Pleurobiliary fistula, a rare complication of hepatocellular carcinoma after locoregional chemotherapy: a case report

A rare complication of the compilation of high intrahepatic biliary pressure and the formation of a subdiaphragmatic abscess is that of pleurobiliary fistula. We present a case of 67-year-old male who presented with pleurobiliary fistula following transarterial chemoembolization in a patient with a large hepatocellular carcinoma, as well as the course of the diagnostic procedures and the therapeutics interventions which took place

Revascularization approaches in patients with radiation-induced carotid stenosis: an updated systematic review and meta-analysis

Background: Ionizing radiation remains a well-known risk factor of carotid artery stenosis. The survival rates of head and neck cancer patients undergoing radiotherapy have risen owing to medical advancements in the field. As a consequence, the incidence of carotid artery stenosis in these high-risk patients has increased.Aims: In this study we sought to compare the outcomes of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) for radiation-induced carotid artery stenosis.Methods: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Eligible studies were identified through a comprehensive search of PubMed, Scopus and Cochrane Central until July 2020. A random-effects model meta-analysis was conducted, and odds ratios (ORs) were calculated. The I-square statistic was used to assess for heterogeneity.Results: Seven studies and 201 patients were included. Periprocedural stroke, myocardial infarction (MI), and death rates were similar between the two revascularization approaches. However, the risk for cranial nerve (CN) injury was higher in the CEA group (OR, 7.40; 95% CI, 1.58–34.59; I2 = 0%). Analysis revealed no significant difference in terms of long-term mortality (OR, 0.41; 95% CI, 0.14–1.16; I2 = 0%) and restenosis rates (OR, 0.69; 95% CI, 0.29–1.66; I2 = 0%) between CEA and CAS after a mean follow-up of 40.5 months.Conclusions: CAS and CEA appear to have a similar safety and efficacy profile in patients with radiation-induced carotid artery stenosis. Patients treated with CEA have a higher risk for periprocedural CN injuries. Future prospective studies are warranted to validate these results

Obstructive Jaundice in Polycystic Liver Disease Related to Coexisting Cholangiocarcinoma

Although jaundice rarely complicates polycystic liver disease (PLD), secondary benign or malignant causes cannot be excluded. In a 72-year-old female who presented with increased abdominal girth, dyspnea, weight loss and jaundice, ultrasound and computed tomography confirmed the diagnosis of PLD by demonstrating large liver cysts causing extrahepatic bile duct compression. Percutaneous cyst aspiration failed to relief jaundice due to distal bile duct cholangiocarcinoma, suspected by magnetic resonance cholangiopancreatography (MRCP) and confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Coexistence of PLD with distal common bile duct cholangiocarcinoma has not been reported so far

Liver transplantation for severe hepatic trauma: Experience from a single center

Liver transplantation has been reported in the literature as an extreme intervention in cases of severe and complicated hepatic trauma. The main indications for liver transplant in such cases were uncontrollable bleeding and postoperative hepatic insufficiency. We here describe four cases of orthotopic liver transplantation after penetrating or blunt liver trauma. The indications were liver failure, extended liver necrosis, liver gangrene and multiple episodes of gastrointestinal bleeding related to portal hypertension, respectively. One patient died due to postoperative cerebral edema. The other three patients recovered well and remain on immunosuppression. Liver transplantation should be considered as a saving procedure in severe hepatic trauma, when all other treatment modalities fail

Superior Mesenteric Artery Dissection after Extracorporeal Shockwave Lithotripsy

The use of shockwave lithotripsy is currently the mainstay of treatment in renal calculosis. Several complications including vessel injuries have been implied to extracorporeal shockwave lithotripsy. We report an isolated dissection of the superior mesenteric artery in a 60-year-old male presenting with abdominal pain which occurred three days after extracorporeal shockwave lithotripsy. The patient was treated conservatively and the abdominal pain subsided 24 hours later. The patient's history, the course of his disease, and the timing may suggest a correlation between the dissection and the ESWL

Hepatic resection for hepatocellular carcinoma exceeding Milan criteria

Background: Many hepatocellular carcinomas (HCCs) are discovered at an advanced stage. The efficacy of transplantation for such tumors is doubtable. The aim of this retrospective study was to determine liver resection efficacy in patients with large HCC regarding long term and disease-free survival. Methods: Between 2002 and 2008, sixty six patients with large HCC (>5 cm) underwent hepatectomy. Fifty nine patients had background cirrhosis due to hepatitis B, C or other reason and preserved liver function (Child A). Liver function was assessed by both Child’s-Pugh grading and MELD score. Conventional approach of liver resection was performed in most cases. Results: The 5-year overall survival was 32% with a median follow up of 33 months. The three year disease-free survival was 33% in our cohort. On multivariate analysis, only tumor size and grade remained independent predictors of adverse long term outcome. Multivariate analysis identified size of the primary tumour and degree of differentiation as risk factors for recurrence. Median blood loss was 540 ml and median transfusion requirements were two units of pack red blood cells. Morbidity included pleural effusion (n = 18), biliary fistula (n = 4), peri-hepatic abscess (n = 4), hyperbilirubinemia (n = 3), pneumonia (n = 5) and wound infection (n = 6). No peri-operative mortality was reported in our study. Conclusion: Partial hepatectomy is safe in selective patients with large HCC. Surgical resection if feasible is suggested in patients with large HCC because it prolongs both overall and disease-free survival with low morbidity. (C) 2009 Elsevier Ltd. All rights reserved

Postoperative Cardiac Damage After Standardized Carotid Endarterectomy Procedures in Low- and High-Risk Patients

Background: We conducted a comparison of postoperative cardiac damage, defined as cardiac troponin I (cTn-I) elevation, after carotid endarterectomy in low- and high-risk patients. Methods: The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) criteria for stratifying patients considered for carotid endarterectomy into low and high surgical risk groups were used prospectively. All patients had preoperative full cardiologic evaluations and cTn-I value assessments that were repeated on postoperative days 1, 3, and 7. Postoperative cTn-I values ranging from 0.05 to 0.5 ng/mL were classified as myocardial ischemia; values >0.5 ng/mL were classified as myocardial infarction. Results: Mortality was 1.2%, the stroke rate was null, and symptomatic myocardial infarction was null. Among the 56 high-risk patients, 8 had cTn-I values >0.5 ng/mL. Among the 106 low-risk patients, 10 patients had cTn-I value >0.5 ng/mL and 4 patients had cTn-I values that were >0.05 ng/mL and <= 0.5 ng/mL. All patients with increased cTn-I levels were asymptomatic. Concerning all patients, the mean preoperative cTn-I value was 0.007 ng/mL, which increased to 0.438 ng/mL on postoperative day 1 (P = 0.017), 0.168 ng/mL on postoperative day 3 (P = 0.06), and 0.019 ng/mL on postoperative day 7 (P = 0.02). In the high-risk group, the mean preoperative cTn-I value was 0.008 ng/mL, which increased to 0.829 ng/mL on postoperative day 1, 0.270 ng/mL on postoperative day 3, and 0.030 ng/mL on postoperative day 7. In the low-risk group, the mean preoperative cTn-I value was 0.007 ng/mL, which increased to 0.198 ng/mL on postoperative day 1, 0.119 ng/mL on postoperative day 3, and 0.013 ng/mL on postoperative day 7. Patients without cardiac damage showed analogous tendencies in their troponin values. Comparison of troponin values between high- and low-risk patients on each day showed no statistical difference. Electrocardiogram alterations were seen in 20 of the 22 patients with asymptomatic troponin elevation but in none without troponin elevation. Conclusions: Carotid endarterectomy is followed by an increase in cTn-I value >0.5 ng/mL in 14% of all cases, although symptomatic cardiac ischemia is very low. However, high-risk patients as defined by the SAPPHIRE criteria do not show an increased risk of cardiac damage compared to low-risk patients. Larger studies using cTn-I as a marker of postoperative cardiac damage, after carotid endarterectomy or stenting, are needed

Hepatic parenchyma resection using stapling devices: peri-operative and long-term outcome

AbstractBackgroundStapler-assisted hepatectomy has not been well established, as a routine procedure, although few reports exist in the literature. This analysis assesses the safety and outcome of the method based on peri-operative data.Materials and MethodsFrom February 2005 to December 2006, endo GIA vascular staplers were used for parenchymal liver transection in 62 consecutive cases in our department. There were 18 (29%) patients with hepatocellular carcinoma (HCC), 31 (50%) with metastatic lesions and 13 (21%) with benign lesions [adenoma, focal nodular hyperplasia (FNH), simple cysts]. Twenty-one patients underwent major resections (33.9%) (i.e. removal of three segments or more) and 41 (66.1%) minor hepatic resections.ResultsMedian blood loss was 260ml. The median total operative time was 150min and median transection time was 35min. No patient required more than 2 days of intensive care unit (ICU) treatment. The median hospital stay was 8 days. Surgical complications included two (3%) cases of bile leak, two (3%) cases of pneumonia, two (3%) cases with wound infection and two (3%) cases with pleural effusion. The peri-operative mortality was zero. In a 30-month median follow-up, all patients with benign lesions were alive and free of disease. The 3-year disease-free survival for patients with HCC was 61% (57% for patients with colorectal metastases) and the 3-year survival 72% (68% for patients with colorectal metastases).ConclusionStapler-assisted liver resection is feasible with a low incidence of surgical complications. It can be used as an alternative for parenchyma transection especially in demanding hepatectomies for elimination of the operating time and control of bleeding

Hepatic resection for large hepatocellular carcinoma in the era of UCSF criteria

Background: Treating patients with hepatocellular carcinoma (HCC) remains a challenge, especially when the disease presents at an advanced stage. The aim of this retrospective study was to determine the efficacy of liver resection in patients who fulfil or exceed University of California San Francisco (UCSF) criteria by assessing longterm outcome. Methods: Between 2002 and 2008, 59 patients with large HCC (>5 cm) underwent hepatectomy. Thirty-two of these patients fulfilled UCSF criteria for transplantation (group A) and 27 did not (group B). Disease-free survival and overall survival rates were compared between the two groups after resection and were critically evaluated with regard to patient eligibility for transplant. Results: In all patients major or extended hepatectomies were performed. There was no perioperative mortality. Morbidity consisted of biliary fistula, abscess, pleural effusion and pneumonia and was significantly higher in patient group B. Disease-free survival rates at 1, 3 and 5 years were 66%, 37% and 34% in group A and 56%, 29% and 26% in group B, respectively (P < 0.01). Survival rates at 1, 3 and 5 years were 73%, 39% and 35% in group A and 64%, 35% and 29% in group B, respectively (P = 0.04). The recurrence rate was higher in group B (P = 0.002). Conclusions: Surgical resection, if feasible, is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. In patients eligible for transplantation, resection may also have a place in the management strategy when waiting list time is prolonged for reasons of organ shortage or when the candidate has low priority as a result of a low MELD (model for end-stage liver disease) score