Axel Beskow

Hepatic artery reconstruction first for the treatment of hilar cholangiocarcinoma bismuth type IIIB with contralateral arterial invasion: a novel technical strategy

BACKGROUND En-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure. METHODS The authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed. RESULTS In both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months. CONCLUSIONS This new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.

Esophageal adenocarcinoma five years after laparoscopic sleeve gastrectomy. A case report

Highlights • There is big concern about reflux appearance after sleeve gastrectomy.• Chronic reflux increases risk of esophageal adenocarcinoma.• We present a case of an esophageal adenocarcinoma after sleeve gastrectomy.• Relationship between sleeve gastrectomy and reflux needs further study.

Giant Esophageal Lipoma

A 65-year-old woman, with previous history of severe kyphoscoliosis and obesity was referred to our hospital complaining of globus, dysphagia, and weight loss for several months. Physical examination was normal. An esophagogram revealed a well-defined mass with a large filling defect in the proximal esophagus, which caused intermittent obstruction. An upper gastrointestinal endoscopy showed a yellowish mass extending from the faringoesophageal junction to the lower middle esophagus, occupying most of its lumen. Diagnostic work-up was completed with a Pneumo 64-slice CT scan that evidenced a 100×47-mm, well-defined hypodense mass consistent with a lipoma, which displayed forward the trachea and bronchus as well as the pulmonary arteries (Fig. 1). An endoscopic resection was intended without success. A surgical exploration was then decided to resect the mass. Through a left lateral cervicotomy, once the esophagus was identified and dissected, a longitudinal esophagotomy was performed, and a soft mass covered with normal mucosa was recognized. The tumor was exteriorized through the esophagotomy and resected (Fig. 2). The patient was discharged without complications at postoperative day 5. The pathology study revealed a lipoma.

Slipped Liver Segment Mimicking an Esophageal Stromal Tumor

A 36-year-old female patient with past medical history of a hiatal procedure in the neonatal period (which was not described in her medical history) for hiatal hernia was referred to our institution for thoracic pain. Abdominal examination was unremarkable. Initially, clinical tests (ECG and echocardiogram) were performed, ruling out cardiac pathology. Barium esophagramwas carried out evidencing a slight filling defect on the distal third of the esophagus with no evidence of recurrent hiatal hernia. A CT scan with distention technique (PnCT) revealed a homogeneous 39 × 26 mm lesion located on the distal esophagus consistent with a submucosal tumor (Fig. 1). An upper gastrointestinal endoscopy showed no organic lesion on the mucosa. Due to the suspicion of esophageal stromal tumor, we executed an endoscopic ultrasound (EUS) which revealed a well circumscribed, hipoechoic, relatively homogeneous mass arising apparently from the fourth layer of the esophagus. The case was presented to a multidisciplinary committee and based on the presumptive diagnosis of esophageal stromal tumor, the patient was considered candidate for resection and underwent an initial laparoscopic ap-

Intussusception as a complication of bariatric surgery in pregnant patients: report of one case and revision of the literature

Abstract Occlusive complications after a laparoscopic Roux-in Y gastric bypass (LRYGB), appear mainly as fibrous membranes of wounds, internal hernias or intussusception. Intussusception after a bariatric surgery occurs in 0.1–0.3% of the cases. We present a case of intussusception in a pregnant patient after a LRYGB.