Alexandru Barcu - Academia.edu (original) (raw)

Papers by Alexandru Barcu

Research paper thumbnail of The Survival Benefit of Repetitive Ultrasound-Guided Liver Resections in the Absence of Chemotherapy for Multiple Colorectal Recurrent Liver Metastases

Chirurgia, 2023

We present the case of a 54-year-old female patient, diagnosed with stage IV rectal cancer, with ... more We present the case of a 54-year-old female patient, diagnosed with stage IV rectal cancer, with multiple (12) synchronous liver metastases, the largest of 10 cm in diameter, bilobar distributed. The operative management consisted in simultaneous ultra-low robotic anterior resection with coloanal anastomosis (protected by ileostomy) and multiple ultrasound-guided non-anatomical liver resections (in open approach). The patient was unable to follow neoadjuvant and adjuvant chemotherapy due to the systemic side effects. The intrahepatic disease presented 2 episodes of recurrence, sanctioned by ultrasound-guided non-anatomical parenchyma sparing liver resections. In total 32 liver metastases were addressed (31 resected and 1 radiofrequency ablated). The patient presented 1 episode of lung recurrence, sanctioned by right superior lobectomy and lymphadenectomy for a singular metastasis. The patient died with disease progression both intra-, and extrahepatically after 34 months post first surgical intervention.

Research paper thumbnail of Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go?

Medicina-lithuania, Oct 10, 2022

This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY

Research paper thumbnail of Limited central hepatectomy for centrally located tumors under ultrasound-guidance: A feasible alternative to formal central hepatectomy

International Journal of Surgery, Mar 1, 2020

Background: Allografts and polytetrafluoroethylene (PTFE) grafts are suitable for middle hepatic ... more Background: Allografts and polytetrafluoroethylene (PTFE) grafts are suitable for middle hepatic vein (MHV) reconstruction during living donor liver transplantation (LDLT). We experienced other complications depending on the type of interposition graft. Methods: Variety of interposition grafts such as cadaveric cryopreserved vessels (iliac vein, iliac artery, and aorta) ringed PTFE graft has been used for middle hepatic vein reconstruction. Results: There were two migrations of the ringed PTPF to the adjacent organ, and there was one fistula of allograft, cryopreserved aorta from a cadaveric donor, to the duodenum. In the case of migrations, duodenoscopy detected ringed PTPF in the duodenal lumen without any symptom at several years later after LDLT. We operated to remove the migrated synthetic graft. The patient who had fistula of the graft to duodenum was admitted via the emergency room because of syncope at posttransplantation eight months. For the first time, we did not know the reason for syncope until melena was found. We separated the duodenum and allograft and performed a simple close of both. And gastrojejunostomy was done. They were discharged without any problem. Conclusion: Artificial graft and even allograft for middle hepatic vein reconstruction can make problem to the adjacent organ.

Research paper thumbnail of Isochoric Supercooling Organ Preservation System

Bioengineering

This technical paper introduces a novel organ preservation system based on isochoric (constant vo... more This technical paper introduces a novel organ preservation system based on isochoric (constant volume) supercooling. The system is designed to enhance the stability of the metastable supercooling state, offering potential long-term preservation of large biological organs at subfreezing temperatures without the need for cryoprotectant additives. Detailed technical designs and usage protocols are provided for researchers interested in exploring this field. The paper also presents a control system based on the thermodynamics of isochoric freezing, utilizing pressure monitoring for process control. Sham experiments were performed using whole pig liver sourced from a local food supplier to evaluate the system’s ability to sustain supercooling without ice nucleation for extended periods. The results demonstrated sustained supercooling without ice nucleation in pig liver tissue for 24 and 48 h. These findings suggest the potential of this technology for large-volume, cryoprotectant-free or...

Research paper thumbnail of Severe liver trauma with complex portal and common bile duct avulsion: A case report and review of the literature

World Journal of Clinical Cases

Research paper thumbnail of Intraoperative Imaging Techniques in Liver Surgery

The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases, 2022

Research paper thumbnail of Salvage Hepatectomy for Giant GIST Liver Metastases Unresponsive to Systemic Therapy—Case Report

Life

Therapeutic decision-making for advanced GIST liver metastases is challenging due to limited clin... more Therapeutic decision-making for advanced GIST liver metastases is challenging due to limited clinical evidence. This case study aims to demonstrate the survival benefit of resection in non-responsive cases. A 40-year-old male presented with abdominal pain, weight loss, altered general status, massive hepatomegaly, and intermittent melaena. He was diagnosed with stage IV GIST with the primary tumor in the ileal loop and multiple gigantic synchronous bilobar liver metastases. Despite 31 months of tyrosine-kinase inhibitor therapy post-primary tumor resection, the disease remained unresponsive. The patient was admitted to our tertiary center with significant hepatomegaly. A two-stage debulking liver resection was performed after a multidisciplinary team decision. The first operation debulked the left hemiliver through a non-anatomical ultrasound-guided resection of segments 2, 3, and 4. The second operation (7 weeks later) debulked the right hemiliver through a right posterior sectione...

Research paper thumbnail of An exploratory study on isochoric supercooling preservation of the pig liver

Biochemistry and Biophysics Reports

Research paper thumbnail of Surgical Treatment for Severe Liver Injuries

The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases, 2022

Research paper thumbnail of 313.6: Early Graft Disfunction After Hypothermic Oxygenated Machine Perfusion of ECD Criteria Liver Grafts: No Longer A Clinical Issue?

Research paper thumbnail of A two-compartment system for subfreezing temperatures preservation of large volumes of organic matter in an isochoric system

ABSTRACTThis is a technology paper on the design of and test results from an 11-liter isochoric (... more ABSTRACTThis is a technology paper on the design of and test results from an 11-liter isochoric (constant volume) chamber, for the preservation of large, organs in a supercooled state. Details of the design are given, as well as a proof that the chamber is isochoric. Five repeats show that in this large chamber, ice nucleation of steam distilled water occurs at – 2 °C within less than 12 hours, in all the repeats. An examination of the experimental results suggests that the ice nucleation starts on the inner walls of the isochoric chamber. A new two compartment isochoric chamber was designed to reduces the probability of ice nucleation on the walls of the chamber. In the two-compartment system, the biological matter and the preservation fluid are introduced in a sealed low-density polyethylene bag, and placed in the center of the isochoric chamber, in such a way that the bag does not touch the walls. The space between the inner walls of the isochoric chamber and the outer walls of t...

Research paper thumbnail of Surgical treatment for severe liver injuries: a single-center experience

Minerva chirurgica, 2020

BACKGROUND The liver is one of the most frequently injured organs in abdominal trauma. The advanc... more BACKGROUND The liver is one of the most frequently injured organs in abdominal trauma. The advancements in diagnosis and interventional therapy shifted the management of liver trauma towards a non-operative management (NOM). Nevertheless, in severe liver injuries (LI), surgical treatment often involving liver resection (LR) and rarely liver transplantation (LT) remains the main option. The present paper analyses a single center experience in a referral HPB center on a series of patients with high-grade liver trauma. METHODS Forty-five patients with severe LI, that benefitted from NOM (6 pts), LRs (38 pts), and LT (1 pt) performed in our center between June 2000 and June 2019, were included in a combined prospective and retrospective study. The median age of the patients was 29 years (median 33, range 10-76), and the male/female ratio of 33/12. Almost all cases had blunt trauma, except 2 with stab wound (4.4%). RESULTS LIs classified according to the American Association for the Surg...

Research paper thumbnail of Parenchyma Sparing ALPPS - A New Technical Variant. Case Presentation (with video)

Surgery, Gastroenterology and Oncology

Research paper thumbnail of Definitive Surgery for Liver Trauma in a Tertiary HPB Center (with video)

Research paper thumbnail of Limited Central Hepatectomy for Centrally Located Tumors: Is There a Place for Standardization?

Surgery, Gastroenterology and Oncology, 2019

Anatomical central hepatectomy is technically demanding and is often excessive. It has an increas... more Anatomical central hepatectomy is technically demanding and is often excessive. It has an increased risk for insufficient remnant liver volume, especially in case of P8 dorsal pedicle for segment 7 and/or P5 dorsal for segment 6, and/or abnormal background liver. On the contrary, limited central hepatectomy (LCH) for centrally located tumors, based on preserving the P8 dorsal and some of P5 and P4 pedicles (depending on tumor placement) is conservative, and therefore has a low risk for insufficient remnant liver volume. It is less technically demanding, when compared to anatomical central hepatectomy. The right side of the resection plane is driven along the P8 dorsal pedicle intersecting the P8 ventral pedicle and as few of the P5 pedicles as possible. The left side of the resection plane is established according to tumor placement anywhere in between the Cantlie's plane and the falciform ligament. The video presents 5 cases that support the conclusion that LCH may be standardized, with good results, especially when using intraoperative ultrasound guidance.

Research paper thumbnail of Intrahepatic Cholangiocarcinoma Involving the Hepatocaval Confluence with Bile Duct Tumor Thrombus Mimicking a Klatskin Tumor: A Case Report

Surgery, Gastroenterology and Oncology, 2018

Background: Intrahepatic cholangiocarcinoma (ICC) is a rare malignant tumor arising from the epit... more Background: Intrahepatic cholangiocarcinoma (ICC) is a rare malignant tumor arising from the epithelial cells of the intrahepatic bile ducts. The aim of the present paper is to report a rare case of centrally located ICC involving the hepatocaval confluence and generating a tumor thrombus in the biliary duct of segment 4 expanding into the left hepatic duct and main common duct, mimicking a type IIIB Klatskin tumor. Case presentation: A 66-year old female presented for epigastric abdominal pain and weight loss, with cytolysis (ALAT= 323 U/l; normal ASAT), high GGT (618 U/L), but normal phosphatase alkaline and bilirubin levels; CA 19-9 was elevated (257 U/mL), while CEA was normal. At dual-phase multi-detector CT and magnetic resonance cholangiopancreatography, a simultaneous ICC and type IIIB perihilar cholangiocarcinoma (Klatskin tumor) were diagnosed. Intraoperatively, the ICC located in segments 1, 4 and 8, infiltrating the left and middle hepatic veins and in contact with the right hepatic vein was confirmed, while the hilar lesion proved to be a bile duct tumor thrombus originating from the ICC. Consequently, a left hepatectomy extended to segments 1 and 8 with hilar approach, with en-bloc resection of main biliary duct, and hilar lymph node dissection was performed. The right hepatic vein and an accessory middle hepatic vein were preserved, accepting 0-mm resection margin at this level. The postoperative outcome was remarkably uneventful. Conclusion: Locally advanced ICC is a challenging presentation for both diagnosis and treatment, for which complex major liver resection is effective when performed in a high volume HPB center.

Research paper thumbnail of New criterion for borderline resectable pancreatic cancer: Invasion of a replaced right hepatic artery

Journal of Translational Medicine and Research, 2016

Background: Loco-regional invasion is not uncommon in a patient diagnosed with a pancreatic cance... more Background: Loco-regional invasion is not uncommon in a patient diagnosed with a pancreatic cancer. A negative resection margins pancreatectomy represents the most important determining factor of survival in patients resected for pancreatic adenocarcinoma. Thus, in order to increase resectability in such patients, extended pancreatectomies were proposed in so-called borderline resectable tumors, including venous, arterial or other surrounding organs removal. Case presentation: A 52-year old male, with pancreatic head cancer invasive into the portal vein and replaced right hepatic artery (rRHA)(from superior mesenteric artery), underwent pancreatico-duodenectomy (PD) with portal vein resection and reconstruction, segmental resection of the rRHA and associated right hemi-hepatectomy. Results: The postoperative outcome was remarkably uneventful except for a self-limited minor bile leak. Negative resection margins of the operative specimen were observed at pathological examination. Conclusion: Proper assessment of the presence and course of a rRHA prior to PD is mandatory for a safe surgery. Invasion of the rRHA is not a contraindication for resection in a patient with pancreatic head cancer and should be included among the borderline resection criteria. Associated right hemi-hepatectomy is a safe option for such a patient in order to achieve negative resection margins.

Research paper thumbnail of Intraoperative Ultrasound Guided Liver Resections: A Single Center Experience

Surgery, Gastroenterology and Oncology, 2018

Background: Liver resection (LR) is the standard treatment for most focal liver lesions. Intraope... more Background: Liver resection (LR) is the standard treatment for most focal liver lesions. Intraoperative ultrasound (IOUS) improves their diagnosis and guides the liver resection. The present paper analyses our experience in IOUS guided LR, reviewing the indications, surgical techniques, and the short-term results. Material and Method: 198 LRs guided by IOUS in 186 patients operated in our center between January 2013 and December 2017 were included in a combined prospective and retrospective study. The median age of the patients was 60 years (mean 57, range 16-79), with a male/female ratio of 109/77, and adult/pediatric patient ratio of 185/1. Results: Malignant lesions were the main indication for IOUS guided LR (164 LRs; 82.8%); among these, colorectal liver metastases were the main indication (66 LRs; 33.3%), followed by hepatocellular carcinoma (44 cases, 22.2%). The mean number of tumors was 3 (range 1-16), and the median diameter of the largest tumor was 40 mm (mean 51; range 3-240). IOUS found new lesions in 22.3% of cases operated for liver metastases (46 LRs), and changed the surgical strategy in 41.9% of cases (83 LRs). Major resection rate was 18.2% (36 LRs); anatomical LRs were performed in 18 cases (9.1%). The median operative time was 330 minutes (mean 334; range 90-920). The median blood loss was 700 ml (mean 900; range 250-9500), with a transfusion rate of 54.8% (108 LRs). Overall and major complication rates were 46.5% (92 LRs) and 7.6% (15 LRs), respectively, while the mortality rate was 2% (4 pts). Conclusion: IOUS should be fully integrated in the modern liver surgery, providing improved diagnosis and optimal resection guidance, increasing resectability and surgical safety, with low perioperative morbidity and mortality.

Research paper thumbnail of Parenchyma Sparing ALPPS Ultrasound Guided Partition Through Segment 4 to Maximize Resectability (with video)

Chirurgia

Asocierea partiţiei hepatice şi a ligaturii venei porte (ALPPS) a evoluat ca strategie de tratame... more Asocierea partiţiei hepatice şi a ligaturii venei porte (ALPPS) a evoluat ca strategie de tratament pentru pacienţii cu tumori hepatice care nu sunt eligibili pentru hepatectomie din cauza unui volum hepatic restant (VHR) cu volum insuficient. Scopul acestui studiu a fost acela de a testa aplicabilitatea unei proceduri chirurgicale care combină conceptul chirurgiei rezective conservatorii cu cel al ALPPS, prin deplasarea planului de transecţie prin segmentul 4, în favoarea VHR, rezultând o nouă variantă tehnică a ALPPS, intitulată parenchyma sparing ALPPS (psALPPS). Pacienţii care nu au fost eligibili pentru ALPPS cu trisecţionectomie dreaptă, din cauza VHR insuficient, au fost consideraţi eligibili pentru psALPPS, constând cu partiţie hepatică prin segmentul 4 folosind ghidaj ecografic. Între aprilie 2017 şi aprilie 2021, cinci pacienţi cu vârsta medie de 68 de ani (interval: 66-78), patru bărbaţi şi o femeie, au beneficiat de psALPPS pentru metastaze hepatice colo-rectale (N=2), colangiocarcinom intrahepatic (N=2) şi carcinom hepatocelular (N=1). VHR standardizat (sVHR) pentru segmentele 2-3 înainte de intervenţia chirurgicală în stadiul 1 ar fi fost în medie de 11,6%. PsALPPS a obţinut chiar şi dublarea sVHR la etapa 1, rezultând o creştere a ps-sVHR de la o medie de Chirurgia (Bucur).

Research paper thumbnail of En-Bloc Complete Segment 1 Resection and Left Hepatectomy for Klatskin Tumor

Chirurgia

En-Bloc Complete Segment 1 Resection and Left Hepatectomy for Klatskin Tumor Chirurgia, 116 (5), ... more En-Bloc Complete Segment 1 Resection and Left Hepatectomy for Klatskin Tumor Chirurgia, 116 (5), 2021 www.revistachirurgia.ro 635 să fie evaluată întotdeauna infiltrarea căii biliare pentru segmentul 1. Dacă este prezentă, întregul segment 1 trebuie îndepărtat pentru a obţine un rezultat oncologic optim. rezecţie hepatică, ghidaj prin ecografie intraoperatorie, tumora Klatskin, hemihepatectomie extinsă la întreg segmentul 1

Research paper thumbnail of The Survival Benefit of Repetitive Ultrasound-Guided Liver Resections in the Absence of Chemotherapy for Multiple Colorectal Recurrent Liver Metastases

Chirurgia, 2023

We present the case of a 54-year-old female patient, diagnosed with stage IV rectal cancer, with ... more We present the case of a 54-year-old female patient, diagnosed with stage IV rectal cancer, with multiple (12) synchronous liver metastases, the largest of 10 cm in diameter, bilobar distributed. The operative management consisted in simultaneous ultra-low robotic anterior resection with coloanal anastomosis (protected by ileostomy) and multiple ultrasound-guided non-anatomical liver resections (in open approach). The patient was unable to follow neoadjuvant and adjuvant chemotherapy due to the systemic side effects. The intrahepatic disease presented 2 episodes of recurrence, sanctioned by ultrasound-guided non-anatomical parenchyma sparing liver resections. In total 32 liver metastases were addressed (31 resected and 1 radiofrequency ablated). The patient presented 1 episode of lung recurrence, sanctioned by right superior lobectomy and lymphadenectomy for a singular metastasis. The patient died with disease progression both intra-, and extrahepatically after 34 months post first surgical intervention.

Research paper thumbnail of Parenchyma-Sparing Liver Resection or Regenerative Liver Surgery: Which Way to Go?

Medicina-lithuania, Oct 10, 2022

This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY

Research paper thumbnail of Limited central hepatectomy for centrally located tumors under ultrasound-guidance: A feasible alternative to formal central hepatectomy

International Journal of Surgery, Mar 1, 2020

Background: Allografts and polytetrafluoroethylene (PTFE) grafts are suitable for middle hepatic ... more Background: Allografts and polytetrafluoroethylene (PTFE) grafts are suitable for middle hepatic vein (MHV) reconstruction during living donor liver transplantation (LDLT). We experienced other complications depending on the type of interposition graft. Methods: Variety of interposition grafts such as cadaveric cryopreserved vessels (iliac vein, iliac artery, and aorta) ringed PTFE graft has been used for middle hepatic vein reconstruction. Results: There were two migrations of the ringed PTPF to the adjacent organ, and there was one fistula of allograft, cryopreserved aorta from a cadaveric donor, to the duodenum. In the case of migrations, duodenoscopy detected ringed PTPF in the duodenal lumen without any symptom at several years later after LDLT. We operated to remove the migrated synthetic graft. The patient who had fistula of the graft to duodenum was admitted via the emergency room because of syncope at posttransplantation eight months. For the first time, we did not know the reason for syncope until melena was found. We separated the duodenum and allograft and performed a simple close of both. And gastrojejunostomy was done. They were discharged without any problem. Conclusion: Artificial graft and even allograft for middle hepatic vein reconstruction can make problem to the adjacent organ.

Research paper thumbnail of Isochoric Supercooling Organ Preservation System

Bioengineering

This technical paper introduces a novel organ preservation system based on isochoric (constant vo... more This technical paper introduces a novel organ preservation system based on isochoric (constant volume) supercooling. The system is designed to enhance the stability of the metastable supercooling state, offering potential long-term preservation of large biological organs at subfreezing temperatures without the need for cryoprotectant additives. Detailed technical designs and usage protocols are provided for researchers interested in exploring this field. The paper also presents a control system based on the thermodynamics of isochoric freezing, utilizing pressure monitoring for process control. Sham experiments were performed using whole pig liver sourced from a local food supplier to evaluate the system’s ability to sustain supercooling without ice nucleation for extended periods. The results demonstrated sustained supercooling without ice nucleation in pig liver tissue for 24 and 48 h. These findings suggest the potential of this technology for large-volume, cryoprotectant-free or...

Research paper thumbnail of Severe liver trauma with complex portal and common bile duct avulsion: A case report and review of the literature

World Journal of Clinical Cases

Research paper thumbnail of Intraoperative Imaging Techniques in Liver Surgery

The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases, 2022

Research paper thumbnail of Salvage Hepatectomy for Giant GIST Liver Metastases Unresponsive to Systemic Therapy—Case Report

Life

Therapeutic decision-making for advanced GIST liver metastases is challenging due to limited clin... more Therapeutic decision-making for advanced GIST liver metastases is challenging due to limited clinical evidence. This case study aims to demonstrate the survival benefit of resection in non-responsive cases. A 40-year-old male presented with abdominal pain, weight loss, altered general status, massive hepatomegaly, and intermittent melaena. He was diagnosed with stage IV GIST with the primary tumor in the ileal loop and multiple gigantic synchronous bilobar liver metastases. Despite 31 months of tyrosine-kinase inhibitor therapy post-primary tumor resection, the disease remained unresponsive. The patient was admitted to our tertiary center with significant hepatomegaly. A two-stage debulking liver resection was performed after a multidisciplinary team decision. The first operation debulked the left hemiliver through a non-anatomical ultrasound-guided resection of segments 2, 3, and 4. The second operation (7 weeks later) debulked the right hemiliver through a right posterior sectione...

Research paper thumbnail of An exploratory study on isochoric supercooling preservation of the pig liver

Biochemistry and Biophysics Reports

Research paper thumbnail of Surgical Treatment for Severe Liver Injuries

The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases, 2022

Research paper thumbnail of 313.6: Early Graft Disfunction After Hypothermic Oxygenated Machine Perfusion of ECD Criteria Liver Grafts: No Longer A Clinical Issue?

Research paper thumbnail of A two-compartment system for subfreezing temperatures preservation of large volumes of organic matter in an isochoric system

ABSTRACTThis is a technology paper on the design of and test results from an 11-liter isochoric (... more ABSTRACTThis is a technology paper on the design of and test results from an 11-liter isochoric (constant volume) chamber, for the preservation of large, organs in a supercooled state. Details of the design are given, as well as a proof that the chamber is isochoric. Five repeats show that in this large chamber, ice nucleation of steam distilled water occurs at – 2 °C within less than 12 hours, in all the repeats. An examination of the experimental results suggests that the ice nucleation starts on the inner walls of the isochoric chamber. A new two compartment isochoric chamber was designed to reduces the probability of ice nucleation on the walls of the chamber. In the two-compartment system, the biological matter and the preservation fluid are introduced in a sealed low-density polyethylene bag, and placed in the center of the isochoric chamber, in such a way that the bag does not touch the walls. The space between the inner walls of the isochoric chamber and the outer walls of t...

Research paper thumbnail of Surgical treatment for severe liver injuries: a single-center experience

Minerva chirurgica, 2020

BACKGROUND The liver is one of the most frequently injured organs in abdominal trauma. The advanc... more BACKGROUND The liver is one of the most frequently injured organs in abdominal trauma. The advancements in diagnosis and interventional therapy shifted the management of liver trauma towards a non-operative management (NOM). Nevertheless, in severe liver injuries (LI), surgical treatment often involving liver resection (LR) and rarely liver transplantation (LT) remains the main option. The present paper analyses a single center experience in a referral HPB center on a series of patients with high-grade liver trauma. METHODS Forty-five patients with severe LI, that benefitted from NOM (6 pts), LRs (38 pts), and LT (1 pt) performed in our center between June 2000 and June 2019, were included in a combined prospective and retrospective study. The median age of the patients was 29 years (median 33, range 10-76), and the male/female ratio of 33/12. Almost all cases had blunt trauma, except 2 with stab wound (4.4%). RESULTS LIs classified according to the American Association for the Surg...

Research paper thumbnail of Parenchyma Sparing ALPPS - A New Technical Variant. Case Presentation (with video)

Surgery, Gastroenterology and Oncology

Research paper thumbnail of Definitive Surgery for Liver Trauma in a Tertiary HPB Center (with video)

Research paper thumbnail of Limited Central Hepatectomy for Centrally Located Tumors: Is There a Place for Standardization?

Surgery, Gastroenterology and Oncology, 2019

Anatomical central hepatectomy is technically demanding and is often excessive. It has an increas... more Anatomical central hepatectomy is technically demanding and is often excessive. It has an increased risk for insufficient remnant liver volume, especially in case of P8 dorsal pedicle for segment 7 and/or P5 dorsal for segment 6, and/or abnormal background liver. On the contrary, limited central hepatectomy (LCH) for centrally located tumors, based on preserving the P8 dorsal and some of P5 and P4 pedicles (depending on tumor placement) is conservative, and therefore has a low risk for insufficient remnant liver volume. It is less technically demanding, when compared to anatomical central hepatectomy. The right side of the resection plane is driven along the P8 dorsal pedicle intersecting the P8 ventral pedicle and as few of the P5 pedicles as possible. The left side of the resection plane is established according to tumor placement anywhere in between the Cantlie's plane and the falciform ligament. The video presents 5 cases that support the conclusion that LCH may be standardized, with good results, especially when using intraoperative ultrasound guidance.

Research paper thumbnail of Intrahepatic Cholangiocarcinoma Involving the Hepatocaval Confluence with Bile Duct Tumor Thrombus Mimicking a Klatskin Tumor: A Case Report

Surgery, Gastroenterology and Oncology, 2018

Background: Intrahepatic cholangiocarcinoma (ICC) is a rare malignant tumor arising from the epit... more Background: Intrahepatic cholangiocarcinoma (ICC) is a rare malignant tumor arising from the epithelial cells of the intrahepatic bile ducts. The aim of the present paper is to report a rare case of centrally located ICC involving the hepatocaval confluence and generating a tumor thrombus in the biliary duct of segment 4 expanding into the left hepatic duct and main common duct, mimicking a type IIIB Klatskin tumor. Case presentation: A 66-year old female presented for epigastric abdominal pain and weight loss, with cytolysis (ALAT= 323 U/l; normal ASAT), high GGT (618 U/L), but normal phosphatase alkaline and bilirubin levels; CA 19-9 was elevated (257 U/mL), while CEA was normal. At dual-phase multi-detector CT and magnetic resonance cholangiopancreatography, a simultaneous ICC and type IIIB perihilar cholangiocarcinoma (Klatskin tumor) were diagnosed. Intraoperatively, the ICC located in segments 1, 4 and 8, infiltrating the left and middle hepatic veins and in contact with the right hepatic vein was confirmed, while the hilar lesion proved to be a bile duct tumor thrombus originating from the ICC. Consequently, a left hepatectomy extended to segments 1 and 8 with hilar approach, with en-bloc resection of main biliary duct, and hilar lymph node dissection was performed. The right hepatic vein and an accessory middle hepatic vein were preserved, accepting 0-mm resection margin at this level. The postoperative outcome was remarkably uneventful. Conclusion: Locally advanced ICC is a challenging presentation for both diagnosis and treatment, for which complex major liver resection is effective when performed in a high volume HPB center.

Research paper thumbnail of New criterion for borderline resectable pancreatic cancer: Invasion of a replaced right hepatic artery

Journal of Translational Medicine and Research, 2016

Background: Loco-regional invasion is not uncommon in a patient diagnosed with a pancreatic cance... more Background: Loco-regional invasion is not uncommon in a patient diagnosed with a pancreatic cancer. A negative resection margins pancreatectomy represents the most important determining factor of survival in patients resected for pancreatic adenocarcinoma. Thus, in order to increase resectability in such patients, extended pancreatectomies were proposed in so-called borderline resectable tumors, including venous, arterial or other surrounding organs removal. Case presentation: A 52-year old male, with pancreatic head cancer invasive into the portal vein and replaced right hepatic artery (rRHA)(from superior mesenteric artery), underwent pancreatico-duodenectomy (PD) with portal vein resection and reconstruction, segmental resection of the rRHA and associated right hemi-hepatectomy. Results: The postoperative outcome was remarkably uneventful except for a self-limited minor bile leak. Negative resection margins of the operative specimen were observed at pathological examination. Conclusion: Proper assessment of the presence and course of a rRHA prior to PD is mandatory for a safe surgery. Invasion of the rRHA is not a contraindication for resection in a patient with pancreatic head cancer and should be included among the borderline resection criteria. Associated right hemi-hepatectomy is a safe option for such a patient in order to achieve negative resection margins.

Research paper thumbnail of Intraoperative Ultrasound Guided Liver Resections: A Single Center Experience

Surgery, Gastroenterology and Oncology, 2018

Background: Liver resection (LR) is the standard treatment for most focal liver lesions. Intraope... more Background: Liver resection (LR) is the standard treatment for most focal liver lesions. Intraoperative ultrasound (IOUS) improves their diagnosis and guides the liver resection. The present paper analyses our experience in IOUS guided LR, reviewing the indications, surgical techniques, and the short-term results. Material and Method: 198 LRs guided by IOUS in 186 patients operated in our center between January 2013 and December 2017 were included in a combined prospective and retrospective study. The median age of the patients was 60 years (mean 57, range 16-79), with a male/female ratio of 109/77, and adult/pediatric patient ratio of 185/1. Results: Malignant lesions were the main indication for IOUS guided LR (164 LRs; 82.8%); among these, colorectal liver metastases were the main indication (66 LRs; 33.3%), followed by hepatocellular carcinoma (44 cases, 22.2%). The mean number of tumors was 3 (range 1-16), and the median diameter of the largest tumor was 40 mm (mean 51; range 3-240). IOUS found new lesions in 22.3% of cases operated for liver metastases (46 LRs), and changed the surgical strategy in 41.9% of cases (83 LRs). Major resection rate was 18.2% (36 LRs); anatomical LRs were performed in 18 cases (9.1%). The median operative time was 330 minutes (mean 334; range 90-920). The median blood loss was 700 ml (mean 900; range 250-9500), with a transfusion rate of 54.8% (108 LRs). Overall and major complication rates were 46.5% (92 LRs) and 7.6% (15 LRs), respectively, while the mortality rate was 2% (4 pts). Conclusion: IOUS should be fully integrated in the modern liver surgery, providing improved diagnosis and optimal resection guidance, increasing resectability and surgical safety, with low perioperative morbidity and mortality.

Research paper thumbnail of Parenchyma Sparing ALPPS Ultrasound Guided Partition Through Segment 4 to Maximize Resectability (with video)

Chirurgia

Asocierea partiţiei hepatice şi a ligaturii venei porte (ALPPS) a evoluat ca strategie de tratame... more Asocierea partiţiei hepatice şi a ligaturii venei porte (ALPPS) a evoluat ca strategie de tratament pentru pacienţii cu tumori hepatice care nu sunt eligibili pentru hepatectomie din cauza unui volum hepatic restant (VHR) cu volum insuficient. Scopul acestui studiu a fost acela de a testa aplicabilitatea unei proceduri chirurgicale care combină conceptul chirurgiei rezective conservatorii cu cel al ALPPS, prin deplasarea planului de transecţie prin segmentul 4, în favoarea VHR, rezultând o nouă variantă tehnică a ALPPS, intitulată parenchyma sparing ALPPS (psALPPS). Pacienţii care nu au fost eligibili pentru ALPPS cu trisecţionectomie dreaptă, din cauza VHR insuficient, au fost consideraţi eligibili pentru psALPPS, constând cu partiţie hepatică prin segmentul 4 folosind ghidaj ecografic. Între aprilie 2017 şi aprilie 2021, cinci pacienţi cu vârsta medie de 68 de ani (interval: 66-78), patru bărbaţi şi o femeie, au beneficiat de psALPPS pentru metastaze hepatice colo-rectale (N=2), colangiocarcinom intrahepatic (N=2) şi carcinom hepatocelular (N=1). VHR standardizat (sVHR) pentru segmentele 2-3 înainte de intervenţia chirurgicală în stadiul 1 ar fi fost în medie de 11,6%. PsALPPS a obţinut chiar şi dublarea sVHR la etapa 1, rezultând o creştere a ps-sVHR de la o medie de Chirurgia (Bucur).

Research paper thumbnail of En-Bloc Complete Segment 1 Resection and Left Hepatectomy for Klatskin Tumor

Chirurgia

En-Bloc Complete Segment 1 Resection and Left Hepatectomy for Klatskin Tumor Chirurgia, 116 (5), ... more En-Bloc Complete Segment 1 Resection and Left Hepatectomy for Klatskin Tumor Chirurgia, 116 (5), 2021 www.revistachirurgia.ro 635 să fie evaluată întotdeauna infiltrarea căii biliare pentru segmentul 1. Dacă este prezentă, întregul segment 1 trebuie îndepărtat pentru a obţine un rezultat oncologic optim. rezecţie hepatică, ghidaj prin ecografie intraoperatorie, tumora Klatskin, hemihepatectomie extinsă la întreg segmentul 1