Hemobilia caused by a ruptured hepatic cyst: a case report

<p>Abstract</p> <p>Introduction</p> <p>Hemobilia is a rare cause of upper gastrointestinal bleeding. More than 50% of hemobilia cases are related to iatrogenic trauma from hepatobiliary procedures, and needle biopsy of the liver represents the most common cause. A minority of hemobilia cases are due to hepatobiliary disorders such as cholangitis, hepatobiliary cancers, choledocholithiasis, and vascular abnormalities in the liver. The classic presentation of hemobilia is the triad of right upper quadrant (biliary) pain, obstructive jaundice, and upper gastrointestinal bleeding. We report a rare case of hemobilia caused by a spontaneous hepatic cyst rupture, where our patient presented without the classical symptoms, in the absence of therapeutic or pathological coagulopathy, and in the absence of spontaneous or iatrogenic trauma.</p> <p>Case presentation</p> <p>A 91-year-old African-American woman was referred to our out-patient gastroenterology clinic for evaluation of mild epigastric pain and intermittent melena. An abdominal computed tomography scan was remarkable for multiple hepatic cysts. Esophagogastroduodenoscopy revealed multiple blood clots at the ampulla of Vater. Endoscopic retrograde cholangiopancreatography showed a single 18 mm-sized filling defect in the common hepatic duct wall at the junction of the right and left hepatic duct, adjacent to one of the hepatic cysts. The ruptured hepatic cyst communicated to the bile ducts and was the cause of hemobilia with an atypical clinical presentation.</p> <p>Conclusion</p> <p>Hemobilia is an infrequent cause of upper gastrointestinal bleeding and rarely occurs due to hepatic cyst rupture. To the best of our knowledge, this is only the second case report in the literature that describes hemobilia due to hepatic cyst rupture. However, it is the first case in the literature of hemobilia due to hepatic cyst rupture in the absence of iatrogenic or spontaneous trauma, and in the absence of a spontaneous or pathological coagulopathy.</p

Liver transplantation for neuroendocrine tumour liver metastases

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Liver resection and transplantation for metastases from gastroenteropancreatic neuroendocrine tumors

Around 60% of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) present liver metastases (NELM), which highly impact on prognosis. Treatment options for NELM mainly depend on the liver disease burden. In this review we propose a treatment algorithm for NELM with disease extension within the interest of liver resection (LR) and liver transplantation (LT). Preliminary resection of the primary and all the extrahepatic disease eases the access to liver-directed treatments and possibly confers a prognostic advantage. Solitary and oligometastatic disease deemed resectable with a conventional surgical commitment should be treated by LR. Despite the prognostic advantage of LR as compared to non-surgical options (80% 5-year overall survival [OS]) and the potential for cure, LR is burdened by high rates of recurrence (40% 5-year recurrence-free survival [RFS]). Neoadjuvant strategies by systemic and locoregional therapies may improve patient selection, especially in cases of borderline resectable NELM. In such patients, the oncological advantage of LR should be weighed against the high surgical risks and has to be preceded by a risk-benefit assessment. In young patients (&lt;55 years) with G1/G2 unresectable NELM limited to &lt;50% of the liver and no extrahepatic disease (Milan-NET criteria), LT may be considered. Patient selection is instrumental for good long-term outcomes (89% 10-year OS). The survival benefit increases over time with respect to non-transplant options. For patients exceeding the Milan-NET criteria, locoregional treatments can downstage the disease and occasionally allow LT. In G3 NETs and in cases not responding to liver-directed treatments, a systemic approach is usually warranted; debulking surgery can be considered in syndromic patients

Influence of surgical margins on outcome in patients with intrahepatic cholangiocarcinoma: a multicenter study by the AFC-IHCC-2009 study group

OBJECTIVE: Define the optimal surgical margin in patients undergoing surgery for intrahepatic cholangiocarcinoma (IHCC). BACKGROUND DATA: Surgery is the most effective treatment for IHCC. However, the influence of R1 resection on outcome is controversial and that of margin width has not been evaluated. METHODS: We studied 212 patients undergoing curative resection of mass-forming-type IHCC. The respective influences on survival of resection status (R0 vs R1), surgical margin width, pTNM stage, and the latter's components were evaluated. RESULTS: Incidence of R1 resection was 24%. Overall, R1 resection was not an independent predictor of survival [odds ratio (OR) 1.2 (0.7-2.1)] in contrast to the pTNM stage [OR 2.10 (1.2-3.5)]. In the 78 pN+ patients, survival was similar after R0 and R1 resections (median: 18 vs 13 months, respectively, P = 0.1). In the 134 pN0 patients, R1 resection was an independent predictor of poor survival [OR 9.6 (4.5-20.4)], as was the presence of satellite nodules [OR 1.9 (1.1-3.2)]. In the 116 pN0 patients with R0 resections, median survival was correlated with margin width ( 641 mm: 15 months; 2-4 mm: 36 months; 5-9 mm: 57 month; 6510 mm: 64 month, P 5 mm was an independent predictor of survival [OR 2.22 (1.59-3.09)]. CONCLUSION: Patients undergoing surgery for IHCC are at high risk of R1 resections. In pN0 patients, R1 resection is the strongest independent predictor of poor outcome and a margin of at least 5 mm should be created. The survival benefits of resection in pN+ patients and R1 resection in general are very low