Clinical outcomes of left hepatic trisectionectomy for hepatobiliary malignancy

Background

Left hepatic trisectionectomy (LHT) is a challenging major anatomical hepatectomy with a high complication rate and a worldwide experience that remains limited. The aim of this study was to describe changes in surgical practice over time, to analyse the outcomes of patients undergoing LHT for hepatobiliary malignancy, and to identify factors associated with morbidity and mortality.

Methods

A cohort study was undertaken of patients who underwent LHT at a single tertiary hepatobiliary referral centre between January 1993 and March 2013. Univariable and multivariable analysis was used to identify factors associated with short- and long-term outcomes following LHT.

Result

Some 113 patients underwent LHT for colorectal liver metastasis (57), hilar cholangiocarcinoma (22), intrahepatic cholangiocarcinoma (12) and hepatocellular carcinoma (11); 11 patients had various other indications. Overall morbidity and 90-day mortality rates were 46·0 and 9·7 per cent respectively. Overall 1- and 3-year survival rates were 71·3 and 44·4 per cent respectively. Total hepatic vascular exclusion and intraoperative blood transfusion were independent predictors of postoperative morbidity, whereas blood transfusion was the only factor predictive of in-hospital mortality. Time period analysis revealed a decreasing trend in blood transfusion, duration of hospital stay, and postoperative morbidity and mortality in the last 5 years.

Conclusion

Morbidity, mortality and long-term survival after LHT support its use in selected patients with a significant tumour burden.

Right salpingo-ovarian and distal ileal entrapment within a paracaecal hernia presenting as acute appendicits

INTRODUCTION

Pericaecal hernias are a rare subgroup of internal abdominal hernias that present with abdominal pain and occasionally with features of bowel obstruction.

PRESENTATION OF CASE

A 72 year old female presented with a 24-h history of sharp, localised right iliac fossa pain, and no other symptoms. Clinical examination confirmed localised peritonism in the right iliac fossa. A tentative diagnosis of acute appendicitis was considered but in view of age a CT scan was performed. An area of abnormality in the right iliac fossa region was noted. At laparoscopy a macroscopically normal appendix and caecum was found. A smooth non-indentable mass in the lateral right iliac fossa contained loops of distal ileum, passing through a retro-caecal mesenteric defect consistent with a paraceacal hernia, with entrapment of the right ovary and fallopian tube. A right salpingectomy as performed and subsequent histopathological examination confirmed infarction of the fallopian tube.

DISCUSSION

Internal abdominal hernias are reported to have a post mortem incidence ranging between 0.2 and 0.9% of which only 10-15% are accounted for by pericaecal hernias. Types of pericaecal hernias include: ileocolic, retrocaecal, ileocaecal and paracaecal. These hernias are predisposed by the embryological development of the caecum retracting to the posterior abdominal wall and forming potential fossae.

CONCLUSION

This case highlights the need to consider a pericaecal hernia as a differential cause of right iliac fossa peritonism, and an indication for radiological imaging such as CT scan when the history is atypical for acute appendicitis.