Major Hepatectomy En Bloc with Cava Vein Resection for Locally Invasive Caudate Lobe Hepatocarcinoma.

BACKGROUND/AIM: Locally advanced liver tumours with vascular invasion have been considered for a long period of time as unresectable lesions, so the patient was further deferred to oncology services for palliation. However, improvement of the surgical techniques and the results reported so far came to demonstrate that extended hepatic and vascular resections might be safely performed in such cases and might significantly improve the long-term outcomes. MATERIALS AND METHODS: A 61-year-old patient was diagnosed with a caudate lobe tumour invading the inferior cava vein and the right hepatic pedicle. RESULTS: The patient was successfully submitted to surgery, and an extended right hepatectomy en bloc with cava vein resection was performed; the continuity of the cava vein was re-established by the placement of a synthetic graft. The postoperative outcome was uneventful. CONCLUSIONS: Although initially considered as a formal contraindication for resection, vascular invasion of the greater vessels should not preclude surgery if complete resection is achievable.

Right Hepatic Artery Aneurysm with Aneurysm-Choledochal Fistula.

66-year-old patient, investigated for jaundice, weight loss, imaging on CT scan with partially thrombosed right hepatic artery aneurysm - compressive effect on the common hepatic canal causing dilation of intrahepatic bile ducts and intimate adhesion to the anterior wall of the portal vein with significant inflammation at this level. Left hepatic artery accessory from the left gastric artery. The embolization of the right hepatic artery with detachable spirals of 5 mm / 20 cm is practiced. Subsequent arteriographies demonstrate occlusion of the aneurysm without repermeabilization of the left hepatic artery. Internalized external biliary drainage is practiced. Control arteriography demonstrates revascularization of the right hepatic lobe in the left hepatic artery, but associating the repermeabilization of the aneurysmal sac in the left hepatic artery. Surgery is decided. Resection of the aneurysm with segmental resection of the portal vein, with T-T anastomosis by interposition of cadaveric venous graft. (video article https://www.revistachirurgia.ro/pdfs/video/voluminos-anevrism-artera-hepatica-2281.mp4).

Distal Pancreatectomy En Bloc With Splenectomy, Celiac Axis and Portal Vein Resection Followed by Arterial Reconstruction Using a Cadaveric Graft - A Case Report and Literature Review.

BACKGROUND/AIM: Locally advanced pancreatic body tumors invading the celiac axis and the portal vein have been considered since long as unresectable lesions; however, due to improvement of surgical techniques, in certain cases surgery with curative intent might be taken in consideration. CASE REPORT: We present the case of a 48-year-old female investigated for epigastric pain that was diagnosed with a locally invasive pancreatic body tumor. The patient was submitted to computed tomography which revealed the presence of a locally advanced pancreatic tumor with no demarcation line with the celiac axis and the portal vein. The endoscopic ultrasound raised the suspicion of malignancy and retrieved a biopsy which demonstrated the presence of a pancreatic adenocarcinoma. The patient was submitted to surgery, distal pancreatectomy en bloc with splenectomy, celiac axis and portal vein resection was performed; the hepatic artery was reconstructed by placing a cadaveric graft while the portal vein was sutured per primam by an end to end anastomosis. The postoperative outcome was favorable, and the patient was discharged in the 10th postoperative day. CONCLUSION: Multiple vascular resections followed by reconstructions might be needed in order to achieve resection with negative margins in patients with pancreatic body tumors.

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.