Research Spotlight

Moisan, F., B. Gayet, M. A. Ward, N. Tabchouri and D. Fuks (2018). “Segment 7 Laparoscopic Liver Resection: Is It Possible to Resect When Metastatic Lesions Border Suprahepatic Veins?” J Gastrointest Surg. May 31. [Epub ahead of print].

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INTRODUCTION: After nearly 25 years of experience, laparoscopic liver resection (LLR) is now recognized as being feasible and safe.1 However, laparoscopic resections of the posterosuperior segments are more technically demanding. They are associated with higher conversions rates, more intraoperative bleeding, and increased operating time.2 Appropriate training is required to approach these resections safely.3 This video demonstrates the technical maneuvers to laparoscopically approach a segment 7 tumor in contact with the right supra hepatic vein. METHOD: The pertinent aspect to perform a segment 7 metastasis resection using minimally invasive techniques is shown. The main steps of this operation include (1) complete release of the right liver from the coronary and triangular ligament, (2) dissection of the retrohepatic vena cava and transection of the hepatocaval ligament, (3) the use of intercostal trocars for direct vision of the inferior vena cava and the right suprahepatic vein,4,5 (4) the use of intraoperative ultrasound to evaluate the position and limits of vascular structures compared to the lesion, (5) careful transection of the hepatic parenchyma, and (6) dissection of the right hepatic vein to separate it from the lesion. RESULTS: The surgery was performed in a 68-year-old male patient. The patient developed synchronous metastases to the liver from a sigmoid colon tumor. Two lesions were identified; a 15 mm subcapsular lesion located in segment 5 and a 45 mm lesion located in segment 7 in contact with the right hepatic vein and inferior vena cava confluence. Previously, laparoscopic sigmoidectomy was performed without complications (TNM classification of the specimen: T3N0, with 31 resected lymph nodes, KRAS gene mutated). Following chemotherapy with FOLFOX + bevacizumab, a good response to the liver lesion was noted on imaging. Subsequently, a laparoscopic resection of the metastases in segment 7 and 5 was performed. The surgery lasted 210 min, intraoperative blood loss was 200 cm(3), no Pringle maneuver was required, and the postoperative period was uneventful with the patient being discharged on postoperative day number four. Pathology of the liver specimens confirmed metastases from colon adenocarcinoma with free surgical margins. DISCUSSION: Some important points achieving easier and safer approach of the posterior segments of the liver by laparoscopic route should be discussed. First, the patient’s semi-lateral position showed in the video allows placing the ports and the optic in a more comfortable position since the lateral portion of the abdominal and thoracic wall becomes anterior. Another important point is the complete liberation of the hepatorenal, falciform, triangular, and right coronary ligaments in order to fully mobilize the liver and convert a segment that is posterior in the anatomical position to an anterior segment for the surgeon. And finally, the use of intercostal trocars that allows a direct and perpendicular view of the right hepatic vein and vena cava represents the most important point. Interestingly, these specific trocars should be inserted through the pleural cavity, during a forced expiration or apnea to avoid lung injury. In this context, the trocar balloon helps the surgeon to avoid displacement or that pneumoperitoneum enters the pleural cavity. At the end of the procedure, we strongly recommend to stitch laparoscopically these diaphragmatic openings after removing the trocars in order to avoid migration of abdominal fluid or bowel incarceration into the pleural cavity during the postoperative period and also to avoid future diaphragmatic hernia. In the present case, the parenchymal transection was performed with Thunderbeat (Olympus(R), Japan), a device integrating both ultrasound dissection and advanced bipolar energy. We use this device because it saves time by sealing vessels up to 7 mm in diameter avoiding the need to use clips in the majority of intrahepatic veins and portal branches. However, currently, several techniques and devices are equivalent for parenchymal transection in laparoscopic liver resection and should be left to the surgeon’s preference, as in open liver procedures. CONCLUSION: Using laparoscopy to remove lesions in the posterior segments of the liver is safe and feasible. Vision from transthoracic port has the added benefit of making the dissection of right hepatic vein and inferior vena cava safer. Mastery of the anatomy is paramount before attempting this approach with minimally invasive techniques. Surgeons who attempt this operation should have expertise with both laparoscopy and liver surgery.

Mehta, N. N., D. B. Shin, A. A. Joshi, A. K. Dey, A. W. Armstrong, K. C. Duffin, Z. C. Fuxench, C. L. Harrington, R. A. Hubbard, R. E. Kalb, A. Menter, D. J. Rader, M. P. Reilly, E. L. Simpson, J. Takeshita, D. A. Torigian, T. J. Werner, A. B. Troxel, S. K. Tyring, S. B. Vanderbeek, A. S. Van Voorhees, M. P. Playford, M. A. Ahlman, A. Alavi and J. M. Gelfand (2018). “Effect of 2 Psoriasis Treatments on Vascular Inflammation and Novel Inflammatory Cardiovascular Biomarkers: A Randomized Placebo-Controlled Trial.” Circ Cardiovasc Imaging 11(6): e007394.

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BACKGROUND: Psoriasis is a chronic inflammatory disease associated with dyslipidemia, cardiovascular events, and mortality. We aimed to assess and compare the effect of treatment of moderate-to-severe psoriasis with adalimumab or phototherapy on vascular inflammation and cardiovascular biomarkers. METHODS AND RESULTS: Randomized, double-blind, trial of adalimumab, phototherapy, and placebo (1:1:1) for 12 weeks, with crossover to adalimumab for 52 weeks total. Outcomes included vascular inflammation by (18)F-fluorodeoxyglucose positron emission tomography/computed tomography and biomarkers of inflammation, insulin resistance, and lipoproteins. Ninety-seven patients were randomized, 92 completed the randomized controlled trial portion; 81 entered the adalimumab extension with 61 completing 52 weeks of adalimumab. There was no difference in change in vascular inflammation at week 12 in the adalimumab group (change compared with placebo, 0.64%; 95% confidence interval, -5.84% to 7.12%) or the phototherapy group (-1.60%; 95% confidence interval, -6.78% to 3.59%) or after 52-week adalimumab treatment (0.02% compared with initiation; 95% confidence interval, -2.85% to 2.90%). Both adalimumab and phototherapy decreased inflammation by serum CRP, interleukin-6. Only adalimumab reduced tumor necrosis factor and glycoprotein acetylation at 12 and 52 weeks. Neither had an impact on metabolic markers (insulin, adiponectin, and leptin). Only phototherapy increased high-density lipoprotein-p at 12 weeks. At 52-week of adalimumab cholesterol efflux and high-density lipoprotein-p were reduced. CONCLUSIONS: Adalimumab reduced key markers of inflammation including glycoprotein acetylation compared with phototherapy with no effect on glucose metabolism and vascular inflammation, and potential adverse effects on high-density lipoprotein. Glycoprotein acetylation improvement may partially explain the beneficial effects of adalimumab seen in observational studies. Larger studies with more detailed phenotyping of vascular disease should assess the comparative differences in the effects of adalimumab and phototherapy seen in our study. CLINICAL TRIAL REGISTRATION: NCT01866592 and NCT01553058.

McKenna, G. J. (2018). “Medication Tradeoffs – Not All Noncompliance Is What It Seems.” Transpl Int. May 15. [Epub ahead of print].

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Admit it. More than once, you’ve scanned a transplant journal, searching for a novel topic, something different from the many ubiquitous registry reviews. You hope you can find something topical, relevant for your patients and timely to current events. You probably didn’t even realize this issue of Transplant International would be the one containing that very topical, relevant and timely manuscript.

McCullough, P. A. (2018). “Editorial: Robertsonian Perspectives on Atherosclerosis: The Power of Direct Observation.” Am J Cardiol 121(11): 1441.

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The contributions of William C. Roberts, MD, to the field of cardiovascular disease have been immense and he has already made a lasting impact of the history of medicine. His study in this issue of Journal discloses highlights from 50 years of studying atherosclerosis in the most intimate manner—by direct examination. Anatomic pathology and histology allow an investigator to create clean lines of inference by asking and answering questions within the bounds of what is observable. This avoids extrapolation beyond the range of the data and is less likely to lead to forms of bias and ultimately reduces the chances of rendering false conclusions. Using direct observation over a very long period of time with a disciplined methodical approach also leads to the discovery of “principles.” When sufficiently strong, these principles can be the basis of future hypothesis testing, clinical strategies for diagnosis, prognosis, and ultimately patient management. In the present study, Roberts addresses 15 questions related to atherosclerosis and its management from which several important principles can be appreciated . . . In cardiovascular medicine, Dr. William C. Roberts, MD, is truly a luminary and we are indebted to his long-standing service. His methods of observation and discipline in defining clinical conditions have kept conclusions within the range of the data, and the resultant impact on our field has been not only vast, but foundational. (Excerpt from Commentary on Quantitative extent of atherosclerotic plaque in major epicardial coronary arteries in patients with fatal coronary heart disease, in coronary endarterectomy specimens in patients with non-fatal coronary artery disease, in aorta-coronary saphenous venous conduits, and means to prevent plaques: a review after studying the coronary arteries for 50 years, W. C. Roberts, Am J Cardiol, 121 (2018).)

Mack, M. J., A. Vasudevan and M. Hamandi (2018). “TAVR in younger patients with aortic stenosis: anything new?” EuroIntervention 14(1): 29-30.

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Transcatheter aortic valve replacement (TAVR) has been shown to be non-inferior to surgical aortic valve replacement (SAVR) in multiple randomised trials in high- and intermediate-risk patients. Most patients studied in these randomised trials were elderly, being for the most part in their late seventies and early eighties in age. Two trials in lower-risk patients which have recently completed enrolment in the USA presumably include younger patients. However, the results of those trials will not be available until mid 2019. In this issue of EuroIntervention, Eggebrecht and colleagues have attempted to shed some light on the outcomes of TAVR compared with SAVR in younger patients prior to the availability of those trial reports . . . In summary, there is little if any new information obtained in this study that helps to inform clinical practice. The cardiology and cardiac surgery community would be better off waiting for the outcomes of randomised trials in lower-risk and presumably younger patients before changing current practice in younger patients. Despite the efforts of the study investigators, there is nothing new here to inform the clinician. (Excerpts from text, p. 29-30; no abstract available.)