Monosegment ALPPS for bilateral colorectal liver metastasis - One is enough.

Associated liver partition and portal vein ligation for staged hepatectomy - ALPPS - procedure emerged as an alternative to treat patients needing extensive hepatic resections, but with a small future liver remnant. Initially described using the left lateral segments as liver remnant, ALPPS has been adapted to leave as remainder only one segment. Describe a case of a patiente with bilobar colorectal liver metastasis submitted to segment 4-1 ALPPS. A 63-year-old man, previously submitted to transversostomy, due to a left colon stenosing adenocarcinoma, associated to bilobar liver metastasis, was referred for our evaluation, after receiving a FOLFOX based chemotherapy. Due to the large load of tumor within the liver, we opted to perform a segment 4-1 ALPPS, which was carried out with an interval of 21 days between first and second stages. The liver remnant increased from 250 cc to 694 cc (18% to 48% of standard liver volume). The patient was discharged 15 days after second stage surgery and was subjected to left colectomy after five months. He is disease-free ten months after liver surgery. Monosegment ALPPS is a challenging, but feasible procedure, that should be criteriously indicated in selected patients and performed by a hepatobiliary surgery team with experience in complex major hepatectomies.

Right gastroepiploic artery as an alternative for arterial reconstruction in living donor liver transplantation.

Background. An adequate blood flow is directly related to graft survival in living donor liver transplantation. However, in some cases, unfavorable conditions prevent the use of the hepatic artery for arterial reconstruction. Herein, we report a case in which the recipient right gastroepiploic artery was used as an option for arterial reconstruction in adult-to-adult living donor liver transplantation. Case Report. A 62-year-old woman, with cirrhosis due to hepatitis B associated with hepatocellular carcinoma, was submitted to living donor liver transplantation. During surgery, thrombosis of the hepatic artery with intimal dissection until the celiac trunk was observed, which precluded its use in arterial reconstruction. We decided to use the right gastroepiploic artery for arterial revascularization of the liver graft. Despite the discrepancy in size between donor hepatic artery and recipient right gastroepiploic artery, anastomosis was performed successfully. Conclusions. The use of the right gastroepiploic artery as an alternative for arterial revascularization of the liver graft in living donor liver transplantation should always be considered when the hepatic artery of the recipient cannot be used. For performing this type of procedure, familiarity with microsurgical techniques by the surgical team is necessary.

Inferior Right Hepatic Vein: A Useful Anatomic Variation for Isolated Resection of Segment VIII.

Anatomical resection of segment VIII (SVIII) is one of the most difficult hepatectomies to perform. Although it is the best choice of surgical treatment for tumors located at SVIII, its feasibility can be compromised when the right hepatic vein (RHV) must be resected en bloc with SVIII. Herein we describe a case of a cirrhotic patient that was submitted to segmentectomy VIII in bloc with the main trunk of the RHV, due to hepatocellular carcinoma. The resection could only be performed because a well developed inferior right hepatic vein (IRHV) was present. Anatomical variations of the liver vascularization should be used by liver surgeons to improve surgical results.

Sarcomas primários do retroperitônio / Primary retroperitoneal sarcomas

Sarcomas de partes moles são tumores raros, sendo 10 por cento a 20 por cento destes localizados no retroperitônio. Metástases para linfonodos e a distância são raras. Os sarcomas primários de retroperitônio devem ser considerados em pacientes com dor abdominal, desconforto ou massa palpável no abdome, sendo descobertos pelo exame físico ou como achados incidentais na Tomografia Computadorizada (TC), Ultra-sonografia (USG) ou Ressonância Magnética (RM). Todos os pacientes com sarcoma de retroperitônio com possibilidade de ressecção devem ser submetidos à laparotomia, devendo o planejamento cirúrgico abranger a completa ressecção do tumor, órgãos e estruturas adjacentes infiltradas. A quimioterapia apresenta resultados desanimadores. No entanto, a radioterapia quandoempregada no pré-operatório, pode beneficiar o paciente. Sarcomas de retroperitônio tendem a apresentar recorrêncialocal. Logo, deve-se fazer seguimento pós-operatório com história clínica, exame físico, radiografia de tórax, TC de abdome e pelve freqüentes, indicando a reoperação, sempre que possível, em caso de recidiva. A sobrevidaglobal em cinco anos é de 40 por cento a 50 por cento, sendo que o diâmetro do tumor, o grau de diferenciação tumoral, a ressecção radical ou paliativa, a necessidade de hemotransfusão durante o ato cirúrgico e a re-ressecção, mesmo que paliativa,nos casos de recidiva ou persistência de doença, são os fatores prognósticos mais importantes.

Inguinal Sentinel Node Biopsy in Epidermoid Carcinoma of the Anal Canal: a Pilot Study

It has been well established that the primary therapeuticapproach to anal squamous-cell carcinoma ischemoradiotherapy. Inguinal lymph node (LN) status isan important prognosis indicator and the presence ofmetastases in the inguinal LN is an independent markerof the local failure and overall survival. The appropriatemanagement of patients with primary anal cancer andclinically uninvolved groins remains controversial.Nowadays there is no reliable diagnostic method toaccurately determine nodal status of the inguinal region.This study was conducted to evaluate the feasibility of anovel assessment method of the nodal status of theinguinal region in patients with epidermoid carcinomaof the anus and anal margin. We advocate that sentinellymph node biopsy is a safe and feasible technique todetect metastases in inguinal nodes.

Standardization of Histopathological Auditing of the Mesorectal Specimen in the Brazilian National CancerInstitute / INCA

Aiming the decrease of local recurrence, the Heald´sstandardization was based on the clinical andpathological studies of Quirke and Reynolds thatdemonstrated the importance of the systematic exam ofthe radial margins which predicted the occurrence ofrecurrence, evidencing that most of the pelvic recurrenceshappened when the circumferential limit was involved.The Abdominal-Pelvic Surgery and Pathology Servicesof Brazilian National Cancer Institute (INCA)standardized the evaluation of radial margin ofextraperitoneal rectum tumors submitted to a curativesurgery since July 2004. Besides that the Quirke’stechnique of histopathological analysis of themesorectum modified by the INCA will be described.