Revisiting Quincke's Triad: A Case of Idiopathic Hepatic Artery Aneurysm Presenting with Obstructive Jaundice.

INTRODUCTION: Hepatic artery aneurysm (HAA) is a rare occurrence. Quincke's triad of hemobilia; abdominal pain, obstructive jaundice, and upper gastrointestinal (GI) bleeding could be detected in one-third of HAA patients. CASE PRESENTATION: We present a case of HAA with all signs of Quincke's triad and shock. The diagnosis of HAA was enforced by CT angiography. An urgent open surgical approach was elected by the surgical team. The patient underwent an uneventful resection of the HAA, and primary repair of the CHA followed with bilioenteric reconstruction. CONCLUSIONS: Recognizing the signs of Quincke's triad aids in prompt diagnosis of hemobilia in HAA, which suggests a rupture of the aneurysm or fistula formation into the biliary tree that would need urgent management by both vascular and HBP surgeons.

Evaluation of donor workups and exclusions in a single-center experience of living donor liver transplantation.

The process of evaluating potential donors in liver transplantation is important to ensure donor safety and provide optimal recipient outcomes. However, there has been no report about donor exclusion rates and reasons for such exclusion in Korea. In this study, we aimed to elucidate the outcomes of potential living liver donor evaluation in a major living donor liver transplantation center. From July 2011 to June 2015, prospectively collected data of 726 potential donors for 588 matched recipients were subsequently evaluated. Among 726 potential donors, 374 potential donors (51.5%) finally reached donation; 352 potential donors (48.5%) were excluded for various reasons. Donor reasons were 29.8%, including medical problems, withdrawal of consent, graft volume issues, and identification of a better suitable donor. Recipient reasons were 20.7%, including recipient death or recovery, allocation to deceased donor, and progressions of hepatocellular carcinoma. A total of 38 (5.2%) potential donors had a fatty liver. Among them, 15 (39.5%) potential donors tried short-term weight reduction and eventually were able to donate. In conclusion, the main reasons for donor exclusion were medical problems and withdrawal of consent. Therefore, thorough medical screening and careful examination for donor voluntarism are important in the donor evaluation process. Liver Transplantation 23 614-624 2017 AASLD.

Keep It or Leave It? Comparison of Preoperative Scoring as Mortality Predictor Post-Pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy (PD) is the common procedure in resectable periampullary malignancies. However, the postoperative mortality rate for PD is relatively high. Mortality scoring system helps surgeons to decide patients' eligibility for surgery to minimize mortality risk. This study aimed to compare four scoring systems for mortality prediction after PD in the Indonesian population. METHODS: In this cross-sectional study, data were retrospectively collected from medical records for patients who underwent PD due to periampullary malignancy between January 2010 and January 2022. We assessed scoring accuracy, cut-off, sensitivity, specificity, negative predictive value, positive predictive value, and area under the curve (AUC) of Naples prognostic score (NPS), Whipple-ABACUS (WA), modified Pitt score (MPS), and Pitt score. RESULT: Of the 116 patients who met the criteria, the mortality rate was 12.1%. Mean age was 51.64 ± 10.22 years consist of 75.9% group <60 years and 24.1% ≥60 years, with 46.6% male and 53.4% female. The AUC from highest to lowest were Pitt Score 0.890 (p<0.001), MPS 0.775 (p 0.001), WA 0.627 (p 0.123), and NPS 0.505 (p 0.949) with the level of accuracy of each score were Pitt Score and MPS 67.2%, WA 50.0%, and NPS 59.5%. CONCLUSION: Pitt and MPS scores have the highest accuracy of all the scoring systems in this study. MPS has the advantage of having fewer components, making it easy to implement. MPS can replace the role of the Pitt Score in predicting post-procedure PD mortality in Indonesia. Further studies that include the intraoperative factors are needed to increase the scoring accuracy.

Challenging retrovesical mass in men: report of a rare liposarcoma case with concurrent COVID-19 infection.

We describe a case of retrovesical liposarcoma in a male patient with concurrent COVID-19. A 50-year-old man had lower urinary tract symptoms and dull pain along his right gluteus. Due to COVID-19 infection, management was delayed. During self-isolation, the patient developed urinary retention and his pain level was an eight on the Visual Analogue Scale. A urinary catheter and an epidural catheter were inserted without any difficulty. Abdominal-pelvic MRI revealed a retrovesical mass suspected of liposarcoma with clear borders from surrounding organs. Following two consecutive negative SARS-CoV-2 PCR tests, we proceeded with surgery. Histopathology was dedifferentiated liposarcoma. Postoperatively, the patient suffered reactivation of COVID-19, and he was eventually discharged after two consecutive negative results on the PCR test on Post Operative Day (POD)-10. Retrovesical dedifferentiated liposarcoma is rare and considered as high-grade liposarcoma. Although surgery may exacerbate COVID-19 infection, surgical resection of symptomatic high-grade sarcoma is prioritised and performed as soon as no infection detected.

Local adaptation of laparoscopic smoke evacuator in COVID-19 pandemic situation.

The pandemic of COVID-19 has been a game changer in many aspects of medical care, including laparoscopic surgery service. Uncertainty in the early pandemic has led to the fear of doing laparoscopic surgery with regard to the possibility of SARS-COV-2 transmission through surgical smoke. We carried out laparoscopic surgery during the COVID-19 pandemic with intention to test our local adaptation of a laparoscopic smoke evacuator. Twenty-five laparoscopic cases for digestive surgery were performed with uneventful results. In summary, a low cost local adaptation of laparoscopic smoke and safe surgical behavior should be the standard of care when delivering laparoscopic surgery service in the pandemic era and forward.

Delivery of digestive surgery services during the COVID-19 pandemic: Indonesian Society of Digestive Surgeons online survey.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, digestive surgery potentially exposes both health-care professionals and vulnerable patients to COVID-19. A survey was conducted with aim to determine the digestive surgery services provided during the COVID-19 pandemic, optimize safety for patients and clinicians, and safeguard health-care services. METHODS: An online survey was conceived and circulated to members of the Indonesian Society of Digestive Surgeons. The survey was conducted in two phases, in April 2020 and July 2020, to evaluate changes in response to the COVID-19 pandemic. RESULTS: Early in the pandemic (April 2020), the median number of major digestive surgeries performed monthly declined from 20 cases (range. 3-100 cases) to 1 case (range. 0-10 cases) (P < .001; Wilcoxon signed-rank test). Most of the cases in April 2020 addressed emergency problems, but more definitive surgeries were performed during the later period of the survey. The importance of screening for COVID-19 with polymerase chain reaction has increased over time, and a more comprehensive screening methodology incorporating real-time polymerase chain reaction, chest CT, and rapid antibody test were evident in 31.37% of July 2020 responses. CONCLUSION: Our survey has shown that surgeons adapted to the evolving pandemic and continue to do so only with appropriate safety assurances.

Adrenal metastasis in sequentially developed combined hepatocellular carcinoma-cholangiocarcinoma: A case report.

The incidence of combined hepatocellular carcinoma-cholangiocarcinoma (cHCC-CC) in a single patient accounts for only 0.4 to 14% of all primary liver cancer. However, the prognosis of its intrahepatic cholangiocarcinoma (ICC) component is poor. We experienced a unique case of a sequentially developed cHCC-CC with adrenal metastasis as the primary presentation and a hidden primary hepatocellular carcinoma. A 65-year-old female with a history of jaundice and abdominal discomfort was diagnosed with S4 ICC measuring 5 cm in diameter, and characterized histologically as papillary adenocarcinoma with intraductal growth, but without any evidence of malignant hepatocyte. S4 segmentectomy with hepaticojejunostomy revealed no additional masses. A follow-up CT scan 3 months after surgery showed a right adrenal mass with markedly increased serum AFP (4950 ng/mL), which was treated with right adrenalectomy. Histopathology revealed a metastatic hepatocellular carcinoma testing positive for AFP, glypican-3, and hepatocytes, but negative for CD-10, inhibin-α, EMA, S-100, and cytokeratin-7. Serum AFP level immediately plummeted to 4.1 ng/mL upon adrenal mass removal. A recurrent S7 liver mass was suspected 1 year later with serum AFP value of 7.6 ng/mL, and characteristic CT imaging of HCC. TACE was performed with good response. Adrenal metastasis may manifest as the primary focus of hepatocellular carcinoma in sequentially developed cHCC-CC patients with hidden primary HCC. cHCC-CC should be considered in the differential diagnosis of cholangiocarcinoma with elevated AFP.