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In 2010, the World Health Organization classified mucin-producing bile duct tumors of the liver into two distinct entities; mucinous cystic neoplasm of the liver (MCN-L) and intraductal papillary mucinous neoplasm of the bile duct. We present the case of a patient with MCN-L having a uniquely pedunculated shape. A 32‐year‐old woman was referred to our institution with a diagnosis of biliary cystic neoplasm. She had undergone left salpingo-oophorectomy for ovarian cancer 15 years ago. Imaging studies showed an 8 cm-sized well defined, multiloculated cystic lesion suggesting a mucinous cystic neoplasm. The cystic mass was pedunculated at the liver capsule and pathologically diagnosed as MCN-L. The mass was resected with partial hepatectomy. The patient recovered uneventfully. She was discharged 7 days postoperatively. The patient has been doing well for 6 months after the operation. The patient will be followed up annually because of the favorable postresection prognosis of MCN-L.

OBJECTIVES We aimed to examine management of double hepatic artery reconstruction in patients under going living-donor liver transplant. MATERIALS AND METHODS Between January 2002 and June 2014, one thousand thirty-six living-donor liver transplants were performed at the Liver Transplant Institute of Malatya Inonu University. Living liver grafts with a single hepatic artery were used in 983 living-donor liver transplants, while grafts with double hepatic artery branches were used in 53 living-donor liver transplants. All of the liver grafts with double hepatic artery branches were right lobe grafts. Hepatic artery anastomosis technique and the other medical data of recipients who used grafts with double hepatic arteries were analyzed retrospectively. RESULTS A double hepatic artery anastomosis was created in 43 recipients, while a single anastomosis was created in the remaining 10 because of ligation of the nondominant hepatic artery branch. In 40 recipients, double hepatic artery branches in the graft were anastomosed with the recipient's right and left hepatic artery. In the remaining 3 recipients, double hepatic artery branches in the graft were anastomosed with the recipient's right hepatic artery and large segment 4 hepatic arteries. Postoperative complications related with hepatic artery anas-tomoses developed in 3 recipients: hepatic artery thrombosis (n = 1), hepatic artery aneurysm (n = 1), and hepatic artery stenosis (n = 1). A recipient with hepatic artery aneurysm immediately underwent a retransplant. A recipient with a hepatic artery thrombosis relapsed and required retransplant, which was treated with thrombectomy on postoperative day 10. A recipient with hepatic artery stenosis was followed conservatively. In our series, the incidence of complications related with double hepatic artery anastomosis was found to be 6.9%. CONCLUSIONS According to our experiences, a double hepatic artery anastomosis does not increase the risk of hepatic artery thrombosis and can be performed safely by surgeons who are experienced with hepatic vascular reconstructions in a living-donor liver transplant recipient.

Rupture of a metastatic liver tumor associated with laryngeal cancer is a very rare complication with no previous case in the literature. We present a case of ruptured liver metastases which was treated conservatively. Dynamic contrast-enhanced computed tomography demonstrated active extravasation and discontinuity of liver capsule. When the patient came to our hospital from the external medical center, we did not see active extravasation on control computed tomography. This case highlights the role of radiologic imaging in the diagnosis and follow-up of ruptured hepatic metastases.

Plastic and metal biliary stents can fail to function properly, such failure being due to a positioning error or to the migration, occlusion, or fracture of the stent. An obstructed biliary stent can act as a nidus, causing complications such as recurrent persistent cholangitis. It can also cause vascular complications (such as bleeding and the formation of pseudoaneurysms), perforate the liver capsule (causing biloma or abscess), or, in rare cases, cause intestinal obstruction or perforation. In this pictorial essay, we demonstrate various interventional radiology techniques for the treatment of biliary stent dysfunction in patients with obstructive biliary disease.Disfunção das próteses biliares plásticas ou metálicas pode ser causada por migração, oclusão, mau posicionamento ou fratura. Uma prótese disfuncional na via biliar pode atuar como

Glisson invasion by CLM is associated with a risk of margin-positive resection, leading to poor long-term outcomes after hepatectomy. This study was performed to evaluate the efficacy of intraoperative ultrasonography (IOUS) for the diagnosis of Glisson’s capsule invasion by colorectal liver metastasis (CLM). This prospective study involved 50 consecutive patients undergoing hepatectomy for CLM. Preoperatively, all patients had undergone gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI). During hepatectomy, a contrast agent (perflubutane) was intravenously injected and Glisson invasion was estimated based on three characteristic findings: a tumor thrombus, peripheral dilatation, and border irregularity/caliber change. The diagnostic abilities of the preoperative and intraoperative imaging studies were evaluated based on pathological examinations of resected specimens. Among 187 CLMs resected, pathological examinations proved Glisson invasion in 24 tumors (13%). IOUS revealed a tumor thrombus in 3 tumors (1.6%), peripheral dilatation in 4 (2.1%), and border irregularity and/or caliber change in 24 (12.8%). The sensitivity and specificity of IOUS with any of the above three findings for diagnosis of Glisson invasion was 79% and 96%, respectively, while preoperative EOB-MRI detected Glisson invasion in only four tumors (sensitivity/specificity, 17%/100%). The cutoff value of caliber change for diagnosis of Glisson invasion was set at 140% by receiver operating characteristic analysis. The R0 resection rates were not significantly different between patients with (82%) and without (85%) Glisson invasion. Identification of characteristic findings (tumor thrombus, peripheral dilatation, and border irregularity/caliber change) by contrast-enhanced IOUS is useful for the prediction of Glisson invasion by CLM.

The perihepatic space is frequently involved in a spectrum of diseases, including intrahepatic lesions extending to the liver capsule and disease conditions involving adjacent organs extending to the perihepatic space or spreading thanks to the communication from intraperitoneal or extraperitoneal sites through the hepatic ligaments. Lesions resulting from the dissemination of peritoneal processes may also affect the perihepatic space. Here we discuss how to assess the perihepatic origin of a lesion and describe the magnetic resonance imaging (MRI) features of normal structures and fluids that may be abnormally located in the perihepatic space. We then review and illustrate the MRI findings present in cases of perihepatic infectious, tumor-related, and miscellaneous conditions. Finally, we highlight the value of MRI over computed tomography.

Background: Angiomyolipoma (AML) is an uncommon mesenchymal tumour usually found in the kidney. The most common extrarenal site is usually the liver. We report a case of adrenal AML with a predominant vascular component co-existing with an adrenal adenoma. Case report: A fifty-year-old male presented with two months history of dysuria. Computed tomography showed a heterogeneous lesion involving the right adrenal gland abutting the right kidney and adjacent liver capsule. Urine noradrenaline levels were elevated. Adrenalectomy specimen showed an encapsulated mass measuring 8 x 5 x3.5 cm with a lobulated, grey to tan brown cut surface with areas of haemorrhage and tiny cystic spaces. Another yellowish nodule measuring 1.3 x 1.2 x 1 cm was also noted at one pole. Microscopy showed a neoplasm composed predominantly thick-walled vascular channels admixed with foci of smooth muscle bundles and adipocytes. Yellowish nodule showed features of adrenal adenoma. HMB-45 was negative and CD34 positivity highlighted the thick and thin walled vessels. Conclusion: We present the very first case of HMB-45 negative adrenal AML with a predominant vascular component and a synchronous adrenal adenoma.

The liver hanging maneuver (LHM) was described by Belghiti et al. to facilitate liver resection and is done classically by creating a space between the caudate lobe and the inferior vena cava starting on the edge of caudate lobe and extending cranially, in a para-caval fashion, towards the space between the right and middle hepatic veins. LHM facilitates liver transection, guides anatomical resections, decreases blood loss, facilitates harvesting of the liver graft in live donors, and also has oncological advantages. We describe a new approach named “up-to-down” to perform LHM in open and laparoscopic liver resections. This approach was mainly used in obese patients, in laparoscopic liver resections and in cases of failure of the classic approach. The advantages/disadvantages, complications, and different modalities of LHM are also summarized. The peritoneal layer between the liver capsule and the infrahepatic vena cava is opened, and a short blind dissection is initiated on the right anterolateral aspect of the inferior vena cava to the left of the hepatic vein of segment VI. The suprahepatic vena cava is exposed, and the space between the right and middle hepatic veins and the vena cava is created by gentle dissection. A 16-Fr nasogastric tube is positioned in the space between the right and middle hepatic vein, pointing inferiorly, and pushed downwards, in a para-caval manner caudally until it is seen inferiorly. The results of this approach are given. LHM facilitates liver resection, and many variations have been described worldwide in open and laparoscopic liver surgery. The up-to-down approach should be part of the surgical armamentarium in order to offer a safer way to achieve LHM in some patients.

The role of the hepatic transudation barrier in determining ascites volume and protein content in chronic liver disease is poorly understood. Therefore, the purpose of the present study was to characterize how chronic sinusoidal hypertension impacts hepatic transudation barrier properties and the transudation rate. The suprahepatic inferior vena cava was surgically constricted, and animals were exposed to either short-term (SVH; 2–3 wk) or long-term venous hypertension (LVH; 5–6 wk). Compared with SVH, LVH resulted in lower peritoneal fluid pressure, ascites volume, and ascites protein concentration. The transudation barrier protein reflection coefficient was significantly higher, and the transudation barrier hydraulic conductivity, transudation rate, and transudate-to-lymph protein concentration ratio were significantly lower in LVH animals compared with SVH animals. The sensitivity of transudation rates to acute changes in interstitial fluid pressures was also significantly lower in LVH animals compared with SVH animals. In contrast, there was no detectable difference in hepatic lymph flow rate or sensitivity of lymph flow to acute changes in interstitial fluid pressures between SVH and LVH animals. Taken together, these data suggest that decreased hepatic transudation barrier permeability to fluid and protein and increased reflection coefficient led to a decrease in the hepatic contribution to ascites volume. The present work, to the best of our knowledge, is the first to quantify an anti-ascites adaptation of the hepatic transudation barrier in response to chronic hepatic sinusoidal hypertension.

This chapter will consider normal development, functional adaptations at birth, and abnormal development. Liver and gallbladder anomalies are sometimes accompanied by abnormalities in other systems or seen as part of a fibrocystic syndrome/ciliopathy. In neonatal cholestasis, or liver failure, the liver may be biopsied. Biopsy rates in these settings vary between centers. Gene chip analysis can be performed on peripheral blood, for conditions with known genetic mutations, and biopsy is regarded by some as a “third-line” investigation in biliary atresia. Despite this, there will always be cases where biopsy is a key contributor to the multidisciplinary diagnosis of neonatal liver disease. An approach to the interpretation of patterns of liver disease, representing common diagnoses, in this age group, is presented in the settings of neonatal jaundice and liver failure. Trauma and iatrogenic causes of liver disease are considered. Intestinal failure-associated liver disease is an example of the pathologist’s role in the timing and appropriateness of transplantation, by staging liver disease and excluding additional diseases or systemic conditions. Examination of the explanted organ confirms disease processes, important in follow-up for potentially recurrent conditions. Finally, the fetal and neonatal liver can be the site of tumor formation. Salient features of these are described.

Pseudolipoma, also known as pseudolipoma of the Glisson's capsule, is an encapsulated lesion that contains degenerated fat and is enveloped by the liver capsule. In this report, we discuss a 37-year-old male presenting with dysuria and microscopic hematuria who revealed an incidental finding of a pseudolipoma on a CT scan of the abdomen.

A 57-year-old man presented to the emergency department with severe abdominal pain. Three months prior to presentation, he had sustained blunt trauma to his right side whilst cycling but had not sought medical attention. On admission, a CT scan showed small bowel obstruction and he underwent an emergency laparotomy. Intraoperatively, a subcapsular liver haematoma was identified, with incarcerated, necrotic small bowel within the liver capsule. The patient underwent deroofing of the haematoma with an omental patch and a small bowel resection with primary anastomosis. Small bowel obstruction is a common presentation in A&E and is responsible for half of emergency laparotomies in the UK each year. Although hepatic haematomas are also a relatively common complication of blunt trauma to the abdomen, associated bowel herniation into the liver capsule is very unusual. We believe this is the first time such a case of small bowel obstruction has been reported in the literature and we discuss details of operative management and highlight key learning points.

Pseudolipomas of Glisson's capsule are rare benign subcapsular liver lesions that typically affect older men. They are composed of degenerating fat that is thought to originate from a detached epiploic appendage. On Computed Tomographic (CT) imaging, pseudolipomas of Glisson's capsule are well-circumscribed and hypoattenuating compared to the hepatic parenchyma. This case report examines three consecutive CT studies in the same patient that show the pseudolipoma migrating to a hepatic subcapsular location over a period of 4.5 months. To our knowledge, this is the first documented case of a pseudolipoma migrating over time and it supports the hypothesis of a migrating epiploic appendage forming a pseudolipoma of Glisson's capsule. A comprehensive review of relevant literature and a discussion of the presented case are provided.

Background In metabolic associated fatty liver disease (MAFLD) vibration controlled transient elastography (VCTE) by Fibroscan has emerged as a non-invasive diagnostic tool for the measurement of controlled attenuation parameter (CAP) and liver stiffness measurement (LSM), which are surrogate markers for hepatic steatosis and fibrosis, respectively. However, obesity constitutes a limitation in terms of creating unreliable examinations due to increased skin to liver capsule distance. Here, we aimed to investigate the feasibility of VCTE in the evaluation of hepatic steatosis and fibrosis in obese individuals. Methods A total of 126 consecutive obese patients (body mass index ≥30 kg/m2) without a known history of MAFLD enrolled in the study. We performed CAP and LSM measurements and calculated Fibrosis-4 Index for each patient and included data of those patients to the analysis, from whom valid measurements were able to be taken. Results Reliable VCTE measurements were able to be obtained in 122 patients (97%), from those in 34 patients with M and 88 patients in XL probe (median age: 50 [18-75], 45 males and 77 females). In 1 patient VCTE failed to take any measurements and in 3 the measurements were classified as unreliable. The mean CAP value was 323 ± 48 dB/m and the median LSM value 5.3 [1.8-34.3] kPa. Conclusion CAP and LSM assessments by Fibroscan are reliable diagnostic tools for the early diagnosis of hepatic steatosis and fibrosis in obese individuals.

This study was conducted to define the effect of abdominal wall thickness (AWT) and its composition on the level of confidence in liver stiffness (LS) measurements obtained with 2-D shear wave elastography (2-D-SWE) in patients with chronic liver disease. In this retrospective study, a total of 1291 patients who underwent LS measurement by 2-D-SWE were enrolled. The abdominal wall was divided into three layers: layer 1 extended from the skin to the subcutaneous fat layer; layer 2 was the muscle layer; and layer 3 extended from the peritoneum to the liver capsule (including the omental fat layer, if present). We regarded the sums of layers 1–3 and layers 1 and 3 as the AWT and non-muscular layer thickness (NMT). Age/sex/body mass index-adjusted multivariate logistic regression analysis was performed to identify factors influencing the level of confidence of LS measurements. Three hundred eighty-six patients (29.9%) were classified in the unreliable LS group (standard deviation/median LS > 0.1). The fourth quartile of AWT and third and fourth quartiles of NMT/AWT were significantly associated with unreliable LS values (odds ratios = 2.103, 1.753 and 1.695, respectively). In conclusion, high AWT and NMT/AWT ratios reduce the confidence in LS measurements obtained with 2-D-SWE.

Background The purpose of this study was to determine the utility of some imaging findings in predicting microvascular invasion (MVI) and hepatocellular carcinoma (HCC) recurrence risk after liver transplantation. Method This retrospective study included 123 patients with histopathologically proven HCC at explant. All HCCs were classified as MVI positive (group I) or negative (group II) based on histopathological findings. In each group, multifocality, largest tumor size, bulging (tumor causing liver capsule expansion), beak sign (the acute angle between the tumor and liver parenchyma), and diffusion restriction on diffusion weighted images (DWI) were evaluated. These findings were compared between the groups by Student’s t test. The relation between the parameters and MVI was analyzed by using the Spearman’s correlation test. Results Of the total patients, 30.1% had MVI (group I) and 69.9% (group II) did not have MVI. Presence of beak sign (P ≤ .005), bulging sign (P = .002), and diffusion restriction (P = .045) were significantly more frequent in group I than group II. The beak sign, bulging sign, and diffusion restriction were correlated with presence of MVI. Largest tumor size and multifocality were higher in group I than group II, but the differences were not statistically significant. Conclusion Radiologists and transplant surgeons should be aware of some clue imaging findings, especially beak and bulging signs because these findings may predict the presence of MVI in HCC. These patients might benefit from histologic confirmation of the tumor characteristics through biopsy and subsequent bridging treatment options before liver transplantation to reduce the risk of recurrence.

Ultrasound examination (ultrasound) takes the first place first among visual methods for analyzing the state of the liver parenchyma. Despite the improvement of ultrasound technology, it does not provide the necessary diagnostic accuracy in determining the stages of liver fibrosis. In this regard, it is necessary to search for additional diagnostic criteria to judge the state of the liver tissue and its superficial structures, primarily liver capsules.Materials and methods: the state of the liver capsule was assessed in 73 children of four age groups (2-18 years) without pathological changes in the hepatobiliary system, which were performed by ultrasound of the abdominal organs during preventive examinations. The structure of the capsule of the liver and visceral peritoneum was evaluated. Results. Direct dependence of the thickness of the liver capsule on the age of children was established (rs = 0.577, p = 0.0000). The capsule and visceral peritoneum represented a single and even echogenic structure (95.9%). Stratification of the leaves was detected in 8 children. A change in the shape of the edge of the right lobe of the liver was observed in 4 children. An increase in the severity of subcapsular blood flow in the liver was not detected in any healthy child.

Background: Radiofrequency ablation for liver tumours is a common practice because of its many advantages including feasibility, relatively low cost, being a day case procedure, and minimal invasiveness. Sub-capsular hepatomas manage-ment represents a challenge due to liability of thermal injury to major organs and occurrence of serious complications.Aim of Study: To assess the safety and technical efficacy of percutaneous radiofrequency ablation after artificial ascites in sub-capsular hepatoma.Methods: In our study, 18 patients had hydro dissection procedure done to facilitate ultrasound guided Radiofrequency Ablation (RFA) for sub-capsular hepatic lesions. Hydro dissection was performed with 5% dextrose in water to displace adjacent structures away from the liver capsule. RFA system with cluster or single internally cooled electrodes were used for treatment of hepatic malignancies. The feasibility, safety, and efficacy of this technique were assessed on follow-up.Results: Our patients' mean age was 59.6 years old. No major complications related to hydro dissection were recorded. One of our patients had a thermal injury (5.5%). No patients suffered from biliary injury, haemorrhage or tumour seeding. Mean hydro dissection displacement of nearby organs was 1.6cm.Conclusion: Hydro-dissection (artificial ascites) proved to improve technical efficacy and safety for ultrasound guided radiofrequency of sub-capsular hepatomas.

An incidental chest x-ray finding of an oval soft tissue opacity in the right costophrenic recess in a 55-year-old man prompted further investigation by unenhanced CT which demonstrated a 3.9 cm diameter lesion of fluid density intimately related to the lateral aspect of the right hemidiaphragm and right lobe of the liver. It was not possible on CT to determine whether this was intrapulmonary, an unusual exophytic hepatic simple cyst, or a diaphragmatic cystic abnormality. Subsequent ultrasound, however, allowed the diagnosis of a diaphragmatic mesothelial cyst by confirming an anechoic, thin-walled cystic structure separate from the liver capsule, from which it moved independently, with a fixed relationship to the diaphragm and splitting of muscular fibres of the right hemidiaphragm around its periphery. This case serves to highlight a rare congenital abnormality of the hemidiaphragm as a cause of a pulmonary nodule visible on a chest radiograph and to illustrate the usefulness of ultrasound in confirming the diagnosis. It also allows a critical review of the literature on intradiaphragmatic mesothelial cysts in adults and children. Keywords: Diaphragm, Mesothelial cyst, Intradiaphragmatic, Congenital

Background: Primary Hepatic Epithelioid Haemangioendothelioma (HEHE) and Primary Hepatic Angiosarcoma (PHA) are rare mesenchymal tumours with different malignant potential. Whereas HEHE demonstrates low to intermediate malignant potential, PHA is an aggressive malignancy with poor prognosis. The knowledge of typical imaging features of these lesions may facilitate correct diagnosis; however, the ultimate diagnosis of HEHE and PHA is based on histopathologic examination. Discussion: The most typical findings helpful in diagnosing HEHE are: Presence of multiple, confluent nodules located at the liver periphery (in young to middle-aged woman), retraction of the liver capsule, marked hyperintensity on T2-weighted images, “target-sign” appearance, progressive centripetal contrast enhancement, and relatively high Apparent Diffusion Coefficient (ADC) values. More than ≥50% of nodules are hyper- or isointense on Hepatobiliary Phase (HBP) images. Conclusion: The imaging features suggestive of PHA are: Occurrence of metastases (lungs, spleen) at the time of diagnosis, presence of a large dominant mass with smaller satellites, heterogeneity and areas of haemorrhage in a dominant mass, progressive contrast enhancement, slightly elevated ADC values as compared to other malignant liver tumours.

Aim: The difficulty of detecting lesions smaller than 1 cm in the preoperative period is still a continuing problem in peritoneal carcinomatosis. Methods: The prospective data of 106 peritoneal carcinomatosis patients were included this study. Preoperative AFP, carcinoembryonic antigen, CA19.9, CA125, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, mean platelet value, platelet distribution width, red cell distribution width and radiological findings compared according to Glisson capsule tumor involvement. Results: Preoperative radiological imaging methods have low accuracy in demonstrating Glisson capsule involvement. Inflammatory and serum tumor markers, except CA125, have been shown to be ineffective at detecting preoperative Glisson capsule involvement. CA125 levels higher than 52.4 were found to be significant in indicating Glisson's capsule involvement. Conclusion: CA125 is more sensitive than radiological and nuclear imaging methods in detecting tumors smaller than 1 cm.

Background We sought to expand the clinico-anatomical limit of the proximal ductal margin (Limit-PDM) for resectability of hilar cholangiocarcinoma (HCCA). Methods The practical boundary of the hilar plate (PBHP) was defined as the location where the bile duct (BD) could not be isolated by dissection. The distance between PBHP and two well-known clinical landmarks of Limit-PDM, the right edge of the bifurcation of the anterior and posterior branch of the right portal vein (Posterior-Landmark) and the left edge of the umbilical portion of the portal vein (Left-Landmark), and histological features around the PBHP were assessed using 55 adult cadaver livers. Results BD was almost always isolatable beyond the traditional clinical landmarks. The median distance was 6.9 mm (interquartile range [IQR] 6.0-8.3 mm) between the PBHP and the Posterior-Landmark, and 8.9 mm (IQR 6.7-10.2 mm) between the PBHP and the Left-Landmark. Histologically, the sheath surrounding the portal triad was loose, thick with few elastic fibers and small arteries near the hepatic hilum. Near the PBHP, the sheath was dense, thin, and abundant with elastic fibers and small arteries. Conclusions Limit-PDM is more peripheral than the traditional clinical landmark-based margin and histological transition near the PBHP was revealed.

Laparoscopic left hemihepatectomy using the Glissonian approach is technically challenging secondary to a thick Glissonian pedicle and limited maneuverability of laparoscopic instruments. This procedure demands extreme caution owing to the high risk of bile leakage associated with left hemihepatectomy. We describe the technical details and surgical outcomes of the intrahepatic Glissonian approach to the ventral aspect of the Arantius ligament in laparoscopic left hemihepatectomy. After detachment of the left side of hilar plate, the meticulous dissection was performed in the liver capsule above the left Glissonian pedicle. Dissection of the ventral aspect of the Arantius ligament creates the space between the liver parenchyma and the left Glissonian pedicle. The left Glissonian pedicle was isolated and encircled using the long curved laparoscopic instrument. During the parenchymal transection, the left Glissonian pedicle was transected using lateral to the Arantius ligament. Between February 2013 and July 2018, 13 consecutive patients underwent pure laparoscopic left hemihepatectomy. The median operation time was 230 min (range 180–300 min), and the median estimated blood loss was 300 mL (range 100–600 mL). Two patients (15%) required transfusion. The median tumor size was 40 mm (range 10–105 mm). All patients showed negative resection margins. The median postoperative hospital stay was 8 days (range 6–15 days). Major postoperative complications occurred in 1 patient (7.7%). No perioperative deaths occurred. An intrahepatic Glissonian approach to the ventral aspect of the Arantius ligament is a feasible and effective technique in laparoscopic left hemihepatectomy.

Attenuation imaging (ATI) is a new noninvasive ultrasound technique for assessing steatosis grade (S). However, validated region-of-interest (ROI) sampling strategies are not currently available. We investigated the diagnostic performance of various ATI-ROI positions for determining histopathologic S in patients with nonalcoholic fatty liver disease (NAFLD). This retrospective study included 105 patients with biopsy-proven NAFLD. All attenuation coefficient (AC, dB/cm/MHz) measurements were obtained by the same hepatologist using a commercially available ultrasound system on the same day as liver biopsy. Mean (± standard deviation) age and body mass index of the patients were 53 (± 18) years and 27.1 (± 4.1) kg/m2, respectively. The numbers of patients with steatosis affecting 66% of hepatocytes were 8, 50, 29, and 18, respectively. The ATI-ROI was placed at three different positions for AC measurement using a dedicated workstation: the upper edge of the area ROI, twice the depth of the liver capsule, and the lower edge of the area ROI. Diagnostic performance was evaluated using the area under the receiver-operating characteristic curve (AUC). The AUCs of AC at the three ATI-ROI positions were 0.734 (95% confidence interval [CI]: 0.470–0.998), 0.750 (0.639–0.861), and 0.878 (0.788–0.968) for S ≥ 1; 0.503 (0.392–0.615), 0.824 (0.741–0.907), and 0.809 (0.724–0.895) for S ≥ 2; and 0.606 (0.486–0.726), 0.849 (0.767–0.932), and 0.737 (0.626–0.848) for S = 3, respectively. For accurate steatosis grade assessment, the ATI-ROI should not be placed at the upper edge of the area ROI.

Background Fascioliasis is a food-borne hepatobiliary zoonosis caused by Fasciola hepatica and Fasciola gigantica. Human infestations are predominantly seen in developing countries where the disease is endemic, but, due to the increase in international travel rates, hepatic fascioliasis is also appearing in nonendemic areas including Europe and the USA. The clinical and laboratory findings are usually nonspecific. Cross-sectional imaging can be very helpful in the diagnosis of fascioliasis as well as to differentiate it from other liver diseases with a very similar clinical picture. The objectives of this case report are to discuss imaging findings of hepatic fascioliasis and to review the literature. Case presentation We report the case of a 35-year-old Iranian patient who presented with right upper quadrant pain, low-grade fever, fatigue, and anorexia. The patient had a history of recent travel to the Gilan Province of Iran, almost a month before the onset of symptoms, which is an endemic area of fascioliasis in the country. Laboratory examinations revealed eosinophilia, elevated hepatic enzymes, and slightly raised C-reactive protein. Contrast-enhanced computed tomography of the patient shows clusters of focal ill-defined hypodense lesions with mild peripheral enhancement in the right liver lobe and subcapsular regions. Magnetic resonance imaging of the liver revealed multiple ill-defined lesions of low signal intensity on the T1-weighted image and high signal intensity on the T2-weighted image, extending from the liver capsule into deeper parenchyma toward periportal regions, which shows mild peripheral enhancement on post-contrast images. Imaging-based diagnosis of fascioliasis was made depending on the characteristic distribution of subcapsular tracts/lesions on the above-mentioned imaging, which was then confirmed by serologic tests using enzyme-linked immunosorbent assay. The patient was treated with triclabendazole, showing great clinical improvement, and was eventually discharged in good health condition. Conclusion The imaging findings in this case report highlight the importance of cross-sectional imaging for further evaluation of suspected cases of fluke-induced liver disease. The hypothesis of hepatic fascioliasis should be always considered when consistent radiological findings are observed. Clusters of tortuous subcapsular lesions with peripheral contrast enhancement extending into deeper liver parenchyma are characteristic imaging findings that strongly suggest hepatic fascioliasis.

Glisson’s capsule which covers the liver extends into the liver at the hilus and covers the portal triad, where it is called Glisson’s sheath. Glisson’s capsule also covers the Glissonian pedicles inside the liver. Couinaud called this sheath the Valoean sheath, after Valoeus, an anatomist from the Middle Ages who first described the liver capsule. The term ‘Glissonian sheath’ is generally used only to refer to the portion of the Glissonian pedicle inside the liver. This paragraph is reprinted from: Lunan Yan, Operative Techniques in Liver Resection. Springer, 2016. ISBN 978-94-017-7409-3.

El hemoperitoneo secundario a estallido hepático no traumático es una causa poco frecuente de abdomen agudo. Se presenta el caso de una paciente con estallido hepático secundario a metástasis de un tumor del estroma gastrointestinal (GIST) que requirió una laparotomía emergente por inestabilidad hemodinámica. Se evidenció intraoperatoriamente una lesión de más de 20 cm dependiente de la pared posterior gástrica y un hemoperitoneo secundario a estallido de metástasis hepáticas y descapsulación de la cápsula de Glisson. Una complicación frecuente de los GIST es la rotura que ocasiona hemorragia digestiva o hemoperitoneo, como ocurrió en nuestro caso.

Hepatogenic photosensitization in cattle is a pathology that can be caused by several diseases, such as chronic fasciolasis, as a consequence of the damage provoked, causing an inability of the liver to excrete photodynamic agents. Fasciolasis is a disease of high prevalence in Uruguay. Photosensitization is one of the clinical signs that can be observed in chronic fasciolasis, based on its ability to produce liver fibrosis, cholangitis with biliary stasis. In this work, two outbreaks of hepatogenic photosensitization in cattle are described in the counties of Tacuarembo and Soriano (Uruguay). The disease affected a herd of Hereford and crossbreed cows, and a herd crossbreed heifers. In both outbreaks animals were grazing in humid woodlands. The main clinical signs observed were weight loss, crusting and peeling of the nose, photophobia, sialorrhea and eye shifts. Main macroscopic findings at necropsy were bilateral necrotic dermatitis of the eyelids, ulcers on the ventral side of the tongue. Thickening of the liver`s Glisson capsule, diffuse hepatic fibrosis and chronic cholangitis with canalicular calcification. Histopathology showed liver fibrosis and canalicular obstruction with the presence of Fasciola hepatica as main lesions. The clinical signs of hepatogenic photosensitization observed in animals are related to the described liver disorders caused by F. hepatica

Intrahepatic cholangiocarcinoma (ICC) represents the second most common primary liver tumor after hepatocellular carcinoma. These tumors arise from the bile ducts epithelium, peripheral to the secondary bifurcation of the left or right hepatic duct. Although most cholangiocarcinomas occur sporadically, the disease incidence is higher, and it develops earlier in the patients with primary sclerosing cholangitis (PSC), choledochal cyst, Caroli disease, clonorchiasis, and viral hepatitis (especially type C). According to their growth pattern, ICCs can be classified into three types: mass-forming, periductal-infiltrating, or intraductal-growing cholangiocarcinoma. Imaging plays the most important role in preoperative characterization of ICC with mass-forming type presenting as lobulated hypovascular lesions causing retraction of liver capsule and peripheral bile duct dilatation. Periductal-infiltating type is very difficult for timely diagnosis and is usually discovered in follow-up of PSC patients as worsening of dominant stricture. Intraductal-growing cholangiocarcinoma is the rarest type of ICC with much better outcome than other ICC forms. It presents usually as polypoid lesion filling the bile ducts with proximal biliary dilatation.

Background: Obesity is a primary limiting factor in liver stiffness measurement (LSM). The impact of obesity has always been evaluated in terms of body mass index (BMI), without studying the effects of skin-to-liver distance (SLD) on LSM. We studied the impact of SLD on LSM in a cohort of obese patients undergoing bariatric surgery and intra-operatory liver biopsy. Materials and Methods: 299 patients underwent LSM by point-shear wave elastography (ElastPQ protocol), with two different ultrasound machines. SLD was measured as the distance between the skin and the liver capsule, perpendicular to where the region of interest (ROI) was positioned. We used the following arbitrary cut-offs

To evaluate the long-term outcomes of surgical treatment of intrahepatic cholangiocarcinoma depending tumor dimensions, vascular invasion, lymph node metastases, cellular differentiation and quality of resection.There were 46 patients with intrahepatic cholangiocellular cancer. Extended hemihepatectomy was made in 14 patients (30.4%), resection of two and three liver segments - in 17 cases (36.9%), standard hemihepatectomy - in 15 patients (32.6%). Liver resection was combined with extrahepatic bile duct resection in 5 (10.9%) patients. Liver resection was followed by biopsy of specimens. Dimension and number of tumors, differentiation grade, resection margin, liver capsule invasion, vascular invasion and regional lymph node metastases were analyzed. Forty-four (95.6%) patients were followed-up in long-term postoperative period. Statistical analysis was performed using Statistica 13.2 (Dell Inc., USA) and IBM SPSS Statistics v.25 (IBM Corp., USA) software package. Survival was analyzed using the Kaplan-Meier method. Overall 1-, 3- and 5-year survival rates with two-sided 95% confidence intervals (95% CI) were calculated using IBM SPSS Statistics v.25 software.Median survival was 37 months, 1-year - 75.9% (60.9-90.9%), 3-year - 57.6% (35.5-79.6%), 5-year - 36% (8.2-63.7%). Median survival after R1 resection was 37 months, R2 resection - 12 months. Median survival was not achieved in R0 group. We found significant differences in overall survival depending on quality of resection. Tumor dimension over 5 cm, low-grade adenocarcinoma, microvascular invasion and lymph node metastases were associated with impaired postoperative survival. However, differences were not significant.The main surgical strategy in patients with intrahepatic cholangiocarcinoma should be ensuring microscopically negative resection margin.Оценка отдаленных результатов хирургического лечения внутрипеченочного холангиоцеллюлярного рака (ВПХЦР) в зависимости от размера опухоли, сосудистой инвазии, наличия метастазов в лимфатических узлах, степени дифференцировки опухоли и радикальности операции.В исследование включены 46 пациентов, оперированных в Национальном медицинском исследовательском центре хирургии им. А.В. Вишневского по поводу ВПХЦР. В 14 случаях (30,4%) выполнена расширенная гемигепатэктомия. В 17 случаях (36,9%) выполнена резекция двух и трех сегментов печени. У 15 пациентов (32,6%) произведена стандартная гемигепатэктомия. Необходимо отметить, что у 5 (10,9%) больных резекцию печени сочетали с резекций внепеченочных желчных протоков. Материал, полученный после резекции печени, подвергался морфологическому анализу. При этом определяли размер и количество опухолей, степень дифференцировки, состояние края резекции, наличие инвазии капсулы печени и сосудистой инвазии, а также наличие метастазов в регионарных лимфатических узлах. В отдаленные сроки наблюдали 44 (95,6%) оперированных больных. Статистический анализ проводилии с помощью программ Statistica 13.2 (Dell Inc., USA) и IBM SPSS Statistics v.25 (IBM Corp., USA). Анализ выживаемости пациентов осуществляли по методу Каплана—Мейера. В программе IBM SPSS Statistics v.25 проводились расчеты кумулятивной 1-летней, 3-летней и 5-летней выживаемости пациентов.Медиана выживаемости составила 37 месяцев. 1-летняя выживаемость составила 75,9% (60,9—90,9%), 3-летняя — 57,6% (35,5—79,6%), 5-летняя — 36% (8,2—63,7%). При анализе влияния радикальности операции на отдаленные результаты медиана выживаемости у пациентов из группы R1 составила 37 месяцев, из группы R2 — 12 месяцев, в группе R0 — не достигнута (больные еще наблюдаются). При этом выявлены статистически значимые различия в выживаемости в группах пациентов с R0, R1 и R2. По другим сравниваемым критериям (размер опухоли, наличие микрососудистой инвазии, метастазы в регионарных лимфатических узлах, степень дифференцировки опухоли) достоверных различий между группами выявлено не было.Основной стратегией хирургического лечения ВПХЦР должна быть агрессивная хирургическая тактика, направленная на достижение микроскопически негативного края резекции.

Liver cirrhosis is a common chronic progressive disease with a high mortality rate. The early diagnosis and treatment of liver cirrhosis is an important research subject in the medical field. In this paper, a novel method is proposed for the accurate extraction of the liver capsule and auxiliary diagnosis of cirrhosis based on high frequency ultrasound images. First, a self-developed method is used to extract the predictive capsule of ultrasound images, which involves the detection of liver ascites with sliding windows, image enhancement with multiscale detail and fuzzy set, structure segmentation with morphological processing, and predictive capsule detection with traversal search method. Thereafter, the real capsule is obtained by the gray difference method according to different gray values between the liver capsule region of the original ultrasound images and the set threshold. Finally, according to the analysis of smoothness, as well as the continuity and fluctuation of predictive and real capsule, four novel features called NoL, VoS, CV, and NoF are proposed for the computer auxiliary diagnosis model. This model is designed on the basis of support vector machine and k-means clustering and can classify normal liver and three liver cirrhosis stages. The experimental results reveal that the accuracy of the liver capsule extraction using this model is 95.13% and final classification accuracy of four stages can reach 92.54%, 88.46%, 89.23% and 94.55%, respectively. The results also indicate that the method proposed in this paper can achieve the classification of liver cirrhosis stages much more accurately and efficiently compared with previously utilized methods.

The portal pressure gradient is considered clinically significant when greater than 10 mmHg. Portal hypertension is classified as prehepatic, hepatic, or posthepatic, depending on the anatomical site of flow impedance. The hepatic venous pressure gradient (HVPG) is considered the gold standard for evaluating the portal pressure gradient in cirrhotic patients with hepatic portal hypertension. HVPG is the difference between wedged hepatic venous pressure and the free hepatic venous pressure. The HVPG correlates closely with stage and outcomes in cirrhosis and accurately predicts mortality. Liver biopsy plays a central role in the diagnosis and management of both diffuse and focal liver disease. In diffuse disease, histopathological assessment establishes etiology and, by determining stage and severity, aids prognostication and management decisions. When contraindications to percutaneous liver biopsy are present, transjugular liver biopsy (TJLB) can be performed. TJLB minimizes the risk of hemorrhage because the liver capsule is not punctured and theoretically any bleeding should return to the venous circulation. Regarding liver biopsy, utilization of a coaxial system has the advantage of allowing multiple samples to be taken from a single-entry point and facilitates subsequent plugged biopsy. Coaxial biopsy is considered the preferred technique by many operators.

Due to the need for quick and effective treatments for liver diseases, which are among the most common health problems in the world, staging fibrosis through non-invasive and economic methods has become of great importance. Taking inspiration from diagnostic laparoscopy, used in the past for hepatic diseases, in this paper ultrasound images of the liver are studied, focusing on a specific region of the organ where the Glisson's capsule is visible. In ultrasound images, the Glisson's capsule appears in the shape of a line which can be extracted via classical methods in literature. By making use of a combination of standard image processing techniques and Convolutional Neural Network approaches, the scope of this work is to give evidence to the idea that a great informative potential relies on smoothness of the Glisson's capsule surface. To this purpose, several classifiers are taken into consideration, which deal with different type of data, namely ultrasound images, binary images depicting the Glisson's line, and features vector extracted from the original image. This is a preliminary study that has been retrospectively conducted, based on the results of the elastosonography examination., Comment: Paper accepted with content unaltered to publish with IEEE Xplore Digital Library - 2020 IEEE Malaysian International Biomedical Conference (MIBEC)

Background To assess the safety and efficacy of cryoablation (CA) devices for the treatment of liver cancer at special sites in a retrospective study. Methods Special site liver cancer was defined as the tumors directly abutting surrounding structures (such as the liver capsule, gallbladder, vessel, diaphragm, intestine, and adrenal gland) with a maximum distance of 1.0 cm between the tumor and these organs. Sixty-six patients (49 men, 17 women; mean age, 60.8 years; age range, 27-82 years) were included. CA procedure was performed to treat 69 tumors under the guidance of computed tomography or ultrasound. Local tumor progression was assessed during the follow-up. A visual analog scale (VAS) evaluated the pain degree. Complications were assessed during and after every procedure. Results The number of tumors under the liver capsule and adjacent to the gallbladder, portal or hepatic vein, diaphragm, intestine, and adrenal gland were 29, 5, 8, 14, 7, and 6, respectively. The median follow-up time was 14 months (range, 2-28 months). In the 69 procedures, the technical success rate was 100%. The cumulative local tumor progression rates at 6, 9, 15, and 24 months were 10.2%, 16.5%, 20.9%, and 30.5%, respectively. No cases of serious complications occurred. During operation, the occurrence rates of subcapsular hemorrhage and pneumothorax were 2.9% and 1.4%, respectively. After the operation, the occurrence rate of biloma, capsular injury, subcapsular planting metastasis, and pneumothorax were 1.4%, 18.8%, 1.4%, and 2.8%, respectively. The average score of 66 patients with a VAS was 2.15±0.63 during the operation. Conclusions Percutaneous CA is safe and effective for patients with special site liver cancer.

Fibrosis remains a serious health concern in patients with chronic liver disease. We recently reported that chemically induced chronic murine liver injury triggers increased expression of junctional adhesion molecules (JAMs) JAM-B and JAM-C by endothelial cells and de novo synthesis of JAM-C by hepatic stellate cells (HSCs). Here, we demonstrate that biopsies of patients suffering from primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC) or autoimmune hepatitis (AIH) display elevated levels of JAM-C on portal fibroblasts (PFs), HSCs, endothelial cells and cholangiocytes, whereas smooth muscle cells expressed JAM-C constitutively. Therefore, localization and function of JAM-B and JAM-C were investigated in three mouse models of autoimmune-driven liver inflammation. A PBC-like disease was induced by immunization with 2-octynoic acid-BSA conjugate, which resulted in the upregulation of both JAMs in fibrotic portal triads. Analysis of a murine model of PSC revealed a role of JAM-C in PF cell-cell adhesion and contractility. In mice suffering from AIH, endothelial cells increased JAM-B level and HSCs and capsular fibroblasts became JAM-C-positive. Most importantly, AIH-mediated liver fibrosis was reduced in JAM-B-/- mice or when JAM-C was blocked by soluble recombinant JAM-C. Interestingly, loss of JAM-B/JAM-C function had no effect on leukocyte infiltration, suggesting that the well documented function of JAMS in leukocyte recruitment to inflamed tissue was not effective in the tested chronic models. This might be different in patients and may even be complicated by the fact that human leukocytes express JAM-C. Our findings delineate JAM-C as a mediator of myofibroblast-operated contraction of the liver capsule, intrahepatic vasoconstriction and bile duct stricture. Due to its potential to interact heterophilically with endothelial JAM-B, JAM-C supports also HSC/PF mural cell function. Together, these properties allow JAM-B and JAM-C to actively participate in vascular remodeling associated with liver/biliary fibrosis and suggest them as valuable targets for anti-fibrosis therapies. (C) 2018 Elsevier Ltd. All rights reserved.

Highlights • We made Roux-en-Y hepaticojejunostomy without transhepatic billiary stent and also without Witzel drainage one month after iatrogenic high transectional lesion (Class E) of both hepatic ducts during laparoscopic cholecystectomy was performed. • We created a part of anastomosis between the jejunum and liver capsula with polydioxanone suture (PDS) 4-0 because of poor quality of the remaining parts of the hepatic ducts. We had to made two separate hepaticojejunal anastomoses (left and right) that we partly connected to the liver capsule, where we had a defect of hepatic ducts, without Witzel enterostomy and transhepatic biliary stent. • There were no significant postoperative complications. • We did magnetic resonance cholangiopancreatography (MRCP) one year after the surgical procedure, which showed the proper width of the intrahepatic bile ducts, with no signs of stenosis of anastomoses. • We tried and managed to avoid such types of drainage and proved that in this way, without those types of drainage, we can successfully do duplex hepaticojejunal anastomoses and that they can survive without complications. • Our case indicates that this approach can be successfully used for surgical repair of iatrogenic lesion of both hepatic ducts., Introduction Most of the case reports about high type iatrogenic hepatic duct injuries reports how to treat and make Roux-en-Y hepaticojejunostomy below the junction of the liver immediately after this condition is recognised during surgical procedure when the injury was made. Hereby we present a case where we made Roux-en-Y hepaticojejunostomy without transhepatic billiary stent and also without Witzel drainage one month after the iatrogenic injury. Presentation of case A 21-year-old woman suffered from iatrogenic high transectional lesion of both hepatic ducts during laparoscopic cholecystectomy in a local hospital. Iatrogenic injury was not immediately recognized. Ten days later due to patient complaints and large amount of bile in abdominal drain sac, second surgery was performed to evacuate biloma. Symptoms reappeared again, together with bile in abdominal sac, and then patient was sent to our Clinical Center. After performing additional diagnostics, high type (Class E) of iatrogenic hepatic duct injury was diagnosed. A revision surgical procedure was performed. During the exploration we found high transection lesion of right and left hepatic duct, and we decided to do Roux-en-Y hepaticojejunostomy. We created a part of anastomosis between the jejunum and liver capsule with polydioxanone suture (PDS) 4-0 because of poor quality of the remaining parts of the hepatic ducts. We made two separate hepaticojejunal anastomoses (left and right) that we partly connected to the liver capsule, where we had a defect of hepatic ducts, without Witzel enterostomy and transhepatic biliary stent. There were no significant postoperative complications. Magnetic resonance cholangiopancreatography (MRCP) was made one year after the surgical procedure, which showed the proper width of the intrahepatic bile ducts, with no signs of stenosis of anastomoses. Discussion In most cases, treatment iatrogenic BDI is based on primary repair of the duct, ductal repair with a stent or creating duct-enteric anastomosis, often used and drainage by Witzel (Witzel enterostomy). Reconstructive hepaticojejunostomy is recommended for major BDIs during cholecystectomy. Considering that the biliary reconstruction with Roux-en-Y hepatojejunostomy is usually made with transhepatic biliary stent or Witzel enterostomy. What is interesting about this case is that these types of drainages were not made. We tried and managed to avoid such types of drainage and proved that in this way, without those types of drainage, we can successfully do duplex hepaticojejunal anastomoses and that they can survive without complications. Conclusion Our case indicates that this approach can be successfully used for surgical repair of iatrogenic lesion of both hepatic ducts.

Patterned bruising of the internal organs is unusual. In these cases a cutaneous pattern of bruising is not observed but the underlying tissue may show unusual injuries that may even be recognizable as a tramline pattern. We report the suicide of a 23-year-old man by jumping off a bridge. At autopsy, an unusual finding was "tramline" bruising of the right liver lobe. The "blunt objects" that inflicted the bruising were determined to be the right ribs which were pushed against the liver capsule as a consequence of the extensive thoracic and vertebral trauma after a fall from a height with intermediate impact.

Aim The assessment of liver fibrosis in patients with hepatitis C is important to predict carcinogenesis. In this study, we evaluated the usefulness of virtual touch quantification (VTQ) for staging liver fibrosis, and investigated factors causing discrepancies between the estimated fibrosis stage using VTQ and the pathological fibrosis stage. Methods Patients with hepatitis C (n = 302) were assessed using VTQ and underwent pathological liver investigation within 1 week before and after VTQ. A receiver operator characteristic (ROC) curve was obtained for VTQ, fibrosis-4 (FIB-4) index, and aspartate aminotransferase-to-platelet ratio index (APRI), and each area under the ROC curve (AUROC) was compared to predict fibrosis stage. We used univariate and multivariate analyses to investigate the factors related to the discrepancy between the estimated fibrosis stage using VTQ and the pathological fibrosis stage. Results At any stage, VTQ was the most accurate for staging liver fibrosis. The VTQ cut-off values were 1.33 m/s (AUROC = 0.822) for ≥F2, 1.51 m/s (AUROC = 0.836) for ≥F3, and 1.92 m/s (AUROC = 0.890) for F4. Skin liver capsule distance (SCD) was the most relevant factor for the discrepancy between the estimated fibrosis stage using VTQ and the pathological fibrosis stage. The SCD cut-off value was 17.5 mm. Conclusions Virtual touch quantification is a non-invasive, simple method that is more accurate for staging liver fibrosis than the FIB-4 index and APRI. However, when the SCD is longer than 17.5 mm, there may be measurement failures.

Splenosis, a form of ectopic splenic tissue, is generally caused by heterotopic autotransplantation of splenic tissues after traumatic splenic rupture or splenectomy. The implants are often localized intraperitoneally, mostly in the left upper quadrant and splenic region. Hepatic foci are seen only on rare occasions. The differential diagnosis of splenosis foci from malignant masses can be challenging by conventional imaging and lead to unnecessary invasive procedures. This manuscript presents radiological and scintigraphic images of splenosis foci located in the peritoneal cavity and liver capsule of a 46-year-old man who underwent splenectomy due to traumatic splenic rupture 30 years ago.

Background: Since the liver is one of the most important organs of the body that can be injured during trauma, that is, during accidents like car crashes, understanding its mechanical properties is of great interest. Experimental data is needed to address the mechanical properties of the liver to be used for a variety of applications, such as the numerical simulations for medical purposes, including the virtual reality simulators, trauma research, diagnosis objectives, as well as injury biomechanics. However, the data on the mechanical properties of the liver capsule is limited to the animal models or confined to the tensile/compressive loading under single direction. Therefore, this study was aimed at experimentally measuring the axial and transversal mechanical properties of the human liver capsule under both the tensile and compressive loadings. Methods: To do that, 20 human cadavers were autopsied and their liver capsules were excised and histologically analyzed to extract the mean angle of a large fibers population (bundle of the fine collagen fibers). Thereafter, the samples were cut and subjected to a series of axial and transversal tensile/compressive loadings. Results: The results revealed the tensile elastic modulus of 12.16 ± 1.20 (mean ± SD) and 7.17 ± 0.85 kPa under the axial and transversal loadings respectively. Correspondingly, the compressive elastic modulus of 196.54 ± 13.15 and 112.41 ± 8.98 kPa were observed under the axial and transversal loadings respectively. The compressive axial and transversal maximum/failure stress of the capsule were 32.54 and 37.30 times higher than that of the tensile ones respectively. The capsule showed a stiffer behavior under the compressive load compared to the tensile one. In addition, the axial elastic modulus of the capsule was found to be higher than that of the transversal one. Conclusions: The findings of the current study have implications not only for understanding the mechanical properties of the human capsule tissue under tensile/compressive loading, but also for providing unprocessed data for both the doctors and engineers to be used for diagnosis and simulation purposes.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) has been proven to be a safe and effective method for diagnosis and treatment of biliary and pancreatic disorders. Major complications of ERCP include pancreatitis, hemorrhage, cholangitis, and duodenal perforation. We report a third case in literature of pneumoperitoneum after ERCP due to rupture of intrahepatic bile ducts and Glisson’s capsule in a peripheral hepatic lesion. Case Report: A 50-year-old male with a history of metastatic pancreatic neuroendocrine tumor and who had a partially covered metallic stent placed in the biliary tree 1 year ago presented to the oncology clinic with fatigue, abdominal pain, and hypotension. He was planned for ERCP for possible cholangitis secondary to obstructed previously placed biliary stent. However, the duodenoscope could not be advanced to the level of the major papilla because of narrowed pylorus and severely strictured duodenal sweep. Forward-view gastroscope was then passed with careful manipulation to the severely narrowed second part of the duodenum where the previously placed metallic stent was visualized. Balloon sweeping of stenting was done. Cholangiography did not show any leak. Following the procedure, the patient underwent CT scan of the abdomen that showed pneumoperitoneum which was communicating with pneumobilia through a loculated air collection in necrotic hepatic metastasis perforating Glisson’s capsule. The patient was managed conservatively. Conclusion: In our case, pneumoperitoneum resulted from rupture of intrahepatic bile ducts and Glisson’s capsule in hepatic metastasis. This case emphasizes the need for close clinical and radiological observation of patients with hepatic masses (primary or metastatic) subjected to ERCP.

Background: aluminum is the third most common element in the earth’s crust and is about 8% of its total mineral components. It is widely used in antacid drugs, food additives and tooth pastes. Moreover, it is added to the drinking water for purification purposes. It is also the metal of choice in making several household cookware and storage utensils despite its toxic effects. Aim of the work: this study aimedto describe the histological changes which occurred in liver of rats exposed to aluminum and also to clarify whether those changes were related to the age of the experimental animals or not. Material and methods: 32 male albino rats were used in this study, 16 adults and they were weighing 150-180 gm and 16 senile and they were weighing 400-450 gm. Group I: was consisted of 16 adult male rats. This group was categorized into two equal subgroups; subgroup IA and subgroup IB. Group II: was consisted of 16 senile male rats. This group was categorized into two equal subgroups; subgroup IIA and sub group IIB. Subgroups IA and IIA were served as control and received distilled water. Subgroups IB and IIB received aluminum chloride in a dose of 475 mg/kg body weight by gastric gavage once daily for three weeks. At the end of the experiment, liver specimens were collected, processed for paraffin blocks and semithin sections and examined by light microscope. Results: liver sections obtained from adult rats received aluminum chloride showed disrupted and discontinuous liver capsule, disorganized hepatic architecture, affection of the hepatocytes especially those under the liver capsule which had small darkly stained nuclei and dilated, distorted and slightly congested central veins. Most of the blood sinusoids appeared either narrow and obliterated or congested. The portal triads showed vascular congestion and dilatation, proliferation of the bile ducts with slight increase in the collagen deposition around the portal triads. Sporadic positive PAS reaction within the cytoplasm of the hepatocytes was also noticed in liver sections stained with PAS stain. Semithin sections stained with toluidine blue showed well circumscribed vacuoles of different sizes inside and outside the hepatocytes. On the other hand, liver sections obtained from senile rats received aluminum chloride showed the same previous changes that occurred in the adult group, but they were exaggerated and there were additional changes such as the presence of irregular homogenous materials and tiny vacuoles in the cytoplasm of most of the hepatocytes. Conclusion: oral administration of aluminum chloride in rats resulted in degenerations in the liver and that was conclusive of toxic hepatitis. These changes were exaggerated among the senile rats which proved that senile rats are more susceptible to the hepatoxicity induced by aluminum. Therefore, it is advised to create awareness among people especially the senile ones about the hazards of extensive use of aluminum.

Owing to several therapeutic advancements, more patients with biliary atresia now survive into adulthood while retaining their native liver. However, the optimal strategy for long-term management of such patients remains unclear. Aiming to establish the current management strategies, we reviewed previous reports of long-term outcome of BA who underwent surgery at our institution as well as the relevant literature, focusing particularly on the treatment of late complications. Approximately 30–40% of long-term survivors of biliary atresia who retain their native liver exhibit late sequelae such as cholangitis and portal hypertension. Early and appropriate intervention with Kasai portoenterostomy is essential for ensuring long-term survival with good quality of life. In our hospital, the current standard for Kasai portoenterostomy involves dissecting the fibrous remnants along the porta hepatis, just on the level of the liver capsule. Cholangitis is an important late complication in biliary atresia, and the possibility of mechanical obstruction of the biliary drainage route or deformity of the intrahepatic bile ducts with or without gallstones should be thoroughly evaluated in patients with intractable cholangitis. Regarding portal hypertension, appropriate interventions such as endoscopic variceal treatment and partial splenic embolization are considered to provide good quality of life when hepatic function is preserved. Appropriate therapeutic management is strongly recommended in selected patients with late complications.

We propose in this paper an automatic method for early diagnosis of cirrhosis using high-frequency ultrasound images. Instead of analyzing image texture, our method exploits image characteristics of liver capsule. To this end, we first propose a novel spatial context-constrained multi-scale method to accurately extract the boundaries of the liver capsule. Our approach detects all the possible edges in scale space, and the irrelevant edges are then filtered out with a spatial context-based energy function. Secondly on this basis, two novel descriptors are proposed to characterize the geometric properties of liver capsule and the changes of liver capsule with the aggravation of liver cirrhosis. These two descriptors are used as features fed into a support vector machine classifier for quantitative analysis in automatic diagnosis. Experiment results show that the proposed method can reliably localize liver capsule and accurately classify ultrasound liver images into normal and cirrhosis classes automatically.

A serious complication of chronic hepatic insufficiency is acute-on-chronic liver failure, a recognized syndrome characterized by acute decompensation of cirrhosis and organ/system failure. We investigated the use of adipose-derived mesenchymal stem cells (AD-MSCs) in an experimental model of acute-on-chronic liver failure, developed by microsurgical extrahepatic cholestasis in rats. Rats undergoing microsurgical extrahepatic cholestasis were treated by intraparenchymal liver injection of human or rat AD-MSCs, undifferentiated or previously differentiated in vitro toward the hepatocyte lineage. The groups treated with rat AD-MSCs showed less ascites, lower hepato- and splenomegaly, less testicular atrophy, and an improvement in serum biochemical hepatic parameters. There was also an improvement in histological liver changes, in which the area of fibrosis and bile duct proliferation were significantly decreased in the group treated with predifferentiated rat AD-MSCs. In conclusion, an isograft of hepatocyte-predifferentiated AD-MSCs injected intraparenchymally 2 weeks after microsurgery in extrahepatic cholestatic rats prevents secondary complications of acute-on-chronic hepatic failure. These data support the potential use of autologous AD-MSCs in the treatment of human cholestasis, and specifically of newborn biliary atresia, which could be beneficial for patients awaiting transplant.

INTRODUCTION Postoperative pain after laparoscopic cholecystectomy has three components: parietal, visceral and referred pain felt at the shoulder. Visceral peritoneal injury on the liver (Glisson’s capsule) during cauterisation sometimes occurs as an unavoidable complication of the operation. Its effect on postoperative pain has not been quantified. In this study, we aimed to evaluate the association between Glisson’s capsule injury and postoperative pain following laparoscopic cholecystectomy. METHODS The study was a prospective case–control of planned standard laparoscopic cholecystectomy with standardized anaesthesia protocol in patients with benign gallbladder disease. Visual analogue scale (VAS) abdominal pain scores were noted at 2 and 24 hours after the operation. One surgical team performed the operations. Operative videos were recorded and examined later by another team to detect presence of Glisson’s capsule cauterisation. Eighty-one patients were enrolled into the study. After examination of the operative videos, 46 patients with visceral peritoneal injury were included in the study group, and the remaining 35 formed the control group. RESULTS VAS pain score at postoperative 2 and 24 hours was significantly higher in the study group than control (P = 0.027 and 0.017, respectively). CONCLUSIONS Glisson’s capsule cauterisation in laparoscopic cholecystectomy is associated with increased postoperative pain. Additional efforts are recommended to prevent unintentional cauterisation.