Case report: appearance of an intestinal metastasis from intrahepatic cholangiocarcinoma occurring 5 years after resection of the primary tumor.

We present the unusual case of a 76-year-old male who developed an intestinal recurrence of the same tumor 5 years after hepatic resection for an intrahepatic cholangiocarcinoma. At the time of the first surgery, the patient had undergone hepatic bisegmentectomy of segments IV and V with an 'en bloc' gallbladder resection and porta hepatis lymphadenectomy for the presence of a focal cholangiocarcinoma measuring about 3.0 x 2.5 cm in diameter. The histological report confirmed intrahepatic cholangiocarcinoma, the resection margins were free from disease, and there were no lymph node metastases. Five years later colonoscopy showed, at the level of the splenic flexure, the presence of a sessile bilobate polypoid neoplasm. The patient underwent left hemicolectomy with a histological diagnosis of an isolated recurrence of cholangiocarcinoma.

Efficacy of a haemostatic matrix for the management of bleeding in patients undergoing liver resection: results from 237 cases.

BACKGROUND: The haemostatic matrix (FloSeal) is a topical agent that provides effective haemostasis in a range of surgical applications. We evaluated this sealant for intraoperative haemostatic effectiveness in an observational series of patients undergoing surgery for the resection of primary and metastatic liver tumours. METHODS: A haemostatic matrix was applied directly to areas of bleeding. The severity of bleeding before and after application was graded on a 5-point scale (0 = no bleeding, 1 = oozing, 2 = moderate blood flow, 3 = heavy blood flow, 4 = spurting blood). The time to complete haemostasis was also recorded. RESULTS: 105 women (age 61 +/- 9 years) and 132 men (age 61 +/- 12 years) were included in this study. One hundred and seventeen patients (49.36%) had pre-operative coagulopathy resulting from co-existent cirrhosis (67 Child-Pugh Class A; 50 Child-Pugh Class B). Prior to administration of a haemostatic matrix, 93 bleeding sites (24.8%) had a bleeding severity score of 2, 269 bleeding sites (71.7%) had a score of 3 and 13 bleeding sites (3.5%) had a score of 4. Following administration of the haemostatic matrix, bleeding stopped completely (score of 0) at 367 (97.9%) of the 375 sites and was reduced to a score of 1 at the remaining 8 sites (2.1%), of which only 2 were in patients with coagulopathy. The mean time to achieve haemostasis in the overall population was 2.9 +/- 1 min; this was significantly increased in patients with coagulopathy versus noncoagulopathic patients (4 +/- 1 vs. 2 +/- 1 min, p < 0.001). CONCLUSIONS: In this prospective, uncontrolled study of 237 consecutive patients undergoing major hepatic surgery to remove primary or metastatic tumours, application of a haemostatic matrix provided rapid and effective intraoperative control of mild to severe bleeding from the liver edge, even in patients with prolonged bleeding times resulting from cirrhosis. This preliminary evidence warrants a randomised, controlled clinical trial with a larger sample size.