Central hepatectomy (CH) is also known as mesohepatectomy and means hepatic resection of segments 4, 5, and 89. Hepatic lesions located in these segments may require extensive resections, such as right, left, extended right or extended left hemi-hepatectomies especially due to their relationship to major vascular and biliary structures. CH represents a potential risk of intraoperative bleeding, biliary injury, and risk of positive margins, but also represent the appealing concept of parenchyma sparing, furthermore in benign lesions.
Is reported a case of a symptomatic patient with a large complex cystic tumor who underwent a CH without tumor violation and no major postoperative complication.
A 61-year old female patient with history of choluria, acholic stools, jaundice and pain in the right upper abdominal quadrant had undergone a cholecystectomy and hepatic cyst unroofing by laparotomy in another institution, 30 months ago. Due to the cholestatic symptoms recurrence, she was refered to our center.
Abdominal MRI showed a cystic lesion in segment 4 with septa and thickened walls, and measuring 9.0 cm. The cyst was demonstrated as isosignal on T1 and hyperintense signal on T2. The confluence of left and right bile ducts was compressed by the cyst, which caused moderate bilateral dilation. The lateral limit of the cyst compressed the left hepatic artery and the left branch of the portal vein, while its lower limit compressed the right portal branch and the right hepatic artery. Other non-complex cystic lesions were scattered through the liver (Figure1). Laboratory tests showed increased canalicular enzymes and bilirubins and negative tumor markers. The case was reviewed at a weekly hepatobiliary multidisciplinary conference and the main hypothesis was a recurred biliary cystadenoma. In order to avoid a right trisectionectomy the decision was to perform a parenchymal preserving resection - central hepatectomy.
The main indications of the use of laparoscopic liver surgery (LLS), in the early days, were benign liver lesions. As LLS became more popular, indications for malignant diseases outnumbered those for benign ones. This study aims to rule out the indications and results of LLS for the treatment of benign liver tumors.
Out of 445 LLS performed in a single center, 100 (22.4%) were for benign tumors. The authors discuss the indications for resection and present their perioperative results.
In total, 100 patients with benign tumors were evaluated. Specifically, these were as follows: 66 cases of hepatocellular adenomas; 14 cases of biliary mucinous neoplasm; 13 cases of focal nodular hyperplasia; 4 cases of angiomyolipomas; and 3 cases of hemangiomas with a mean size of 7.6 cm (ranging from 3.1 to 19.6 cm). The total morbidity rate was 19%, with 9% classified as Clavien-Dindo grades 3 or 4. No mortality was observed.
LLS for benign liver tumors is safe and presents excellent results. However, indications for resection are increasingly restricted and should not be performed just because it is a minimally invasive procedure.
Many patients with serous cystadenoma of the pancreas (SCP) underwent surgery due to diagnostic doubt.
The aim of this study was to analyze the causes of low accuracy in diagnosing SCP.
This is a retrospective study of patients with SCP from a database of two hepatopancreatic biliary surgery outpatient clinics between 2006 and 2020. Patients with typical SCP lesions in imaging exams (e.g., tomography, magnetic resonance imaging [MRI], and endoscopic ultrasound [EUS]) and patients whose pathological testing confirmed this diagnosis were included.
A total of 27 patients were included in this study. Most patients were women (85.18%), and the mean age was 63.4 years. Only one patient had typical pancreatitis symptoms. MRI was the most performed method (62.9%). The lesion was single in 88.9%, and the average size was 4 cm. The typical microcystic aspect was found in 66.6%. EUS was performed in 29.6% of cases. The mean carcinoembryonic antigen value in patients undergoing cyst puncture was 198.25 ng/mL. Surgical treatment was performed in 10 cases (37%). The cause of surgery in seven of these cases was due to a suspicion of mucinous cystadenoma based on an identification of atypical lesions (unilocular with or without septa and macrocystic) in imaging exams. A suspicion of intraductal papillary mucinous neoplasm with “worrying factors” was the indication for surgery in two cases. The last case underwent surgical treatment for a solid-looking lesion which was suspected of cancer. The complication rate ≥Clavien-Dindo 2 was 30%, and the clinically relevant pancreatic fistula rate (B and C) was 30%. Mortality was nil.
The atypical morphological presentation of SCP, particularly unilocular and macrocystic lesions, is the main indication for surgery. Only the implementation of new, efficient, and reproducible diagnostic methods can reduce the number of unnecessary surgeries among these patients.
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