Two-Stage Liver Transplantation with Temporary Porto-Middle Hepatic Vein Shunt

Two-stage liver transplantation (LT) has been reported for cases of fulminant liver failure that can lead to toxic hepatic syndrome, or massive hemorrhages resulting in uncontrollable bleeding. Technically, the first stage of the procedure consists of a total hepatectomy with preservation of the recipient's inferior vena cava (IVC), followed by the creation of a temporary end-to-side porto-caval shunt (TPCS). The second stage consists of removing the TPCS and implanting a liver graft when one becomes available. We report a case of a two-stage total hepatectomy and LT in which a temporary end-to-end anastomosis between the portal vein and the middle hepatic vein (TPMHV) was performed as an alternative to the classic end-to-end TPCS. The creation of a TPMHV proved technically feasible and showed some advantages compared to the standard TPCS. In cases in which a two-stage LT with side-to-side caval reconstruction is utilized, TPMHV can be considered as a safe and effective alternative to standard TPCS

Laparoscopic resection vs laparoscopic radiofrequency ablation for the treatment of small hepatocellular carcinomas: A single-center analysis

AIM To compare survival and recurrence after laparoscopic liver resection (LLR) and laparoscopic radiofrequency ablation (LRFA) for the treatment of small hepatocellular carcinoma (HCC). METHODS Between June 1, 2005 and November 30, 2010, 46 patients (62.26 \ub1 8.55 years old; female/male: 12/34) treated for small HCC were enrolled following strict criteria. Patients with better liver function and larger tumors were referred for LLR (n = 24), while those with poorer liver function and multiple tumors were referred for LRFA (n = 22), and they were then followed for similar durations (44.74 \ub1 21.3 mo for LLR vs 40.27 \ub1 30.8 mo for LRFA). RESULTS The LLR and LRFA groups were homogeneous with regard to age, sex, etiology of liver cirrhosis, and AFP levels. The overall survival (OS) and disease- free survival (DFS) probability was 0.354 and 0.260, respectively. A significantly higher OS was observed in the LLR group (LLR: 0.442; LRFA: 0.261; P = 0.048), whereas no statistical difference was found for DFS (LLR: 0.206; LRFA: 0.286; P = 0.205). In the LRFA group was treated a greater number of nodules (LLR: 1.41 \ub1 0.77; LRFA: 2.72 \ub1 1.54; P < 0.001). Cox regression analysis found the number of intraoperative HCC nodules as the unique variable statistically significant for OS (hazard ratio: 2.225; P < 0.001). The rank-hazard plot showed a steeper increase of relative hazard for intraoperative nodules > 2. CONCLUSION Our preliminary results confirm the superiority of hepatic resection on thermoablation in the treatment of small HCC in selected patients, when both approaches are made laparoscopically. LLR showed better results compared to LRFA in terms of OS. These data need to be confirmed by further studies on a larger number of patients

The procedure outcome of laparoscopic resection for ′small′ hepatocellular carcinoma is comparable to vlaparoscopic radiofrequency ablation

Background: The aim of this study was to compare the effectiveness of laparoscopic liver resection (LLR) and laparoscopic radiofrequency ablation (LRFA) in the treatment of small nodular hepatocellular carcinoma (HCC). Patients and Methods: We enrolled 50 cirrhotic patients with similar baseline characteristics that underwent LLR (n = 26) or LRFA (n = 24), in both cases with intraoperative ultrasonography. Operative and peri-operative data were retrospectively evaluated. Results: LLR included anatomic resection in eight cases and non-anatomic resection in 18. In LRFA patients, a thermoablation of 62 nodules was achieved. Between LLR and LRFA groups, a significant difference was found both for median diameters of treated HCC nodules (30 vs. 17.1 mm; P < 0.001) and the number of treated nodules/patient (1.29 ± 0.62 vs. 2.65 ± 1.55; P < 0.001). A conversion to laparotomy occurred in two LLR patient (7.7%) for bleeding. No deaths occurred in both groups. Morbidity rates were 26.9% in the LLR group versus 16.6% in the LRFA group (P = 0.501). Hospital stay in the LLR and LRFA group was 8.30 ± 6.52 and 6.52 ± 2.69 days, respectively (P = 0.022). The surgical margin was free of tumour cells in all LLR patients, with a margin <5 mm in only one case. In the LRFA group, a complete response was achieved in 90.3% of thermoablated HCC nodules at the 1-month post-treatment computed tomography evaluation. Conclusions: LLR for small peripheral HCC in patients with chronic liver disease represents a valid alternative to LRFA in terms of patient toleration, surgical outcome of the procedure, and short-term morbidity

Successful Transplant of a Liver Graft After Giant Hepatic Artery Aneurysm Resection and Reconstruction

The shortage of organs has pushed transplant surgeons to accept liver grafts with extended criteria, but severe vascular abnormalities may still discourage the use of otherwise acceptable organs. We report herein the case of a liver graft with a 64-mm aneurysm of the proper hepatic artery extended to the origin of the right and left hepatic branches. The graft was deemed unsuitable for transplant by all other centers in the region. However, liver function tests were normal, and there was no evidence of compromised arterial supply. At back table, we resected the aneurysm and anastomosed the right and left hepatic arteries to a vascular graft obtained from the distal tract of the donor's superior mesenteric artery. After portal reperfusion, we anastomosed the mesenteric graft to the recipient's hepatic artery at the origin of the gastroduodenal artery. The postoperative course and the subsequent 6-month follow-up were uneventful. In conclusion, the presence of a hepatic artery aneurysm should not be an absolute contraindication to the use of a liver graft. The present case emphasizes the possibility to utilize an organ that would have been otherwise discarded

Pitfalls and fatal complications after iterative endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography management of biliary tract cysts. When to do open surgery (cyst resection; hepaticojejunostomy) or liver transplant?

Biliary tract cysts are a group of rare congenital diseases that have been classified by Todani in 8 types. Hepaticojejunostomy has been the preferred intervention for Type I and IV biliary cysts. It has been postulated that, due to the low incidence of cancerization of Types II and III biliary cysts, a less invasive approach could be suggested, namely cyst resection in Type II, and endoscopic sphincterotomy with opening of choledochocele in small (<3 cm) Type III cysts from old patients. Moreover, Caroli disease has been proposed to be treated by percutaneous biliary drainages. The aim of the present study is to propose the therapeutics strategies to follow for the management of biliary tract cysts, in case of failure of percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP). From 2008 to May 2014, three patients with congenital biliary tract cysts were followed. Two patients were found to be affected by bilateral liver Caroli disease and another young patient was found to be affected by a Type III biliary cyst (choledochocele). Patients affected by Caroli disease presented cholangitis, jaundice and fever and have been submitted to PTC. PTC, after an initial brief relief of the symptoms, failed in both cases. One of these patients with recurrent post PTC cholangitis was then successfully treated by orthotopic liver transplant. The other patient affected by Caroli disease died after multiple PTC. The young patient affected by choledochocele suffered from pancreatitis and jaundice and was submitted to ERCP. Endoscopic resection of choledochocele was followed by hemorrhagia and a fatal fungal sepsis. Minimally invasive approaches have been widely used in the management of biliary tract cysts. Diffuse bilateral Caroli disease of the liver can be initially managed by percutaneous drainage but if cholangitis recurs, in our opinion, it is useful to consider an open surgery procedure such as orthotopic liver transplant. Type III biliary cyst (choledococele) can be managed by ERCP if patient is old and the cyst is small (<3 cm) but when the cyst is larger than 3 cm, symptomatic, and the patient is young, one approach to take into consideration is open duodenostomy with choledochocele resection and reimplantation of the common bile and of Wirsung ducts into the duodenal mucosa

Coherent THz Emission Enhanced by Coherent Synchrotron Radiation Wakefield

Abstract We demonstrate that emission of coherent transition radiation by a ∼1 GeV energy-electron beam passing through an Al foil is enhanced in intensity and extended in frequency spectral range, by the energy correlation established along the beam by coherent synchrotron radiation wakefield, in the presence of a proper electron optics in the beam delivery system. Analytical and numerical models, based on experimental electron beam parameters collected at the FERMI free electron laser (FEL), predict transition radiation with two intensity peaks at ∼0.3 THz and ∼1.5 THz, and extending up to 8.5 THz with intensity above 20 dB w.r.t. the main peak. Up to 80-µJ pulse energy integrated over the full bandwidth is expected at the source, and in agreement with experimental pulse energy measurements. By virtue of its implementation in an FEL beam dump line, this work promises dissemination of user-oriented multi-THz beamlines parasitic and self-synchronized to EUV and x-ray FELs