Vladislav Brasoveanu

Living Donor Liver Transplantation for Unresectable Liver Adenomatosis Associated with Congenital Absence of Portal Vein: A Case Report and Literature Review

Patient: Female, 21 Final Diagnosis: Unresectable liver adenomatosis associated with congenital absence of portal vein Symptoms: — Medication: — Clinical Procedure: Living donor liver transplantation Specialty: Transplantology Objective: Rare disease Background: Abernethy malformation (AM), or congenital absence of portal vein (CAPV), is a very rare disease which tends to be associated with the development of benign or malignant tumors, usually in children or young adults. Case Report: We report the case of a 21-year-old woman diagnosed with type Ib AM (portal vein draining directly into the inferior vena cava) and unresectable liver adenomatosis. The patient presented mild liver dysfunction and was largely asymptomatic. Living donor liver transplantation was performed using a left hemiliver graft from her mother. Postoperatively, the patient attained optimal liver function and at 9-month follow-up has returned to normal life. Conclusions: We consider that living donor liver transplantation is the best therapeutic solution for AM associated with unresectable liver adenomatosis, especially because compared to receiving a whole liver graft, the waiting time on the liver transplantation list is much shorter.

Major hepatectomies for perihilar cholangiocarcinoma: Predictors for clinically relevant postoperative complications using the International Study Group of Liver Surgery definitions

BACKGROUND/AIM Major hepatectomies are widely used in curative-intent surgery for perihilar cholangiocarcinoma, but morbidity rates are high. The aim of the study is to explore potential predictors for clinically relevant complications after major hepatectomies for perihilar cholangiocarcinoma. METHODS Seventy patients were included. Univariate and multivariate analyses were performed for risk factors of morbidities using the International Study Group of Liver Surgery definitions. RESULTS Severe morbidity rate was 36.5%. Clinically relevant posthepatectomy liver failure, bile leak, and hemorrhage rates were 24%, 22%, and 8.5%, respectively. A neutrophil-to-lymphocyte ratio > 3.3 is an independent prognostic factor for severe complications (hazard ratio = 1.258; 95% confidence interval 1.008-1.570; p = 0.042) while the number of blood units > 3 is an independent prognostic factor for clinically relevant liver failure (hazard ratio = 1.254; 95% confidence interval 1.082-1.452; p = 0.003). Biliary drainage and portal vein resection were not statistically correlated with any postoperative complication (p ≥ 0.101). Significantly higher bilirubinemia levels were observed in patients with postoperative hemorrhage (p = 0.023). CONCLUSION Clinically relevant morbidity rates after major hepatectomies for perihilar cholangiocarcinoma are high. Liver failure represents the main complication and is correlated with the number of transfused blood units. A patient with increased bilirubinemia appears to have a high risk for postoperative hemorrhage. Biliary drainage and portal vein resection does not appear to have a detrimental effect on morbidities. Neutrophil-to-lymphocyte ratio is a novel independent predictor for severe morbidity after major hepatectomies for perihilar cholangiocarcinoma and may contribute to better and informed decision-making.

Curative-intent Surgery for Perihilar Cholangiocarcinoma with and without Portal Vein Resection - A Comparative Analysis of Early and Late Outcomes

Introduction: The safety of portal vein resection (PVR) during surgery for perihilar cholangiocarcinoma (PHC) has been demonstrated in Asia, America, and Western Europe. However, no data about this topic are reported from Eastern Europe. The aim of the present study is to comparatively assess the early and long-term outcomes after resection for PHC with and without PVR. PATIENTS AND METHODS The data of 21 patients with PVR were compared with those of 102 patients with a curative-intent surgery for PHC without PVR. The appropriate statistical tests were used to compare different variables between the groups. Results: A PVR was performed in 17% of the patients. In the PVR group, significantly more right trisectionectomies (p=0.031) and caudate lobectomies (0.049) were performed and, as expected, both the operative time (p=0.015) and blood loss (p=0.002) were significantly higher. No differences between the groups were observed regarding the severe postoperative morbidity and mortality rates, and completion of adjuvant therapy. However, in the PVR group the postoperative clinicallyrelevant liver failure rate was significantly higher (p=0.001). No differences between the groups were observed for the median overall survival times (34 vs. 26 months, p = 0.566). A histological proof of the venous tumor invasion was observed in 52% of the patients with a PVR and was associated with significantly worse survival (p=0.027). CONCLUSION A PVR can be safely performed during resection for PHC, without significant added severe morbidity or mortality rates. However, clinically-relevant liver failure rates are significantly higher when a PVR is performed. Furthermore, increased operative times and blood loss should be expected when a PVR is performed. Histological tumor invasion of the portal vein is associated with significantly worse survival.

Resection of Concomitant Hepatic and Extrahepatic Metastases from Colorectal Cancer - A Worthwhile Operation?

Background: The benefit of hepatic resection in case of concomitant colorectal hepatic and extrahepatic metastases (CHEHMs) is still debatable. The purpose of this study is to assess the results of resection of hepatic and extrahepatic metastases in patients with CHEHMs in a high-volume center for both hepatobiliary and colorectal surgery and to identify prognostic factors that correlate with longer survival in these patients. METHOD It was performed a retrospective analysis of 678 consecutive patients with liver resection for colorectal cancer metastases operated in a single Centre between April 1996 and March 2016. Among these, 73 patients presented CHEHMs. Univariate analysis was performed to identify the risk factors for overall survival (OS) in these patients. Results: There were 20 CHMs located at the lymphatic node level, 20 at the peritoneal level, 12 at the ovary and lung level, 12 presenting as local relapses and 9 other sites. 53 curative resections (R0) were performed. The difference in overall survival between the CHEHMs group and the CHMs group is statistically significant for the entire groups (p 0.0001), as well as in patients who underwent R0 resection (p 0.0001). In CHEHMs group, the OS was statistically significant higher in patients who underwent R0 resection vs. those with R1/R2 resection (p=0.004). Three variables were identified as prognostic factors for poor OS following univariate analysis: 4 or more hepatic metastases, major hepatectomy and the performance of operation during first period of the study (1996 - 2004). There was a tendency toward better OS in patients with ovarian or pulmonary location of extrahepatic disease, although the difference was not statistically significant. CONCLUSION In patients with concomitant hepatic and extrahepatic metastases, complete resection of metastatic burden significantly prolong survival. The patients with up to 4 liver metastases, resectable by minor hepatectomy benefit the most from this aggressive onco-surgical management.

Spleno-pancreatectomyEn Blocwith Parcelar Gastrectomy for Splenic Artery Aneurysm – A Case Report and Literature Review

Splenic artery aneurysms are common arterial lesions which might remain asymptomatic for a long period of time. In certain cases, these lesions might encounter a significant growth and might become symptomatic. Once diagnosed, a therapeutic strategy should be taken in consideration in order to avoid the apparition of life-threatening complications such as aneurysmal rupture. This is a case report of a 45-year-old patient diagnosed with a splenic artery aneurysm who was successfully submitted to an aneurysmal resection en bloc with distal spleno-pancreatectomy and parcelar gastrectomy.

Association Between Secondary Peritoneal Hydatidosis and Peritoneal Carcinomatosis from Ovarian Cancer – A Case Report

Peritoneal carcinomatosis from ovarian cancer is unfortunately a very common finding, especially in patients diagnosed in very late stages of the disease. Nonetheless, it is not the only pathological condition inducing a diffuse involvement of the peritoneum; other entities can have an infectious or miscellaneous origin. However, the association of peritoneal carcinomatosis and parasitic infection has never been reported so far. We present the case of a 50-year-old patient who had been submitted to surgery for a hepatic hydatid cyst. Four years later, the patient was diagnosed with disseminated peritoneal lesions, which proved to have both parasite and neoplastic origin. The patient was re-submitted to surgery, and debulking resection of all pathological lesions was achieved. Although it is very rare, the association of peritoneal carcinomatosis and peritoneal hydatidosis should be taken into consideration whenever the patient reports a suggestive medical history for those two pathological findings.

Successful Resection of a Non-functional Paraganglioma with Celiac Trunk Invasion Followed by Common Hepatic Artery Reimplantation – A Case Report and Literature Review

Paragangliomas, as well as phaeochromocytomas, are vascular neuroendocrine lesions that might be encountered between neck and pelvis. In certain cases, a preoperative diagnosis is difficult to be established, so resection might be needed whenever a suspect mass is discovered at the imaging studies. Moreover, there are cases in which resection and reconstruction of an important vascular structure might be imposed. In this case report a 59-year-old patient was investigated for upper abdominal pain with postprandial features and was diagnosed with a retroperitoneal tumor of 4/6/7cm invading the celiac trunk. The tumor was successfully resected and the common hepatic artery was reinserted in the celiac stump.

Reconstruction of Inferior Right Hepatic Veins in Living Donor Liver Transplantation

Background: A proper knowledge of the anatomy of the liver (including its vascular particularities) is mandatory in cases which are going to be submitted to major hepatic resection, including living donor liver transplantation. Case Report: We present the case of a living donor liver transplantation in which a particularity of the anatomy of the hepatic veins was reported for the donor: two inferior hepatic veins for segments 5 and 6. This particularity imposed the need for creation of a supplemental anastomosis in the recipient: a phleboplasty of the two inferior veins followed by direct re-implantation into the inferior cava vein. However, the postoperative course was uneventful for both the donor and the recipient. Conclusion: In certain cases presenting vascular particularities such as two inferior hepatic veins, phleboplasty followed by reimplantation into the inferior cava vein might be needed in order to provide a good vascular outflow of the liver graft.

The Impact on the Long-term Outcomes of Hormonal Status After Hepatic Resection for Breast Cancer Liver Metastases

Background/Aim: Breast cancer remains one of the most frequently encountered malignancies worldwide, which is in most cases diagnosed in early stages of disease. However, although surgery and adjuvant oncological treatment are performed with curative intent, a certain number of cases will develop distant metastases. In cases presenting oligometastatic disease, surgery might be tempted in order to maximize the benefit in terms of survival. The aim of this paper was to identify which cases could benefit most after liver resection for breast cancer liver metastases. Materials and Methods: The study included 67 patients submitted to surgery for breast cancer liver metastases between 2003 and 2017 in the “Dan Setlacec” Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute. Results: Patients diagnosed with hormone-positive breast tumors reported a significantly higher disease-free and overall survival after resection of the primary tumor. After resection for breast cancer liver metastases, patients presenting hormone receptors at the level of the metastatic sites also experienced a better outcome when compared to those in which hormonal receptors were absent. However, the difference was not statistically significant. Conclusion: Liver resection for breast cancer liver metastases seems to be associated with the best outcomes in terms of survival in patients presenting positive hormonal receptors status.

Operative Management and Outcomes of 150 Patients with Curative-intent Surgery for Perihilar Cholangiocarcinomas: A Single Institute East European Perspective

Introduction: The knowledge of current approach and outcomes of curative-intent surgery for perihilar cholangiocarcinoma (PHC) has been highlighted in studies of the literature including mainly East Asian and Western patients. Thus, papers presenting the curative-intent surgery in East Europe are scarce. The study aims to present the operative management and outcomes of curative-intent surgery for PHC in an East European institutional experience. Patients and methods: The data of all patients with curative-intent surgery for PHC between 1996 and 2017 were retrospectively reviewed from a prospective maintained electronic database at our Department of Surgery. The assessment was made for the operative management and early and late outcomes. Results: Liver resections were performed in 80.7% of patients, with caudate lobectomies in 64.7% of cases. Vascular resections were performed in 19.4% of patients. Preoperative biliary drainage was performed in 26% of patients. Negative resection margins were obtained in 76.7% of patients. Overall and severe morbidity rates were 57.3% and 24%, respectively. Postoperative bile leak, liver failure and hemorrhage rates were 31.3%, 24.7% and 10%, respectively. The 90-day mortality rate was 6%. The median overall and disease-free survival times were 26 months and 21 months, respectively. Conclusion: The standard approach for curative-intent surgery for PHC implies bile duct resection associated with major hepatectomies, including caudate lobectomy. Expertise in referral surgical centers of East Europe is associated with morbidity, mortality and overall survival rates comparable with those reported in Western centres, despite low rate of preoperative biliary drainage and no use of portal vein embolization. Improvements of preoperative optimization with portal vein embolization and biliary drainage may potentially lead to better early and long-term outcomes.