Strategies to Perform Emergency Laparoscopic Partial Liver Resection for Ruptured Hepatocellular Carcinoma.

BACKGROUND/AIM: Laparoscopic hepatic resection is currently used for ruptured hepatocellular carcinoma (HCC); however, it is technically challenging. We developed and implemented surgical strategies for emergency laparoscopic partial liver resection in selected patients with peripheral lesions who were hemodynamically stable and without severe liver dysfunction. PATIENTS AND METHODS: The surgical techniques used were as follows. First, the Pringle maneuver was performed to control hepatic blood inflow (step 1). Next, strong hemostatic agents were applied at the rupture point of the tumor (step 2). The hanging tape was positioned along the dorsal side of the resection line to control the partial blood inflow and outflow of the tumor, as well as to expose the surgical plane (step 3). The liver parenchyma was dissected along the hanging tape (step 4). We performed emergency laparoscopic partial liver resection in three patients who were in a pre-shock status. RESULTS: The tumors were located in segments 6 (cases 1 and 2) and 2 (case 3). The tumor diameters were 90, 62, and 80 mm. The Preoperative Child-Pugh scores were B7, B9, and B8. The hemostatic products performed well and controlled bleeding from the ruptured HCC. The hanging tape facilitated the dissection of the liver parenchyma. The operative time and intraoperative blood loss were 135 min and 400 ml, 266 min and 200 ml, and 191 min and 495 ml for cases 1, 2, and 3 respectively. There were no in-hospital deaths. CONCLUSION: Emergency laparoscopic partial liver resection could be an option for patients with ruptured HCC.

Clonorchis sinensis on the prognosis of patients with spontaneous rupture of Hepatocellular Carcinoma: An inverse probability of treatment weighting analysis.

BACKGROUND: We examined the impact of the Clonorchis sinensis (C. sinensis) infection on the survival outcomes of spontaneous rupture Hepatocellular Carcinoma (srHCC) patients undergoing hepatectomy. METHODS: Between May 2013 and December 2021, 157 consecutive srHCC patients who underwent hepatectomy were divided into an no C. sinensis group (n = 126) and C. sinensis group (n = 31). To adjust for differences in preoperative characteristics an inverse probability of treatment weighting (IPTW) analysis was done, using propensity scores. Overall survival (OS) and recurrence-free survival (RFS) were compared before and after IPTW. Multivariate Cox regression analysis was performed to determine whether the C. sinensis infection was an independent prognostic factor after IPTW. RESULTS: In original cohort, the no C. sinensis group did not show a survival advantage over the C. sinensis group. After IPTW adjustment, the median OS for the C. sinensis group was 9 months, compared to 29 months for the no C. sinensis group. C. sinensis group have worse OS than no C. sinensis group (p = 0.024), while it did not differ in RFS(p = 0.065). The multivariate Cox regression analysis showed that C. sinensis infection and lower age were associated with worse OS. CONCLUSIONS: The C. sinensis infection has an adverse impact on os in srHCC patients who underwent hepatectomy.

Spontaneous rupture of renal angiomyolipoma in pregnancy mimicking preterm labour.

Ruptured renal angiomyolipoma in pregnancy is uncommon. Pregnant women may present with nonspecific symptoms such as flank or abdominal pain, contraction pain and haematuria. A thorough assessment is needed to reach the correct diagnosis. Management varies between conservative measures, radiological intervention or surgery depending on the patient's haemodynamic status and foetal condition. We present a case of a woman in her 30s, gravida 5 para 3+1 at 28 weeks of gestation, who presented with pain. The pain worsened, and she went into hypovolaemic shock. An exploratory laparotomy and emergency caesarean section were done. Retroperitoneal haematoma was found intraoperatively, but the source of bleeding was difficult to determine. An abdominal CT angiogram subsequently revealed an ongoing bleeding from a ruptured angiomyolipoma. An emergency nephrectomy was performed, and the bleeding was secured.

Rare case of haemoperitoneum secondary to a ruptured ovarian ectopic pregnancy superimposed by a bleeding corpus luteum cyst.

An adolescent female presented with an acute abdomen and elevated beta-human chorionic gonadotropin levels and underwent a laparoscopy for a suspected ruptured ectopic pregnancy. Intraoperatively, a ruptured haemorrhagic corpus luteal cyst and tissues suggestive of products of conception were noted in the same ovary. Histology confirmed an ovarian ectopic pregnancy. Haemorrhagic ovarian cysts, and ectopic pregnancies, can cause acute pelvic pain in women of childbearing age. Their similar clinical signs and symptoms pose a diagnostic dilemma for any gynaecologist. Ruptured corpus luteal cysts, as well as ruptured ovarian ectopic pregnancies, should be considered rare but differential diagnoses in women presenting with acute abdominal pain, an adnexal mass and ultrasound features of haemoperitoneum. The mainstay of treatment is a diagnostic laparoscopy, which is a safe and feasible management strategy without compromising patient safety or ovarian function in the long run.

Transarterial embolization followed by staged hepatectomy versus emergency hepatectomy for ruptured HCC: a meta-analysis.

BACKGROUND: To compare the efficacy and safety between emergency hepatectomy (EH) and emergency transarterial embolization (TAE) followed by staged hepatectomy (SH) in the treatment of spontaneous ruptured hepatocellular carcinoma (rHCC). METHODS: Databases (PubMed, EMBASE, Web of science, Cochrane Library, ClinicalTrial.gov, CNKI, Wanfang and VIP) were searched for all relevant comparative studies from January 2000 to October 2020. Odds ratio (OR) and mean difference (MD) with 95% confidence interval (CI) were pooled for dichotomous and continuous variables, respectively. Subgroup analyses based on the kind of embolization were conducted. RevMan 5.3 software was adopted for meta-analysis. RESULTS: Eighteen studies with 871 patients were finally included in this meta-analysis, 448 in EH group and 423 in TAE + SH group. No significant difference was observed in successful hemostasis (P = 0.42), postoperative hospital stay (P = 0.12), complication rate (P = 0.08) between EH and TAE + SH group. However, TAE + SH group was associated with shorter operating time (P < 0.00001), fewer perioperative blood loss (P = 0.007), fewer blood transfusion (P = 0.003), lower in-hospital mortality (P < 0.00001) and higher 1-year survival as well as 3-year survival (P < 0.0001; P = 0.003) compared with EH group. CONCLUSION: Compared with EH, TAE + SH could reduce perioperative operating time, blood loss, blood transfusion, mortality rate and increase the long-term survival rate of the rHCC patients, which may be a better treatment for resectable rHCC.

A rare case of infection and spontaneous rupture in ovarian mucinous cystadenoma.

Ovarian cysts exhibit variable clinical presentations depending on their size, type and resulting sequelae. Rupture of ovarian cysts is infrequent, and cyst infections are even rarer. Here, we report an unusual case involving a young, non-pregnant woman who presented acutely with features of peritonitis and sepsis and was found to have a complex adnexal mass. Following a rigorous diagnostic evaluation, which included an urgent exploratory laparotomy and salpingo-oophorectomy, common diagnoses including tubo-ovarian abscess, endometriotic cyst and pelvic tuberculosis were ruled out. Instead, she was diagnosed with an ovarian mucinous cystadenoma that had become infected, possibly due to pelvic inflammatory disease, leading to spontaneous rupture. Such a presentation has rarely been reported, especially in a non-pregnant setting. Therefore, we emphasise the importance of considering this rare complication as a potential differential diagnosis in similar clinical presentations and discuss the management implications, including the importance of adequately treating pelvic inflammatory disease.

Spontaneous rupture of breast pseudoaneurysm: a rare case.

Ehlers-Danlos syndrome (EDS) type IV is a hereditary autosomal dominant disease associated with skin and vascular fragility, hyperextensibility and joint hypermobility. Spontaneous arterial rupture is one of its higher-risk features.The authors describe a case of a woman with EDS type IV who presented with a spontaneous breast haematoma associated with a pseudoaneurysm of a branch of the left internal mammary artery. The patient underwent a minimally invasive endovascular approach that was uneventful. However, 6 months later, she presented in the emergency room with a similar episode on the contralateral breast. There were no signs of active bleeding, and she stayed under surveillance. Nine months later, she was asymptomatic.Aneurysms of branches of the internal mammary artery are rare and prone to rupture. Early diagnosis and treatment are imperative, and this case demonstrates that an endovascular approach is a safe treatment option.

Clinical features of patients with previous spontaneous rupture of ovarian endometrioma operated electively: a case-control study.

BACKGROUND: The aim of the study is to investigate the proportion and clinical features of previous spontaneously ruptured ovarian endometrioma among women who underwent elective surgery for endometrioma. METHODS: This retrospective study was based on a cohort of elective surgeries for endometrioma performed by the same gynecologic team at Peking Union Medical College Hospital from January 2017 to October 2022. Patients diagnosed with previous spontaneously ruptured endometrioma during elective surgery were enrolled in the ruptured group. In the same cohort, patients with unruptured endometrioma treated during the same period were selected as the unruptured group by 1:2 matching according to age. Demographic and clinical information were collected and compared between two groups. RESULTS: A total of 422 patients in the cohort were diagnosed with endometrioma. There were 38 patients (9.0%) in ruptured group and 76 patients in unruptured group. All enrolled participants were treated by laparoscopic surgery. In ruptured group, 86.8% patients had a history of acute abdominal pain, which was only 13.2% in unruptured group (P < 0.001). Compared to unruptured group, patients diagnosed with ruptured endometrioma had a lower BMI (P = 0.021), larger maximum diameter of endometrioma (P = 0.040), higher proportion of cul-de-sac partial obliteration rather than complete obliteration (P = 0.003). CONCLUSIONS: Spontaneous rupture of endometrioma is not rare. The proportion of spontaneous rupture of endometrioma in our study was higher than that reported in the literatures. In women with endometrioma, the onset of acute abdominal pain should be considered a rupture of cyst, especially in patients with big cysts.

[Spontaneous splenic rupture. Case report and literature review]. / Ruptura esplénica espontánea. Reporte de caso y revisión de la literatura.

Background: Spontaneous splenic rupture is often life threatening due to delay in diagnosis and treatment. Abdominal pain, Kehr's sign, nausea, bloating, altered consciousness, and intestinal obstruction may be present. In larger splenic lesions, signs of peritonitis and hypovolemic shock are present. Contrast-enhanced computed tomography is the election study. Diagnosis is confirmed by negative viral serology and normal spleen on gross and histopathologic inspection. The most frequent treatment in splenectomy. Clinic case: A 30-year-old male with no medical history presented with generalized abdominal pain accompanied by Kehr's sign. He is diagnosed with ruptured spleen by contrast-enhanced computed tomography and successfully treated with splenectomy. He was discharged 6 days after surgery. Conclusions: Spontaneous rupture of the spleen is uncommon, but with high morbidity and mortality. It must be a differential diagnosis in the face of abdominal and/or chest pain, and the corresponding imaging studies should be carried out if the patient's conditions allow it, or their search during an exploratory laparotomy.

Introducción: la ruptura esplénica espontánea frecuentemente es mortal debido a la demora en el diagnóstico y tratamiento. Se puede presentar dolor abdominal, signo de Kehr, náuseas, distensión abdominal, alteración de la consciencia y obstrucción intestinal. En lesiones esplénicas más grandes, se presentan signos de peritonitis y shock hipovolémico. El estudio de elección es la tomografía computarizada contrastada. El diagnóstico se confirma por serología viral negativa y bazo normal en la inspección macroscópica e histopatológica. El tratamiento más frecuente es la esplenectomía. Caso clínico: paciente hombre de 30 años de edad, sin antecedentes patológicos, con dolor abdominal generalizado, acompañado del signo de Kehr. Es diagnosticado con ruptura de bazo por tomografía computarizada contrastada y tratado exitosamente con esplenectomía. Se egresa a los 6 días postquirúrgicos. Conclusiones: la ruptura espontánea del bazo es poco común, pero con alta morbimortalidad. Debe ser un diagnóstico diferencial ante un dolor abdominal y/o torácico, y realizar los estudios de imagen correspondientes si las condiciones del paciente lo permiten o bien su búsqueda durante una laparotomía exploratoria.

Spontaneous rupture of an unscarred uterus during pregnancy: A rare but life-threatening emergency: Case series.

RATIONALE: In most cases, uterine rupture occurs during the third trimester of pregnancy or during labor. Even fewer reports have been published about the occurrence of this condition without a gynecologic history of any surgical procedure. Due to their scarcity and variable clinical presentation, early diagnosis of uterine rupture may be difficult, and if the diagnosis is not timely, the condition may be life-threatening. PATIENT CONCERNS: Herein, 3 cases of uterine rupture from a single institution are described. Three patients are at different gestational weeks and all have no history of uterine surgery. They came to the hospital due to acute abdominal pain, which is characterized by severe and persistent pain in the abdomen, with no apparent vaginal bleeding. DIAGNOSES: All 3 patients were diagnosed with uterine rupture during the operation. INTERVENTIONS: One patient underwent uterine repair surgery; while the other 2 underwent subtotal hysterectomy due to persistent bleeding and pathological examination after surgery confirmed placenta implantation. OUTCOMES: The patients recovered well after the operation, and no discomfort occurred in the follow-up. LESSONS: Acute abdominal pain during pregnancy can pose both diagnostic and therapeutic challenges. It is important to consider the possibility of uterine rupture, even in cases where there is no history of prior uterine surgery. The key to the treatment of uterine rupture is to shorten the diagnosis time as much as possible, this potential complication should be carefully monitored for and promptly addressed to ensure the best possible outcomes for both the mother and the developing fetus.

Two cases of spontaneous rupture of the uterine artery in the perinatal period: A case report.

RATIONALE: Uterine artery spontaneous rupture is a rare but potentially life-threatening complication during pregnancy and puerperium. The lack of typical symptoms makes it difficult to diagnose, which can result in serious consequences for both the mother and fetus. PATIENT CONCERNS: Case 1 presented with fainting and lower abdominal discomfort, while Case 2 developed hypotension after delivery and remained in poor condition even after rehydration. DIAGNOSES: Both cases were diagnosed with uterine artery spontaneous rupture, with intraoperative findings revealing ruptures in different branches of the uterine artery. INTERVENTIONS: Both cases underwent surgical interventions, with laparoscopic surgery performed in Case 1 and repair of the ruptured artery in Case 2. OUTCOMES: Both cases had successful outcomes, with the ruptured arteries repaired and the patients discharged from the hospital within a week after surgery. LESSONS: Uterine artery spontaneous rupture is a rare but potentially life-threatening complication that may present with atypical symptoms. Early diagnosis and prompt surgical intervention are crucial in preventing serious complications for both the mother and fetus. Clinicians should maintain a high level of suspicion for this condition when evaluating patients presenting with unexplained symptoms or signs of peritoneal irritation during pregnancy and puerperium.

DELAYED SURGERY FOR GIANT SPONTANEOUS RUPTURE OF THE DISTAL THORACIC AORTA CAUSED BY CYSTIC MEDIAL NECROSIS.

Spontaneous (idiopathic) thoracic aortic rupture (STAR) is uncommon and assumes a rupture of the normal-sized thoracic aorta with no visually apparent aortic disease. Since 1961 about fifty reports have been published. STAR is established in cases of thoracic normal-sized aorta rupture with no traumas, aneurysms/dissections, infection, inflammation, connective tissue diseases, aortic and adjacent organs tumors/metastases, previous surgery, and occurring during pregnancy and the peripartum. Atherosclerosis penetrated atherosclerotic ulcer, neurofibromatosis type I, peri- and postpartum estrogen-mediated elastin irregularities of the aortic media, and cystic medial necrosis (CMN) were identified as a cause of STAR when histopathological examinations were performed. A case of a 68-year-old man with giant STAR of the descending aorta in the background of CMN is reported here. The patient in terminal hemodynamic condition was successfully treated by delayed open surgery two weeks after the disease's onset.

Clinical characteristics and laparoscopic surgical outcomes of ovarian dermoid cysts complicated by spontaneous rupture: nine cases and a literature review.

OBJECTIVE: To clarify the clinical characteristics and laparoscopic surgical outcomes of dermoid cysts complicated by spontaneous rupture. METHODS: This was a single-center retrospective observational study of patients with dermoid cysts treated between January 2005 and December 2021. RESULTS: Among 1205 cases of dermoid cysts, spontaneous rupture occurred in nine and torsion occurred in 83 cases. No obvious triggers for rupture were identified, except for one postpartum case with fundal uterine pressure maneuver. Rupture was identified by computed tomography (CT) in six cases. Patients with ruptured cysts had significantly higher serum C-reactive protein (CRP), cancer antigen 125 (CA125), carbohydrate antigen 19-9 (CA19-9), and squamous cell carcinoma antigen (SCC) levels compared with patients with uncomplicated dermoid cysts or cysts with torsion. Laparoscopic management was possible except for one case with severe adhesion, which required laparotomy. Two patients required prolonged postoperative administration of antibiotics due to refractory chemical peritonitis. CONCLUSION: Combined use of CT imaging and elevated levels of CRP, CA125, CA19-9, and SCC may help to differentiate cyst rupture from torsion. Laparoscopic surgery may be a feasible option; however, prompt laparotomic conversion should be considered in cases with difficult adhesiolysis. Refractory chemical peritonitis may occur after successful surgical management.

Severe hepatic rupture in HELLP syndrome.

OBJECTIVE: To describe the multidisciplinary approach that led to the successful management of severe hepatic rupture in HELLP syndrome at 35 weeks of gestation. CASE REPORT: The clinical course and management procedure of a 34-year-old female patient with ruptured liver due to HELLP syndrome, who was admitted with symptoms lasting about 4 hours (pain in the right hypochondrium, nausea, vomiting, flashes before the eyes) are described in the form of a case report. An acute caesarean section was performed, during which a rupture of the subcapsular hematoma of the liver was dia-gnosed. Subsequently, the patient developed hemorrhagic shock and coagulopathy with the need for repeated surgical revisions of bleeding from the rupture of the liver. CONCLUSION: Subcapsular hematoma rupture is a rare but serious complication of HELLP syndrome. This case shows the importance of early dia-gnosis and prompt termination of pregnancy in the shortest possible time in pregnancy after 34 weeks. The most fundamental factor that influenced the patient's outcome and morbidity was the management of multidisciplinary cooperation and the correct timing of individual steps.

Prognosis of spontaneously ruptured hepatocellular carcinoma: a propensity score matching study.

PURPOSE: Spontaneous rupture is a fatal complication of hepatocellular carcinoma (HCC). This study compared the prognosis of spontaneously ruptured HCC (srHCC) with that of non-ruptured HCC (nrHCC). METHODS: A total of 185 srHCC patients and 1085 nrHCC patients treated by hepatectomy between February 2005 and December 2017 at Zhongshan Hospital were retrospectively reviewed and enrolled. The overall survival (OS) and time to recurrence (TTR) were evaluated. A 1:2 propensity score matching (PSM) analysis was performed using the nearest neighbor matching with a caliper of 0.2. RESULTS: Before PSM, patients with srHCC who underwent hepatectomy (n = 185) had a poorer prognosis than those with nrHCC (n = 1085; 5-year OS, 39.1% vs 59.2%, P < 0.001; 5-year TTR, 83.8% vs 54.9%, P < 0.001). After PSM, patients with srHCC (n = 156) had higher 5-year TTR (83.2% vs 69.0%, P < 0.001) but comparable 5-year OS with those with nrHCC (n = 312, 44.0% vs 46.0%, P = 0.600). Univariate and multivariate analyses demonstrated spontaneous rupture as an independent risk factor for TTR (hazard ratio [HR], 1.681; 95% confidence interval [CI] 1.326-2.132; P < 0.001), but not for OS (HR: 1.074; 95% CI 0.823-1.401; P = 0.600). Further analysis revealed that srHCC was not appropriate to be assigned as T4 stage in American Joint Committee on Cancer classification. CONCLUSION: Spontaneous rupture of HCC is not a risk factor for survival. If resected eventually, srHCC may achieve comparable survival with nrHCC.

Spontaneous bladder rupture after non-traumatic vaginal delivery: a rare case report.

Spontaneous bladder rupture (SBR) is a rare condition and often missed diagnosis, especially after a non traumatic vaginal delivery. A 32-year-old para 3 woman, consulted for abdominal pain and anuria two days after instrumental vaginal delivery with forceps for foetal distress in second sate of labour. Blood tests were suggestive of an acute renal failure. An abdominocentesis revealed a clear fluid looking like ascites. The ultrasound and computed tomography (CT) scan showed a large abdominal effusion. An exploratory laparoscopy revealed a bladder perforation which was sutured after laparotomy. SRB is extremely rare after a non traumatic vaginal delivery. It is associated with significant morbidity and mortality. Symptoms are mostly non-specific. It is suspected when post partum abdominal pain is associated with an effusion and renal failure signs. If suspected, the uroscanner remains the gold standard for diagnostic. Laparotomy is the standard surgical approach in this condition. Abdominal pain with elevated serum creatinine should be suspicious of SBR in post-partum.

Spontaneous globe rupture in a patient with extensive ocular surgical history.

Globe rupture is visually dramatic in appearance for emergency clinicians and is a sight-threatening injury for the patient. It requires prompt ophthalmologic surgical intervention for optimal outcomes. Cases are typically the result of ocular trauma; however, this case highlights a rare instance of spontaneous globe rupture in a patient with an extensive ocular surgical history.

Management of a rare case of intraventricular ruptured dermoid cyst and chemical meningitis.

INTRODUCTION: Intraventricular dermoid cyst are very rare benign tumour. Due to benign nature, it may go un-noticed for years and might present with sudden rupture. Ruptured cyst can cause chemical meningitis, hydrocephalus, seizures etc. Due to lack of data, there are no defined guidelines about its management. We are reporting an interesting case of ruptured intraventricular dermoid cyst and chemical meningitis, who was managed successfully and will review the literature. CASE REPORT: A 48 years male patient was brought with complaint of sudden mental deterioration, irritability, headache, vomiting for 3 days. He had history of seizures for 1 year. On examination, his higher mental functions were deteriorated, had neck rigidity and left lower limb weakness. CT/MRI brain confirmed diagnosis of right frontal horn ruptured dermoid cyst with scattered fat droplets, hydrocephalus and ventriculitis. Excision of cyst was done via right trans-sulcal (superior frontal sulcus) approach. Patient recovered well. DISCUSSION: Intraventricular dermoid cyst are a rare benign lesion. Due to potential of rupture, it must be surgically treated. Steroids should be used to treat chemical meningitis. Various individual case reports have shown good outcome after surgical management. CONCLUSION: We recommend early surgery, thorough ventricular wash with ringer lactate, post-operative extraventricular drain and steroid cover to manage ruptured cyst and chemical meningitis.