Silk suture granuloma with false-positive findings on PET/CT accompanied by peritoneal metastasis after colon cancer surgery

IntroductionSuture granuloma is a rare benign tumor caused by suture material, which usually appears several months or years after surgery.Presentation of caseA 71-year-old man underwent sigmoidectomy and partial hepatectomy (S6) for sigmoid colon cancer and synchronous liver metastasis at a previous hospital. At 4 postoperative months, surveillance computed tomography (CT) revealed a suspicious tumor at the hepatic resection stump. He was referred to our hospital for further examinations and treatments. Positron emission tomography/CT (PET/CT) revealed abnormal hepatic F-18 fluorodeoxyglucose (FDG) uptake below the diaphragm at the S5/S8 surface. Peritoneal metastasis was suspected and surgery was performed. White nodules were found in the Douglas pouch. A diagnosis of adenocarcinoma was confirmed by frozen section analysis of the nodules. He underwent a partial hepatectomy (S5/S8) and partial resection of the diaphragm. Pathological examination showed that the liver tumor was a foreign body granuloma that included silk suture material.DiscussionAlthough postoperative PET/CT surveillance is useful following malignant tumor resection, it is important to note that PET/CT false-positive findings are possible. Furthermore, PET/CT cannot detect small peritoneal metastases, necessitating a thorough abdominal examination.ConclusionIn cases of malignancy, the possibility of postoperative suture granuloma should be considered. In addition, a thorough surgical examination of the abdomen should be performed in cases of suspected recurrence.     

Near-infrared fluorescence-guided metastasectomy for hepatic gastrointestinal stromal tumor metastases using indocyanine green: A case report

Introduction and importanceGastrointestinal stromal tumors are the most prevalent mesenchymal tumors of the gastrointestinal tract. Distant metastases are most often found in the liver or peritoneum with surgery being the preferred treatment option. In our center, fluorescence-guided surgery with indocyanine green is used as standard-of-care for hepatic metastases in colorectal cancer. This case report describes fluorescence-guided metastasectomy for a hepatic gastrointestinal stromal tumor in two patients undergoing open liver resection and radiofrequency ablation.Case presentationA 69-year old women was seen during follow-up after laparoscopic resection of a GIST in the lesser curvature of the stomach. Contrast-enhanced computed tomography imaging showed two suspicious lesions in liver segment VI and VIII. Intraoperative near-infrared fluorescence imaging of the liver clearly revealed the lesion in segment VIII, and an additional lesion in segment V – which was not seen on preoperative CT-imaging, neither on intraoperative ultrasonography. The lesion in segment VI was not seen with NIRF imaging due to its deeper location in the liver parenchyma. The second case is an 82-year old man who was also diagnosed with liver metastases from a GIST in the stomach and was scheduled for near-infrared fluorescence-guided liver resection and radio frequency ablation.Clinical discussionIn this case report we demonstrated the feasibility of fluorescence-guided surgery in detection of liver metastases and treatment planning of two patients with hepatic GIST metastases using indocyanine green.ConclusionNIRF-imaging with ICG is useful for identification of preoperatively discovered lesions, surgical resection planning and margin evaluation, and for detection of additional hepatic GIST metastases.     

Ante situm liver resection with inferior vena cava replacement under hypothermic cardiopolmunary bypass for hepatoblastoma: Report of a case and review of the literature

IntroductionHepatoblastoma with tumour thrombi extending into inferior-vena-cava and right atrium are often unresectable with an extremely poor prognosis. The surgical approach is technically challenging and might require major liver resection with vascular reconstruction and extracorporeal circulation. However, which is the best surgical technique is yet unclear.Presentation of caseA 11-months-old boy was referred for a right hepatic lobe mass(90 × 78 mm) suspicious of hepatoblastoma with tumoral thrombi extending into the inferior-vena-cava and the right atrium, bilateral lung lesions and serum alpha-fetoprotein level of 50.795 IU/mL. After 8 months of chemotherapy (SIOPEL 2004-high-risk-Protocol), the lung lesions were no longer clearly visible and the hepatoblastoma size decreased to 61 × 64 mm. Thus, ante situm liver resection was planned: after hepatic parenchymal transection, hypothermic cardiopulmonary bypass was started and en bloc resection of the extended-right hepatic lobe, the retro/suprahepatic cava and the tumoral trombi was performed with concomitant cold perfusion of the remnant liver. The inferior-vena-cava was replaced with an aortic graft from a blood-group compatible cadaveric donor. The post-operative course was uneventful and after 8 months of follow-up the child has normal liver function and an alpha-fetoprotein level and is free of disease recurrence with patent vascular graft.ConclusionsWe report for the first time a case of ante situ liver resection and inferior-vena-cava replacement associated with hypothermic cardiopulmonary bypass in a child with hepatoblastoma. Herein, we extensively review the literature for hepatoblastoma with thumoral thrombi and we describe the technical aspects of ante situm approach, which is a realistic option in otherwise unresectable hepatoblastoma.     

Evaluation of washout using subtraction MRI for the diagnosis of hepatocellular carcinoma in cirrhotic patients with spontaneously T1-hyperintense nodules

PurposeThe purpose of this study was to assess the value of subtraction imaging on post-arterial phase images (i.e., portal venous, delayed/transitional and hepatobiliary phases) for the non-invasive diagnosis of hepatocellular carcinoma (HCC) in spontaneously hyperintense nodules on T1-weighted imaging in patients with cirrhosis.Materials and methodsForty-five patients with a total 55 hepatic nodules that were spontaneously hyperintense on T1-weighted images were initially retrieved. All patients underwent MRI examination of the liver using extracellular agent. Each nodule was assessed for sensitivity and specificity using LI-RADS (Liver Imaging Reporting and Data System) during two reading sessions performed first without then with subtraction images on post-arterial phase images. The final standard of reference was defined by a step-by-step algorithm previously published combining histology, typical imaging, alfa fetoprotein and follow-up.ResultsForty-six nodules (26 HCC) in 39 patients with cirrhosis were analyzed. Using LI-RADS, the sensitivity and specificity for the diagnosis of HCC were 64% (95% CI: 41–83) and 67% (95% CI: 41–87) without subtraction; and 73% (95% CI: 50–89) (P > 0.999) and 33% (95% CI: 13–59) (P = 0.553) on subtraction imaging using extracellular contrast agent. Fifty-five percent (22/40) of nodules displayed a washout without subtraction and 70% (28/40) did so on subtraction imaging obtained with extracellular contrast agent. Twenty nodules out of 40 (50%) were classified LI-RADS 5 without subtraction, and 28 out of 40 nodules (70%) with subtraction.ConclusionThe results of this study suggest that the use of subtraction imaging on post-arterial phase images (i.e., PVP, DP/TP and HBP) is not relevant for the non-invasive diagnosis of HCC for spontaneously hyperintense nodules on T1-weighted images in patients with liver cirrhosis.     

Usefulness of Contrast-Enhanced Intraoperative Ultrasonography (CE-IOUS) in Patients with Colorectal Liver Metastases after Preoperative Chemotherapy

Aims

The aim of this study was to evaluate the ability of contrast-enhanced intraoperative ultrasonography to detect colorectal liver metastases after preoperative chemotherapy compared with intraoperative ultrasound and preoperative imaging techniques.

Methods

From January 2010 to December 2011, 28 patients with colorectal liver metastases underwent intraoperative ultrasonography and contrast-enhanced intraoperative ultrasonography during hepatectomy following preoperative chemotherapy. The findings were compared to preoperative imaging using contrast-enhanced ultrasonography, computed tomography, magnetic resonance imaging, and/or fluorodeoxyglucose positron emission tomography.

Results

Preoperative imaging techniques detected 58 metastatic lesions in 28 patients. In 32 % of patients (n?=?9), intraoperative ultrasound detected 24 missed hepatic nodules. In 14 % of patients (n?=?4), contrast-enhanced intraoperative ultrasonography detected an additional six nodules and change in operative management occurred in 18 % of patients. Using univariate analysis, we found three factors significantly related to detection of additional metastases with contrast-enhanced intraoperative ultrasonography: three or more metastases before chemotherapy (p?=?0.047), resolution of at least one metastasis (p?=?0.011), and small liver metastases (largest lesion size ≤20 mm) after chemotherapy (p?=?0.007).

Conclusion

In patients undergoing surgery for colorectal liver metastases after chemotherapy, contrast-enhanced intraoperative ultrasonography improved both the sensitivity of intraoperative ultrasonography to detect liver metastases and the R0 hepatic resection rate.     

Predictive model for microvascular invasion of hepatocellular carcinoma among candidates for either hepatic resection or liver transplantation

BackgroundMicrovascular invasion is the strongest prognostic factor of survival in patients with hepatocellular carcinoma. We therefore developed a predictive model for microvascular invasion of hepatocellular carcinoma to help guide treatment strategies in patients scheduled for either hepatic resection or liver transplantation.MethodsPatients with hepatocellular carcinoma who underwent hepatic resection or liver transplantation from 1994 to 2016 were divided into training and validation cohorts. A predictive model for microvascular invasion was developed based on microvascular invasion risk factors in the training cohort and validated in the validation cohort.ResultsA total of 910 patients (425 having received hepatic resection, 485 having received liver transplantation) were included in the training (n = 637) and validation (n = 273) cohorts. Multivariate analysis identified α-fetoprotein ≥100 ng/mL (relative risk 3.05, P < .0001), tumor size ≥40 mm (relative risk 1.98, P = .0002), nonboundary hepatocellular carcinoma type (relative risk 1.91, P = .001), neutrophil-to-lymphocyte ratio (relative risk 1.86, P = .002), and aspartate aminotransferase (relative risk 1.53, P = .02) as associated with microvascular invasion. The estimated probability of microvascular invasion ranged from 17.0% in patients with none of these factors to 86.9% in the presence of all factors. This model achieved a C-index of 0.732 in the validation cohort. The 5-year overall survival of patients with ≥50% probability of microvascular invasion was poorer than that of patients with <50% probability (hepatic resection; 39.1% vs 61.2%, P < .0001, liver transplantation; 5-year overall survival, 54.8% vs 79.0%, P = .05).ConclusionThis model developed from preoperative data allows reliable prediction of microvascular invasion in candidates for either hepatic resection or liver transplantation.     

Pathologic correlation with near infrared-indocyanine green guided surgery for pediatric liver cancer

PurposeHepatoblastoma (HB) and hepatocellular carcinoma (HCC) are the most common primary malignant tumors of childhood. Intraoperative indocyanine green (ICG) administration with near-infrared imaging (NIR) has emerged as a surgical technology that can be used to assist with localization of pulmonary metastases secondary to HB; however, there has been limited application as an adjunct for resection of the primary liver tumor and assessment of extrahepatic disease.MethodsWe present 14 patients treated for HB, HCC, and malignant rhabdoid tumor at our institution with the use of intraoperative NIR-ICG guidance. All patients were treated with 0.2–0.75 mg/kg IV ICG, 48–96 h prior to surgery. Intraoperative NIR-ICG guided imaging was performed with several commercial devices.ResultsIntraoperative NIR-ICG guidance allowed pulmonary metastasectomy in five patients using thoracoscopy or thoracotomy allowing for visualization of multiple nodules not seen on preoperative imaging most of which were positive for malignancy. NIR-ICG guidance allowed for assessment of extrahepatic extension in three patients; an HCC patient with extrahepatic lymph node extension of disease, an HB patient with extrapulmonary thoracic recurrence in the diaphragm and chest wall, and a patient with tumor rupture at diagnosis with peritoneal nodules at the time of surgery. This technique was used to guide partial hepatectomy in 11 patients for which the technique enabled successful identification of tumor and tumor margins. Three patients had nonspecific staining of the liver secondary to decreased timing from ICG injection to surgery or biliary obstruction. NIR-ICG enabled resection of satellite HB lesions in three multifocal patients and confirmed a benign satellite lesion in two additional patients.ConclusionsIntraoperative use of NIR-ICG imaging during partial hepatectomy enabled enhanced identification and guidance for surgical resection of extrahepatic disease and multifocal liver tumors for the treatment of children with primary liver cancer.     

建立兔靠近腹主动脉VX2肝癌模型

目的建立兔邻近腹主动脉VX2肝癌模型,为高强度聚焦超声（HIFU）消融肝脏大血管旁肿瘤研究选择最佳建模时间点提供实验依据。方法采用手术直视下组织块包埋法对45只新西兰大白兔于肝门处接种VX2瘤块,接种后第14、21、28天行MRI,观察成瘤率、肿瘤体积和肿瘤一腹主动脉间距。结果接种后动物存活率为92．11％（41／45）,成瘤率为95．12％（39／41）。MRI示接种后第14天T2WI呈高信号,增强后VIBEFST1WI示肿瘤明显强化;第21天肿瘤T2WI呈高信号,肿瘤不均匀强化;第28天肿瘤边缘环形强化,中心无强化,肿瘤出现继发性坏死;肿瘤体积随时间逐渐增大,肿瘤一腹主动脉间距逐渐减小,差异均有统计学意义（P均〈0．05）。结论直视下组织块包埋法建立兔邻近腹主动脉VX2肝癌模型操作简单、重复性好、成功率高,肿瘤接种后21天为研究HIFU消融肝脏大血管旁肿瘤作用的最佳时间点。     

Recurrence at surgical margin following hepatectomy for colorectal liver metastases is not associated with R1 resection and does not impact survival

BackgroundResection margin status has traditionally been associated with tumor recurrence and oncological outcome following liver resection for colorectal liver metastases. Previous studies, however, did not address the impact of resection margin on the site of tumor recurrence and did not differentiate between true local recurrence at the resection margin and recurrence elsewhere in the liver. This study aimed to determine whether positive resection margins determine local recurrence and whether recurrence at the surgical margin influences long-term survival.MethodsClinicopathological data and oncological outcomes of patients who underwent curative resection for colorectal liver metastases between 2012 and 2017 at 2 major hepatobiliary centers (Bern, Switzerland, and Berlin, Germany) were assessed. Cross-sectional imaging following hepatectomy was reviewed by radiologists in both centers to distinguish between recurrence at the resection margin, defined as hepatic local recurrence, and intrahepatic recurrence elsewhere. The association between surgical margin status and location of tumor recurrence was evaluated, and the impact on overall survival was determined.ResultsDuring the study period, 345 consecutive patients underwent hepatectomy for colorectal liver metastases. Histologic surgical margins were positive for tumor cells (R1) in 63 patients (18%). After a median follow-up time of 34 months, tumor recurrence was identified in 154 patients (45%). Hepatic local recurrence was not detected more frequently after R1 than after R0 resection (P = .555). Hepatic local recurrence was not associated with worse overall survival (P = .436), while R1 status significantly impaired overall survival (P = .025). Additionally, overall survival was equivalent between patients with hepatic local recurrence and patients with any intrahepatic and/or extrahepatic recurrence. In patients with intrahepatic recurrence only, oncological outcomes improved if local hepatic therapy was possible (resection or ablation) in comparison to patients treated only with chemotherapy or best supportive care (3-year overall survival: 85% vs 39%; P < .0001).ConclusionThe incidence of hepatic local recurrence after hepatectomy for colorectal liver metastases is independent of R1 resection margin status. Additionally, hepatic local recurrence at the resection margin is not associated with worse overall survival compared with any other intra- or extrahepatic recurrence. Therefore, R1 status at hepatectomy seems to be a surrogate factor for advanced disease without influencing location of recurrence and thereby oncological outcome. This finding may support decision-making when extending the indication for surgery in borderline resectable colorectal liver metastases.     

Indeterminate Pulmonary Nodules Represent Lung Metastases in a Significant Portion of Patients Undergoing Liver Resection for Malignancy

Introduction

Despite detection on imaging before resection of hepatic malignancies, the natural history of indeterminate pulmonary nodules (IPN) is unknown. The objective of this study is to determine how often IPN detected on imaging before surgery for hepatic malignancies represent lung metastases.

Methods

Demographics, comorbidities, tumor characteristics, and surgical treatments of patients with pre-operative IPN who underwent liver resection and/or radiofrequency ablation for malignant diagnoses were reviewed.

Results

From 2000 to 2010, 90 patients with at least one IPN underwent liver resection or radiofrequency ablation for malignancy. Of these, 44 (48.9?%), 32 (35.6?%), and 14 (15.6?%) patients had colorectal cancer liver metastases (CRCLM), primary hepatobiliary malignancies (HB), and other cancers, respectively. The median number of IPN was 1. The median size was 4?mm. Twenty (22?%) patients had isolated lung recurrence after hepatic surgical therapy. Eighty percent occurred in the exact location of the pre-operative IPN. Isolated lung recurrence was more common among patients with CRCLM compared to those with HB and other cancers (42.9 vs. 9.4 vs. 14.3?%, p?=?0.004).

Conclusion

Pre-operatively detected IPN represent lung metastases in a substantial portion of patients undergoing surgery for hepatic malignancy. IPN are more likely to represent lung metastases in patients with CRCLM compared to those with primary HB and other cancers.     

临界可切除肝癌行肝动脉灌注化疗联合肝动脉栓塞术转化治疗的疗效

背景与目的 对于临界可切除的原发性肝癌,目前我国原发性肝癌诊疗指南（2022年版）推荐仍是肝动脉插管化疗栓塞术（TACE）、外科手术切除或系统抗肿瘤治疗。当前原发性肝癌的术前转化治疗已经取得了很大的进展,但对于具体转化治疗方案尚在探索中。本研究探讨临界可切除肝癌行FOLFOX方案的肝动脉灌注化疗（HAIC）联合肝动脉栓塞术（TAE）局部转化治疗的真实世界疗效。方法 收集2019年4月—2022年2月采用FOLFOX方案的HAIC联合TAE转化治疗的22例临界可切除（CNLC分期Ⅱb期）原发性肝癌患者的临床资料,根据改良实体瘤疗效评价（mRECIST）标准评估肿瘤客观缓解率（ORR）、疾病控制率（DCR）,分析转化手术切除率和术后标本的病理缓解率以及转化治疗后手术与未手术患者的预后情况。结果 22例患者均完成HAIC联合TAE治疗,主要不良反应包括上腹痛、低热、短期的肝功能损害等,但没有发生不可逆的严重并发症。转化治疗后,肿瘤ORR、DCR分别为63.6%、86.3%,但有3例（13.6%）患者出现肿瘤进展。转化治疗结束后14例患者行肝癌手术切除,转化手术切除率为63.6%,手术顺利,均能达到R₀切除,无术后死亡病例。术后病理检查有10例（71.4%）为主要病理缓解（MPR）,但无1例能达到完全病理缓解（CPR）。14例手术患者的无复发生存期平均为14.7个月;手术患者的总生存期明显优于未手术患者（22.7个月vs. 13.2个月,P=0.018）。结论 HAIC联合TAE转化治疗对于临界可切除肝癌具有良好的耐受性,是安全可行的,能取得较高ORR、DCR和转化手术切除率。虽然大多数术前转化治疗后能达到MPR,但CPR较低,手术切除仍是肝癌转化治疗后患者获得长期生存的关键。     

Liver Transplant for Adult Recurrent Hepatic Mesenchymal Hamartoma and a Feasible Treatment Modality: A Case Report and Literature Review

BackgroundAdult hepatic mesenchymal hamartoma (HMH) is an extremely rare hepatic tumor. Recurrence following complete resection is uncommon. Liver transplantation (LT) is described as a possible treatment option in nonresectable HMH.We conducted a systematic review investigating LT in adult HMH followed by a case report describing evidence of extensive recurrence following complete resection of large right-sided HMH requiring LT.Case ReportA 46-year-old woman with symptomatic large right-hepatic HMH underwent right hemi-hepatectomy with histologic evidence of complete resection. Two and a half years postresection, she presented with abdominal pain and distension; imaging revealed large multi-septated hepatic cystic lesions within the liver suggestive of extensive recurrence of disease with concerns of malignant sarcomatous transformation. After a multidisciplinary team discussion, the lesion was deemed unresectable and the patient was referred for LT. Findings on transplantation included giant multiple hepatic cystic lesions occupying the entire abdomen and histopathological analysis confirmed recurrent HMH with no malignancy.The 6-month follow-up was unremarkable with no signs of postoperative complications or rejection.ConclusionWe identified only 3 reported adult unresectable HMH cases in the English literature requiring LT, with good clinical outcome and no rejection on a 1-year follow-up. To our knowledge, we report the first recurrent HMH that required LT in the English literature. Current evidence suggests possible malignant sarcomatous transformation of those lesions.No guidelines exist on postresection surveillance for HMH; however, given their malignant potential, we suggest a benefit of imaging-based surveillance following HMH resection. Offering LT for nonresectable or recurrent HMH is a feasible treatment modality with a reported good outcome.     

Hepatic inflammatory pseudotumor: A case series

INTRODUCTIONInflammatory pseudotumor (IPT) is a rare lesion consisted of inflammatory and myofibroblastic cells. These lesions may be found in different organs. There are less than 300 described cases.PRESENTATION OF CASECase 1. 64-year-old cirrhotic male with a palpable epigastric mass. CT showed a lesion in liver segments 2 and 3 and left hepatic artery aneurism. Percutaneous embolization and wide spectrum antibiotics were tried, however the lesion grew. Left lateral hepatectomy was performed, and HIPT diagnosed. The patient died due to multiple organ dysfunction. Case 2. 30-year-old male with abdominal pain and fever. CT showed a hepatic hilar lesion. Surgical resection was performed after an ineffectual antibiotic trial, and HIPT was confirmed. The patient is doing well. Case 3. 73-year-old female with abdominal pain and fever. CT showed a 7 cm lesion in the left liver lobe. Unrewarding cancerous screening was performed, and unsuccessful antibiotic course was tried. Resection was performed, and HIPT diagnosed. The patient is doing well. Case 4. 50-year-old cirrhotic male with abdominal pain. CT showed a segment 6 lesion and portal vein thrombosis. Considering cancer as the first hypothesis and the MELD score of 9, segmentectomy was performed. HIPT was the final diagnosis. The patient died due to abdominal sepsis.DISCUSSIONHIPT is a lesion with a vast list of differential diagnosis. Antibiotics are the first line of therapy, although surgery is often necessary. Overall prognosis is good, although comorbidities may worsen it.CONCLUSIONHIPT is a rare and misleading entity.     

Additional Hepatocellular Carcinomas Undetectable before Surgery

The presence of small additional hepatocellular carcinomas (HCCs) undetectable before hepatic resection is a crucial topic for hepatic surgeons. We assessed the incidence of pathologically diagnosed multiple HCCs in 267 patients who underwent hepatic resection for HCC. Ninety-five additional HCC nodules were detected in 72 of the patients (27%). The survival rate of these 72 patients was significant worse than for the 195 with single nodular HCC (p= 0.0013). Twenty-one (22%) were detected before surgery, 29 (31%) during surgery, and 45 (47%) on pathologic examination after surgery. The mean nodule diameters for each group were 2.1, 1.0, and 0.9 cm, respectively (p < 0.0001). None of the 21 nodules detected before surgery was well differentiated, whereas 30 of the 74 nodules in the other two groups were well-differentiated. Although the mean nodule diameter of the well-differentiated HCC group was the smallest, there was no significant difference among the three groups assigned according to tumor differentiation (p= 0.2355). Altogether, 9 of 16 patients with additional nodules detected before surgery (56%) and 49 of 59 with additional nodules detected during or after surgery (88%) had cirrhosis of the liver. The odds ratio for detecting a new HCC nodule during or after surgery in the presence of cirrhosis was 5.444 (p= 0.0087). Improvement in the detection of small additional HCC nodules before and during surgery and meticulous follow-up after surgery are necessary for patients with cirrhosis. For patients without cirrhosis, surgical treatment may be performed according to the results of preoperative imaging studies.     

Management of a ruptured hydatid cyst involving the ribs: Dealing with a challenging case and review of the literature

IntroductionHydatid liver cysts can rupture into neighboring structures in 15–60% of patients, and most often involves the bile duct, the bronchi, and the peritoneal/pleural cavities. Rarely, chest or abdominal wall involvement occurs that are challenging to manage. This case report and literature review describes the management of patients with chest wall and rib invasion.Presentation of caseA 74-year-old woman, of Spanish origin, presented with right upper quadrant abdominal pain and tender localized swelling. On computer tomography (CT) assessment, the rupture of a hydatid cyst into the right anterior chest wall was identified. Partial involvement of the 10th and 11th rib were noted. The diagnosis was confirmed by a serological test. Surgical treatment involved a radical en bloc right hepatic resection together with resection of the involved ribs, diaphragm and subcutaneous tissue. Primary diaphragm and wall closures were performed. The postoperative course was uneventful with three weeks of albendazole treatment. CT follow-up at six months demonstrated the absence of recurrence.DiscussionComplete resection is the gold standard treatment of patients with hydatid cysts with the aim to remove all parasitic and pericystic tissues.ConclusionThe present report illustrates that an aggressive surgical en bloc resection is feasible and should be preferred for the treatment of hydatid cysts with rupture into the chest wall, even when the ribs are involved.     

CT引导下微波消融治疗肝癌术后复发的疗效分析

目的分析CT引导下微波消融治疗肝癌术后复发的应用价值。方法回顾性分析53例接受肝癌切除术后肝内结节型复发患者,共151个复发病灶;采用CT超引导下行经皮肝穿刺微波消融治疗,术后1个月复查肝功能、甲胎蛋白(AFP)、增强CT或MR,采用改良实体瘤治疗疗效评价标准评价肿瘤治疗疗效,观察患者术后并发症情况,随访患者疾病进展时间及生存时间。结果共完成93例次消融治疗,平均1.7次/例,其中完全有效33例(33/53,62.26%)、部分有效13例(13/53,24.53%),总有效率86.79%(46/53)。1例患者出现热损伤,2例术中出现胆心反射,1例伤口感染,1例术后腹腔出血。53例患者6个月、1年、2年生存率分别为88.68%(47/53)、56.60%(30/53)、20.75%(11/53),中位生存时间11.8个月,总的生存时间17.7个月。结论 CT引导下微波消融治疗肝癌术后结节型复发微创、安全、有效。     

Large mesenteric cyst mimicking an ovarian cyst in an 8-year-old: A case report

Introduction and importancePediatric mesenteric cysts, rare and usually benign intra-abdominal tumors, are a difficult preoperative diagnosis due to ambiguous clinical characteristics. The final diagnosis is typically established only during surgery or histological analysis.Case presentationAn 8-year-old female presented with five days of worsening abdominal pain, associated with nausea, vomiting, and fever, as well as vague tenderness in the right quadrants on examination. Computed tomography imaging showed a 10.5 × 8.7 × 7 cm abdominal mass, most suspicious for a cystic mass of ovarian origin. Upon diagnostic laparoscopy, a mesenteric cyst extending to the root of the mesentery was visualized and entirely resected after conversion to an exploratory laparotomy. Histopathological examination of both the cystic fluid and specimen suggest a benign mesenteric cyst.Clinical discussionAlthough mesenteric cysts are noticeably rare, it is important differential to consider in pediatric patients with non-specific symptoms like abdominal pain and distention, intestinal obstruction, or a palpable abdominal mass. Notably, these cysts can be managed successfully by complete surgical resection with an excellent outcome.ConclusionThis report recounts an interesting case of a large mesenteric cyst that mimicked an ovarian cyst in a pre-pubertal girl.     

Intraoperative indocyanine green-visualization in a difficult to localize central cholangiocarcinoma – A case report

Introduction and importanceNear infrared fluorescence imaging with indocyanine green (ICG) can facilitate the intraoperative tumour localization and therefore a complete resection. Cholangiocarcinoma is an aggressive tumour and complete resection improves the outcome. Therefore, it is necessary to localize the tumour exactly but the translation of the preoperative imaging into the intraoperative setting can be difficult based only on sonography, computed tomography or magnetic resonance imaging.Case presentation/clinical findings and investigations/interventions and outcomeIn this case a hepatic lesion suspicious for cholangiocarcinoma was discovered accidentally. Further diagnostics were unable to prove the diagnosis, therefore right hepatectomy was recommended and performed. Preoperatively ICG was administered and near infrared imaging was used intraoperatively clearly localizing the tumour, thus facilitating the resection. The intra- and postoperative course was uneventful.Relevance and impactThis case report supports the very promising intraoperative use of fluorescence imaging for the localization of superficial hepatic tumours. Timing and correct administration of ICG is important.     

Synchronous hepatic metastasis and metachronous Krukenberg tumor from advanced colon cancer. A case report with an unexpected disease-free survival

BackgroundIn the international literature we have never found a long survival in patients treated for a colon cancer with synchronous hepatic metastases and for a metachronous Krukenberg tumor.Presentation of caseA 46-year old woman for an advanced colon cancer with a synchronous hepatic metastases was subjected to a left hemicolectomy and a resection of liver segment V (R0 resection; T4N2bM1; stage IVa according AJCC 2010). After one year a CT of the abdomen revealed an expansive formation of the left ovary. The patient was subjected to a bilateral ovariectomy, hysterectomy and hiperthermic intraperitoneal chemotherapy (HIPEC). The patient, after several cycles of adjuvant chemotherapy, is disease-free 13 years after surgery.DiscussionTo our knowledge, in the literature there do not appear to be cases of such disease-free survival. The survival of patient despite the prognostic indexes is discussed. The authors discus the importance of an adequate surgical treatment especially for liver metastases simultaneously treated to colon cancer. The authors also focus on chemotherapy (FOLFOX and then FOLFIRI) performed in a pre-biological era. Furthermore, the degree to which the HIPEC may have had an impact is still unknown, although it seems to be the gold standard for the treatment of the microscopic peritoneal neoplastic remnant.ConclusionThe authors emphasize that the long term survival in colon cancer with hepatic and ovarian metastases is possible as long as it has an adequate surgical approach, a tailored chemotherapy and an intensive follow-up. Most likely new prognostic markers will have to be identified.     

Complex abdominal wall reconstruction after oncologic resection in a sequalae of giant omphalocele: A case report

IntroductionTrauma injuries and oncologic resection are common aetiologies of complex abdominal wall defect. Reconstruction of abdominal wall is an everlasting question for general, paediatric and reconstructive surgeons. The plethora of techniques, bioprosthetic and engineered tissues offer countless possibilities.Presentation of caseThe patient was a 28 years old woman, with past history of untreated giant liver omphalocele, admitted for a suspicious hepatic tumefaction without specific clinical signs. The thoraco abdominopelvic CT scan revealed lung metastasis and a bilobed left hepatic tumour. Pre-operative cytologic findings of mild differentiated hepatocellular carcinoma differed from the post-operative findings of hepatoblastoma. The full-thickness abdominal wall defect after a radical resection was reconstructed with a combined acellular dermal matrix, NPWT and skin graft solution. A total epithelization was obtained after 8 weeks follow-up.DiscussionHepatoblastoma in adult is rare, with no consensus. A radical resection in context of giant untreated omphalocele is an unusual challenge for the surgical team. The pre-operative evaluation, the defect classification and the general conditions of the patient are paramount steps for an appropriate reconstruction. Primary or delayed reconstruction with myocutaneous flap as gold standard, depends on the oncologic management and anticipated post-operative complications. Acellular dermal matrix used for a bridged fascial repair directly on viscera and covered by NPWT, favourited a healthy granulation tissue. The full-thickness defect was then reconstructed with an ADM, NPWT and skin graft instead of an association with the myocutaneous flap. The patient follow-up was emphasized in the hepatoblastoma, but the complications of this reconstruction strategy are unknown. A total epithelization was obtained, the abdominal bulge or hernia is the first complication under surveillance.ConclusionDelayed reconstruction after an oncologic large abdominal wall resection has the advantage to manage post-operative complications and prepare alternative solutions. Acellular dermal matrix was not first designed for skin tissue regeneration, some authors as us experimented the conclusion that this matrix could be used for permanent abdominal wall reconstruction.