Reza Kianmanesh

Hepatic abscess: Diagnosis and management

Microbial contamination of the liver parenchyma leading to hepatic abscess (HA) can occur via the bile ducts or vessels (arterial or portal) or directly, by contiguity. Infection is usually bacterial, sometimes parasitic, or very rarely fungal. In the Western world, bacterial (pyogenic) HA is most prevalent; the mortality is high approaching 15%, due mostly to patient debilitation and persistence of the underlying cause. In South-East Asia and Africa, amebic infection is the most frequent cause. The etiologies of HA are multiple including lithiasic biliary disease (cholecystitis, cholangitis), intra-abdominal collections (appendicitis, sigmoid diverticulitis, Crohns disease), and bile duct ischemia secondary to pancreatoduodenectomy, liver transplantation, interventional techniques (radio-frequency ablation, intra-arterial chemo-embolization), and/or liver trauma. More rarely, HA occurs in the wake of septicemia either on healthy or preexisting liver diseases (biliary cysts, hydatid cyst, cystic or necrotic metastases). The incidence of HA secondary to Klebsiella pneumoniae is increasing and can give rise to other distant septic metastases. The diagnosis of HA depends mainly on imaging (sonography and/or CT scan), with confirmation by needle aspiration for bacteriology studies. The therapeutic strategy consists of bactericidal antibiotics, adapted to the germs, sometimes in combination with percutaneous or surgical drainage, and control of the primary source. The presence of bile in the aspirate or drainage fluid attests to communication with the biliary tree and calls for biliary MRI looking for obstruction. When faced with HA, the attending physician should seek advice from a multi-specialty team including an interventional radiologist, a hepatobiliary surgeon and an infectious disease specialist. This should help to determine the origin and mechanisms responsible for the abscess, and to then propose the best appropriate treatment. The presence of chronic enteric biliary contamination (i.e., sphincterotomy, bilio-enterostomy) should be determined before performing radio-frequency ablation and/or chemo-embolization; substantial stenosis of the celiac trunk should be detected before performing pancreatoduodenectomy to help avoid iatrogenic HA.

Management of large incisional hernias with loss of domain: A prospective series of patients prepared by progressive preoperative pneumoperitoneum

BACKGROUNDnThe surgical treatment of giant incisional hernias with loss of domain is challenging due to the possibility of intra-abdominal hypertension after the herniated content is returned to the peritoneal cavity. Progressive preoperative pneumoperitoneum has been described before repair of the hernia, although its efficacy has not been demonstrated clearly. Our aim was to evaluate the efficacy of preoperative progressive pneumoperitoneum in expanding the volume of the peritoneal cavity and the outcomes after surgical treatment of incisional hernias with loss of domain.nnnMETHODSnAll consecutive patients with incisional hernias with loss of domain undergoing preoperative progressive pneumoperitoneum and operative repair were included in a prospective observational study. All patients had pre- and postoperative progressive pneumoperitoneum computed tomography of the abdomen. Open incisional hernias with loss of domain repair consisted of anatomic reconstruction of the abdominal wall by complete closure of the defect and reinforcement with a sublay synthetic mesh, whenever possible.nnnRESULTSnThe cohort was composed of 45 patients (mean age, 60.5xa0years). Before the preoperative progressive pneumoperitoneum, the mean volume of the herniated content was 38% of the total peritoneal volume. The mean abdominal volume increased by 53% after the preoperative progressive pneumoperitoneum. One patient died during preoperative progressive pneumoperitoneum, but the postoperative mortality was zero, giving a mortality rate of 2% to the treatment using preoperative progressive pneumoperitoneum. Complete reduction of the herniated content intraperitoneally with primary closure of the fascia was achieved in 42 out of 45 patients (94%). Reinforcement by a synthetic mesh was possible in 37 patients (84%). Overall, surgical complications related directly to the operative procedure occured in 48% of cases. The rates of overall and severe morbidity were 75 and 34%, respectively. At a mean follow-up of 18.6xa0months, the recurrence rate was 8% (3 out of 37 patients) with non-absorbable meshes and 57% (4 out of 7 patients) with absorbable mesh.nnnCONCLUSIONnPreoperative progressive pneumoperitoneum increased the volume of the abdominal cavity in patients with incisional hernias with loss of domain, allowing complete reduction of the herniated content and primary fascial closure in 94% of patients, with acceptable overall morbidity.

Preservation of the arterial vascularisation after hepatic artery pseudoaneurysm following orthotopic liver transplantation: long-term results.

BACKGROUNDnHepatic artery pseudoaneurysm (HAP) is a serious complication of orthotopic liver transplantation (OLT). The aim of this study was to determine risk factors for HAP and the best management of this complication.nnnMATERIAL AND METHODSnBetween 1990 and 2005, 787 OLT were performed at our center. Patients who developed HAP were identified from our prospective database and risk factors of HAP were identified. Management of HAP was analyzed retrospectively.nnnRESULTSnThere were 16 OLT (2.5%) complicated by HAP [median delay =13 days; range: 4-100 days]. Presentation was massive bleeding with shock (n=13), pain (n=2), or transient gastrointestinal bleeding (n=1). Bacteriological culture of HAP wall or ascites fluid was positive in 13 (81%) patients. Bilio-enteric anastomosis and biliary leak were identified as risk factors for HAP (p=0.011 and 0.002, respectively), whereas indication for OLT, surgical technique (full-graft OLT versus other techniques), and re-LT were not. Mortality rate after HAP rupture was 53% (7/13), but no deaths occurred in the 3 patients treated before rupture. Treatment included: excision and immediate revascularization [n=7; early mortality =2 (28%), long-term graft survival =4 (57%)], hepatic artery ligation [n=5; early mortality =3 (80%);, long-term graft survival with good liver function =0], and endovascular treatment [n=2; early mortality =0, long-term survival with good liver function =2].nnnCONCLUSIONSnHAP post-OLT carries a high mortality rate when detected after rupture, but recognition before rupture usually allows a successful outcome. Reconstruction with bilio-enteric anastomosis and postoperative biliary leak increase the risk for HAP. In these settings, CT with contrast injection should be performed to screen for HAP when there is any suspicion. Graft revascularization should be attempted whenever possible.

A Rare Cause of Chronic Abdominal Pain: Recurrent Sub-torsions of an Accessory Spleen

Accessory spleen is defined as one, two, or three nodules of additional ectopic splenic parenchyma hung by a vascular pedicle generally near the spleen. Despite a relatively high frequency (from 10 to 30 % of the population based on autopsy studies), most accessory spleens are asymptomatic. Although cases of accessory spleen were clearly described in the literature, this perplexing diagnosis is often delayed and rarely made preoperatively. We repot episodic recurrences of abdominal pain in a 66-year-old man attributed to iterative sub-torsions of an accessory spleen, as well as a comprehensive review of the literature.

Determining the best recipient vessel site for autologous microsurgical breast reconstruction with DIEP flaps: An anatomical study

INTRODUCTIONnThe deep inferior epigastric perforator (DIEP) flap is a reliable and reproducible technique for autologous microsurgical breast reconstruction. Several recipient vessels sites for microvascular anastomosis have been described such as the internal thoracic vessels, the thoracodorsal vessels, and the circumflex scapular vessels. Nonetheless, the choice of the recipient site depends mainly on individual operators experience and preferences, and currently the best recipient vessel site is under debate. This anatomical observational study aimed to determine whether anatomy could address this dilemma by determining the best vessel diameter to match the donor with these three recipient sites.nnnMETHODSnOur series reports 80 dissections of the three anatomical regions of interest. Forty formalin-preserved female cadavers were dissected bilaterally. Internal vessels diameter measurements were recorded with a vascular gauge ranging from 1.0 to 5.0xa0mm with successive half-millimeter graduations.nnnRESULTSnThe median diameter of the deep inferior epigastric (DIEA), internal thoracic (ITA), circumflex scapular (CSA), and thoracodorsal arteries (TDA) were: 2.0, 2.5, 2.5, and 1.5xa0mm, respectively. The median diameter of the deep inferior epigastric, internal thoracic, circumflex scapular, and thoracodorsal veins were: 3.0, 3.0, 3.0, and 2.5xa0mm, respectively. At the individual level, the perfect match between DIEA and ITA was significantly more frequent than between DIEA and TDA (pxa0=xa00.002), and it was more frequent between DIEA and CSA than between DIEA and TDA (pxa0=xa00.009).nnnCONCLUSIONSnThis study supports the use of the internal thoracic pedicle as the first recipient vessel choice, which should be considered, at least anatomically, as the best one with the closest diameter matching with the donor pedicle.

Bevacizumab to Treat Cholangiopathy in Hereditary Hemorrhagic Telangiectasia: Be Cautious: A Case Report.

AbstractHereditary hemorrhagic telangiectasia (HHT) is an inherited vascular dysplasia characterized by mucocutaneous telangiectasia and visceral arteriovenous malformations. Hepatic involvement with vascular malformations may lead to portal hypertension, biliary ischemia, and high-output cardiac failure. There is no curative treatment for the disease. Liver transplantation is indicated for life-threatening complications, but it carries significant risk due to surgery and immunosuppressive treatment. Some case reports or small open studies suggest that bevacizumab, a recombinant humanized anti-VEGF monoclonal antibody, should be efficient in limiting bleeding and in reducing liver disease in HHT.We report a case of a 63-year-old woman with HHT presenting with ischemic cholangiopathy. Liver transplant was indicated, but given a previous encouraging report showing a regression of biliary disease with bevacizumab in 3 patients with HHT this drug was proposed. No significant efficacy but a severe adverse effect was observed after 3 months: bilateral pulmonary embolisms, thrombosis in the right atrial cavity, and thrombosis of the right hepatic vein were evidenced. Bevacizumab was stopped; anticoagulant started. Four months later, the patient received a transplanted liver. She feels well 1 year later.This case report intends to provide the information for clinicians to consider the use of bevacizumab in HHT. Whereas several uncontrolled series and case reports have suggested the efficacy of this drug in reducing bleeding and liver disease, no severe side effects were mentioned to date. For the first time in HHT we report a life-threatening side effect of this drug and no efficacy. Moreover, systemic thrombosis, the observed complication, may preclude transplantation. To date, caution seems still indispensable when considering the use of bevacizumab in HHT.

Open retromuscular large mesh reconstruction of lumbar incisional hernias including the atrophic muscular area

PurposeLumbar incisional hernias (LIH) are a rare wall defect, whose surgical management is challenging because no recommendation exists. Moreover, LIH are frequently associated with flank bulging which should be taken into account during LIH surgical repair. We aimed to describe a cohort of patients operated on for LIH using a homogeneous surgical technique and to report surgical outcomes.MethodsThe records of all consecutive patients operated on in a specialized surgical center between January 2009 and January 2015 were retrospectively reviewed. The same open technique was performed, i.e., using a mesh into the retroperitoneal space posteriorly, placed with the largest overlap inferiorly and posteriorly, and fixed through the controlateral abdominal wall muscles under strong tension to correct the flank bulging.ResultsThe cohort included 31 patients, of median age 62, who presented two or more comorbidities in 68% of cases. LIH was recurrent in 45% of patients, and was related to nephrectomy in 61% of patients. The mesh was totally extraperitoneal in 65% of patients. The postoperative mortality rate was null. The rate of specific surgical complications was 32.3%, and the rate of overall postoperative morbidity (Clavien-Dindo classification) was 38.7%. After a median follow-up of 27.5xa0months, the recurrence rate was 6.5% and 9.7% reported chronic pain.ConclusionThe open approach for LIH repair was safe and enabled treating flank bulging simultaneously in all patients. Due to the paucity of adequate scientific studies, this reproducible open method could help moving toward a standardization of LIH surgical management.

Anatomical and CT approach of the adipose tissue: application in morbid obesity.

AbstractPurposeThe importance and proportion of visceral adipose tissue (VAT) represent the best criterion to define obesity. Because VAT value is difficult to obtain in clinical practice, the nindication for bariatric surgery is still based at present on Body Mass index (BMI), even though BMI is a poor predictor of obesity-related morbid complications. This correlation study aimed at determining a simple and accurate computed tomography (CT) anatomic marker, which can be easily used clinically, well correlated with the volume of VAT and consequently with morbid complications.MethodsWe studied 108 CT scans of patients presenting with morbid obesity. Several simplified measures (external and internal abdominal diameters and circumferences) were conducted on CT scan view, going through the fourth lumbar vertebra (L4), in addition to various vertebral measurements (area of the vertebra, sagittal and transversal diameters), VAT and subcutaneous adipose tissue (SAT). Then, we reported the simplified measures values on the vertebral areas, and we calculated the Bertin index. Finally, we conducted a correlation study between all variables to obtain accurate VAT measurements.ResultsThe internal abdominal circumference and the Bertin index showed the best correlations with VAT in morbidly obese patients (rxa0=xa00.84 and 0.85, respectively). BMI and anthropometric measures were not correlated with VAT.ConclusionCT scan study allows to simply approximate VAT value in morbidly obese patients. An abdominal CT scan could be part of the tests used in the evaluation of obese patients to base therapeutic strategies on VAT values and not on BMI as it is the case today.

Standard of Open Surgical Repair of Suprapubic Incisional Hernias

BackgroundSuprapubic incisional hernias (SIH) are a rare wall defect, whose surgical management is challenging because of limited literature. The proximity of the hernia to bone, vascular, nerve, and urinary structures, and the absence of posterior rectus sheath in this location imply adequate technique of surgical repair. We aimed to describe a cohort of female patients operated on for SIH after gynecological surgery using a homogeneous surgical technique and to report surgical outcomes.MethodsThe records of all consecutive patients operated on for SIH in a specialized surgical center between January 2009 and January 2015 were retrospectively reviewed. The same open technique was performed, i.e., using a mesh placed inferiorly in the preperitoneal space of Retzius, with large overlap, and fixed on the Cooper’s ligaments, through the muscles superiorly and laterally with strong tension, in a sublay or underlay position.ResultsThe cohort included 71 female patients. SIH were recurrent in 31% of patients and was related to cesarean in 32 patients (45.1%) and to gynecologic surgery in 39 patients (54.9%). The mesh was totally extraperitoneal in 76.1% of patients. The postoperative mortality rate was null. The rate of specific surgical complications was 29.6%. After a median follow-up of 30.3xa0months, the recurrence rate was 7%.ConclusionThe open approach for SIH repair was safe and efficient. Due to the paucity of adequate scientific studies, this reproducible open method could help moving toward a standardization of SIH surgical management.

Surgical procedures in liver transplant patients: A monocentric retrospective cohort study

BACKGROUNDnPre-existing chronic liver diseases and the complexity of the transplant surgery procedures lead to a greater risk of further surgery in transplanted patients compared to the general population. The aim of this monocentric retrospective cohort study was to assess the epidemiology of surgical complications in liver transplanted patients who require further surgical procedures and to characterize their post-operative risk of complications to enhance their medical care.nnnPATIENTS AND METHODSnFrom January 1997 to December 2011, 1211 patients underwent orthotropic liver transplantation in our center. A retrospective analysis of prospectively collected data was performed considering patients who underwent surgical procedures more than three months after transplantation. We recorded liver transplantation technique, type of surgery, post-operative complications, time since the liver transplant and immunosuppressive regimens.nnnRESULTSnAmong these, 161 patients (15%) underwent a further 183 surgical procedures for conditions both related and unrelated to the transplant. The most common surgical procedure was for an incisional hernia repair (nxa0=xa0101), followed by bilioenteric anastomosis (nxa0=xa044), intestinal surgery (nxa0=xa023), liver surgery (nxa0=xa08) and other surgical procedures (nxa0=xa07). Emergency surgery was required in 19 procedures (10%), while 162 procedures (90%) were performed electively. Post-operative mortality and morbidity were 1% and 30%, respectively. According to the Dindo-Clavien classification, the most common grade of morbidity was grade III (46%), followed by grade II (40%).nnnCONCLUSIONnSurgical procedures on liver transplanted patients are associated with a significantly high risk of complications, irrespective of the time elapsed since transplantation.