Surgery is the only known curative treatment option for cholangiocarcinoma. Ex situ liver surgery and autotransplantation are promising approaches in cases that cannot be treated by conventional methods and particularly in the presence of centrally localized liver tumors as well as tumors that invade the main vascular structures. A 53-year-old female patient presented with abdominal pain and nausea. Abdominal tomography showed a tumoral mass lesion that filled the left lobe of the liver and invaded the left hepatic vein and the inferior vena cava. Cholangiocarcinoma diagnosis was reached based on biopsy findings, and the patient was scheduled for surgery as positron emission tomography did not indicate any other disease focus. The patient underwent ex situ liver resection and autotransplantation. She was discharged on the 7 th postoperative day. A 68-year-old male presented with abdominal pain, weakness, and weight loss. Laboratory analysis indicated elevated carbohydrate antigen 19-9: 400 U/ml and alpha-fetoprotein (AFP): 2000 U/ml, and there was no other pathology. Abdominal tomography showed a mass that filled the center of the liver and invaded the left hepatic vein and the inferior vena cava. Pathological findings of the biopsy sample were reported as combined hepatocellular-cholangiocellular carcinoma. The patient's AFP levels continued to increase despite transcatheter arterial chemoembolization and radiofrequency ablation therapy. Surgery was decided as indocyanine green clearance test, and the result was 8.5%. He underwent ex situ liver resection and autotransplantation. Unfortunately, he died on the 4 th postoperative day due to respiratory failure. Ex vivo liver resection and partial liver autotransplantation should be considered for the surgical treatment of locally advanced cholangiocarcinomas that invaded the main vascular structures.
Castleman disease is a lymphoproliferative disorder with unknown etiology and pathogenesis. While the disease may involve all parts of the body, the mediastinum appears to be the most common part of involvement. In this study, we present two cases of Castleman disease with different localizations that mimicked malignancy. A 62-year-old female patient presented with jaundice. Laboratory analysis indicated aspartate aminotransferase: 250 U/L, total bilirubin: 4 mg/dl, and carbohydrate antigen (CA) 19-9: 900 U/ml. Computerized tomography (CT) of the abdomen showed a mass originating from the pancreas head which resulted in a biliary tract obstruction. A positron emission tomography-computed tomography (PET/CT) showed that the only site of involvement was the pancreas head. A decision was made to perform pancreaticoduodenectomy. During intra-abdominal exploration, lymphadenopathies were identified in the surroundings of the retropancreatic portal vein and the hepatic artery. Histopathological investigation of the dissected lymph nodes demonstrated findings consistent with granulomatous plasma-cell-rich Castleman disease. A 55-year-old female patient presented with abdominal pain, nausea, and vomiting. Computerized tomography of the abdomen showed an abdominal mass of 7 cm, originating from the mesenterium, with high-contrast uptake in the mesenterium in the lower abdominal quadrant. The mesenteric mass was resected along with segmentary small intestine resection. Histopathological investigation of the mass showed a giant granulomatous structure that consisted of plasma cells consistent with Castleman disease. Castleman disease should be kept in mind during differential diagnosis of locally advanced lymph nodes observed during preoperative investigations and intraoperative exploration.
Surgery is the only treatment method in pancreatic cancer. Unfortunately, metastatic diseases or invasion of the main vascular structures are observed in a majority of cases at the time of diagnosis; these structures originate from the body, neck, and tail of the pancreas and are considered inoperable. The first celiac artery resection for the treatment of cancer was described by Appleby in 1953. Here, we describe our hepatic artery reconstruction technique in a case with pancreatic body cancer. A 37-year-old male patient was admitted to our emergency department due to syncope. The patient was diagnosed with acute renal failure secondary to fluid loss. Thereafter, his general condition was stable and laboratory results improved. Abdominal computed tomography was performed. Pancreatic cancer originating from the pancreatic body was detected. A pancreatic biopsy was performed and neoadjuvant gemcitabine and paclitaxel chemoradiotherapy were initiated. Surgical treatment was recommended for the identification of regression after neoadjuvant chemoradiotherapy. Following intraoperative Doppler ultrasonography, en bloc distal pancreatectomy and splenectomy involving the celiac artery trunk and total gastrectomy were performed. However, surgical margin reliability in frozen section revealed that the tumor was still present. Therefore, the surgical procedure was replaced with total pancreaticoduodenectomy. Hepatic artery reconstruction was performed from the left main iliac artery using a 4-mm ringed GORE-TEX® graft. The iliac-hepatic bypass for hepatic artery reconstruction in pancreatic cancer could be an alternative surgical technique.
The incidence of complex hepatobiliary injury secondary to blunt abdominal injuries varies between 3.4 and 5%. A 25-year old male patient underwent an urgent operation due to a motorcycle accident. During intraabdominal exploration, Grade 4 laceration was detected at the liver and bleeding was controlled through primary repair. In the postoperative seventh day, he was referred due to 1500 cc bile leakage from the drainage tube. During the operation, an extensive Kocher maneuver was done and the second part of duodenum was observed to be exposed to total avulsion from the head of the pancreas. Pancreatoduodenectomy was planned due to presence of ischemic changes in the second part of duodenum. In the postoperative follow-up, the abdomen was closed with a controlled abdominal closure procedure. The clinical findings of biliary tract injuries secondary to blunt abdominal injuries often manifest themselves late and early diagnosis is possible only with suspicion.
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