Agustín Cristiano

Focal nodular hyperplasia and hepatic adenoma: current diagnosis and management

Benign liver tumors are common lesions that can be classified into cystic and solid lesions. Cystic lesions are the most frequent; however, they rarely represent a diagnostic or therapeutic challenge. In contrast, solid lesions are more difficult to characterize and management remains controversial. The wide availability and use of advanced imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging have led to increased identification of incidental liver masses. Although some of these incidentally discovered masses are malignant, most are benign and must be included in the differential diagnosis. In this article we review FNH and HA. Its etiology, biological behavior, diagnosis, and treatment will be highlighted.

Ante‐situm resection: a novel approach to avoid extracorporeal circulation using a transient portacaval shunt

Hepatic tumours located at the hepatocaval confluence or compromising the inferior vena cava (IVC) are not often resectable using conventional techniques. To overcome this problem, different surgical procedures have been described. Ex-vivo resection techniques provide excellent accessibility to tumours placed around the IVC that otherwise would be unresectable. These ex-vivo techniques include in-situ, ante-situm and ex-situ resections. The in-situ technique performs hypothermic perfusion of the liver, with cross-clamping but without sectioning of the vena cava and the hepatic pedicle. The ante-situm approach also includes hypothermic perfusion, with cross-clamping of the major vessels and division of the suprahepatic IVC for complete exposure of the liver, preserving the hepatic artery and biliary tree. And finally, the ex-situ technique requires cross-clamping and division of the major vessels for complete removal of the liver, allowing a bench procedure before re-implantation of the organ. The two main problems regarding ex-vivo procedures are the low hepatic tolerance to warm ischaemia and the splanchnic congestion secondary to vascular exclusion. Hypothermic hepatic perfusion and veno-venous bypasses, frequently used in classic ex-vivo resections, are two well-known strategies to avoid these complications. This report describes a novel technique of ante-situm resection using an in-vivo veno-venous bypass between the portal vein and the IVC with a cadaveric venous graft in a patient with IVC replacement. Case

Enucleación laparoscópica de una neoplasia intraductal papilar mucinosa de ramos periféricos localizada en la cabeza del páncreas. Una nueva alternativa

The surgical strategy for treating intraductal papillary mucinous neoplasm (IPNM) of the peripheral branches continues to be controversial. The extension of the surgical resection is still under debate, especially in patients with non-invasive lesions. In these patients, the objective is to preserve as much of the remaining parenchyma as possible. We present the case of a 39-year-old man with a history of recurring episodes of acute pancreatitis. Multislice computed tomography (MSCT) and magnetic resonance cholangiopancreatography (MRCP) showed a pancreatic cyst located in the posterior region of the head of the pancreas, which probably communicated with the main pancreatic duct (Fig. 1). The size of the tumor was 19 mm. Serum levels of CA 19.9 and CEA were normal. The preoperative evaluation was completed with endoscopic ultrasound, which ruled out the presence of other nodules. With the diagnosis of IPNM of the peripheral branches, we decided to resect the lesion. The patient was taken to the operating room with the intention of performing a laparoscopic Whipple procedure. An extended Kocher maneuver was done with complete mobilization of the head of the pancreas. Intraoperative ultrasound enabled us to precisely locate the lesion, which was protruding from the posterior side. At that time, we decided to perform enucleation with preservation of the pancreatic parenchyma and the duodenum. The cyst was dissected with an electroscalpel, and the communicating duct was identified and ligated while preserving the main pancreatic duct and enucleating the tumor (Fig. 2). The frozen histology sections of the cyst showed lowgrade dysplasia. The patient recovered without complications and was discharged from the hospital on the fifth day post-op. The definitive pathology report determined the lesion to be a borderline IPNM. The patient has been symptom-free after 4 months of follow-up. The extension of the pancreatic resection for the surgical treatment of peripheral branch IPNM continues to be a topic of debate. In patients with non-invasive tumors, the long-term results in terms of endocrine and exocrine pancreatic insufficiency should be taken into special consideration. Conservative procedures seem to be an alternative to major pancreatic resections in this type of disease. Central and distal spleen-preserving pancreatectomies have become common treatments in cystic tumors and IPNM of peripheral branches without suspected malignancy. But preservation of the pancreatic parenchyma can be difficult for lesions located in the head of the pancreas or in the uncinate process, for which pancreaticoduodenectomy continues to be the traditional approach. For this reason, enucleation can be useful in these difficult locations. Little has been published in the international literature with regards to the enucleation of benign peripheral branch

Resection of a Retroperitoneal Bronchogenic Cyst: Laparoscopic Approach

Bronchogenic cysts are rare, benign, congenital anomalies of the primitive foregut encountered in the posterior mediastinum. Retroperitoneal location is uncommon, with only a few cases reported in the literature. We present a 46-year-old man who was examined for a complaint of nonspecific chronic abdominal pain. An abdominal computed tomography scan and magnetic resonance imaging scan were performed and revealed a mass in the peripancreatic region in relation to the left adrenal gland. Because a definitive diagnosis was uncertain, the patient underwent a laparoscopic resection. The pathology showed a cystic lesion consistent with retroperitoneal bronchogenic cyst. The patient had an uneventful postoperative recovery. Surgical resection of these lesions is mandatory to arrive at a differential diagnosis with other retroperitoneal lesions. The laparoscopic approach should be performed by experienced surgeons.

Haemoperitoneum with hereditary haemorrhagic telangiectasia

In August, 2011, an 83-year-old woman presented to our emergency department with several days of diff use persistent abdominal pain. She also reported an episode of lower gastrointestinal bleeding with symptoms of orthostasis. She had a history of cardiac failure, pulmonary hypertension, and epistaxis of un known cause. On initial physical examination she was haemodynamically stable without signs of acute ab dom inal disease. She had oral mucocutaneous telangiectases. Gastric lavage was done, and no evidence of upper gastrointestinal bleeding was seen. Blood tests showed a haematocrit concentration reduction from 25% to 20%, and a haemoglobin of 69 g/L. She was admitted for blood transfusion and assessment. After 5 days, she developed acute abdominal pain, tachycardia (135 beats per min), and hypotension (80/40 mm Hg). Sonography of the abdomen showed a large amount of free abdominal fl uid. Multi-detector computed tomography (MDCT) of the abdomen and pelvis confi rmed intra-abdominal fl uid and also showed liver arteriovenous malformations. CT-guided paracentesis confi rmed a diagnosis of haemo peritoneum. An emergency surgical exploration of the abdominal cavity was done because of her poor clinical condition. Explor ation showed haemo peritoneum and a portal vein branch with active bleeding due to the vascular malformations (fi gure). Haemostatic suturing was done to stop bleeding, and the abdominal cavity was drained. She had an uneventful postoperative course and was discharged at postoperative day 10. At last follow-up in Lancet 2013; 381: 962