Resection of an intra-operative ruptured hepatocellular carcinoma with continuous pringle maneuver and in situ hypothermic perfusion through the inferior mesenteric vein: a case report.

Intra-operative tumor rupture is a serious complication during resection of large hepatocellular carcinoma (HCC) leading to more blood loss. We report our experience in applying continuous Pringle maneuver with in situ hypothermic perfusion via inferior mesenteric vein catheterization to the portal vein of the remnant liver for resection during an extended left lobectomy of a large HCC which ruptured intraoperatively. Using this method, we successfully managed the patient without any further morbidity. This technique provides easier accessibility of in situ perfusion, decreases operative blood loss and prevents warm ischemic injury to the remnant liver during parenchymal transection. This method could be effective for the resection of large ruptured HCC.

Right hepatectomy after spontaneous hepatic rupture in a patient with preeclampsia: A case report.

INTRODUCTION: Spontaneous hepatic rupture associated with preecalmpsia or HELLP syndrome is a rare and life threatining event, only 200 cases have been reported in the literature. PRESENTATION OF CASE: We present a case of a 31 year old female with 28 weeks of gestation that presented with acute abdominal pain, elevated blood pressure and altered liver enzymes an abdominal ultrasound that showed a subcapsular hematoma occupying the whole right lobe and free abdominal fluid, she required emergent laparotomy, C-section, hepatic packing, followed by angioembolization and finally right hepatectomy. DISCUSSION AND CONSLUSION: Spontaneous hepatic rupture due to preeclampsia or HELLP syndrome is a medical emergency, it requires a prompt and decisive treatment. Multiple treatment modalities are available, from simple hepatic packing to endovascular embolization, but in extreme situations a formal hepatectomy might be required.

Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication.

BACKGROUND: Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances. METHOD: A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR. RESULTS: From January 2009 to July 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16-110) after LT. Biliary reconstruction included duct-to-duct (n = 9) and hepatico-jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in-hospital death. In the follow-up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well. CONCLUSIONS: In case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.

How to improve the outcome in patients with AJCC stage I hepatocellular carcinoma.

AIM: Survival of patients with stage I hepatocellular carcinoma (HCC) is higher than in patients with more advanced disease, however many of them will ultimately die of tumor recurrence and liver failure. Our objective focuses on identifying the pathological and clinical factors that could affect disease-free (DFS) and overall survival (OS). In addition we reviewed the treatment offered for recurrence and its impact on OS. PATIENTS AND METHODS: Between January 1992 and December 2002, a total of 473 patients who underwent hepatectomy for HCC at the Kaohsiung Chang Gung Memorial Hospital were enrolled in this study. Relevant clinicopathological and perioperative variables were subjected to univariate and multivariate analysis. RESULTS: A total of 224 patients with a mean follow-up period of 4.6 years were analyzed. The 1-, 3-, 5-, and 10-year DFS rates were 82.5%, 57.6%, 46.9% and 32.0% respectively. The 1-, 3-, 5-, and 10-year OS rates were 91.5%, 83.0%, 70.1% and 56.3% respectively. The multivariate analysis identified age >50 years, Indocyanine Green (ICG) clearance test and cirrhosis as independent factors that negatively impact DFS and age ≥ 50 years, resection type, presence of complications and tumor recurrence as factors affecting OS. In patients with recurrence (n=130), the factors that negatively impact OS were blood transfusion, age ≥ 50, blood loss and presence of surgical complications. CONCLUSION: Meticulous surgical technique is the key to improving the outcome of patients with stage I HCC. The presence of complications was the only modifiable clinicopathological factor that affected the OS in our study.

Clinicopathological factors impact the survival outcome following the resection of combined hepatocellular carcinoma and cholangiocarcinoma.

Studies have demonstrated poor survival outcomes for patients with resected combined hepatocellular carcinoma-cholangiocarcinoma tumours (CHCC-CC). Our objectives are to report on our institutional experience regarding the clinico-pathological and prognostic features of CHCC-CC and to compare our results with published series. The clinico-pathological features and outcomes of 11 patients with CHCC-CC who had a complete surgical resection for primary liver cancer were reviewed. There were 8 male and 3 female patients. The overall median age was 61 years. Active hepatitis B and hepatitis C infections were present in 6 (54%) and 2 (18%) patients, respectively. Alcoholism was present in one case. Cirrhosis was present in 8 (72%) cases. There were no causative factors identified in 2 patients with non-cirrhotic livers. The median AFP value was 30.56 ng/ml. A single mass located in the right lobe and a single mass located in the left lobe of the liver was noted in 6 (54%) and 4 (36%) patients, respectively. Bilobar involvement was observed in one case. Major and minor resections were performed in 2 (18%) and 9 (81%) cases, respectively. The median tumour size was 3 cm. Tumours measuring >5 cm were identified in only 2 (18%) cases. The majority of the cases were classified as stage I (54%) and stage II (36%). Four patients died 11-50 months after the surgery. Postoperative tumour recurrences were observed in 5 (45.45%) patients within 4 years of surgical resection. The overall 1- and 3-year survival rates in this series were 80% and 69.3%. Our series demonstrated cases of CHCC-CC with more favourable pathological traits and survival outcomes compared with similar studies.