrial ultrastructure were reduced (p < 0.01). CONCLUSION: IPC exerts a powerful protective effect against hepatic I/RI in the early phase of reperfusion, which may be mediated by preservation of mitochondrial structure and inhibition of caspase-3 activity.

Multivisceral transplantation for diffuse portomesenteric thrombosis in a patient with life-threatening esophagogastroduodenal bleeding.

Portal vein thrombosis is the most common cause of portal hypertension in noncirrhotic patients. Variceal bleeding is difficult to treat in these patients, especially those with prehepatic diffuse portal mesenteric thrombosis. In a patient with refractory esophagogastroduodenal variceal bleeding as a result of diffuse portomesenteric thrombosis and portal hypertension, life-threatening bleeding was unresponsive to endoscopic therapy and other surgical procedures. A multivisceral transplant was performed. It was curative and also lifesaving. There is only one report in the literature mentioning multivisceral transplantation for a patient with life-threatening esophagogastroduodenal bleeding; however that patient had protein C deficiency. Our patient had normal liver and intestinal function tests and no signs of hypercoagulable disease. We believe that multivisceral transplantation should be considered as a treatment option for patients with diffuse mesenteric thrombosis, even in the absence of liver and intestinal failure, when other treatment options for variceal bleeding have failed, particularly in a younger patient with a relatively good nutritional status before transplantation.

Laparoscopic distal pancreatectomy for insulinoma with preservation of the spleen.

We report on a successful laparoscopic distal pancreatectomy due to insulinoma, preserving the spleen and the splenic vessels in a 29-year-old male patient who presented with repeated syncope due to hypoglycemia. The ultrasound exam did not show the pancreatic lesion; it was only the angiotomography of the pancreas that revealed a 3-cm mass located at the transition from the body to the tail of the pancreas. The laparoscopic distal pancreatectomy was performed using a harmonic scalpel (Ethicon EndoSurgery/UltraCision), without mechanical suturing. There were no intra- or postoperative complications or hypoglycemias during the 6 months of follow-up. When it is performed by experienced laparoscopic surgeons, this is a technically feasible procedure, safe for the treatment of benign lesions of the pancreas body and tail.

Tratamento percutâneo do abscesso hepático piogênico / Percutaneous treatment of pyogenic liver abscess

Objetivo:Revisar os casos de abscesso hepático tratados por uma única equipe cirúrgica no serviço de cirurgia geral do HG/UCS e CHB de Caxias do Sul. Pacientes e métodos: entre 1997 e 2002, sete pacietes tratados por abscesso hépatico foram revisados, determinando-se a etiologia, a apresentação clínica, os métodos diagnósticos utilizados, o tratamento e a morbidade dos procedimentos realizados. Resultados: Todos apresentavam abscesso hepático piogênico; a forma de contaminação mais prevalente foi a biliar (43por cento). A idade média foi de 46,5 anos e 71por cento eram homens. a febre (100por cento) e a dor abdominal (85,7por cento) foram os achados clínicos mais frequentes. A US e a TC foram realizadas em todos os doentes, demonstrando predomínio das lesões bilaterais (71,42por cento). A aspiração percutânea guiada por TC foi utilizada como tratamento em cinco (71,42por cento; em dois destes associou-se a drenagem externa, enquanto que em apenas um realizaou-se a drenagem cirúrgica. A antibioticoterapia IV prolongada foi usada em todos os casos, enquanto a antibioticoterapia isoloda, semente em um (14,29por cento) doente com microabscessos hepáticos. Não houve complicações atribuídas aos procedimentos percutâneos e a taxa de mortalidade foi de 14por cento (um paciente). Conclusões: O diagnóstico precoce, a realização de adequada drenagem através de métodos minimamente invasivos, associados a antibioticoterapia intravenosa prolongada, parece ser a melhor conduta inicial frente a pacientes com abscessos hepáticos piogênicos

Monolobar Caroli's disease in an adult. Case report.

Caroli's disease is the dilatation of the segmental intrahepatic bile ducts which generally presents in a diffuse form, but may occasionally involve only a single lobe, commonly the left one. We report the case of a 64-year-old male who presented with a clinical picture of obstructive jaundice, with Caroli's disease in segments II and III of the liver. Preoperative diagnosis was made using abdominal ultrasound and computed tomography scan, confirmed by endoscopic retrograde cholangiopancreatography. The treatment used was segmentectomy II and III (left lobectomy--Couinaud's classification) of the liver. Macroscopic examination of the resected specimen revealed cystic dilatation of the intrahepatic bile ducts and intrahepatic lithiasis. Histologically there was no evidence of malignancy. Liver resection is the treatment of choice for Caroli's disease confined to a single lobe or segment, eliminating the potential for cholangitis, lithiasis and carcinoma.

"Sump syndrome" recidivante após o tratamento endoscópico: relato de caso / Recurrent sump syndrome after endoscopic therapy: case report

A sump syndrome é uma rara complicação, usualmente associada a anastomoses coledocoduodenais, caracterizada por dor internitente, pancreatite e colangite de repetição. Estas manifestações são decorrentes do refluxo de conteúdo gastroentérico para dentro da anastomose biliar e seu acúmulo acima do esfíncter de Oddi. Relato de caso: Descreve-se o caso de uma paciente submetida a uma anastomose coledocoduodenal para o tratamento de litíase da via biliar principal, a qual evoluiu com episódios recorrentes de colangite, microabscesso hepático e choque séptico. Após o insucesso de duas esfincterotomias endoscópicas, optou-se pelo tratamento cirúrgico. Durante o intra-operatório realizous-se uma anastomose duodenojejunal término-lateral em Y de Roux devido à presença de uma reação fibrosa intensa ao nível do pedículo hepático, o que possibilitou a realização de uma anastomose hepaticojejunal término-lateral em Y de Roux. A paciente apresentou excelente evolução, permanecendo assintomática no 32§ mês de pós-operatório. Conclusão: Este procediemnto demonstrou ser uma opção terapêutica eficaz para pacientes com sump syndrome ecorrente após esfincterotomia endoscópica.

Intermittent total pedicular clamping in hepatic resections in non-cirrhotic patients.

BACKGROUND/AIMS: Evaluation of intermittent total pedicular clamping in hepatic resections in non-cirrhotic patients. METHODOLOGY: A prospective study was made of 72 patients submitted to hepatic resections using intermittent total pedicular clamping. Patients were placed in 5 groups for analysis according to the duration of liver ischemia (each 20 minutes). Tolerance of liver ischemia was assessed by analysis of postoperative morbimortality and biochemical test. RESULTS: Five patients (6.9%) died during the postoperative period and sixteen patients (23.8%) developed specific complications, however, none of the variables analyzed in this study proved to be an independent risk factor for the development of postoperative morbimortality. The transaminases presented a statistically significant relationship with duration of ischemia (P < 0.002), while the late rise was influenced by postoperative mortality (P < 0.009). Prothrombin time was influenced by the duration of ischemia and by postoperative mortality (P = 0.014) but, on the other hand, the bilirubin levels only showed the influence of mortality (P < 0.002). CONCLUSIONS: Immediate postoperative liver function was better preserved in patients submitted to less than 80 minutes of clamping. The late rise of bilirubin and transaminases and the drop in prothrombin time could be considered indicators of a bad postoperative course.