Acquired diaphragmatic hernia after hepatectomy and liver transplantation in adults and children: A case series and literature review.

BACKGROUNDS/AIMS: Acquired diaphragmatic hernia is a rare complication following liver surgery in adult and pediatric patients. This study aims to describe main features occurring in adult and pediatric patients after liver surgery and report an up-date review of the literature. METHODS: All adult and pediatric patients who were diagnosed with postoperative acquired diaphragmatic hernia in Lyon and Marseille University Hospitals were included in this study. Diagnosis, clinical, radiologic, and therapeutic data were analysed retrospectively from medical papers and/or electronic records. RESULTS: Thirteen adults with a median age of 50 years (range, 30-67 years) and 5 children aged 2.4 years (range, 0.9-4 years) were diagnosed with acquired diaphragmatic hernia after a median time of 65.1 (range, 1.8-244.7) and 2 (range, 0.33-10.9) months, respectively, following surgeries (5 live-donor right hepatectomies, 5 right and 1 left hepatectomies for tumors and cysts, and 2 whole liver transplantations in adults; and 5 liver transplantations with left lateral section in children). Eleven patients presented digestive and/or thoracic symptoms whereas seven were asymptomatic and diagnosed by routine imaging follow-up. All patients were re-operated with a median delay of 2.4 months (range, 0-25.3 months) for adults and 1 day (range, 0-2 days) for children. Two recurrences resulted in a secondary surgical repair. CONCLUSIONS: Acquired diaphragmatic hernia is a rare and potentially serious event after liver surgery. Recognition and surgical repair of this particular complication should be considered in the setting of unexplained abdominal and/or thoracic symptoms. Preventive measures should be taken intraoperatively.

Traumatic Abdominal Wall Hernia-A Series of 12 Patients and a Review of the Literature.

BACKGROUND: The traumatic abdominal wall hernia (TAWH) is strongly associated with blunt abdominal trauma. The importance of the CT scan cannot be underestimated-the diagnosis of TAWH is easy to miss clinically, but simple to spot radiologically. We report a case series of patients managed in a French-level one trauma centre, to contribute our experience in the detection and management of associated injuries, and of the hernia itself. METHODS: All patients (n = 4238) presenting to a single-level one trauma centre for trauma resuscitation (including systematic full-body computerised tomography) from November 2014 to February 2020 were screened for the presence of TAWH and prospectively added to our database. Particular attention was paid to the late detection of associated intra-abdominal injuries. Finally, the choice of management of the hernia itself was noted. A literature review of all case series and individual case reports until the time of writing was performed and summarised. RESULTS: We report 12 cases of TAWH amongst 4238 patients presenting to the trauma resuscitation bay between November 2014 and February 2020. All patients underwent a contrast-enhanced CT immediately after stabilisation. No patients had clinically detected TAWH prior to CT. Intra-abdominal injuries were found in 9 patients (75%), and urgent surgery was required in 7 patients (58.3%). Two (28.5%) of these seven patients had a missed diagnosis of intra-abdominal injury at the time of the index CT scan, although the TAWH had been detected. Based on our literature review, 271 patients across 12 case series were identified. In total, 183 (67;5%) of these patients were reported to have ≥ 1 associated intra-abdominal injuries. In total, 127 (46,8%) patients required an urgent laparotomy for management of these injuries. Five (3.9%) of the patients requiring urgent laparotomy had a missed CT diagnosis of intra-abdominal injury but not of TAWH at the time of the baseline CT. CONCLUSIONS: TAWH is a rare clinical entity that may alert to more significant, associated trauma lesions. The CT scan is the imaging modality of choice, to both diagnose and classify the hernia and to screen for other injuries. The presence of TAWH must lower the threshold to operatively explore or at least closely monitor these patients, in view of the high rate of false-negative findings at index imaging.

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) Procedure for Non-resectable Peritoneal Carcinomatosis (with Video).

BACKGROUND: Peritoneal carcinomatosis (PC) is a common evolution of abdominal cancers and is associated with poor prognosis in the absence of aggressive multimodal therapy.1 Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a safe and innovative approach, which enhances the effect of chemotherapy 2 without reported renal/hepatic toxicity.3,4 It requires mastery of technical aspects to reduce postoperative morbidity, increase effectiveness, and prevent caregiver chemotherapy exposure. We, therefore, report herein the surgical protocol after 2 years of implementation in our university center specialized in PC management, accompanied by a short video, to share our experience. METHODS: The procedure was performed under general anesthesia and capnoperitoneum (12 mmHg, 37 °C) using two balloon trocars placed in the midline, in accordance with the open laparoscopic technique. Explorative laparoscopy allowed Sugarbaker peritoneal cancer index to be determined. Parietal biopsies were taken, and ascites was removed for peritoneal cytology. The nebulizer was inserted and connected to a high-pressure injector. A pressurized aerosol containing chemotherapy agents was then administered; cisplatin (7.5 mg/m2 in 150 ml 0.9%NaCl) immediately followed by doxorubicin (1.5 mg/m2 in 50 ml 0.9%NaCl), or oxaliplatin alone (92 mg/m2 in 150 ml 0.9%NaCl), based on PC origin and chemotherapy history. The aerosol was kept in a steady-state for 30 min then exhausted through a closed filter system, and trocars were retracted. Each step is illustrated in the video. CONCLUSION: This video protocol provides a better understanding of the PIPAC procedure and the safety measures essential for this method of chemotherapy administration. It should help all teams wishing to implement a PIPAC therapy program.

Total Mesenteric Peritonectomy for Peritoneal Metastases (with video).

BACKGROUND: Complete cytoreductive surgery (CRS), combining organ resection and peritonectomy, is the only potentially curative treatment for patients with peritoneal metastases (PM).1 , 2 Diffuse mesenteric PM usually represents a contraindication for CRS.3 This report presents a standardized total mesenteric peritonectomy, which provides a therapeutic option of complete CRS for patients with diffuse mesenteric PM. PATIENT: A 73-year-old man had a diagnosis of PM caused by an urachal adenocarcinoma (signet cell type). Initial assessment found a 60-mm urachal tumor above the dome of the urinary bladder. Dedicated magnetic resonance imaging (MRI)4 and explorative laparoscopy confirmed the presence of diffuse mucinous PM suspected of pseudomyxoma peritonei arising from urachus. The patient was treated by a systemic induction chemotherapy including cisplatin, fluorouracil, and docetaxel, with an almost full regression of the PM shown on control MRI. The man then was treated with CRS and hyperthermic intraperitoneal chemotherapy.5 TECHNIQUE: Exploration found persistent diffuse macro-nodular PM with a good response to chemotherapy, a 16/39 peritoneal cancer index,6 and no digestive tract or other organ involvement. The CRS procedure included complete urachus resection, together with appendicectomy, cholecystectomy, omentectomy, and a total parietal and mesenteric peritonectomy, with a completeness of cytoreduction score6 of 1, as illustrated in the video. At this writing, after 6 months of follow-up evaluation, the patient remains free of symptomatic peritoneal disease or local recurrence. CONCLUSION: Total mesenteric peritonectomy can be safely performed with the reported technique irrespective of how widespread PM is along the mesentery as long as few small bowel serous membranes are involved.

Sporadic intra-abdominal desmoid tumor: a unusual presentation.

Desmoid tumors are rare potentially aggressive benign tumors. Various etiologies and recurrent factors have been presented and discussed. A case of an abdominal desmoid tumor with vascular mesenteric invasion in a 32-year-old female, over 2 years after pregnancy is presented. Pre-operative biopsy was not contributive, diagnosis was made after surgery. Resection required two vascular bypasses. Desmoid tumors appear frequently in women of child-bearing age (during or after pregnancy), hormonal signaling is probably involved, but pathways remain unknown. Multiple predictive factors of recurrence are discussed but not strongly identified due to underpowered studies: resection margins, age, sex, tumor's size and location. Recent development is in favor of a non-aggressive treatment such as 'wait and see' procedures. Without radical treatment, these tumors could generate bowel compression or perforation. Due to their location and high risk of complication, surgery is the most fitted option.