Branislav Kocman

Right hepatectomy due to portal vein thrombosis in vasculobiliary injury following laparoscopic cholecystectomy: a case report

IntroductionVasculobiliary injury composed of bile duct, portal vein and hepatic artery injury is a rare, but the most severe, complication after cholecystectomy that may require hepatectomy or even urgent liver transplantation.Case presentationWe present a case of a 36-year-old Caucasian woman with a biliary sepsis and a large right liver lobe abscess due to an extreme vasculobiliary injury after laparoscopic cholecystectomy. Bismuth type IV biliary duct injury, portal vein thrombosis and injury of right hepatic artery were identified, resulting in life-threatening septic episodes. Right hepatectomy with Roux-en-Y hepaticojejunostomy and reconstruction of her portal vein with a vein allograft were performed. She fully recovered and remained well during 3 years of follow-up.ConclusionsAlthough rare, the impact of vasculobiliary injuries after cholecystectomy highlights the need for constant alertness and prompt management in order to minimize the risk of the routine operative procedure. Hepatectomy with biliary and vascular reconstruction should be considered early in the management of vasculobiliary injury to avoid the development of life-threatening consequences.

Successful management of unsuspected retroperitoneal paraganglioma via the use of combined epidural and general anesthesia: a case report

IntroductionSimilar to pheochromocytomas, paragangliomas can secrete catecholamines, although they are usually non-functional and clinical presentation is non-specific. We present a case of accidental, intra-operatively diagnosed neuroendocrine-active sympathetic paraganglioma, which was suspected and confirmed during elective retroperitoneal tumor removal.Case presentationA 25-year-old Caucasian Croatian man, American Society of Anesthesiologists status 1, underwent elective surgery for retroperitoneal tumor removal. The tumor had been discovered by chance during a routine examination and was suspected to be a sarcoma. Our patient had no history of previous medical conditions nor did he have symptoms characteristic of a neuroendocrine secreting tumor. The results of ultrasound and magnetic resonance imaging studies showed a large, well demarcated retroperitoneal tumor mass in his upper abdomen localized between the aorta and vena cava, measuring approximately 9×6×4.5cm. In the operating room an epidural catheter was inserted at the T7 to T8 level prior to induction of general anesthesia. Epidural analgesia was maintained by an infusion pump with local anesthetic and opiate mixture. During the surgical excision of the tumor, hemodynamic changes occurred, with hypertension (205/110mmHg) and tachycardia (up to 120 beats/minute). In spite of the fact that the surgical field of work did not include adrenal glands whose direct manipulation could explain this occurrence, there was a high degree of suspicion for the presence of a neurosecreting tumor. His clinical symptoms were relieved after administration of urapidil, esmolol and magnesium sulfate. After tumor excision, our patient developed severe hypotension. Hemodynamic stability was reinstated with aggressive volume replacement, with crystalloids and colloids, vasopressors and hydrocortisone. His post-operative course was unremarkable and on the eighth post-operative day our patient was discharged from hospital, with no consequences or symptoms on follow-up two years after surgery.ConclusionsOur patient’s case emphasizes the need to consider the presence of extra-adrenal paragangliomas in the differential diagnosis of retroperitoneal tumors, despite their rare occurrence. In our patient’s case, invasive hemodynamic monitoring during combined general anesthesia and epidural analgesia and early recognition of catechol-induced symptoms raised suspicion of the existence of a paraganglioma, and this led to an adequate therapeutic approach and favorable outcome of the surgery. Pre-operative recognition of paragangliomas could lead to better pre-operative preparation, but even high clinical suspicion in undiagnosed forms during surgery and the availability of rapid and short-acting vasodilatators, α-blockers and β-blockers might favor good outcome.

Perioperative volume replacement therapy for orthopic liver transplantation-observational, retrospective study

Aim: A significant fluid loss occurs during liver transplantation, which needs to be replaced. In this study, we analyzed whether fluid replacement strategies during liver transplantation have changed over a five-year period. Materials and methods: In this observation, retrospective study, we collected data on 155 patients who underwent liver transplantation at the University Hospital “Merkur”, 79 in 2015 and 76 in 2010. We analyzed total blood loss, total replaced fluid volume and the volume of crystalloids, colloids, erythrocyte concentrates, fresh frozen plasma and platelets applied. We employed the Student t-test for statistical analysis. Results: Total blood loss (ml) in 2015 and 2010 was 6526 ± 4194 and 11122 ± 6685, respectively, P < 0.001. Replaced fluid volume (ml) in 2015 and 2010 was the following: total fluid volume 9640 ± 6017 and 18433 ± 7282, P < 0,001; crystalline 5077 ± 1443 and 5674 ± 2326, P = 0.055; colloids 1853± 814 and 2244 ± 1188, P = 0.018; autologous blood 1097 ± 1160 and 1927 ± 2608, P = 0.011; homologous blood 1293 ± 1247 and 2979 ± 2196, P < 0.001; fresh frozen plasma 2244 ± 1523 and 5429 ± 1954, P < 0.001; platelets 349 ± 387 and 426 ± 313, P = 0.176. Conclusions: This study showed a *Dopisni autor: Dr. sc. Jadranka Pavičić Šarić, dr. med. Klinička bolnica Merkur, Odjel anestezije, reanimatologije i intenzivnog liječenja Zajčeva 19, 10000 Zagreb e-mail: jpavicic58@gmail.com Klinička bolnica Merkur, Odjel anestezije, reanimatologije i intenzivnog liječenja, Zagreb Volumna nadoknada tijekom transplantacije jetre – opservacijska, retrospektivna studija Perioperative volume replacement therapy for orthopic liver transplantation-observational, retrospective study Jadranka Pavičić Šarić*, Branislav Kocman, Denis Guštin, Jelena Zenko, Vanja Vončina, Petra Ožegović Izvorni znanstveni članak/Original scientific article