Segments IVb Research Articles

Single stage management of suspected gallbladder cancer guided by intraoperative frozen section analysis: A retrospective cohort study.

The management of radiologically suspected gallbladder cancers (GBC) that lack definitive radiological features usually involves performing a first-stage routine laparoscopic cholecystectomy, followed by an open second-stage liver resection (segments IVB and V) and hilar lymphadenectomy (extended cholecystectomy) if subsequent formal histology confirms a malignancy. Performing a cholecystectomy with an intraoperative frozen section to guide the need for conversion to an extended cholecystectomy as a single-stage procedure has multiple benefits compared to a two-stage approach. However, the safety and efficacy of this approach have not yet been evaluated in a tertiary setting. A retrospective cohort study was performed using a database of all consecutive patients with suspected GBC who had been referred to our tertiary unit. Following routine cholecystectomy, depending on the operative findings, the gallbladder specimen was removed and sent for frozen-section analysis. If malignancy was confirmed, the depth of tumour invasion was evaluated, followed by simultaneous extended cholecystectomy, when appropriate. The sensitivity and specificity of frozen section analysis for the diagnosis of GBC were measured using formal histopathology as a reference standard. A total of 37 consecutive cholecystectomies were performed. In nine cases, GBC was confirmed by intraoperative frozen section analysis, three of which had standard cholecystectomy only as their frozen section showed adenocarcinoma to be T1a or below (n=2) or were undetermined (n=1). In the remaining six cases, malignant invasion beyond the muscularis propria (T1b or above) was confirmed; thus, a synchronous extended cholecystectomy was performed. The sensitivity (95% CI 66.4%-100%) and specificity (95% CI 87.7%-100%) for identifying GBC using frozen section analysis were both 100%. The net cost of the single-stage pathway in comparison to the two-stage pathway resulted in overall savings of £3894. Intraoperative frozen section analysis is a reliable tool for guiding the use of a safe, single-stage approach for the management of GBC in radiologically equivocal cases. In addition to its lower costs compared to a conventional two-stage procedure, intraoperative analysis also affords the benefit of a single hospital admission and single administration of general anaesthesia, thus greatly enhancing the patient's experience and relieving the burden on waiting lists.

Predicting successful ultrasound-guided biopsy of liver lesions.

To determine the factors that affect successful ultrasound-guided biopsy of liver lesions and build a model predicting feasibility of US-guided liver biopsy. This is IRB-approved HIPAA-compliant retrospective review of consecutive ultrasound-guided targeted liver biopsies performed or attempted between 1/2018 and 9/2020 at a single tertiary academic institution with a total of 501 patients included. Mann-Whitney and chi-square tests were used to compare continuous and categorical variables, respectively. Logistic regression model was built to predict feasibility of successful ultrasound-guided biopsy. Liver lesion biopsy was successfully performed with US guidance in 429/501 (86%) patients. Lesions not amenable for US biopsy were smaller (median size 1.6 cm vs 3.3 cm, p < 0.0001) and deeper within the liver (median depth 9.0 cm vs 5.8 cm, p < 0.0001). The technical success rate was lowest for lesions in segment II (40/53, 75%), while lesions in segment IVb (87/91, 96%) had highest success rate (p < 0.003). US targeting in patients with 1 or 2 lesions was less feasible than in patients with 3 or more lesions, 126/180 (70%) vs. 303/321 (94%), (p < 0.0001). Model including lesion size, depth, location, and number of lesions predicts feasibility of US-guided biopsy with Area under the ROC curve (AUC) = 0.92. Linear logistic regression model that includes lesion size, depth and location, and number of lesions is highly successful in predicting feasibility of ultrasound-guided biopsy for liver lesions. Smaller lesions, deeper lesions, and lesions in segment II and VIII in patients with less than 3 lesions were less feasible for ultrasound-guided biopsy of liver lesions.

Automated liver segmental volume ratio quantification on non-contrast T1–Vibe Dixon liver MRI using deep learning

PurposeTo evaluate the effectiveness of automated liver segmental volume quantification and calculation of the liver segmental volume ratio (LSVR) on a non-contrast T1-vibe Dixon liver MRI sequence using a deep learning segmentation pipeline. MethodA dataset of 200 liver MRI with a non-contrast 3 mm T1-vibe Dixon sequence was manually labeledslice-by-sliceby an expert for Couinaud liver segments, while portal and hepatic veins were labeled separately. A convolutional neural networkwas trainedusing 170 liver MRI for training and 30 for evaluation. Liver segmental volumes without liver vessels were retrieved and LSVR was calculated as the liver segmental volumes I-III divided by the liver segmental volumes IV-VIII. LSVR was compared with the expert manual LSVR calculation and the LSVR calculated on CT scans in 30 patients with CT and MRI within 6 months. ResultsTheconvolutional neural networkclassified the Couinaud segments I-VIII with an average Dice score of 0.770 ± 0.03, ranging between 0.726 ± 0.13 (segment IVb) and 0.810 ± 0.09 (segment V). The calculated mean LSVR with liver MRI unseen by the model was 0.32 ± 0.14, as compared with manually quantified LSVR of 0.33 ± 0.15, resulting in a mean absolute error (MAE) of 0.02. A comparable LSVR of 0.35 ± 0.14 with a MAE of 0.04 resulted with the LSRV retrieved from the CT scans. The automated LSVR showed significant correlation with the manual MRI LSVR (Spearman r = 0.97, p < 0.001) and CT LSVR (Spearman r = 0.95, p < 0.001). ConclusionsA convolutional neural network allowed for accurate automated liver segmental volume quantification and calculation of LSVR based on a non-contrast T1-vibe Dixon sequence.

Aberrant Vascular Anatomy Associated With Artifactual Focal Avidity in the Liver on PSMA PET.

68 Ga-prostate-specific membrane antigen (PSMA) PET/CT is a valuable tool for staging and restaging of prostate cancer. Prostate-specific membrane antigen expression is not specific to prostate cancer, as it is expressed in normal tissues as well as in neoplastic and nonneoplastic processes. Awareness of the broad possibility of lesions with PSMA avidity is necessary to recognize normal variants and avoid potential pitfalls in image interpretation. We present a series of cases showing physiologic focal PSMA avidity in hepatic segment IVb. We correlate this uptake with aberrant hepatic vasculature. The awareness of this variant is important for accurate image interpretation to prevent additional invasive procedures, undue treatment escalation, and denial of curative treatment to patients.

Short- and long-term outcomes of laparoscopic radical gallbladder resection for gallbladder carcinoma: A multi-institutional retrospective study in Japan.

Laparoscopic resection of gallbladder carcinomas remains controversial. This study aimed to evaluate the surgical and oncological outcomes of laparoscopic procedures for suspected gallbladder carcinoma (GBC). In this retrospective study, data regarding suspected GBC treated with laparoscopic radical cholecystectomy before 2020 in Japan, was included. Patient characteristics, surgical procedure details, surgical outcomes, and long-term outcomes were analyzed. Data of 129 patients with suspected GBC who underwent laparoscopic radical cholecystectomy were retrospectively collected from 11 institutions in Japan. Among them, 82 patients with pathological GBC were included in the study. Laparoscopic gallbladder bed resection was performed in 114 patients and laparoscopic resection of segments IVb and V was performed in 15 patients. The median operation time was 269 min (range: 83-725 min), and the median intraoperative blood loss was 30 mL (range: 0-950 mL). The conversion and postoperative complication rates were 8% and 2%, respectively. During the follow-up period, the 5-year overall survival rate was 79% and the 5-year disease-free survival rate was 87%. Recurrence was detected in the liver, lymph nodes, and other local tissues. Laparoscopic radical cholecystectomy is a treatment option with potential favorable outcomes in selected patients with suspected GBC.

Comparative analysis of postoperative curative effect of liver wedge resection and liver IVb + V segment resection in patients with T2b gallbladder cancer.

To compare the therapeutic effects of wedge resection and liver segment IVb + V resection on patients with T2b gallbladder cancer. The clinical and pathological data of 40 patients with gallbladder cancer admitted to the Second Affiliated Hospital of Nanchang University from January 2017 to November 2019 were retrospectively analyzed, and they were divided into two groups according to different surgical methods. The control group underwent liver wedge resection, while the experimental group underwent liver segment IVb + V resection. Preoperative age, bilirubin index, tumor markers, postoperative complications and survival were compared between the two groups. Log-rank test was used for univariate analysis, and Cox proportional hazards regression model was used for multivariate analysis. Kaplan-Meier survival curves were drawn. Univariate analysis showed that tumor markers and degree of differentiation were the risk factors for the prognosis of patients with gallbladder carcinoma after radical cholecystectomy (P < 0.05). Multivariate analysis showed that the elevation of CA125 and CA199, poor differentiation, and Lymph node metastasis were independent risk factors for the prognosis of gallbladder carcinoma after radical resection (P < 0.05). According to the 3-year survival rate, the survival rate of patients with liver 4B + 5 segment resection + cholecystectomy was higher than that of patients with 2 cm liver wedge resection + cholecystectomy (41.6% vs. 72.7%). Patients with T2b gallbladder cancer should be treated with liver segment IVb + V resection, which is helpful to improve the prognosis of patients and should be widely promoted.

PSUN369 Glucagonoma-Associated Dilated Cardiomyopathy in a Young Female: A Case Report

Abstract Background Dilated cardiomyopathy has been reported in patients with glucagonoma. Since glucagon increases myocardial cAMP levels independent of beta adrenoreceptor blockade, thereby increasing heart rate and cardiac output, chronic excessive glucagon stimulation of the heart may lead to cardiomyopathy (Chang-Chretien, 2004). Clinical Case A 26 year old female presented with a 2-year history of palpable epigastric mass, vomiting and weight loss. Abdominal CT showed a heterogeneously enhancing, lobulated pancreatic head-body mass measuring 6.7×6.1×9.9 cm and a hypo-enhancing nodule in hepatic segment IVb, worrisome for metastasis. Endoscopy-guided FNAB of the pancreatic mass revealed a well-differentiated pNET, Grade 3. Chromogranin and synaptophysin stains were positive, Ki-67 index was 33.6%. She was lost to follow-up. After 4 months, she was admitted due to 1 week history of increased vomiting episodes up to 10x daily and abdominal discomfort with 2 day history of incomprehensible speech and right-sided weakness. On examination, she was weak-looking, tachycardic (114 bpm), underweight (BMI 17.45 kg/m2) and with palpable, hard, non-tender epigastric mass measuring 10×7 cm. She also had hyperpigmented patches on both legs initially manifesting as intermittent oozing excoriations over the past 2 years. Cranial MRI revealed subacute CVD infarct. Anticoagulation was given. On the second day, she started having diarrheal episodes. Supportive management was given. Serum glucagon was markedly elevated (&amp;gt;25,000 pg/mL, normal &amp;lt;80). Serum PP (6562 pg/mL, normal &amp;lt;228) and gastrin (621 pg/mL, normal 13-115) were elevated. Serum VIP (&amp;lt;50 pg/mL, normal &amp;lt;75) was normal. Further investigations showed prediabetes (FBS 112 mg/dL, HbA1c 5.7%) and normocytic, normochromic anemia. Screening for MEN1 was unremarkable. On the third day, she had progression of slurred speech and right-sided weakness. Cranial MRI revealed acute lacunar infarcts. As part of hypercoagulability workup, 2D-Echocardiogram showed depressed ejection fraction (20.9%), dilated LV with normal relative wall thickness, and global hypokinesia of the LV wall, confirming dilated cardiomyopathy. Carotid and Venous Duplex scans were normal. Anti-heart failure regimen was initiated. Due to her current neurologic, cardiac and metabolic conditions, she cannot proceed with surgery and chemotherapy. She was given octreotide injection 30 mg every 4 weeks for 3 doses. Post-treatment, repeat abdominal CT and 2D-Echocardiogram showed no significant change. In the meantime, she had improved appetite and no recurrence of vomiting nor diarrhea. She denies palpitations and can better tolerate walking and climbing stairs. Conclusion We reported a rare case of glucagonoma in a young female with documented constellation of symptoms and complications associated with the syndrome, prominently including dilated cardiomyopathy. It is therefore recommended that cardiovascular evaluation should be initiated at the time of glucagonoma diagnosis for timely and appropriate management. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Hepatic Necrosis Mimicking Infiltrative Masses in Acute Budd-Chiari Syndrome With Hereditary Protein C Deficiency

ABSTRACTWe report the case of a patient with an unusual acute Budd-Chiari syndrome (BCS). The patient presented with high-grade fever and right upper quadrant pain. Infiltrative lesions at the right hepatic lobe and segment IVB with intrahepatic inferior vena cava and right hepatic vein thrombus appeared on abdominal imaging. Liver biopsy revealed hepatic infarction compatible with acute BCS. Thrombophilia work-up demonstrated low protein C activity with the -1657C/T mutation of the PROC gene. Necrotic liver mass with acute BCS related to congenital protein C deficiency was diagnosed. Patient symptoms and necrotic masses improved after anticoagulant treatment for 4 months.

Technical efficacy and local recurrence after stereotactic radiofrequency ablation of 2653 liver tumors: a 15-year single-center experience with evaluation of prognostic factors

Purpose To assess the technical outcome and local tumor control of multi-probe stereotactic radiofrequency ablation (SRFA) in a large series of patients. Furthermore, to determine factors accounting for adverse outcomes. Material and methods Between 2003 and 2018, 865 patients were treated by SRFA for 2653 primary and metastatic liver tumors with a median tumor size of 2.0 cm (0.5 − 19 cm). Primary technical efficacy (PTE) and local recurrence (LR) were evaluated, and possible predictors for adverse events analyzed using uni- and multi-variable binary logistic regression. Results Overall, 2553 of 2653 tumors were successfully ablated at initial SRFA resulting in a PTE rate of 96.2%. Predictors of lower PTE rates were age > 70 years, tumor size > 5 cm, number of probes, location close to liver capsule/organs and segment II. LR occurred in 220 of 2653 tumors (8.3%) with the following predictors: age, tumor type/size, conglomerates, segments I/IVa/IVb, number of probes and location close to major vessels/bile duct. Multivariable analysis revealed tumor size > 5 cm (odds ratio [OR] 3.153), age > 70 years (OR 1.559), and location in segment II (OR 1.772) as independent prognostic factors for PTE, whereas tumor location close to major vessels (OR 1.653) and in segment IVb (OR 2.656) were identified as independent prognostic factors of LR. Conclusions Stereotactic RFA is an attractive option in the management of primary or metastatic liver tumors with good local tumor control, even in large tumors. The presented prognostic factors for adverse local oncological outcome might help to stratify unfavorable tumors for ablation.

Choledochal cyst type I-A: a case report

Choledocal cysts are cystic dilations that can occur in a single or multiple form in the biliary tree. Cysts can be congenital or acquired and are associated with numerous anatomical abnormalities. The presence of pain in the upper right quadrant of the abdomen, jaundice and palpable abdominal mass form the classic triad that is present in 15% to 45% of patients. We report the case of a 19-year-old woman patient, who she was admitted with abdominal pain in the right hypochondrium, nausea and vomiting, which evolved into jaundice. When seeking medical care, a large liver cyst and cholelithiasis. Imaging exams revealed liver cyst in segments IV-B,V and VI, lithiasis and biliary polyp.

Mucinous cystic neoplasm of liver masquerading as hydatid cyst: An error needs to be avoided

Mucinous cystic neoplasms (MCNs) are uncommon non-invasive lesion of the liver. The diagnosis of such lesions relies heavily on the histopathological findings. They are often misinterpreted as hydatid cysts clinically and on imaging leading to impartial resection. A 32-year-female presented with pain in upper abdomen and a well-defined cystic lesion with thin septae in segment III/IV of liver. Robotic deroofing of cyst was performed. Microscopy confirmed the diagnosis of mucinous cystadenoma. In view of histopathology and raised fluid carcinoembryonic antigen and CA19-9, she was re-operated for complete excision of cystadenoma. Subsequent, histopathology reported mucinous cystadenoma with clear margins. In another case, a 57-year-female presented with awareness of lump in right hypochondrium. A large unilocular cystic mass lesion noted in the segment IVb/V of liver. Intraoperatively, ~1 liter of cyst fluid was drained with de-roofing done. Her histopathology was suggestive of MCN of the liver with no features of malignancy. She was contacted but lost to follow-up. However, after 2 years she reported with complaints of pain in upper abdomen. Contrast enhanced computed tomography of abdomen revealed a persistent multilocuated cystic lesion in the remaining segment IVb of the liver. Re-resection of residual lesion was performed and histopathology confirmed MCN. Both the patients are doing well after 1 year of re-do surgery and having no features of recurrence. MCNs of liver are rare with wide clinical & radiological presentation and may be misdiagnosed pre-operatively as hydatid cyst especially in endemic zones. Complete excision, even if re-do surgery is required, prevents future recurrence and malignant conversion.

A rare case of recurrent pyogenic cholangiohepatitis: Case report

A 47-year-old female presented with Easy fatigability, abdominal pain for 4 days. Past history of open cholecystectomy with Common bile duct exploration and Choledocho Duodenostomy done 13 years before. She later had multiple episodes of abdomen pain with fever on and off. ERCP revealed stone in common bile duct but not retrieved and patient lost follow-up. During this hospitalisation patient had fever, Jaundice and Sepsis with Acute Kidney Injury. Ultrasound Abdomen showed Hypoechoic lesion in seg IV left lobe liver. Mild pneumobilia. CECT Abdomen showed Pneumobilia, ill-defined hypodense lesions in segment IVA, II, III causing left lobe Intrahepatic biliary radicle dilation. MRCP showed Multiple tiny T2 hyperintense lesions with surrounding edema in SEGMENT IVB? Cholangitic abscess. Patient was taken up for surgery. Intraoperatively Left lateral segment II, III fibrotic, left hepatic duct & branches grossly dilated, stones retrieved from LHD; Left lateral sectionectomy, hepaticojejunostomy, jejunojejunostomy with access loop done. This was a rare case of recurrent pyogenic cholangiohepatitis managed surgically.

Hepatectomy strategy for T2 gallbladder cancer between segment IVb and V resection and wedge resection: A propensity score-matched study

BackgroundLiver resection is recommended for T2 gallbladder cancer, but the optimal hepatectomy strategy remains controversial. We aimed to assess the safety and effectiveness of segment IVb and V resection versus wedge resection in patients with T2 gallbladder cancer. MethodsThis is a retrospective multicenter propensity score-matched study in China. Overall survival, disease-free survival, perioperative complications, and hospital length of stay were used to evaluate safety and effectiveness. ResultsThere are a total of 512 patients. 112 of 117 patients undergoing segment IVb and V resection were matched to 112 patients undergoing wedge resection. After matching, segment IVb and V resection demonstrated no statistical difference in overall survival (hazard ratio, 0.970 [0.639–1.474]; P = .886), but significance in disease-free survival (hazard ratio, 0.708 [0.506–0.991]; P = .040). Patients with incidental gallbladder cancer (hazard ratio, 0.390 [0.180–0.846]; P = .019), stage T2b (hazard ratio, 0.515 [0.302–0.878]; P = .016), and negative lymph nodes status (hazard ratio, 0.627 [0.406–0.991]; P = .043) were associated with improved disease-free survival after segment IVb and V resection, but not in wedge resection. However, perioperative complications occurred more frequently after segment IVb and V resection (28.5% vs 9.1%, P < .001) along with the longer hospital length of stay (17.3 vs 10.2 days, P < .001). Notably, patients with jaundice (odds ratio, 4.053 [1.361–12.23]; P = .013), undergoing laparoscopic resection (odds ratio, 2.387 [1.059–4.484]; P = .028) or surgeon performing per the first 10 segment IVb and V resections (odds ratio, 2.697 [1.035–6.998]; P = .041), were the independent risk factors for perioperative complications in the segment IVb and V resection group. ConclusionT2 gallbladder cancer patients undergoing segment IVb and V resection rather than wedge resection have an improved disease-free survival, especially for incidental gallbladder cancer or hepatic-sided (T2b) gallbladder cancer. However, high rates of perioperative complications and longer hospital length of stay after segment IVb and V resection indicated that surgeons must rely on their own surgical skills and the patient profile to decide the optimal hepatectomy strategy.

Pure large cell neuroendocrine carcinoma of the gallbladder, is surgical relentlessness beneficial? A case report and literature review

Pure large cell neuroendocrine carcinoma of the gallbladder is a rare disease. However, the prognosis of this aggressive tumor is poor with short survival after diagnosis. We are describing in this manuscript a case of pure large cell neuroendocrine carcinoma in which survival exceeded 26 months, after performing two curative surgeries. We are reporting the case of a 68-year-old woman with a history of recovered right breast carcinoma and operated 6 years later for a completely asymptomatic gallbladder tumor of 31 mm. In this case, curative surgery was performed allowing monobloc resection of the gallbladder and the hepatic segments IVb and V, a lymph node dissection was performed to. The histological examination of the specimen and immunohistochemistry confirms that the tumor was a grade 3 pure large cell neuroendocrine carcinoma of gallbladder with lymph node invasion, the hepatic and biliary surgical margins were free. Postoperative adjuvant chemotherapy was administered and the evolution was eventless until the discovery at 20 months of a lymph node considered being metastatic recurrence. A second surgery was performed allowing removal of three lymph nodes. This time, a different protocol of chemotherapy was administered to our patient who remains alive and without recurrence at 26 months from her first surgery. Surgical relentlessness with free margins resections associated with appropriate chemotherapy probably improves the survival of patients suffering from this rare and aggressive tumor.

Hepatectomy type determines long term outcomes in patients with T1/T2 gladder bladder cancer

Presenter: Muhammad Khan MD | University of Southern California, Westchester Medical center Background: Optimal surgical treatment for T1 and T2 gallbladder cancer is not well defined in the literature. We utilized a national database to assess clinical outcomes based on the hepatectomy strategy - segment IVb and V resection versus wedge resection, in patients with T1 and T2 gallbladder cancer. Methods: We utilized the 2004-2017 national cancer database to select patients with T1 and T2 gallbladder cancer. We then stratified them based on the type of the hepatectomy – wedge resection vs segment 4b and 5 resections. The two groups were assessed for differences in 30-day outcomes, and 5-year survival rates. Results: A total of 5,047 patients were included in the analysis. T1 and T2 stage gallbladder cancer patients were more likely to have a wedge resection than a segment IVb & V liver resection (94.8% vs 5.3%: p-0.01). We found no difference in 30-day mortality and readmission rates based on the surgical approach. Segment IVb & V liver resection was associated with improved 5-year survival in T1 (92 months vs 74; p-0.01) and T2 disease (75 months vs 55; p-.001). Conclusion: T1 and T2 gallbladder cancer patients undergoing segment IVb and V resection rather than wedge resection have improved 5-year survival.

An overview on diagnosis and surgical management of gallbladder cancer

Gallbladder cancer is among the most deadly cancers, and it continues to present surgeons with numerous challenges. Cholelithiasis, an abnormal pancreaticobiliary junction, and focal mucosal microcalcifications are all known risk factors for gallbladder carcinoma. The most common histologic type in most patients is adenocarcinoma, which is frequently associated with Kras and p53 mutations. Endoscopic ultrasonography, magnetic resonance cholangiopancreatography, as well as helical computed tomography, as well as radiologic or endoscopic improvements in endoscopic ultrasonography as well as magnetic resonance cholangialpancratia, have improved preoperative staging. Cholecystectomy (subsegmental surgical excision of segments IVB but instead V plus a hepatoduodenal ligament lymphadenectomy) for advanced disease without indications of distant metastasis (T2–4/N0-N2) or a radical cholecystectomy (subsegmental resection of segments IVB as well as V plus a hepatoduodenal musculotendinous lymphadenectomy) for severe stages without indications of distant metastasis More extensive hepatic resection, such as extended right hepatectomy or central segmentectomy with caudate lobectomy, has been recommended by certain surgeons. Patients who underwent a pancreaticoduodenectomy to enhance distal ductal margins as well as lymphadenectomy for T3 or T4 malignancies were studied by Japanese surgeons. These patients had a reduced incidence of tumor recurrence but no benefit in terms of survival. Adjuvant treatment options are still restricted. The most frequent postoperative treatment is radiation therapy with fluorouracil radio sensitization. Capecitabine, oxaliplatin, & bevacizumab are now being studied in the treatment of gallbladder cancer in clinical studies.

Hepatic Mucinous Cystic Neoplasm Deceptive as Hydatid Cyst: Message Learned

Purpose: Mucinous cystic neoplasms (MCN) are infrequent non-invasive lesion of the liver. The diagnosis of such lesions relies mainly on the histopathological findings. They are often misinterpreted as hydatid cysts clinically and on imaging leading to partial resection or deroofing. Case presentation: Case 1: A 32-year-lady presented with upper abdominal pain and on evaluation found to have well-defined cystic lesion with smooth wall and thin septae in segment III/IV of liver. Robotic deroofing of cyst wall was performed. Microscopic examination revealed it to be mucinous cystadenoma. In view of histopathology and raised fluid CEA and CA 19-9 levels, she was re-operated for complete excision of cystadenoma. Subsequent, histopathology reported mucinous cystadenoma with clear margins. Case 2: A 57-year-lady presented with complaint of awareness of lump in right hypochondrium. On evaluation, a large unilocular cystic mass lesion was noted in the segment IV/V of liver. Intraoperatively, ∼1 liter of cyst fluid was drained with de-roofing of cyst wall was performed. Her histopathology was suggestive of MCN of the liver with no features of high-grade dysplasia or malignancy. She was contacted but lost to follow up. However, after 2 years she again reported with complaints of pain in upper abdomen. CECT abdomen revealed a recurrent multilocuated cystic lesion in the remaining segment IVb of the liver. She was counselled and re-resection of residual lesion with gall bladder was performed. Histopathology examination again confirmed MCN. Now, both the patients are doing well after 1 year of re-do surgery and having no features of recurrence. Conclusion: MCN-L are rare with a wide clinical with radiological presentation and may be misdiagnosed pre-operatively. Complete excision, even if re-do surgery has to be done as it prevents future recurrence and malignant conversion.

Hepatopancretoduodenectomy for gallbladder cancer with duodenal infiltration. Report of 1 case

Presenter: Fabio Vergara MD | IPS Universitaria - Servicios de Salud de la Universidad de Antioquia Background: Gallbladder cancer is the most common cancer of the biliary tract . Surgical resection is the election treatment for curative intention. Hepatopancreatoduodenectomy is a technique for remove the advanced gallbladder cáncer with infiltrated parts within the liver, lower biliary tract and the peripancreatic region. However, in this technique were reported to have a higher postoperative morbidity (70 - 80%) and mortality around 30%. Methods: We presented a case of gallbladder cancer with duodenal and distal biliary tract infiltration. A 68 years old woman admitted for jaundice and weight loss. Abdominal ultrasound with evidence of cholelithiasis and bile duct dilatation. MRI was performed and a gallbladder tumor was found with infiltration of the bile duct in contact with the duodenum. Tumorals markers with ca 19.9: 350U/L. Extension studies without metastases. It was decided to take surgery for oncological resection. Duodenal infiltration was found intraoperatively, so it was decided to perform hepatopancreatoduodenectomy that includes hepatectomy segments IVB and V, pancreatoduodenectomy and lymphadenectomy. Results: The intraoperative evolution occurred without the need for vasopressor support or blood transfusion. The surgical time was 240 minutes. The patient was extubated and taken to the ICU for surveillance. He presented a type B pancreatic fistula, which required medical management with analogues of somatostatin, parenteral nutrition and antibiotherapy. Discharged after 15 days. Pathology confirms a gallbladder cancer with nodal metastases an duodenal infiltration. Conclusion: Hepatopancreatoduodenectomy is a complex surgery. It is a surgery that contains both hepatic and pancreatic resection surgical techniques. Is beneficial for selected patients to achieved R0 resection in advanced gallbladder cancer. However, the indications should be carefully evaluated because of greater morbidity rates. This surgery is recommended to be done in centers with experience in hepatopancreatobiliary surgery.

A prospective observational study of branching pattern of middle hepatic vein on contrast enhanced computed tomography

Background: The main purpose of pre-operative imaging in liver transplantation is to expose the arterial and venous vascular map. Prior to transplantation it is necessary to image the vascular structures property due to complex nature of liver vascular anatomy and its frequent variations. CT is a useful method not only in the determination of hepatic arterial anatomy, hepatic venous anatomy, accessory hepatic veins and portal veins variations.Methods: This was a prospective observational study performed at the department of surgery, Gandhi Medical College Bhopal and study of CECT was carried out in the department of radiodiagnosis with approval from college ethical committee on 100 patients during a period of 2 years from 2017 to 2019.Results: In study of 100 cases were studied. The study mainly done on the MHV mainly its length, width draining segments of liver by MHV and accessory hepatic veins. In overall cases maximum cases had drainage from segment IVb, V and segment VIII. The segment 5 accessory vein is the most common single accessory vein found in the study.Conclusions: Many parameters of MHV have studied in the study and understanding of these parameters is undoubtedly important for operating surgeon its anatomical draining patterns, draining liver segments and has got the presence of the various accessory veins in the liver. Recognition of these accessory hepatic veins is important because some of these accessory veins may become useful in segmental liver transplantation.

Ciliated hepatic foregut cysts: A case series and literature review

Background: Ciliated hepatic foregut cysts (CHFCs) are rare, uniloculate, cystic lesions of embryological origin and are of significance due to their malignant potential. They are the only ciliated cystic lesions known to occur in the liver, tend to be asymptomatic and are found more frequently in male patients. They are often incidental findings on imaging or during surgery, typically in segment IV of the liver. This study highlights two cases of CHFCs managed at a regional tertiary centre in 2018, and reviews the current literature on CHFCs. Material and Methods: A PubMed search for CHFCs was completed.Of the aforementioned two patients with CHFCs, relevant clinical information was obtained from electronic patient records. Results: The literature review yielded 81 papers. Although the exact aetiology is unknown, several reports hypothesize that CHFCs originate from detachment and migration of buds from the oesophageal and bronchial regions of the foregut that are entrapped by the liver during embryonic development. CHFCs are mostly found in segments IVA and IVB, and have unique histology; ciliated pseudostratified columnar epithelium. The mechanism of malignant transformation is unclear but rate of transformation is estimated at 6%. Case 1: A 47 year old fit and healthy male whose CHFC was identified incidentally on imaging, underwent laparoscopic segment IV hepatic resection with CHFC confirmed histologically. Case 2: A 64 year old male with haemangiopericytoma of the brain, who developed a liver metastasis; also haemangiopericytoma. His CHFC was an incidental finding wholly excised during an ALPPS procedure for resection of this metastasis. Conclusion: CHFCs are rare lesions. The malignant transformation risk is based on anecdotal case series data. The evidence for optimum management is lacking; and a patient-centred choice between long term follow-up or definitive laparoscopic resection must be made. Recommendation for surgery is based on level 3 evidence.