Left Lobe Of Liver Research Articles

Image quality optimization: dynamic contrast-enhanced MRI of the abdomen at 3T using a continuously acquired radial golden-angle compressed sensing acquisition

IntroductionThe image quality of continuously acquired free-breathing Dynamic Contrast-Enhanced (DCE) golden-angle radial Magnetic Resonance Imaging (MRI) of abdomen suffers from motion artifacts and motion-related blurring. We propose a scheme by minimizing patients’ motion status from breathing as well as optimizing the acquiring parameters to improve image quality and diagnostic performance of DCE-MRI with Golden-Angle Radial Sparse Parallel (GRASP) sequence of abdomen.MethodsThe optimization scheme follows two principles: (1) reduce the impact on images from unpredictable and irregulate motions during examination and (2) adjust the sequence parameters to increase the number of radial views in each partition. For the assessment of image quality, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), the severity of radial artifact, the degree of image sharpness, and a visual scoring of image quality with a 5-point scale were assessed.ResultsA total of 64 patients were included in this study before (16 men, 14 women, age: 54.9 ± 17.0) and after (18 men, 16 women, age: 58.6 ± 12.6) the optimization scheme was performed. The results showed that the SNR values of right and left lobe of liver in both plain phase and arterial phase were significantly increased (All P < 0.001) after the GRASP sequence been optimized. Significant improvements in CNR values were observed in the arterial phase (All P < 0.05). The significant differences in scores at each phase for visual scoring of image quality, noise of the right and left lobe of liver, radial artifact, and sharpness indicating that the image quality was significantly improved after the optimization (All P < 0.001).ConclusionOur study demonstrated that the optimized scheme significantly improved the image quality of liver DCE-MRI with GRASP sequence both in plain and arterial phases. The optimized scheme of GRASP sequence could be a superior alternative to conventional approach for the assessment of liver.

Vascular Anatomy of Segment IV of the Liver in Live Liver Donors.

Studies on the anatomy of the liver have helped surgeries such as liver resection. Liver resection is of significance in liver transplantation. In liver resection, the anatomy of segment IV is very important as it is more prone to ischemia. The primary objective is to study the anatomical variations of the hepatic artery and hepatic vein of segment IV from MDCT images of the hepatic vasculature in living liver donors. This study aims to document the anatomy of the hepatic artery supplying segment IV and its venous drainage in 300 living liver donors. In this retrospective study, 600 MDCT images of hepatic vasculature were observed, and the interpretations were recorded. The origin of the artery to segment IV was documented.The observations of the hepatic vein were tabulated as classified in Nakamura's study. Segment IV artery originates from the left hepatic artery (LHA) in 72% of the cases and the right hepatic artery(RHA) in 23%. Hepatic venous drainage of segment IV comprises type I, type II, andtype III in 14.33%, 53.67%, and30% of cases, respectively. Type I anatomy of the hepatic vein is preferred in both right and left lobe liver transplantationas the drainage from segment IV is safe. Vascularity to segment IV is key in living liver donors, as donor safety is of utmost importance in the case of living donor liver transplantation.

Impact of Tracer Dose Reduction in [18 F]-Labelled Fluorodeoxyglucose-Positron Emission Tomography ([18 F]-FDG)-PET) on Texture Features and Histogram Indices: A Study in Homogeneous Tissues of Phantom and Patient.

Histogram indices (HIs) and texture features (TFs) are considered to play an important role in future oncologic PET-imaging and it is unknown how these indices are affected by changes of tracer doses. A randomized undersampling of PET list mode data enables a simulation of tracer dose reduction. We performed a phantom study to compare HIs/TFs of simulated and measured tracer dose reductions and evaluated changes of HIs/TFs in the liver of patients with PETs from simulated reduced tracer doses. Overall, 42 HIs/TFs were evaluated in a NEMA phantom at measured and simulated doses (stepwise reduction of [18 F] from 100% to 25% of the measured dose). [18 F]-FDG-PET datasets of 15 patients were simulated from 3.0 down to 0.5 MBq/kgBW in intervals of 0.25 MBq/kgBW. HIs/TFs were calculated from two VOIs placed in physiological tissue of the right and left liver lobe and linear correlations and coefficients of variation analysis were performed. All 42 TFs did not differ significantly in measured and simulated doses (p > 0.05). Also, 40 TFs showed the same behaviour over dose reduction regarding differences in the same group (measured or simulated), and for 26 TFs a linear behaviour over dose reduction for measured and simulated doses could be validated. Out of these, 13 TFs could be identified, which showed a linear change in TF value in both the NEMA phantom and patient data and therefore should maintain the same informative value when transferred in a dose reduction setting. Out of this Homogeneity 2, Entropy and Zone size non-uniformity are of special interest because they have been described as preferentially considerable for tumour heterogeneity characterization. We could show that there was no significant difference of measured and simulated HIs/TFs in the phantom study and most TFs reveal a linear behaviour over dose reduction, when tested in homogeneous tissue. This indicates that texture analysis in PET might be robust to dose modulations.

Comparative analysis of different methods of retraction of the left lobe of the liver during laparoscopic sleeve gastrectomy

The global obesity epidemic has led to the increasing popularity of bariatric surgeries. Laparoscopic sleeve gastrectomy is currently the most popular bariatric procedure for obesity. Retracting of the left liver lobe during laparoscopic sleeve gastrectomy is important for achieving an optimal surgical field.&#x0D; Aim. The aim of our study was to evaluate the results of using different methods of retraction of the left liver lobe during laparoscopic sleeve gastrectomy in patients with morbid obesity.&#x0D; Materials and methods. The 86 patients who underwent laparoscopic sleeve gastrectomy were divided into three groups based on the liver retraction method used: group 1 (ENDO RETRACT™ II), group 2 (Nathanson) and group 3 (Clickline Surgical Sponge Holder). All groups were evaluated in terms of demographic characteristics; liver function tests just before surgery and on the 1st and 2nd postoperative day (POD); developing complications and length of hospital stay.&#x0D; Results. The groups did not differ significantly in terms of demographic characteristics (p &gt; 0.05). The Nathanson liver retractor (group 2) caused a significant rise in ALT and AST at POD 1 and POD 2 compared with group 1 and 3 (p &lt; 0.05). The ENDO RETRACT™ II liver retractor (group 1) caused a higher incidence of liver injury than other groups. It led to statistical significance prolonged total operation time (p = 0.003), increased blood loss (p = 0.002) and prolonged postoperative hospital stay (p = 0.001) compared with other groups.&#x0D; Conclusions. The technique of left lobe retraction during laparoscopic sleeve gastrectomy using Clickline Sur- gical Sponge Holder is safe and effective. The use of this technique causes significantly less measurable liver damage and does not lead to an increase in the level of liver enzymes.

A marginal branch of the left hepatic artery running along the umbilical vein and supplying the anterior surface of the liver left lobe: a report of 5 cases in 12 Japanese human fetuses.

In human fetuses, the left hepatic artery (LHA) issues the marginal artery that runs along the umbilical vein and, sometimes, reaches the umbilicus. The further observation demonstrated that, in 5 of 12 Japanese midterm fetuses (crown-rump length mm: 46, 50, 54, 59, 102), the marginal artery issued not only a thin umbilical branch but also a liver parenchymal branch that took a posterosuperior recurrent course in a peritoneal fold and supplied the anterior surface of the liver left lobe (segment III). However, in 22 Spanish fetuses of which gestational ages corresponded to the Japanese ones, we did not find the parenchymal branch. Therefore, between human populations, there seemed to be a considerable difference in the incidence as to whether or not the marginal artery issues the liver parenchymal branch. The parenchymal branch might be degenerated at the later stages due to friction between the liver free surface and growing diaphragm.

Neglected Biliary Stent with Hepatico-lithiasis Causing Left Lobe Pyogenic Liver Abscess with Rupture into Left Pleural Cavity: A rare Life-threatening Emergency

Abstract Biliary tract disease is currently the leading cause of pyogenic liver abscess (PLA) and complications of rupture are associated with high mortality and morbidity even with current medical knowledge advancement. We report a 35-year-old female who presented in emergency setting with complaints of jaundice, abdominal pain, fever, and respiratory distress. Patient had prior history of endoscopic management of biliary stones about 6 years back followed by asymptomatic period. Patient was managed by percutaneous drainage of left lobe liver abscess and left pleural empyema after initial resuscitation with further investigations revealing biliary stent with left hepatic abscess with transdiaphragmatic extension into left hemithorax. Neglected biliary stent has been reported to cause severe cholangitis with PLAs and these patients require immediate timely attention to the management of abscess and its complications.

181 Lessons Learned from Complex Abdominal Wall Reconstruction for the Management of Giant Paraoesophageal Hernia - a Case Analysis

Abstract Aim In this case report, we present a new method in the management of a giant hiatus hernia: the use of crural relaxing incisions. This new method in combination with previously known strategies including botox and preoperative optimisation for surgery with weight loss and prehabiliation can result in a more effective surgical hiatus hernia repair and subsequently lead to a reduced risk of hiatus hernia recurrence. Case Presentation 71yo man admitted to hospital with a one-week history of generalised abdominal pain, nausea, vomiting and chest pain. He had a background of a known large hiatus hernia for the last 10 years. An abdominal CT showed a large type IV hiatus hernia containing the stomach, transverse colon, pancreatic body, and pancreatic neck. CT guided botulinum toxin A injections were given by interventional radiology during which the muscle bellies of the transversus abdominus, internal and external obliques were targeted. The patient was placed on a meal replacement (Optifast) diet. A laparoscopic thoraco-abdominal hiatus repair was performed finding a giant hiatus hernia containing the entire stomach, first part of the duodenum, left lobe of liver, transverse colon, small bowel and distal pancreas. Due to the size of the hiatus hernia and the potential tension likely to result from a repair, both right and left crural relaxing incisions were made to facilitate closure. Crural closure was reinforced with a Bio A mesh secured in a C configuration covering the right crural relaxing incision. The patient recovered well postoperatively. Follow up imaging did now show recurrence.

Living Donor-Initiated Domino Split-Liver Transplantation in Pediatric Setup: A Case Report With Literature Review

In patients undergoing liver transplantation for metabolic diseases, removing the patient's liver for transplantation to another recipient is called "domino liver transplantation." The extracted liver can be divided and transplanted into 2 recipients, which is called domino split-liver transplantation in the literature. However, in our study, the domino liver was obtained from a pediatric patient. A patient with maple syrup urine disease (MSUD) underwent a living donor liver transplant, and the explanted liver was divided in situ into right and left lobes and transplanted to 2 separate patients. Demographic data, surgical techniques, postoperative period, and patient follow-ups were evaluated. The father's left lobe liver graft was transplanted into a 12-year-old boy with MSUD. The removed liver was divided in situ into right and left lobes. The left lobe was transplanted to a 14-year-old male patient, whereas the right lobe was transplanted to a 67-year-old male patient. The donor and the first recipient were discharged on postoperative days 5 and 22. The second pediatric patient who underwent domino split-left lobe transplantation was discharged on postoperative day 23. The adult patient who underwent domino split-right lobe transplantation died on postoperative day 12 owing to massive esophageal variceal bleeding. Patients who underwent liver transplantation due to MSUD are among the best donor choices for domino liver transplantation. If the extracted liver has a sufficient volume and anatomic features for a split, it can be used in "selected cases."

Feature-guided deep learning reduces signal loss and increases lesion CNR in diffusion-weighted imaging of the liver

PurposeThis research aims to develop a feature-guided deep learning approach and compare it with an optimized conventional post-processing algorithm in order to enhance the image quality of diffusion-weighted liver images and, in particular, to reduce the pulsation-induced signal loss occurring predominantly in the left liver lobe. MethodsData from 40 patients with liver lesions were used. For the conventional approach, the best-suited out of five examined algorithms was chosen. For the deep learning approach, a U-Net was trained. Instead of learning “gold-standard” target images, the network was trained to optimize four image features (lesion CNR, vessel darkness, data consistency, and pulsation artifact reduction), which could be assessed quantitatively using manually drawn ROIs. A quality score was calculated from these four features. As an additional quality assessment, three radiologists rated different features of the resulting images. ResultsThe conventional approach could substantially increase the lesion CNR and reduce the pulsation-induced signal loss. However, the vessel darkness was reduced. The deep learning approach increased the lesion CNR and reduced the signal loss to a slightly lower extent, but it could additionally increase the vessel darkness. According to the image quality score, the quality of the deep-learning images was higher than that of the images obtained using the conventional approach. The radiologist ratings were mostly consistent with the quantitative scores, but the overall quality ratings differed among the readers. ConclusionUnlike the conventional algorithm, the deep-learning algorithm increased the vessel darkness. Therefore, it may be a viable alternative to conventional algorithms.

Conservative approach in adult right-sided Bochdalek hernia with an intrathoracic ectopic kidney

Bochdalek hernia (BH) is a congenital diaphragmatic defect primarily diagnosed in neonates and is usually left-sided. Adult diagnosis, especially of right-sided BH is exceedingly rare and usually presents with symptoms. Till now, only 31 cases have been diagnosed to be right-sided BH along with intrathoracic kidney. This report presents a 26-year-old asymptomatic male who was incidentally diagnosed with a massive right congenital diaphragmatic hernia. Imaging revealed severe abdominal herniation, a right intrathoracic ectopic kidney, and a right liver lobe hypoplasty along with hypertrophied left liver lobe extending down to the pelvic cavity. Several surgeons were consulted, with controversial opinions on whether elective surgery should be performed or withheld. Due to the high risk associated with surgery and the patient’s choice, the surgery was deferred. For almost 18 months, the patient did not report any symptoms or complications. This case highlights the rarity of asymptomatic right-sided BH in adults and the challenges in determining a management approach. Also, it proposes a conservative approach for such patients as a management modality. Most extensive diagrammatic defect reported is estimated to have a neck defect of 10 cm. Most BH cases have been treated surgically and reports on the outcome of a conservative approach are exceedingly rare. In such cases, patient preferences and a thorough risk assessment play vital roles in decision-making regarding conservative versus surgical approaches.

Assessment of hepatic function employing hepatocyte specific contrast agent concentrations to multifactorially evaluate fibrotic remodeling.

Diffuse parenchymal liver diseases are contributing substantially to global morbidity and represent major causes of deaths worldwide. The aim of our study is to assess whether established hepatic fat and iron quantitation and relaxometry-based quantification of hepatocyte-specific contrast material as surrogate for liver function estimation allows to evaluate liver fibrosis. Retrospective consecutive study. Seventy-two healthy patients (mean age: 53 years) without known liver disease, 21 patients with temporary elevated liver enzymes (mean: 65 years) and 109 patients with biopsy proven liver fibrosis or cirrhosis (mean: 61 years), who underwent liver magnetic resonance imaging (MRI) with a hepatocyte-specific contrast agent [gadoxetate disodium, gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA), 0.25 mmol/mL Primovist, Bayer AG, Leverkusen, Germany] at 1.5 T (n=133) and at 3 T (n=69), were included. Fibrosis was classified using the histopathological meta-analysis of histological data in viral hepatitis (METAVIR) and the clinical Child-Pugh scores. Gd-concentration were quantified using T1 map-based calculations. Gd-concentration mapping was performed by using a Look-Locker approach prior to and 912±159 s after intravenous administration of hepatocyte specific contrast agent. Additionally, parenchymal fat fraction, R2*, bilirubin, gender and age were defined as predicting factors. Diagnostic accuracy was calculated in a monoparametric (linear regression, predictor: Gd-concentration) and multiparametric model (predictors: age, bilirubin level, iron overload, liver fat fraction, Gd concentration in the left and right liver lobe). Mean Gd-concentration in the liver parenchyma was significantly higher for healthy patients ([Gd] =0.51 µmol/L) than for those with liver fibrosis or cirrhosis ([Gd] =0.31 µmol/L; P<0.0001) and with acute liver disease ([Gd] =0.28 µmol/L), though there were no significant differences for the latter two groups. There was a significant moderate negative correlation for the mean Gd-concentration and the METAVIR score (ρ=-0.44, P<0.0001) as well as for the Child-Pugh stage (ρ=-0.35, P<0.0001). There was a significant strong correlation between the bilirubin concentration and the Gd-concentration (ρ=-0.61, P<0.0001). The diagnostic accuracy for the discrimination of healthy patients and patients with known fibrosis or cirrhosis was 0.74 (0.71/0.60 sensitivity/specificity) in a monoparametric and 0.76 (0.85/0.61 sensitivity/specificity) in a machine learning based multiparametric model. T1 mapping-based quantification of hepatic Gd-EOB-DTPA concentrations performed in a multiparametric model shows promising diagnostic accuracy for the detection of fibrotic changes. Liver biopsy might be replaced by imaging examinations.

Magnetic Resonance Diffusion Tensor Imaging Characterize the Hepatic Ischemia-Reperfusion Injury in an Animal Study

Hepatic ischemia-reperfusion (I/R) injury is the main cause of morbidity and mortality after hepatectomy; thus, new methods for reducing I/R injury are required. The aim of this study is to evaluate changes in the average apparent diffusion coefficient (ADCavg) and fractional anisotropy (FA) in rabbits with partial hepatic I/R injury with magnetic resonance diffusion tensor imaging (DTI). The left lobe of the rabbit liver underwent 60 minutes of ischemia followed by 0.5, 2, 6, 12, 24, and 48 hours of reperfusion. T2-weighted images (T2WI), T1-weighted images (T1WI), DTI, and contrast-enhanced T1WI were performed; 6 b values were used for DTI on 6 diffusion directions. The serum levels of transaminases and liver histopathology findings were examined. In the early stage of I/R (0.5 hour), ADCavg decreased significantly and increased sharply to 2 hours, then increased from 6 hours to 48 hours of reperfusion, except for a transient decrease (24 hours). Meanwhile, FA showed almost the opposite trend, drastically increasing during the first 0.5 hour and then slightly decreasing until 48 hours of reperfusion, except for an obvious decrease in the 2-hours group. The serum levels of liver markers and the pathologic scores were sharply increased in the I/R group after reperfusion and correlated with DTI of hepatic tissue after I/R. Diffusion tensor imaging is feasible for imaging I/R-induced liver damage and can discriminate isotropic properties of the liver after I/R injury with objective changes in the ADCavg and FA. Diffusion tensor imaging can be a promising novel approach for use in clinical management after liver surgery.

Insulin Resistance Is the Main Characteristic of Metabolically Unhealthy Obesity (MUO) Associated with NASH in Patients Undergoing Bariatric Surgery.

(1) Background: Metabolically healthy obesity (MHO) is a concept that applies to obese patients without any elements of metabolic syndrome (metS). In turn, metabolically unhealthy obesity (MUO) defines the presence of elements of metS in obese patients. The components of MUO can be divided into subgroups regarding the elements of inflammation, lipid and glucose metabolism and cardiovascular disease. MUO patients appear to be at greater risk of developing non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) compared to MHO patients. The aim of this study was to evaluate the influence of different MUO components on NAFLD and NASH in patients with morbid obesity undergoing bariatric surgery. (2) Methods: 141 patients undergoing bariatric surgery from September 2015 and October 2021 at RWTH Aachen university hospital (Germany) were included. Patients were evaluated pre-operatively for characteristics of metS and MUO (HbA1c, HOMA, CRP, BMI, fasting glucose, LDL, TG, HDL and the presence of arterial hypertension). Intraoperatively, a liver biopsy was taken from the left liver lobe and evaluated for the presence of NAFLD or NASH. In ordinal regression analyses, different factors were evaluated for their influence on NAFLD and NASH. (3) Results: Mean BMI of the patients was 52.3 kg/m2 (36-74.8, SD 8.4). Together, the parameters HbA1c, HOMA, CRP, BMI, fasting glucose, LDL, TG, HDL and the presence of arterial hypertension accounted for a significant amount of variance in the outcome, with a likelihood ratio of χ2 (9) = 41.547, p < 0.001, for predicting the presence of NASH. Only HOMA was an independent predictor of NASH (B = 0.102, SE = 0.0373, p = 0.007). Evaluation of steatosis showed a similar trend (likelihood ratio χ2 (9) = 40.272, p < 0.001). Independent predictors of steatosis were HbA1c (B = 0.833, SE = 0.343, p = 0.015) and HOMA (B = 0.136, SE = 0.039, p < 0.001). (4) Conclusions: The above-mentioned model, including components of MUO, was significant for diagnosing NASH in patients with morbid obesity undergoing bariatric surgery. Out of the different subitems, HOMA independently predicted the presence of NASH and steatosis, while HbA1c independently predicted steatosis and fibrosis. Taken together, the parameter of glucose metabolism appears to be more accurate for the prediction of NASH than the parameters of lipid metabolism, inflammation or the presence of cardiovascular disease.

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

Percutaneous endoscopic gastrostomy (PEG) is a well-established, minimally invasive, and easy to perform procedure for nutrition delivery, applied to individuals unable to swallow for various reasons. PEG has a high technical success rate of insertion between 95% and 100% in experienced hands, but varying complication rates ranging from 0.4% to 22.5% of cases. To discuss the existing evidence of major procedural complications in PEG, mainly focusing on those that could probably have been avoided, had the endoscopist been more experienced, or less self-confident in relation to the basic safety rules for PEG performance. After a thorough research of the international literature of a period of more than 30 years of published "case reports" concerning such complications, we critically analyzed only those complications which were considered - after assessment by two experts in PEG performance working separately - to be directly related to a form of malpractice by the endoscopist. Malpractice by the endoscopist were considered cases of: Gastrostomy tubes passed through the colon or though the left lateral liver lobe, bleeding after puncture injury of large vessels of the stomach or the peritoneum, peritonitis after viscera damage, and injuries of the esophagus, spleen, and pancreas. For a safe PEG insertion, the overfilling of the stomach and small bowel with air should be avoided, the clinician should check thoroughly for the proper trans-illumination of the light source of the endoscope through the abdominal wall and ensure endoscopically visible imprint of finger palpation on the skin at the center of the site of maximum illumination, and finally, the physician should be more alert with obese patients and those with previous abdominal surgery.

Noninvasive mechanical destruction of liver tissue and tissue decellularisation by pressure-modulated shockwave histotripsy.

Boiling histotripsy (BH) is a promising High Intensity Focused Ultrasound (HIFU) technique that can be used to mechanically fractionate solid tumours at the HIFU focus noninvasively, promoting tumour immunity. Because of the occurrence of shock scattering phenomenon during BH process, the treatment accuracy of BH is, however, somewhat limited. To induce more localised and selective tissue destruction, the concept of pressure modulation has recently been proposed in our previous in vitro tissue phantom study. The aim of the present study was therefore to investigate whether this newly developed histotripsy approach termed pressure-modulated shockwave histotripsy (PSH) can be used to induce localised mechanical tissue fractionation in in vivo animal model. In the present study, 8 Sprague Dawley rats underwent the PSH treatment and were sacrificed immediately after the exposure for morphological and histological analyses (paraffin embedded liver tissue sections were stained with H&E and MT). Partially exteriorised rat's left lateral liver lobe in vivo was exposed to a 2.0 MHz HIFU transducer with peak positive (P +) and negative (P -) pressures of 89.1 MPa and -14.6 MPa, a pulse length of 5 to 34 ms, a pressure modulation time at 4 ms where P + and P - decreased to 29.9 MPa and - 9.6 MPa, a pulse repetition frequency of 1 Hz, a duty cycle of 1% and number of pulses of 1 to 20. Three lesions were produced on each animal. For comparison, the same exposure condition but no pressure modulation was also employed to create a number of lesions in the liver. Experimental results showed that a partial mechanical destruction of liver tissue in the form of an oval in the absence of thermal damage was clearly observed at the HIFU focus after the PSH exposure. With a single pulse length of 7 ms, a PSH lesion created in the liver was measured to be a length of 1.04 ± 0.04 mm and a width of 0.87 ± 0.21 mm which was 2.37 times in length (p = 0.027) and 1.35 times in width (p = 0.1295) smaller than a lesion produced by no pressure modulation approach (e.g., BH). It was also observed that the length of a PSH lesion gradually grew towards the opposite direction to the HIFU source along the axial direction with the PSH pulse length, eventually leading to the generation of an elongated lesion in the liver. In addition, our experimental results demonstrated the feasibility of inducing partial decellularisation effect where liver tissue was partially destructed with intact extracellular matrix (i.e., intact fibrillar collagen) with the shortest PSH pulse length. Taken together, these results suggest that PSH could be used to induce a highly localised tissue fractionation with a desired degree of mechanical damage from complete tissue fractionation to tissue decellularisation through controlling the dynamics of boiling bubbles without inducing the shock scattering effect.

Hemophagocytic lymphohistiocytosis associated with hepatocellular carcinoma.

A man in his 60s was admitted because of abdominal pain and fatigue. Contrast enhanced computed tomography (CECT) showed a hypovascular tumor, 7cm in size, in the left lobe of liver. He had no history of alcohol consumption. HBs antigen and HCV antibody were negative. For definitive diagnosis, biopsy of the hepatic tumor was performed. After the biopsy, the patient suddenly got high fever, and blood tests showed WBC 22,000/L, Hb 8.9g/dL, Plts 11.6 × 104/L, AST 140IU/L, ALT 93IU/L, LDH 635U/L. He died on the following day despite of supportive therapy. Autopsy revealed that the hepatic tumor was poorly differentiated hepatocellular carcinoma (HCC) and that hemophagocytic macrophages were found in the bone marrow and spleen. Based on the pathological findings of autopsy, he was finally diagnosed with hemophagocytic lymphohistiocytosis (HLH) associated with HCC. HLH is a rare and life-threaded disorder of immune overactivation. Malignancy-associated HLH is well-known; however, it is usually associated with malignant lymphoma. To our knowledge, this is the first reported case of HLH associated with HCC, which was diagnosed by autopsy. Although extremely rare, our case highlights that HLH should be considered as a differential diagnosis of unknown high fever and bicytopenia in patients with solid tumors, including HCC.

Totally laparoscopic associating simultaneous bile duct and portal vein ligation for planned hepatectomy for primary liver cancer: a case report

BackgroundSome patients with liver cancer lose the chance to have surgical treatment due to insufficient future remnant liver. To address this problem, individual or occlusion of both the portal vein and the bile duct was used to achieve quick hypertrophy. This is the first study reported in which simultaneous ligation of the portal vein and the bile duct was applied as the first step of planned hepatectomy of primary liver cancer.Case presentationHere we report a case of a 38-year-old Asian male patient with hepatocellular carcinoma with tumor thrombus in the right anterior branch of the portal vein. Right hemihepatectomy can be curative, but patients face a high risk of liver failure because of the small volume of the remaining left liver lobe. Hence we developed a two-step liver resection strategy in which the patient underwent laparoscopic simultaneous bile duct and portal vein ligation of the right hepatic lobe prior to right hemihepatectomy under laparoscopy. Using this procedure, we achieved fast hypertrophy of the left liver lobe and successfully reversed the primary unresectability.ConclusionThis case report demonstrates that simultaneous bile duct and portal vein ligation may be a feasible option for those patients with liver cancer who cannot get surgical treatment due to insufficient future remnant liver.

Anesthesia Management in Laparoscopic Donor Hepatectomy: The First Report from Turkey

We aimed to report a single-center experience in laparoscopic donor left-side and right-side hepatectomy cases regarding preoperative evaluation, perioperative and anesthetic management protocols, and postoperative follow-up. Laparoscopic donor left-side and right-side hepatectomy cases were included in the study because of their excessive transection area and bleeding potential. Medical records of living donors were reviewed in terms of age, sex, body mass index (BMI), presence of consanguinity with the recipient, perioperative and early postoperative biochemical parameters, hemodynamic changes during surgery, duration of surgery, the ratio of liver volume to total liver volume, perioperative complications, and length of hospital stay. Eighty-one laparoscopic living-donor hepatectomy procedures were performed in our unit between 2018 and 2022. Six laparoscopic donor right-side cases and two left-side cases were retrospectively reviewed. Donors' mean age and BMI were 29.6 ± 8.6 years and 23.1 ± 4.3, respectively. The average weights of the right and left lobe liver grafts were 727 g and 279 g, respectively, constituting 65.8% and 22.7% of the total liver volume, respectively. The mean operation time was 593 ± 94 minutes, and the mean volume of blood loss was 437 ± 294 mL. A major complication, namely portal vein stenosis, developed in 1 donor (1/8), and portal vein patency was achieved postoperatively. Anesthesia management and teamwork between surgeons and anesthesiologists are the most important building blocks for donor safety, which is of the utmost priority. Effective communication and cooperation in the operating room may prevent potential donor complications and improve postoperative recovery time.

Right and left liver lobe biopsies by minilaparoscopy reveal clinically significant sampling error in staging and grading of autoimmune hepatitis.

Liver diseases may affect the liver heterogeneously, especially in autoimmune hepatitis (AIH). Hence, the aim of this study was to assess the added benefit of double biopsy of both liver lobes during minilaparoscopy in guiding treatment decisions in patients with AIH. We identified all patients with AIH or variant syndromes (AIH/PBC and AIH/PSC) at our center, who underwent a double biopsy of both liver lobes via minilaparoscopy between 01/2016 and 12/2020. A total of 114 patients received a biopsy of both liver lobes (AIH: N = 83, AIH/PBC: N = 26, AIH/PSC: N = 7). Differences in inflammatory activity as assessed by Ishaks's modified hepatitis activity index (mHAI) were observed in 72 (63%) patients. The difference was ≥2/18 points and ≥3/18 points in 32 (28%) and 11 (10%) patients, respectively. Starting or intensification of immunosuppression should be discussed at a mHAI of 4-5, while a mHAI≥6 prompts intensified immunosuppression in most cases. In 19/114 (17%) and 17/114 (15%) patients mHAI ≥4 or ≥6 was found in only one liver lobe, respectively. In ten patients, severe fibrosis (≥F3) was only found in one liver biopsy. Overall, therapeutically relevant histological differences were observed in 39/114 (34%) patients, which had a direct impact on treatment decisions in 24 patients (21%). No major adverse outcome occurred by taking biopsies from both liver lobes. Obtaining a double biopsy of both liver lobes is a safe procedure during minilaparoscopy that results in more accurate grading and staging and that may impact on treatment decisions in patients with AIH.

Intra-examination agreement between multi-echo gradient echo and confounder-corrected chemical shift-encoded MR sequences for R2* estimation as a biomarker of liver iron content in patients with a wide range of T2*/R2* and proton density fat fraction values.

To investigate the intra-examination agreement between multi-echo gradient echo (MEGE) and confounder-corrected chemical shift-encoded (CSE) sequences for liver T2*/R2* estimations in a wide range of T2*/R2* and proton density fat fraction (PDFF) values. Exploratorily, to search for the T2*/R2* value where the agreement line breaks and examine differences between regions of low and high agreement. Consecutive patients at risk for liver iron overload who underwent MEGE and CSE sequences within the same exam at 1.5T were retrospectively selected. Regions of interest were drawn in the right and one in the left liver lobes on post-processed images for R2*(sec-1) and PDFF (%) estimation. Agreement between MEGE-R2* and CSE-R2* was evaluated using intra-class correlation coefficient (ICC) and Bland-Altman analysis. 95% confidence intervals (CI) were computed. Segment-and-regression analysis was performed to find the point where the agreement between sequences is interrupted. Regions of low and high agreement were examined using tree-based partitioning analyses. 49 patients were included. Mean MEGE-R2* was 94.2s-1 (range: 31.0-737.1) and mean CSE-R2* 87.7 (29.7-748.1). Mean CSE-PDFF was 9.12% (0.1-43.3). Agreement was strong for R2* estimations (ICC: 0.992,95%CI 0.987,0.996), but the relation was nonlinear and possibly heteroskedastic. Lower agreement occurred when MEGE-R2* > 235s-1, with MEGE-R2* values consistently lower than CSE-R2*. Higher agreement was observed when PDFF < 14%. MEGE-R2* and CSE-R2* strongly agree, though at higher iron content, MEGE-R2* is consistently lower than CSE-R2*. In this preliminary dataset, a breaking point for agreement was found at R2* > 235. Lower agreement was observed in patients with moderate to severe liver steatosis.