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Journal of Gastrointestinal Surgery
Abstracts
and debris-like echoes in the gallbladder. ERCP was performed, and the cholangiogram demonstrated a filling defect in the choledochus due to debris, stone or mucinous material. CT and MRI showed thickness of the G.B. wall and stone, no abnormal findings of the pancreas. We suspected mucin-producing carcinoma of the gallbladder or chronic cholecystitis. So we tried laparoscopic method for diagnosis. After laparoscopic method,we suspected mucin-producing carcinoma of the gallbladder. We converted open method and performed cholecystectomy with partial hepatectomy, resection of the common bile duct and lymphnodes dissection. Papillomatous tumor with mucin was occupied at the body of the gallbladder and histologically it was mucinous adenocarcinoma with invasion to sub serosa of the gallbladder. There are a few reports of mucin-producing carcinoma of the gallbladder with obstructive jaundice.
186 The Worlds First Long Term Survivor After Ex-Vivo Liver Resection and Partial Autotransplantation for Advanced Hilar Cholangioccarcinoma Albert K Chui, Nitin A Rao, Eddie R Island, Joseph W Lau, The Chinese University of Hong Kong, Shatin, Hong Kong Bismuth type IV cholangiocarcinoma (CC) carries a poor prognosis. In-situ resection is risky and tumor clearance is usually not possible. Ex-vivo liver resection and autotransplantation (Atx) is theoretically an option. There are only 5 previously reported cases of this procedure for CC in the English literature, and most of them died early in the postoperative period. The only long-term survivor reported previously died of tumor recurrence at 13 months. We are reporting a patient who has survived for 17 months without any sign of tumor recurrence. This potentially represents the worlds first cure for CC using this technique. This patient is a 26-year-old female who was transferred to our unit with obstructive jaundice. Ultrasound and CT examination revealed a hilar liver mass. Bilateral PTBD were inserted and a Bismuth type IV CC was confirmed by laparoscopic ultrasound examination. Angiogram showed involvement of the portal vein by the tumor at the confluence. In situ resection was deemed impossible due to the tumor location. In view of the patients young age, ex-vivo resection of segments 5, 6, 7, 8 and part of 4 was performed followed by a partial liver Atx. The left portal vein was connected to the main portal vein trunk using an internal jugular vein interposition graft. Biliary drainage was reconstituted using a roux-en-Y jejunal loop anastomosed to the individual bile ducts draining segments 2, 3, and 4. She was discharged on postoperative day 45. The pathology specimen demonstrated CC with clear margins. MRI and CT examinations done over the following 17 months show hypertrophied remnant liver with no evidence of recurrence. On follow up she is doing well and has returned to her daily routine. In conclusion, ex-vivo liver resection and Atx can be considered as a viable option for cure among highly selected patients with CC.
187 Hepatic Artery Pseudoaneurysm Obscured by Closed Suction Drain Christopher Carr, C Wright Pinson, Vanderbilt University, Nashville, TN NH is a 64 year old female with a h/o retroperitoneal Leiomyosarcoma. In 6/1999 she underwent right nephrectomy and IVC resection. In December, 2001 she had segment 7 of her liver resected for recurrence. In April, 2002 MRI revealed a mass in her porta hepatis that enhanced on PET scan. NH underwent resection of the porta hepatis mass. The mass displaced the portal structures anteriorly, and it involved a hepatic artery originating from the celiac axis. The dominant hepatic artery emanated from the SMA and was situated at the posterolateral aspect of the hepatoduodenal ligament. On POD 7
NH was discharged home with a drain since a small amount of bilious output was present. On POD 15 she presented with acute abdominal pain and with blood in her JP. Until this time the abdominal drain fluid had remained low in quantity (20cc/day) and its character had not changed since her discharge from the hospital. She was diaphoretic, tachycardic, and had significant abdominal tenderness. She stabilized hemodynamically after transfusion of blood. An abdominal CT scan revealed a large amount of blood around the liver with no active extravasation. An arteriogram revealed no active bleeding source and no pseudoaneurysm. Due to the degree of hemoperitoneum, exploratory laparotomy was performed and the perihepatic hematoma was evacuated. No active source of bleeding was identified. On POD 9 following exploration, NH developed recurrent bleeding in her JP drain. This bleeding was self-limited, ending within minutes. Subsequently NH became orthostatic and developed melena. EGD revealed hemobilia. NH then underwent arteriography revealing a hepatic artery aneurysm from a branch of her right hepatic artery. For treatment of this aneurysm, her right hepatic artery was coil-embolized. The etiology of this aneurysm was likely a consequence of her initial operation when her portal mass was resected. During this resection, her right hepatic artery may have been injured but was not clinically evident immediately. Over the ensuing two weeks, however, a small area along the artery probably broke down leading to the formation of a pseudoaneurysm which was likely responsible for her initial episode of bleeding. The immediate question becomes “Why was the pseudoaneurysm not appreciated on the initial arteriogram?” The small pseudoaneurysm was not identified on abdominal exploration. This is not unusual especially in a previously operated field. It does seem unusual, however, that a bleeding pseudoaneurysm was not appreciated on the initial arteriogram. On reevaluation of the studies, it was appreciated that her original JP drain was sitting immediately adjacent to the right hepatic artery. It therefore may have been involved in both trauma to the artery as the vessel beat against this foreign body and in obscuring detection of the bleeding hepatic artery pseudoaneurysm.
188 Use of a Polytetrafluoroethylene Tube and Patch in the Repair of a Difficult Duodenal Stump Nestor A Gomez, Eduardo Roura, Carlos Leon, Paola Vargas, Jorge Zapatier, Institute of Digestive Diseases “Esperanza Foundation”, Guayaquil, Ecuador; University of Guayaquil, Guayaquil, Ecuador Introduction: Special care must be taken to avoid any complication in the duodenal stump such as suture dehiscence. We wish to communicate the successful results obtained with a polytetrafluoroethylene tube and patch used to repair a duodenal stump that suffered dehiscence of the sutures several times. Case Report: This is a case of a 35years-old woman in whom a hepaticojejunostomy was performed previously, due to an iatrogenic choledocus injury. Because of bile leakage drainage, a second celiotomy was indicated, and a duodenal wall defect with edematous borders was found. The primary repair was unable, so a partial section of the duodenum was made. During the next 24 days, the patient suffered dehiscence of the sutures in the duodenal stump 3 times. Because of the difficulty in closing the borders, a polytetrafluoroethylene tube was sutured to the duodenal borders, and exteriorized through the lateral abdominal wall. The patient improved, and 30 days later the duodenal wall was not edematous. The tube was withdrawn, and a polytetrafluoroethylene patch was sutured covering the duodenal stump. The patient had a good evolution and was discharged with periodical checkouts. Discussion: Primary repair is the first choice of treatment for gut wall defects. In our patient primary closure was not possible because of the inflammation of the duodenal wall, a leading factor in the incompetence of the stump sutures. Clinical and experimental trials had tested the effectiveness
Journal of Gastrointestinal Surgery
Abstracts
and debris-like echoes in the gallbladder. ERCP was performed, and the cholangiogram demonstrated a filling defect in the choledochus due to debris, stone or mucinous material. CT and MRI showed thickness of the G.B. wall and stone, no abnormal findings of the pancreas. We suspected mucin-producing carcinoma of the gallbladder or chronic cholecystitis. So we tried laparoscopic method for diagnosis. After laparoscopic method,we suspected mucin-producing carcinoma of the gallbladder. We converted open method and performed cholecystectomy with partial hepatectomy, resection of the common bile duct and lymphnodes dissection. Papillomatous tumor with mucin was occupied at the body of the gallbladder and histologically it was mucinous adenocarcinoma with invasion to sub serosa of the gallbladder. There are a few reports of mucin-producing carcinoma of the gallbladder with obstructive jaundice.
186 The Worlds First Long Term Survivor After Ex-Vivo Liver Resection and Partial Autotransplantation for Advanced Hilar Cholangioccarcinoma Albert K Chui, Nitin A Rao, Eddie R Island, Joseph W Lau, The Chinese University of Hong Kong, Shatin, Hong Kong Bismuth type IV cholangiocarcinoma (CC) carries a poor prognosis. In-situ resection is risky and tumor clearance is usually not possible. Ex-vivo liver resection and autotransplantation (Atx) is theoretically an option. There are only 5 previously reported cases of this procedure for CC in the English literature, and most of them died early in the postoperative period. The only long-term survivor reported previously died of tumor recurrence at 13 months. We are reporting a patient who has survived for 17 months without any sign of tumor recurrence. This potentially represents the worlds first cure for CC using this technique. This patient is a 26-year-old female who was transferred to our unit with obstructive jaundice. Ultrasound and CT examination revealed a hilar liver mass. Bilateral PTBD were inserted and a Bismuth type IV CC was confirmed by laparoscopic ultrasound examination. Angiogram showed involvement of the portal vein by the tumor at the confluence. In situ resection was deemed impossible due to the tumor location. In view of the patients young age, ex-vivo resection of segments 5, 6, 7, 8 and part of 4 was performed followed by a partial liver Atx. The left portal vein was connected to the main portal vein trunk using an internal jugular vein interposition graft. Biliary drainage was reconstituted using a roux-en-Y jejunal loop anastomosed to the individual bile ducts draining segments 2, 3, and 4. She was discharged on postoperative day 45. The pathology specimen demonstrated CC with clear margins. MRI and CT examinations done over the following 17 months show hypertrophied remnant liver with no evidence of recurrence. On follow up she is doing well and has returned to her daily routine. In conclusion, ex-vivo liver resection and Atx can be considered as a viable option for cure among highly selected patients with CC.
187 Hepatic Artery Pseudoaneurysm Obscured by Closed Suction Drain Christopher Carr, C Wright Pinson, Vanderbilt University, Nashville, TN NH is a 64 year old female with a h/o retroperitoneal Leiomyosarcoma. In 6/1999 she underwent right nephrectomy and IVC resection. In December, 2001 she had segment 7 of her liver resected for recurrence. In April, 2002 MRI revealed a mass in her porta hepatis that enhanced on PET scan. NH underwent resection of the porta hepatis mass. The mass displaced the portal structures anteriorly, and it involved a hepatic artery originating from the celiac axis. The dominant hepatic artery emanated from the SMA and was situated at the posterolateral aspect of the hepatoduodenal ligament. On POD 7
NH was discharged home with a drain since a small amount of bilious output was present. On POD 15 she presented with acute abdominal pain and with blood in her JP. Until this time the abdominal drain fluid had remained low in quantity (20cc/day) and its character had not changed since her discharge from the hospital. She was diaphoretic, tachycardic, and had significant abdominal tenderness. She stabilized hemodynamically after transfusion of blood. An abdominal CT scan revealed a large amount of blood around the liver with no active extravasation. An arteriogram revealed no active bleeding source and no pseudoaneurysm. Due to the degree of hemoperitoneum, exploratory laparotomy was performed and the perihepatic hematoma was evacuated. No active source of bleeding was identified. On POD 9 following exploration, NH developed recurrent bleeding in her JP drain. This bleeding was self-limited, ending within minutes. Subsequently NH became orthostatic and developed melena. EGD revealed hemobilia. NH then underwent arteriography revealing a hepatic artery aneurysm from a branch of her right hepatic artery. For treatment of this aneurysm, her right hepatic artery was coil-embolized. The etiology of this aneurysm was likely a consequence of her initial operation when her portal mass was resected. During this resection, her right hepatic artery may have been injured but was not clinically evident immediately. Over the ensuing two weeks, however, a small area along the artery probably broke down leading to the formation of a pseudoaneurysm which was likely responsible for her initial episode of bleeding. The immediate question becomes “Why was the pseudoaneurysm not appreciated on the initial arteriogram?” The small pseudoaneurysm was not identified on abdominal exploration. This is not unusual especially in a previously operated field. It does seem unusual, however, that a bleeding pseudoaneurysm was not appreciated on the initial arteriogram. On reevaluation of the studies, it was appreciated that her original JP drain was sitting immediately adjacent to the right hepatic artery. It therefore may have been involved in both trauma to the artery as the vessel beat against this foreign body and in obscuring detection of the bleeding hepatic artery pseudoaneurysm.
188 Use of a Polytetrafluoroethylene Tube and Patch in the Repair of a Difficult Duodenal Stump Nestor A Gomez, Eduardo Roura, Carlos Leon, Paola Vargas, Jorge Zapatier, Institute of Digestive Diseases “Esperanza Foundation”, Guayaquil, Ecuador; University of Guayaquil, Guayaquil, Ecuador Introduction: Special care must be taken to avoid any complication in the duodenal stump such as suture dehiscence. We wish to communicate the successful results obtained with a polytetrafluoroethylene tube and patch used to repair a duodenal stump that suffered dehiscence of the sutures several times. Case Report: This is a case of a 35years-old woman in whom a hepaticojejunostomy was performed previously, due to an iatrogenic choledocus injury. Because of bile leakage drainage, a second celiotomy was indicated, and a duodenal wall defect with edematous borders was found. The primary repair was unable, so a partial section of the duodenum was made. During the next 24 days, the patient suffered dehiscence of the sutures in the duodenal stump 3 times. Because of the difficulty in closing the borders, a polytetrafluoroethylene tube was sutured to the duodenal borders, and exteriorized through the lateral abdominal wall. The patient improved, and 30 days later the duodenal wall was not edematous. The tube was withdrawn, and a polytetrafluoroethylene patch was sutured covering the duodenal stump. The patient had a good evolution and was discharged with periodical checkouts. Discussion: Primary repair is the first choice of treatment for gut wall defects. In our patient primary closure was not possible because of the inflammation of the duodenal wall, a leading factor in the incompetence of the stump sutures. Clinical and experimental trials had tested the effectiveness