Left Hepatic Lobectomy Research Articles

Aggressive surgical management of recurrent lymph node and pancreatic head metastases of resected fibrolamellar hepatocellular carcinoma: a case report.

Fibrolamellar hepatocellular carcinoma is a rare liver tumor with the propensity to metastasize to the lymph nodes months or years after initial surgery. However, its metastatic spread to the pancreas was previously reported only in a child.We present an unusual case of a young female patient who was repeatedly treated by surgical excision of abdominal and mediastinal lymph node recurrences between 2 and 6 years after left hepatic lobectomy for fibrolamellar hepatocellular carcinoma. At 8 years following her initial surgery, the patient was diagnosed with pancreatic head metastasis and a pancreaticoduodenectomy was performed. Postoperative course was uneventful and the patient did not experience recurrence within the last 18 months.The metastasis of fibrolamellar hepatocellular carcinoma to the pancreas is highly exceptional but possible and its excision appears warranted as well.

Liver Autotransplantation for the Treatment of Unresectable Hepatic Metastasis: An Uncommon Indication—A Case Report

Ex situ ex vivo liver surgery represents a method to expand the surgical indications to treat otherwise unresectable liver tumors. We report the case of a 38-year old woman with hepatic metastasis from a pancreatoblastoma that was judged to be unresectable due to the involvement of the three hepatic veins. To treat the primary tumor, she underwent a pancreaticoduodenectomy, adjuvant chemotherapy, and thermal ablation of a liver metastasis. After appropriate preoperative study and with the permission of the ethics committee, she underwent ex situ ex vivo liver resection. The hepatectomy was performed by removing the whole liver en bloc with the retrohepatic vena cava. The inferior vena cava was reconstructed by interposition of a prosthetic graft. The ex situ ex vivo hepatic resection, a left hepatic lobectomy included the lesion in segments 1-5-7-8. The two hepatic veins were reconstructed using patches of saphenous vein. The organ was preserved continuously for 6 hours using hypothermic perfusion with 4°C Celsior solution. The liver was then reimplanted performing an anastomosis between the reconstructed hepatic veins and the caval prostheses. The patient was discharged at postoperative day 22 and is currently disease-free at 8 months after surgery and 44 months after the initial diagnosis. Ex situ, ex vivo liver surgery offers an additional option for patients with both primary and secondary liver tumors considered to be unresectable using traditional surgical approaches.

Malignant Retroperitoneal Extra-Gastrointestinal Stromal Tumor: A Case Report

Context : Extragastrointestinal stromal tumors (EGIST) are extremely uncommon neoplasm. To the best of our knowledge, only one retroperitoneal EGIST case has been reported in Oncolgy, in 2005 （PubMed search result). Case Report: A 67-year old female patient presented with epigastric discomfort, dyspepsia, and anemia. Ultrasonographic examination of the abdomen showed the location of the tumor was between the tail of the pancreas and the spleen (retroperitoneal), it was variable in size of 12.3cm×7.2cm×14cm. Color Doppler Flow Imaging (CDFI) showed no flow signals with arterial-venous doppler spectrum in the masses ．Contrast-enhanced computed tomography of the abdomen revealed a heterogeneously enhancing mass (8.23cm×14.2cm) and abundant blood supply of the tumor. The patient underwent gastroscopes-guided biopsy from the fundus of stomach for pathologic diagnosis and the result indicated chronic superficial gastritis. A complete gross excision was performed. Retroperitoneal tylectomy, left hepatic lobectomy, enterolysis, and liver biopsy were performed. Two weeks post operation, the patient was discharged without any postoperative problems. The final diagnosis of retroperitoneal EGIST was confirmed by histopathological examination and immunohistochemical findings (CD117 positivity). Conclusion: We report a very rare case of retroperitoneal EGIST. Although the

Left hepatic lobectomy in a long-term biliary atresia survivor

Surgery was performed on day 43 for biliary atresia. Left lobectomy with preservation of Roux-en-y cholecystojejunostomy was performed for refractory cholangitis after 25 years. Our case is currently awaiting liver transplantation. This is the second report of liver resection in a long-term biliary atresia survivor in the English literature.

Live liver donors: Are they at a higher risk for post-operative thrombotic complications?

Live liver donor transplantation to adult recipients is becoming a common practice, increasing the organ pool and providing an alternative to whole cadaveric liver transplantation. These patients are healthy adults without serious medical conditions and typically have normal coagulation profiles preoperatively. Right hepatic lobectomy is usually performed for adult recipients, while left hepatic lobectomy is performed for pediatric recipients. Removal of the whole right lobe from the donors may expose theses patients to multiple intraoperative and postoperative complications. Hypercoagulability has been identified as a serious complication which leads to thromboembolic phenomena with potential fatal consequences. The primary aim of this review is to look at possible changes in post-operative coagulation dynamics that may increase the risk for development of thromboembolic complications in live liver donors. In this article, we stress the importance of addressing the issue that conventional clotting tests (PT, INR, PTT) are unable to detect a hypercoagulable state, and therefore, we should examining alternative laboratory tests to improve diagnosis and early detection of thrombotic complications. Measurement of natural anticoagulant/procoagulant biomarkers combined with conventional coagulation studies and thromboelastography offers a more accurate assessment of coagulation disorders. This allows earlier diagnosis, permitting appropriate intervention sooner, hence avoiding potential morbidity and mortality. Biomarkers that may be evaluated include, but are not limited to: protein C, soluble P-selectin, antithrombin III, thrombin-antithrombin complex, and thrombin generation complex.

Long-term results of choledochoduodenostomy in benign biliary obstruction

To determine the long-term results of choledochodudenostomy in patients with benign billiary obstruction. This prospective study was conducted at Sheri Kashmir Institute of Medical Sciences Srinagar Kashmir, India over a period of 10 years from January 1997 to December 2007. The total number of patients who underwent choledochoduodenostomy during this period was 270. On the basis of etiology of biliary tract obstruction, patients were divided into a calculus group, an oriental cholangiohepatitis group, a benign biliary stricture group and others. Patients were followed for a variable period of 13 mo to 15 years. Choledochoduodenostomy (CDD) with duo-denotomy was performend in four patients. CDD with removal of T- tube, CDD with left hepatic lobectomy and CDD with removal of intra biliary ruptured hydatid was performed in three patients each. In the remaining patients only CDD was performed. Immediate post operative complications were seen in 63 (23%) patients, while long-term complications were seen in 28 (11%) patients, which were statistically significant. Three patients died during hospitalization while four patients died in the late post-operative period. Our conclusion is that CDD is safe and produces good long term results when a permanent biliary drainage procedure is required.

Laparoscopic left lateral segmentectomy for metachronic metastases of small intestine adenocarcinoma: a case report

Hepatectomy has been the standard treatment for metachronic metastases of non-colorectal (NCR) origin, mainly when the disease-free interval is more than two years. Laparoscopic hepatectomy has become the golden standard mainly for left side resections, due to lower morbidity, shorter hospital stay, early recovery and good cosmetic outcome. The authors report the case of a female patient with two metachronic metastases (ten years of disease-free survival), of non-colorectal origin (adenocarcinoma of small intestine), treated by laparoscopic left lateral segmentectomy (left hepatic lobectomy) with success. The postoperative progress was satisfactory. To date, the patient has presented no tumoral recurrence (six months of follow-up period). Laparoscopic left lateral segmentectomy can be satisfactorily performed in selected cases of hepatic metastasis. This approach presents low morbidity and good cosmetic result. The lack of alternative treatments and the poor prognosis of untreated cases have justified surgical resection in order to increase overall survival. Nevertheless, this approach should be performed by hepatic surgery expertise teams trained on advanced laparoscopic procedures.

Hepatocellular carcinoma presenting as polymyositis: a paraneoplastic syndrome

Polymyositis as a paraneoplastic syndrome associated with hepatocellular carcinoma is quite rare; only a few cases have been reported. We report a case of a 50-year-old female who presented with subacute quadriparesis, neck muscle weakness, elevated creatinine phosphokinase, a myogenic pattern on the EMG and was diagnosed as having polymyositis, a paraneoplastic syndrome associated with hepatocellular carcinoma with negative hepatic viral markers and a positive ANA. Improvement in patient symptoms and areduction in creatinine phosphokinase, which occurred after lobectomy, supports this rare association.

Hepatic Radioembolization Complicated by Fulminant Hepatic Failure

A 68-year-old man with a history of metastatic colorectal carcinoma underwent left hepatic lobectomy and right hepatic wedge resection as initial treatment of his metastatic disease. He subsequently underwent right lobar radioembolization for treatment of a segment 8 lesion. At 6 weeks postembolization, he developed hepatic dysfunction which rapidly progressed to fulminant liver failure. A liver biopsy revealed hepatic venous obstruction and fibrosis. The patient died 14 weeks after radioembolization.

Video: Totally Laparoscopic Left Lateral Segmentectomy for Hepatic Malignancies: A Modified Technique

We present our series of over 30 totally laparoscopic left hepatic lobectomies (hepatic segments II/III) performed only for malignancy. The short- and long-term results support this technique as safe and efficient. This video will illustrate the pertinent issues regarding trocar placement, intrahepatic anatomy, and the technical maneuvers necessary to perform the modified approach using totally laparoscopic techniques.

P-29 Left hepatic lobectomy in a long-term biliary atresia survivor

P-29 Left hepatic lobectomy in a long-term biliary atresia survivor

Preoperative Detection of Malignant Transformation in a Choledochal Cyst

1 A female patient presented with jaundice and upper abdominal pain. Physical examination revealed cleral icterus and right upper quadrant abdominal tenderness. aboratory investigations were significant for total bilirubin of .7 mg/dL (normal, 0.2–1.3 mg/dL) and alkaline phosphatase of 89 U/L (normal, 38 –126 U/L). A computed tomogram of the bdomen revealed a dilated common bile duct (CBD) of 6 cm ith distal bile duct narrowing (Figure A). An endosopic ultraound examination to rule out underlying malignancy revealed CBD of 7 cm with large amount of sludge and no mass lesions Figure B). Endoscopic retrograde cholangiopancreatography as then undertaken for evaluating the bile duct wall layers by sing intraductal ultrasound and to decompress the CBD. At ndoscopic retrograde cholangiopancreatography, the patient as diagnosed to have a type I choledochal cyst (Figure C), and here was no evidence of anomalous pancreaticobiliary juncion. Intraductal ultrasound revealed papillary projections in he bile duct wall consistent with malignant transformation Figure D). A biliary sphincterotomy was undertaken with rainage of black bile. The patient underwent bile duct resection (Figure E) and epaticojejunostomy. Histopathology revealed flat and papilary biliary intraepithelial neoplasia with multiple foci of highrade dysplasia but without deeper invasion (Figure F). Because he proximal left bile duct margin revealed focal epithelial typia, the patient subsequently underwent left hepatic lobecomy with intrahepatic biliary-enteric reconstruction. The paient had an uneventful postoperative course and was disharged home 10 days later. Choledochal cysts are rare congenital anomalies occurring in in 100,000 –150,000 live births in the United States.1 There is

A Rare Case of Metastatic Hepatocellular Carcinoma to the Colon with Associated Paraneoplastic Syndrome

Purpose: Hepatocellular carcinoma (HCC) is an aggressive malignancy with poor prognosis that is associated with a 4-6 month mean survival. Early detection with surgical resection offers the best chance for long-term survival. There are rare cases of patients with extrahepatic HCC recurrences. We report an unusual case of extrahepatic HCC occurring 18 and 36 months following initial presentation. Results: A 79-year-old man presented with 1 month of persistent epigastric pain. An abdominal CT revealed a large (16.5 × 13.8 cm), lobulated mass in the left hepatic lobe. Hepatitis B and C serology were negative. An alpha feto-protein (AFP) was 123 ng/mL. A left hepatic lobectomy was performed. Pathology revealed a high grade hepatocellular carcinoma. Surveillance included serial AFPs (which had normalized) and regular CT scans. Sixteen months after hepatic resection, he had a gastric outlet obstruction. An abdominal CT revealed a large (8.4 × 8.1 cm) exophytic gastric mass. An AFP was 23 ng/mL. An EGD with EUS revealed a retrogastric mass with cystic components. FNA obtained necrotic tissue and tumor fragments consistent with metastatic HCC. A distal gastrectomy with roux gastrojejunostomy was performed. Pathology revealed a poorly differentiated carcinoma consistent with the primary HCC. He remained clinically stable for 18 months when an abdominal CT revealed a mid-transverse colon mass. A colonoscopy performed prior to the hepatic resection removed 5 diminutive tubular adenomas. A repeat colonoscopy revealed a partially obstructing, malignant appearing mass. Biopsies revealed a poorly differentiated carcinoma consistent with metastatic HCC. Additionally, biopsies of the nodular mucosa in the cecum revealed lamina propria, intraepithelial and muscularis mucosal eosinophils. The peripheral eosinophil count was 24%. A transverse colectomy with primary anastomosis was performed. The specimen was described as an eccentric fungating lesion involving the full thickness of the bowel with gross invasion of the pericolic fat. There were no other intra-abdominal masses or liver metastases. Conclusion: This is a rare case of extrahepatic HCC metastases occurring at 18 and 36 months following hepatic resection. Gastrointestinal involvement of HCC is highly unusual, occurring in 0.5-2% of cases. The most common site of GI involvement is the duodenum, followed by stomach and least often colon. The presumed mode of transmission is direct invasion of the GI tract. However, hematogenous spread to the colon has been speculated and is thought to have occurred in this patient. Awareness of the unusual occurrence of extrahepatic metastatic HCC is important to ensure adequate surveillance following primary resection.

Long-term survival after a repetitive surgical approach in a patient with acinar cell carcinoma of the pancreas and recurrent liver metastases: Report of a case

Acinar cell carcinoma is a relatively rare malignant neoplasm, which represents 1%-2% of all pancreatic exocrine tumors. Its prognosis is thought to be poor, especially when it metastasizes to the liver. This report concerns a case of a long-term survivor of metastatic acinar cell carcinoma who was successfully treated with repetitive surgery. A 62-year-old man underwent a distal pancreatectomy for a pancreatic tumor, which was histologically diagnosed as an acinar cell carcinoma. The tumor recurred in the liver three times within 41 months. At the first recurrence, four hepatic lesions appeared 7 months after the initial pancreatectomy and were managed with an extended left hepatic lobectomy and partial liver resection. Thereafter, a solitary nodule in Segment 6 was identified 21 months after the second surgery and was treated with a partial liver resection. A solitary lesion in Segment 8/5 appeared 11 months after the third surgery and was also managed by a partial liver resection. The patient has remained disease-free for 22 months since the last surgery and has survived 65 months since the initial diagnosis. Although no consensus has been reached on surgery for metastatic acinar cell carcinoma, the current case has important implications for establishing an appropriate treatment strategy.

Resection of hilar cholangiocarcinoma with left hepatectomy after pre-operative embolization of the proper hepatic artery

BackgroundRight or right-extended hepatectomy including the caudate lobe is the most common treatment for hilar cholangiocarcinoma (HC). A 5-year survival of up to 60% can be achieved using this procedure if R0-resection is obtained. However, for some patients a left-sided liver resection is necessary to obtain radical resection. The close relationship between the right hepatic artery and the HC in these patients frequently limits the ability to achieve a radial R0-resection without difficult vascular reconstruction. The aim of the present study was to describe the outcome of patients who underwent pre-operative embolization of the proper hepatic artery in an effort to induce development of arterial collaterals thus allowing the resection of the proper and right hepatic artery without vascular reconstruction. MethodsIn patients presenting with HC who were considered to require a left hepatic lobectomy and in whom pre-operative work up revealed possible tumour invasion of the right hepatic artery, transcatheter arterial embolization (TAE) of the proper hepatic artery or the left and right hepatic arteries was performed. Three weeks later, a left-sided hepatectomy with resection of all portal structures except the portal vein was performed. ResultsIn six patients, pre-operative embolization of the proper hepatic artery was performed. Almost instantaneously in all six patients arterial flow signals could be detected in the liver using Doppler ultrasonography. No patient died peri-operatively. In all six patients an R0 radial resection was achieved and in three an R0 proximal transection margin was obtained. All post-operative complications were managed successfully using percutaneous drainage procedures. No patient developed local recurrence and two patients remain disease free more than 7 years after surgery. SummaryAfter pre-operative embolization of the proper hepatic artery, resection of the HC with left hepatectomy is a promising new approach for these technically demanding patients, giving them the chance of a cure.

Simultaneous Laparoscopic Anterior Resection and Left Hepatic Lobectomy for Stage IV Rectal Cancer

We report the case of a 68-year-old female patient affected by rectal cancer and a synchronous metastatic lesion measuring 8 cm in diameter in the left hepatic lobe. After a laparoscopic ultrasonography exploration of the liver to detect possible occult metastases, a simultaneous colorectal resection and a left hepatic lobectomy including a partial resection of segment IV were performed. Five ports were used for the entire procedure. The resected specimens were extracted through a Pfannenstiel incision. The procedure was completed laparoscopically. Total operative time was 455 minutes with negligible intraoperative blood loss. The postoperative hospital stay was 12 days. At 4-month follow-up, the patient recovered completely. A computed tomography scan performed at this time showed no signs of recurrent disease. This report confirms the feasibility of the laparoscopic approach to simultaneous hepatic and colorectal resections in stage IV rectal cancer. The known advantages of the miniinvasive approach could make such complex procedures more endurable.

Hepatic angiosarcoma five years following spontaneous intraperitoneal bleed of a hepatic mass

Primary hepatic angiosarcoma is a rare and rapidly fatal disease. We present the highly unusual identification of this lesion five years after the initial clinical presentation.In 2003, a 32-year-old man presented with abdominal pain, tachycardia, and evidence of hemorrhage. A CT scan showed a hepatic mass with intralesional hemorrhage, intraperitoneal blood, and splenomegaly. The patient was stabilized clinically. Laparoscopic core biopsies demonstrated no malignancy, only findings consistent with an old hemorrhage. Contralateral lobe biopsies revealed normal liver tissue. A metastatic workup was negative and the decision was made to observe the patient clinically with radiographic follow-up, given his suspected portal hypertension based on thrombocytopenia and splenomegaly.Sequential imaging demonstrated a decrease in the size of the mass from 12.0 cm in 2003 to 3.0 cm in 2007. Subsequent newly identified esophageal varices prompted a reevaluation of the case. A repeat biopsy demonstrated a neoplasm of vascular etiology and uncertain malignant potential. By early 2008 the lesion had increased to 4.8 cm and was resected via a left hepatic lobectomy. An extremely vascular lesion with surrounding dense fibrosis was identified and pathologic examination demonstrated a high-grade angiosarcoma.We are unaware of any previous reports suggesting such a prolonged natural history of hepatic angiosarcoma. This case may represent the possibility of malignant transformation of a lower grade vascular neoplasm such as hepatic epithelioid hemangioendothelioma to an angiosarcoma.

Preoperative 3D volumetric analysis for liver congestion applied in a patient with hilar cholangiocarcinoma

Postoperative hepatic failure preceded by insufficient remnant liver function is one of the major causes of mortality. The aim of this article was to present the usefulness of preoperative three-dimensional volumetric analysis applied in liver resection to avoid congestion in the remnant liver. The patient was a 45-year-old man with hilar cholangiocarcinoma. After bilateral percutaneous biliary transhepatic drainage, left hepatic lobectomy combined with total caudectomy was planned. Large inferior right hepatic vein (IRHV) and middle right hepatic vein (MRHV) was demonstrated by multidetector row computed tomography. By analyzing with liver simulation software, total liver volume and the remnant volume were 2,519.6 and 1,849.3 cm(3), respectively. The drainage volume of each vein was as follows: middle hepatic vein = 337.5 cm(3) (18.7%, ratio to the remnant right lobe); right hepatic vein = 627.9 cm(3) (34.8%); MRHV = 187.0 cm(3) (10.4%); IRHV = 651.9 cm(3) (36.1%). If we dissect both MRHV and IRHV, 46.5% of the remnant liver becomes congested. We planned to preserve these two veins. Operation was successfully performed without congestion. This modality provides a precise image of the intrahepatic structure and enables us to evaluate the congested area. This is important for a patient with a marginal amount of remnant liver, in which even a small congestion leads to a fatal consequence.

Hepatocellular Carcinoma Arising in Non-cirrhotic, Non-alcoholic Steatohepatitis

Purpose: Background: Non-alcoholic fatty liver disease is significantly associated with the metabolic syndrome manifested by obesity and insulin resistance. Diabetes (DM) is a known independent risk factor for Hepatocellular carcinoma (HCC). HCC usually occurs in the setting of cirrhosis, with the notable exception of HCC occurring in non-cirrhotic Hepatitis B or with toxin exposure. HCC occurs in cirrhosis related to non-alcoholic steatohepatitis (NASH). There have been case reports in the literature of HCC arising in patients with NASH without cirrhosis. We report 2 additional cases of HCC arising in patients with NASH without cirrhosis. Case 1: A 50 year-old white female with hypertension and anemia presented to our institution for further evaluation of recently diagnosed HCC. She had developed a flu-like illness with abdominal pain, and a computed tomography scan demonstrated 3 liver masses in the left lobe (largest measured 14 cm). There was no history of toxin exposure or alcohol use. She did have a prior history of blood transfusion and oral contraceptive pill use. There was no prior documented diagnosis of DM, but fasting glucose was 121 mg/dL. Physical examination was unremarkable; BMI was 42 kg/m2. The patient underwent left hepatic lobectomy. Histology of the resected liver revealed three discrete nodules measuring 14.5, 6.5, and 2 cm that of well-to-moderately-differentiated hepatocellular carcinoma. The uninvolved liver was non-cirrhotic and showed moderate steatosis consistent with NASH. Case 2: An 84 year-old white female with DM, hypertension, hyperlipidemia, and NASH on a prior liver biopsy presented to an outside institution with nausea. Bidirectional endoscopy noted only a hiatal hernia. Computed tomography of the abdomen revealed a 4.5 cm irregular mass in the dome of the right lobe of the liver. Physical exam was unremarkable; BMI was 25.7 kg/m2. The patient underwent resection of segment 7 of the liver. Histology of the resected liver revealed a 4.2 cm subcapsular, moderately differentiated hepatocellular carcinoma. The adjacent liver demonstrated mild to moderate macrovesicular steatosis consistent with NASH and stage 3 bridging fibrosis without cirrhotic nodularity. Comments: HCC generally occurs in the setting of pre-existing liver damage, namely cirrhosis. We report 2 additional cases of HCC occurring in NASH in the absence of cirrhosis. These cases add to the evidence that HCC can occur in the absence of cirrhosis and suggest that factors contributing to NASH may also predispose to neoplastic development in the absence of cirrhosis. It is concluded that patients with NASH may need screening for HCC.

Complete resection of hepatoblastoma originating in the caudate lobe: case report and literature review

Hepatoblastoma originating in the caudate lobe is extremely rare, and resection is technically challenging. The aim of this study was to report our experience of complete resection of hepatoblastoma originating in the caudate lobe and review the literature. A 12-month-old boy was admitted for investigation of an upper abdominal mass. Imaging studies showed an irregularly lobulated 8-cm solid tumor in the left lobe of the liver. Serum alpha-fetoprotein was 67,700 ng/mL. This tumor was diagnosed as hepatoblastoma (PRETEXT II) and chemotherapy (3 courses of CDDP and ADR) was performed. After chemotherapy, the tumor had shrunk to a resectable size and its origin in the caudate lobe could be determined. Left hepatic lobectomy with en bloc resection of the caudate lobe was performed. Total blood loss was 10 mL, and the operation lasted 9 h. His postoperative course was uneventful. Preoperative chemotherapy facilitated complete resection by left hepatic lobectomy with total excision of the caudate lobe.