Ante-situm Liver Resection for Giant Hepatic Tumour - Case Report and Review of Literature.

Ex-situ liver surgery refers to complex liver resections involving hepatic vascular exclusion and a warm ischemia time (WIT) of more than 90 minutes that allows liver resection and vascular reconstruction in patients with giant liver tumours with a difficult approach . Ante-situm liver resections, otherwise called "œex-situ in-vivo" resections is achieved through externalization of the liver outside of the abdominal cavity by clamping and sectioning of the efferent pedicles (suprahepatic veins) ("ex situ") without cutting the afferent vascular pedicle ("in vivo"), thus leaving the hepatic pedicle intact. We present a case report of a 36 yo male patient diagnosed by MRI scan with giant liver tumor in the left hemiliver. A left "ex-situ in-vivo" hepatectomy was performed by dissecting and ligating the left and middle hepatic veins, clamping and sectioning the right hepatic vein, Pringle maneuver, externalization of the liver followed by the tumor resection and right hepatic vein reimplantation. The short warm ischemia time (hepatic resection + liver reimplantation - 30 minutes) allowed us to perform the procedure without installing a veno-venous or porto-caval shunt otherwise used in all of ex-situ procedures described in the literature reviewed in this presentation. Ex-situ liver resection is a viable procedure for giant liver tumours in highly selected cases. It facilitates resection of large liver tumours that would be otherwise unresectable, extending the indications of surgical treatment.

Costs and efficacy of "on demand" low-dose immunoprophylaxis in HBV transplanted patients: experience in the Romanian program of liver transplantation.

BACKGROUND: HBV in liver transplant (LT) patients is associated with good outcomes and the challenges are primarily focused around optimizing prophylactic regimens with hepatitis B immune globulin (HBIG) and minimizing related costs. AIM: To identify recurrence rates in patients transplanted for HBV or HBV+HDV infection in whom a combined "on demand" low-dose HBIG was used, maintaining low anti-HBs titres (not below 50 IU/L). METHODS: Medical records of 42 patients transplanted for HBV or HBV+HDV induced cirrhosis between April 2000 and September 2007 at Fundeni Clinical Institute were analyzed. Patients received immunoprophylaxis with lamivudine and HBIG (10,000 IU within anhepatic phase and daily within the first postoperative week, followed by 2,500 IU on demand). HBV recurrence rates and survival during follow-up were evaluated using the Kaplan Meier method. RESULTS: HBV recurrence rate was 4.8% after a median of 1.8 years. Three year patient survival rate was 70%. None of the patients died due to liver failure related to HBV recurrence. Using our "on demand" low-dose administration of HBIG, the total mean cost for HBIG and lamivudine for patient per month of survival was 598.3 Eur. The projected monthly cost for the "ideal" schedule/patient was 2,017 Eur. CONCLUSION: Individualization of immunoprophylaxis after LT for HBV related disease according to the lowest protective anti-HBs titers in combination with lamivudine is probably the best approach for non-replicative pre-LT patients in terms of costs and efficacy.

Large multilocular serous cystadenoma of the pancreatic head.

We present the case of an 88-year-old female, investigated for upper abdominal pain and upper abdominal mass, exhibiting at the computed tomography a large tumour located in the head of the pancreas, compressing the common bile duct and with uncertain preoperative diagnosis (benign/malign). The histopathological findings of the operative specimen (cephalic pancreatoduodenectomy) revealed a large serous multilocular cystadenoma. There are presented the clinical, imaging and pathological correlations in the present case, also analysing the limits of the imaging preoperative diagnosis and indications for surgery in cystic tumours of the pancreas.

Adrenalectomy for metastases from hepatocellular carcinoma - a single center experience.

BACKGROUND: Adrenal metastases (AM) from hepatocellular carcinoma (HCC) are rarely seen in clinical practice. The treatment is not standardized, the indications and efficacy of different therapeutic approaches being still controversial. PATIENTS: Between January 1995 and December 2005, 174 patients underwent liver resection for HCC in our center. AM were detected in four patients (2.3%): three of them had HCC and synchronous AM, and the remaining one developed AM 10 months after liver resection. All the patients with AM were treated by adrenalectomy (simultaneously with liver resection in synchronous metastases), followed by systemic chemotherapy. Non-resectable multifocal liver recurrences occurred in two patients, one of them having also a contralateral adrenal metastasis; these two patients are presently alive 26 and 43 months after adrenalectomy, respectively. Another patient died by liver recurrence 27 months postoperatively. The fourth patient is disease-free at 17 months after the initial operation. CONCLUSIONS: Adrenalectomy for AM from HCC should be performed whenever the primary tumor is well therapeutically controlled and the patient has a good performance status. Adrenalectomy offers the chance of more than 2 years survival in many patients. However, once AM are detected, the prognosis remains poor.