Retromesenteric Omental Flap for Complete Arterial Coverage During Pancreaticoduodenectomy: Surgical Technique

Postoperative pancreatic fistula is a frequent complication of pancreaticoduodenectomy that can trigger arterial lesions resulting in post-pancreatectomy hemorrhage (PPH) in up to 10-15% of cases. We describe an original omental flap technique including mobilization of the greater omentum through the retromesenteric window allowing coverage of all exposed peripancreatic arteries before reconstruction. This technique, used in 146 patients, did not carry any specific morbidities except for one case of partial flap necrosis treated conservatively and was associated with a significant reduction in grade B/C PPH

Hepatic Vein (HV) Reconstruction (HVR) for Liver Tumors Involving Hepatocaval Confluence (HCO) Is Safe and Feasible to Achieve R0 Resection

Purpose: Surgical resection remains the cornerstone treatment for liver tumors. Local recurrence risk is determined by surgery radicality which forces significant parenchymal sacrifice or R1 resection in case of vascular involvement. Jump-graft between intra-parenchymal origin and superior stump HVR might be necessary to preserve remnant liver adequate outflow when radical surgery requires a resection at HCo. Methods: Monocentric retrospective analysis of intraoperative data and outcomes in 16patients who underwent HVR(2018-2021) was performed. After tumor dissection under ultrasound control, proximal and distal HV stumps were clamped and involved hepatocaval segment resected in single block. Reconstruction was performed by interposition of vascular graft between both stumps. Results: Patients presented with different conditions: liver metastasis (n=13), intrahepatic cholangiocarcinoma (n=1), hepatocellular carcinoma (n=2). Non-frozen ABO-compatible venous homograft (n=12), autologous peritoneal patch/tube (n=3), autologous veins (n=1) were used as jump-grafts. Median HV clamping duration was 63min(54-90min). Pedicular clamping was only performed when HVR was associated to IVC replacement(n=2). Double HVR was also performed (n=3). HVR patency at day7 was 94%(15/16), at 3months 81%(13/16). Median blood loss was 1100ml(837-1700ml), R0 resection was achieved in 13/16(81%). Severe morbidity (Clavien III-IV) reached 25%(4/16). Small for size syndrome was null. Day90 mortality was null. Conclusion: In our series, R0 resection rate was high as well as early and late graft patency. Morbi-mortality was acceptable. HVR technique allows replacement of a single or double HV without significant bleeding nor need for pedicle clamping (if not associated to IVC replacement). Therefore, HVR should be considered as a realistic option in parenchymal-sparing strategy or radical surgery

Ex-vivo liver resection and autotransplantation (ELRA) for inferior vena cava (IVC) leiomyosarcoma : expanding surgical limits for oncological resection, a case report

Ex-situ liver resection and autotransplantation (ELRA) for inferior vena cava (IVC) leiomyosarcoma extending in right atrium ; stretching surgical limits for oncological resection. A 84-years patient was referred to our institution for abdominal mass suspicious for sarcoma. She suffered from dysphagia, nausea, epigastralgy, bilateral lower limbs oedema and dyspnea (NYHA grade 2) rapidly degrading. She was in excellent general condition (ECOG 0) without relevant past medical history. Thoraco-abdominal scanner revealed a 15 x 5 x 5 cm mass originating from retrohepatic IVC, invading cavo-hepatic confluence with a intracaval thrombus protruding in right atrium for 2 cm without any metastasis. IVC leiomyosarcoma was diagnosed on biopsy. After consultation of multidisciplinary sarcoma board, a surgical indication was retained gived the quickly evoluting symptomatology and excellent general status. Under veno-venous extracorporeal circulation, a sterno-laparotomy was performed consisting in a right nephrectomy for exposure and en-bloc complete liver resection with retrohepatic IVC after atriotomy for intra-cardiac thrombus exraction. Tumorectomy (retrohepatic IVC + segment I) was performed on back table. Native IVC was reconstructed with a double tubulized graft originating from heterologous iliac vein confluence and bovine pericardium. A second tubulized heterologous venous patch was used for reconstruction of retrohepatic IVC ; permitting a side-to-side cavo-caval anastomosis for liver reimplantation. Post-operative evolution was marked by a pyelonephritis, treated by antibiotics and a disabling gastroparesia, spontaneously et slowly resolving. Patient was discharged on post-operative day 32. Pathological examination confirmed diagnosis of a 16 x 5 cm IVC leiomyosarcoma, pT4N0L0Pn0 R0. 3 months after surgery, general status was conserved with disappearance of symptoms. CT scanner revealed no recurrence and a permeable IVC reconstruction

Successful emergency resection of a massive intra-abdominal hemophilic pseudotumor.

An intra-abdominal pseudotumor is a rare complication of hemophilia. Surgical treatment is associated with high morbidity and mortality rates and reported cases are scarce. We present a 66-year-old Caucasian male suffering from severe hemophilia type A treated for 10 years with Factor VIII. Major complications from the disease were chronic hepatitis B and C, cerebral hemorrhage and disabling arthropathy. Twenty-three years ago, retro-peritoneal bleeding led to the development of a large intra-abdominal pseudotumor, which was followed-up clinically due to the high surgical risk and the lack of clinical indication. The patient presented to the emergency department with severe sepsis and umbilical discharge that had appeared over the past two days. Abdominal computed tomography images were highly suggestive of a bowel fistula. The patient was taken to the operating room under continuous infusion of factor VIII. Surgical exploration revealed a large infected pseudotumor with severe intra-abdominal adhesions and a left colonic fistula. The pseudotumor was partially resected en bloc with the left colon leaving the posterior wall intact. The postoperative period was complicated by septic shock and a small bowel fistula that required reoperation. He was discharged on the 73(rd) hospital day and is well 8 mo after surgery. No bleeding complications were encountered and we consider surgery safe under factor VIII replacement therapy

Gastric Perforation due to Giant Trichobezoar in a 13-Year-Old Child

Trichotillomania and trichotillophagia can cause the formation of enormous intragastric hairballs. We report the case of a 13-year-old girl who was brought to the emergency service for evaluation of an acute abdomen. Abdominal CT scanner showed a giant gastric trichobezoar which had to be removed by susombilical laparotomy and transverse gastrotomy. This case illustrates the fairly uncommon perforation risk of these gastric bezoars

Ventral Primary Hernia with Liver Content

Background. Herniation of the liver through the anterior abdominal wall is an extremely rare phenomenon. Most cases occur within an incisional hernia (mostly upper abdomen surgery or cardiac surgery). Only two reports mentioned liver herniation without previous abdominal incision. Case Presentation. We report the case of a 70-year-old woman presenting an epigastric swelling. Radiological findings showed a liver herniation in a primary ventral hernia. This case is the first to have been described requiring semiurgent hernia repair associated with partial liver resection. Conclusion. This case is, to the best of our knowledge, the first case of primary ventral hernia with liver content necessitating wedge resection of the left liver lobe

Retromesenteric omental flap as arterial coverage in pancreaticoduodenectomy: A novel technique to prevent postpancreatectomy hemorrhage.

Clinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant postoperative pancreatic fistula. Prevention of postpancreatectomy hemorrhage by arterial coverage with a round ligament plasty or an omental flap is controversial. This study assessed the impact of arterial coverage with an original retromesenteric omental flap on postpancreatectomy hemorrhage after pancreaticoduodenectomy. This single-center retrospective study included 812 open pancreaticoduodenectomies (2012-2021) and compared 146 procedures with arterial coverage using retromesenteric omental flap to 666 pancreaticoduodenectomies without arterial coverage. The Fistula Risk Score was calculated. The primary endpoint was a 90-day clinically relevant postpancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery classification. There were more patients with a Fistula Risk Score ≥7 in the arterial coverage-retromesenteric omental flap group: 18 (12%) versus 48 (7%) (P < .01). Clinically relevant postpancreatectomy hemorrhage was less frequent in the arterial coverage- retromesenteric omental flap group than in the no arterial coverage group: 5 (3%) versus 66 (10%), respectively (P = .01). Clinically relevant postoperative pancreatic fistula occurred in 28 (19%) patients in the arterial coverage- retromesenteric omental flap group compared with 165 (25%) in the no arterial coverage group (P = .001). There were fewer reoperations for postpancreatectomy hemorrhage or postoperative pancreatic fistula in the arterial coverage- retromesenteric omental flap group: 1 (0.7%) versus 32 (5%) in the no arterial coverage group (P = .023). In multivariate analysis, arterial coverage with retromesenteric omental flap was an independent protective factor of clinically relevant postpancreatectomy hemorrhage (odds ratio 0.33; 95% confidence interval [0.12-0.92], P = .034) whereas postoperative pancreatic fistula of any grade (odds ratio = 10.1; 95% confidence interval: 5.1-20.3, P < .001) was predictive of this complication. Arterial coverage with retromesenteric omental flap can reduce rates of clinically relevant postpancreatectomy hemorrhage after pancreaticoduodenectomy. This easy and costless technique should be prospectively evaluated to confirm these results

Distal pancreatectomy for pancreatic neoplasia: is splenectomy really necessary? A bicentric retrospective analysis of surgical specimens.

While distal pancreatectomy with splenectomy (DPS) is the reference treatment for pancreatic body and tail neoplasia, oncological benefits of splenectomy have never been demonstrated. Involvement of spleen, splenic hilum and lymph nodes (LN) was therefore assessed on DPS specimens. All DPS pancreatic neoplasia specimens obtained in 2 Brussels University Hospitals over 15 years (2004-2018) were reviewed retrospectively, using both preoperative radiological imaging and postoperative pathological analyses of splenic parenchyma, hilar tissue and LN. The total of 130 DPS specimens included 85 adenocarcinomas, 37 neuroendocrine neoplasms and 8 other carcinomas. Tumours involved the pancreatic body without tail invasion for 59 specimens (B, Body group), and the pancreatic tail with/without body for 71 (T, Tail group). At pathology, direct splenic and/or hilar involvement was observed in 13 T specimens (13/71, 18.3%), but in none belonging to the Body group. The observed numbers of splenic hilar LN (only reported in 49/130 patients) were low, only one T adenocarcinoma had positive splenic LN in addition to direct splenic involvement. Splenectomy remains justified during pancreatectomy for neoplasia involving the pancreatic tail, but in case of pancreatic body tumours, its benefits should be questioned in the light of absent splenic LN/parenchymal involvement