Hepatic Vein (HV) Reconstruction (HVR) for Liver Tumors Involving Hepatocaval Confluence (HCO) Is Safe and Feasible to Achieve R0 Resection

Purpose: Surgical resection remains the cornerstone treatment for liver tumors. Local recurrence risk is determined by surgery radicality which forces significant parenchymal sacrifice or R1 resection in case of vascular involvement. Jump-graft between intra-parenchymal origin and superior stump HVR might be necessary to preserve remnant liver adequate outflow when radical surgery requires a resection at HCo. Methods: Monocentric retrospective analysis of intraoperative data and outcomes in 16patients who underwent HVR(2018-2021) was performed. After tumor dissection under ultrasound control, proximal and distal HV stumps were clamped and involved hepatocaval segment resected in single block. Reconstruction was performed by interposition of vascular graft between both stumps. Results: Patients presented with different conditions: liver metastasis (n=13), intrahepatic cholangiocarcinoma (n=1), hepatocellular carcinoma (n=2). Non-frozen ABO-compatible venous homograft (n=12), autologous peritoneal patch/tube (n=3), autologous veins (n=1) were used as jump-grafts. Median HV clamping duration was 63min(54-90min). Pedicular clamping was only performed when HVR was associated to IVC replacement(n=2). Double HVR was also performed (n=3). HVR patency at day7 was 94%(15/16), at 3months 81%(13/16). Median blood loss was 1100ml(837-1700ml), R0 resection was achieved in 13/16(81%). Severe morbidity (Clavien III-IV) reached 25%(4/16). Small for size syndrome was null. Day90 mortality was null. Conclusion: In our series, R0 resection rate was high as well as early and late graft patency. Morbi-mortality was acceptable. HVR technique allows replacement of a single or double HV without significant bleeding nor need for pedicle clamping (if not associated to IVC replacement). Therefore, HVR should be considered as a realistic option in parenchymal-sparing strategy or radical surgery

The use of autologous peritoneum in surgery of portal hypertension: H-shape splenorenal shunt using simple layer peritoneal tube.

The management of portal hypertension complicated by iterative gastro-intestinal bleeding remains challenging, especially in a low-income environment. Interventional radiology and endoscopic treatments are not always accessible, and a definitive surgical option may prove to be lifesaving. We report a new technique of surgical portosystemic shunt that can be performed in all contexts. We describe the surgical technique of a H-shaped splenorenal shunt using autologous rolled up peritoneum as a vascular graft

In-depth Clinical, Haemodynamic and Volumetric Assessment of the RAPID-type Auxiliary Liver Transplantation; Are We Simply Dealing with a Transplant Model of ALPPS?

Purpose: RAPID (Resection And Partial Liver Transplantation with Delayed total hepatectomy) consists of a left hepatectomy associated with orthotopic implantation of a left lobe. The rapid volumetric increase of the graft allows a right completion hepatectomy within 15 days. The technical difficulties encountered in this complex procedure are significant and there are still few cases described in the literature. Methods: Six donors and 6 recipients undergoing RAPID transplantation were included in a prospective single-centre protocol. We analyse the early kinetics growth rate (eKGR) by comparing it to that observed in patients receiving a partial graft alone. We performed intraoperative flow and pressure measurements in all patients. Data on conventional Living Donor Liver Transaplantation (LDLT) recipient were extracted retrospectively. We performed sequential hepatobiliary scintigraphy. Results: The indication for transplantation was colorectal and neuroendocrine metastases. Mean Graft-Recipient Weight Ratio was 0,41. No patient presented with Small-for-Size syndrome. 90 days mortality was 16.6%. The mean follow-up for the 5 living recipients was 648 days without associated morbidity. The clinical course of the donors was unremarkable. There was no difference in eKGR between RAPID and LDLT grafts. The indexed portal flow was significantly higher in RAPID than in LDLT. The technique exposes small volume grafts (GRWR <0.5) to full porto-mesenteric flow but this hyperflow only requires surgical modulation in 1 in 6 cases.Sequential analysis eKGR shows no linearity. It was greater in the first week than in the second week after transplantation: mean volume increase of 70.17±27.13% versus 24±12.77%. Conclusions: We highlight the excellent clinical results of the RAPID surgical technique despite initial graft volumes well below those recommended for conventional LDLT. The initial hypothesis of accelerated surgical liver regeneration has not been established: the growth rate of the grafts in the RAPID model corresponds to that found in LDLT

Hepatic regeneration in a rat model is impaired by chemotherapy agents used in metastatic colorectal cancer.

Administering Oxaliplatin prior to resection of colorectal liver metastases often induces a Sinusoidal Obstruction Syndrome (SOS), which can affect postoperative patient outcome. Bevacizumab (Anti-VEGF-A) can decrease the severity of SOS and the associated risk of postoperative liver failure. We investigated the impact of both Oxaliplatin (Oxali) and Bevacizumab on liver regeneration in a rat model

Indocyanin Green (ICG) for Colonic Viability Assessment in Left Pancreatic Minimal Invasive Surgery (MIS)

Background: Large distal pancreatic tumors may involve the transverse or splenic flexure mesocolon. R0 resection of such lesions may be extended to the mesocolon. Interruption of the arc of Riolan may be difficult to assess especially in MIS. Case report: We report a case of a 17 years old male presenting epigastric pain. The CT scan showed two lesions of the distal pancreas of 7x8cm and 4x3.5cm with aspects compatible with a solid pseudopapillary tumor. The octreo PET showed no fixation of the two lesions. A laparoscopic distal pancreatectomy with splenic preservation was attempted. Transverse and splenic flexure mesocolon were involved by the lesions. The dissection of the mesocolon to release the tumors lead to probable interruption of arc of Riolan and to a doubt on colonic optimal vascularisation after the surgery. We therefore used ICG to assess the viability of the colonic splenic flexure. Discussion and Conclusion: This short video illustrates how ICG can be simply used in left pancreatic surgery when R0 resection requires removal of splenic flexure mesocolon and partial interruption of arc of Riolan. In this case, ICG confirms the adequate perfusion of the splenic flexure and its safe preservation without any need of colonic resection

700 Laparoscopic Pancreatic Resections in a French Center: Evolution of the Indications and Outcome

Introduction: Large monocentric series of laparoscopic pancreatic resection (LPR) are still lacking. This series studied evolution of indications and outcome of LPR. Methods: This is a retrospective monocentric study. Main contraindications were major vascular invasion and pancreatitis. Demographics, surgical, and postoperative outcome data were studied. We compared the first 350 LPR (2008-2016) and the last 350 LPR (2017-2020). Results: From 2008 to 2020, 700 LPR were performed including 191 PD (27%), 344 DP (50%), 92 CP (13%), 69 Enucleation (10%) and 4 TP (1%). The applicability of laparoscopy increased from 10% before 2010 to 40% in 2020. Mean age and BMI were 56 (17-87) and 25 kg/m2 (15-48), respectively and 406 were female (58%).The main indications: IPMN (169; 24%), NET (167; 24%) and pancreatic adenocarcinoma (124, 18%). The surgical outcomes showed conversion (3%), mean operative duration (207; 30-540 mn), blood loss (213; 0-2500 ml), transfusion (4%), mortality (9; 1.3%), overall morbidity (56%), POPF B/C (19%), bleeding (7%), re-intervention (7%), readmission (6%) and mean hospital stay 16(2-104). The second period versus the first period showed more comorbidities (39% vs 52%; p<0.0001), less noninvasive IPMN (39% vs 18%; p<0.001, less splenectomy (17% vs 9%,p=0.002), less conversion (4% vs 2%,p=0.046), less POPF (24% vs 15%,p=0.001), less bleeding (9% vs 5%,p=0.036), less re-intervention (10% vs 5%,p=0.004) and a shorter hospital stay (18 vs 13; p<0.001). Conclusion: This large series including all types of pancreatic resections showed more patients with comorbidities and evolution in the indications. The good outcome is furthermore improved with the experience