RENATO MICELLI LUPINACCI
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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.
- Laparoscopic Resection of Hepatocellular Carcinoma: When, Why, and How? A Single-Center Experience(2014) HERMAN, Paulo; PERINI, Marcos Vinicius; COELHO, Fabricio Ferreira; KRUGER, Jaime Arthur Pirolla; LUPINACCI, Renato Micelli; FONSECA, Gilton Marques; LOPES, Felipe de Lucena Moreira; CECCONELLO, IvanPurpose: The aim of this study was to evaluate short- and intermediate-term results of laparoscopic liver resection in selected patients with hepatocellular carcinoma (HCC). Patients and Methods: Eighty-five patients with HCC were subjected to liver resection between February 2007 and January 2013. From these, 30 (35.2%) were subjected to laparoscopic liver resection and were retrospectively analyzed. Special emphasis was given to the indication criteria and to surgical results. Results: There were 21 males and 9 females with a mean age of 57.4 years. Patients were subjected to 10 nonanatomic and 20 anatomic resections. Two patients were subjected to hand-assisted procedures (right posterior sectionectomies); all other patients were subjected to totally laparoscopic procedures. Conversion to open surgery was necessary in 4 patients (13.3%). Postoperative complications were observed in 12 patients (40%), and the mortality rate was 3.3%. Mean overall survival was 29.8 months, with 3-year overall and disease-free survival rates of 76% and 58%, respectively. Conclusions: Laparoscopic treatment of selected patients with HCC is safe and feasible and can lead to good short- and intermediate-term results.
- Tumor growth pattern as predictor of colorectal liver metastasis recurrence(2014) PINHEIRO, Rafael S.; HERMAN, Paulo; LUPINACCI, Renato M.; LAI, Quirino; MELLO, Evandro S.; COELHO, Fabricio F.; PERINI, Marcos V.; PUGLIESE, Vincenzo; ANDRAUS, Wellington; CECCONELLO, Ivan; D'ALBUQUERQUE, Luiz CarneiroBACKGROUND: Surgical resection is the gold standard therapy for the treatment of colorectal liver metastases (CRM). The aim of this study was to investigate the impact of tumor growth patterns on disease recurrence. METHODS: We enrolled 91 patients who underwent CRM resection. Pathological specimens were prospectively evaluated, with particular attention given to tumor growth patterns (infiltrative vs pushing). RESULTS: Tumor recurrence was observed in 65 patients (71.4%). According to multivariate analysis, 3 or more lesions (P = .05) and the infiltrative tumor margin type (P = .05) were unique independent risk factors for recurrence. Patients with infiltrative margins had a 5-year disease-free survival rate significantly inferior to patients with pushing margins (20.2% vs 40.5%, P = .05). CONCLUSIONS: CRM patients with pushing margins presented superior disease-free survival rates compared with patients with infiltrative margins. Thus, the adoption of the margin pattern can represent a tool for improved selection of patients for adjuvant treatment.
- Hepatocellular adenoma: an excellent indication for laparoscopic liver resection(2012) HERMAN, Paulo; COELHO, Fabricio Ferreira; PERINI, Marcos Vinicius; LUPINACCI, Renato Micelli; D'ALBUQUERQUE, Luiz Augusto Carneiro; CECCONELLO, IvanObjectives: Laparoscopic resection for benign liver disease has gained wide acceptance in recent years and hepatocellular adenoma (HA) seems to be an appropriate indication. This study aimed to discuss diagnosis and treatment strategies, and to assess the feasibility, safety and outcomes of pure laparoscopic liver resection (LLR) in a large series of patients with HA. Methods: Of 88 patients who underwent pure LLR, 31 were identified as having HA. Diagnosis was based on radiological evaluation and resections were performed for lesions measuring >5.0 cm. Results: The sample included 29 female and two male patients. Their mean age was 33.2 years. A total of 27 patients had a single lesion, one patient had two and one had four lesions. The two remaining patients had liver adenomatosis. Mean tumour size was 7.5 cm. Three right hepatectomies, 17 left lateral sectionectomies and 11 wedge resections or segmentectomies were performed. There was no need for blood transfusion or conversion to open surgery. Postoperative complications occurred in two patients. Mean hospital stay was 3.8 days. Conclusions: Hepatocellular adenoma should be regarded as an excellent indication for pure LLR. Pure LLR is safe and feasible and should be considered the standard of care for the treatment of HA when performed by surgeons with experience in liver and laparoscopic surgery.
- 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.
- Hepatic Epithelioid Hemangioendothelioma: An Unusual Lesion of the Liver(2012) LUPINACCI, Renato Micelli; ROCHA, Manoel de Souza; HERMAN, Paulo
- Prognostic implication of mucinous histology in resected colorectal cancer liver metastases(2014) LUPINACCI, Renato Micelli; MELLO, Evandro Sobroza; COELHO, Fabricio Ferreira; KRUGER, Jaime Arthur Pirolla; PERINI, Marcos Vinicius; PINHEIRO, Rafael S.; FONSECA, Gilton Marques; CECCONELLO, Ivan; HERMAN, PauloBackground. Colorectal mucinous adenocarcinoma (MAC) is a subtype of colorectal adenocarcinoma with prominent mucin production associated with proximal location of tumor, advanced stage at diagnosis, microsatellite instability, and BRAF mutation. The prognostic implication of MAC in colorectal cancer liver metastases (CRCLM) is unknown. The purpose of our study was to determine the frequency and elucidate the prognostic implication of mucinous histology in CRCLM. Methods. The medical records of 118 patients who underwent CRCLM resection between 2000 and 2010 were reviewed. Clinicopathologic variables and outcome parameters were examined. Resected specimens were submitted to routine histologic evaluation. Patients were grouped according to the metastasis mucinous content: >50%, MAC;.<50%, adenocarcinoma with intermediated mucinous component (AIM); and without any mucinous component, non-MAC (NMA). Results. Mean follow-up after resection was 37 months. Tumor recurrence was, observed in 75% of patients. Overall survival and disease-free survival rates after hepatectomy were 61%, 56%, and 26%, 24% at 3 and 5 years, respectively. Tumors with mucinous component (AIM and MAC) were related to proximal location of the primary tumor and were more frequently observed in females. Multivariate analysis revealed that MAC was an independent negative prognostic factor (hazard ratio, 3.13; 95% CI, 1.30-6.68; P = .011) compared with non-MAC (NMA and AIM). Conclusion. MAC has an adverse prognostic impact compared with NMA, which may influence therapeutic strategy raising an important subject for discussion and future investigation.
- 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].
- Intrahepatic Lymphatic Invasion but not Vascular Invasion is a Major Prognostic Factor after Resection of Colorectal Cancer Liver Metastases(2014) LUPINACCI, Renato Micelli; MELLO, Evandro Sobrosa; PINHEIRO, Rafael S.; MARQUES, Gilton; COELHO, Fabricio Ferreira; KRUGER, Jaime Arthur Pirolla; PERINI, Marcos Vinicius; HERMAN, PauloDespite advances in diagnosis and surgical strategies, up to 70 % of patients will develop recurrence of the disease after resection of colorectal cancer liver metastases (CRCLM). The purpose of our study was to determine the frequency of four different mechanisms of intrahepatic dissemination, and to evaluate the impact of each mechanism on patient outcomes. The medical records of 118 patients who underwent a first resection of CRCLM during the period between 2000 and 2010 were reviewed. Clinicopathologic variables and outcome parameters were examined. Resected specimens were submitted to routine histological evaluation, and immunohistochemical staining with D2-40 (lymphatic vessels), CD34 (blood vessels), CK-7 (biliary epithelium), and CK-20 (CRC cells). The mean follow-up after resection was 38 months. Tumor recurrence was observed in 76 patients, with a median interval of 13 months after resection. Overall survival and disease-free survival (DFS) rates after hepatectomy were 62 and 56 %, and 26 and 24 % at 3 and 5 years, respectively. Intrahepatic microscopic invasion included portal venous in 49 patients, sinusoidal in 43 patients, biliary in 20 patients, and lymphatic in 33 patients. Intra-hepatic lymphatic invasion was the only mechanism of dissemination independently associated with the risk of hepatic recurrence (odds ratio 2.75) and shorter DFS (p = 0.006). Intrahepatic lymphatic invasion is a significant prognostic factor. Other mechanisms of invasion, although frequently observed, are not related to recurrence or survival, suggesting that the lymphatic system is the main route for dissemination of CRCLM. Furthermore, immunohistochemical detection of intrahepatic lymphatic invasion might be of value in clinical practice.
- Video assisted resections. Increasing access to minimally invasive liver surgery?(2015) COELHO, Fabricio Ferreira; PERINI, Marcos Vinícius; KRUGER, Jaime Arthur Pirola; LUPINACCI, Renato Micelli; MAKDISSI, Fábio Ferrari; D'ALBUQUERQUE, Luiz Augusto Carneiro; CECCONELLO, Ivan; HERMAN, PauloObjective: To evaluate perioperative outcomes, safety and feasibility of video-assisted resection for primary and secondary liver lesions. Methods: From a prospective database, we analyzed the perioperative results (up to 90 days) of 25 consecutive patients undergoing video-assisted resections in the period between June 2007 and June 2013. Results : The mean age was 53.4 years (23-73) and 16 (64%) patients were female. Of the total, 84% were suffering from malignant diseases. We performed 33 resections (1 to 4 nodules per patient). The procedures performed were non-anatomical resections (n = 26), segmentectomy (n = 1), 2/3 bisegmentectomy (n = 1), 6/7 bisegmentectomy (n = 1), left hepatectomy (n = 2) and right hepatectomy (n = 2). The procedures contemplated postero-superior segments in 66.7%, requiring multiple or larger resections. The average operating time was 226 minutes (80-420), and anesthesia time, 360 minutes (200-630). The average size of resected nodes was 3.2 cm (0.8 to 10) and the surgical margins were free in all the analyzed specimens. Eight percent of patients needed blood transfusion and no case was converted to open surgery. The length of stay was 6.5 days (3-16). Postoperative complications occurred in 20% of patients, with no perioperative mortality. Conclusion : The video-assisted liver resection is feasible and safe and should be part of the liver surgeon armamentarium for resection of primary and secondary liver lesions.