Perihepatic Fluid Collections Research Articles

Fantastic flukes and where to find them

We describe the case of a middle-aged Chinese migrant with a background of metastatic hepatocellular carcinoma (HCC) who was found to have a parasitic perihepatic fluid collection masquerading as a malignant collection. The aspirate of this showed no organisms on gram stain with negative cultures. A smear and cell block for cytology showed moderate bile, debris, and proteinaceous material with occasional macrophages. No malignant cells were seen, however a few clustered and single egg like structures were noted suggestive of parasitic eggs of a liver fluke.

S1764 Localized Truncal Xanthoderma Secondary to Bile Leakage Post Laparoscopic Cholecystectomy

Introduction: Xanthoderma is a yellow to yellow-orange discoloration of the skin. The 2 main pathologies leading to xanthoderma are jaundice and carotenoderma. Although the most common mechanism for jaundice is the elevation of serum bilirubin, localized jaundice can rarely occur in the settings of bile leakage into the retroperitoneal space. Case Description/Methods: A 40-year-old female patient presented with biliary pain. Examination showed right upper quadrant tenderness. Initial labs revealed total bilirubin of 49 µmol/L, with a direct bilirubin of 47µmol/L (Table). The US abdomen showed cholelithiasis. MRCP showed a small distal CBD stone; CBD diameter was 9 mm. She underwent laparoscopic cholecystectomy with an intraoperative cholangiogram. The small distal CBD stone was pushed to the duodenum. Repeated IOC showed a smooth passage of contrast. Her clinical status didn’t improve postoperatively, and her bilirubin was persistently elevated. Localized yellowish discoloration of the right side of the abdominal wall and the suprapubic area was observed 5 days after the surgery (Figure A). Repeated MRCP showed suspicious distal CBD stone with gall bladder bed collection and diffuse inflammatory change of the right abdominal wall. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a bile leak at the site of the cystic stump (Figure A) and a small filling defect in the distal CBD. Sphincterotomy and CBD stenting were performed. The bilirubin improved gradually after ERCP, but the abdominal pain persisted. CT abdomen showed large perihepatic and perisplenic fluid collection measuring 10x 17.6x 20 cm, necessitating US-guided percutaneous drainage. Turbid yellow fluid was drained, confirming that the collection was a biloma related to the bile leak. Four weeks later, the percutaneous drain was removed after the collection resolved. Repeated ERCP showed no biliary leak. Discussion: In our patient, the localized xanthoderma post laparoscopic cholecystectomy was secondary to bile leakage from the cystic duct stump. In a similar case report, the authors explained that the localized xanthoderma occurred as a result of bile staining of the tissues deep to the membranous layer of the superficial fascia (fascia of Scarpa) after the bile has leaked from the cystic duct through the hepatoduodenal ligament. The management of our patient involved sphincterotomy and bile duct stenting combined with percutaneous drainage of the collections.Figure 1.: A: Localized yellowish discoloration of the anterior abdominal wall. B: An ERCP fluoroscopic image showing contrast leakage near the cystic stump. Table 1. - Laboratory investigations Laboratory test Patient's value Normal range Total bilirubin 49 µmol/L 0-21 Direct bilirubin 47 µmol/L 0-9 AST 287 U/L 0-32 ALT 249 U/L 0-33 Alkaline phosphatase 264 U/L 35-104

Pleural empyema caused by dropped gallstones after laparoscopic cholecystectomy for acute cholecystitis: a case report

BackgroundDropped gallstones during laparoscopic cholecystectomy (LC) sometimes induce postoperative infectious complications. However, pleural empyema rarely occurs as a complication of LC.Case presentationWe present the case of a 66-year-old woman with right pleural empyema. She previously underwent LC for acute gangrenous cholecystitis 11 months ago. The operative report revealed iatrogenic gallbladder perforation and stone spillage. The bacterial culture of the gallbladder bile was positive for Escherichia coli. Chest and abdominal computed tomography revealed right pleural effusion, perihepatic fluid collection, and multiple small radiopaque density masses. Although ultrasound-guided transthoracic drainage was performed, the drainage was incomplete, and systemic inflammatory reaction persisted. Consequently, thoracotomy and laparotomy with gallstone retrieval were performed, and the patient recovered completely. The patient has remained well without complications after 14 months of follow-up.ConclusionsWe report a rare case of pleural empyema caused by dropped gallstones after LC. This case emphasized the importance of completely retrieving the dropped gallstones to prevent late infectious complications after LC.

S2653 Candida Liver Abscesses Due to a Penetrating Duodenal Ulcer

Introduction: Fungal infections of the liver commonly occur in patients with neutropenia, hematologic malignancies, and chemotherapy. The most common isolated agents are species of the Candida family, originating from the translocation of the gastrointestinal tract to the liver. Here, we present a rare case of multiple fungal abscesses in an immunocompetent host due to a perforating duodenal ulcer. Case Description/Methods: A 59-year-old man with COPD, hypertension, peptic ulcer disease, and obesity presented for altered mental status and fever. He was found to have right lower lobe pneumonia and complete heart block treated with antibiotics, temporary transvenous pacing then leadless permanent pacemaker. During his stay, he presented with melena. He underwent an upper endoscopy that showed a large 40 mm nonbleeding cratered duodenal ulcer with possible perforation and a superficial gastric ulcer with a flat pigmented spot. A CT scan of the abdomen and pelvis showed 3 perihepatic fluid collections along the left lobe, right lobe, and gallbladder fossa with the largest measuring 9cmx1.5cmx9cm and associated pneumobilia. There was no intra-abdominal free air. The patient was clinically stable, afebrile, and denied significant abdominal pain. There were no signs of peritoneal irritation on the physical exam. He did have a persistent neutrophilic leukocytosis with a white cell count of 18,400/ml, Hemoglobin 9g/dl, total bilirubin 0.6 mg/dl, AST 29 IU/l, ALT 38 IU/l, Alkaline phosphatase 53IU/L. The patient was managed conservatively with broad-spectrum antibiotics and proton pump inhibitors. He underwent urgent percutaneous drainage of the 2 largest abscesses. Cultures from the collections grew Candida albicans only. Blood cultures were negative. Thus, the patient was treated with micafungin then transitioned to fluconazole for a 6-week course of therapy. Amoebic and Echinococcus antibodies, and HIV tests were negative. A follow-up CT showed resolution of the liver collections. Discussion: This is a rare case of candida liver abscesses as a complication of a penetrating large duodenal ulcer successfully treated with conservative management. Pyogenic liver abscesses are unusual presentations of perforated gastroduodenal ulcers. In addition to the drainage of the collections, antifungal agents should be considered in the initial antimicrobial regimen choice even in immunocompetent hosts.Figure 1.: From A to C: CT demonstrated liver abscesses (frontal and axial views); D: Upper endoscopy showing a cratered duodenal ulcer.

Occurrence of spontaneous fistulas detected by contrast filling during computed tomography-guided percutaneous drainage placement of splenic and perisplenic fluid collections.

Fistulas are serious complications of splenic and perisplenic fluid accumulations, which are often difficult to detect by routine imaging methods. To evaluate the occurrence of spontaneous fistulas detectable during computed tomography-guided percutaneous drainage placement (CTGDP) with contrast filling of splenic or perisplenic fluid collections and to assess characteristics in comparison with perihepatic or peripancreatic fluid accumulations, also being treated with CTGDP. In 127 CTGDP-procedures, pre-interventional CTs conducted with intravenous contrast agent were compared to post-interventional CTs including contrast filling of the drain to identify spontaneous fistulas. Patient and case characteristics were evaluated, and therapeutic consequences of fistula identification were analyzed. A total of 43 perisplenic, 40 peripancreatic, and 44 perihepatic drains were evaluated; 13 (30.2%) perisplenic, 7 (17.5%) peripancreatic, and 10 (22.7%) perihepatic fistulas were observed. Concerning the frequency of fistulas, no significant difference was found between the patient groups (P = 0.39). All fistulas were solely proven in CT scans including contrast filling of the drain. Seven fistulas (23.3%) required additional interventions. Perihepatic drains were significantly more often associated with recent surgery (P < 0.001). The mean size of peripancreatic drains was significantly greater (11.8 ± 3.9 F; P < 0.001) than in perihepatic or perisplenic fluid collections. Spontaneous fistulas detected during CTGDP of splenic or perisplenic fluid collections are common. Post-interventional contrast filling of the drain drastically improves the detection rate of perisplenic, peripancreatic and perihepatic fistulas simultaneously initiating appropriate follow-up interventions.

Accidental transhepatic percutaneous endoscopic gastrostomy tube placement with subtotal gastrectomy

An 81-year-old woman with a medical history of cerebral infarction and recurrent aspiration pneumonia was referred to our department for insertion of a PEG tube. In addition, she had undergone subtotal gastrectomy with Billroth II anastomosis for treatment of gastric cancer. PEG tube placement was carried out in the interventional radiology room with a fluoroscopic evaluation. A PEG tube was located at the lesser curvature side of the midbody (A). The patient tolerated the procedure with no immediate adverse event. After the procedure, no free air was seen on chest and abdominal radiographs. Three days after the procedure, the inflammation markers were significantly higher than expected, so we checked the CT of the abdomen. Imaging showed a transhepatic placement of the PEG tube and a small perihepatic fluid collection with mild biliary duct dilatation (B, C). Broad-spectrum antibiotics were used, with close observation. Eleven days after the PEG tube insertion, we removed the PEG tube with an endoscopic snare at the direction of the oral side. We used histoacryl to close the gastrohepatic fistula (D). After the procedure, the patient showed no procedure-related adverse events. As far as we know, this is the first reported case of transhepatic PEG tube placement in the setting of subtotal gastrectomy.

Contemporary Management of Hepatic Cyst Disease: Techniques and Outcomes at a Tertiary Hepatobiliary Center

BackgroundHepatic cyst disease is often asymptomatic, but treatment is warranted if patients experience symptoms. We describe our management approach to these patients and review the technical nuances of the laparoscopic approach. MethodsMedical records were reviewed for operative management of hepatic cysts from 2012 to 2019 at a single, tertiary academic medical center. ResultsFifty-three patients (39 female) met the inclusion criteria with median age at presentation of 65 years. Fifty cases (94.3%) were performed laparoscopically. Fourteen patients carried diagnosis of polycystic liver disease. Dominant cyst diameter was median 129 mm and located within the right lobe (30), left lobe (17), caudate (2), or was bilobar (4). Pre-operative concern for biliary cystadenoma/cystadenocarcinoma existed for 7 patients. Operative techniques included fenestration (40), fenestration with decapitation (7), decapitation alone (3), and excision (2). Partial hepatectomy was performed in conjunction with fenestration/decapitation for 15 cases: right sided (7), left sided (7), and central (1). One formal left hepatectomy was performed in a polycystic liver disease patient. Final pathology yielded simple cyst (52) and one biliary cystadenoma. Post-operative complications included bile leak (2), perihepatic fluid collection (1), pleural effusion (1), and ascites (1). At median 7.1-month follow-up, complete resolution of symptoms occurred for 34/49 patients (69.4%) who had symptoms preoperatively. Reintervention for cyst recurrence occurred for 5 cases (9.4%). ConclusionsOutcomes for hepatic cyst disease are described with predominantly laparoscopic approach, approach with minimal morbidity, and excellent clinical results.

Continuous versus pulsed microwave ablation in the liver: any difference in intraoperative pain scores?

BackgroundThis study prospectively compared intraoperative pain scores during percutaneous microwave ablation of the liver in patients randomized between continuous and pulsed energy delivery algorithms.MethodsDuring a 12-month period, 20 patients who underwent microwave liver ablation were prospectively randomized between 2 different energy delivery modes: “continuous mode” (CM, n=10) and “pulsed mode” (PM, n=10). All ablation sessions were performed using the same microwave ablation platform under computed tomographic guidance and intravenous analgesia. Within 30 min post ablation, all patients completed a questionnaire assigning a numeric pain intensity score from 0 (no pain) to 10.ResultsMean pain scores were 8.17±1.850 in the CM group and 4.50±1.567 in the PM group, with a statistically significant difference of 3.667±2.807 pain units (P=0.001). The mean procedure time was 53.5±20.90 min in the PM group vs. 58.5±17.44 min in the CM group (P=0.279). The mean size of the lesions was 2.81±0.95 cm in the PM group and 2.81±0.85 cm in the CM group (P=0.984). On a per-lesion basis, technical success was achieved in all evaluable tumors in both groups. No difference was noted in the local tumor control on the 6-month imaging evaluation. No complications were observed in the CM arm, while small perihepatic hemorrhagic fluid collections were reported in the PM group.ConclusionsBoth algorithms for microwave energy delivery have comparable treatment effects in terms of 6-month local tumor control for liver lesions <3 cm in diameter. PM treatments compared to CM appear to induce significantly less pain in patients undergoing percutaneous liver ablation under intravenous analgesia.

Incidence, Location, and Natural History of Perihepatic Fluid Collections after Orthotopic Liver Transplantation

Objective: The purpose of this study was to evaluate the common locations of perihepatic fluid collections after liver transplantation, assess their complexity, and understand their natural history and clinical significance. Materials and Methods: A retrospective analysis of 189 postoperative orthotopic liver transplant patients was performed using serial CT or MRI to characterize perihepatic fluid collections. Location, size, complexity of the collections, and clinical course were evaluated. Results: 76 patients (40%) presented with perihepatic fluid collections with a total of 116 collections. 45 pts (59%), had a one collection, 23 pts (30%) had two, 7 pts (9%) had three and one patient (1%) had four. Collections were seen in predictable locations, with 38 (33%) in segment 5/6, 37 (32%) in the ligamentum venosum/pericaval region, 12 (10%) in the porta hepatis, 11 (9%) the pericapsular/subdiagphramatic location, 10 (9%) along the fissure for ligamentum teres, and the remaining 8 (7%) collections in ‘other’ less frequent perihepatic locations. The vast majority, 100/116 (86%) of all collections were simple and 95/105 (90%) of the collections resolved, decreased or stable on follow up. Collections located in pericapsular /subdiaphragmatic region were significantly more likely to be complex. 16/116 (14%) of the collections were complex, and 4 of these required intervention. Conclusions: Perihepatic fluid collections are seen in 40 % of patients after liver transplant. Fluid collections are often in predictable locations, most commonly seen in segment 5/6, the ligamentum venosum/ pericaval region, the porta hepatis, and the fissure for ligamentum teres. Collections in these locations tend to be simple by imaging criteria and rarely require follow up. Radiologists interpreting post liver transplant patients should be familiar with the common locations of these collections, and when asymptomatic, recognize these as incidental. Further evaluation may be warranted if collections are symptomatic, enlarging, have complex imaging features, or located in an atypical location.

A Case of Perforated Cholecystitis Presenting as Persistent Pleural Effusion

Gallbladder perforation is an uncommon complication of cholecystitis that can result in perihepatic abscess. We present a case of persistent right-sided pleural effusion secondary to perihepatic abscess from perforated gallbladder. A 46-year-old male with paraplegia secondary to T4 spinal cord injury was admitted after presenting with fever, cough, and shortness of breath. He had previously been treated at an outside hospital with an oral antibiotic course for a presumed pneumonia. CT chest showed a large rightsided pleural effusion. A pleural pigtail catheter was placed with persistent large-volume output. Initial imaging of the chest incidentally revealed a large peri-hepatic fluid collection. This was further investigated with an abdominal CT which revealed a large perihepatic rim-enhancing fluid collection with multiple gallstones in the gallbladder neck and small collections in the gallbladder fundus suspicious for a site of perforation. He was sent for interventional-radiology guided drain placement with plan for outpatient cholecystectomy. Output from the pleural pigtail decreased and the drain was removed with resolution of sepsis and shortness of breath. Gallbladder perforation is a relatively infrequent complication of acute cholecystitis. Often, intial symptoms of cholecystitis are masked due to uncontrolled diabetes or, as in this case, spinal cord injury. As far as the authors of this case are aware, perforated gallbladder resulting in pleural effusion has not yet been described in the literature.2921 Figure 1. Perihepatic abscess

Symptomatic Perihepatic Fluid Collections After Hepatic Resection in the Modern Era

BackgroundImprovements in liver surgery have led to decreased mortality rates. Symptomatic perihepatic collections (SPHCs) requiring percutaneous drainage remain a significant source of morbidity. Study DesignA single institution’s prospectively maintained hepatic resection database was reviewed to identify patients who underwent hepatectomy between January 2004 and February 2012. ResultsData from 2173 hepatectomies performed in 2040 patients were reviewed. Overall, 200 (9 %) patients developed an SPHC, the majority non-bilious (75.5 %) and infected (54 %). Major hepatic resections, larger than median blood loss (≥360 ml), use of surgical drains, and simultaneous performance of a colorectal procedure were associated with an SPHC on multivariate analysis. Non-bilious, non-infected (NBNI) collections were associated with lower white blood cell (WBC) counts, absence of a bilio-enteric anastomosis, use of hepatic arterial infusion pump (HAIP), and presence of metastatic disease, and resolved more frequently with a single interventional radiology (IR) procedure (85 vs 46.5 %, p < 0.001) more quickly (15 vs 30 days, p = 0.001). ConclusionsSPHCs developed in 9 % of patients in a modern series of hepatic resections, and in one third were non-bilious and non-infected. In the era of modern interventional radiology, the need for re-operation for SPHC is exceedingly rare. A significant proportion of minimally symptomatic SPHC patients may not require drainage, and strategies to avoid unnecessary drainage are warranted.

Lactococcus Septicemia With Perihepatic Fluid Collection in End-Stage Renal Disease Patient

A 38 year old African American male presented to the emergency room with complaints of having chills, fever, and shortness of breath. His past medical history was significant for sickle cell disease SS-type, end-stage renal disease dialysis dependent, diastolic congestive heart failure, and hemochromatosis. The patient stated that while receiving dialysis he started having the above symptoms. Blood cultures were taken at the dialysis center, and he was administered vancomycin and gentamicin. His temperature was recorded as 101.1, and he was hypotensive. The patient also admitted to gradual onset of abdominal pain, primarily on the right side and dull in nature;also, he had productive cough and rhinorrhea that started 3 to 4 days prior to admission. Of significance, this patient was in a hospital 2 weeks prior for symptomatic anemia and shortness of breath. He was admitted for severe sepsis perhaps secondary to healthcare-associated pneumonia and transaminitis possibly secondary to hemochromatosis vs hypoperfusion due to sepsis. He received hemodialysis, additional blood cultures were drawn, and placed on broad spectrum antibiotics, which included vancomycin, zosyn, and levofloxacin. Chest x-ray showed cardiomegaly and increased interstitial markings likely related to cardiac decompensation. CT abdomen and pelvis without contrast showed airspace opacity in the right lung base, enlarged liver with nodular contour compatible with cirrhosis, moderate amount of loculated perihepatic collection, and a calcified failed right sided kidney transplant. Laboratory data included a white blood cell count of 62,700, neutrophil percentage of 90.1%, and 14% bands on manual differential. Lactic acid 4.3 mm/l, procalcitonin 91.46 ng/ml, ammonia 64 μM/l. The patient's hepatic panel showed an albumin of 2.7 gm/dl, alkaline phosphatase 193 mu/ml, alanine transaminase 98 mu/ml, aspartate transaminase 242 mu/ml, direct bilirubin 5.9 mg/dl, and total bilirubin 10.9 mg/dl. The patient had a CT-guided drainage of the inferior perihepatic fluid collection. Approximately 200cc of amber colored fluid was removed and a drainage bag was placed. Fluid analysis and chemistries were consistent with exudative process. Infectious diseases was consulted for documented blood culture positivity for Lactococcus and Escherichia coli, with recommendation to continue vancomycin and zosyn, discontinue levofloxacin, and send perihepatic fluid for gram stain, culture, and cytology. The patient's fevers resolved and his white blood cell count continued to trend downwards from a peak of 62, 700. He was transferred from the medical intensive care unit to the medical floor for further management.

Hepatic lymphatics: anatomy and related diseases.

The liver normally produces a large amount of lymph. It is estimated that between 25% and 50% of the lymph received by the thoracic duct comes from the liver. In normal conditions, hepatic lymphatics are not depicted on cross-sectional imaging. They are divided in lymphatics of deep system (lymphatics following the hepatic veins and the portal tract) and those of superficial system (convex surface and inferior surface). A variety of diseases may affect hepatic lymphatics and in general they manifest as lymphedema, lymphatic mass, or cystic lesions. Abnormal distended lymphatics are especially seen in periportal spaces as linear hypoattenuations on CT or strong linear hyperintensities on heavily T2-weighted MR imaging. Lymphatic tumor spread as in lymphoma and lymphangitic carcinomatosis manifests as periportal masses and regional lymph node enlargement. Lymphatic disruption after trauma or surgery is depicted as perihepatic fluid collections of lymph (lymphocele). Lymphatic malformation such as lymphangioma is seen on imaging as cystic spaces of variable size.

Dropped Gallstones Causing a Perihepatic Abscess and Empyema.

Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy is a well-known occurrence; however, the consequences of spillage of gallstones in the peritoneum and particularly intrathoracic complications are less defined. We describe the delayed development of a perihepatic abscess and empyema in a patient five years following laparoscopic cholecystectomy secondary to dropped gallstones. A 53-year-old man with medical history significant for a laparoscopic cholecystectomy five years prior to acute cholecystitis presented with purulent cough, hemoptysis, night sweats, and right-upper quadrant (RUQ) pain. Computed tomography (CT) scan revealed 5.4 cm right-sided subpulmonic and 5.9 cm perihepatic fluid collections with an 8 mm focal radiopaque density within the perihepatic fluid collection. Open intra-abdominal exploration resulted in retrieval of a 1 cm intraperitoneal gallstone. Laparoscopic cholecystectomy is a common surgical operation during which gallstone spillage can occur, causing both intra-abdominal and intrathoracic complications, presenting even years after surgery. This necessitates an attempt to retrieve all free intra-abdominal gallstones during the initial operation.

Right Upper Quadrant Abdominal Pain Ten Years Post-laparoscopic Cholecystectomy

Purpose: A 72-year-old woman with past history of laparoscopic cholecystectomy 10 years ago presented with a 6-month history of intermittent right upper quadrant abdominal and flank pain without association with food intake. She denied fever and weight loss. Physical examination revealed erythema and tenderness in the right lateral aspect of the upper abdomen. Labs were unremarkable. Computed tomography (CT) of the abdomen showed a complex 21 x 5.8 x 8.8 cm perihepatic fluid collection with internal septations, which fistulized through the abdominal wall and formed a 5.6 x 2 cm subcutaneous fluid collection in the right flank. HIDA scan and MRCP ruled out bile leak. Ultrasound guided drainage of the abscess drained thick, greenish fluid. The patient was empirically started on ceftriaxone and metronidazole. Bacterial and fungal cultures as well as PPD, Echinococcus, and Entamoeba serology were all negative. Cytology revealed proteinaceous material with few inflammatory cells and many degenerated structures, suspicious for, yet not definitive of, Echinococcus cyst. Patient received a 6-week course of albendazole, and PAIR procedure (puncture, aspiration, injection, and re-aspiration) was performed with no improvement in symptoms. Repeat CT scan showed persistence of the abscess. An exploratory laparotomy was performed with 500 ml of fluid drained and evacuated 28 gallstones, confirmed by pathology, from the cavity. The fluid cultures were again negative. Repeat CT scan performed a month after the surgery showed near complete resolution of the abscess. Gallbladder perforation during laparoscopy cholecystectomy can result in spillage of gallstones into the peritoneal cavity, which may lead to the development of intra-abdominal abscesses that are easily misidentified as tumors or parasitic infections on radiography due to their similar appearance. The rarity and chronicity of this problem makes the diagnosis very challenging. Treatment requires exploratory laparotomy to remove all dropped gallstones. Less invasive procedures such as percutaneous drainage are effective for resolving acute symptoms, but allow recurrence of abscess. Most patients get a short course of antibiotics based on fluid cultures that typically reveal E. coli, Klebsiella pneumoniae, and Enterococcus. Interestingly, in our patient, the cultures were negative, suggesting that the development of the abscess was secondary to foreign body reaction to the dropped gallstones. Our case illustrates the importance of considering dropped gallstones in the differential diagnosis of intra- or extraperitoneal abscesses in any patient with a history of laparoscopic cholecystectomy, regardless of the time elapsed since surgery.

Abstract No. 406 - Role of interventional radiology in the management of posthepatectomy collections

Purpose To evaluate the role of image-guided percutaneous drainage in the management of post-hepatectomy perihepatic fluid collections. Materials and Methods An institutional database was used to retrospectively identify patients who underwent drainage for a post-hepatectomy peri-hepatic collection between 2007 and 2011. Medical records were reviewed to determine patient demographics, indications for surgery, imaging documentation of fluid collection(s), drainage procedure and follow-up. Technical success was defined as the successful placement of a drainage catheter within the fluid collection. Primary clinical success was defined as resolution of fluid collection by placement of drainage catheter. Secondary clinical success was defined as resolution of the peri-hepatic fluid collection after secondary manipulation of drainage catheter not requiring surgery. Results Between 2007 and 2011, 20 patients (M:F=12:8) with a mean age of 67 years (range: 49-80 years), underwent drainage of a post-hepatectomy peri-hepatic fluid collection. Sixteen patients (80%) underwent computed tomography guided drainage and 4 (20%) underwent ultrasound guided drainage. The mean collection size was 8.3 cm (range 2.2 cm -18 cm) and mean duration of catheter drainage was 26.5 days, (range 25- 89 days). Technical success was 100%, primary clinical success rate was 75 % (15/20) and the secondary clinical success rate was 20% (4/20) with an overall clinical success rate of 95%. One patient required surgical management of the collection for continuous high biliary output following successful catheter placement. None of the patients had procedure related complications. Conclusion Image-guided percutaneous catheter drainage of post-hepatectomy fluid collections is safe and effective procedure that is associated with high clinical success. Percutaneous drainage should be considered for the management of post-hepatectomy peri-hepatic collections.

Gallbladder perforation following transarterial chemoembolisation; a rare but serious complication

Transarterial chemoembolisation (TACE) is the mainstay of treatment for large or multifocal hepatocellular carcinoma (HCC). However, this procedure is not without potential complications. We report the case of a 72-year-old...

Endoscopic Retrograde Cholangiopancreatography Is an Effective Treatment for Bile Leak After Severe Liver Trauma

Biliary leak after severe hepatic trauma is a complex problem requiring multidisciplinary care. We report on our experience with endoscopic management of posttraumatic bile leaks and clarify the role of endoscopic retrograde cholangiopancreatography (ERCP). A retrospective analysis was performed on all patients who sustained liver injury and underwent ERCP from September 2003 to September 2009. Patients who had associated biliary leak were identified. Patient demographics, injury characteristics, liver operations, endoscopic treatment, and success of endoscopic intervention were reviewed. Liver injury was managed in an interdisciplinary fashion, including immediate or delayed operation or angiography or both for primary or adjunctive hemostasis. ERCP with stenting and sphincterotomy was used to treat biliary fistulae. Sequelae of liver injury including biloma or other perihepatic fluid collection were also managed by computed tomography scan-guided or ultrasound-guided drainage. A total of 26 patients underwent ERCP for the management of biliary fistula as a result of severe hepatic trauma. There were 14 (54%) blunt injuries. In every patient (100%), ERCP with stenting and sphincterotomy was successful in controlling bile leak. All patients eventually had removal of stents and drains, with resolution of leak. Two patients had concomitant treatment of associated pancreatic ductal injury. ERCP is useful as both a diagnostic and therapeutic tool for the safe treatment of biliary ductal injuries after severe liver trauma and should be part of a multidisciplinary treatment algorithm.

Functional hepatobiliary MR imaging in children

Clinical application efforts for the hepatocyte-specific MRI contrast agent gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) have mainly been directed toward detection and characterization of various hepatic masses in the adult population. Here we report our initial experience with Gd-EOB-DTPA for evaluating congenital and acquired hepatobiliary pathologies in the pediatric population. Twenty-one consecutive children receiving Gd-EOB-DTPA for functional hepatobiliary evaluation at our institution were retrospectively identified with IRB approval. The use of Gd-EOB-DTPA was classified in each case as definite, potential, or no clinical utility, focusing on the clinical value gained beyond traditional noncontrast fluid-sensitive MR cholangiopancreatography (FS-MRCP) and other imaging modalities. Definite added value of Gd-EOB-DTPA was found in 12 patients, with potential value in 4 patients, and no value in 5 patients. Benefit was seen in cases of iatrogenic and non-iatrogenic biliary strictures, perihepatic fluid collections for biliary leak, hepatobiliary dysfunction in the absence of hyperbilirubinemia, and in the functional exclusion of cystic duct occlusion that can be seen in acute cholecystitis. This is the first reported series of children with Gd-EOB-DTPA and this early work suggests potential pediatric applications.

Outcomes of Laparoscopic Liver Resection for Lesions Located in the Right Side of the Liver

Laparoscopic right-sided liver resection may be feasible and safe. Retrospective analysis. Department of surgery at a university hospital. Of 103 consecutive laparoscopic liver resections performed from May 1, 2003, to April 30, 2007, 46 patients underwent a right-sided laparoscopic liver resection. Six operations required conversion (13%) to open surgery. Overall, data from 40 patients with benign liver tumors (n = 2), intrahepatic duct stones (n = 3), liver metastasis from colorectal cancer (n = 8), and hepatocellular carcinomas (n = 27) were analyzed. Feasibility and operative outcome. The operations included 12 major resections (5 right hemihepatectomy and 7 right posterior sectionectomy) and 28 minor resections (14 segmentectomy and 14 tumorectomy). No operative mortality, subsequent operation, or life-threatening complications occurred. Overall, 11 patients (28%) experienced complications; 2 had bile leakage, 6 had perihepatic fluid collection, 2 had prolonged ascites, and 1 had pleural effusion. All recovered after conservative management. The mean operation time was 300 minutes, the mean blood loss was 620 mL, and the mean hospital stay was 11 days. For lesions located at segment VII or VIII (n = 15), the mean operation time and amount of blood loss in those receiving a minor liver resection were similar to those who received a major resection (P = .21 and .88, respectively). Although greater technical refinement is required for a minor resection in the superior part of the right side of the liver, laparoscopic right-sided liver resection is feasible and safe.