Successful management of a ruptured cystic artery pseudoaneurysm with embolization and cholecystectomy: A case report.

Key Clinical Message: Cystic artery pseudoaneurysm is a rare phenomenon associated with cholecystitis. We describe the successful management of angioembolisation and cholecystectomy. Abstract: Cystic artery pseudoaneurysm (CAP) is a rare but clinically significant condition with various etiological factors. Cholecystitis is a prominent cause, often leading to inflammation-induced arterial wall erosion and pseudoaneurysm formation. CAP can present with a range of symptoms, including hemobilia, upper GI bleeding, and jaundice. Despite its rarity, CAP warrants attention in emergency care due to its potential for life-threatening arterial bleeding. Timely diagnosis is crucial, with imaging techniques playing a key role. Depending on the clinical context, management options include endovascular embolization and surgical intervention. Due to the limited cases, standard protocols remain elusive. A 64-year-old woman presented with abdominal pain, anorexia, and weight loss, prompting an evaluation for possible gallbladder cancer. She experienced sudden abdominal pain and upper gastrointestinal bleeding (hematemesis). Laboratory findings revealed leukocytosis, anemia, and abnormal liver function tests. Imaging showed gallbladder wall thickening, luminal contraction, and a pseudoaneurysm in the cystic artery. The patient underwent angioembolization followed by cholecystectomy, confirming acute cholecystitis and CAP with thrombosis. This case underscores the importance of early recognition and appropriate management in CAP, particularly when accompanied by acute cholecystitis.

Long-term survival after hepatic resection for colorectal liver metastases: a single-center study in Iran.

BACKGROUND: Surgical resection of colorectal cancer liver metastasis (CRLM) has been associated with improved survival in these patients. The purpose of this study was to investigate the usefulness of liver metastasectomy, also finding independent factors related to survival after liver metastasectomy. METHODS: In a retrospective study, all patients with CRLM who underwent resection of liver metastases between 2012 and 2022 at Imam Khomeini Hospital Complex in Tehran, Iran, were enrolled. All patients were actively followed based on clinicopathologic and operative data. RESULTS: A total of 248 patients with a median follow-up time of 46 months (Range, 12 to 122) were studied. Eighty-six patients (35.0%) underwent major hepatectomy, whereas 160 (65.0%) underwent minor hepatectomy. The median overall survival was 43 months (Range, 0 to 122 months), with estimated 1-, 3- and 5-year overall survival rates of 91%, 56%, and 42%, respectively. Multivariate analysis demonstrated that a metastasis size > 6 cm, major hepatectomy, rectum as the primary tumor site, and involved margin (< 1 mm) were independent factors associated with decreased overall survival (OS). CONCLUSION: Surgical resection is an effective treatment for patients with CRLM that is associated with relatively favorable survival. A negative margin of 1 mm seems to be sufficient for oncological resection.

Liver Transplant for Hepatocellular Carcinoma in Post-Milan Criteria Era: A Long-Term Single-Center Experience.

OBJECTIVES: We investigated the outcomes of liver transplant in patients with hepatocellular carcinoma. MATERIALS AND METHODS: Prospectively, recipients of deceased donor liver transplants from 2007 to 2021 at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran, were enrolled into the study. The Milan criteria were applied for selection of liver transplant candidates diagnosed with hepatocellular carcinoma. Patients with diagnosis of acute liver failure and who underwent secondary liver transplant were excluded. All patients diagnosed with hepatocellular carcinoma were given mechanistic target of rapamycin inhibitor with calcineurin inhibitor minimization 4 weeks after liver transplant. Patients were assigned to the experimental group (with hepatocellular carcinoma; n = 82) or the control group (without hepatocellular carcinoma; n = 1076). We recorded the etiologies of liver cirrhosis in the experimental group, demographic data from all patients, and postoperative complications. RESULTS: Of 1158 total patients, mean age was 44.15 ± 14.71 years (range, 1-73 years) and 712 were male patients (61.5%). In the experimental group (n = 82), there were 76 patients (92.68%) who were within the Milan criteria; others were excluded intraoperatively. All patients were followed for a median of 65.3 ± 40.8 months (range 10-197 months). Patient survival rates in the experimental group and control group at 3 months, 1 year, and 3 years were 89%, 80%, and 78% versus 84%, 81%, and 70%, respectively (P = .742). Hepatocellular carcinoma reoccurred in 6 patients (7.31%) at mean of 16.83 months postoperatively. CONCLUSIONS: Liver transplant for patients with hepatocellular carcinoma in the post-Milan criteria era is associated with acceptable outcomes.

Liver Transplant in Patients With Autoimmune Hepatitis: A Large Single-Center Study.

OBJECTIVES: Autoimmune hepatitis is a rare indication for liver transplant in Western countries. Our goal was to identify characteristics and long-term outcomes of patients who underwent liver transplant for autoimmune hepatitis-related end-stage liver disease at our center. MATERIALS AND METHODS: Adult patients who underwent primary liver transplant from January 2007 to March 2022 at Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran, were enrolled in our study. RESULTS: Among 1107 patients enrolled in our study, mean age was 45.94 ± 12.43 years (range, 16-73 years) and 423 (38.2%) female patients were included. Autoimmune hepatitis was the underlying cause of cirrhosis in 177 patients (experimental group); the other 930 patients did not have autoimmune hepatitis (control group). All patients were followed for a median of 60 ± 40.3 months (range, 3-187 months) after transplant. In the experimental group, patient survival rates at 1 month, 1 year, and 3 years were 87%, 81%, and 78%, which were not significantly different between the 2 groups (P = .445). Recurrence of autoimmune hepatitis was detected in 8 patients (4.5%) in the experimental group. Acute allograft rejection was more significantly detected in the patients with recurrence of autoimmune hepatitis than in patients without recurrence of autoimmune hepatitis. CONCLUSIONS: Liver transplant in patients with autoimmune hepatitis is safe and is associated with good outcomes.

Surgical Management of Intestinal Failure; Initial Experiences from an Intestinal Failure, Rehabilitation and Transplant Unit in Iran.

BACKGROUND: Intestinal failure (IF) is a life-threatening medical condition. The management of IF in low- and middle-income countries without home parenteral nutrition (HPN) remains unclear. We recently established an intestinal rehabilitation unit (IRU) and aimed to provide our experience on the current management and outcomes of IF in Iran. METHODS: In this cross-sectional case series, data were collected from an established database on IF in the Shiraz Transplant Center in Abu Ali Sina hospital, affiliated to Shiraz University of Medical Sciences, Iran from January 2018 to October 2018. RESULTS: Overall, 30 patients with a mean age of 44.13 ± 10.32 years, which included 25 males, were recruited. Short bowel syndrome (SBS) (60%) and enterocutaneous fistulae (27%), as complication of previous surgeries, were the main causes of IF. The most common type of IF was type 3 (67 %). Mesenteric ischemia was the leading mechanism of IF (47%). Fifteen patients (50%) received autologous gastrointestinal reconstruction surgery (AGIRS), and two (7%) patients had serial transverse enteroplasty (STEP). At the end of follow-up, 15 patients recovered from IF (50%). The overall survival rate was 83.3%. CONCLUSION: This series introduced the results of a multidisciplinary program for the treatment of IF in a middle-income country that lacks facilities for HPN. Our protocol of care, understanding the need for development of HPN, showed promising clinical outcomes.

Liver Transplant for Metastatic Neuroendocrine Tumors: A Single-Center Report of 15 Cases.

OBJECTIVES: Liver transplant has been shown to be a good treatment option for patients with nonresectable tumors that are limited to liver and that do notrespond to medicaltreatment. In this study, our aim was to share our experience in management of patients with neuroendocrine tumors and liver metastasis by liver transplant with and without more extensive surgical interventions. MATERIALS AND METHODS: We performed a 6-year (2011- 2017) retrospective study of data from the Namazi Hospital Transplant Research Center. Inclusion and exclusion criteria were determined based on pretransplant policy in our center. Our study included 15 patients with mean age of 33.3 years. RESULTS: Of the 15 patients included, 53.3% (n = 8) had liver transplant alone, 26.6% (n = 4) had multiorgan transplant, 6.66% (n = 1) underwentWhipple procedure and liver transplant, and 6.66% (n = 1) had segmental ileal resection and liver transplant. Six early mortalities occurred during the posttransplant hospital stay, and 2 patients with multiorgan transplant died in the followup period. In addition, 1 patient needed retransplant during follow-up due to chronic rejection. CONCLUSIONS: In patients with neuroendocrine tumors, the therapeutic approach to the liver metastasis and the prognosis can be determined based on the natural history of the disease, severity and progression of symptoms,tumor biology, location, and differentiation. Early diagnosis and management are needed to allow less invasive treatment protocols, which could result in more favorable outcomes.

Guideline for Management of Mesenteric Ischemia: Shiraz Intestinal Failure Unit Protocol.

We have recently established an intestinal rehabilitation unit (IRU) in Abu Ali Sina transplantation center affiliated to Shiraz University of Medical Sciences, Iran. Our intestinal failure rehabilitation and transplant program aims to provide state-of-the-art care for adult patients with different degrees of intestinal insufficiency and failure. In the IRU, we aimed to design an algorithmic approach to patients with small bowel ischemia and short bowel syndrome (SBS) based on our institutional experience in our country and based on other pioneering studies from other regions of the world.

The Effect of Blood Loss in the Presence and Absence of Severe Soft Tissue Injury on Hemodynamic and Metabolic Parameters; an Experimental study.

INTRODUCTION: The effect of severe soft tissue injury on the severity of hemorrhagic shock is still unknown. Therefore, the present study was aimed to determine hemodynamic and metabolic changes in traumatic/hemorrhagic shock in an animal model. METHODS: Forty male rats were randomly divided into 4 equal groups including sham, hemorrhagic shock, soft tissue injury, and hemorrhagic shock + soft tissue injury groups. The changes in blood pressure, central venous pressure (CVP) level, acidity (pH), and base excess were dynamically monitored and comparedsented. RESULTS: Mean arterial blood pressure decreased significantly in hemorrhagic shock (df: 12; F=10.9; p<0.001) and severe soft tissue injury + hemorrhagic shock (df: 12; F=11.7; p<0.001) groups 15 minutes and 5 minutes after injury, respectively. A similar trend was observed in CVP in severe soft tissue injury + hemorrhagic shock group (df: 12; F=8.9; p<0.001). After 40 minutes, pH was significantly lower in hemorrhagic shock (df: 12; F=6.8; p=0.009) and severe soft tissue injury + hemorrhagic shock (df: 12; F=7.9; p=0.003) groups. Base excess changes during follow ups have a similar trend. (df: 12; F=11.3; p<0.001). CONCLUSION: The results of this study have shown that the effect of hemorrhage on the decrease of mean arterial blood pressure, CVP, pH, and base excess is the same in the presence or absence of soft tissue injury.

Effects of Intravenous Fluid Therapy on Clinical and Biochemical Parameters of Trauma Patients.

INTRODUCTION: The administration of crystalloid fluids is considered as the first line treatment in management of trauma patients. Infusion of intravenous fluids leads to various changes in hemodynamic, metabolic and coagulation profiles of these patients. The present study attempted to survey some of these changes in patients with mild severity trauma following normal saline infusion. METHODS: This study comprised 84 trauma patients with injury of mild severity in Shahid Rajaei Hospital, Shiraz, Iran, during 2010-2011. The coagulation and metabolic values of each patient were measured before and one and six hours after infusion of one liter normal saline. Then, the values of mentioned parameters on one and six hours after infusion were compared with baseline measures using repeated measures analysis of variance. RESULTS: Eighty four patients included in the present study (76% male). Hemoglobin (Hb) (df: 2; F=32.7; p<0.001), hematocrit (Hct) (df: 2; F=30.7; p<0.001), white blood cells (WBC) (df: 2; F=10.6; p<0.001), and platelet count (df: 2; F=4.5; p=0.01) showed the decreasing pattern following infusion of one liter of normal saline. Coagulation markers were not affected during the time of study (p>0.05). The values of blood urea nitrogen (BUN) showed statistically significant decreasing pattern (df: 2; F=5.6; p=0.007). Pressure of carbon dioxide (PCO2) (df: 2; F=6.4; p=0.002), bicarbonate (HCO3) (df: 2; F=7.0; p=0.001), and base excess (BE) (df: 2; F=3.3; p=0.04) values showed a significant deteriorating changes following hydration therapy. CONCLUSION: It seems that, the infusion of one liter normal saline during one hour will cause a statistically significant decrease in Hb, Hct, WBC, platelet, BUN, BE, HCO3, and PCO2 in trauma patients with mild severity of injury and stable condition. The changes in, coagulation profiles, pH, PvO2, and electrolytes were not statistically remarkable.