Ligation of the middle hepatic vein to increase hypertrophy induction during the ALPPS procedure

Purpose Here, we analyse the technical modification of the ALPPS procedure, ligating the middle hepatic vein during the first step of the operation to enhance remnant liver hypertrophy. Methods In 20 of 37 ALPPS procedures, the middle hepatic vein was ligated during the first step. Hypertrophy of the functional remnant liver volume was assessed in addition to postoperative courses. Results Volumetric analysis showed a significant volume increase, especially for patients with colorectal metastases. Pre-existing liver parenchyma damage (odds ratio = 0.717, p = 0.017) and preoperative chemotherapy were found to be significant predictors (odds ratio = 0.803, p = 0.045) of higher morbidity and mortality. In addition, a survival benefit for maintenance of middle hepatic vein was shown. Conclusion This technical modification of the ALPPS procedure can accentuate future liver remnant volume hypertrophy. The higher morbidity and mortality observed are most likely associated with pre-existing parenchymal damage within this group.

Modified Oesophago-Gastric Dissociation (M-OGD) — a technical modification

Adhesions and fibrosis following failed primary surgery for severe gastro-oesophageal reflux (GOR) in neurologically impaired children (NI) can render mobilization of the lower oesophagus and oesophago-jejunal anastomosis a technically demanding exercise both at open surgery and laparoscopy. This paper presents the Modified Oesophago-Gastric Dissociation (M-OGD) as a less complex technical modification of the original Total Oesophago-Gastric Dissociation (TOGD). The stomach is detached from the oesophago-gastric junction with an articulated 5-mm stapler, leaving a 5-mm strip of stomach attached to the oesophagus. An end-to-side isoperistaltic oesophago-jejunostomy is created between the gastric stump and the isoperistaltic jejunal Roux loop. A jejuno-jejunal anastomosis restores bowel continuity. Between May 2018 and February 2020, M-OGD was performed on 3 NI patients with a weight of 9–27.3 kg (median = 14 kg). Median age at surgery was 60 months (18–180), median surgical time 170 min (146–280), median re-feeding time was 3 days (2–5), and median length of stay was 20 days (11–25). All patients healed primarily and after a median follow-up of 3 months, there were no problems related to the oesophago-jejunal anastomosis. M-OGD reduces the difficulties of redo oesophageal surgery following failed anti-reflux procedures, with a safer oesophago-jejunal anastomosis and a good long-term outcome.

An Expedited Transition to the Back Wall Suturing for Side-to-Side In Situ Microvascular Anastomosis: A Technique Update

BACKGROUND The side-to-side in situ microvascular anastomosis is an important tool in the cerebrovascular neurosurgeon's armamentarium. The execution of the side-to-side anastomosis, however, can be limited by the inability to acquire sufficient visualization and approximation of the recipient and donor vessels. OBJECTIVE To expedite the transition to the back wall suturing of the donor and recipient vessels during side-to-side in situ microvascular anastomosis. METHODS Incorporation of the first suture throw from the outside to the inside of the vessel lumen with the initial stay suture at the proximal apex of the arteriotomy is described. The apical knot is tied between one limb of the resultant loop and the free end of the suture. The remainder of side-to-side anastomosis can then be completed in a standard fashion starting from the inside of the lumen. RESULTS This modification allows for an expedited transition to the back wall suturing of the 2 arterial segments and avoids difficulties associated with taking the first bite from behind the knot at the proximal apex of the arteriotomy or the transfer of the needle between the approximated vessels. This updated technique is illustrated with a case example, illustration, and video. CONCLUSION This technical modification for the side-to-side anastomosis helps optimize microsurgical efficiency by limiting needle, suture, and vessel handling after the initial suture placement, which has classically been a challenge of this bypass.