Left Liver Lobectomy Research Articles

A rare case of cavernous hemangioma accompanied with diffuse hepatic hemangiomatosis

BackgroundHepatic cavernous hemangioma (CH) is the most common hepatic benign tumor. Most cases are solitary, asymptomatic, and found incidentally. In symptomatic cases with rapidly growing tumors and coagulopathy, surgical treatment is considered. In rare cases, diffuse hepatic hemangiomatosis (DHH) is reported as a comorbidity. The etiology of DHH is unknown.Case presentationA 29-year-old female patient had a history of endometriosis treated with oral contraceptives. Hepatic CH was incidentally detected in the segment IVa of the liver according to the Couinaud classification. Follow-up computed tomography (CT) and ultrasound sonography showed the growth of the lesion and formation of multiple new lesions near the first. Enhanced CT and magnetic resonance imaging (MRI) revealed that the new lesions were different from CH. Although oral contraceptives were stopped, all lesions grew in size. Malignancy and possibility of rupture of these tumors were considered due to the clinical course, and we opted for surgical removal of the tumors. Left liver lobectomy and cholecystectomy were performed. Surgical findings were small red spot spreading and a mass in segment IV of the liver. Pathological examination revealed a circumscribed sponge-like tumor with diffuse irregular extension to the adjacent area. Both of the lesions consisted of blood-filled dilated vascular spaces lined by flat endothelium without atypia. The diagnosis was hepatic CH with DHH. The patient was discharged on postoperative day 12 uneventfully.ConclusionWe report the successful resection of CH with DHH. The case findings suggest a relationship between oral contraceptive use and enlargement of CH and DHH. Although DHH has been poorly understood, a few previously published cases reported DHH occurrence in patients using oral contraceptives. In such cases, the decision to perform surgical resection should be made after careful examination.

S2419 Recurrent Oriental Cholangiohepatitis

INTRODUCTION: Recurrent cholangiohepatitis was first recognized as a clinical entity in the 1930s and is most commonly found in people of Southeast Asian origin. We present a case of recurrent pyogenic cholangiohepatitis with hepatic abscess in a patient of oriental origin. CASE DESCRIPTION/METHODS: 58 y/o male with medical history of hypertension who was admitted with 4 days of fevers and RUQ abdominal pain. He was hypotensive with leukocytosis and elevated lactate. He had a history of Choledochoduodenostomy, done in Korea, due to primary intrahepatic choledocholithiasis. CT A&P showed left hepatic lobe mass containing dilated fluid-filled structures, left hepatic lobe atrophy, and pneumobilia and broad spectrum antibiotics were initiated. IR guided drainage of liver lesion was performed and catheter tube was placed. Fluid drained grew E. Coli and VRE. AFP, CEA, and CA 19-9 were negative. Stool negative for O&P. MRCP showed intrahepatic ductal dilatation of the left hepatic lobe and central intrahepatic ductal dilatation in the right hepatic lobe. EUS showed hepatic abscess and a gastrohepatic lymph node was biopsied, which showed reactive lymphoid tissue and no malignant cells. ERCP was done, but strictures in left intrahepatic bile ducts were not amenable for stent placement and drainage. PTC was performed and internal biliary drainage catheter was placed. Diagnosis of Oriental Cholangiohepatitis was made. Patient was offered left liver lobectomy for definitive treatment, he deferred. He clinically improved and was discharged. DISCUSSION: Oriental Cholangiohepatitis is characterized by recurrent cholangitis secondary to bile stasis and stone formation proximal to biliary strictures. Left hepatic duct, especially the left lateral segmental duct, is most commonly affected. Pneumobilia and hepatic atrophy are common findings on imaging. Intrahepatic calculi are visualized in up to 90% cases. Management includes antibiotic therapy, stricture dilation, biliary drainage, stone removal and liver resection. ERCP has advantage of therapeutic intervention over MRCP. Liver resection decreases the risk of recurrent attacks of cholangitis, abscess and eliminates the risk of carcinoma in the atrophic segment of liver. Incidence of oriental cholangiohepatitis is increasing in the western world due to immigration and diagnosis should be considered in patients in epidemiologic and clinical settings, with radiologic findings of intrahepatic ductal dilation even in the absence of visualization of intrahepatic stones.

Multimodal treatment including surgery for esophageal adenocarcinoma with liver oligo-metastases: a pathological complete response but early brain metastasis.

Survival of patients with stage IV esophageal adenocarcinoma is exceedingly poor, with less than 5% surviving 5years. Current National Comprehensive Cancer Network guidelines recommend only palliative and supportive measures for patients with metastatic esophageal cancer. Treatment for stage IV disease is chemotherapy in selected patients, while the role of radiation therapy and surgical resection remain controversial. We report herein a young patient with esophageal adenocarcinoma and synchronous liver metastasis who underwent induction chemotherapy with encouraging downstaging, then two-field esophageal resection with left liver lobectomy. Despite a complete response of esophageal and residual liver lesions, early progression with isolated brain metastasis occurred 2months after discharge. Our case highlights that despite progress in perioperative chemotherapy, the role of surgery remains uncertain for patients with esophageal cancer and synchronous M1 disease who exhibit excellent response to neoadjuvant treatment.

2478 Approach to a Foreign Body (Fish Bone) Resulting in a Liver Abscess With Antibiotic-Evading Filamentation of Bacterial Organisms Resembling Fungal Hyphae

INTRODUCTION: Foreign bodies that are ingested may migrate from the gastrointestinal (GI) tract into different organs of the body and cause a variety of clinical manifestations including fever of unknown origin. In this vignette we describe the case of a transmural fish bone migration from the stomach to the liver causing a recurrent liver abscess. CASE DESCRIPTION/METHODS: A 76 year old Caucasian male with a past medical history of hypertension presented to the hospital with a left liver lobe abscess that was aspirated six years ago. All cultures at that time were negative and apparently resolved with antibiotics. About two months prior to his hospital admission, he started developing subjective fevers and malaise, with CT Scan of the abdomen showing a possible liver mass in the left lobe. He underwent a liver biopsy of this lesion that showed multiple caseating granulomas. Infectious work up was negative. Despite broad spectrum antibiotics, the patient continued with low grade fevers. Pancultures were negative and a left liver lobectomy and cholecystectomy was pefomed. CT imaging of the liver showed a multiloculated 7.2 cm lesion in the left lobe of the liver consistent with an abscess, with a linear foreign body which extended from the stomach into the left lobe liver lesion (Figure 1). During surgery, the foreign body was identified and removed. Surgical histology of the foreign body showed bone fragments lined by osteocytes and calcifications, which was identified as a “fish bone.” Furthermore, the left liver lobe showed prominent granulomatous inflammation with necrosis and microabscesses with no evidence of malignancy. Special stain GMS-F was positive for filamentous organisms that most closely resembled nocardia or streptomyces (Figure 2). DISCUSSION: This is the first case report showing filamentation of bacteria resembling a fungal infection causing a liver abscess due to a fish bone that penetrated the left lobe of the liver. Filamentation is a bacterial defense mechanism against eradication by antibiotics, which explains failure of resolution of the infection with antimicrobials. Studies have reported incomplete bacterial replication leading to the appearance of filamentation resembling fungal species. This phenomenon should be considered by clinicians when treating challenging liver foreign body abscesses.

Amelioration of postoperative cognitive dysfunction in mice by mesenchymal stem cell-conditioned medium treatments is associated with reduced inflammation, oxidative stress and increased BDNF expression in brain tissues

ObjectiveMesenchymal stem cells (MSCs) are widely used in regeneration and repair of various tissues and organs, and whether MSC-conditioned medium (MSC-CM) has protective effects in postoperative cognitive dysfunction (POCD) remains largely unknown. We aimed to assess the therapeutic effect and explore the mechanisms of MSC-CM therapy in a POCD mouse model. MethodsSixty C57BL/6 mice were randomly assigned to 3 groups: control, POCD and POCD + MSC-CM. The POCD mouse model was established by left liver lobectomy. While mice in the control group were sham-operated, mice in the POCD + MSC-CM group were immediately administrated with MSC-CM after operation. The Morris water maze was used to determine cognitive function of mice at 1, 3, and 7 days after operation. The levels of IL-1β, IL-6, TNF-α and malondialdehyde in brain tissues at 3 days after operation were assessed by ELISA, while the protein level of brain derived neurotrophic factor (BDNF) was determined by western blot. ResultsLeft liver lobectomy induced POCD in mice resulted in decrease of cognitive function, increase of brain IL-1β, IL-6, TNF-α and malondialdehyde levels, and decreased BDNF expression, while administration of MSC-CM significantly reversed these changes. ConclusionMSC-CM ameliorates POCD in mice, and its protective roles are associated with reduced levels of inflammatory factors, attenuated oxidative stress, and increased BDNF expression.

Left Hepatic Lobectomy in the Living Donor—Comparison Between Open vs Laparoscopic Surgery

Laparoscopic hepatic surgery dramatically changed surgical practice in the last decades, improving outcomes in correctly selected patients. The reduction of postoperative pain, lower rate of complication, early return to work activities, and better esthetic result have been well described in several studies. The success of these procedures would inevitably clash in the more complex and delicate field of hepatectomy in the living donor. The 2nd International Consensus of the Conference on Laparoscopic Liver Surgery considers laparoscopic hepatectomy in the donor as an ideal procedure. The aim of this study is to compare the results between conventional and laparoscopic surgery; prospective data and retrospective analysis of 55 cases of live liver donor lobectomy were collected between January 2013 and June 2018. The mean age was 30.4 years in the video laparoscopic technique and 32.1 years in conventional surgery; the majority of donors were male in both groups. The mean time of ischemia was 70.2 minutes (range, 50–120 minutes) in laparoscopic surgery and 80.2 minutes (range, 50–165 minutes) in conventional surgery. The surgical time ranged from 270 to 800 minutes (mean, 452 minutes) in laparoscopic surgery and ranged from 300 to 600 minutes (mean, 424 minutes) in conventional surgery. The mean length of hospital stay was 2.2 days in laparoscopy and 3.97 days in conventional surgery. Laparoscopic left liver lobectomy in the living donor is safe and feasible. There was no significant difference in surgical time; however, the time of hospitalization was lower in patients submitted to laparoscopic technique.

Rare case of idiopathic sclerosing cholangitis, which was difficult to distinguish from cholangiocarcinoma: A case report.

It is often difficult to correctly diagnose patients who present with dilation of the bile duct. Cholangiocarcinoma, primary sclerosing cholangitis (PSC) and immunoglobulin (Ig)G4-related sclerosing cholangitis must be considered as potential diagnoses for these cases. The current study presents a 73-year-old female patient who presented with a high fever and abdominal pain. Contrast-enhanced computed tomography and magnetic resonance cholangiopancreatography revealed stenosis and dilation of the intrahepatic bile duct without solid components. It was suspected that the patient had intrahepatic cholangiocarcinoma. A left liver lobectomy, cholecystectomy and distal gastrectomy combined with a D2 lymph node dissection were performed. A pathological examination of the liver revealed increased fibrosis in the stroma, irregular bile duct dilation and clusters of inflamed lymph cells. No carcinoma or IgG4-positive plasma cells were observed and the typical findings of PSC were not detected. Based on these clinical and pathological results, the diagnosis was idiopathic sclerosing cholangitis, which is particularly rare. It is often difficult to preoperatively differentiate between cholangiocarcinoma and benign bile duct stenosis.

Primary hepatic gastrinoma: Report of a case and review of literature

Primary hepatic gastrinoma is a very rare ectopic gastrinoma with less than 20 cases reported worldwide. We report the case of a patient with hypergastrinemia who was subjected to exhaustive preoperative and intraoperative imaging and also careful surgical exploration of the duodenum and pancreas which failed initially to identify the primary tumour. Eventually the patient was subjected to left liver lobectomy, as a small palpable lesion was noted intraoperatively. The diagnosis of gastrinoma requires a high index of clinical suspicion and the flawless cooperation of many specialties.

Severe Complication After a Doxorubicin-Eluting-Bead Embolization: Surgical Management and Pathological Findings

Doxorubicin-eluting-bead embolization (DEB) is considered a safe and efficient treatment of hepatocellular carcinoma (HCC) with a low complication rate and an increased tumor response compared with conventional transarterial chemoembolization. We describe a case of a 69-year-old patient who underwent DEB for HCC and who developed a liver abscess requiring urgent left liver lobectomy. Despite this severe complication, efficacy of DEB embolization was histologically proved as a large ischemic zone with complete tumor necrosis.

Early Bioprosthetic Valve Deterioration After Carcinoid Plaque Deposition

Early Bioprosthetic Valve Deterioration After Carcinoid Plaque Deposition

Combined abdominal aortic aneurysmectomy and other abdominal operations.

Co-existence of intra-abdominal non-vascular disease with an abdominal aortic aneurysm (AAA) poses a difficult surgical challenge. Review of hospital records of 602 patients undergoing elective surgery for AAA during a 9-year period identified 61 (10.3%) patients with a co-existent intra-abdominal non-vascular disease requiring surgery. The concomitant operations were 26 cholecystectomies, 11 inguinal hernia repairs, 2 small bowel resections, 5 left and 5 right hemicolectomies and 1 low anterior resection for colorectal carcinoma, 1 gastrectomy for gastric carcinoma, 5 nephrectomies, one salvage cystectomy for renal carcinoma and 1 left liver lobectomy for hepatrocellular carcinoma. Additional procedures for benign diseases prolonged the operative time by a mean of 35 (range 20-105) minutes and the major operations for malignancy by 120 (range 60-225) minutes. The overall hospital mortality and morbidity rates in the whole series of AAA (n = 602) remained as low as 0.66% and 13.6% respectively. There was no mortality and only two complications occurred in patients undergoing the combined procedure (n = 61). During a follow up period of 4-70 months, no graft infections were detected. In selected patients, the one stage approach is safe and effective. Attention should be given to the technical details and the rules of antisepsis. In elderly patients with AAA, a co-existent malignancy should be actively excluded.

Acceleration of hepatobiliary dynamics in liver transplant donors

This study compared hepatobiliary scintigraphy findings in livers before and after liver graft donation to examine whether there is a change in hepatobiliary dynamics. Nine donors underwent hepatobiliary scintigraphy with intravenous injection of Tc-99m mebrofenin 1 day before and during the first week after left liver lobectomy. Five donors also underwent additional scintigraphy more than 1 year postsurgery. Images were acquired every second for the first minute, and then every minute for the next 40 minutes. Hepatic arterial perfusion index and portal perfusion index(PPI) were calculated from the images acquired during the first minute. For the function phase the computed parameters included: hepatic extraction efficiency, (HEE), time to appearance of activity in the intrahepatic biliary channels, and in the intestine, time to half maximal activity, and activity retained in the liver parenchyma at 40 minutes.Time to appearance of intrahepatic biliary channels and of intestinal activity was shorter among scintigraphies obtained within 1 week postsurgery compared to the preoperative values. Early after the operation HEE increased and PPI decreased significantly. Visual inspection of the scintigraphy scan obtained in all donors, within the first week postsurgery revealed hypertrophy of the right liver lobe. None of the patients showed progression of right lobe activity to the left side, even among scans obtained more than 1 year after donation. Reduced time to activity in the biliary channels and intestine and increased HEE suggest acceleration of hepatobiliary dynamics.

Acquired inhibitors to the coagulation factor XII associated with liver disease

Three patients with liver disease and prolonged activated partial thromboplastine time (APTT) on routine tests are presented. One woman had metastatic liver disease from gastric carcinoma, a second woman had autoimmune hepatitis, and one man had severe chronic hepatitis B. APTT was not corrected after mixing experiments with 25%, 50%, and 75% of normal pool plasma, indicating the presence of an acquired inhibitor. In all three cases, factor XII coagulant activity was reduced: <1%, <1%, and 3%, respectively, while all of the other coagulation factors were normal. In all three cases no other auto-antibody was detected. In the first patient, APTT was normalized after a left liver lobectomy, whereas the primary lesion remained unresected. In the second patient, the FXII activity was improved after corticosteroid therapy but never returned to normal values. In the third patient, the APTT was improved after hydroxychloroquine therapy. None of the patients had hemorrhagic or thrombotic phenomena.

Bile duct cysts in adults: a multi-institutional retrospective study. French Associations for Surgical Research.

To review the features of adult patients undergoing surgery for bile duct cysts, focusing on the anatomy of the biliary tree as well as the long-term outcome. Bile duct cysts (BDCs) are uncommon in Western countries, and the majority of reported cases originate from Asia. Japanese authors have emphasized the frequent association of extra- and intrahepatic bile duct dilatations, but grading of patients based on Todani's classification is often hindered by the absence of an accurate definition of types IC and IVA cysts. Moreover, despite the increasing use of extrahepatic cyst excision, little is known about the long-term outcome in patients with intrahepatic bile duct involvement. Forty-two adult patients with BDC were treated between 1980 and 1992 in 17 institutions of the French Associations for Surgical Research. Clinical presentation, radiologic presurgical evaluation, and surgical procedures were analyzed. The long-term postsurgical outcome was derived from patient charts, attending physicians, or direct patient contact. Twelve patients (30%) had recurrent abdominal pain or jaundice from childhood. Seven (17%) had undergone prior cystenterostomy. Twenty-one (50%) had a Todani-type IVA cyst with extra- and intrahepatic bile duct involvement. Of these, nine had segmental, exclusively left-sided intrahepatic bile duct dilatation. Biliary carcinoma was encountered in five patients (12%). Extrahepatic cyst excision with a Roux-en-Y hepaticojejunostomy was performed in 34 patients with type I or IV cysts. The overall operative mortality rate was 2.4%. Long-term results were clearly correlated with cyst type: during a mean follow-up of 8.4 years, 11 of 12 patients (92%) treated by cyst excision for type I cyst remained free of symptoms, whereas 31% of patients who underwent surgery for type IV cyst had episodic or severe cholangitis with intrahepatic stones. In patients with BDC, particular attention must be given to the associated intrahepatic bile duct dilatations. We propose a modification of Todani's classification to distinguish cystic, segmental, and fusiform dilatations of the intrahepatic biliary tree in type IV cysts. In patients with segmental left intrahepatic cystic dilatations, combined left liver lobectomy and extrahepatic cyst excision is suggested to decrease late postsurgical biliary complications.

Laparoscopic anatomical (hepatic) left lateral segmentectomy—technical aspects

Laparoscopic liver surgery is a tremendous challenge. The authors report a left liver lobectomy and removal by a total laparoscopic approach. Anatomical left lateral laparoscopic segmentectomy was performed on a woman who had a symptomatic hepatic adenoma. The patient was discharged after an uncomplicated postoperative recovery; the hospital stay and convalescence period were very short. The cosmetic result was good.