Left Hepatic Lobe Research Articles

The impact of elastography with virtual touch quantification of future remnant liver before major hepatectomy.

Liver elastography with virtual touch quantification (VTQ) measures the velocity of the shear wave generated by a short-duration acoustic force impulse, with values expressed in units of velocity (m/s). VTQ can evaluate right or left hepatic lobes separately. VTQ might be appropriate for the evaluation of future remnant liver after hepatectomy. We analyzed 95 patients underwent liver elastography with VTQ and both future remnant liver and resected side before hepatectomy of more than two sections, except for central bisectionectomy. We divided the patients into a high VTQ group (≥1.52 m/s, n=37, 39%) and a low VTQ group (<1.52 m/s, n=58, 61%) according to the VTQ of future remnant liver. Transient elastography could not be performed in 22 cases due to tumor size. We defined the group with liver stiffness measurement (LSM) ≥7.9 kPa as the high LSM group (n=29, 40%) and those with LSM <7.9 kPa as the low LSM group (n=44, 60%). We investigated the outcome after hepatectomy and the correlations between the VTQ of future remnant liver and other indicators for hepatic fibrosis. The high VTQ group showed significantly higher postoperative ascites (19% vs. 3%; P=0.01), pathological fibrosis (19% vs. 5%; P=0.03), and rates of patients with postoperative T-bil ≥2.0 mg/dL (70% vs. 40%; P<0.01). The high LSM group showed no significant postoperative outcomes compared to the low LSM group. The high VTQ group showed a higher frequency of male gender (78% vs. 57%; P=0.03), higher indocyanine green retention rate at 15 min (ICGR15) (10.5% vs. 6.3%; P<0.01), hyaluronic acid (100 vs. 67 ng/mL; P=0.02), type IV collagen 7S (7.6 vs. 5.1 ng/mL; P<0.01), Mac-2 binding protein glycan isomer (M2BPGi) (1.19 vs. 1.00; P=0.01), Fibrosis-4 (FIB-4) index (2.25 vs. 1.76; P=0.01), and aspartate aminotransferase to platelet ratio index (APRI) score (0.64 vs. 0.41; P<0.01). We also observed an especially strong positive correlation between the high VTQ and hyaluronic acid or type IV collagen 7S. Elastography with VTQ for future remnant liver before major hepatectomy is an accurate and useful method as a preoperative evaluation.

The predictive role of parathyroid hormone for non-alcoholic fatty liver disease based on invasive and non-invasive findings in candidates of bariatric surgery

Non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH) and hepatic fibrosis are the most detrimental hepatic abnormalities associated with increased body weight with devastating clinical outcomes. Therefore, there is a substantial necessity for efficient management strategies, including significant weight reduction. Bariatric surgery has been used as a therapeutic approach in a selected obese patient with NAFLD/NASH and other cardiometabolic comorbidities. The study is focused on the predictive role of PTH with the indices of hepatic steatosis/NAFLD and NASH based on liver biopsy, elastography, and sonography in morbidly obese patients. Ninety patients with BMI between 35 and 40 kg/m2 with more than two comorbidities who referred to Imam Reza outpatient clinic from December 2016 to September 2017 were recruited and underwent initial assessments, including demographic profiles, psychological assessment, anthropometric measurements, hepatic biopsy, and basic laboratory tests. Liver stiffness was evaluated using two-dimensional shear wave elastography (2D-SWE) at least two weeks before liver biopsy. The histological analysis of the liver was performed using biopsy samples which obtained from left hepatic lobe during bariatric surgery under direct surgeon observation using a 16-gauge Tru-cut needle. The study was approved by the ethical committee (IR.MUMS.fm.REC.1396.312). The level of PTH was significantly high in patients with positive histology for hepatic fibrosis, steatosis, and NASH/NAFLD compared to patients with negative histology (p = 0.005, p = 0.009, and p = 0.013, respectively). Also, patients with liver fibrosis confirmed by elastography had significantly higher serum PTH concentration than patients without fibrosis (p = 0.011). PTH was also positively correlated with hepatic fibrosis, NASH, and steatosis (p = 0.007, p = 0.012, p = 0.023, respectively). High levels of PTH was significantly associated with histological indices of (hepatic fibrosis, steatosis, NAFLD and NASH) and elasticity indices. Therefore, it is imperative to assess for high levels of PTH in the morbidly obese population pre-and post-bariatric surgery. However, for a more robust and comprehensive assessment, a randomized controlled trial is needed. The study was conducted in accordance with the practice guidance in the diagnosis and management of NAFLD from the American association for the study of liver disease (AASLD) 2018. Evidence obtained from well-designed cohort or case-control analytic studies.

A Case Report on Methimazole-Induced Cholestatic Jaundice in an Elderly Man With Hyperthyroidism

Background: The early detection and diagnosis of the causes of jaundice in a hyperthyroid patient taking antithyroid medications are paramount for the appropriate management of these patients. Clinical Case: A 72 year old male is admitted due to septic shock secondary to pneumonia and funguria, acute kidney injury secondary to sepsis, type 2 diabetes mellitus, uncontrolled and Graves’ disease with thyroid nodules (Tirads 4). On physical examination, he has icteresia and generalized jaundice. Methimazole was started 12 days ago. Initial tests were consistent with a cholestatic pattern of jaundice: slightly elevated alanine aminotransferase 70 U/L (16-63), aspartate aminotransferase 84 U/L (15-37) and significantly elevated alkaline phosphatase 662 U/L (46-116), total bilirubin 12.16 mg/dl (0.20-1.0), conjugated bilirubin 11.29 mg/dl (0-0.20) and unconjugated bilirubin 0.87 mg/dl (0-0.80). He has hypoalbuminemia and normal prothrombin time. He has negative anti-Smith antibody, anti-ribonucleoprotein, anti-mitochondrial antibody, and positive anti-nuclear antibody 1:160 speckled pattern. Hepatitis Profile showed chronic hepatitis A infection. Upper Abdomen Ultrasound showed ill-defined border in the left hepatic lobe; intrahepatic ducts and common bile duct are not dilated; gallbladder is contracted with no evident intraluminal echoes. Whole Abdomen with 4-phase Dynamic Liver CT Scan showed multiple ill-defined hypoattenuating lesions in the entire liver parenchyma; intrahepatic ducts, common bile duct, and pancreatic duct are not dilated; and gallbladder is normal in size without intraluminal calculus with possible metastases at spleen, left adrenal gland and tail of pancreas. He has normal AFP and elevated CEA. Methimazole was discontinued at admission and was started on Hydrocortisone 100 mg/IV every 8 hrs. Repeat liver profile panel showed decreasing trends after 4 days of holding methimazole. Repeat fT4 after 6 days of high dose hydrocortisone showed a decrease from 3.09 ng/dl to 1.98 ng/dl (0.89-1.76). Hydrocortisone was continued and tapered accordingly. Plans for RAI discussed. Conclusion: This case emphasizes the need to be vigilant for the very rare but serious adverse events of antithyroid medications.

Metastatic Non-Functional Pancreatic Neuroendocrine Tumor in a Patient With a Pathogenic TSC1 Mutation

Abstract Introduction: Tuberous sclerosis complex (TSC) is an autosomal dominant multisystem disorder caused by mutations in two tumor suppressor genes (TSC1 and TSC2) encoding proteins critical in cell growth and proliferation and is associated with an increased risk for benign and malignant tumors. Pancreatic neuroendocrine tumors (PNET) occur in 1.5-1.8% of patients with TSC. They have been primarily reported in TSC2, with only a few cases in the context of TSC1. We describe a non-functional metastatic PNET in a patient with a known pathogenic TSC1 mutation. Case Description: A 49-year old female with a past medical history of bipolar disease, a family history of TSC1 in a daughter, a known pathologic TSC1 mutation (c.2356C&amp;gt;T), and previous history of renal cell carcinoma (RCC) was evaluated for a pancreatic lesion with likely liver metastases. Two years prior to the presentation, a 10 mm pancreatic lesion was initially noted on the CT scan during a renal mass evaluation. Nephrectomy confirmed the RCC. Two years later, surveillance imaging revealed two new lesions in the liver, and the pancreatic lesion had enlarged to 1.3 cm. She denied symptoms suggestive of a functional PNET, and her physical exam was unremarkable. Gallium-68 dotatate (GA-68) PET/CT scan demonstrated avid lesions of both the pancreatic tail and left hepatic lobe. Biopsy of the 3 cm liver mass revealed a metastatic high-grade neuroendocrine carcinoma (mib-1 proliferation index of 15%) favoring a primary PNET. Immunohistochemical stains were positive for chromogranin A, synaptophysin, EMA, PAX 8, CK 20, and villin. Stains for CA 19-9 and CK 7 were negative. Biochemical testing suggested that the PNET was non-functional. Specifically, serum concentrations of gastrin, somatostatin, glucagon, glucose, C-peptide, proinsulin, pancreatic polypeptide, chromogranin A, and vascular endothelial growth factor were within normal limits. The patient underwent distal pancreatectomy and resection of the liver mass. Pathological specimens confirmed the diagnosis of a PNET. The patient remained asymptomatic and was monitored regularly with MRI and GA-68 PET/CT scans without further evidence of the disease for 1.5 years. Conclusions: We conclude that this patient harboring a c.2356C&amp;gt;T TSC1 mutation developed a non-functional metastatic PNET. PNET is a likely component of TSC1.

Particulars of Medical and Surgical Treatment of Liver Abscess in Septic Patient– Case Report

Abstract First described by Bright in 1836, who reports two cases secondary to suppurative angiocolitis and pilephlebitis, intrahepatic suppurations were, until the era of the discovery of antibiotics, one of the most dreaded causes of mortality, reaching a rate of almost 100%. Today, both the incidence of liver abscesses and the mortality rate have been significantly reduced, as the introduction of antibiotics has dramatically reduced the number of septic piles due to peritoneal outbreaks. Their etiology is more recently, most frequently, a biliary or neoplastic disease. On the other hand, the improvement of germ isolation techniques has made it possible to identify anaerobic germs with maximum frequency, and diagnostic and treatment performance has increased so much with the advent of non-invasive or minimally-invasive procedures that the overall mortality rate of 70% in 1975 is now about 30–38%. We present the case of a 75-year-old male patient with no known history of ilnesses who is admitted for fever, chills, myalgia, arthralgia and visual disturbances with onset of approximately one week. Biologically he presents with leukocytosis with marked neutrophilia, mild thrombocytopenia and significant biological inflammatory syndrome. Suspicion is raised for a diagnosis of Sepsis with unspecified starting point with possible pyogenic cavernous sinus thrombosis, a complication suggested by the presence of visual disturbances. Neuro-imaging evaluation by CT and brain MRI is performed, with the diagnosis of thrombosis being refuted. Abdominal CT is performed which identifies a space replacement formation in the left hepatic lobe for which MRI evaluation is required. MRI detects an expansive hepatic formation with semiology suggestive of liver abscess. Treatment was instituted with a combination of broad-spectrum antibiotics and antifungal treatment, but the evolution was unfavourable with maintenance of leukocytosis with marked neutrophilia and progression of inflammatory samples. It was necessary to evaluate the case by a multidisciplinary team (infectious disease specialist, gastroenterologist, surgeon) to establish the appropriate therapeutic management, with surgical resolution of the case, with a favourable postoperative evolution.

Abstract No. 206 Comparing the safety and efficacy of ultrasound-guided random percutaneous liver biopsy: right versus left hepatic lobe approaches

Abstract No. 206 Comparing the safety and efficacy of ultrasound-guided random percutaneous liver biopsy: right versus left hepatic lobe approaches

Linear Morphometric Parameters of the Liver in Children and Adolescents according to Intravital Imaging Findings

The aim of the study is to define age and gender regularities of the linear morphometric parameters of the liver in children and adolescents on the basis of intravital imaging findings.Material and methods. The authors analyzed computed tomograms of the abdominal cavity in 75 children without visible pathology. All patients were divided into 4 groups depending on their age: early childhood, first childhood, second childhood, adolescence. The transverse, anteroposterior and vertical dimensions of the right and left hepatic lobes were investigated on 16-slice computed tomographs. The obtained findings were processed using variational statistical analysis, the mean value (M), standard error (m) and the statistical significance were defined using the Student's t-test.Results. There was a significant increase in the anteroposterior size of the right hepatic lobe in separate sections at different age periods. A statistical significance between the parameters of the anteroposterior size of the right hepatic lobe was registered in girls and boys within the following groups: on one section in the 2nd group of patients, on two sections in the 4th group of patients. A statistical significance between the parameters of the transverse size of the right hepatic lobe was registered on one section (ThXII) in the 2nd and 3rd groups, and on two (ThXI and LI) and three (ThXI, ThXII and LI) sections in the 3rd and 4th groups of girls and boys, respectively. A statistical significance between the parameters of the transverse size of the right hepatic lobe in girls and boys were recorded only in the 4th group on three sections (ThXI, ThXII and LI). The vertical size of the right hepatic lobe was significantly higher in the 2nd and 4th groups, and the differences in the parameters between girls and boys were noted only among adolescents. A significant increase in the anteroposterior size of the left hepatic lobe was registered only in girls of the 2nd and 3rd groups on two sections (ThXII and LI); a significant increase in the transverse size was only registered at the LI level in these groups of patients. A significant increase in the vertical size of the left hepatic lobe was only detected in girls of the first childhood compared with girls of the early childhood. No statistical significance was registered for any of the linear parameters of the left hepatic lobe between girls and boys of the same groups.Conclusion. Thus, there was a significant increase in the anteroposterior and transverse dimensions of the right hepatic lobe in separate sections and an increase in the vertical size between individual groups of the studied patients, as well as a statistical significance between girls and boys of the same group. A significant increase in the anteroposterior and transverse dimensions of the left hepatic lobe was detected only in girls of the 2nd and 3rd groups if compared with the girls of the 1st group. No significant differences were registered between girls and boys of the same groups for any of the linear parameters of the left hepatic lobe.

Laparoscopic anatomical segment III resection for a giant focal nodular hyperplasia (FNH): advantages of the extraglissonean approach—a case report

: In recent years the laparoscopic approach in liver surgery has gained wide acceptance compared to open surgery, especially in cases of benign liver lesions. Many of these, i.e., focal nodular hyperplasia (FNH), have an important vascular inflow depending from nutrient vessels, which hamper sometimes a proper resection. We report in this video a 24-year-old male with a fortuitous diagnosis of a 10×8×7 cm FNH in the left hepatic lobe, with its characteristic central nutrient vessel. Given the size of the lesion, surgical excision was indicated and performed a laparoscopic resection of segment III following an extraglissonean approach. This approach enables an intrahepatic identification of the targeted glissonean pedicle for segment III without dissecting the hepatoduodenal ligament. It also permits the localization and clamp of the vascular inflow of the tumor leading to tumor shrinkage, which facilitates the resection without invading the tumor capsule and thus respecting the portal pedicles for the other segments. The patient did not present postoperative complications and was discharged on the third postoperative day. The definitive pathology confirmed the diagnosis of FNH. A detailed preoperative anatomical study of the liver segments allows a better planning of liver surgeries. More specifically, this selective transfisural glissonean approach avoids a dissection of the hepatoduodenal ligament and therefore the risk of a postoperative bile leak.

Efficacy and safety of EUS-guided hepaticoesophagostomy (EUS-HES) for malignant biliary obstruction: the first case series.

EUS-guided hepaticoesophagostomy (EUS-HES) was reported as an alternative procedure when puncture through the esophagus was inevitable. However, the existing data is very limited. We aimed to evaluate the efficacy and safety of EUS-HES in patients with difficult malignant biliary obstruction. All cases who underwent EUS-HES at our institute were retrospectively reviewed. A total of 11 patients underwent EUS-HES from January 2011 to December 2017. Five were male, and the mean age was 57.9 ± 6.3years. The majority of the patients (8 out of 11 patients) had a biliary obstruction caused by cholangiocarcinoma. The technical success was 100%. The mean procedure time was 73.2 ± 37.6min. The main reason for EUS-HES was the improper alignment of the bile duct due to left lobe hypertrophy. The clinical success was 90.9%. The mean overall survival was 97.8 ± 68.5days. No major procedure-related complication, particularly pneumomediastinum, occurred. EUS-HES is a technically feasible and safe procedure to provide biliary drainage, especially in patients with left hepatic lobe hypertrophy. Using a bougie dilator instead of balloon dilation can avoid previously reported complications.

Revision of a Previous Capella Bypass due to dysphagia, GERD and Candy Cane Syndrome.

Capella ringed gastric bypass is a technical variant of gastric bypass which seeks to improve long-term outcomes with a greater restriction. Frequent complications are due to the band, due to its inclusion or slippage, without being able to reject others. Our purpose is to present the video of a revisional bariatric surgery made by laparoscopic approach in a patient with a previous open retrogastric retrocolic Capella gastric bypass. The patient presents dysphagia, gastroesophagic reflux disease (GERD), and pain, with a BMI of 36 kg/m2. Her supplementary tests show a hiatal hernia, GERD, and a Candy Cane Syndrome. The surgery was difficult due to multiple adhesions. Hiatal hernia was repaired and pillars were closed. The band was visualized intraoperatively close to the gastrojejunal anastomosis, although the high endoscopy did not detect neither stenosis nor difficulty of passage to the gastric pouch. It showed the retrogastric gastrojejunal anastomosis with a normal food loop and a 15-cm widened blind loop (Candy Cane Syndrome), which was resected. She had a left pneumonia and damage in left hepatic lobe (LHL). She was discharged after antibiotic treatment for 7 days. The patient has improved clinically, without dysphagia nor GERD. Her current BMI is 29.8 kg/m2. In conclusion, bariatric revisional surgery can lead to serious complications, but it is justified in patients withpoor quality of life. A ringed retrocolic retrogastric bypass poses more difficulties in revisional procedures. It is mandatory to know which technique was performed before. The duration of the procedure can result in more complications like liver damage.

Laparoscopic repair of hepatic herniation through a ventral incisional hernia: a case report

BackgroundVentral incisional hernia is a common problem after abdominal surgery. Most patients with these hernias present with greater omentum and gastrointestinal prolapse. However, hepatic herniation through a ventral incisional hernia is a rare phenomenon that has been seldom reported in the literature. We report the case of a ventral incisional hernia with hepatic herniation treated with laparoscopic repair.Case presentationA 68-year-old Japanese women with a history of myocardial resection for hypertrophic cardiomyopathy 1 year earlier was admitted to our hospital with symptoms of vomiting and epigastric pain. Physical examination showed a 4-cm epigastric mass. Abdominal computed tomography revealed left hepatic lobe herniation through the lower edge of a mid-sternal incision. We diagnosed the patient with a ventral incisional hernia with hepatic herniation. The patient underwent laparoscopic hernia repair. During an 18-month follow-up, no recurrence or symptoms have been observed.ConclusionsTo the best of our knowledge, this is the first case report of laparoscopic repair of ventral incisional hernias with hepatic herniation. Laparoscopic repair was useful and suitable for this rare herniation due to its minimally invasive nature and ability to achieve sufficient visibility of the surgical field. Laparoscopic repair could be a potential treatment option for elective surgery for this disease, which is often treated conservatively.

An unusual presentation of a hepatic ductal malformation in a Boxer dog

AbstractAn 11‐year‐old male neutered Boxer presented for evaluation of an external ear canal mass, postoperatively diagnosed as a benign inflammatory lesion. Preoperative staging of the ear mass identified a 10‐cm mass affecting the majority of the left lateral hepatic lobe, with inconclusive cytology. A left lateral liver lobectomy was performed. Histopathology revealed the hepatic parenchyma was largely effaced and replaced by a myriad of small calibre tubules lined by well‐differentiated biliary epithelium (cytokeratin19 and cytokeratin7 positive (CK19+, CK7+) supported by abundant fibrosis. Small cords and islands of hepatocytes (hepatocyte paraffin1 positive) (HepPar1+) were entrapped throughout these bile ducts. Analysis of the proliferation index via antigen KI‐67 (Ki67) immunohistochemistry confirmed lack of proliferative activity. Histological and immunohistochemical features were consistent with a ductal plate malformation (DPM). This is the first time a DPM of this size has been described on a computed tomography (CT) scan.

Intrahepatic Intraductal Papillary Cystic Neoplasm of the Bile Duct: A Case Report

Abstract Introduction and importance Intraductal papillary neoplasm of the bile duct (IPNB) is a tumour with a very low incidence in the Western world, characterised by a high risk of malignant transformation and unknown prognosis. It is a new entity which was adopted by the WHO in 2010 as a precursor lesion of cholangiocarcinoma. Intrahepatic bile duct is the most common site of origin for IPNB. Case presentation Hereby, we present a case of an asymptomatic 63- year-old man, referred to our department after routine ultrasonography showing a multifocal cystic lesion on the left hepatic lobe. Further screening modalities (CT, MRI abdo) confirmed a complex cystic liver lesion with atypical features. The patient underwent left hepatectomy. Histopathology showed a cystic type intrahepatic IPNB, which was completely resected (R0). The follow up in 2 yrs post-operation showed no signs of recurrence. Clinical discussion The diagnosis and management of IPNB remain challenging. A multimodality imaging approach is essential in order to diagnose IPNB, assess tumour location and extent and plan the optimal treatment strategy. Conclusion Complete surgical resection (R0) with close postoperative follow-up offers long-term survival.

How to Rescue a Extreme Vasculobiliary Injury from Liver Failure

To describe a case treated with "tricks of the trade", in order to avoid liver transplantation in a patient with extreme vasculobiliary injury (VBI). A 22 years old woman underwent a open cholecystectomy with bile duct exploration. An important inflammatory process was found and massive bleeding from the hepato-duodoenal pedicle, requiring several stiches of hemostasis, ending the surgery without proper identification of the pedicle structures. Patient developed jaundice and commitment of conscience. Three days after, she was transferred due to increased deterioration of clinical condition. A CT scan was performed revealing a right liver lobe infarct, absence of the right and left hepatic artery, normal flow of an accessory artery from left gastric artery, portal vein thrombosis. Patient was taken to the OR. Surgical findings where: bile peritonitis, right hepatic lobe necrosis and ischemia of left lobe, complete resection of the common bile duct at the level of the confluence of right and left ducts, thick stiches on main portal vein and complete section of the hepatic artery. The accessory artery of the left gastric was not damaged. With those findings, a right hepatectomy was performed with revascularization of the left hepatic lobe using a jump-graft from superior mesenteric vein to left portal branch at the level of REX process, with a cadaveric iliac vein and Roux-en-Y hepaticojejunostomy to the left hepatic duct. After four months, patient has adequate biliary drainage and normal portal and arterial flows with good regeneration of the left hepatic lobe.

Giant gastric carcinosarcoma infiltrating the left hepatic lobe: a case report

Gastric carcinosarcoma is a rare biphasic tumor that consists of both carcinomatous and sarcomatous components. Clinical presentation and neoplastic markers are not specific for the disease. Moreover, CT scan cannot distinguish among gastric carcinoma, sarcoma or carcinosarcoma, so it is essential to perform histopathological and immunohistochemical analysis on biopsy specimens or resected tissue to ensure a correct diagnosis. A 72-year-old woman was transferred to our Department from another hospital with a diagnosis of a bleeding tumor localized on the lesser gastric curve, infiltrating the left hepatic lobe. The mass was treated as a gastric malignant mesenchymal neoplasia (gastro-intestinal stromal tumor versus sarcoma) infiltrating the liver. Owing to the bleeding, no further invasive examinations, such as fine needle aspiration biopsy, were planned. Furthermore, no neoadjuvant chemotherapy could be administered before surgery due to persistent anaemia. The scheduled surgical procedure was an atypical gastric resection with “en bloc” hepatic resection. This operation included upper polar and lesser curve resection, with tubulization of the stomach along the greater curve, as well as left lateral hepatic sectionectomy. Histopathological examination and immunohistochemical staining confirmed the diagnosis of gastric carcinosarcoma. This is first report of gastric carcinosarcoma with local liver infiltration, treated with surgical resection.

A case of intrahepatic pancreatic pseudocyst developed as a complication of pancreatitis

Introduction: Pancreatic pseudocyst is located usually in lesser sac and peripancreatic space and is rarely developed in the liver. The intrahepatic pancreatic pseudocyst(IHPP) following acute pancreatitis is extremely rare with very limited number of clinical reports about IHPP. Methods: A 70-year-old woman was referred because of upper abdominal pain of 3 days' duration. An abdominal CT scan revealed 11x10 cm sized cystic mass in the left lateral section of liver. On EUS findings, a huge hypoechoic lesion with internal echogenicity was noted in the lesser sac. EUS-guided gastrocystostomy was performed and analysis of cystic fluid showed a high level of amylase (21,200 U/L). After the endoscopic procedure, severe abdominal pain developed and physical examination showed peritoneal irritation sign. An emergency operation was performed. Results: On operation findings, a huge cystic tumor was located in the left lateral section of liver without direct communication with pancreas. However, mass-like necrotic tissue was filled with in the hepatoduodenal ligament, hepatogastric ligament, and Glisson sheath of the left hepatic lobe. Left lateral sectionectomy was performed. Pathologic examination confirmed the pseudocyst with findings of non-epithelialized granulation tissue of the cystic wall. Conclusion: IHPP should be considered when a huge intrahepatic cystic lesion is found in patients with recent episodes of pancreatitis. The high level of amylase on cystic fluid analysis plays a key role in the diagnosis of IHPP. Drainage procedure or surgical resection can be considered, if necessary, for the treatment of IHPP.

Peritonitis and Necrotizing Hepatitis in Ara ararauna Caused by a Foreign Body

Background: The ingestion of foreign bodies in parrots has already been described and associated with the curious behavior of the birds or with stressful conditions. Foreign bodies in the gastrointestinal tract are usually diagnosed through clinical signs, laboratory tests, and radiographic findings in the historical data. Foreign bodies are usually metallic and can lodge in any segment of the gastrointestinal tract, commonly found in the proventricle and gizzard. This study investigated a case of necrotizing hepatitis due to a foreign body in Ara ararauna (Linnaeus, 1758).Case: An approximately 9-month-old specimen of caninde macaw, had sudden death and was referred for autopsy. The macroscopic examination revealed a fibrous, thick, reddish membrane involving the left hepatic lobe and partially the gizzard in continuity with the peritoneum. Inside the capsule, the liver had a friable and necrotic appearance and the gizzard had a focal perforation area containing a foreign body (gavage probe). We performed the histopathological examination of the liver and gizzard and observed that the membrane surrounding the liver and partially the gizzard had a chronic inflammatory process with a marked proliferation of fibrous tissue and fibrin deposition. The hepatic parenchyma of the left lobe showed diffuse and marked necrosis, with signs of ischemic necrosis. In the region of transmural perforation of the gizzard, the mucosa showed a focal area of extensive necrosis accompanied by the presence of intralesional bacteria. The lesions observed are attributed to the perforation of the organs by the foreign body. It is not known whether the bird ingested the object accidently during food handling as a young or due to the curious behavior of the bird or even the stress it may have been exposed to. The post-mortem examination revealed localized peritonitis and encapsulating necrotizing hepatitis, focally extensive and accentuated, associated with foreign body perforation.Discussion: The curious habit of parrots, can provide the ingestion of foreign bodies, in which they lodge in the gastrointestinal tract. Generally, the clinical signs are nonspecific, however, proventricular impaction, stasis and even perforations in the mucosa of organs can be observed. In the present study, we suspect that the Caninde macaw accidentally ingested a gavage probe during feeding management as a young. This object lodged in the bird's ventricle, perforating the organ and reaching the liver, due to intimate contact with the gizzard, providing a picture of ventriculitis and necrotizing hepatitis. Necrotizing hepatitis due to foreign body has been reported in the literature due to ingestion of perforating foreign body with lesion in the left ventricle and lobe, however we have no knowledge of reports with the presence of a capsule involving the left hepatic lobe, similar to a capsule like this, we understand that our report is the first description of encapsulating necrotizing hepatitis in birds. We believe that this capsule of connective tissue was formed, due to the inflammatory process in the peritoneal cavity, in birds the deposition of fibrin can form a structure similar to a capsule, in order to trap cells and the agent responsible for inflammation, preventing septicemia. Transmural perforation in the gizzard, observed in this case, allowed bacterial translocation that may have contributed to the worsening of the chronic condition and death due to the accumulation of toxins or bacterial translocation of the gastric tract, leading to liver infection and sepsis. We concluded that the presence of the perforating foreign body was responsible for the peritonitis and encapsulating necrotizing hepatitis in Ara ararauna.

A Proposed Algorithm for Endoscopic Ultrasound-Guided Rendezvous Technique in Failed Biliary Cannulation.

Background: The selection of an approach route in endoscopic ultrasound-guided rendezvous (EUS-RV) for failed biliary cannulation is complicated. We proposed an algorithm for EUS-RV. Methods: We retrospectively evaluated consecutive EUS-RV cases between April 2017 and July 2020. Puncturing the distal extrahepatic bile duct (EHBD) from the duodenal second part (D2) (DEHBD/D2 route) was attempted first. If necessary, puncturing the proximal EHBD from the duodenal bulb (D1) (PEHBD/D1 route), puncturing the left intrahepatic bile duct (IHBD) from the stomach (LIHBD/S route), or puncturing the right IHBD from the D1 (RIHBD/D1 route) were attempted in this order. Results: A total of 16 patients were included. The DEHBD/D2 route was used in 10 (62.5%) patients. The PEHBD/D1 route was attempted in five (31.3%) patients, and the biliary puncture failed in one patient in whom the RIHBD/D1 route was used because of tumor invasion to the left hepatic lobe. The LIHBD/S route was applied in one (6.3%) patient. Successful biliary cannulation was achieved in all patients eventually. The time from the puncture to the guidewire placement in the DEHBD/D2 route (3.5 min) was shorter than that in other methods (14.0 min) (p = 0.014). Adverse events occurred in one (6.3%) patient with moderate pancreatitis. Conclusions: The proposed algorithm might be useful for the selection of an appropriate approach route in EUS-RV.

Hepatic artery aneurysm: rare cause of epigastralgia and melena

A 67-year-old woman presented to the emergency department with epigastric pain and tarry stool of several days’ duration. She presented with normal vital signs and mild epigastric tenderness. Laboratory results...

Solitary extrapleural fibrous tumor with hepatic bilobar metastases: multimodal approach treatment

BackgroundSolitary fibrous tumor is an unusual fibroblastic mesenchymal neoplasm typically described in the pleura. It may appear anywhere with a varied anatomic distribution and essentially it can develop from any soft tissue or visceral location. Its course is usually indolent and it rarely causes distant metastases, so it has a prolonged survival rate. It sometimes presents itself as a disseminate disease being the liver the most frequently involved location. In these occasions, the management should be discussed in a multidisciplinary tumor committee formed by surgeons, oncologists and radiologists. Surgery remains the gold standard for treatment.Case representationWe present the case of a woman with a tumor in the left abdominal wall and bilobar massive liver metastases, both locations histologically diagnosed as solitary fibrous tumor. She receives biological treatment for a severe case of Crohn´s disease. Evaluated in a multidisciplinary committee, surgery was recommended for both the primary lesion and the liver metastases. The hepatobiliary surgeons considered a two-stage hepatectomy with portal vein embolization (PVE) as the best strategy. After the first procedure consisting in cleaning the left hepatic lobe followed by PVE the future liver remnant volume (FLRV) was considered inadequate, so the patient was also treated with right transarterial radioembolizacion with yttrium 90 (TARE-Y90) intending a double goal: to treat the tumor and to increased the FLRV. Furthermore, a severe flare of Crohn´s disease forced us to intensify the patient’s treatment with the addition of biological agents (infliximab and adalimumab) until complete remission of the symptoms. The second stage of the liver surgery had to be postponed for more than 6 months and could finally be carried out without complications, achieving an R0 resection. The postoperative course was uneventful and the follow up has showed no recurrence to date.ConclusionSolitary fibrous tumours with extensive liver metastases are infrequent but when they appear modern surgical strategies like two stage hepatectomy are the treatment of choice and must be carried out by specialised units. The therapeutic decisions should be guided by a multidisciplinary committee.