Left Hepatic Lobectomy Research Articles

Long-term survival after multidisciplinary treatments for HER2-positive advanced gastric cancer with multiple liver and lung metastases

BackgroundTrastuzumab-based chemotherapy is a standard treatment regimen for human epithelial growth factor 2 (HER2)-positive gastric cancer. This is a case of a patient who has survived 12 years after being diagnosed with advanced gastric cancer with multiple liver and lung metastases.Case presentationA woman in her 70s underwent total gastrectomy, cholecystectomy, and left hepatic lobectomy for gastric cancer with liver metastasis. One month after the surgery, multiple liver metastases appeared. After two courses of S-1 + CDDP chemotherapy, the liver metastases disappeared, and new lung metastases occurred. Because the primary tumor was HER2 positive, S-1 + CDDP + trastuzumab chemotherapy was performed. After one course of chemotherapy, the blood test showed pancytopenia, and CDDP was discontinued. S-1 + trastuzumab chemotherapy was then initiated, and as a result, the lung metastases disappeared. The patient is alive without recurrence 12 years after the surgery.ConclusionsWe encountered a case of long-term survival after multidisciplinary treatments for HER2-positive advanced gastric cancer with multiple liver and lung metastases.

Establishment and assessment of postoperative cognitive impairment in intermittent hypoxia rats.

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a chronic disease characterized by repeated episodes of apnea or hypopnea, accompanied by intermittent awakening and sleep disturbances. The incidence of OSAHS is increasing and has become a serious disease. In recent years, more and more evidence shows that OSAHS is closely related to postoperative neurocognitive disorders, and the preparation of models of postoperative cognitive impairment in intermittent hypoxia animals is an important way to study its pathogenesis and intervention targets. This study aims to explore the establishment and evaluation of the animal model of postoperative cognitive impairment in intermittent hypoxia rats. A total of 108 male SD rats were randomly divided into 8 groups: a control group (C group, n=27), a surgery group (S group, n=27), an intermittent hypoxia 7 d group (H1 group, n=9), an intermittent hypoxia 14 d group (H2 group, n=9), an intermittent hypoxia 21 d group (H3 group, n=9), an intermittent hypoxia 7 d operation group (O1 group, n=9), an intermittent hypoxia 14 d operation group (O2 group, n=9), and an intermittent hypoxia 21 d operation group (O3 group, n=9). The rats in the H1, H2 and H3 group treated with intermittent hypoxia for 7, 14, and 21 d, respectively. The rats in the O1, O2 and O3 groups received left lateral hepatic lobectomy after 7, 14, and 21 d intermittent hypoxia, respectively. The rats in each group were subjected to open field test, new object recognition test, and Barnes Maze test. The expression of IL-1β mRNA in hippocampus of rats was detected at the 1st day after the surgery. Compared with the C, S, and H2 groups, the discrimination index in novel object recognition test 6 h and 1 d after the surgery of the O2 group was significantly lower (P<0.05), the latency and errors in Barnes maze at the 1st day and 2nd day after the surgery were increased significantly (P<0.05) and the expression of IL-1β mRNA in hippocampus was significantly increased at the 1st day after the operation (P<0.05). However, there was no difference in the preference index in NORT 6 h and 1 d after the surgery, the latency and errors in Barnes maze and the expression of IL-1β mRNA in hippocampus between the O1 group and the H1 group, the H3 group and the O3 group (all P>0.05). The rate with intermittent hypoxia 14 d pretreatment with anesthesia and laparotomy could be established the animal model of postoperative cognitive impairment.

A216 WHEN CANCER CASTS THE FIRST STONE: A CASE REPORT OF GALLBLADDER CANCER PRESENTING AS GALLSTONE ILEUS

BackgroundGallstone ileus is a rare cause of mechanical bowel obstruction. It occurs when a biliary stone passes through a cholecystoenteric fistula and becomes impacted in the bowel lumen, most commonly at the terminal ileum or ileocecal valve.Gallbladder cancer is rare and often has a poor prognosis. Many patients present with advanced-stage disease and only 10% of patients are candidates for surgical resection. Early research has shown there is an increased incidence of gallbladder cancer among patients with gallstone ileus. To date, this relationship remains poorly understood.AimsTo present a case of an elderly female whose gallbladder cancer presented after causing a cholecystoenteric fistula and gallstone ileus.MethodsA retrospective review of a single patient case.ResultsOur patient was a 78-year-old female with a background history of hypertension, iron-deficiency anemia, osteoporosis, and treated bilateral breast cancer. She initially presented with acute cholecystitis, complicated by a concurrent pulmonary embolism. Given her need for systemic anticoagulation, she was treated non-operatively with antibiotics and an outpatient cholecystectomy was planned.She returned to hospital eight months later reporting two days of nausea and vomiting. A repeat CT scan showed a cholecystoduodenal fistula with a 3.5cm x 2.6cm gallstone impacted 20cm from the ileocecal valve. A laparoscopic-assisted enterolithotomy was performed and her postoperative course was uneventful.One month later, a CT scan was organized by her family physician to follow-up on incidental liver lesions. While the liver lesions were deemed benign, there was new lobulated soft tissue within the gallbladder, measuring 4.8cm x 4.7cm x 6.2cm, suspicious for a primary gallbladder malignancy. A follow-up MRI confirmed an intraluminal mass with direct invasion into hepatic segment III as well as marked segment III intrahepatic biliary dilatation. Endoscopy to the duodenum and cholecystoduodenal fistula was performed with a biopsy confirming gallbladder adenocarcinoma.She underwent an open radical cholecystectomy, left hepatic lobectomy, antrectomy, resection of 1st portion of duodenum, and reconstruction with a Roux-en-Y gastrojejunostomy. Final pathology and staging confirmed a pT3pN0M0 adenocarcinoma of the gallbladder with a fistula tract within the cancer extending to the duodenum. She was then referred to a cancer center to complete a six-month course of adjuvant chemotherapy with capecitabine.ConclusionsGallstone ileus is a cause of mechanical bowel obstruction and rarely, it can be the first presentation of gallbladder cancer. Gallbladder cancer has a poor prognosis with many patients presenting with late-stage disease. As a result, we recommend the consideration of post-enterolithotomy imaging in select patients to evaluate for evidence of malignancy.Funding AgenciesNone

A Case of Intraductal Oncocytic Papillary Neoplasms of the Bile Duct (IOPN) Metachronously Arising in the Liver

62-year-old woman presented with left hypochondriac pain and a giant cystic lesion in the left lobe of the liver was pointed out by CT examination. The tumor appeared a multilocular cystic lesion connecting to the left hepatic duct and included a solid component with internal septum, which were enhanced by contrast CT. Preoperative diagnosis was a intraductal papillary neoplasm of the bile duct or intrahepatic cholangiocarcinoma, and a left hepatic lobectomy was performed. Macroscopically, it was a multilocular cystic lesion, 17 cm in size, containing abundant mucin and papillary nodule. Microscopically, papillary growth of the cuboidal neoplastic cells comprising with eosinophilic cytoplasm and enlarged nuclei in the dilated bile ducts was observed. The tumor was diagnosed as a intraductal oncocytic papillary neoplasm of the bile duct (IOPN). Four years after the left hepatectomy, a tumor, 2 cm in size, was found in the caudate lobe and the partial caudate lobectomy was performed. Pathologically, the secondary lesion revealed the similar morphology as the primary tumor. By genomic analysis, identical mutation in CTNNB1 was detected in both tumors. That is, the metachronous tumor arising in caudate lobe was originated from primary cancer clone, and considered as a postoperative recurrence in the remnant intrahepatic bile duct. This is a rare case of IOPN metachronously arisen in the liver. The repeated surgical attempts were possibly contributed to prolonged survival.

Laparoscopic major (&gt; 2 segments) hepatectomy in Greece

Despite gaining traction around the world, laparoscopic approach to major hepatectomy, defined as resection of at least two neighboring hepatic segments, has not been fully adopted in Greece. We sought to describe our growing experience. Data on six patients who underwent major hepatic resection in the last year in two major urban hospitals. The predominant indication for hepatectomy in these patients were metastatic disease to the liver. Three patients had colorectal metastases, one patient had metastatic melanoma, and two patients had benign pathology. There were two males and four females, with an average age of 59 (range: 52-71 years). Four patients had a solitary lesion and two had two lesions. Four patients had received pre-hepatectomy disease-specific chemotherapy or immunotherapy. The median size of the lesion was 5 cm (range: 3.5-12 cm). Two patients underwent a right hepatic lobectomy, one a left hepatic lobectomy together with a right colectomy, and three patients underwent right anterior sectorectomy. All operations were done purely laparoscopic except one, where a hand port was employed due to the size of the lesion. Median operative time was 190 minutes and median stay at the hospital was 2 nights. No patient required intensive care unit monitoring. There was no 30-day mortality. Major laparoscopic hepatic resection can be accomplished safely in well selected patients in the current Greek health system. Patients who have a laparoscopic hepatectomy benefit from a short hospital stay, without jeopardizing the safety of the operation.

Primary hepatic follicular lymphoma 5 years post sustained virological response from hepatitis C viral infection

A 72-year-old man who was treated with a combination of simeprevir with peginterferon and ribavirin for hepatitis C virus (HCV) infection (genotype 1b) 5 years ago and has been treated...

Mixed adenoneuroendocrine carcinoma with loss of HER2 positivity after trastuzumab-based chemotherapy for HER2-positive gastric cancer: a case report

BackgroundTrastuzumab (T-mab)-based chemotherapy is a standard regimen for human epithelial growth factor 2 (HER2)-positive gastric cancer. However, some patients have demonstrated a change in HER2 status after T-mab-based treatment of breast cancer. We report a rare case of mixed adenoneuroendocrine carcinoma with loss of HER2 positivity after T-mab-based chemotherapy for HER2-positive gastric cancer.Case presentationA 60-year-old man presented with a mass of the upper abdomen, which was diagnosed as adenocarcinoma with a HER2 score of 3+ by endoscopic biopsy. He received seven cycles of combination chemotherapy with capecitabine, cisplatin, and T-mab. Subsequently, he underwent open total gastrectomy, distal pancreatosplenectomy, and extended left hepatic lobectomy as a conversion surgery. The surgically resected specimen demonstrated both adenocarcinoma and neuroendocrine components; therefore, it was diagnosed as HER2-negative mixed adenoneuroendocrine carcinoma. Although the patient received additional chemotherapy, multiple liver metastases appeared at 3 months postoperatively and he died at 6 months postoperatively because of the rapidly progressing metastatic tumor.ConclusionsWe encountered a rare case of rapidly progressive mixed adenoneuroendocrine carcinoma that was negative for HER2 expression after T-mab treatment combined with chemotherapy.

Radical resection of an initially unresectable intrahepatic cholangiocarcinoma after chemotherapy with using gemcitabine, cisplatin, and S-1: report of a case

BackgroundMetastatic biliary tract cancer (BTC) has poor prognosis. Recently, patients with metastatic BTC who respond well to systemic chemotherapy can be treated by radical resection or “conversion surgery.”Case presentationA 67-year-old male patient was diagnosed with intrahepatic cholangiocarcinoma with para-aortic metastases [cT2N1M1, stage IVB]. He was enrolled in our phase II study for unresectable BTC consisting of cisplatin (25 mg/m2 i.v. for 30 min) followed by gemcitabine (1000 mg/m2 i.v. for 30 min) on days 1 and 8 and oral S-1 on alternate days. After 8 courses of this regimen, marked regression of para-aortic lymph metastases was achieved, and we performed extended left hepatic lobectomy with the caudate lobe, concomitant portal vein resection, and lymph node dissection including the para-aortic region. The patient made a satisfactory recovery and was discharged on postoperative day 25. Histopathological examination revealed more than 50% of the tumor area replaced with fibrosis, and curative resection was achieved (ypT2N1M1, stage IVB, Evans criteria IIb). The patient received adjuvant chemotherapy using S-1 for 12 months and remains well with no evidence of tumor recurrence as of 48 months after surgery.ConclusionsWe herein report a successfully treated case of advanced BTC with para-aortic lymph node metastases by conversion surgery after combination chemotherapy using gemcitabine, cisplatin, and S-1.

Hepatic pleomorphic leiomyosarcoma after surgery for gastric gastrointestinal stromal tumor: a case report

BackgroundPleomorphic leiomyosarcomas (PLMSs) are extremely rare tumors. We present the first case of hepatic primary PLMS after surgery for gastric gastrointestinal stromal tumor (GIST).Case presentationThe patient was a 62-year-old man who was referred to our hospital for resection of a hepatic tumor arising after gastric GIST surgery that was resistant to imatinib and sunitinib. A 40-mm tumor in the left lobe of the liver and three small nodules in the right lobe were detected. We performed hepatic left lobectomy and partial resections for three lesions. According to the histopathological and immunohistochemical findings and c-kit gene mutations analysis, the main tumor was diagnosed as a PLMS.ConclusionIt is necessary to consider the possibility that imatinib-resistant GIST recurrence lesions are a different kind of soft-tissue sarcoma. Accurate diagnosis is required to not miss the opportunity for radical excision of PLMS.

Type IV cholangiocellular carcinoma in a patient with neurofibromatosis Type 1

Background: Neurofibromatosis type 1 is an inherited disease of autosomal dominant type. Although risk of malignancy is much more than normal population, cholangiocellular carcinoma is not a common type of malignancy in these patients. Methods: We report a patient with NF type 1 and cholangiocellular carcinoma. Results: Thirty one years old male patient admitted to clinic with the complaint of back pain, jaundice and pruritis. On physical examination there was icterus and too many neurofibromas and cafe au lait spots. In laboratory evluation, liver enzymes and cholestatic markers were eleveated and total and conjugated bilirubin levels were 16 and 14 mg/dl respectively. Magnetic resonance imaging revealed us dilated intrahepatic biliary ducts and a mass located in klatskin point. The tumor was extending to both left and right common hepatic ducts (type IV Klatskin tumor). Right anterior duct was totally invased by tumor and right posterior duct was intact just at the confluence of right posterior and right anterior duct. With these findings we planned percutaneous transhepaitc biliary drainage. After bilirubin levels achieved below 3 mg/dl value, we performed extended left hepatic lobectomy and qaudate lobectomy. Conclusion: We conclude that cholangicellular carcinoma must be kept in mind as an entity in patients with neurofibromatosis type 1. According to our knowledge, this is the second case of co-occurence of neurofibromatosis type 1 and cholangiocellular carcinoma reported in english literature.

Intraductal papillary neoplasm of the bile duct: a single-center retrospective study.

ObjectiveIntraductal papillary neoplasm of the bile duct (IPNB) has been increasingly recognized and reported. However, its clinical features are still controversial because of its low incidence. In the present study, we investigated the characteristics of IPNB.MethodsIn total, 28 patients with IPNB were treated at our institution from January 2000 to December 2016. Clinical data were collected and a retrospective accurate database was constructed. Demographic characteristics, perioperative management, and prognosis were retrospectively analyzed.ResultsAbdominal discomfort was the most common symptom. Preoperative imaging revealed biliary tract dilatation in 23 patients. Left lateral or left hepatic lobectomy was the most frequently performed surgical procedure. Histological analysis revealed malignancy in 17 patients. Eighty-eight lymph nodes were swept from the patients with malignant disease, but only three were metastatic. Twenty-one patients were followed up for 3 to 60 months (mean, 29.4 ± 18.2 months). Seven patients died during the follow-up period. Patients with benign tumors had significantly greater disease-free survival.ConclusionsIPNB is a rare biliary disease that occurs mainly in patients of advanced age. The most common symptom is abdominal discomfort. Lymphatic metastasis is uncommon. Patients with benign tumors may have a better prognosis than those with malignant tumors.

Incidence and Prognosis of Primary Gastrinomas in the Hepatobiliary Tract

Importance Zollinger-Ellison syndrome (ZES) is a life-threatening disease caused by a malignant tumor that secretes gastrin (gastrinoma). Gastrinomas typically occur in the pancreas or the duodenum. Objective To describe the incidence and prognosis of very unusual gastrinomas originating in the hepatobiliary tract. Design, Setting, and Participants This study included 223 consecutive patients at the National Institutes of Health and Stanford University Hospital who were enrolled in a prospective protocol to treat ZES using proton pump inhibitors to control acid hypersecretion and surgical resection to ameliorate the tumoral process. Data were collected from June 1982 to August 2017. Main Outcomes and Measures Incidence, location, surgical results, and cure rate and overall survival among patients with gastrinomas that originate in the liver or bile ducts. Cure was defined as serum gastrin levels within the reference range, negative results of a secretin test, and no tumor found on imaging. Results Of the 223 patients who underwent surgery to remove gastrinomas, 7 (3.1%) had liver or biliary tract primary tumors, including 5 men and 2 women (mean age at diagnosis, 43 years; range 27-54 years). The mean serum gastrin level was 817 pg/mL (range, 289-2700 pg/mL). Each patient had positive results of a secretin test. None had evidence of multiple endocrine neoplasia 1. Four patients had primary tumors in the liver (1 in segment II, 2 in segment IV, and 1 in segment V); 3, in the bile duct (1 in the right hepatic duct, 1 in the left hepatic duct, and 1 in the common hepatic duct). Surgical resection required 1 right hepatic lobectomy, 1 left lateral segmentectomy, 2 left hepatic lobectomies, 1 central hepatectomy, and 2 bile duct resections. Four patients had nodal metastases, and no patient had distant metastases. No operative deaths occurred, but 3 patients had complications, including bile duct stricture, portal vein stricture, and biliary fistula. Each patient was disease free in the immediate postoperative period, and 3 had recurrences in the liver and portal lymph nodes (at 3, 11, and 15 years). Three patients (43%) remained free of disease at follow-up ranging from 24 months to 26 years. Conclusions and Relevance Primary gastrinomas of the hepatobiliary tract are uncommon (3%), but the hepatobiliary system is the second most frequent extraduodenopancreatic primary location (after the lymph nodes). These tumors can occur outside the gastrinoma triangle and must be specifically considered. Furthermore, their discovery changes the operative approach because aggressive liver or bile duct resection is indicated, with high rates of long-term cure and survival and acceptable rates of complications. In addition, their discovery dictates that lymph nodes in the porta hepatis should be routinely excised because nearly 50% of patients will have lymph node metastases.

Planned Arterioportal Shunting in a Patient with Rupture of a Proper Hepatic Artery Aneurysm after a Left Hepatic Lobectomy

Planned Arterioportal Shunting in a Patient with Rupture of a Proper Hepatic Artery Aneurysm after a Left Hepatic Lobectomy

Thoracoscopic left S4a subsegmentectomy.

A 63-year-old woman who underwent a left hepatic lobectomy for hilar cholangiocarcinoma was referred to our department for further management. Chest computed tomography showed a lung nodule that was increased in size to 8 mm in the S4a. The differential diagnosis was metastasis versus primary lung cancer. Thoracoscopic left S4a subsegmentectomy was performed. The operative time was 158 min. The blood loss was minimal. Air leakage was not observed, and a chest tube was removed on POD 1. The patient was discharged home on POD 3. The final diagnosis was primary lung cancer (T1aN0M0 stage IA). Surgical margin was 2.0 cm.

Thoracoscopic left S4a subsegmentectomy

A 63-year-old woman who underwent a left hepatic lobectomy for hilar cholangiocarcinoma was referred to our department for further management. Chest computed tomography showed a lung nodule that was increased in size to 8 mm in the S4a. The differential diagnosis was metastasis versus primary lung cancer. Thoracoscopic left S4a subsegmentectomy was performed. The operative time was 158 min. The blood loss was minimal. Air leakage was not observed, and a chest tube was removed on POD 1. The patient was discharged home on POD 3. The final diagnosis was primary lung cancer (T1aN0M0 stage IA). Surgical margin was 2.0 cm.

Evaluating the American College of Surgeons national surgical improvement project risk calculator in extrahepatic biliary malignancy: results from the U.S. extrahepatic biliary malignancy consortium

Objective: To assess the accuracy of the ACS NSQIP calculator for estimating risk after operation for gallbladder cancer and extrahepatic cholangiocarcinoma. Methods: Adult patients with gallbladder cancer, distal or hilar cholangiocarcinoma who underwent curative-intent, complete resection January, 2000–December, 2014 were included. The ability of the NSQIP calculator to accurately predict a particular outcome was assessed using the c-statistic (0.7 or above score for reasonable models) and Brier score (zero score for perfect models). Results: 854 adult patients were included. The most commonly performed procedures included right or left hepatic lobectomy (254, 29.7%), pancreaticoduodenectomy (132, 15.5%) and trisegmentectomy (118, 13.8%). 185 patients experienced surgical site infection (SSI) (21.7%, median predicted risk of 9.6%, range: 1.9–36.6%). There was 2.1% mortality (median predicted risk of 0.5%, range: 0–19.4%). There were 57 (6.7%) reoperations (median predicted risk of 3.3%, range: 0.9–13.2%). 169 (19.7%) patients were readmitted (median predicted risk of 9.1%, range: 2.6–32.2%). The median length of stay in the cohort was 8 days (Range: 0 119 days) and the median predicted length of stay was 6.5 days (Range: 2.5–25.5 days). The c-statistics for SSI, mortality, reoperation and readmission were 0.64, 0.74, 0.68 and 0.57 and Brier scores were 0.17, 0.02, 0.06 and 0.16 respectively (FIGURE). Conclusion: The ACS NSQIP Risk Calculator estimates the risk of mortality reasonably well for patients with gallbladder and extrahepatic biliary malignancy but generally underestimates risk of several other postoperative complications. Future modifications of the calculator for some patient populations are needed before widespread use of the tool can be encouraged.

Safety and Efficacy of Y-90 Radioembolization After Prior Major Hepatic Resection.

To evaluate the safety and efficacy of yttrium-90 radioembolization (RE) following left or right hepatic lobectomy. Between 2011 and 2016, 15 patients underwent RE with Y90-resin microspheres following right (8/15) or left (7/15) hepatic lobectomy. In eight patients, the whole liver remnant was treated during a single session, whereas the remaining seven patients received up to 3 selective RE at 1- to 2-month intervals. The administered patient activity was calculated based on the body surface area (BSA) method in all cases. In addition, CT-based volumetry of the liver remnant was performed and used to calculate the absorbed liver dose. Patient follow-up data were retrospectively analyzed regarding signs of radioembolization-induced liver disease (REILD), defined as occurrence of bilirubin >3.0mg/dl and ascites within 1-2months after treatment without tumor progression or bile duct occlusion. The mean volume of the liver remnant was 1.471±341ml, the mean administered amount of activity amounted to 1.31±0.74GBq, and the calculated mean absorbed dose was 42.8±20.6Gy. The early response to treatment was generally positive, with only one patient showing signs of progressive disease of the treated area on follow-up examinations within the first 2months post-RE. None of the 15 patients developed a REILD. Y-90 radioembolization following extended hepatic lobectomy appears to be safe and effective. Although the standard BSA-based dosing seems to suffice to avoid REILD, it results in quite variable liver doses due to variable hypertrophy of the liver remnant post-hepatectomy. Level IV, Case series.

Achievement of long-term stent patency in endoscopic ultrasonography-guided right bile duct drainage after left hepatic lobectomy (with video).

A 72-year-old female with advanced rectal cancer presented with obstructive jaundice 6 months after undergoing left hepatic lobectomy for liver metastases. Computed tomography revealed a dilated right intrahepatic bile duct, and a new liver metastasis appeared in her right hepatic lobe [Figure 1a]. Endoscopic retrograde cholangiopancreatography (ERCP) revealed severe stricture at the hepatic hilum; however, insertion of an ERCP catheter into the right anterior intrahepatic duct was unsuccessful [Figure 1b]. Subsequently, endoscopic ultrasonography-guided right hepatic bile duct drainage (EUS-RBD) was attempted. The right anterior intrahepatic duct could be well-visualized with an echoendoscope from the duodenal bulb and was punctured with a 19-gauge aspiration needle [Figure 2a]. A 0.025-inch angle-tip guidewire (VisiGlide 2; Olympus Medical Systems, Tokyo, Japan) was inserted into the biliary system [Figure 2b], and following dilation of the fistula track by a 7-Fr biliary bougie dilator (Soehendra Biliary Dilation Catheter, Cook Medical, Winston-Salem, North Carolina, USA), a covered self-expandable metal stent (10 mm × 100 mm, Niti-S Biliary Covered Stent; Taewoong Medical, Seoul, South Korea) was successfully deployed through the duodenal bulb [Figure 2c and Video 1]. The total procedure time was 42 min. The postoperative period was uneventful, and both jaundice and never mentioned before resolved in a week. Chemotherapy was resumed for advanced rectal cancer immediately after discharge. The patient died 767 days after EUS-RBD because of the progression of her underlying disease; however, she remained free of jaundice until death.Figure 1: (a) Computed tomography image showing a dilated right intrahepatic bile duct and liver metastasis in the right hepatic lobe. (b) Cholangiography image obtained by endoscopic retrograde cholangiopancreatography showing a severe stricture at the hepatic hilum. Repeated attempts to insert an endoscopic retrograde cholangiopancreatography catheter into the right anterior intrahepatic duct failedFigure 2: (a) The right anterior intrahepatic duct was punctured using a 19-gauge aspiration needle under endosonographic guidance. (b) After the injection of contrast agent, a 0.025-inch guidewire was inserted into the biliary system. (c) A covered metal stent (10 mm wide and 100 mm long) was successfully deployed into the right hepatic bile duct via the duodenal bulbEUS-guided biliary drainage is a recently developed alternative technique in patients with biliary obstruction for failed ERCP.[12] Various techniques have been described; however, limited data are available regarding EUS-RBD[345] and long-term follow-up data are lacking. This is the first case which attained long-term stent patency in EUS-RBD after left hepatic lobectomy. The use of the Spyglass System (Boston Scientific, Natick, Massachusetts, USA) to facilitate selective placement of a guidewire in the context of difficult biliary strictures has been reported.[6] However, even if a guidewire had been successfully inserted across this stricture, the configuration and site of the stricture would have made placement of a self-expandable metal stent difficult, and a plastic stent would have to be used. Plastic stents tend to occlude within a few months, and the patient would have had to undergo repeat ERCP procedures for palliative drainage. In contrast, EUS-RBD using a self-expandable metal stent allowed long lasting effective drainage. In conclusion, EUS-RBD could be an effective palliative option for right intrahepatic bile duct drainage, which is expected to maintain the patient's quality of life and achieve long-term stent patency and survival. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Clinical effect of 37 cases of emergency common bile duct exploration and left lateral lobectomy

Objective To investigate the therapeutic effect and safety of acute obstructive cholangitis underwent emergency exploration of common bile duct and left hepatic lobectomy. Methods A retrospective descriptive study was used.The clinical data of 37 cases of acute common bile duct exploration with left lateral lobectomy in the Central Hospital of Shangluo from January 2015 to January 2010 were collected.The patients received emergency common bile duct exploration and left lateral lobectomy of the liver.Outcome measures: (1)patients with surgery; (2)major complications: postoperative bile leakage, residual stones, intraoperative bleeding; (3)postoperative drainage, residual stones and recovery of patients. Results 37 patients was performed in 16 cases, the average operation time was 120min, hepatic left lateral lobe resection average 23min, average amount of bleeding was 80mL.Postoperative stump 1 case of bile leakage, bile duct stones residue in 3 cases, intraoperative bleeding in 3 cases, postoperative return pathology intrahepatic cholangiocarcinoma in 1 case. Conclusion Emergency treatment of common bile duct exploration and left lateral lobectomy is a safe and feasible surgical approach, which can avoid the the reinfection of left lateral lobe. Key words: Cholangitis; Cholestasis; Hepatectomy; Emergency treatment

Pathological complete response after percutaneous isolated hepatic perfusion in hepatocellular carcinoma with portal vein tumor thrombosis: a case report

BackgroundAlthough the effectiveness of perioperative adjuvant therapy in the treatment of hepatocellular carcinoma (HCC) has been investigated, the efficacy of preoperative therapy is unclear. Herein, we report a case of pathological complete response after percutaneous isolated hepatic perfusion (PIHP) for HCC involving portal vein tumor thrombosis (PVTT).Case presentationA 77-year-old woman was referred to our institute with a liver mass detected on a routine health screening. Computed tomography revealed a 28 × 25 mm HCC in the left lobe of the liver and a tumor thrombus in the left and right portal branches (T4N0M0, stage IVA). The patient received a single dose of preoperative PIHP with doxorubicin plus mitomycin C, without severe toxicity. After the chemotherapy, she underwent extended left hepatic lobectomy and thrombectomy of the PVTT. No cancer cells were detected during histopathological analysis, indicating pathological complete response. She remained relapse-free 12 months after the surgery.ConclusionsWe experienced a case of pathological complete response after preoperative PIHP with doxorubicin plus mitomycin C for HCC involving PVTT.