Step-up approach in emphysematous hepatitis: A case report

BACKGROUND

Emphysematous hepatitis (EH) is a rare, rapidly progressive fulminant gas-forming infection of the liver parenchyma. It is often fatal and mostly affects diabetes patients.

CASE SUMMARY

We report a case of EH successfully managed by a step-up approach consisting of aggressive hemodynamic support, intravenous antibiotics, and percutaneous drainage, ultimately followed by laparoscopic deroofing. Of 11 documented cases worldwide, only 1 of the patients survived, treated by urgent laparotomy and surgical debridement.

CONCLUSION

EH is a life-threatening infection. Its high mortality rate makes timely diagnosis essential, in order to navigate treatment accordingly.

Spontaneous rupture of hemorrhagic hepatic cyst: two case reports

Background

Spontaneous rupture of a hemorrhagic hepatic cyst is extremely rare. There is no standard treatment recommended for this condition. We report two cases of hemorrhagic hepatic cysts that spontaneously ruptured and were successfully treated with laparoscopic deroofing. We review the literature and discuss the characteristic features of spontaneous rupture of hemorrhagic hepatic cysts and their treatment.

Case presentation

The first patient was an 85-year-old man admitted for sudden-onset right hypochondralgia and fever. Computed tomography revealed a 13-cm hepatic cyst occupying the right lobe of the liver and spontaneous rupture of the cyst. Laparoscopic deroofing was performed and continuous oozing from the cystic wall was found. Histological examination revealed a simple hepatic cyst. The patient was discharged on postoperative day 6. In the second case, a 77-year-old woman who had been followed up for a simple hepatic cyst (13 cm) was admitted for sudden onset of right hypochondralgia. Computed tomography demonstrated a 9.9-cm hepatic cyst occupying segment 4 of the liver. Laparoscopic deroofing was performed and continuous oozing from the cystic wall was observed. Histological examination revealed a simple hepatic cyst. The patient was discharged on postoperative day 6.

Conclusion

Laparoscopic deroofing was performed in patients with spontaneous rupture of hemorrhagic nonparasitic hepatic cysts.

Comparison of aspiration with sclerotherapy and laparoscopic deroofing for the treatment of symptomatic simple renal cysts: a systematic review and meta-analysis

There are currently several strategies for the treatment of symptomatic simple renal cysts, such as aspiration with sclerosants and laparoscopic deroofing. However, no clear indication exists for choosing between them. Here, we carried out a systematic review and a meta-analysis of studies, which compared symptomatic and radiological success between aspiration with sclerotherapy and laparoscopic deroofing. Results were reported as relative risk (RR) and 95% confidence interval (95% CI) using laparoscopic deroofing as control group. The symptomatic and radiological successes were evaluated by 6 and 3 studies, respectively. Notably, aspiration with sclerotherapy was associated with higher risk of failure than laparoscopic deroofing (RR = 2.82; 95% CI = 1.84–4.31 for symptomatic failure; RR = 8.31; 95% CI = 4.22–16.38 for radiological failure). On the other hand, however, aspiration with sclerotherapy was associated with less frequent complications, shorter treatment duration and post-treatment hospital stay, and lower costs. Thus, our work underlines benefits and drawbacks of each intervention, raising the need for further studies to design guidelines for the management of simple renal cysts.

Refractory lymphatic ascites following laparoscopic management of renal lymphangiectasia: An unusual presentation

Renal lymphangiectasia characterised by either unilocular or multilocular cystic lesion in and around the kidney is an uncommon condition. Presentation of these lesions is quite varied, which along with its uncommon occurrence adds to the challenges in the management of this condition. Most of these cases are managed conservatively and very rarely need any intervention. We present an unusual complication of refractory lymphatic ascites following laparoscopic deroofing of a unilocular renal lymphangiectasia in a 21-year-old gentleman who presented with left flank pain. The ascitic fluid analysis suggested non-chylous lymphatic ascites. The surgical outcome was rather exasperating for the patient than the disease itself. Hence, in the interest of the patient with minimal symptoms, if the imaging is highly suggestive of renal lymphangiectasia, either no intervention or the least invasive procedures should be attempted, whenever possible.

Technical challenges in treating recurrent non-parasitic hepatic cysts

PURPOSE

Simple non-parasitic hepatic cysts (NPHC) are relatively frequent and often asymptomatic. When symptomatic, surgery is recommended. Most patients can be treated with laparoscopic deroofing. However, recurrence rate varies greatly, and there is no consensus on the optimal approach for symptomatic recurrences.

MATERIALS AND METHODS

A retrospective study on 33 patients surgically treated for symptomatic simple NPHC was performed. Recurrence was considered only when symptomatic.

RESULTS

Most patients were initially submitted to laparoscopic deroofing. Symptomatic recurrence was found in five patients treated with laparoscopic deroofing. Specific location of the cysts was a common characteristic. In three cases, recurrence was unsuccessfully treated with open deroofing, and patients were submitted to resection. Open deroofing does not offer any advantage in terms of recurrence in comparison with laparoscopic deroofing.

CONCLUSION

Laparoscopic deroofing can be proposed for symptomatic recurrent cysts, except for cysts located in S4, S7 and S8, where recurrence rates are higher and complete resection should be undertaken.

Laparoscopic deroofing for polycystic liver disease using laparoscopic fusion indocyanine green fluorescence imaging

BACKGROUND

Laparoscopic deroofing is widely used for the treatment of symptomatic polycystic liver disease (PCLD). However, bile leakage is a common complication of surgical management for PCLD. Until now, indocyanine green fluorescence imaging (IGFI) has played an active role in hepatobiliary surgery. Herein, we report the effective application of a laparoscopic fusion IGFI system, known as PINPOINT, for laparoscopic deroofing.

METHODS

In this study, we performed laparoscopic deroofing for PCLD using the laparoscopic fusion IGFI system. We conducted the procedure mainly under the normal view mode, occasionally switching to the fusion IGFI mode. First, we confirmed that the liver cysts did not contain bile using the fusion IGFI mode and then used a percutaneous puncture needle to remove the fluid from some of the giant cysts. Second, using the fusion IGFI mode, we were able to detect thin biliary branches and to adjust the division line of the cyst wall accordingly or, occasionally, to ligate the branches. Finally, we searched for and identified unexpected small bile leakage and then closed it using sutures.

RESULTS

The laparoscopic fusion IGFI system can simultaneously show fluorescent images, such as cholangiography and the liver parenchyma, on the normal color view. In the fusion IGFI mode, the intrahepatic bile duct and liver parenchyma can be easily discriminated in real time throughout the procedure. Accordingly, the laparoscopic fusion IGFI system is useful for the surgical treatment of PCLD, in which the boundary between the liver cysts and the liver parenchyma can otherwise be difficult to identify. This technique also enables the branches of Glisson's capsule to be identified without any other intervention.

CONCLUSION

The novel application of the laparoscopic fusion IGFI system allows reliable navigation for PCLD surgery.

Successful aspiration and ethanol sclerosis of a large, symptomatic, simple liver cyst: Case presentation and review of the literature

Simple liver cysts are congenital with a prevalence of 2.5%-4.25%. Imaging, whether by US, CT or MRI, is accurate in distinguishing simple cysts from other etiologies, including parasitic, neoplastic, duct-related, and traumatic cysts. Symptomatic simple liver cysts are rare, and the true frequency of symptoms is not known. Symptomatic simple liver cysts are predominantly large (> 4 cm), right-sided, and more common in women and older patients. The vast majority of simple hepatic cysts require no treatment or follow-up, though large cysts (> 4 cm) may be followed initially with serial imaging to ensure stability. Attribution of symptoms to a large simple cyst should be undertaken with caution, after alternative diagnoses have been excluded. Aspiration may be performed to test whether symptoms are due to the cyst; however, cyst recurrence should be expected. Limited experience with both laparoscopic deroofing and aspiration, followed by instillation of a sclerosing agent has demonstrated promising results for the treatment of symptomatic cysts. Here, we describe a patient with a large, symptomatic, simple liver cyst who experienced complete resolution of symptoms following cyst drainage and alcohol ablation, and we present a comprehensive review of the literature.