Replaced right and common hepatic arteries with lienogastric trunk: a rare variant of celiaco-mesenteric anatomy.

We report a rare variant in mesenteric arterial anatomy: replacement of the right hepatic and common hepatic arteries to the SMA in a patient treated for hepatocellular carcinoma. The potential clinical implications of this unusual variation of celiaco-mesenteric anatomy will be discussed.

Hepatocellular carcinoma: From diagnosis to treatment.

Primary liver cancer is the sixth most common cancer overall and the second most common cause of cancer mortality worldwide. Hepatocellular carcinoma accounts for up to 90% of all primary hepatic malignancies and represents a major international health problem. While surgical resection and transplantation are the cornerstone of therapy in early-stage hepatocellular carcinoma, locoregional therapy and sorafenib are beneficial in those with more advanced disease or those who are not surgical candidates. At times, the integration of both surgical and locoregional therapy may be necessary. Hence, hepatocellular carcinoma requires a multidisciplinary approach to determine the most appropriate treatment as well as the timing of various treatments for optimal outcomes.

The importance of surgical margins in primary malignancies of the liver.

Resection is an important treatment modality for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Anatomic resection is generally preferred for HCC. When anatomic resection is not feasible, prospective data have demonstrated an improved outcome among HCC patients who have a resection with wide versus narrow surgical margins. Similarly, among patients with ICC, R1 resection has been associated with worse outcomes. In addition, margin width may also impact risk of recurrence and survival. As such, provided adequate functional liver remnant remains, anatomic resection with wide margins is recommended for HCC and ICC.

Role of Locoregional and Systemic Approaches for the Treatment of Patients with Metastatic Neuroendocrine Tumors.

Although gastroenteropancreatic neuroendocrine tumors are often perceived as being indolent tumors, more than half of the patients will harbor liver metastases at the time of diagnosis. Gastroenteropancreatic neuroendocrine tumors have the potential to be aggressive and resistant to therapy, making the integration of both locoregional and systemic therapy even more critical in the treatment of patients with locally advanced or metastatic lesions. Over the last several years, significant advancements have been made in the surgical treatment, liver-directed therapy, and medical management of gastroenteropancreatic neuroendocrine tumors. While surgical resection is the cornerstone of therapy, cytoreductive surgery, orthotopic liver transplantation, local ablation, and intra-arterial therapy all improve the prognosis of patients suffering with locally advanced or metastatic disease. In addition, great strides have been made in the medical management of gastroenteropancreatic neuroendocrine tumors, particularly with the evolution of novel molecular targeted therapy, such as everolimus and sunitinib. Hence, gastroenteropancreatic neuroendocrine tumor is becoming a disease process requiring more of a multi-disciplinary approach with the integration of both locoregional and systemic therapies for improved outcomes.

Ex vivo lung perfusion allows successful transplantation of donor lungs from hanging victims.

BACKGROUND: Donor lungs acquired from victims of asphyxiation by hanging are not routinely used for lung transplantation because of the associated lung injury. Ex vivo lung perfusion (EVLP) is a technique to evaluate marginal donor lungs before transplantation. We report here our experience with the use of EVLP in donor lungs procured from victims of asphyxia by hanging. METHODS: Lungs from 5 donors who became brain dead secondary to hanging were evaluated by EVLP. Donor organs were perfused according to trial protocol. Donor lungs were accepted for transplantation if they maintained a PaO2 greater than or equal to 350 mm Hg, had a clear roentgenogram, and had no significant worsening of physiologic metrics. RESULTS: Perfused organs included single and double lung blocs, and all were perfused without technical incident. Three of the 5 donor organs evaluated met criteria for transplantation after 3 hours of EVLP and were transplanted. Donor organs rejected for transplantation showed either signs of worsening PaO2 or deterioration of physiologic metrics. There were no intraoperative complications in the patients who underwent transplantation, and all were alive at 30 days. CONCLUSIONS: We report here the successful use of EVLP to assess donor lungs acquired from victims of asphyxiation by hanging. The use of EVLP in this particular group of donors has the potential to expand the available donor pool. We demonstrate that EVLP is a viable option for evaluating the function of lung allografts before transplantation and would recommend that all donor lungs obtained from hanging victims undergo EVLP to assess their suitability for transplantation.