Simple Hepatic Cysts Research Articles

Effectiveness of CT-guided sclerotherapy with estimated ethanol concentration for treatment of symptomatic simple hepatic cysts

The mean Hounsfield value of 99.9% ethanol did get down to -190 Hounsfield units (HU), there was a linear correlation between ethanol concentration and Hounsfield values. We aimed to evaluate whether sclerotherapy with estimated ethanol concentration was helpful in improving the success rate for treatment of symptomatic simple hepatic cysts. Forty-five patients with 52 symptomatic simple hepatic cysts were enrolled in this study. Twenty-one patients (24 cysts, group A) were treated by sclerotherapy without estimated ethanol concentration and 24 patients (28 cysts, group B) with estimated ethanol concentration. The Chi-square test and Mann-Whitney U test were used to compare the difference in characteristics and treatment outcomes of the subjects between these two groups. The mean cyst size before and after treatment were 8.4cm and 2.3cm, respectively, in group A, and 8.2cm and 0.8cm, respectively, in group B. There was no significant difference in the initial size of hepatic cysts between the groups. However, the final size was significantly smaller in group B (P=0.022). The mean ethanol exposure time was 18.3minutes in group B, which was less than that in group A (P<0.001). The success rate was significantly higher in group B (96.4%) than in group A (70.8%) (P=0.03). There were no major complications in either group. CT-guided sclerotherapy with estimated ethanol concentration yields better results than those without estimated ethanol concentration in the treatment of symptomatic simple hepatic cysts.

Gait Disturbance and Dysarthria Presenting as the First Manifestation of Recurrent Colorectal Adenocarcinoma

Purpose: Approximately 20% of patients with colon cancer have metastatic disease at the time of presentation. It usually spreads to regional lymph nodes, liver, lungs, and peritoneum. Initial signs and symptoms might be referable to any of these areas. A 79-year-old man with past medical history of rectal adenocarcinoma diagnosed in 2006, for which he had lower anterior resection and partial colectomy with subsequent chemotherapy and radiotherapy. He presented with a one-week history of gait disturbance, dizziness, slurred speech, and difficulty with his handwriting. He also reported a recent 30-pound weight loss. Brain CT showed a right-sided heterogeneous cerebellar lesion measuring 2.8 x 2.5 cm that was confirmed with MRI. CT of the chest and abdomen showed a right upper lobe lung mass adjacent to the esophagus measuring 3.2 x 2.4 cm, and simple hepatic cysts. EUS was performed, and FNA of the lung mass confirmed the diagnosis of metastatic colon adenocarcinoma that was immunoreactive for CK20 and CDX2. Subsequently, the patient underwent craniotomy and tumor resection, which confirmed the diagnosis of metastatic colon adenocarcinoma to the cerebellum. Neurological symptoms due to brain metastasis could represent the first manifestation of colon cancer even without liver involvement, despite that the liver is considered the most common site of distal metastasis in colorectal adenocarcinoma and lung cancer being the most common source of brain metastasis.FigureFigure

Gastrointestinal disorders in primary immunodeficiencies

Introduction: Primary immunodeficiencies (PIs) are a group of diseases that are characterized by an increase in the risk of infections, with manifestations in different organs and systems. The gastrointestinal tract (GIT) is a major lymphoid organ of the body, which is frequently affected in patients with PIs. Gastrointestinal clinical manifestations such as chronic diarrhea, malabsorption, or the inflammatory bowel disease (IBD), as well as autoimmune disorders that affect the GIT (celiac disease or pernicious anemia), appear with relative frequency. Aim: In this paper, we present the case series of patients diagnosed with PIs. These patients were followed up by a specialized medical team at the Hospital Arquitecto Marcide in Ferrol (Galicia—Spain). Materials and method: This is a retrospective study that reviews the medical records of patients diagnosed with PIs. Consultations were followed up until April 30, 2013. Results: The consultation tracked 21 patients, 52.4% of whom were women. The mean age was 58.25 years old (range 34–76). Common variable immunodeficiency (CVID) was diagnosed in 76.2% of the patients IgG subclass deficiency in 9.5%, hyper-IgM syndrome in 9.5% and x-linked agammaglobulinemia in 4.8%. Recurrent respiratory infections appeared in 61.9% of the patients. Gastrointestinal disorders were diagnosed in 61.8% of the patients along the track: chronic diarrhea (28.6%), malabsorption and weight loss (23.8%), acute gastroenteritis (19.9%), sprue-like syndrome (19%), chronic atrophic gastritis (14.3%), pernicious anemia (14.3%) and IBD (4.8%). No statistically significant differences were found between the type of PI and gastrointestinal manifestations (p = 0.83). Liver ultrasound showed abnormalities in 33.3% of the patients: steatosis (14.3%), hepatomegaly (9.5%) and simple hepatic cyst (9.5%). Gastric adenocarcinoma was diagnosed in 9.5% of the patients (2 patients). Intravenous immunoglobulin replacement therapy is being used in 66.7% of the patients. Conclusion: PIs are often associated with gastrointestinal disorders. Among our patients, the most frequent was chronic diarrhea, followed by malabsorption and weight loss. Gastric neoplasms appear with relative frequency. A protocolled monitoring and active search for gastrointestinal disorders is, therefore, recommended for patients with PIs.

Hepatobiliary cystadenomas

Hepatobiliary cystadenomas are rare cystic tumours that can arise from any portion of the biliary tract but most commonly develop intrahepatically. They typically cause non-specific symptoms and are often detected incidentally. Cystadenomas can be mistaken for simple hepatic cysts on radiological imaging, which leads to inadequate treatment. Hepatobiliary cystadenomas have a malignant predisposition and a high recurrence rate. Complete excision including hepatic resection is therefore generally recommended. Three cases of hepatobiliary cystadenoma were identified at one unit over a six-month period. Their clinical details and management are reported. Three female patients are described aged 25, 37 and 73 years. One patient presented because of recurrent infection, one presented because of pressure related symptoms and one lesion was identified incidentally. All patients were investigated by ultrasonography and computed tomography (CT), two additionally had magnetic resonance imaging (MRI) and one had a liver biopsy. The tumours were 4-16cm in size and all lesions were excised by non-anatomical, parenchyma sparing resections. Histology revealed mixed epithelium with underlying ovarian-like stroma. The management of hepatic cystadenomas as well as operative and pathological findings are discussed. Preoperative ultrasonography, CT and MRI is recommended, and early referral for specialist hepatobiliary review is advised. Operative resection is also recommended and complete excision was achieved in these cases. This strategy is supported by the current literature and recurrence has been shown to be unlikely.

When Nature Meets Nurture: Persistent Yersinia Infection

PRESENTATION When the patient’s symptoms are alleviated, it might seem that the causative infection has cleared. But that was not the case for a 62-year-old man with type 2 diabetes who presented with a 1-week history of constipation, lower abdominal cramping, rectal pressure, and hematochezia. In the emergency department, laboratory testing detected leukocytosis with a white blood cell count of 19 x 10 cells/mm and an elevated neutrophil count. Computed tomography (CT) of the patient’s abdomen and pelvis demonstrated marked inflammation of the rectal wall. He was admitted and underwent colonoscopy, which confirmed the presence of proctitis but was otherwise normal. Four days after admission, his stool culture grew pan-sensitive Yersinia enterocolitica. A diagnosis of Yersinia proctitis was made. Simple hepatic cysts seen on CT were felt to be incidental. The patient was prescribed a 5-day course of oral ciprofloxacin. He returned home and had complete symptom resolution. However, 3 weeks after completing treatment, he experienced gradual onset of severe pain that began in the right upper quadrant of the abdomen and radiated to his back and right shoulder. This was accompanied by malaise, intermittent fevers, and anorexia. He reported a 21-pound unintentional weight loss over the preceding 2 months. One month after discharge, he returned to the emergency department.

Intracystic hemorrhage complicating multiple liver cysts

The occurrence of intracystic hemorrhage in benign liver cysts is usually seen in huge solitary cysts in older individuals. Hemorrhage complicating one of the multiple cysts has rarely been reported. We report a case of multiple simple hepatic cysts with intracystic hemorrhage complicating one of the cysts. A 60-year-old woman was admitted with complaints of abdominal discomfort of 6 months duration and abdominal pain with increasing intensity of 2 months duration, not responding to analgesics and was anicteric. On thorough evaluation, a diagnosis of complicated liver cyst was made and her severe symptoms necessitated intervention. Per-operatively, multiple thick walled huge cysts were seen on the surface of the liver. The largest one in the right lobe was complicated by hemorrhage. The cysts were aspirated and deroofed. There were no solid components or biliary communications in the cysts.

Endoscopic-Ultrasound Guided Ethanol Ablation of a Giant Hepatic Cyst Causing Biliary Obstruction

Introduction: Simple hepatic cysts have a prevalence of 2.5 to 4.25 percent and are more common in women and in patients older than forty years. They usually have a benign course, with a minority causing outlet or biliary obstruction-related complications that require therapeutic intervention. Percutaneous sclerotherapy and surgery appear effective, however are limited by procedure-related morbidity. Alternative methods of cyst drainage that prevent recurrence with minimal risks would be optimal. Here we describe a case of EUS-guided simple hepatic cyst drainage and ethanol sclerotherapy. Case Report: A 72-year-old African American man presented with nausea, abdominal distension, jaundice, anorexia and pruritus for one week with abnormal liver tests. MRI demonstrated a simple hepatic cyst in the right lobe, measuring 12.2 × 10.2 × 15 cm (average radius: 6.233 cm, giving a volume of 1014.33 cm3) causing a mass effect on the porta hepatis and intrahepatic biliary ductal dilatation. The patient desired a minimally invasive approach without percutaneous drains. As a first step, ERCP was performed to evaluate cyst-biliary communication and rule out the presence of cholangiocarcinoma, followed by cyst drainage and sclerotherapy with a 98 percent alcohol solution in the second step. After treatment, EUS demonstrated a collapsed cyst, resulting in complete resolution of the biliary obstruction. The patient tolerated the procedure well and his symptoms resolved immediately. At our patient's follow up visit in one year, he continues to be doing well with none of the symptoms recurring and laboratory examination showing normal values. The repeat MRI done at this point shows that the cyst is now 7.9 × 4.8 × 7.5 cm (average radius: 3.367 cm, giving a volume of 159.89 cm3) showing an 84.2 percent decrease in volume. Discussion: We recommend endoscopic-ultrasound guided ethanol sclerotherapy, without the need of further sessions from the time of ERCP, as a one session therapeutic intervention. We have described to our knowledge, the first case of EUS-guided ethanol ablation of a simple hepatic cyst causing biliary obstruction and have shown it to be feasible, safe and effective (durable) without need for further sessions. This report supports the need for further prospective studies.

Liver specific magnetic resonance imaging contrast medium for evaluation of focal liver lesions – Initial experience at a service hospital

BackgroundContrast enhanced MRI is today considered the investigation modality of choice in detection and characterization of focal liver lesions. The conventional MRI contrast media like Gadolinium (Gd) chelates undergo elimination through the urinary pathway and are not selectively concentrated or metabolized in the liver. Gadobenate dimeglumine (Chemical name: Gadolinium-BOPTA) is a promising newer liver specific MRI contrast medium having additional properties of selective uptake and biliary excretion by hepatocytes. Our study was designed as a pilot study to evaluate the utility of Gd-BOPTA in detection and characterization of focal liver lesions. MethodsFifty-three consecutive patients with focal liver lesions (excluding only simple hepatic cysts) detected on ultrasonography and CT abdomen, were prospectively subjected to standardized MRI protocol for the liver, using Gd-BOPTA as the intravenous contrast medium. An additional T1W axial scan of the liver was incorporated in the study protocol, at a delay of 2 h post-contrast, in all patients. ResultsIn the study population, the combination of USG and contrast enhanced CT abdomen findings were adequate to reach a definitive diagnosis in 70% of the patients. The liver specificity of Gd-BOPTA contributed to improved lesional characterization in 9/50 patients (18%) on the delayed phase images. ConclusionThe study revealed that the liver specific properties of Gd-BOPTA can be used to obtain additional information to improve characterization of focal hepatic lesions, when delayed phase scans are included in the study protocol.

Sclerotherapy of simple hepatic cysts by repeated aspiration and alcohol instillation

The efficacy and safety of traditional alcohol sclerotherapy procedures are controversial in the management of large simple hepatic cysts. In this study, we aimed to develop and evaluate a novel alcohol sclerotherapy procedure, termed repeated aspiration and alcohol instillation sclerotherapy, for the treatment of simple hepatic cysts. A prospective, double-blind, randomized study was performed. Sixty-seven patients with large simple hepatic cysts were randomized into two groups to receive either single-session alcohol retention sclerotherapy (alcohol was instilled into the cyst cavity, kept for 20 minutes and aspirated) or repeated aspiration and alcohol instillation sclerotherapy (instillation of 30-70 ml of alcohol and immediate aspiration with repetition 3 to 6 times until the estimated alcohol concentration exceeded 80%). The cyst volume reduction was calculated to compare the efficacy of the two procedures. We evaluated the safety of the procedure by monitoring side effects and assaying blood alcohol concentrations at 0, 0.5, 1, 2 and 3 hours after sclerotherapy. The cyst volume reduction in patients undergoing repeated aspiration and alcohol instillation sclerotherapy was significantly higher than that in those receiving alcohol-retention sclerotherapy. The concentration of alcohol in the last aspirated cyst fluid was correlated with the mean volume reduction in patients undergoing repeated aspiration and alcohol instillation sclerotherapy but not in the alcohol-retention group. Only minor side effects occurred in both groups. Although elevated blood alcohol concentration was noted in all patients, it declined to normal levels within 2-3 hours after treatment. There were no significant differences in blood alcohol concentration between the two groups. Repeated aspiration and alcohol instillation sclerotherapy is superior to single-session alcohol-retention sclerotherapy in the management of large simple hepatic cysts.

Prevalence of Non-Cardiac Pathology on Clinical Transthoracic Echocardiography

Non-cardiac findings (NCFs) are seen in more than a third of cardiac computed tomographic and cardiac magnetic resonance imaging studies. The prevalence and importance of NCFs in transthoracic echocardiographic (TTE) imaging is unknown. The aim of this study was to determine the prevalence of NCFs on TTE imaging. The subcostal images of all comprehensive adult TTE studies performed at one institution in December 2008 were retrospectively reviewed for NCFs by a radiologist with fellowship training in cardiovascular and abdominal radiology and blinded to the TTE report findings and clinical histories. Additional TTE image orientations were assessed in a subset of 300 studies. NCFs were categorized as benign (e.g., simple hepatic cyst), indeterminate (e.g., ascites), or worrisome (e.g., liver metastases). If an indeterminate or worrisome NCF was identified, the patient's electronic medical record was reviewed to determine if the NCF was previously known. Of 1,008 TTE studies (443 inpatient, 565 outpatient) in 922 patients, 77 NCFs were identified in 69 patients (7.5%). These included 20 benign (26%), 52 indeterminate (67%), and five worrisome (7%) NCFs. Intermediate and worrisome NCFs were more common in inpatient TTE studies (9% vs 3% outpatient, P = .002). The additional views demonstrated 2% more NCFs. Record review demonstrated that 60% of worrisome and 67% of indeterminate NCFs were previously known. No unknown NCF ultimately led to a change in patient management. Clinical TTE studies demonstrate NCFs in 7.5% of all patients, with an increased prevalence on inpatient studies. Although 75% of NCFs were potentially management changing, the majority of these were previously known and very unlikely to lead to management changes. Further study is needed to validate these findings in other populations and to assess their clinical impact.

Laparoscopic excision of an antenatally diagnosed large simple hepatic cyst in the newborn

Non-parasitic hepatic cysts are rare in infants and children. Advances in antenatal imaging have improved their detection, while development of laparoscopic techniques has expanded options for treatment. We present a case of an antenatally diagnosed non-parasitic hepatic cyst in a neonate, which was successfully excised laparoscopically with no recurrence.

Biliary cystadenoma: short- and long-term outcome after radical hepatic resection

The intrahepatic biliary cystadenoma is a rare benign tumor of the liver, originating from an intrahepatic bile duct: it becomes symptomatic only when it causes obstruction of the bile duct itself. Regardless of the various diagnostic modalities available, it is difficult to distinguish preoperatively the cystadenoma both from a simple liver cyst, and from a cystic carcinoma of the bile duct. An incomplete surgical removal of the cyst often results in a higher risk of size increase and recurrence, even considering that the lesion may degenerate into a cystadenocarcinoma. Between January 2004 and May 2011, 1,173 liver resections were carried out at the Hepatobiliary Surgery Unit of San Raffaele Hospital: 12 of these were performed for cystadenoma. Forty-six patients underwent laparoscopic liver cysts deroofing: definitive histological examination in six of these patients revealed instead the diagnosis of cystadenoma. In 50% of cases, the diagnosis of cystadenoma was therefore acquired as a result of an incidental finding. The patients were all female, median age 45 years. The liver resection included six cases of left hepatectomy, three left lobectomies, and three of the right hepatectomy. The operations were performed by laparotomy, with the exception of two left lobectomies completed laparoscopically. In all cases, the postoperative course was without major complications. The resection was radical in all cases and the median hospital stay was 5 days. At a median follow-up of 16 months (range 7-30), all patients are alive and disease free. Biliary cystadenomas can easily be misunderstood and interpreted as simple hepatic cysts. Radical surgical resection is necessary and provides good short- and long-term outcomes.

Laparoscopic Management of a Giant Hepatic Cyst With Fibrin Glue Fixation of the Omentum

Approximately 4.5% to 7% of the population will have simple hepatic cysts, but only 5% of these will require treatment. Drainage options include interventional, laparoscopic, and open techniques ranging from simple aspiration to liver resection. We present a case where a giant hepatic cyst was treated laparoscopically and omentum was fixed in the defect using fibrin glue to prevent recurrence. A 69-year-old female patient presented with a recurrent simple hepatic cyst after percutaneous aspiration had failed. Her symptoms were related to the size of the cyst. Laparoscopic drainage was performed with cyst wall excision. Omentum was fixed in the defect using fibrin glue. She was discharged after 24 hours without complication. There are many ways to treat nonparasitic liver cysts. The laparoscopic approach limits morbidity with excellent results. The use of fibrin glue to secure omentum in the defect is a simple technique to limit recurrence.

Hepatic and pulmonary cystic echinococcosis in a patient from the Central African Republic

Apical lung opacity was diagnosed in an asymptomatic 30 year-old woman native of Central African Republic by routine chest X-ray. CT scan demonstrated an excavated pulmonary mass and revealed a simple hepatic cyst. Tuberculosis was suspected but mycobacterial cultures remained negative. Three months later, ultrasonography showed septations within the hepatic lesion suggestive of cystic echinococcosis. The detection of seric anti-Echinococcus antibodies was positive. Hepatic and pulmonary cysts were removed surgically and association with three-month course of albendazole resulted in a favorable outcome. Cystic echinococcosis is exceptional in Central Africa and to our knowledge never reported from the Central African Republic.

Lessons learned from 100 initial cases of laparoscopic liver surgery

PurposeLaparoscopic liver resection (LLR) is now widely accepted and is being increasingly performed. The present study describes our experience with LLR at a single center over an eight-year period.MethodsThis retrospective study enrolled 100 patients between October 2002 and February 2010. Forty-six benign lesions and 54 malignant lesions were included. The LLR performed included 58 pure laparoscopy procedures, 18 hand-assisted laparoscopy procedures and 24 hybrid technique procedures.ResultsThe mean age of the patients was 57 years; among these patients, 31 were over 65 years of age. The mean operation time was 220 minutes. The overall morbidity was 11% and the mortality was zero. Among the 20 patients with simple hepatic cysts, 50% unexpectedly recurred. Among the 41 patients with hepatocellular carcinoma, 21 patients (51%) underwent preoperative radiofrequency ablation therapy or transarterial chemoembolization. During parenchymal-transection, 11 received blood transfusion. The width of the resection margins was under 0.5 cm in 11 cases (27%); 0.5 to 1 cm in 22 cases (54%) and over 1 cm in eight cases (12%). There was no port site seeding, but argon beam coagulation-induced tumor dissemination was observed in two cases. The overall two-year survival rate was 75%.ConclusionThis study suggests that the applications for LLR can be gradually expanded when assuring that the safety and curability of LLR are equivalent to that of open liver resection.

Recent trends in treatment of hepatic non parasitic cystic lesions: Outcome of laparoscopic management

Background: Hepatic cystic lesions of non parasitic origin are mostly benign single, multiple, or diffuse cysts which contain clear serous fluid. Asymptomatic patients usually need no active treatment apart from follow up. In some patients, the cysts become painful and symptomatic which necessitate surgical intervention in the form of surgical deroofing or fenestration. Open surgical techniques used to be the treatment of choice since there is no harm to establish a free communication between the cyst and the peritoneal cavity because the cystic fluid contains no bile or microorganisms and its composition is similar to plasma. Recently, laparoscopic surgery is the treatment of choice as it can give similar results with less morbidity, and shorter hospital stay. The aim of this study was to evaluate the postoperative morbidity and, the incidence of relapses in the laparoscopic treatment of non-parasitic hepatic cysts and with polycystic liver disease during one year of postoperative follow up. Patients and methods: From March 2005 to September 2009, twenty patients (18 patients with simple non-parasitic hepatic cysts and 2 patients with polycystic liver disease (PCLD) with few large cysts in the anterior hepatic segments) of a mean age of 42 years (range 23-62) and of both sexes (16 women and 4 men) underwent laparoscopic fenestration and deroofing at Ain Shams University Hospitals. Before embarking on surgery, routine investigations, US, CT and serological tests for hydatid disease were requested. Tumour markers and bacteriological, chemical and cytological examination of the cystic fluid aspirated under US-guidance were requested if needed. Results: Computed tomography with contrast enhancement revealed simple hepatic cysts in 18 cases with a mean diameter of 10 cm (range 5-14 cm). There were 8 in the left lobe (segment II and III) and 10 in the right hepatic lobe. Polycystic liver disease was seen in 2 cases with a mean cyst diameter of 8 cm (range 6-10 cm). The dominant cyst was in the right hepatic lobe in 1 case and in the left lobe in the other case. Serological test for hydatid was done and was negative for all cases. Laparoscopic deroofing was completed successfully in 16 cases and conversion was needed in 4 cases in which the cysts were deeply seated and inaccessible by the laparoscope. Open surgical deroofing was possible in 2 cases and left lateral segmentectomy was done in 2 cases. There was neither perisurgical mortality nor significant morbidity in this study. One year postoperative results showed recurrence of the cyst in two cases. Conclusion: Laparoscopy can be considered a safe and efficacious treatment for non-parasitic hepatic cysts and with polycystic liver disease.

Biliary Obstruction Due to a Huge Simple Hepatic Cyst Treated with Laparoscopic Resection

Most hepatic cysts are asymptomatic, but complications occasionally occur. We describe a patient with biliary obstruction due to a huge simple hepatic cyst treated with laparoscopic resection. A 60-year-old Japanese woman was admitted to our hospital because of a nontender mass in the right upper quadrant of the abdomen. Laboratory tests revealed the following: serum total bilirubin, 0.6 mg/dL; serum aspartate aminotransferase, 100 IU/L; serum alanine aminotransferase, 78 IU/L; serum alkaline phosphatase, 521 IU/L; and serum gamma glutamic transpeptidase, 298 IU/L. Abdominal computed tomography, ultrasonography, and magnetic resonance cholangiopancreatography revealed a huge hepatic cyst, 13 cm in diameter, at the hepatic hilum, accompanied by dilatation of the intrahepatic bile duct and obstruction of the common bile duct. We diagnosed biliary obstruction due to a huge hepatic cyst at the hepatic hilum, and laparoscopic surgery was performed. A huge hepatic cyst was seen at the hepatic hilum. After needle puncture of the huge cyst, the anterior wall of the cyst was unroofed, and cholecystectomy was done. Intraoperative cholangiography through a cystic duct revealed stenosis of the duct. Subsequent decapsulation of the cyst was performed in front of the common bile duct. After this procedure, cholangiography revealed that the stenosis of the common bile duct had resolved. Histopathological examination of the surgical specimen confirmed the hepatic cyst was benign. The postoperative course was uneventful, and the results of liver function tests normalized. The patient was discharged 7 days after operation. Computed tomography 3 months after operation revealed disappearance of the hepatic cyst and no dilatation of the intrahepatic bile duct.

Technical Report of a Novel Surgical Technique: Laparoscopic Cyst Fenestration and Falciform Ligament Pedicle Graft for Treatment of Symptomatic Simple Hepatic Cysts

Simple hepatic cysts are common and infrequently develop into large symptomatic cysts that require surgical therapy. These benign cysts have been shown to be amenable to minimally invasive surgery; however, recurrences of symptoms have been reported. Our experience with over 200 simple hepatic cysts has lead to the development of a novel therapy to resolve symptoms associated with large simple hepatic cysts and reduce the rate of recurrent symptoms. An observational study demonstrating our experience with a novel minimally invasive technique for the management of symptomatic simple hepatic cyst. A total of 6 cases were identified where laparoscopic mini-fenestration and placement of a falciform pedicle graft was used. There were no operative complications and 4 of 6 patients were discharged home the day of surgery. With mean follow-up of 9.6 months, there has not been any recurrence to date. One patient required an open hepatic resection for the treatment of a cystadenoma. Laparoscopic mini-fenestration and placement of a falciform ligament pedicle graft shows promising early results as a treatment for the simple hepatic cyst. Long term follow-up data is required.

Differentiation Between Biliary Cystic Neoplasms and Simple Cysts of the Liver: Accuracy of CT

The objective of our study was to determine significant CT findings for the differentiation of biliary cystic neoplasms from simple hepatic cysts and to assess whether radiologists' performance for the differentiation is improved with the knowledge of significant CT criteria. Review of surgical and pathologic records identified 25 patients with pathologically proven biliary cystic neoplasms (biliary cystadenomas [n = 8], biliary cystadenocarcinomas [n = 4]) or simple cysts [n = 13]). Two radiologists retrospectively reviewed CT images in consensus for the location, size, and outer margin of the lesion and for the presence of an internal septum, upstream bile duct dilatation, a transient hepatic attenuation difference (THAD), calcifications, a mural nodule, three or more other cysts, and a thick septum or outer wall. Individual CT findings considered significant for the differentiation were determined using univariate statistical analyses. Then, two successive review sessions for the differentiation between the two disease entities were independently performed by two other reviewers using a 4-point confidence scale. At the first session, no information was provided to reviewers for differentiation. At the second session, however, the reviewers were told of the results of univariate analyses. Radiologists' performance was evaluated using pairwise comparison of receiver operating characteristic (ROC) curves. The mean size of biliary cystic neoplasms (9.5 cm) was not significantly different from that of simple cysts (11.2 cm). The presence of upstream bile duct dilatation achieved the highest specificity (100%) for the differentiation of biliary cystic neoplasms from simple cysts, followed by THAD (84.6%), lesion location at the left lobe (76.9%), and coexistence of fewer than three other cysts (69.2%). The area under the curve of reviewers 1 and 2 significantly increased from 0.686 and 0.654 to 0.997 and 0.936, respectively, when the reviewers knew the information about the significant CT criteria (p = 0.003 and p = 0.008, respectively). Upstream bile duct dilatation, lesion location at the left hepatic lobe, fewer than three coexistent cysts, and THAD were found to be highly suggestive CT findings for the differentiation of biliary cystic neoplasms from simple hepatic cysts. Radiologists' performance was significantly improved with the knowledge of these highly suggestive CT criteria.

Spontaneous rupture of a giant hepatobiliary serous cystadenoma: report of a case and literature review

Hepatobiliary cystadenomas are rare cystic neoplasms that often occur in middle age women, and spontaneous rupture is extremely rare. The exact etiology of these tumors is unknown. Diagnosis is often delayed, while misdiagnosis and inappropriate treatment may result in unfavorable outcome. We report a case of hepatobiliary serous cystadenoma with mesenchymal stroma, initially misdiagnosed as simple hepatic cyst with intracystic hemorrhage. The rapid growth of the giant tumor leads to spontaneous rupture, almost turned into a life-threatening event. After emergency formal liver resection, the patient recovered well without recurrence during the 6-month follow-up period. We also reviewed the literature, proposed possible factors for the tumor's rapid growth, and discuss the current diagnostic and treatment modalities.