Huge Liver Research Articles

"Zoom Resection": A Two-Step Wedge Liver Resection Technique to Resect Deep Tumors and Spare Parenchyma

In certain cases, huge liver resections are required to deal with deep tumors located near vascular pedicles. However, this implies a higher risk of postoperative liver failure and mortality. Liver parenchyma sparing techniques play an essential role in decreasing these risks. In November 2018, our surgical team reported a new two-step wedge liver resection technique to resect deep tumors in an easy way. Although it was a case report, more patients have already been successfully operated with this approach since then. Regarding the technique itself, intraoperative ultrasound is a very important tool employed to plan and guide both steps of the procedure. Initially, we put stitches and resect a cylindrical piece of normal liver parenchyma above the deep tumor. This way, we can "superficialize" the tumor. After that, we place stitches on the future specimen and resect it in the same way it is done with superficial metastases. The main advantage of this procedure is the clear sight and vascular control that can be achieved in those cases in which the tumor is close to vascular pedicles. As a result, the bigger the chance of preserving vascular pedicles, the bigger the chance of sparing parenchyma as well. We have named this procedure “zoom resection” because its dynamics is similar to that of the photograph camera telescopic system.

Small Cystic Pancreatic Neuroendocrine Neoplasm with Huge Liver and Bone Metastases

Pancreatic neuroendocrine neoplasms occasionally have a cystic component. We herein report a case of multiple hepatic tumors, including a huge one and a 24-mm sized pancreatic cystic lesion. The hepatic tumor showed an enhancement pattern consistent with hepatic adenoma. The pancreatic cystic lesion revealed a thickened outside border and a solid inside component, which was enhanced following a contrast study, suggesting cystic pancreatic neuroendocrine neoplasm. Surgical resection was performed. After the surgery, somatostatin receptor scintigraphy detected an occult lumbar spine metastasis. Huge multiple liver and bone metastases of the neuroendocrine neoplasm G2 component were seen, with a G1 small primary lesion.

Hepatocellular carcinoma in young morbid obese patients with non-alcoholic fatty liver disease

We report the two youngest cases of hepatocellular carcinoma (HCC) in non-alcoholic fatty liver disease (NAFLD) among our 119 NAFLD-HCC patients. A 36-year-old man was referred to our hospital due to a 5cm in diameter liver tumor with elevation of α-fetoprotein and des-γ-carboxy prothrombin found at his annual health check. He had no symptoms other than 20kg weight loss. He has been morbidly obese since he was a child. At the time of the diagnosis of NAFLD-HCC, blood chemistry showed FIB4-index 0.52, α-fetoprotein 11.1ng/mL and des-γ-carboxy prothrombin 361 mAU/mL. He underwent curative operation. The non-cancerous lesion showed steatohepatitis with mild fibrosis. A 41-year-old man was diagnosed as having a huge liver tumor (15cm in diameter) during medical examination for 10kg weight loss. He had no clinical symptoms except weight loss. He has been morbidly obese since childhood. NAFLD was diagnosed at age 20. At the time of the HCC diagnosis, blood chemistry showed FIB4-index 1.42, α-fetoprotein 1974ng/mL, and des-γ-carboxy prothrombin 82,602mAU/mL. He underwent curative operation. We have to be aware that HCC can develop in young NAFLD patients without advanced fibrosis. Concerning tumor markers, elevation of des-γ-carboxy prothrombin was more sensitive than α-fetoprotein.

MON-901 Primary Amenorrhea, Growth Arrest and Metabolic Syndrome Due to an Unclassified Hepatocellular Adenoma

Primary Amenorrhea, Growth Arrest and Metabolic Syndrome Due to an Unclassfied Hepatocellalar Adenoma. Background: Hepatocellular adenoma is a rare benign neoplasm, seldom ascribed as the cause of endocrine and metabolic derrangement. We herein report a case of primary amenorrhea, growth arrest and metabolic syndrome due to huge hepatocellular adenoma. En bloc resection of the tumor normalized all the disturbances. Clinical Case: A 16-year-old girl, who is one of the quintuplets, complained of primary amenorrhea and growth arrest for the past 2 years. Her height (150cm) and weight (40kg) was at the 3rd percentile, whereas waist circumference (75cm) was at the 90th percentile for chronological age. She was hypertensive (145/115mmHg) on admission. Plasma cholesterols (TC 6.3mmol/L, LDL-c 3.76mmol/L), triglyceride (2.66mmol/L) and uric acid (532μmol/L) were elevated. Evaluation of GH/IGF-1 axis showed normal GH (0.90–2.53 μg/L) with extremly low IGF-1 concentration (35.29–39.74 ng/mL), and the latter was unresponsive to hGH stimulation. Computer tomography identified a huge liver mass (18.2cm×13.7cm×21cm). The patient underwent an uneventful open right hepatic lobectomy and cholecystectomy, and the tumor was en bloc resected. Immunohistochemistry indicated an unclassified hepatocellular adenoma, which was confirmed by whole exome sequencing. Her menarche started 6 months later followed by regular cycles without hormone replacement. IGF-1 concentration (471 ng/mL), blood pressure (102/62mmHg), lipid profile (TC 4.2mmol/L, LDL-c 2.51mmol/L, TG 1.44mmol/L) were all nomalized 10 months after surgery, and the girl had a reduction in waist circumference by 5cm, and a small gain in height by 2cm. Conclusion: We provide evidence that liver-derived IGF-1 has a direct effect on skeletal and pubertal development, blood pressure, viseral adiposity and dyslipidemia. Though rare, we propose the need to look into cases with heptocellular adenoma, for the existence of IGF-1 deficiency and its impact on endocrine and metabolic derangment.

Indocyanine green fluorescence imaging via endoscopic nasal biliary drainage during laparoscopic deroofing of liver cysts.

Laparoscopic deroofing of liver cysts is widely accepted as the treatment of symptomatic huge liver cysts. As bile leakage is a common complication of this procedure, indocyanine green (ICG) imaging has played an active role in detecting intrahepatic biliary tract. However, infusion ICG imaging needs time rag after injection due to moving from bloodstream to bile, and also, additional injection is needed when the fluorescent imaging is not clear. To cover this weakness of ICG imaging, we first applied ICG imaging via 5-Fr endoscopic nasal biliary drainage (ENBD) during laparoscopic deroofing of liver cysts. This technique promptly gives us ICG imaging after ICG injection from ENBD; in addition, direct ICG imaging sometimes reveals minor leakage from sealing line and staple lines; therefore, we believe that direct ICG imaging via ENBD helps us to prevent post-operative bile leakage.

Comparative effect of CalliSpheres drug loading microspheres and lipiodol transarterial chemoembolization in the treatment of huge primary liver cancer

回顾性分析71例通过CalliSpheres载药微球经导管动脉化疗栓塞（DEB-TACE）或碘油经导管动脉化疗栓塞（cTACE）治疗的巨块型肝癌患者，其中DEB-TACE组31例，cTACE组40例，比较治疗前后肝功能变化，统计两组患者总的生存期变化，分析影响患者预后的相关因素；发现DEB-TACE较cTACE的肝脏毒性小、局部肿瘤控制效果好，且能延长患者生存期，是治疗巨块型肝癌的安全、有效的方法。.

Partial response after treatment with Conversion chemotherapy

Rationale:Many studies have reported radical resection for liver metastasis and the primary tumor could represent an important prognostic factor in patients affected by colorectal liver metastases (CRLM). However, resection of huge liver metastases from colon cancer has been seldom reported.Patient Concerns:A 58-year-old man presented with huge liver metastases from colon cancer. Laboratory tests revealed elevated tumor markers and a wild-type mutation in the K-RAS gene. A computed tomography scan demonstrated unresectable liver masses with a 16.5-cm maximum diameter and intrahepatic duct dilatation due to compression by the liver metastases.Diagnosis:The patient was diagnosed with stage IV descending colon carcinoma with multiple huge hepatic metastases.Interventions:He was administered 3 treatment courses, including 9 cycles of combined chemotherapy with mFOLFOX6 plus cetuximab (mFOLFOX6 + Cet), and the liver masses reduced. After a preoperative assessment by a multidisciplinary team when the 9 cycles of systemic chemotherapy had been completed, the patient underwent hepatectomy, followed 4 months later by a laparoscopic colectomy. We used a reverse strategy (liver-first) for the patient.Outcomes:In this case, liver-first treatment (systemic chemotherapy of mFOLFOX6 + Cet) was an effective treatment for unresectable CRLM. No postoperative complications occurred. The patient continued to receive postoperative chemotherapy (mFOLFOX6 + Cet) at the latest follow-up. During the 17 months of follow-up, tumor recurrence was un-noted.Lessons:Treating colorectal cancer patients with huge hepatic metastases is possible, and surgeons should consider various treatment options in the management of these patients.

A Huge Liver Cyst Manifesting Dyspnea and Edema.

A Huge Liver Cyst Manifesting Dyspnea and Edema.

Progress in research of radiofrequency ablation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in the world, and its incidence is on the rise. Surgical resection is the standard method for the treatment of primary or metastatic HCC. In the past ten years, the local ablation of liver tumor has become more and more mature, and it has been proved to be an effective method for the treatment of malignant liver diseases. Whether used alone or in combination, it can control the growth of the tumor to a certain extent and prolong the survival time. It also improves the quality of life. This article begins with the mechanism of radiofrequency ablation in the treatment of liver cancer, and introduces in detail the research progress in the treatment of small liver cancer, large liver cancer, huge liver cancer and metastatic liver cancer by radio frequency ablation and the evaluation of the curative effect after operation. Key words: Carcinoma, hepatocellular; Hepatectomy; Catheter ablation

Liver transplantation after complete hepatic artery avulsion secondary to blunt abdominal trauma

Background: Hepatic artery avulsion secondary to blunt abdominal trauma is a rare cause of massive hemoperitoneum. Ischemic cholangiopathy it is a possible complication secondary to its ligation. Methods: We report the case of a trauma patient with ischemic cholangiopathy secondary to hepatic artery ligation who required liver transplant (LT). Results: A 37-year-old man was admitted to the emergency room after falling from a third-floor flat. During surgical exploration, a massive hemoperitoneum secondary to hepatic artery avulsion was observed. Reconstruction of the artery could not be achieved so it was ligated. He was admitted to ICU, improving progressively of his hemodynamic instability and ischemic hepatic failure. MRI, 34 days after surgery, showed diffuse ischemic cholangiopathy. After severe repeated cholangitis he was included for LT that was performed 70 days after surgery using a classic technique due to its huge liver volume (4200 gr). During immediate postoperative period he was reoperated four times due to hemoperitoneum and necrohemorrhagic pancreatitis. On day 36th after LT, he developed a nonsurgical intracranial hemorrhage, dying 2 days after. Conclusion: Diffuse ischemic cholangiopathy secondary to hepatic artery lesion is an uncommon indication of LT. Traumatized patients with vascular lesions should be transferred to a specialized center.

Laparoscopic anatomical resection of segment 7 and segment 8 when right hepatic vein reconstruction was not necessary

Introduction: For a huge liver cancer in segment 7 and 8 with right hepatic vein (RHV) involvement, some patients with large inferior right hepatic veins (IRHV) can avoid complex vascular reconstruction after en bloc resection of segment 7 and 8 and RHV. In such a situation, safe laparoscopic surgery becomes possible. Method: This is a case report about a 9.7cm HCC in segment 7 and 8 with RHV involvement inside liver parenchyma. This patient had at least two large IRHV in computed tomography. In this operation, I transected the parenchyma along the middle hepatic vein first to create a midline plane. Then the right major Glisson's pedicle and S8 pedicle next to it were exposed in parenchyma from the opened liver midline. After S8 pedicle was transected, I advanced the dissection between segment 5 and 8 ( the transverse plane) and cut the tributaries and the dominant tract of RHV in this plane. The surface of a large IRHV was exposed in this transverse plane too. In another direction, I deepened the midline plane to expose IVC superior to the liver hilum. The root of RHV was ligated and cut from IVC. The root of the large IRHV on IVC was exposed in this midline plane between RHV and liver hilum. So, the large IRHV was preserved in both midline and transverse plane. I further advanced the parenchyma dissection to cross the surface of IRHV, and then deepened the dissection dorsally to separate the segment 7 & 6. Triangular and coronary ligaments were cut at last. Result: Hepatopetal portal flows were all preserved. Conclusion: In summary, this laparoscopic operation was performed using caudal to cranial (midline), medial to lateral ( between S5-S8), and ventral to dorsal (between S6-S7) approach. There was not any dissection between IVC and segment 1 right portion behind liver hilum.

Undifferentiated Embryonal Sarcoma of the Liver: An Enigma of Diagnosis

A 20-year-old man presented with peritonitis requiring emergency laparotomy. He was found to have a huge liver abscess on the right lobe. Open drainage was performed but the abscess was persistently unresolved upon follow up. Computed tomography (CT) revealed a solid liver lesion with raised Ca 19-9. Right hepatectomy was subjected and histology was consistent with a rare and aggressive case of embryonal sarcoma of the liver. Despite oncologic resection, he developed local recurrence and succumbed to death in 6 month postoperatively. We describe a unique aetiology of liver abscess with literature reviews of undifferentiated embryonal sarcoma of the liver.

Hepatocellular carcinoma producing granulocyte colony-stimulating factor: diagnosis and treatment

Granulocyte colony-stimulating factor (G-CSF) is a naturally occurring glycoprotein that is synthesized by stromal cells in bone marrow. Several cases of G-CSF-producing malignant tumors in various organs have been reported, but it is extremely rare in hepatocellular carcinoma (HCC). Here, we report a rare case of HCC producing G-CSF. The patient presented with a continuous fever and had a huge liver mass in the right lobe with portal vein tumor thrombus (PVTT) in the right first branch. He had marked granulocytosis, and his serum level of G-CSF was elevated. A complete curative liver resection was performed after preoperative radiotherapy to PVTT. The pathological findings of the resected specimen revealed poorly/moderately differentiated HCC, and immunohistochemical staining of G-CSF was negative the first time it was tested, but the second time, it was positive in the cytoplasm of other tumor cells of HCC. Only a few cases of G-CSF-producing HCC have been reported, and they resulted in rapid tumor growth, metastases, and poor prognosis. In our case with PVTT, there was no liver recurrence, although multiple lung metastases occurred at 8months after curative resection. We should consider G-CSF-producing HCC and diagnose promptly when encountering liver tumor patients with leukocytosis, and we should perform multimodal treatment including radiation, radical surgery, and chemotherapy.

Laparoscopic cholecystectomy difficulties, challenges and surprises

Introduction: Laparoscopic cholecystectomy is considered since long time as gold standard treatment for cholecystolithiasis. Preoperatively surgeon can anticipate difficulty of the procedure and prepare a plan how to deal with it. Sometimes the surgeon can be faced with a surprise intra-operatively. Methods: We collected retrospectively a series of cases subjected to laparoscopic cholecystectomy in Alexandria university from 2014 to 2017, in which there were technical or anatomical difficulties, intra-operative surprises, and how was the procedure completed safely. From 350 cases of laparoscopic cholecystectomy, 23 cases considered difficult or with intra-operative challenge. we had one case of acute cholecystitis in a child with situs invertus totalis, one case of left sided gall bladder, one case of gall stones after left donor hepatectomy, one case of heamangioma adherent to the gall bladder, one case diagnosed a huge liver cyst, one case child 4 years with acute cholecystitis and pancreatitis, five cases with previous big abdominal surgeries, one case with multiple whitish spots all over the liver, one case of accessory bile duct, three cases of caterpiller hump, two cases of stump cholecystectomy, and 4 cases of laparoscopic cholecystectomy after failed open cholecystectomy. Conclusion: Laparoscopic cholecystectomy is a frequently performed surgery with expected difficulties and challenges to the surgeons.

Left Lobe Mobilization Strategy of Right-Sided Major Hepatectomy for Treatment of a Tumor Causing Severe Inferior Vena Cava Compression: A Novel Strategy Using the Modified Liver-Hanging Maneuver

Massive bleeding during major hepatectomy is associated with greater mortality and morbidity.1 Our previous study shows that inferior vena cava (IVC) compression by tumor and an anterior approach without the liver-hanging maneuver (LHM) are risk factors for massive bleeding.2 The LHM is useful for controlling bleeding in deeper parenchymal transection planes.3 However, severe compression of the IVC by tumor makes it difficult to insert a hanging tape.4 The study shows a novel modified LHM strategy for severe IVC compression to minimize intraoperative bleeding. The procedure was disassembled into six steps: (1) the glissonian bifurcation is encircled using an extrahepatic approach (2) the hepatic ligaments are dissected, and the root of each hepatic vein trunk is exposed (3) the left lobe is fully mobilized, and the short hepatic veins are carefully dissected with a systematic procedure established from hemi-left lobe procurement in living donor liver transplantation5 (4) the tape is inserted from the space between the right and middle hepatic vein trunks into the glissonian bifurcation along the anterior surface of the IVC (5) liver parenchymal transection is performed with upward pulling of the tape (6) the right hepatic vein is dissected, and the right lobe is dissected from the diaphragm and the right hepatic ligaments. Right hepatectomy with this procedure was performed for two patients with IVC compressed by hepatocellular carcinoma. The operative times were respectively 483 and 396min. The respective estimated blood losses were 1195 and 485ml, without transfusion. Both patients had acceptable outcomes without complications. The novel modified LHM strategy ensured minimal bleeding in the resection of a huge liver tumor causing severe IVC compression.

A rare case of pericarditis and pleural empyema secondary to transdiaphragmatic extension of pyogenic liver abscess

BackgroundTransdiaphragmatic extension of pyogenic liver abscess is the rarest cause of pericarditis and pleural empyema. It is a rapidly progressive and highly lethal infection with mortality rates reaching 100% if left untreated. However, the transmission route, treatment methods and prognosis have not been well studied.Case presentationA 65-year-old male patient presented with a fever, dyspnea, and right upper quadrant abdominal pain. Computed tomography of the chest and abdomen showed huge liver abscess without full liquefaction in the left lobe, large amount of left pleural effusion, and mild pericardial effusion, and the patient was treated with parenteral antibiotics and pigtail insertion at the left pleura. However, four days later, cardiac tamponade was developed and surgical drainage of the abscess and pericardium was performed. Klebsiella pneumonia was isolated from pleural empyema. Twenty-five days after surgery, the patient was discharged without any complications.ConclusionsHerein, we report a rare case of pleural empyema and pericarditis in that resulted from the extension of huge pyogenic liver abscess. Early surgical treatment may have prevented progression of the pericarditis to the more dismal purulent pericarditis. We also review pertinent English literature on pericarditis as a complication of PLA.

Hepatocellular Carcinoma Arising in a Huge Hepatocellular Adenoma with Bone Marrow Metaplasia.

Hepatocellular adenoma (HCA) is the most common type of benign liver tumor, and its major complication is malignant transformation to hepatocellular carcinoma (HCC). Here, we report a case of HCC arising in HCA with bone marrow metaplasia in a 24-year-old Korean woman who presented with abdominal discomfort. A huge liver mass was found on abdominal ultrasonography. She underwent surgical hepatic resection, and the resected specimen was entirely involved by a 20-cm-sized tumor. Histological review revealed a well differentiated HCC arising from inflammatory HCA with β-catenin nuclear positivity and bone marrow metaplasia that contained hematopoietic cells. This case was unique because malignant transformation, inflammatory type HCA, β-catenin nuclear staining, and bone marrow metaplasia were simultaneously observed. Additionally, it should be noted that a large HCA with β-catenin activation can undergo malignant transformation and should be surgically resected in a timely manner.

Liver Transplantation for Polycystic Liver Disease Due to Huge Liver With Related Complications: A Case Report

Polycystic liver disease is characterized by multiple cystic lesions on the liver. It is an uncommon autosomal dominant disease. The cysts' diameters range from 20 to 30 cm to small microscopic nodules. Generally, more than half of the liver parenchyma is covered. The mass effect of the liver created by the large cysts can cause life-threatening symptoms such as weight loss, reduction of oral intake, and malnutrition. Liver transplantation is the best treatment option in symptomatic patients. We present a patient who had polycystic liver and kidney disease, and we performed liver transplantation because of his life-threatening symptoms.

Size control mechanism in animals

It remains to be mysterious for years as how distinct animals and their organs attain proper sizes. About a decade ago, Science listed “Top 125” to-be-solved scientific issues and included “size control mechanism” into it. Elucidation of the molecular, cellular and evolutionary mechanism of size control in animals especially in mammals would help us to better understand and manipulate the growth, development and regeneration of individuals and organs, which in turn will improve the modern regenerative medicine. Here in this review, we discussed the size control mechanism of animals and their organs. The animal body size is largely determined by their living environment, such as temperature, food and their geographic distribution. The animal’s organ size is directly associated with their body size and meanwhile affected by the organ function. Larger animals naturally have larger organ size and the organs which play more important physiological roles tend to have larger size. All organs finally evolve to a most “fit” size which reaches the balance between function and energy consumption. Basically body and organ size is determined by cell numbers but barely by cell size, so the size is tightly controlled by the rate and passages of cell proliferation. For a specific type of cells, how many progeny they produced is decided by how many cells are in need. Therefore, in the organ, the most abundant cells are those play most important physiological roles. As cell proliferation takes time, the lower animals with long life span can usually grow into very large size. And larger animals tend to have a longer fetal stage to accumulate sufficient immature stem cells to give rise to more mature cells. The cell proliferation rate is also inherently decided by the species or in another word their genetic background. Xeno-tranplantation of stem cell experiment demonstrated that the donor cells can form an organ whose size is in between the donor and recipient species, suggesting both genetic background and environment can affect the organ size. At molecular level, basically all regulator of cell proliferation can affect body and organ size. Some signal pathways such as mTOR and Hippo play critical roles in size control. Constitutive activation of Hippo pathway will generate over-size organs such as huge liver and gut. Other factors such as stem cell number, nutrition condition and mechanical pressure can also affect the organ and body size. To sum up, size matters for animals. The body and organ size is influenced by many factors of genetic, cellular and tissue levels. Animals of different size altogether form a biosphere with high complexity. They have diverse demand for sunlight, atmosphere, nutrition, space and trace elements, which makes them a stable ecological cycle.

Feasibility of radiofrequency ablation as an alternative to surgical intervention in patients with huge multiloculated pyogenic liver abscesses: A retrospective cohort study.

This retrospective cohort study investigated the feasibility of radiofrequency (RF) ablation as an alternative to surgical intervention in patients with huge multiloculated pyogenic liver abscesses (PLAs).From August 2010 to April 2016, 83 patients with PLA were admitted to Beijing Chao-Yang Hospital, China. Four of these patients had huge multiloculated PLAs and underwent RF ablation plus antibiotics. The inclusion criteria for RF ablation were as follows: multiloculated PLA confirmed by computed tomography (CT) or magnetic resonance imaging (MRI), widest diameter of the PLA ≥5 cm, failure to respond to or not suitable to treatment with percutaneous drainage (PD), and patient refusal of surgery. The safety and effectiveness of RF ablation were initially assessed. All patients were commenced on antibiotics on admission to our hospital. CT-guided percutaneous catheter drainage was attempted in one patient but was unsuccessful. The main organism isolated from cultures of these patients’ blood or abscess samples was Klebsiella pneumoniae (3/4). RF ablation was performed as soon as eligibility according to the above criteria was established.RF ablation was technically successful in all 4 study patients, all PLAs being completely eradicated. The median duration of fever after RF ablation was 4.5 days. No abscesses recurred; thus, this strategy for managing PLA was 100% successful (4/4). No procedure-related deaths or major complications occurred. One patient had an asymptomatic right pleural effusion that resolved with conservative treatment including albumin infusion and diuretics.Our preliminary data indicate that RF ablation is a safe, feasible, and effective treatment for huge multiloculated PLAs. It should be considered as an alternative treatment for patients who fail to respond to or not suitable for PD plus antibiotics and refuse surgical intervention.