Rapid liver regeneration with ALPPS might be associated with hepatocyte proliferation induced by mTOR pathway activation.

BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

Laparoscopic Nissen Fundoplication fails in almost 15% of patients and most of them must be re-operated in order to improve reflux symptoms, esophagitis, or hiatal hernia. Surgical options are to redo LNF, distal gastrectomy alone or combination of both procedures. Redoing LNF, is associated with high rate of postoperative complications and re-failure. Purpose To present the early and medium-term postoperative outcomes of patients submitted to Laparoscopic Toupet Fundoplication combined with Distal Gastrectomy with Roux-en-Y gastrojejunostomy. Methods prospective study including 23 patients submitted to Laparoscopic Nissen Fundoplication who presented recurrence of gastroesophageal reflux after the operation. They were studied with endoscopy, barium swallow, manometry and 24 h pH monitoring in order to determine presence of esophagitis, anatomical deformities, defective Lower Esophageal Sphincter and pathologic acid reflux. Surgical process consisted on re-establishing the anatomy of the esophago-gastric junction, and then perform laparoscopic Toupet fundoplication combined with distal gastrecvtomy and Roux Y gastrojejunostomy. Results After surgery statistically significant improvement regarding heartburn (p < 0.0001), dysphagia (p < 0.0001) and retrosternal chest pain (p < 0.0001) as well as in the endoscopic esophagitis was observed. No significant LES pressure increase after the operation was observed. (from 7.88 + 2.7 to 10.5 + 3.36) (p = 0.15), but the abnormal acid reflux improved significantly after the reoperation, %time pH < 4 decreases from 12.00 + 6.62 to 4.3 + 4.04 (0.0004) and DeMeester score from 44.82 + 21.8 to 11.95 + 5.14 (0.0008) respectively. Conclusion The proposed procedure is safe option to treat successfully patients after failed Nissen fundoplication. Reflux symptoms, esophagitis, presence oh hiatal hernia and reflux score improved after the procedure.

The portal pedicles are wrapped in connective tissue known as the Walaeus sheath, which are abutting Laennec's capsule covering the liver parenchyma. Precise knowledge of this anatomic relationship allows for dissection of this interspace and early control of segmental portal pedicle (Glissonian Pedicle Transection Method (GPTM)). Subsequent systemic administration of Indocyanine Green (ICG) leads to negative counterstaining of the to be resected segment. Methods: A 60 year old healthy female patient with invasive lobular breast cancer, grade 2, ER+, PR+, Her-2 neg, Ki-67 80%, cT2N0M1. A synchronous solitary breast cancer liver metastasis was diagnosed at the border between segments 6 and 7. After treatment with Letrozole and Palbociclib for one year achieving stable disease, the patient was considered for liver metastasectomy. Results: With the patient in the French Position and following intraoperative liver ultrasound, after lowering the hilar plate, the portal pedicle of segment 6 was dissected out using GPTM approach. After test-clamping, an appropriate demarcation was observed and ICG administered systemically. This led to negative counterstaining of segment 6 and allowed for precise anatomic dissection under near-infrared vision. Conclusion: Laparoscopic application of GPTM facilitates anatomically precise liver resection through early pedicle control. Negative counterstaining using ICG under nearinfrared vision leads to visual enhancement of the anatomically precise borders. They typically do not follow straight lines and are therefore difficult to precisely dissect. ICG counterstaining reveals patient specific anatomic variations that would be a challenge to determine especially laparoscopically.