Novel Use of the Falciform Ligament for MHV Reconstruction During Laparoscopic Hepatectomy of Colorectal Liver Metastasis.

BACKGROUND: Laparoscopic hepatectomy (LH) with oncological R0 resection combined with systemic therapy offers the best chance of cure for colorectal liver metastasis. However, tumors in vicinity of major hepatic veins require complex technique. Parenchyma-sparing resection with involved vein resection and peritoneal patch reconstruction could be an efficacious alternative to preserve liver volume for adjuvant chemotherapy and avoid venous congestion of the remnant liver.1,2 METHODS: A 64-year-old female, with history of colon cancer, had new diagnosis of liver metastatic tumor of S8 (2.8 cm), which was considering encroached on middle hepatic vein (MHV) with distal part patent. Thus margin-negative, parenchyma-sparing liver resection with involved vein resection and proximal MHV reconstruction was indicated for oncological radicality. RESULTS: With the patient in modified French position, we dissected falciform ligament and right coronary ligament to expose the crypt between right hepatic vein (RHV) and MHV. Intraoperative ultrasound localized the tumor and resection margin. Parenchymal dissection was performed caudally to cranially, left to right, to ligate dorsal branch of G8 (G8d) and V8 and expose main trunk of MHV. The involved side-wall of MHV was incised after the proximal and distal parts clamped. Peritoneal patch was harvested from falciform ligament to repair MHV side-wall before clamps released. The patient had an uneventful recovery and remained disease-free at 1 year postoperatively with patency of distal MHV by image. CONCLUSIONS: LH with MHV reconstruction by falciform ligament for metastatic lesion is technically demanding but feasible with oncological radicality and volume preservation for adjuvant chemotherapy.

Diagnostic accuracy of pre-operative breast magnetic resonance imaging (MRI) in predicting axillary lymph node metastasis: variations in intrinsic subtypes, and strategy to improve negative predictive value-an analysis of 2473 invasive breast cancer patients.

BACKGROUND: The value and utility of axillary lymph node (ALN) evaluation with MRI in breast cancer were not clear for various intrinsic subtypes. The aim of the current study is to test the potential of combining breast MRI and clinicopathologic factors to identify low-risk groups of ALN metastasis and improve diagnostic performance. MATERIAL AND METHODS: Patients with primary operable invasive breast cancer with pre-operative breast MRI and post-operative pathologic reports were retrospectively collected from January 2009 to December 2021 in a single institute. The concordance of MRI and pathology of ALN status were determined, and also analyzed in different intrinsic subtypes. A stepwise strategy was designed to improve MRI-negative predictive value (NPV) on ALN metastasis. RESULTS: 2473 patients were enrolled. The diagnostic performance of MRI in detecting metastatic ALN was significantly different between intrinsic subtypes (p = 0.007). Multivariate analysis identified tumor size and histologic type as independent predictive factors of ALN metastases. Patients with HER-2 (MRI tumor size ≤ 2 cm), or TNBC (MRI tumor size ≤ 2 cm) were found to have MRI-ALN-NPV higher than 90%, and these false cases were limited to low axillary tumor burden. CONCLUSION: The diagnostic performance of MRI to predict ALN metastasis varied according to the intrinsic subtype. Combined pre-operative clinicopathologic factors and intrinsic subtypes may increase ALN MRI NPV, and further identify some groups of patients with low risks of ALN metastasis, high NPV, and low burdens of axillary disease even in false-negative cases.

The role of Roux-en-Y hepaticojejunostomy for the management of biliary complications after living donor liver transplantation.

INTRODUCTION: Post living donor liver transplantation (LDLT) biliary complications can be troublesome over the post-operative course of patients, especially those with recurrent cholangitis or choledocholithiasis. Thus, in this study, we aimed to evaluate the risks and benefits of Roux-en-Y hepaticojejunostomy (RYHJ) performed after LDLT as a last option to deal with post-LDLT biliary complications. METHODS: Retrospectively, of the 594 adult LDLTs performed in a single medical center in Changhua, Taiwan from July 2005 to September 2021, 22 patients underwent post-LDLT RYHJ. Indications for RYHJ included choledocholithiasis formation with bile duct stricture, previous intervention failure, and other factors. Restenosis was defined if further intervention was needed to treat biliary complications after RYHJ was performed. Thereafter, patients were categorized into success group (n = 15) and restenosis group (n = 4). RESULTS: The overall success rate of RYHJ in the management of post-LDLT biliary complications was 78.9% (15/19). Mean follow-up time was 33.4 months. As per our findings, four patients experienced recurrence after RYHJ (21.2%), and mean recurrence time was 12.5 months. Three cases were recorded as hospital mortality (13.6%). Outcome and risk analysis presented no significant differences between the two groups. A higher risk of recurrence tended to be related to patients with ABO incompatible (ABOi). CONCLUSION: RYHJ served well as either a rescue but definite procedure for recurrent biliary complications or a safe and effective solution to biliary complications after LDLT. A higher risk of recurrence tended to be related to patients with ABOi; however, further research would be needed.

Migration of a Retained Surgical Suture Needle in the Common Bile Duct.

Retained surgical foreign bodies have been a cause of concern since physicians began operating on patients. Retained surgical foreign bodies in the common bile duct (CBD) are rare and may cause cholangitis and jaundice. We report the case of a patient who initially presented with fever and right upper-quadrant abdominal pain. He had received cholecystectomy and choledochojejunostomy 28 years ago and had been well since then. Abdominal computed tomography (CT) revealed left-lobe liver abscess and a linear curve of high-density material. Endoscopic retrograde cholangiopancreatography (ERCP) displayed mild dilatation of the common bile duct (CBD) and choledojejunostomic fistula of the middle CBD. A curved, linear, rusty, metallic surgical suture needle was detected and successfully removed under ERCP.

TGF-ß1 in plasma and cerebrospinal fluid can be used as a biological indicator of chronic pain in patients with osteoarthritis.

INTRODUCTION: Previous studies have demonstrated that cytokines, transforming growth factor (TGF-ß1), and brain-derived neurotrophic factor (BDNF) can impact the intensity of pain in rodents. However, the roles of cytokines, TGF-ß1 and BDNF in humans with chronic pain in osteoarthritis remains unclear, and no comparison between plasma and central cerebral spinal fluid (CSF) has been conducted. METHODS: Patients with osteoarthritis who were scheduled to receive spinal anesthesia were enrolled. The intensity of pain was evaluated with a visual analogue scale (VAS). In addition, patients with genitourinary system (GU) diseases and without obvious pain (VAS 0-1) were included as a comparison (control) group. The levels of TGF-ß1, BDNF, tumor necrosis factor-α (TNF-α), and interleukin (IL)-8 within the CSF and plasma were collected and evaluated before surgery. RESULTS: The plasma and CSF TGF-ß1 levels were significantly lower in the osteoarthritis patients with pain (VAS ≥ 3) than in the GU control patients. Downregulation of plasma BDNF was also found in osteoarthritis patients with pain. The Spearman correlation analysis showed that the VAS pain scores were significantly negatively correlated with the levels of TGF-ß1 in the CSF of patients with osteoarthritis. However, there was no significant correlations between the pain scores and the levels of BDNF, TNF-α, and IL-8 in either the CSF or plasma. CONCLUSIONS: TGF-ß1 but not BDNF, TNF-α, or IL-8 may be an important biological indicator in the CSF of osteoarthritis patients with chronic pain.

Bilateral spontaneous massive renal hemorrhage in a peritoneal dialysis patient: A case report.

RATIONALE: Non-traumatic bilateral spontaneous massive renal hemorrhage confined to the subcapsular and perirenal space, also known as Wünderlich syndrome, can occur suddenly and insidiously and cause serious consequences if not properly identified and managed. We report a case of bilateral spontaneous massive renal hemorrhage in a series of devastating episodes. PATIENT CONCERNS: A 38-year-old woman undergoing peritoneal dialysis for 7 years for end-stage renal disease presented with disturbances in consciousness and sudden hypotension. DIAGNOSIS: The patient's laboratory results indicated an abrupt drop in hemoglobin level. Emergent abdominal computed tomography (CT) showed a rupture of the lower pore of the left kidney, with massive hemoretroperitoneum. A second sudden reduction in hemoglobin level occurred 2 months later during the same admission course, with poor response to urgent blood transfusion. Contrast extravasation at the lower pole of the right kidney and posterior pararenal space along with a subcapsular hematoma was revealed on abdominal CT. INTERVENTION: The patient's initial episode was managed with emergent transcatheter arterial embolization (TAE) of the left renal artery and again after the second episode for occlusion of the inferior branches of the right renal artery. OUTCOMES: After the first episode, immediate postprocedural angiography showed total occlusion of the left renal artery without contrast extravasation. Follow-up CT performed 10 days after the first TAE showed a residual left perirenal hematoma that extended to the left retroperitoneal and left upper pelvic region, without active bleeding. No follow-up imaging was done after the second TAE except for immediate postprocedural angiography, which showed no additional contrast extravasation of the right renal artery. LESSONS: Bilateral spontaneous massive renal hemorrhage is rare and generally occurs in patients undergoing dialysis. Known studies appear primarily in case reports. Most patients can be treated successfully with TAE when diagnosed early.

Surgical management of complicated gynecomastia (associated with foreign body injection) with single-port 3-dimensional videoscope-assisted endoscopic subcutaneous mastectomy and concurrent liposuction: A case report.

RATIONALE: Gynecomastia is a common benign breast disorder in men. Surgical management of gynecomastia includes that of a subcutaneous mastectomy with or without concurrent liposuction. Herein, the authors presented a case of complicated gynecomastia (gynecomastia with concurrent foreign body injection) which was successfully managed with an innovative technique that offered acceptable operative time, minimal complications, good recovery and satisfactory aesthetic outcome. PATIENT CONCERNS: A 39-year-old Taiwanese man who developed gynecomastia along with self-injection of foreign body (salad oil) over the past 10 years for breast enlargement presented as symptomatic bilateral breast lumps. DIAGNOSIS: Bedside sonography revealed multiple large droplets of oil in the subcutaneous tissue bilaterally, resembling cystic lesions. INTERVENTION: Bilateral single-port 3-dimensional videoscope-assisted endoscopic subcutaneous mastectomy was performed after bilateral breast liposuction. Operative findings include bilateral gynecomastia and previous bilateral breast foreign body material. The total weight of lipoaspirate was 400 grams and 300 grams for right and left side respectively. Subcutaneous mastectomy specimen weight was 820 grams and 661 grams for right and left breast tissue. OUTCOMES: Operative duration was 315 minutes and intraoperative blood loss at 150 ml. Patient was discharged 2 days after the operation, and subsequent follow up ultrasound showed complete removal of foreign bodies and fibrotic breast tissue. Patient was satisfied with the post-operative aesthetic outcomes. LESSONS: Single-port 3-dimensional videoscope-assisted endoscopic subcutaneous mastectomy with concurrent liposuction is a promising and safe surgical option for patient with complicated gynecomastia and severe fibrosis.