Management of grade III-IV blunt liver traumas: a comparative, observational study.

AIM: The aim of the present study was to assess the impact of angiographic embolization in view of expanding indications for the conservative management of grade III-IV liver injuries. METHODS: Fifty adult patients with grade III-IV hepatic trauma were admitted to our Hepato-Biliary-Pancreatic Surgery and Level II Regional Trauma Center from 1993 to 2010 and retrospectively analyzed. Injury severity, management strategies and outcomes of patients admitted between 1993 and 2005 were analyzed and compared with those admitted between 2005 and 2010. Univariable and multivariable logistic models were fitted to investigate the differences between the two time windows studied, in particular with regard to morbidity, mortality, treatment and outcomes, the use of non-operative management and of angiographic embolization. RESULTS: At univariable analysis the majority of the patients treated after 2005 were more likely to have undergone arterial embolization, and less likely to have incurred morbidity, conversion to surgery, or to be admitted to the Intensive Care Unit after initial treatment (baseline category). At multivariable analysis the patients treated before 2005 were more likely to be older than 25 years to receive angiographic embolization and less likely to undergo conversion to surgery after failure of non-operative management. CONCLUSION: The criteria for the conservative treatment of blunt liver trauma is presently often based on hemodynamic stability in injured patients, but its successful management should, instead, be based also on early CT recognition of arterial bleeding and prompt use of angiographic embolization to control it.

Hepatic cystic lesion in adult: a challenging diagnosis of undifferentiated primary embryonal sarcoma.

Cystic lesions of the liver are common. Most of these represent benign simple cysts that generally require no intervention. The diagnosis of simple hepatic cysts is straightforward in the face of typical radiographic findings; however, diagnostic uncertainty, based solely on radiographic criteria alone, is not an uncommon clinical dilemma. In this report, we present a case of a 47 old woman with a cystic liver lesion and acute epigastric pain. The patient had no previous history of oral contraceptive assumption or liver disease. A tender mass was palpable on the upper right quadrant of the abdomen. The abdominal ultrasound (US) showed a cystic lesion with a possible hemorrhagic component on right liver lobe. Abdominal computed tomography (CT) and magnetic resonance (MR) revealed a complex cystic lesion with possible intracystic hemorrhage. The patient was submitted to operation and resection; the final histologic diagnosis revealed a primary undifferentiated embryonal sarcoma of the liver. She relapsed 24 months after a new hepatic resection and chemo-embolization, she is alive at 29 months after first surgery.

Liver resection in elderly: comparative study between younger and older than 70 years patients. Outcomes and implications for therapy.

BACKGROUND AND AIM: to identify the factors that could influence the outcome of the old aged patients underwent liver resection for hepatocellular carcinoma (HCC) or colorectal liver metastases (LMCRC). PATIENT AND METHODS: the Authors identified 51 patients older 70 years-old over 12-years period underwent resection for HCC (n 26) or for LMCRC (n 25). This group was compared with a cohort of 93 patients younger than 70 years who underwent resections in the same period. We have evaluated the results in terms of peroperative morbidity and mortality. RESULTS: the mean age of 51 elderly patients was 74 years-old. Thirty-five were treated with anatomical resection. Cirrhosis was present in 26 patients while 27 had co-morbidities. Thirteen patients developed complications and the mean age of these were 76 years compared with 73 of the patients who have not (p= .01). No mortality was registered. The cirrhosis, blood transfusions, anatomical resection and diameter of the lesion did not influence the outcome. CONCLUSIONS: our results indicate the age per se should not be considered a contraindication for surgery, that proved to be safe and curative therapy, but showed that old age, using 75 years as a cut-off, in association with at least one comorbid medical condition could be considered as relevant factor of morbidity.

Combined endoscopic and laparoscopic removal of ingested large foreign bodies. Case report and decisional algorithm.

Foreign body ingestion is a rare occurrence, but quite more frequent in children; adults with mental disorders, bulimia, and dentition alterations; and prison inmates. Most foreign bodies pass spontaneously through the first digestive tract and can move along the entire alimentary canal without giving rise to any major damage. On the contrary, when foreign bodies, because of their shape, size or potential for danger, must be removed, endoscopy is the method of choice. In a small percentage of cases, however, it may be necessary to remove the foreign body surgically. In such cases, the laparoscopic technique certainly can prove to be a most valuable tool, and can be recommended as a first approach. We describe a case in which a large foreign body was accidentally ingested. After a brief analysis of the data in the literature, we propose the decision-making algorithm that we follow.

Temporary axillo-femoral bypass graft for renal transplant protection during aortic aneurysm repair.

Aortic surgery in renal transplant recipients requires a method of maintaining intraoperative graft perfusion. Here we present a case in which temporary axillo-femoral bypass was used to perfuse a renal transplant during the aortic aneurysm repair; the rationale of inserting the temporary axillo-femoral bypass on transverse arteriotomies is pointed out. Other methods of renal graft perfusion are discussed.

Management of spontaneous bleeding due to hepatocellular carcinoma.

BACKGROUND: Spontaneous rupture is a life-threatening complication of HCC, occurring in 4.8-26% of cases. Liver failure is the main cause of death. Debates still remain on the most appropriate treatment in such patients because of the high operative mortality of emergency surgery and the high risk of rebleeding and less satisfying mid- and long-term results of nonoperative procedures like angiographic embolization. Early and long-term results of a surgically oriented treatment, based on prompt evaluation of the functional liver reserve and tumor resectability was retrospectively review-ed. METHODS: From January 1994 to December 2000, 11 patients (7 males and 4 female, mean age 66.2 (11.86 years) were treated for ruptured HCC, in 10 cases involving a cirrhotic liver. Seven patients underwent emergency surgery and 4 patients transcutaneous arterial embolization (TAE). Liver resection was performed in patients with preserved liver function, after ultrasonography and/or CT scan demonstrated hemoperitoneum and a single resectable liver tumour (5 cases). In one patient with cirrhosis, ultrasonography showed only hemoperitoneum. A bleeding nodule was discovered intraoperatively and resected in a liver with a multinodular HCC. Another patient under-went emergency resection after referral at our Unit with a surgical packing. In 4 cases with poor liver function and/or unresectable tumour TAE of the neoplasm was performed, in one case after surgical packing. Mortality, morbidity and patients survival after treatment were analyzed. All patients had at least 1 year follow-up. RESULTS: All patients underwent minor resection; 2 left lobectomies, 1 segmentectomy (VII), 1 bisegmentectomy (VII-VIII), and 3 wedge resections. Postoperative course was complicated by ascites in 5 cases and subphrenic abscess in one case. Four patients died 3, 4, 6 and 62 months after surgery; 3 patients are actually alive 22, 25, and 89 months after surgery. Four patients were submitted to TAE: all patients died within 6 months. CONCLUSIONS: When ruptured HCC is suspected, preserved liver function (Child A-B7) and a resectable hepatic tumour are considered clear indications to surgery. Emergency liver resection achieved good early and long-term results. In cases of advanced liver disease or multinodular HCC a non-operative approach, like TAE, must be attempted. Surgical direct hemostasis or hepatic artery ligation must be reserved for patients with uncontrollable o recurrent bleeding after TAE.

Supra infection of amoebic liver abscess consequent to acute appendicitis. Clinical case.

Amoebic liver abscess is the most common extra-intestinal manifestation of amebiasis with approximately 10% of the world's population infected by this parasite. Actually, incidence of this infection is also increasing in industrialized countries, as a consequence of the more frequent immigration or travelling. Only 3-10% of patients with intestinal amebiasis develop liver abscess. A clinical case of suprainfection of amoebic liver abscess consequent on acute appendicitis is presented.

Squamous cell liver cancer arising from an epidermoid cyst.

Squamous cell liver cancer (SCLC) arising from an epidermoid intestinal cyst is rare. Only 65 cases of this cyst have been reported since 1850, with 2 reported cases of squamous cell cancer. We describe here the case of a 21-year-old man who complained of mild pain, a feeling of fullness in the right upper quadrant of the abdomen, and fever and weight loss, who developed SCLC arising from an epidermoid intestinal cyst. The clinical presentation, management, and pathological findings are discussed.