Surgical Management of Giant Hepatic Haemangioma - Need for Redefining the Nomenclature According to the Size

Introduction: Haemangiomas are the most common benign tumours of the liver. Most of them are asymptomatic. Giant hepatic haemangioma is defined as size greater than 5 cm in diameter. The surgical treatment for giant hepatic haemangioma is not very well defined and reported. Here we analysed the treatment outcome of giant hepatic haemangiomas and redefined the nomenclature according to the size and proposing an algorithm for management of all hepatic haemangiomas. Material and Methods: Retrospective analyses of 6 giant hepatic haemangioma more than 10 cm in size treated by a single surgeon were included. The clinical characteristics, diagnosis, managements and outcomes were recorded. Review of literature was done for definitions, management strategies and outcome of giant haemangiomas and an algorithm was proposed. Results: Five patients were female and the mean age was 36.6 years (range 32 to 45). Pain abdomen was the most common symptoms (100%). Ultrasound abdomen was the initial diagnostic modality followed by contrast enhanced computed tomography. The mean size of haemangioma was 17.4cm (range 12cm to 32cm). Four patients had haemangioma in the left lobe and two had in the right lobe of liver. Formal hepatectomy was done in three patients and enucleation was done in three patients. The mean operating time was 3.66 hours (range 2.5 hours to 5 hours). The mean blood loss was 840ml (range 300ml to 1500ml). There was no surgical morbidity or mortality. On follow-up no haemangioma related complications are reported. Conclusions: Giant hepatic haemangioma is mostly symptomatic. Hepatectomy and enucleation can be done without significant morbidity and mortality. There is a need for redefining the nomenclature of giant hepatic haemangiomas according to the size

Stent Endarterectomy and patch closure of occluded infrarenal aortic bare metal stent for critical limb ischemia

The technological advances in the field of percutaneous procedures have facilitated the increased use of endovascular modalities for peripheral arterial disease management with benefit of decreased morbidity. Progression of disease in this group of patients has further led to the rise of difficult-to-manage group of patients. We report a case of occluded bare metal infrarenal aortic stent, which was managed by stent endarterectomy of the stent-bearing segment of aorta followed by repair of aortic segment with patch aortoplasty. The patient is doing fine at 8 months of follow-up. This case describes the feasibility of the management of occluded aortic stents placed for occlusive disease by endarterectomy with explantation of stents as revascularization procedure in good-risk patients for surgery

Primary Leiomyosarcoma of Gallbladder: A Rare Diagnosis

Leiomyosarcoma of the gallbladder is a rare entity, constituting about 1.4 per 1000 gallbladder malignancies. Literature review shows female preponderance in sixth decade of life, due to unknown reasons. We report one such rare case of a 50-year-old female admitted with pain in right upper abdomen. On examination, mass was felt in right hypochondrium. The ultrasound abdomen showed mass with loss of interface with liver and cholelithiasis. CECT abdomen showed polypoidal gallbladder malignancy with ill-defined interface with liver. She was operated upon with diagnosis of carcinoma gallbladder; extended cholecystectomy was done. Histopathological examination revealed spindle-cell proliferation and possibility of malignant tumor of mesenchymal origin was kept. This was later confirmed on immunohistochemistry

Dysphagia Aortica: Diagnostic Dilemma and Therapeutic Paradigm

Objective: Intrinsic esophageal pathologies constitute prime cause for dysphagia clinically. However, thoracic esophageal domain is prone to extrinsic compression by various vascular afflictions including aneurysms with attendant therapeutic challenges. Herein, we present a case series of dysphagia aortica with emphasis on its appropriate management option based on grade of dysphagia. Methods: Patients who presented to the vascular division of our tertiary care referral institute between January 2014 and October 2015 with dysphagia due to extrinsic esophageal compression by aneurysmal thoracic aorta form the basis for this report. Prior to referral, all patients were evaluated elsewhere to rule out intrinsic causes and computed tomography angiogram performed delineating aortic aneurysm in four patients and penetrating aortic ulcer in one. Patient cohort included one female and four male patients whose age ranged from 40 to 68 years, with a median of 62 years. Left posterolateral thoracotomy provided access to an aneurysm which was repaired using interposition polyester graft in four patients. Due to severe comorbidities which precluded open surgery, one patient who presented with mild dysphagia was managed by endovascular stent graft repair. Results: Degree of dysphagia was assessed between grades 0 and 4 as in literature. All patients, including four open conventional and one endovascular, recovered well and left hospital totally symptom free. Conclusion: Dysphagia due to vascular diseases in the thoracic domain is an uncommon clinical entity. Patients with thoracic aortic aneurysm presenting with severe dysphagia deserve open surgical repair to provide optimal symptomatic relief in addition to saving life. The state-of-the-art endovascular stent grafting may be considered in very elderly patient having severe comorbidities presenting with mild dysphagia

Hybrid Strategy for Residual Arch and Thoracic Aortic Dissection following Acute Type A Aortic Dissection Repair

Progressive dilatation of the false lumen in the arch and descending aorta has been encountered in one-third of survivors as a late sequelae following repair of ascending aortic dissection. Conventional treatment for the same requiring cardiopulmonary bypass and deep hypothermic circulatory arrest is associated with high morbidity and mortality especially in the elderly cohort of patients. Herein we report a case of symptomatic progressive aneurysmal dilatation of residual arch and descending thoracic aortic dissection following repair of type A aortic dissection, successfully treated by total arch debranching and ascending aortic prosthesis to bicarotid and left subclavian bypass followed by staged retrograde aortic stent-graft deployment. This case report with relevant review of the literature highlights this clinical entity and the present evidence on its appropriate management strategies. Close surveillance is mandatory following surgical repair of type A aortic dissection and hybrid endovascular procedures seem to be the most dependable modality for salvage of patients detected to have progression of residual arch dissection