PAULO HERMAN
Projetos de Pesquisa
Unidades Organizacionais
Departamento de Gastroenterologia, Faculdade de Medicina - Docente
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
LIM/37 - Laboratório de Transplante e Cirurgia de Fígado, Hospital das Clínicas, Faculdade de Medicina
Instituto Central, Hospital das Clínicas, Faculdade de Medicina
LIM/37 - Laboratório de Transplante e Cirurgia de Fígado, Hospital das Clínicas, Faculdade de Medicina
11 resultados
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- Diagnosis and Impact of Hilar Lymph Node Micrometastases on the Outcome of Resected Colorectal Liver Metastasis(2013) LUPINACCI, Renato M.; HERMAN, Paulo; COELHO, Fabricio C.; VIANA, Eduardo F.; D'ALBUQUERQUE, Luiz A. C.; CECCONELLO, IvanBackground/Aims: Liver resection is the only curative therapy for metastatic colorectal cancer. However, recurrence occurs in the majority of the cases. Hilar lymph node metastases occur with a high frequency but the methodology for its detection and the impact on the outcome of patients undergoing hepatectomy is still unknown. Methodology: Twenty-six patients submitted to partial liver resection and systematic lymphadenectomy were studied prospectively. Lymph nodes considered negative by hematoxylin and eosin (H&E) staining were analyzed by serial sectioning and immunohistochemistry (IHC) with anti-human pancytokeratin antibody AE1/AE3. Recurrence-free and overall survivals were compared among LN groups. Results: The mean number of dissected lymph nodes were 6.3 per patient. H&E showed microscopic involvement of LN in 2 patients and 3 patients had metastases identified only by IHC. The median follow-up was 39.3 months. Sixteen patients (61.5%) recurred after liver resection and although no statistical difference in survival was demonstrated there was a trend towards shorter recurrence-free survival among microscopic positive LN. Conclusions: Microscopic LN metastases may have impact in the outcome of patients submitted to curative hepatectomy. A better definition of micrometastases to LN is warranted, as though the potential benefit of hilar lymphadenectomy and chemotherapy selection by hilar lymph node status.
- Ligadura da veia porta associada à bipartição do fígado para hepatectomia em dois estágios (ALPPS): experiência brasileira(2013) TORRES, Orlando Jorge Martins; FERNANDES, Eduardo de Souza Martins; OLIVEIRA, Cassio Virgilio Cavalcante; LIMA, Cristiano Xavier; WAECHTER, Fabio Luiz; MORAES-JUNIOR, Jose Maria Assunção; LINHARES, Marcelo Moura; PINTO, Rinaldo Danese; HERMAN, Paulo; MACHADO, Marcel Autran CesarBACKGROUND: Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. To induce rapid and significant hepatic hypertrophy, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients which tumor is previously considered unresectable. AIM: To present the Brazilian experience with ALPPS approach. METHOD: Were analyzed 39 patients who underwent hepatic resection using ALPPS in nine hospitals. The procedure was performed in two steps. The first operation was portal vein ligation and in situ splitting. In the second operation the right hepatic artery, right bile duct and the right hepatic vein were isolated and ligated. The extended right lobe was removed. There were 22 male (56.4%) and 17 female (43.6%). At the time of the first operation, the median age was 57.3 years (range: 20-83 years). RESULTS: The most common indication was liver metastasis in 32 patients (82.0%), followed by cholangiocarcinoma in three (7.7%). Two patients died (5.2%) during this period and did not undergo the second operation. The mean interval between the first and the second operation was 14.1 days (range: 5-30 days). The volume of the left lateral segment of the liver increased 83% (range 47-211.9%). Significant morbidity after ALPPS was seen in 23 patients (59.0%). The mortality rate was 12.8% (five patients). CONCLUSION: The ALPPS approach can enable resection in patients with lesions previously considered unresectable. It induces rapid liver hypertrophy avoiding liver failure in most patients. However still has high morbidity and mortality.
- Adenoma hepático(2013) SZOR, Daniel José; URSOLINE, Mauricio; HERMAN, PauloBACKGROUND: Benign liver tumors, due to its relative easeness its imaging identification, have their incidence increasing in population in recent years, becoming frequent in the clinical picture and often a challenge for clinicians and surgeons. Doctors began to face dilemmas related to diagnosis in asymptomatic patients with liver nodules. AIM: Update the knowledge of hepatic adenomas due to the crescent diagnosis seen in the recent years. METHODS: Was performed a literature review consulting Medline/PubMed, SciELO, Embase, Lilacs database with the following descriptors: hepatic adenoma, surgery, medical treatment, diagnosis, pathophysiology and molecular biology. CONCLUSION: The diagnosis of incidental asymptomatic lesions is a major dilemma in clinical practice because it brings intense distress for patients and their families, and often become a challenge for the physician or surgeon. Injury is of particular interest because it can provide both benign evolution or potentially lethal complications. Recently, its resection is no more mandatory; currently, more individualized treatment are required, aiming less morbidity. In light of new advances in molecular biology, the physician who diagnoses the lesion must identify the potential unfavorable evolution, and recognize cases who need more aggressive medical management.
- Extended preoperative chemotherapy, extent of liver resection and blood transfusion are predictive factors of liver failure following resection of colorectal liver metastasis(2013) RIBEIRO, H. S. C.; COSTA JR., W. L.; DINIZ, A. L.; GODOY, A. L.; HERMAN, P.; COUDRY, R. A.; BEGNAMI, M. D. F. S.; MELLO, C. A. L.; SILVA, M. J. B.; ZURSTRASSEN, C. E.; COIMBRA, F. J. F.Aim: The aim of this study was to determine the incidence and prognostic factors of postoperative liver failure in patients submitted to liver resection for colorectal metastases. Method: Patients with CLM who underwent hepatectomy from 1998 to 2009 were included in retrospective analysis. Postoperative liver failure was defined using either the 50-50 criteria or the peak of serum bilirubin level above 7 mg/dL independently. Results: Two hundred and nine (209) procedures were performed in 170 patients. 120 surgeries were preceded by chemotherapy within six months. The overall morbidity rate was 53.1% and 90-day mortality was 2.3%. Postoperative liver failure occurred in 10% of all procedures, accounting for a mortality rate of 9.5% among this group of patients. In multivariate analysis, extent of liver resection, need of blood transfusion and more than eight preoperative chemotherapy cycles were independent prognostic factors of postoperative liver insufficiency. This complication was not related with the chemotherapy regimen used. Conclusion: We conclude that postoperative liver failure has a relatively low incidence (10%) after CLM resection, but a remarkable impact on postoperative mortality rate. The amount of liver resected, the need of blood transfusion and extended preoperative chemotherapy are independent predictors of its occurrence and this knowledge can be used to prevent postoperative liver failure in a multidisciplinary approach.
- Laparoscopic Hepatic Posterior Sectionectomy: A Hand-assisted Approach(2013) HERMAN, Paulo; KRUEGER, Jaime Arthur Pirola; PERINI, Marcos Vinicius; COELHO, Fabricio Ferreira; LUPINACCI, Renato MicelliHepatic resection remains a challenging procedure in laparoscopy, requiring trained surgical teams and specialized centers.1 (-) 3 Operating on the posterior segments of the liver brings additional concerns, such as vascular control, right liver mobilization from the retroperitoneum and diaphragm, and a large transection area.1 (,) 3 (-) 6 Here we present a case of a hepatitis B-positive 42-year-old woman with a neoplastic nodule on the right posterior section of the noncirrhotic liver. Pneumoperitoneum was made through a hand port, and three additional trocars were placed. Intrahepatic glissonian pedicle control was achieved after liver mobilization. Parenchymal transection was performed through the demarcation line between the anterior well vascularized and the posterior ischemic right segments of the liver. All surgical steps were performed with hand assistance. Operative time was 210 min, and estimated blood loss was 300 ml. Postoperative was uneventful. The patient was discharged on the fourth postoperative day. Histological evaluation confirmed the diagnosis of a well-differentiated hepatocellular carcinoma. The patient was free of disease after 18 months of follow-up. Our video shows a standardized operative strategy in which the hand assistance plays important role. Posterosuperior segments of the liver are still less often approached by laparoscopic surgery as a result of its limitations on visualization, mobilization, pedicle control, and parenchymal transection.1 (,) 3 (,) 6 Hand assistance helps solve these issues, making assisted resection easier than a purely laparoscopic approach and more advantageous over the open technique, providing the benefits of laparoscopy without compromising oncological safety.7.
bookPart Metástases hepáticas do câncer colorretal(2013) HERMAN, Paulo; D'ALBUQUERQUE, Luis A. Carneiro; LUPINACCI, Renato M.- Manejo atual das metástases hepáticas de câncer colorretal: recomendações do Clube do Fígado de São Paulo(2013) LUPINACCI, Renato Micelli; COELHO, Fabricio Ferreira; PERINI, Marcos Vinicius; LOBO, Edson José; FERREIRA, Fabio Gonçalves; SZUTAN, Luiz Arnaldo; LOPES, Gaspar de Jesus; HERMAN, PauloApproximately half of patients with colorectal cancer present with liver metastases during the course of their disease, which directly affect prognosis and is responsible for two thirds of deaths related to the disease. In the last two decades the treatment of liver metastases from colorectal cancer (CRCLM) provided significant gain in survival when all treatment options are available to the patient. In this context, surgical treatment remains as the only chance of cure, with five-year survival rates of 25-58%. However, only 1/4 of the patients have resectable disease at diagnosis. For this reason, one of the key points in the current management of patients with CRCLM is the development of strategies that facilitate complete resection of liver lesions. The advent and refinement of ablative methods have expanded the possibilities of surgical therapy. The emergence of new chemotherapy regimens and the introduction of targeted therapies has provided high response rates and has permanently altered the management of these patients. The multimodal therapy and the involvement of different medical specialties has increasingly enabled CRCLM treatment to approached the ideal treatment, i.e., an individualized one. Based on an extensive review of literature and on experience from some of the most important specialized centers of Brazil, the São Paulo Liver Club began a process of multi-institutional discussions that resulted in the recommendations that follow. These recommendations, however, are not intended to be absolute, but useful tools in the therapeutic decision process for this complex group of patients.
- Dimensão da margem cirúrgica nas ressecções de metástase hepática de câncer colorretal: impacto na recidiva e sobrevida(2013) HERMAN, Paulo; PINHEIRO, Rafael S.; MELLO, Evandro S.; LAI, Quirino; LUPINACCI, Renato M.; PERINI, Marcos V.; PUGLIESE, Vincenzo; ANDRAUS, Wellington; COELHO, Fabricio F.; CECCONELLO, Ivan; D'ALBUQUERQUE, Luiz C.BACKGROUND: Approximately 50% of the patients with a colorectal tumor develop liver metastasis, for which hepatectomy is the standard care. Several prognostic factors have been discussed, among which is the surgical margin. This is a recurring issue, since no consensus exists as to the minimum required distance between the metastatic nodule and the liver transection line. AIM: To evaluate the surgical margins in liver resections for colorectal metastases and their correlation with local recurrence and survival. METHODS: A retrospective study based on the review of the medical records of 91 patients who underwent resection of liver metastases of colorectal cancer. A histopathological review was performed of all the cases; the smallest surgical margin was verified, and the late outcome of recurrence and survival was evaluated. RESULTS: No statistical difference was found in recurrence rates and overall survival between the patients with negative or positive margins (R0 versus R1); likewise, there was no statistical difference between subcentimeter margins and those greater than 1 cm. The disease-free survival of the patients with microscopically positive margins was significantly worse than that of the patients with negative margins. The uni- and multivariate analyses did not establish the surgical margin (R1, narrow or less than 1 cm) as a risk factor for recurrence. CONCLUSION: The resections of liver metastases with negative margins, independently of the margin width, had no impact on tumor recurrence (intra- or extrahepatic) or patient survival
- Laparoscopic bisegmentectomy 6 and 7 using a Glissonian approach and a half-Pringle maneuver(2013) HERMAN, Paulo; KRUEGER, Jaime; LUPINACCI, Renato; COELHO, Fabricio; PERINI, MarcosDespite accumulated experience and advancing techniques for laparoscopic hepatectomy, surgeons still face challenging resections that require specific and innovative intraoperative maneuvers [1-3]. The right posterior sectionectomy presents special concerns about its location, the extensive transection area, and the difficult access to the pedicle [4, 5]. The intrahepatic Glissonian approach allows safe en masse control of the portal structures without prolonged dissection [2]. Its association with the half-Pringle maneuver results in less bleeding during parenchymal transection [1, 6]. A 34-year-old woman was referred for treatment of an 8-cm hepatocellular adenoma located at segments 6 and 7. She was placed in a semi-supine position, and six ports were located in a distribution that resembled a Makuuchi incision. The right liver was mobilized, and preparation for an anatomic Glissonian approach was performed. A vascular clamp was placed to ensure that full control of the right posterior pedicle was possible. Then a vascular stapler replaced it, with division of the right posterior Glissonian pedicle. A vascular clamp was inserted from the inferior right-flank 5-mm trocar for performance of a half-Pringle maneuver of the right pedicle to minimize blood loss during parenchymal transection. The liver parenchyma was transected with a harmonic scalpel and a vascular stapler. The right hepatic vein was divided intraparenchymally with a vascular stapler. The specimen was extracted through a Pfannenstiel incision. The total surgical time was 210 min, and the estimated blood loss was 200 ml. No blood transfusion was required. The recovery was uneventful, and hospital discharge occurred on postoperative day 5. Pathology confirmed the diagnosis of an hepatocellular adenoma. Technical issues initially hindered the development of laparoscopic liver resections [7-10]. Surgeons were concerned about hemostasis, bleeding control, safe and effective parenchymal transection, adequate visualization, and the feasibility of working on deeper regions of the liver. During the past decade, many limitations were overcome, but lesions located on the posterosuperior liver are still considered tough to beat [5, 11]. Large series and extensive reviews [12-14] show that resections located on the posterior segments still are infrequent. Limited access to the portal triad, difficult pedicle control, and a large transection area and its anatomic location, attached to the diaphragm and retroperitoneum and hidden from the surgeon's view, makes such resections defying. The authors' team has performed 97 laparoscopic hepatectomies, including resection of 6 lesions in the right posterior sector. In their series, half-pedicle clamping was used for 12 patients, and they adopt such a maneuver as an inflow control when operating on peripheric lesions with difficult vascular control (e.g., enucleations or posterosuperiorly located segmentectomies). This technique is safe and useful because it reduces liver ischemic aggression, a very important issue with diseased livers (e.g., steatosis, steatohepatitis, prolonged chemotherapy, cirrhosis) [6, 15]. In their series, the authors applied the Glissonian intrahepatic approach in 7 cases (2 left hepatectomies and 5 right hepatectomies). They understand that laparoscopy applies perfectly to oddly (posterosuperior) located tumors and that right posterior sectionectomy can be accomplished safely. In fact, they share the opinion of other specialized hepatobiliary centers, believing that this may be the preferred approach [16].
bookPart Abscessos do Fígado(2013) COELHO, Fabricio Ferreira; VIANA, Eduardo Freitas; CLEVA, Roberto de; HERMAN, Paulo