Transcatheter arterial embolization for massive hemobilia with N-butyl cyanoacrylate (NBCA) Glubran 2.

BACKGROUND: Massive hemobilia is a life-threatening condition and therapeutic challenge. Few studies have demonstrated the use of N-butyl cyanoacrylate (NBCA) for massive hemobilia. PURPOSE: To investigate the efficacy and safety of transcatheter arterial embolization (TAE) using NBCA Glubran 2 for massive hemobilia. MATERIAL AND METHODS: Between January 2012 and December 2019, the data of 26 patients (mean age 63.4 ± 12.6 years) with massive hemobilia were retrospectively evaluated for TAE using NBCA. The patients' baseline characteristics, severities of hemobilia, and imaging findings were collected. Emergent TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil. Technical success, clinical success, procedure-related complications, and follow-up outcomes were assessed. RESULTS: Pre-procedure arteriography demonstrated injuries to the right hepatic artery (n = 24) and cystic artery (n = 2). Initial coil embolization distal to the lesions was required in 5 (19.2%) patients to control high blood flow and prevent end-organ damage. After a mean treatment time of 11.2 ± 5.3 min, technical success was achieved in 100% of the patients without non-target embolization and catheter adhesion. Clinical success was achieved in 25 (96.2%) patients. Major complications were noted in 1 (3.8%) patient with gallbladder necrosis. During a median follow-up time of 16.5 months (range 3-24 months), two patients died due to carcinomas, whereas none of the patients experienced recurrent hemobilia, embolic material migration, or post-embolization complications. CONCLUSION: NBCA embolization for massive hemobilia is associated with rapid and effective hemostasis, as well as few major complications. This treatment modality may be a promising alternative to coil embolization.

Mesenteric Vascular Injury in Trauma: An NTDB Study.

BACKGROUND: Although abdominal trauma remains a major cause of morbidity and mortality, there has not been a large-scale multicenter study regarding outcomes in patients who incur mesenteric vascular injuries. The goal of this retrospective analysis was to investigate the factors associated with outcomes in patients with trauma diagnosed with mesenteric vascular injuries. METHODS: A retrospective database analysis was performed on patients who sustained a mesenteric vascular injury (MVI, ICD-9 902.20-902.29) identified by the 2012 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, emergency room (ER) and final hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score (ISS), and injury type (blunt or penetrating). RESULTS: Of the 1,133 total patients included, blunt trauma accounted for 740 (65%) of the injuries, whereas penetrating trauma accounted for 364 of the injuries (32%). Patients with penetrating injuries were 1.43 times more likely to die from their injuries than those suffering from blunt trauma (95% CI 1.04-1.98, P < 0.05). Patients with a higher ISS (>16) were 5.39 times more likely to die from their injuries than those with a lower ISS (95% CI 1.89-15.4, P = 0.002); if ISS was >25, the patient was 15.1 times more likely to die (95% CI 5.5-41.7, P < 0.001). Men were more likely to suffer from penetrating injuries than women (37% vs. 13%, P < 0.001), and African Americans were nearly 4 times more likely to present with penetrating injuries (69% vs 17%, P < 0.001). Age was also associated with mortality as patients >65 years and between 21 and 44 years were more likely to die from their injuries than patients in other age categories. Of the 740 patients with blunt MVIs, 326 (44%) were taken directly from the ER to the operating room (OR) and 306 (41%) to the intensive care unit (ICU), whereas with penetrating MVIs, 311 (85%) were taken to the OR from the emergency department and 18 (5%) to the intensive care unit. Of the 740 blunt MVIs, 115 died (16%), compared with 76 (21%) of the penetrating MVIs (P < 0.001). Injuries to the hepatic and superior mesenteric arteries were associated with higher mortality, with OR 2.03 and 3.03, respectively (P < 0.001). CONCLUSIONS: The presence of mesenteric arterial injury warrants rapid identification and management as these injuries are associated with significant morbidity and mortality, with penetrating mechanism, injury to large mesenteric vessels, and increased ISS associated with increased mortality.

Laparoscopic repair of transected right hepatic artery during cholecystectomy: A report of two cases.

In laparoscopic cholecystectomy (LC), the treatment of iatrogenic biliary tract injury has been given much attention. However, most accidental right hepatic artery (RHA) injuries are treated with simple clipping. The reason is that the RHA has difficulty in revascularization, and it is generally considered that RHA injury does not cause serious consequences. However, some studies suggest that some cases of RHA ligation can cause a series of pathological changes correlated to arterial ischemia, such as liver abscess, bile tumor, liver atrophy and anastomotic stenosis. Theoretically, RHA blood flow should be restored when possible, in order to avoid the complications of right hepatic ischemia. The present study involved two patients, including one male and one female patient. Both patients were admitted to the hospital with the diagnosis of chronic cholecystitis and gallbladder stone, and developed ischemia of the right half hepatic after accidental transection of the RHA. Both patients underwent continuous end-end anastomosis of the RHA with 6-0 Prolene suture. After the blood vessel anastomosis, the right half liver quickly recovered to its original bright red. No adverse complications were observed in follow-ups at three and six months after the operation. Laparoscopic repair of the RHA is technically feasible. Reconstruction of the RHA can prevent complications associated with right hepatic ischemia.

An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy.

PURPOSE: Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt. METHODS: A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes. RESULTS: Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases. CONCLUSIONS: We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

Hemobilia due to Hepatic artery pseudoaneurysm secondary to collateral circulation formation after liver trauma: a case report.

BACKGROUND: Hemobilia due to rupture of hepatic artery pseudoaneurysm and recurrent hemorrhage caused by hepatic artery collateral circulation are both rare complications after liver trauma. There have been a number of separate reports of both complications, but no cases have been reported in which the two events occurred in the same patient. Here we report a recurrent hemorrhage in the bile duct due to hepatic artery pseudoaneurysm secondary to collateral circulation formation after hepatic artery ligation in a patient with liver trauma. CASE PRESENTATION: A 52-year-old male patient was admitted to our hospital for liver trauma (Grade IV according to the American Association for the Surgery of Trauma (AAST) grading system) with active bleeding after a traffic accident. Hepatic artery ligation was performed for hemostasis. Three months after the surgery, the patient was readmitted for melena and subsequent hematemesis. Selective angiography examination revealed the formation of collateral circulation between the superior mesenteric artery and right hepatic artery. Moreover, a ruptured hepatic artery pseudoaneurysm was observed and transcatheter arterial embolization (TAE) was performed for hemostasis at the same time. After the treatment, the patient recovered very well and had an uneventful prognosis until the last follow-up. CONCLUSION: For patients with hepatic trauma, the selection of the site of hepatic artery ligation and the diagnosis and treatment methods of postoperative biliary hemorrhage are crucial for the prognosis of the disease.

Use of the Gastroduodenal Artery in Hepatic Artery Reconstruction for Iatrogenic Hepatic Artery Injury During Laparoscopic Total Gastrectomy: Case Report and Review of the Literature.

Iatrogenic injury of the hepatic artery is a potential hazard of hepatopancreatobiliary and gastric surgery. Prompt recognition and specialist management is paramount to limit morbidity for the patient. Several reconstruction options have been reported in the literature, but the optimum approach should be tailored to the individual patient bearing in mind variations in anatomy, clinical conditions, and other concurrent operative interventions. We report the case of a successful hepatic artery reconstruction using the gastroduodenal artery as a transposition graft for inadvertent transection of the common hepatic artery during laparoscopic total gastrectomy. In expert hands, the use of the gastroduodenal artery for extra-anatomic reconstruction of the hepatic artery is a safe, feasible, and effective option.

Surgical and oncological implications of aberrant arterial anatomy in patients undergoing pancreatoduodenectomy.

Whipple's pancreatoduodenectomy is a complex surgical procedure and any aberrant arterial anatomy may have serious surgical implications. The objective of our study was to analyse the frequency of aberrant hepatic artery and compare the outcomes in patients with normal anatomy. Clinical data and computed tomography scans of 45 consecutive patients who underwent Whipple's procedure from 2007 to 2016 were reviewed. Group 'A' included patients with aberrant hepatic artery while group 'B' with normal anatomy. Aberrant hepatic artery was present in 11 (24%) patients and type V was the most common variant (n=5, 45%). Morbidity rate in group A was 82% and group B was 62% (p= 0.288), while 30-day mortality rate was 18% and 9% respectively (p=0.582). There was no difference in the oncological clearance in both the groups. Aberrant hepatic artery does not seem to influence the morbidity, mortality and tumour resection margins in patients undergoing Whipple's procedure.

Management of post cholecystectomy vascular injuries.

INTRODUCTION: Vasculobiliary and vascular injuries following cholecystectomy are the most serious complications requiring complex surgical management resulting in greater patient morbidity and mortality. METHODOLOGY: The study was performed at a tertiary teaching hospital of North India. Records of patients referred for biliary or vascular injury sustained during cholecystectomy were reviewed retrospectively to identify patients with vascular injury between January 2009 and March 2018. Clinical profile, hospital course and outcome of these patients were analysed. RESULTS: Over nine years, 117 patients were referred for cholecystectomy related complications. Total incidence of vascular injury was 5.1% (6/117). Combined vasculobiliary injury (VBI) occurred in 3.4% (4/117) while isolated vascular injury was present in 1.7% patients (2/117). Most (5/6) patients were operated for uncomplicated gall stone disease. Incidences of portal vein (PV) and right hepatic artery (RHA) injuries were equal (3/6). PV injuries were repaired either during cholecystectomy (1/3) or during re-exploration after damage control packing (2/3). RHA injuries presented as pseudoaneurysm and were managed surgically (2/3) or by coil embolization (1/3). All VBI referrals (4/117) were following open cholecystectomy. In VBI patients, vascular injury was diagnosed intra-operatively in two while it was diagnosed several weeks after cholecystectomy in two others. Biliary injury manifested as bile leak post-operatively in all four of them. Nature of biliary injury could be characterized in only 50% (2/4) patients. Definitive repair of biliary injury was performed in one patient only. There was one mortality in our series. CONCLUSION: Vascular injury is an uncommon complication of cholecystectomy with catastrophic outcome if not managed timely and properly. Adequate surgeon training, keeping the possibility of aberrant vasculobiliary anatomy in all cases, and proper surgical technique is crucial for prevention of such injuries. However in such an event, proper documentation and referral to tertiary centre will help in decreasing morbidity and further litigation.

Incidence and management of arterial injuries during pancreatectomy.

PURPOSE: The incidence of intraoperative arterial injury during pancreatectomy is not well described. This study aims to evaluate the incidence, management, and outcome of arterial injuries during pancreatectomy. METHODS: This is a retrospective study of 1535 consecutive patients undergoing pancreatectomy between 2006 and 2016 at Oslo University Hospital. The type of arterial injury and potential contributing factors were analyzed. Short-term outcomes were compared between patients with arterial injury and patients undergoing a planned arterial resection due to tumor involvement. RESULTS: Arterial injury was diagnosed in 14 patients (incidence 0.91%), while planned arterial resection was performed in 22 patients. The injuries were located in the superior mesenteric artery (n = 5), right hepatic artery (n = 5), common hepatic artery (n = 2), left hepatic artery (n = 1), and celiac trunk (n = 2). The artery was reconstructed in all except one patient. In 11 patients with injury, peripancreatic inflammation, aberrant arterial anatomy, close relationship between tumor and injured artery, or a combination of the three were found. Median estimated blood loss was 1100 ml in both groups. Rate of severe complications (≥ Clavien grade IIIa), comprehensive complication index, and 90-day mortality for patients with intraoperative arterial injury vs planned arterial resection were 43 vs 45% (p = 0.879), median 35.9 vs 21.8 (p = 0.287), and 14.3 vs 4.5% (p = 0.551), respectively. CONCLUSION: Arterial injury during pancreatectomy is an infrequent and manageable complication. Early recognition and primary repair in order to restore arterial liver perfusion may improve outcome. However, the morbidity is high and comparable to patients undergoing a planned arterial resection.

Early presentation of ruptured post-traumatic hepatic artery pseudoaneurysm.

Visceral artery aneurysms (VAA) are an uncommon but well recognized condition. Hepatic artery aneurysms (HAA) represent 14-20% of all visceral artery aneurysms. Post traumatic hepatic artery pseudoaneurysm is an uncommon delayed complication of blunt liver trauma. Here we present a case of a 27 year old male with blunt abdominal trauma who developed a post traumatic pseudoaneurysm of the hepatic artery just proximal to its bifurcation into the left and right branches. The pseudoaneurysm ruptured within 12 hours of injury and he required double ligation of the hepatic artery as well as right and left hepatic arteries . However, the bleeding continued through the retrograde flow from the gastroduodenal artery and hence, ligation of gastrodudenal artery was also done. The decision of complete devasularisation of liver was taken as an emergency lifesaving procedure. The patient recovered and was discharged without sequel.

Complications after endovascular treatment of hepatic artery stenosis after liver transplantation.

BACKGROUND: Hepatic artery stenosis (HAS) after liver transplantation can progress to hepatic artery thrombosis (HAT) and a subsequent 30% to 50% risk of graft loss. Although endovascular treatment of severe HAS after liver transplantation has emerged as the dominant method of treatment, the potential risks of these interventions are poorly described. METHODS: A retrospective review of all endovascular interventions for HAS after liver transplantation between August 2009 and March 2016 was performed at a single institution, which has the largest volume of liver transplants in the United States. Severe HAS was identified by routine surveillance duplex ultrasound imaging (peak systolic velocity >400 cm/s, resistive index <0.5, and presence of tardus parvus waveforms). RESULTS: In 1129 liver transplant recipients during the study period, 106 angiograms were performed in 79 patients (6.9%) for severe de novo or recurrent HAS. Interventions were performed in 99 of 106 cases (93.4%) with percutaneous transluminal angioplasty alone (34 of 99) or with stent placement (65 of 99). Immediate technical success was 91%. Major complications occurred in eight of 106 cases (7.5%), consisting of target vessel dissection (5 of 8) and rupture (3 of 8). Successful endovascular treatment was possible in six of the eight patients (75%). Ruptures were treated with the use of a covered coronary balloon-expandable stent graft or balloon tamponade. Dissections were treated with placement of bare-metal or drug-eluting stents. No open surgical intervention was required to manage any of these complications. With a median of follow-up of 22 months, four of eight patients (50%) with a major complication progressed to HAT compared with one of 71 patients (1.4%) undergoing a hepatic intervention without a major complication (P < .001). One patient required retransplantation. Severe vessel tortuosity was present in 75% (6 of 8) of interventions with a major complication compared with 34.6% (34 of 98) in those without (P = .05). In the complication cohort, 37.5% (3 of 8) of the patients had received a second liver transplant before intervention compared with 12.6% (9 of 71) of the patients in the noncomplication cohort (P = .097). CONCLUSIONS: Although endovascular treatment of HAS is safe and effective in most patients, target vessel injury is possible. Severe tortuosity of the hepatic artery and prior retransplantation were associated with a twofold to threefold increased risk of a major complication. Acute vessel injury can be managed successfully using endovascular techniques, but these patients have a significant risk of subsequent HAT and need close surveillance.

The Complication of Hepatic Artery Injuries of 1,304 Percutaneous Transhepatic Biliary Drainage in a Single Institute.

PURPOSE: To determine frequency of and assess risk factors for hepatic artery (HA) injury during percutaneous transhepatic biliary drainage (PTBD) and to discuss the technique and report the clinical outcome of embolization for HA injury. MATERIALS AND METHODS: Over a 14-year period (2002-2016), 1,304 PTBD procedures in 920 patients were recorded. The incidence of HA injury was determined, and possible associated risk factors were analyzed. When injury occurred, HA embolization was performed at the site as close to the bleeding point as possible. Clinical outcomes of these patients after embolization were reported. RESULTS: Of 1,304 PTBD procedures, a left-sided approach was used in 722 procedures (55.4%), and intrahepatic duct (IHD) puncture under ultrasound guidance was used in 1,161 procedures (90.1%). The IHD was nondilated in 124 (9.5%) patients. The punctured ductal entry site was peripheral in 1,181 (90.6%) patients. In this series, 8 procedures (0.61%) were complicated by HA injury. IHD dilatation status was the only risk factor (P = .017) for HA injury. Embolization was performed with technical and clinical success in all 8 patients. No recurrent hemobilia, intraabdominal bleeding, or other sequelae of HA injury after embolization was noted during 1 week to 84 months of follow-up. CONCLUSIONS: HA injury is a relatively rare complication of PTBD. IHD dilatation status was the only risk factor for HA injury in this study. When HA injury occurred, embolization therapy was effective in managing this complication.

Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: Risk Factors Associated with Mortality and Complications.

PURPOSE: To evaluate risk factors predicting death and complications of primary therapy for hepatic and gastric duodenal artery pseudoaneurysms following endovascular treatment (EVT) after pancreaticoduodenectomy (PD). MATERIALS AND METHODS: Between April 2004 and December 2014, 28 patients (mean age, 64.7 y) with post-PD hemorrhage underwent EVT. Prevention of hepatic artery blockage via stents or side-holed catheter grafts was stratified in cases without a replaced hepatic artery. Mortality and major hepatic complications following EVT were evaluated according to age; sex; surgery-EVT interval; presence of portal vein stenosis, shock, and coagulopathy at EVT onset; and post-EVT angiographic findings. RESULTS: All hemorrhages were successfully treated with microcoils (n = 17; 61%), covered stents (n = 1; 3%), bare stent-assisted coil embolization (n = 5; 18%), or catheter grafts with coil embolization (n = 5; 18%). Hepatic arterial flow was observed after EVT in 18 patients (64%). Mortality and major hepatic complication rates were 28.6% and 32.1%, respectively. Hemorrhagic shock and coagulopathy at EVT onset (n = 8 each; odds ratio [OR], 27; 95% confidence interval [CI], 3.1-235.7; P < .01) were significantly associated with mortality. Coagulopathy at EVT onset (adjusted OR [aOR], 48.1; 95% CI, 3.2-2,931), portal vein stenosis (n = 16; aOR, 16.9; 95% CI, 1.3-721.9), and no visualization of hepatopetal flow through the hepatic arteries (n = 10; aOR, 29.5; 95% CI, 2.1-1,477) were significantly associated with major hepatic complications. CONCLUSIONS: EVT should be performed as soon as possible before the development of shock or coagulopathy. Hepatic arterial flow visualization decreases major hepatic complications.

Arterial dissections during transcatheter arterial chemoembolization for hepatocellular carcinoma: a 19-year clinical experience at a single medical institution.

Background Arterial dissections during transcatheter arterial chemoembolization (TACE) procedures are not rare and can limit the successful treatment of unresectable hepatocellular carcinoma (HCC). Purpose To evaluate the incidence of arterial dissections during TACE procedures, the rate of spontaneous lumen recovery, and the predictive factors of dissecting stenosis during follow-up. Material and Methods Based on 69,651 TACE procedures from 1997 to 2016, patients who had procedure-related arterial dissections were identified by procedure report search. More than two months after the date of dissection, dissecting stenosis was evaluated using a three-grade scale: subclinical narrowing with diameter loss under 30%, overt stenosis with diameter loss over 30%, and occlusion. Pearson Chi-square and two-sample t-test were used to assess potential prognostic markers for dissecting stenosis. Results Eighty-four arterial dissections directly related to TACE were identified in 83 patients, resulting in an incidence of 0.12% (84/69651). After more than two months, normal or subclinical narrowing, overt stenosis, occlusion, and doubling were seen in 39 (46.4%), 26 (31.0%), 13 (15.5%), and one (1.2%) patients, respectively. No follow-up images were obtained for five (6.0%) patients. On univariate analysis, the dissection ratio (the ratio of the length to the diameter of the dissection) alone was related to dissecting stenosis ( P = 0.035). Conclusion The incidence of iatrogenic dissection during TACE was approximately 0.12%. Less than 50% of the iatrogenic dissections showed normal or subclinical narrowing during follow-up of at least two months. The dissection ratio alone was the predictive factor for dissecting stenosis during follow-up.

From Laparoscopic Cholecystectomy to Liver Transplantation: When the Gallbladder Becomes the Pandora s Box.

Bile duct injuries (BDI) tend to be more complex in laparoscopic than in open cholecystectomy procedures, and frequently involve young adults with benign pathologies. The ultimate consequence may be a liver transplantation (LT), making this situation one of the most rare transplant indications. Fatal post-transplant outcome is extreme infrequently reported. Aim of this study is to report on our single-case experience and to review the literature concerning lethal outcome after LT for major BDI following cholecystectomy. A 36-year old obese caucasian woman underwent a laparoscopic cholecystectomy for symptomatic cholecystolithiasis at an outside institution. Intraoperatively, she sustained an E4 BDI in conjunction with total transection of the right hepatic artery. The surgeon converted to an open laparotomy, examined the site, placed two drains, and immediately transferred the patient to our center for further evaluation and treatment. At relaparotomy, a dearterialized right liver as well as 7 bile duct orifices was found; a right hemihepatectomy and a Roux-en-Y drainage of 4 left-sided bile ducts were performed. The postoperative course was complicated by bile leaks requiring re-operation and relapsing episodes of cholangitis and intrahepatic bilomas, requiring re-submissions of the patient and conservative treatment with intravenous antibiotics and percutaneous drainage procedures, respectively. She subsequently developed severe endocarditis leading to cardiac mitral and aortic valves insufficiency (grade III and II, respectively) demanding mechanical replacement of them. The patient developed secondary biliary cirrhosis, was listed to Eurotransplant with a Model for End-Stage Liver Disease score of 39, and underwent LT 19 months after the laparoscopic cholecystectomy. Histology of the explanted liver showed 50% parenchymal necrosis, chronic cholestasis and cirrhosis. On post-transplant day 5, she developed cardiogenic shock associated with pericardial tamponade that despite adequate surgical drainage progressed to multi-organ failure and death 2 days later. The two most frequent complications of hepatobiliary surgery that may ultimately require LT are: 1) lesions of the bile duct leading to recurrent cholangitis, chronic cholestasis, and secondary biliary cirrhosis, and 2) hilar vascular lesions (almost always arterial) associated with fulminant hepatic failure. Up to date there have been very few publications about LT as a treatment option following major BDI. To the best of our knowledge, 4 deaths post-LT after major BDI during laparoscopic cholecystectomy are reported in the literature (1-3) (Table 1). The indications for LT in these 4 cases were fulminant hepatic failure (n=2) (2) and secondary biliary cirrhosis (n=2) (1, 3) and the deaths occurred 6 days, 1 month, 7 and 18 months post-operatively, respectively. Five additional fatal outcomes after LT for secondary biliary cirrhosis after major BDI during open cholecystectomy were reported in the literature (3-5). Four patients died at 7 days, 1 month, 7 and 8 months post-LT, respectively (3-4). The fifth patient died after 2 subsequent transplants for hepatic artery thrombosis unrelated to the initial injury sustained during cholecystectomy (5). This indeed displeasing analysis of the overall 10 cases shows, that despite the very few post-transplant fatal outcomes reported in the literature, this is a real scenario representing one of the most dreaded outcomes of a seemingly simple procedure such as cholecystectomy.

[Endovascular and surgical treatment of a patient with traumatic rupture of the aorta and hepatic artery].

Traumatic rupture of the aorta is the second most common cause of death in closed chest injury. The latest findings of autopsy showed that 80% of lethal outcomes in aortic injury occur in the prehospital period. Taking into consideration the incidence and high rate of death prior to the diagnosis stage, aortic rupture in closed thoracic injury is an important problem. Due to the characteristic mechanism of the development (during sharp deceleration of the body) this type of traumatic lesion of the aorta became known as "deceleration syndrome". The most vulnerable to tension aortic portion is its neck where the mobile part of the thoracic aorta is connected to the fixed arch in the place of the arterial ligament attachment. Open surgical intervention in patients with severe closed chest injury (often concomitant injury) is associated with high mortality and complications. Currently endovascular prosthetic repair of the aorta is a method of choice at the primary stage of treatment of patients with aortic injury. In this article we present a rare case report of concomitant lesion of large vessels (the descending aortic portion and proper hepatic artery) in a patient with severe concomitant injury, as well as peculiarities of diagnosis and combined treatment (endovascular prosthetic repair of the aorta and hepatic artery with an aotovein).

Comparison of complete pathologic response and hepatic injuries between hepatic arterial infusion and systemic administration of oxaliplatin in patients with colorectal liver metastases.

BACKGROUND: Whether hepatic arterial infusion (HAI) of oxaliplatin influences the rates of complete pathologic response (CPR) and severe oxaliplatin-related lesions (SOxL) in patients with colorectal liver metastases (CRLM) is unknown. This study aimed to compare the incidence of CPR and SOxL between systemic (intravenous, IV) and HAI administration. METHODS: All patients with initially unresectable CRLM who had undergone hepatic resection in two expert centers between 2004 and 2010 after at least 6 cycles of oxaliplatin-based chemotherapy administered either via HAI (n = 18) or IV (n = 50) were included. The presence of CPR and SOxL were evaluated by two pathologists. A 1:2 case match using a propensity score was used. RESULTS: A CPR was observed significantly more often after HAI (33 vs. 10 %, P = 0.03). However, SOxL had occurred more frequently in patients in the HAI group versus the IV group, 66 and 20 %, respectively (P < 0.001). On a well-balanced cohort, HAI was associated with higher chance of CPR (odds ratio 9.33, 95 % confidence interval 1.59-54.7) but also higher risk of SOxL (odds ratio 13.7, 95 % confidence interval 3.08-61.3). A CPR markedly enhanced overall survival (OS) and disease-free survival (median OS of 114 vs. 42 months, P = 0.02; median disease-free survival of 51 vs. 12 months, P = 0.002). Patients with SOxL did not experience different outcome (median OS of 42 vs. 50 months, respectively; P = 0.92) CONCLUSIONS: HAI of oxaliplatin increases the likelihood of a CPR at the cost of a higher incidence of SOxL in patients with initially unresectable CRLM.

An alternative technique for harvesting marginal liver grafts with a replaced or accessory right hepatic artery.

The presence of a replaced or accessory right hepatic artery (R/A RHA) originating from the superior mesenteric artery represents one of the most common anatomical vascular variants of the hepatic artery and comprises the most frequently injured vessels during liver harvesting. Vascular arterial injuries following liver procurement are associated with decreased patient and graft survival and higher retransplantation rates. We describe an alternative technique for harvesting marginal liver grafts with replaced or accessory right hepatic arteries in the absence of pancreatic procurement. The entire procedure is divided and schematically described in six steps for didactical purposes. This technique has been used in 72 liver harvests over a three-year period with no R/A RHA injury. The technical advantages and limitations of this alternative method are discussed.

Complications After Laparoscopic Cholecystectomy: A Video Evaluation Study of Whether the Critical View of Safety was Reached.

BACKGROUND: Achieving the critical view of safety (CVS) before transection of the cystic artery and duct is important to reduce biliary duct injury in laparoscopic cholecystectomy. To gain more insight into complications after laparoscopic cholecystectomy, we investigated whether the criteria for CVS were met during surgery by analyzing videos of operations performed at our institution. METHODS: All consecutive patients who underwent a completed laparoscopic cholecystectomy between 2009 and 2011 were included. The videos of the operations of patients with complications were independently reviewed and rated by two investigators with a third consulted in the event of a disagreement. The reviewers answered consecutive questions about whether the CVS criteria were met. Patients who underwent an elective laparoscopic cholecystectomy and had no complications were used as a control group for comparison. RESULTS: Of the 1108 consecutive patients who had undergone a laparoscopic cholecystectomy during the study period, 8.8 % developed complications (average age 51 years) and 1.7 % had bile duct injuries [six patients (0.6 %) had a major bile duct injury, type B, D, or E injury]. In the 65 surgical videos available for analysis, CVS was reached in 80 % of cases according to the operative notes. However, the reviewers found that CVS was reached in only 10.8 % of the cases. Only in 18.7 % of the cases the operative notes and video agreed about CVS being reached. CVS was not reached in any of the patients who had biliary injuries. In the control group, CVS was reached significantly more often in 72 %. CONCLUSIONS: In our institutional series of laparoscopic cholecystectomies with postoperative complications, CVS was reached in only a few cases. Evaluating surgical videos of laparoscopic cholecystectomy cases are important and we recommend its use to improve surgical technique and decrease the number of biliary injuries.