Giant hepatic hydatid cyst： A case report

Large type 1 cysts are prone to perforation. Furthermore, insufficient drainage with subsequent abscess is a frequent problem of large cysts. We report here a case of a 19-year old man who was admitted to the hospital with pain in the right upper quadrant and epigastric region. An asymmetrical right upper quadrant enlargement was detected on physical examination. Ultrasonography and computerized tomography revealed a type 1 giant hydatid cyst in the right hepatic lobe, measuring 16 cm in diameter. During operation, partial cystectomy and drainage were done. The large dead space was obliterated by the ‘sandwich’ method. Omentum and gelatin sponges were used to fill the cavity. The postoperative period was uneventful and the patient was discharged on the 5th postoperative day.     

Resection of a cholangiocarcinoma via laparoscopic hepatopancreato- duodenectomy: A case report

Some laterally advanced cholangiocarcinomas behave as ductal spread or local invasion,and hepatopancreatoduodenectomy(HPD)may be performed for R0 resection.To date,there have been no reports of laparoscopic HPD(LHPD)in the English literature.We report the first case of LHPD for the resection of a BismuthⅢa cholangiocarcinoma invading the duodenum.The patient underwent laparoscopic pancreaticoduodenectomy and right hemihepatectomy.Child’s approach was used for the reconstruction.The patient recovered well with bile leakage from the 2nd postoperative day and was discharged on the 16th postoperative day with a drainage tube in place which was removed 2 wk after discharge.Postoperative pathology revealed a well-differentiated cholangiocarcinoma andthe margin of liver parenchyma,pancreas and stomach was negative for metastases.The results suggest that LHPD is a feasible and safe procedure when performed in highly specialized centers and in suitable patients with cholangiocarcinoma.     

Atrial embolism caused by portal vein embolization:Treatment by percutaneous withdrawal and stenting

Hepatectomy remains the only curative treatment for many primary and secondary liver cancers.Portal vein embolization(PVE) has been used to increase the volume of the future liver remnant and thus lower the risk of small-for-size syndrome and postoperative liver failure.This technique has proven its safety,with a low post-procedure morbidity rate.Here,we describe a very rare case in which a young patient suffered a glue embolism to the right atrial cavity following PVE in preparation for a major hepatectomy for colorectal metastasis.The foreign body was withdrawn from the heart with a femoral,percutaneous device and trapped against the wall of the femoral vein with a self-expanding metal stent.Our report shows that this previously unknown complication of PVE can be resolved without recourse to sternotomy and open heart surgery.     

Successful treatment of conversion chemotherapy for initially unresectable synchronous colorectal liver metastasis

A 72-year-old woman with a sigmoid colon cancer and a synchronous colorectal liver metastasis(CRLM),which involved the right hepatic vein(RHV)and the inferior vena cava(IVC),was referred to our hospital.The metastatic lesion was diagnosed as initially unresectable because of its invasion into the confluence of the RHV and IVC.After she had undergone laparoscopic sigmoidectomy for the original tumor,she consequently had 3 courses of modified 5-fluorouracil,leucovorin,and oxaliplatin(m FOLFOX6)plus cetuximab.Computed tomography revealed a partial response,and the confluence of the RHV and IVC got free from cancer invasion.After 3 additional courses of m FOLFOX6 plus cetuximab,preoperative percutaneous transhepatic portal vein embolization(PTPE)was performed to secure the future remnant liver volume.Finally,a right hemihepatectomy was performed.The postoperative course was uneventful.The patient was discharged from the hospital on postoperative day 13.She had neither local recurrence nor distant metastasis 18 mo after the last surgical intervention.This multidisciplinary strategy,consisting of conversion chemotherapy using FOLFOX plus cetuximab and PTPE,could contribute in facilitating curative hepatic resection for initially unresectable CRLM.     

Complete or partial split in associating liver partition and portal vein ligation for staged hepatectomy: A systematic review and meta-analysis

BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) has been adopted by liver surgeons in recent years. However, high morbidity and mortality rates have limited the promotion of this technique. Some recent studies have suggested that ALPPS with a partial split can effectively induce the growth of future liver remnant(FLR) similar to a complete split with better postoperative safety profiles. However, some others have suggested that ALPPS can induce more rapid and adequate FLR growth, but with the same postoperative morbidity and mortality rates as in partial split of the liver parenchyma in ALPPS(p-ALPPS).AIM To perform a systematic review and meta-analysis on ALPPS and p-ALPPS.METHODS A systematic literature search of Pub Med, Embase, the Cochrane Library, and Clinical Trials.gov was performed for articles published until June 2019. Studies comparing the outcomes of p-ALPPS and ALPPS for a small FLR in consecutive patients were included. Our main endpoints were the morbidity, mortality, and FLR hypertrophy rates. We performed a subgroup analysis to evaluate patients with and without liver cirrhosis. We assessed pooled data using a random-effects model.RESULTS Four studies met the inclusion criteria. Four studies reported data on morbidity and mortality, and two studies reported the FLR hypertrophy rate and one study involved patients with cirrhosis. In the non-cirrhotic group, p-ALPPS-treated patients had significantly lower morbidity and mortality rates than ALPPStreated patients [odds ratio(OR) = 0.2; 95% confidence interval(CI): 0.07–0.57; P= 0.003 and OR = 0.16; 95%CI: 0.03-0.9; P = 0.04]. No significant difference in the FLR hypertrophy rate was observed between the two groups(P 0.05). The total effects indicated no difference in the FLR hypertrophy rate or perioperative morbidity and mortality rates between the ALPPS and p-ALPPS groups. In contrast, ALPPS seemed to have a better outcome in the cirrhotic group.CONCLUSION The findings of our study suggest that p-ALPPS is safer than ALPPS in patients without cirrhosis and exhibits the same rate of FLR hypertrophy.     

Surgical treatment of a patient with peliosis hepatis: A case report

This report describes a case of a space-occupying lesion in the right liver in a 38-year-old man who was found to have peliosis hepatis. Clinical data of this patient were presented, including medical history, laboratory test and imaging results, and postoperative pathological findings (hematoxylin and eosin staining). Review of his medical history showed that the patient had been bitten by a dog three years earlier. B-mode ultrasonography revealed an uneven echo mass in the right hemiliver, and magnetic resonance imaging scans also showed a mass in the anterior segment of the right liver. Upon surgical removal, the mass was found to be 4.0 cm × 3.8 cm × 3.8 cm in size and located in segment Ⅵ. The mass had a dark and soft appearance, with an irregular edge on intraoperative ultrasonography. Postoperative pathological findings revealed many small capsules filled with blood cells. The patient was diagnosed with peliosis hepatis based on his medical history of having been bitten by a dog, presence of mild anemia, and lack of characteristic symptoms, including fever of unknown origin, abdominal pain, and hepatosplenomegaly, combined with intraoperative and postoperative pathologic findings. The operation was successful, and after being treated with anti-infection agents, the patient had a good recovery.     

Co-existence of hepatocellular adenoma and focal nodular hyperplasia in a young female

Focal nodular hyperplasia (FNH) and hepatocellular adenoma (HA) are both benign hepatocellular lesions, presenting mainly in women of childbearing age in non-cirrhotic, non-fibrotic livers. Simultaneous occur-rence of these two lesions is extremely rare. We herein report a case of a young female without any predis-posing risk factors who presented to our emergency department complaining of acute abdominal pain. Imaging studies revealed a 6 cm lesion in the right hepatic lobe and a 2.5 cm lesion in the left hepatic lobe, respectively. In view of the patient’s symptoms and lack of a confirmed diagnosis based on imaging, we performed a bisegmentectomy Ⅴ-Ⅵ and a wedge resection of the lesion in segment Ⅲ by laparotomy. Postoperative course was uneventful and the patient was discharged on the fourth postoperative day. The pathology report demonstrated an HA in segments Ⅴ-Ⅵ and FNH in segment Ⅲ, respectively. Six months later, the patient remains asymptomatic with normal liver function tests, ultrasound and magnetic reso-nance imaging follow-up. To our best knowledge, this is the first case to describe simultaneous occurrence of HA and FNH without the presence of any known risk factors for these entities. The uncertainty in diagnosis and acuteness of presenting symptoms were estab-lished criteria for prompt surgical intervention.     

Spontaneous rupture of splenic hamartoma in a patient with hepatitis C virus-related cirrhosis and portal hypertension： A case report and review of the literature

Spontaneous rupture is a rare complication of splenic hamartoma. A review of the literature revealed only four such cases. To the best of our knowledge, this is the first report of spontaneous rupture of splenic hamartoma associated with liver cirrhosis and portal hypertension. A 53-year-old woman, who was followed up for aortic dissection and hepatitis C virus (HCV)-related liver cirrhosis, was referred with sudden left chest and shoulder pain. An abdominal ultrasound showed intraabdominal bleeding, and computed tomography indicated rupture of a splenic tumor. Emergent splenectomy was carried out. The postoperative course was uneventful, and the patient was discharged on the 13th postoperative day. Pathology revealed the tumor to be a ruptured splenic hamartoma. The non-tumorous splenic parenchyma revealed congestive changes. We consider that the presence of liver cirrhosis and portal hypertension are risk factors for spontaneous rupture of the splenic hamartoma.     

Massive hepatic necrosis with toxic liver syndrome following portal vein ligation

Right portal vein ligation (PVL) is a safe and widespread procedure to induce controlateral liver hypertrophy for the treatment of bilobar colorectal liver metastases. We report a case of a 60-year-old man treated by both right PVL and ligation of the glissonian branches of segment 4 for colorectal liver metastases surrounding the right and median hepatic veins. After surgery, the patient developed massive hepatic necrosis with secondary pulmonary and renal insufficiency requiring transfer to the intensive care unit. This so-called toxic liver syndrome finally regressed after hemofiltration and positive oxygen therapy. Diagnosis of acute congestion of the ligated lobe was suspected. The mechanism suspected was an increase in arterial inflow secondary to portal vein ligation concomitant with a decrease in venous outflow due to liver metastases encircling the right and median hepatic vein. This is the first documented case of toxic liver syndrome in a non-cirrhotic patient with favorable issue, and a rare complication of PVL.     

Bronchial bleeding caused by recurrent pneumonia after radical esophagectomy for esophageal cancer

We herein report a case of bronchial bleeding afterradical esophagectomy that was treated with lobectomy.A 65-year-old male who underwent subtotal esophagectomy with three-field lymph node dissection for esophageal carcinoma was referred to our hospital because of sudden hemoptysis.After the esophagectomy,bilateral vocal cord paralysis was observed,and the patient suffered from repeated episodes of aspiration pneumonia.Bronchoscopy revealed hemosputum in the right middle lobe bronchus,and contrast-enhanced computed tomography showed tortuous arteries arising from the right inferior phrenic artery and left subclavian artery toward the right middle lobe bronchus.Although bronchial arterial embolization was performed twice to control the recurrent hemoptysis,the procedures were unsuccessful.Right middle lobectomy was therefore performed via video-assisted thoracic surgery.Engorged bronchial arterys with medial hypertrophy and overgrowth of the small branches were noted near the bronchus in the resected specimen.The patient recovered uneventfully and was discharged on postoperative day 14.     

Liver abscess after implantation of dental prosthesis

Pyogenic liver abscesses are rare but a life-threatening important condition. Dental procedures constitute only rare cases of pyogenic liver abscesses, with only a few cases in the literature. We report a patient with liver abscess following a dental procedure. A 74 years old diabetic male patient was admitted to our hospital with complaints of fatigue, 40 ℃ fever, rigors and right upper quadrant pain, 3-4 d after a dental procedure. Physical examination revealed fever and tenderness in the right upper quadrant. Laboratory examination revealed leucocytosis, elevated erythrocyte sedimentation rate and Creactive protein and moderately elevated transaminases. An abscess was detected in radiological examination in the medial part of the left lobe of liver, neighboring the gall bladder. He was suc-cessfully treated with percutaneous abscess drainage and antibiotherapy.     

Traumatic rupture of a type Ⅳ a choledochal cyst in an adult male

Choledochal cyst (CC) is a rare, congenital anomaly of the bile ducts. We describe a 26-year-old male patient who was transferred to our hospital with a reported traumatic rupture of cystic liver lesions following a fall. At the time of injury, the patient experienced severe abdominal pain. He was found to have peritonitis and abdominal hemorrhage, which is quite rare. Laparot-omy revealed 3000 mL fluid consisting of a mixture of blood, bile and inflammatory effusion in the peritoneal cavity. The liver, gallbladder, spleen, stomach, duo-denum, small intestine, and colon appeared normal. A large cystic mass was discovered near the porta hepatis. This mass, which connected to the hepatic bifurcation and gallbladder had a 5 cm rupture in the right wall with active arterial bleeding. Abdominal com-puted tomography (CT) and emergency laparotomy revealed rupture of a huge type Ⅳa CC. The patient was successfully managed by primary cyst excision, cholecystectomy, and Roux-en-Y end-to-side hepatico-jejunostomy reconstruction. The postoperative course was uneventful and the patient was discharged on the 12 th day of hospitalization. Four weeks after surgery,abdominal CT scan showed pneumatosis in the intra-hepatic bile duct, and intrahepatic dilatation which decreased following adequate biliary drainage. The patient has remained well in the close follow-up period for 9 mo.     

Esophageal reconstruction with remnant stomach:A case report and review of literature

The number of patients developing esophageal cancer after gastrectomy has increased.However,gastric remnant is very rarely used for reconstruction in esophageal cancer surgery because of the risk of anastomotic leakage resulting from insufficient blood flow.We present a case of esophageal cancer using gastric remnant for esophageal substitution after distal gastrectomy in a 57-year-old man who presented with a 1-month history of mild dysphagia and a background history of alcohol abuse.Gastroscopy showed a 1.2 cm × 1.0 cm bulge tumor of the lower third esophagus with the upper margin located 39 cm from the dental arcade.Computed tomography of the chest showed lower third esophageal wall thickening.The patient underwent en bloc radical esophagectomy with a two-field lymph node dissection of the upper abdomen and mediastinum via a left-sided posterolateral thoracotomy through the seventh intercostal space.The upper end of the esophagus was resected 5 cm above the tumor.The gastric remnant was used for reconstruction of the esophago-gastrostomy and placed in the left thoracic cavity.The patient started a liquid diet on postoperative day 8 and was discharged on the 10 th postoperative day without complications.In this report,we demonstrate that the gastric remnant may be used for reconstruction in patients with esophageal cancer as a substitute organ after distal gastrectomy.     

Percutaneous cervical carotid artery access with stenting of the left internal carotid artery in an elderly patient

To describe the successful endovascular treatment in a nonagenarian with symptomatic internal carotid artery stenosis using direct carotid artery access. An independent 98 year-old man was admitted to our hospital for symptoms of progressive weakness with disorientation and dysphasia. Carotid Duplex ultrasonography was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery by velocities of 608/240 cm/sec. The patient refused surgical endarterectomy and thus he was referred for carotid artery stenting. Using the femoral artery approach and multiple catheter techniques, access to the common carotid artery could not be accomplished safely. The procedure was aborted and he was therefore brought back to the catheterization laboratory the following day for direct carotid access. Carotid artery stenting was accomplished by using of a 6F sheath percutaneously in the left common carotid, cerebral protection device (CPD) and a Nitinol stent. The patient was discharged the following day without complications. At 14 months follow-up the patient is functional and independent without recurrence of symptoms. Carotid artery stenting via direct access can be accomplished in patients when the femoral artery approach is anatomically prohibitive. In this case of advanced age and the patient’s refusal for surgery, direct carotid access was his only option.     

Percutaneous cervical carotid artery access with stenting of the left internal carotid artery in an elderly patient

To describe the successful endovascular treatment in a nonagenarian with symptomatic internal carotid artery stenosis using direct carotid artery access. An independent 98 year-old man was admitted to our hospital for symptoms of progressive weakness with disorientation and dysphasia. Carotid Duplex ultrasonography was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery by velocities of 608/240 cm/sec. The patient refused surgical endarterectomy and thus he was referred for carotid artery stenting. Using the femoral artery approach and multiple catheter techniques, access to the common carotid artery could not be accomplished safely. The procedure was aborted and he was therefore brought back to the catheterization laboratory the following day for direct carotid access. Carotid artery stenting was accomplished by using of a 6F sheath percutaneously in the left common carotid, cerebral protection device (CPD) and a Nitinol stent. The patient was discharged the following day without complications. At 14 months follow-up the patient is functional and independent without recurrence of symptoms. Carotid artery stenting via direct access can be accomplished in patients when the femoral artery approach is anatomically prohibitive. In this case of advanced age and the patient‘s refusal for surgery, direct carotid access was his only option.     

Laparoscopic approach to retrorectal cyst

Retrorectal cysts are rare benign lesions in the presacral space which are frequently diagnosed in middle-aged females. We report here our experience with two symptomatic female patients who were diagnosed as having a retrorectal cyst and managed using a laparoscopic approach. The two patients were misdiagnosed as having an ovarian cystic lesion after abdominal ultrasonography. Computer tomograghy （CT） scan was mandatory to establish the diagnosis. The trocar port site was the same in both patients. An additional left oophorectomy was done for a coexisting ovarian cystic lesion in one patient in the same setting. There was no postoperative morbidity or mortality and the two patients were discharged on the 5th and 6th post operative days, respectively. Our cases show that laparoscopic management of retrorectal cysts is a safe approach. It reduces surgical trauma and offers an excellent tool for perfect visualization of the deep structures in the presacral space.     

Anatomic resection of liver segments 6-8 for hepatocellular carcinoma

AIM:To report the devised anatomic liver resection of segments 6,7 and 8 to improve the resection rate for patients with right liver tumors.METHODS:We performed anatomic liver resection of segments 6,7 and 8 to guarantee the maximum preservation of the remaining normal liver tissue.Segment 5 was determined by two steps of Glissonean pedicle occlusion.And a"┏┛"shaped broken resection line was marked upon the diaphragmatic surface of the liver.Selective right hemihepatic inflow occlusion was used to reduce blood loss during parenchymal transection between segments 6 and 5 and between segments 8 and 5.If needed,total hepatic Glissonean pedicle occlusion was used during parenchymal transection between segment 8 and the left liver.RESULTS:Compared to right hemihepatectomy,the percentage of future liver remnant volume was increased by an average of 13.9%if resection of segments 6,7 and 8 was performed.Resection of segments 6,7 and 8 was completed uneventfully.After hepatectomy,the inflow and outflow of segment 5were maintained.There was no perioperative mortality,postoperative abdominal bleeding or bile leakage in this group.Alpha-fetoprotein(AFP)returned to the normal range within 2 mo after the operation in all the patients.One patient died 383 d postoperatively due to obstructive suppurative cholangitis.One patient suffered from severe liver dysfunction shortly after surgery and had intrahepatic recurrence 4 mo postoperatively.Postoperative lung metastasis was found in one patient.No tumor recurrence was found in the other patients and the parameters including liver function and AFP level were in the normal range.CONCLUSION:Anatomic liver resection of segments6,7 and 8 can be a conventional operation to improve the overall resection rate for hepatocellular carcinoma.     

Auxiliary partial liver transplantation for acute liver failure using "high risk" grafts: Case report

Acute liver failure(ALF) is a reversible disorder that is associated with an abrupt loss of hepatic mass, rapidly progressive encephalopathy and devastating complications. Despite its high mortality, an emergency liver transplantation nowadays forms an integral part in ALF management and has substantially improved the outcomes of ALF. Here, we report the case of a 32-year-old female patient who was admitted with grade Ⅳ hepatic encephalopathy(coma) following drug-induced ALF. We performed an emergency auxiliary partial orthotopic liver transplantation with a "high risk" graft(liver macrovesicular steatosis approximately 40%) from a living donor. The patient was discharged on postoperative day 57 with normal liver function. Weaning from immunosuppression was achieved 9 mo after transplantation. A follow-up using CT scan showed a remarkable increase in native liver volume and gradual loss of the graft. More than 6 years after the transplantation, the female now has a 4-year-old child and has returned to work full-time without any neurological sequelae.     

Pseudoachalasia: A peculiar case report and review of the literature

Pseudoachalasia is a rare secondary achalasia, which accounts for only a small subgroup of patients. We describe a 77-year-old woman with recent onset of dysphagia and typical esophageal manometric findings of achalasia. Moreover, esophageal manometric findings of vascular compression at 36 cm from the nose were associated with dysphagia. An upper endoscopy showed the absence of lesions both in the esophagus and gastro-esophageal junction, whilst a 15-mm ulcer on the gastric angulus was detected. The gastric ulcer resulted in being a diffuse signet ring cell carcinoma at histology, suggesting pseudoachalasia. An abdominal computed tomography scan showed an irregular concentric thickening of the gastro-esophageal junction wall extending for 7 cm and a dilated ascending thoracic aorta with no presence of the inferior vena cava, with an enlarged azygos as the source of vascular compression of esophagus. Moreover, cardia involvement from diffuse signet ring cell carcinoma of the gastric angulus was also recognized as the cause of dysphagia. The cancer was not suitable for a surgical approach in an old patient with cardiovascular comorbidities and support therapy was started. In our ambulatory series, pseudoachalasia was eventually diagnosed in 4.7% of 234 consecutive patients with esophageal manometric finding suggestive of achalasia. We also reviewed cases in the literature and aimed to evaluate the reported causes of pseudoachalasia.     

Efficacy of neoadjuvant therapy and surgical rescue for locally advanced hepatoblastomas:10 year single-center experience and literature review

AIM:To report our experience with long-term outcomes after multimodal management therapy.METHODS:An observational retrospective study was performed containing seven patients with hepatoblastoma(Hbl)treated in our institution,a tertiary referral center,from 2003 to 2011.Demographic,preoperative,surgical,and outcome variables were collected.A survival analysis and a review of the current literature related to combination neoadjuvant chemotherapy and surgical resection on Hbl were performed.RESULTS:The median age at surgery was 14.4 mo,with a male to female ratio of 4:3.Pretext staging at diagnosis was as follows:stageⅠ,4 cases;stageⅡ,2 patients;and stageⅢ,1 case.Mean pretreatment tumor volume was 735 cm3.Five out of seven patients received neoadjuvant chemotherapy according to SIOPEL-3 or SIOPEL-6 protocols.Tumor volume and alphafetoprotein levels significantly dropped after neoadjuvant therapy.Surgical procedures performed included hemihepatectomies,segmentectomies and atypical resection.All patients received chemotherapy after surgery.Median postoperative hospital stay was 8 d.All patients were alive and disease-free after a median follow-up period of 23 mo.With regards to the literature review,seventeen articles were found that were related to our search.CONCLUSION:Our series shows how multimodal management of Hbl,exhaustive control and a meticulous surgical approach leads to almost 100%complete resection with optimal postoperative results.