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Bacterial liver abscesses caused by ingested bodies are very uncommon. In the current report, a unique case of a 50-year-old man associated with diabetes mellitus who suffered from sepsis and a liver abscess because of the migration of a fishbone that lodged in the left hepatic lobe is presented. The diagnosis was confirmed by enhanced computed tomography examination of the upper abdomen. The patient subsequently underwent laparoscopic surgery, and was discharged on postoperative day 12 without any complications. The present study discusses the clinical features and treatment of this case. J Curr Surg. 2021;11(3):65-68 doi: https://doi.org/10.14740/jcs444

The aim of the study is to define age and gender regularities of the linear morphometric parameters of the liver in children and adolescents on the basis of intravital imaging findings.Material and methods. The authors analyzed computed tomograms of the abdominal cavity in 75 children without visible pathology. All patients were divided into 4 groups depending on their age: early childhood, first childhood, second childhood, adolescence. The transverse, anteroposterior and vertical dimensions of the right and left hepatic lobes were investigated on 16-slice computed tomographs. The obtained findings were processed using variational statistical analysis, the mean value (M), standard error (m) and the statistical significance were defined using the Student's t-test.Results. There was a significant increase in the anteroposterior size of the right hepatic lobe in separate sections at different age periods. A statistical significance between the parameters of the anteroposterior size of the right hepatic lobe was registered in girls and boys within the following groups: on one section in the 2nd group of patients, on two sections in the 4th group of patients. A statistical significance between the parameters of the transverse size of the right hepatic lobe was registered on one section (ThXII) in the 2nd and 3rd groups, and on two (ThXI and LI) and three (ThXI, ThXII and LI) sections in the 3rd and 4th groups of girls and boys, respectively. A statistical significance between the parameters of the transverse size of the right hepatic lobe in girls and boys were recorded only in the 4th group on three sections (ThXI, ThXII and LI). The vertical size of the right hepatic lobe was significantly higher in the 2nd and 4th groups, and the differences in the parameters between girls and boys were noted only among adolescents. A significant increase in the anteroposterior size of the left hepatic lobe was registered only in girls of the 2nd and 3rd groups on two sections (ThXII and LI); a significant increase in the transverse size was only registered at the LI level in these groups of patients. A significant increase in the vertical size of the left hepatic lobe was only detected in girls of the first childhood compared with girls of the early childhood. No statistical significance was registered for any of the linear parameters of the left hepatic lobe between girls and boys of the same groups.Conclusion. Thus, there was a significant increase in the anteroposterior and transverse dimensions of the right hepatic lobe in separate sections and an increase in the vertical size between individual groups of the studied patients, as well as a statistical significance between girls and boys of the same group. A significant increase in the anteroposterior and transverse dimensions of the left hepatic lobe was detected only in girls of the 2nd and 3rd groups if compared with the girls of the 1st group. No significant differences were registered between girls and boys of the same groups for any of the linear parameters of the left hepatic lobe.

BACKGROUND AND AIMS This study aimed to compare contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) with fundamental B-mode endoscopic ultrasonography (EUS) and contrast-enhanced computed tomography (CE-CT) for the diagnosis of left hepatic lobe metastases of pancreatic adenocarcinoma. METHODS In this single-center prospective study, CE-CT, EUS, and CH-EUS were performed to detect left hepatic lobe metastases in patients with pancreatic adenocarcinoma, and the detection rates were compared between EUS plus CH-EUS and the other two modalities. Subgroup comparisons of between-modality detection rate were performed in patients with only metastases of

We report the case of a 87-year-old woman admitted to our Emergency Department for mild abdominal pain associated with vomiting. An abdominal X-ray showed gas present in the portal venules of the left hepatic lobe, a finding associated with numerous surgical and medical conditions. The patient was successfully managed with conservative treatment. Isolated intrahepatic gas is a rare radiologic finding; emergency surgery should be performed only when there are signs of associated acute intestinal infarction.

The editorial published in this same journal entitled "Sombras del tratamiento actual del hepatocarcinoma en España: una verdad incómoda" has awakened the need to review the available scientific literature on the precise diagnosis of hepatocarcinoma based on a clinical case. A 58-year-old male patient has a radiological finding in the left hepatic lobe of a new lesion of 3.5 cm in size. Nuclear magnetic resonance imaging and computerized axial tomography confirmed the typical radiological behavior of hepatocarcinoma. However, the definitive pathological anatomy (A-P) after surgery was compatible with intrahepatic cholangiocarcinoma. The main national and international clinical guides offer the use of imaging tests for diagnosis, especially in high-risk patients. However, diagnostic biopsy is not included as mandatory in the hepatocarcinoma diagnostic process, although it may be recommended in some cases. The interest of the clinical case we present establishes the relevance of reaching a histological diagnosis of certainty, since imaging tests can objectify findings that are confusing with other tumor histologies, with future therapeutic and prognostic implications.

The hydatid cyst with double location (lung and liver) is a challenge for the thoraco-abdominal border surgery mainly due to the difficulty of choosing the approach (thoracotomy and laparotomy versus thoracotomy and phrenotomy). We present a case of hydatid cyst with dual location (right lung and left hepatic lobe) resolved by right thoracotomy and right transphrenic approach.

Robotic-assisted surgery for the management of hepatic echinococcosis was introduced in 2016. The advantage it offers over laparoscopy is less rigidity with the use of the 360° rotation of the Endo-Wrist technology, thus allowing the preservation of the integrity of the liver tissue. Herein, we report the first successful robotic resection of the left lobe of the liver for hydatid disease in the Middle East. Our patient is a 71-year-old man found to have a large left hepatic lobe hydatid disease on CT scan. The hydatid liver disease was resected completely with an operation time of 130 min and minimal intraoperative blood loss. Patient did well postoperatively and was discharged home on day 2. Our experience shows that robotic surgery for hydatid disease of the liver can be safely performed, with an excellent outcome to the patient. It also provides unique technical advantages in the field of minimal-invasive surgery.

Endoscopic retrograde cholangiopancreatography (ERCP) is minimally invasive procedure commonly performed for biliary and pancreatic diseases. According to literature, the most common related complication are pancreatitis, post-sphincterotomy bleeding, perforation and cholangitis. This is rare and exceptional ERCP complication and only few cases have been reported. We report a case of rare post-ERCP complication, subcapsular liver hematoma that was diagnosed 16 hour post-ERCP in 28-year-old lady with intra-abdominal collection, ultrasound guided drainage of suspected bile leak was done, but the drained fluid was bloody (blood mixed with bile), with total amount of 900 ml in the first 36 hours. Patient received 2 units packed RBCs and she maintain her vital sign and hemoglobin 8.5 g/dl. Computed tomography scan of abdomen revealed a large left hepatic lobe subcapsular hematoma 16x7x12 cm with no active bleeding causing compression of the left hepatic vessels. On the basis of laboratory, clinical, and hemodynamic parameters the patient was hemodynamically stable. She was managed conservatively with only ultrasound guided drained of abdominal collection and no any radiological or surgical intervention needed for the hematoma.

Ciliated hepatic foregut cyst (CHFC) is a rare cystic liver disease that predominantly affects adult men and is usually asymptomatic. From embryonic of the foregut origin, CHFC presents the average size of 3.6 cm and they are well defined, are unilocular and are located in the medial segment of the left hepatic lobe. Diagnosis is based on incidental finding in radiological examinations which are with hypoechoic images on ultrasound, hypo or isoattenuating on computer tomography and hyperintense on T2 ponderation on MRI. Definitive diagnosis is given with the histological study evidencing the four layers typical of the cyst wall. The monitoring is important because of the possibility of malignant transformation in about 5% of cases. This theme has relevance due to the increase in incidence, difficulty of diagnosis, complications and the lack of knowledge of the scientific community. The purpose of this literature review is to demonstrate the importance of the diagnosis, the clinical-diagnostic features and suspicion of the frame. A review was made on the period from March 2014 to July 2015. The descriptors used were: "ciliated hepatic foregut cyst"; "diagnosis of ciliated hepatic foregut cyst" and "image of ciliated hepatic foregut cyst". We emphasize the importance of CHCH as a differential diagnosis for cystic lesions of the liver, given its importance for symptomatic patients with lesions and to patients that are asymptomatic, due of the risk of malignancy described in the literature. The complementary propaedeutic is indispensable to elucidate the diagnosis, being essential the histopathological study.

25-year-old man with IgA deficiency treated with two months of chemotherapy and proton therapy for gastroesophageal junction adenocarcinoma. Restaging PET/CT18 days post-therapy demonstrated two new foci of increased FDG uptake in the left hepatic lobe, which were favored to represent radiation injury as opposed to new metastases. Follow-up MRI with contrast two weeks later demonstrated hypoenhancement and T1/T2 hypointensity in the liver, without restricted diffusion, which correlated with the dominant FDG-avid focus. The hepatic lesions resolved on subsequent FDG PET/CT and MRI studies, confirming the diagnosis of acute radiation injury.

The patient aged 66 years was admitted to the General Surgery Clinic for pain in the upper abdominal quadrant with posterior irradiation and weight loss. Two and a half years before the patient underwent surgery for a hiatal hernia when a Nissen fundoplication was performed by laparoscopic approach. CT was performed which confirmed the presence of a large abscess at the level of the left hepatic lobe and lobe atrophy (Figure no. 1, Figure no. 2). Surgery was undertaken. Abdominal exploration identified ischemia and necrosis of segments 2 and 3 of the liver so a resection was decided upon (Figure no. 3, Figure no 4). The postoperative evolution was favorable. NB: Ischemic necrosis of the left hepatic lobe most likely occurred after the surgical treatment of the hiatal hernia when the left hepatic artery was resected on dissection which was probably the only source of blood supply for the left lobe. It is important that these vascular abnormalities are known by the surgeon so during dissection of the gastrohepatic ligament any arteries identified should be protected to avoid a possible necrosis of the left hepatic lobe.

Hepatic herniation through an abdominal incisional hernia is a rare phenomenon that has been seldom reported in the medical literature. When present, this may cause patients significant distress and is associated with complications such as hepatic encephalopathy and Budd-Chiari syndrome. Most cases can be managed conservatively through observation, but many cases require surgical intervention to preserve hepatic function. Our case consists of a 54-year-old man who presented with asymptomatic herniation of the left hepatic lobe through an abdominal incisional hernia.

Background and Objectives. The feasibility and safety of single-port laparoscopic surgery for left lateral liver lobectomy are largely unknown. This study is aimed at comparing the effectiveness and safety between single-port laparoscopic (SPL) and conventional multiport laparoscopic (CL) surgeries for hepatic left lateral sectionectomy. Methods. A total of 65 patients receiving laparoscopic hepatic left lateral sectionectomy between January 2008 and July 2015 were included and divided into the SPL group (n=40) and the CL group (n=25). Results. There was no significant difference in the operative time, estimated intraoperative blood loss, length of hospital stay, and incidences of postoperative complications (biliary leakage, hemorrhage, and contusion at incision) between groups (all P>0.05). However, the SPL group had a significantly lower VAS pain score (at 24 h but not 7 days postoperation) and higher cosmetic satisfaction scores (at both 2 months and 6 months postoperation) than the CL group (all P<0.01). Moreover, multivariate linear regression analysis further confirmed the superior pain score and cosmetic outcome in the SPL group. Conclusions. Single-port laparoscopic hepatic left lateral sectionectomy is a safe and feasible treatment for patients with lesions in the left hepatic lobe. Patients with benign lesions in the left hepatic lobe are more suitable to receive single-port laparoscopic hepatic left lateral sectionectomy than those with malignancies.

Abstract Aim: Different animals are used as experimental models for the hepatic Ischemia- Reperfusion (IR) injury investigations and for each one of these animal models, many different surgical approaches have been performed. The aim of our study was to establish a new surgical pig model in which a hemi-liver is used to study the pathophysiology of hepatic IR injury. Contro-lateral hemi-liver is used as an internal control in the same animal. Methods: Liver ischemia was performed in six pigs by clamping the hepatic artery and vein and the portal vein to isolate the left hepatic lobe. Four hours of warm ischemia were followed by 4-hourrs of reperfusion. Biochemical and hematological analyses were performed throughout the experiments. Needle biopsies were obtained prior to ischemia and then hourly during the reperfusion for evaluation of tissue damage. To assess local temperature gradients on the liver surface a focal plane array detector camera was used. Results: Four hours ischemia induced mild signs of hepatic damage on the left ischemic lobe while more dramatic changes were evidenced after 2-hours reperfusion. Absence of tissue damage was detected on the right lobe. The liver functional test reached their maximum value at 2-4 hours after reperfusion. Conclusion: Our model is easy to perform, feasible and reproducible. This surgical model minimizes biases dependent on the individual response of different animals under the same conditions. In this IR model the new technology of an infrared thermocamera was used to control temperature changes and provide clinically important real-time information during surgery. Abbreviations: IR: Ischemia/Reperfusion; IV: Intravenous; ALP: Alkaline Phosphatase; ALT: Serum Alanine Aminotrasferase; AST: Aspartate Aminotransferase; LDH: Lactate Dehydrogenase; ROI: Region of Interest Keywords: Animal model; Infrared imaging; Liver ischemia reperfusion injury, Liver transplantation

The pancreas is easily investigated in children thanks to the relative lack of fat tissue and the large left hepatic lobe with an optimal acoustic window. The use of high frequency, even linear transducers, usually results in detailed images of all pancreatic areas. A wide spectrum of pancreatic pathologic conditions can be identified and monitored at ultrasound although they are relatively uncommon during childhood compared to the adult. In this paper we briefly review the anatomy, technique, and sonographic aspects of normal and pathological pediatric pancreas.

Purpose We aimed to evaluate the imaging features of bile duct adenoma (BDA) on ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Methods Retrospective search in our institution database was performed for histologically confirmed BDA. Their imaging studies before histologic confirmation were reviewed. The search identified seven adults (mean age, 52.9 years) with histologically proven single BDA each. US (n=3), CT (n=5), and MRI (n=3) were performed before histologic confirmation. Additionally, a systematic English literature review for BDA and reported imaging findings since 2000 was also conducted using the following search criteria "bile duct adenoma, peribiliary hamartoma, biliary adenoma, CT, ultrasound, MRI" (date range: 01/01/2000 through 08/31/2016). The imaging findings of those cases reported were summarized and compared with our series. Results All seven individual nodules were well circumscribed. Five lesions were located in the right hepatic lobe and two in the left hepatic lobe. On US, lesions appeared hypoechoic (n=2) and hyperechoic (n=1). BDA was hypodense on unenhanced CT images (n=1). On MRI, BDA were hypointense on T1 (n=3), hyperintense on T2 (n=3), and hyperintense on diffusion-weighted images (n=2). On contrast-enhanced CT and MRI, BDAs showed arterial phase hyperenhancement that persisted on portal venous/delayed phase images. Conclusion BDA demonstrates characteristic arterial phase hyperenhancement that persisted into the portal venous and delayed phases on CT and MRI, which may be useful in differentiating from other hepatic lesions.

Purpose After radiopharmaceutical injection, a heightened 123I-MIBG concentration is frequently observed in the left hepatic lobe compared to the right one, but the reason of this finding remains unknown. Our aim was to retrospectively analyze the different 123I-MIBG uptake pattern between the two hepatic lobes and correlate our results with some epidemiological/clinical features. Methods Ninety-four 123I-MIBG scintigraphies from 71 patients were selected. Regions of interest were drawn in the right and left lobes using transverse tomographic sections and left to right activity ratios (L/R ratio) were calculated at 6 and 24 h after radiotracer administration. Results Twenty-seven examinations were positive for hypermetabolic lesions while the remaining 67 were negative. In all cases mean early and delayed L/R ratios were greater than 1.00; average early L/R ratio was 1.37 and delayed L/R ratio 1.52. The delayed L/R ratio was significantly higher than the early one. There was no difference in the L/R ratios with regard to age, gender, primary disease and result of scintigraphy. Conclusions 123I-MIBG uptake was higher in left hepatic lobe compared to right and this ratio did not correlate with any epidemiological or clinical feature. The reason of this metabolic is not yet explained and some biomolecular hypotheses could be tested in 3D dynamic in vitro models.

RESUMO Objetivo Avaliar as dimensões do fígado e do baço em pacientes com lúpus eritematoso sistêmico de início pediátrico (LESp) e controles saudáveis. Métodos Foram submetidos a uma ultrassonografia do abdome 30 pacientes com LESp e 30 voluntários saudáveis controle. Foram feitas duas medições do fígado no lobo hepático esquerdo (craniocaudal e anteroposterior) e três no lobo hepático direito (LHD) (craniocaudal posterior [CCP-LHD], craniocaudal anterior e anteroposterior). Foram também avaliadas três medidas das dimensões do baço: longitudinal, transversal e anteroposterior. Foram avaliados dados demográficos, clínicos e laboratoriais, SLEDAI-2K, ECLAM, SLAM e tratamento. Resultados A idade média foi semelhante nos pacientes com LESp e controles (170,31 ± 27,81 vs. 164,15 ± 39,25 meses; p = 0,486). A média da dimensão CCP-LHD foi significativamente maior no grupo LESp em comparação com os controles (13,30 ± 1,85 vs. 12,52 ± 0,93, p = 0,044). Não houve diferenças nos outros parâmetros biométricos do fígado e do baço (p > 0,05). Uma análise especifica realizada apenas nos pacientes com LESp de acordo com a dimensão CCP-LHD ≥ 13,3 cm versus < 13,3 cm mostrou que a mediana do SLEDAI-2K [8 (0-18) vs. 2 (0-8), p = 0,004], ECLAM [4 (0-9) vs. 2 (0-5), p = 0,019] e SLAM [5 (1-13) vs. 2 (0-14), p = 0,016] era significativamente maior em pacientes com maior dimensão CCP-LHD, do mesmo modo que a frequência de nefrite (77% vs. 29%, p = 0,010). As enzimas hepáticas foram semelhantes nos dois grupos (p > 0,05). Foi observada uma correlação positiva entre o SLEDAI-2K e a dimensão CCP-LHD (p = 0,001, r = +0,595). Evidenciou-se uma correlação negativa entre a duração da doença e a dimensão longitudinal do baço (p = 0,031, r = −0,394). Conclusão Os dados levantam a possibilidade de que a atividade da doença pode levar a uma hepatomegalia subclínica e localizada durante o curso da doença. A duração da doença resultou em atrofia do baço em pacientes com LESp. ABSTRACT Objective To evaluate liver and spleen dimensions in childhood-onset systemic lupus erythematosus (c-SLE) patients and healthy controls. Methods 30 c-SLE patients and 30 healthy control volunteers underwent abdominal ultrasound. The following two liver measurements were performed in left hepatic lobe: craniocaudal and anteroposterior and three in right hepatic lobe (RHL): posterior craniocaudal (PCC-RHL), anterior craniocaudal and anteroposterior. Three spleen dimension measurements were also evaluated: longitudinal, transverse and anteroposterior. Demographic, clinical and laboratorial data, SLEDAI-2K, ECLAM, SLAM and treatment were assessed. Results Mean current age was similar in c-SLE and controls (170.31 ± 27.81 vs. 164.15 ± 39.25months; p = 0.486). The mean of PCC-RHL dimension was significantly higher in c-SLE compared to controls (13.30 ± 1.85 vs. 12.52 ± 0.93, p = 0.044). There were no differences between the other hepatic biometrics and splenic parameters (p > 0.05). Further analysis in c-SLE patients according to PCC-RHL dimension ≥ 13.3 cm versus < 13.3 cm showed that the median of SLEDAI-2K [8(0-18) vs. 2(0-8), p = 0.004], ECLAM [4(0-9) vs. 2(0-5), p = 0.019] and SLAM [5(1-13) vs. 2(0-14), p = 0.016] were significantly higher in patients with higher PCC-RHL dimension, likewise the frequencie of nephritis (77% vs. 29%, p = 0.010). Liver enzymes were similar in both groups (p > 0.05). Positive correlation was observed between SLEDAI-2K and PCC-RHL (p = 0.001, r = +0.595). Negative correlation was evidenced between disease duration and longitudinal dimension of spleen (p = 0.031, r = −0.394). Conclusion Our data raises the possibility that disease activity could lead to a subclinical and localized hepatomegaly during the disease course. Long disease duration resulted to spleen atrophy in c-SLE patients.

Invasive aspergillosis, an infection most frequently induced by Aspergillus fumigatus and Aspergillus flavus, typically occurs in immunocompromised patients and is usually transmitted through inhalation of Aspergillus spores. As the lungs are by far the most common site involved in invasive aspergillosis and invasive aspergillosis in immunocompetent hosts is very rare, there have been a few case reports of extra-pulmonary, disseminated invasive aspergillosis in immunocompetent persons. Herein, we report a case of an adult, male, immunocompetent patient with disseminated invasive aspergillosis that successively spread from the right adrenal gland to the left hepatic lobe. The patient was successfully treated through surgical excisions of his adrenal and hepatic masses followed by voriconazole therapy. To our knowledge, this is the first case report of invasive aspergillosis affecting the adrenal glands.

A 47-year-old male presented with a six-month history of fatigue and a four-month history of alanine and aspartate aminopherase elevation. Laboratory examination revealed that the serum α-fetoprotein (AFP) level was 371.51 μg/l (normal range, 0–20 μg/l), and a computed tomography scan revealed a hypodense lesion in the left hepatic lobe. During laparotomy, a dark red-colored soft tumor (1.5×1.7 cm in diameter) was found in segment eight of the liver. Intra-operative pathology and post-operative histopathology examinations revealed that the tumor was a hepatic cavernous hemangioma. The serum AFP level was decreased to 24.45 μg/l by the second post-operative week. The literature was searched and only three similar cases were found. A brief review of this rare disease entity was produced, which attempted to explain this appearance reasonably.

Background: Some studies have shown that statins have a promising effect on protection against reperfusion injury. Aim: To evaluate the ability of ischemic postconditioning, statins and both associated to prevent or minimize reperfusion injury in the liver of rats subjected to ischemia and reperfusion by abdominal aorta clamping. Method: Were used 41 Wistar rats, which were distributed into five groups: ischemia and reperfusion (I/R), ischemic postcondictioning (IPC), postconditioning + statin (IPC+S), statin (S) and Sham. It was performed a medium laparotomy, dissection and isolation of the infra-renal abdominal aorta; excepting Sham group, all the others were submitted to the aorta clamping for 70 min (ischemia) and posterior clamping removing (reperfusion, 70 min). In the IPC and IPC+S groups, postconditioning was performed between the ischemia and reperfusion phases by four cycles of reperfusion and ischemia lasting 30 s each. In IPC+S and S groups, preceding the surgical procedure, administration of 3.4 mg/day of atorvastatin was performed for seven days by gavage. The left hepatic lobe was removed for histological study and euthanasia was performed. Results: The mean hepatic injury was 3 in the I/R group, 1.5 in the IPC group, 1.2 in the IPC+S group, 1.2 in the S group, and 0 in the SHAM group. The I/R group had a higher degree of tissue injury compared to the others in the statistical analysis and there was no difference between the others (p

Background Agenesis of the left hepatic lobe is a rare anomaly. It is defined as the absence of liver tissue to the left of the gallbladder fossa. Additionally, agenesis of the left hepatic lobe accompanied by hepatocellular carcinoma is quite rare. We experienced the case of a patient with agenesis of the left hepatic lobe, undergoing laparoscopic hepatectomy for HCC. Case presentation A 79-year-old man was referred to our department with epigastralgia. Abdominal computed tomography revealed agenesis of the left hepatic lobe, accompanied by hepatocellular carcinoma in segments 7 and 8. He underwent laparoscopic partial hepatectomy of segments 7 and 8. The operative findings revealed complete agenesis of the liver to the left of the falciform ligament. The patient had a favorable clinical course without liver dysfunction or any complications. Conclusions We experienced a case with agenesis of the left hepatic lobe undergoing laparoscopic hepatectomy for HCC. Awareness of such anomaly is important for surgeons to avoid postoperative complications.

Background: This study was conducted to investigate whether apparent diffusion coefficient (ADC) measurements by dividing the liver into left and right hepatic lobes may be utilized to improve the accuracy of differential diagnosis of benign and malignant focal liver lesions. Materials and Methods: A total of 269 consecutive patients with 429 focal liver lesions were examined by 3-T magnetic resonance imaging that included diffusion-weighted imaging. For 58 patients with focal liver lesions of the same etiology in left and right hepatic lobes, ADCs of normal liver parenchyma and focal liver lesions were calculated and compared using the paired t-test. For all 269 patients, ADC cutoffs for focal liver lesions and diagnostic accuracy in the left hepatic lobe, right hepatic lobe and whole liver were evaluated by receiver operating characteristic curve analysis. Results: For the group of 58 patients, mean ADCs of normal liver parenchyma and focal liver lesions in the left hepatic lobe were significantly higher than those in the right hepatic lobe. For differentiating malignant lesions from benign lesions in all patients, the sensitivity and specificity were 92.6% and 92.0% in the left hepatic lobe, 94.4% and 94.4% in the right hepatic lobe, and 90.4% and 94.7% in the whole liver, respectively. The area under the curve of the right hepatic lobe, but not the left hepatic lobe, was higher than that of the whole liver. Conclusions: ADCs of normal liver parenchyma and focal liver lesions in the left hepatic lobe were significantly higher than those in the right hepatic lobe. Optimal ADC cutoff for focal liver lesions in the right hepatic lobe, but not in the left hepatic lobe, had higher diagnostic accuracy compared with that in the whole liver.

We report the case of a 67-year-old male with epigastric pain and weight loss during the last nine months. Physical examination revealed a hard palpable mass in the epi-mesogastrium. An abdominal ultrasound identified a large, heterogeneous and hypovascular mass, which compressed the left hepatic lobe and the pancreas.

Introduction: Solitary fibrous tumors (SFTs) are a rare type of spindle cell neoplasm, composed of cellular and collagenous components, predominantly arise from the pleura. SFTs of the liver (SFTL) are uncommon with little number of cases reported in English literature. The diagnosis is based on histological and morphological characteristics, associated with immunohistochemical markers and molecular analysis. The rarity of this tumor makes it difficult to evaluate its prognosis and natural course. Surgical resection remains the mainstay of treatment. The present study reports a new case of SFTL and has the main purpose of updating the current knowledge. Case Report: A 42-year-old woman presented with right hypochondrial discomfort and postprandial fullness. Magnetic nuclear resonance of the upper abdomen showing nodular expansive formation with well-defined contours and limits, located in left hepatic lobe. Insidious evolution, after three years of detection by imaging examination, submitted left hepatectomy. Macroscopically, a nodular mass, white color, firm and elastic, measuring 3.2×3.0 cm. Microscopic examination evidenced fusocellular proliferation, hypocellular and hypercellular areas (mild atypia), with predominance of a sclerotic pattern. The immunohistochemical study revealed ki-67 1%, positivity for STAT6, CD34 and Bcl-2. The diagnosis was of Solitary Fibrous Tumor Hepatic. Conclusion: The SFTL is rare, with only 85 cases reported in the English Literature including the present case. The clinical presentation is habitually indolent. SFTL due to its rarity, its clinical presentation, study, treatment, and prognosis are not well known.

Rationale and Objectives To determine possible differences between the left and right hepatic lobes in apparent diffusion coefficient (ADC) values of benign and malignant focal liver lesions (FLLs) and normal liver parenchyma. Materials and Methods Thirty-six patients (16 males, 20 females; mean age 56.8 years) with FLLs of the same etiology in both the left and right hepatic lobes (13 patients with 26 benign FLLs and 23 patients with 46 malignant FLLs) who underwent 1.5T magnetic resonance imaging (MRI) including diffusion-weighted MRI (b values: 0 and 800 seconds/mm) with respiratory gating and without cardiac gating were included in this Health Insurance Portability and Accountability Act–compliant and institutional review board–approved study. ADC values of normal liver parenchyma and FLLs in each hepatic lobe were calculated and compared by using Student's t-test and Wilcoxon signed-rank test, respectively. Results The mean ADC values of normal liver parenchyma, benign FLLs, and malignant FLLs were significantly higher (P Conclusion ADC values of benign and malignant FLLs calculated from noncardiac-gated DW-MRI are significantly higher in the left hepatic lobe compared with the right hepatic lobe. This may be a limitation for characterization of FLLs based on ADC measurements.

A 61-year-old patient, with sudden abdominal pain, associated palpable epigastric mass, a lesion 15-cm in diameter indented the left hepatic lobe, was examined with several imaging.

The left hepatic lobe is divided into three subsegments according to anatomical landmarks; however, there are several variations in the vascular territories of the left hepatic arterial branches. Hepatocellular carcinoma (HCC) located near the umbilical fissure or at the left side of the umbilical portion of the left portal vein has frequent crossover blood supply. HCC located in the caudal aspect of the lateral segment has a variety of feeding arteries, and is infrequently supplied by the caudate artery or the medial subsegmental artery (A4), and by the lateral left hepatic arteries. HCC located in the posterior aspect of segment 4 is frequently supplied by the caudate artery or a small A4 branch arising from the caudate artery. In addition, the left inferior phrenic, right and left internal mammary, right and left gastric, cystic, and omental arteries are well known extrahepatic collateral pathways supplying HCC in the left hepatic lobe, especially when the hepatic artery is attenuated by previous transcatheter arterial chemoembolization (TACE). Interventional radiologists should have sufficient knowledge of vascular territories in the left hepatic arterial branches and extrahepatic collaterals to perform effective TACE for HCC located in the left hepatic lobe.

Introduction: The authors report a single-access laparoscopic Nissen fundoplication (SALN) performed with new curved reusable instruments. Case report: A 21-year-old woman sought care for symptomatic grade B esophagitis and hiatal hernia. A reusable 11-mm trocar was inserted in the umbilicus and a 10-mm, 30° angled, nonflexible, standard length scope was used. Curved reusable instruments (Karl Storz-Endoskope) were transumbilically introduced without trocars. The left hepatic lobe was retracted thanks to the distal curve of the grasper. The cruraplasty and wrap were performed using curved needle holder and intracorporeal sutures. Results: No extraumbilical trocar was necessary. Laparoscopic time was 108 minutes, and umbilical scar length was 16 mm. Discharge was allowed after 48 hours. Conclusions: SALN is feasible to be performed with curved reusable instruments, which avoid the conflict between the instruments' tips inside the abdomen or between the surgeon's hands outside. Cost of the procedure remains similar to standard laparoscopy because only reusable material is used. © The Author(s) 2011.

Background:Laparoscopic left lateral hepatic sectionectomy (LLLHS) has been widely accepted because of the benefits of minimally invasive surgery. We aimed to assess the benefits and drawbacks of left lateral sectionectomy (of segments II/III) compared with laparoscopic and open approaches.M

We report a case in which hepatectomy was performed to treat a patient with metastatic liver cancer 12 years after nephrectomy for renal cell carcinoma. The patient was a 56–year old man. Abdominal CT and MRI showed tumors with diameters of 8.5 cm and 2.5 cm in S2 and S4, respectively, of the liver, and many nodules with a diameter of 1 cm or less, all in the left hepatic lobe. FDG–PET/CT revealed a SUVmax of the tumors of 35, suggesting very high accumulation of FDG. Based on the history of renal cell carcinoma and normal hepatitis virus marker values a diagnosis of metastatic liver cancer from renal cell carcinoma was made. Distant metastasis was found only in the liver. Extended left hepatectomy was carried out, and the histologic findings confirmed metastasis by renal cell carcinoma. The patient had a good surgical postoperative course and was discharged on postoperative day 7. No signs of recurrence were observed at the 20 month follow–up examination. Hepatic metastasis by renal cell carcinoma generally has a poor prognosis, and since no specific, effective pharmacotherapy has been established, hepatectomy is an option, if the safety of surgery can be assured.

Purpose To prospectively compare the image acquisition time and image quality obtained by navigator setting under the left hepatic lobe vs. on the right diaphragm on magnetic resonance cholangiopancreatography (MRCP) using a free-breathing navigator-triggered prospective acquisition correction technique (PACE). Materials and Methods Fifty consecutive patients prospectively underwent three-dimensional T2-weighted turbo spin-echo MRCP using PACE with the navigator randomly set either under the left hepatic lobe or on top of the right diaphragm. Image acquisition time and subjective image quality were compared on a five-point scale using Student's t-test and Mann–Whitney's U test, respectively. Results There was no significant difference for mean acquisition time (6.1±1.6 vs. 6.3±1.2 min, P=.689) between the left hepatic lobe group and right diaphragm group. Mean subjective image quality was significantly worse in the left hepatic lobe group than in the right diaphragm group (4.1 vs. 4.7, P=.044). Conclusion Setting the navigator under the left hepatic lobe for MRCP using PACE causes the data processing to be more difficult. As well, under current circumstances, it does not contribute to reducing acquisition time or improving the image quality.

AIM: To analyze the virtual touch tissue quantification (VTTQ) and virtual touch imaging quantification (VTIQ) techniques, and identify possible factors that may influence VTTQ and VTIQ measurements. METHODS: One hundred and eighty-six (104 women/82 men) of 323 subjects met the inclusion criteria (age > 18 years, no history of chronic or gastrointestinal disease, body-mass index (BMI) < 30 kg/m², a fasting period of at least three hours, no history of hepatotoxic pharmaceuticals, alcohol consumption < 24 g/d in men and < 12 g/d in women, and normal findings upon ultrasound examination of the abdomen). Measurements were taken at depths of 50 mm with VTTQ, 15 mm and 25 mm with VTIQ in the right hepatic lobe, and at 15 mm with only VTIQ in the left hepatic lobe. The examiner acquired six measurements per position, thereby giving 24 measurements in total. RESULTS: The 95% confidence intervals of mean were 1.23-1.29 m/s for VTTQ and 1.29-1.37 m/s, 1.17-1.23 m/s, and 1.48-1.57 m/s for VTIQ in a depth of 15 mm and 25 mm in the right hepatic lobe and 15 mm in the left hepatic lobe. Only superficial measurements in the right hepatic lobe with the VTIQ method exhibited an effect of age on shear wave velocity. Measurements acquired using the 6C1 probe with the VTTQ method showed no dependence on BMI. By comparison, BMI influenced measurements taken with the VTIQ method using the 9L4 probe in the superficial and deep areas of the right hepatic lobe, as well as in the left hepatic lobe (P = 0.0160, P = 0.0019, P = 0.0173, respectively). Gender influenced measurements at depths of 50 mm with VTTQ and 25 mm with VTIQ in the right hepatic lobe (P = 0.0001, P = 0.0269). Significant differences were found between measurements with the 6C1 (VTTQ) and 9L4 probes (VTIQ) (P = 0.0067), between superficial and deep measurements (P < 0.0001), and between the right and left lobes of the liver (P < 0.0001). CONCLUSION: Measurements in the right lobe and deep regions are preferable. Gender differences must be considered. BMI must be considered when assessing VTIQ technology.

We present the case of an 80-year-old male with squamous cell carcinoma with bilobar hepatic metastases who underwent targeted Yttrium-90 radioembolization of the right hepatic lobe lesion. Subsequently, there was complete regression of the nontargeted, left hepatic lobe lesion. This may represent the first ever reported abscopal effect in radioembolization. The abscopal effect refers to the phenomenon of tumor response in nontargeted sites after targeted radiotherapy. In this article, we briefly review the immune-mediated mechanisms responsible for the abscopal effect.

Radioembolization with (90)Y microspheres is a locoregional radiation therapy for unresectable hepatic neoplasm. Non-target delivery of (90)Y microspheres resulting in gastrointestinal (GI) symptoms is a recognized complication; there is minimal knowledge regarding the radiation effect to the gastric wall from left hepatic lobe (90)Y treatments. Our aim was to study the incidence of GI complications when the target tissue (hepatic parenchyma ± tumor) is in close proximity to the gastric wall. We hypothesized that liver (tumor) to stomach proximity does not correlate with increased toxicity.Between November 2011 and September 2013, we studied all patients who underwent left lobe radioembolization with (90)Y glass microspheres. With Institutional Review Board (IRB) approval, we retrospectively reviewed MRI/CT images of these patients, identifying a subset of patients with the left hepatic lobe1 cm from the gastric wall. Patients were seen in clinic 1 month posttreatment and subsequently at 3-month intervals. Short- and long-term gastric adverse events were tabulated.Ninety-seven patients successfully underwent left hepatic lobe (90)Y microsphere radioembolization in which the average distance from the liver to the stomach wall was 1.0 ± 2.8 mm. The average dose for patients who received radioembolization to the left hepatic lobe was 109 ± 57 Gy. Fifty patients had tumor within 1 cm of the gastric wall. The average dose for patients who received radioembolization to the left hepatic lobe with tumor within 1 cm of the gastric wall was 121 ± 41 Gy. There were no reportable or recordable medical events. Of the patients, 34% reported abdominal pain that was grade 1-2; 65% of the patients reported no abdominal pain. None of the 97 patients developed a clinically evident GI ulcer.Patients with left lobe tumors adjacent to or abutting the stomach do not exhibit acute or chronic radiation effects following radioembolization with glass microspheres.

High resolution imaging of the left hepatic lobe can be obtained via endoscopic ultrasound (EUS), allowing for detection of unsuspected metastatic disease during cancer staging. The frequency at which occult liver metastases are detected during EUS staging of cancer of the esophagus and cardia is unknown.Over an 18-month period, 98 patients underwent EUS staging for a new diagnosis of cancer of the esophagus and cardia. Wire-guided dilation was performed if necessary. Standard radial examination was followed by curvilinear evaluation with attention to the left hepatic lobe. All suspicious liver lesions were aspirated under EUS guidance.The radial and curvilinear echoendoscope were successfully passed to the antrum in 86% and 81% of cases, respectively, without complication. Thirty-two percent of patients required dilation. Lesions suspicious for left hepatic lobe metastases were found in 7% of cases that could be completely evaluated by EUS, all of which underwent EUS-guided fine needle aspiration. All lesions were proven metastases: four true-positive and one false-negative cytologic result.Curvilinear EUS examination of the left hepatic lobe in addition to standard radial EUS examination can be performed safely when staging cancer of the esophagus and cardia. Dedicated left hepatic lobe examination should be performed as it avoids unnecessary surgery in a subset of these patients by detection of occult liver metastases.

A wandering or ectopic spleen, a rare congenital condition caused by improper fixation of the ligamentous attachments, was identified during a postmortem examination of a 10-month-old female who had died of Streptococcus pneumoniae sepsis. The wandering spleen was autoinfarcted and adherent to the left hepatic lobe, with resultant functional hyposplenism.

Starting from a real case of a 69-year old patient affected by cholangiocarcinoma, we intend to discuss the accuracy and appropriateness of the diagnostic and therapeutic procedures adopted. This case shows in particular that a more accurate preoperative staging could probably avoid the patient unnecessary laparotomy. According to the indications in the medical literature, this patient could possibly benefit from chemotherapy, but a chemoembolization of liver metastases was performed. However in the literature no available evidence suggests that this treatment would be beneficial in this kind of clinical picture. Eventually, when the disease was already at an advanced stage and worsened due to a necrosis of the left hepatic lobe and a cholangitic infection, a repositioning of the stent on the stent was performed, despite in the literature the life expectancy cut-off for this procedure is at least 6 months. We also discuss the communication between the physician, the patient and the family, which was probably based on overly optimistic and unrealistic expectations. This led to a number of surgical procedures, which were not certainly helpful and indeed were probably even harmful for this patient. In addition, these procedures caused unnecessary costs borne by the healthcare system. In conclusion, we advocate that discussion and self-assessment must be always promoted, so that the healthcare professionals can review the process and the outcome of their treatment as well as their behavior to understand if it could have been more appropriate to offer actual benefits to the patients in terms of better quality of life and longer life expectancy.

OBJETIVO: Avaliar, qualitativa e quantitativamente, as alterações morfológicas hepáticas e esplênicas por ressonância magnética (RM) em pacientes portadores de esquistossomose mansônica crônica, e a reprodutibilidade do método na avaliação hepatoesplênica destes pacientes. MATERIAIS E MÉTODOS: Realizou-se estudo prospectivo em 28 pacientes esquistossomóticos submetidos à RM de abdome superior. Os exames foram realizados em equipamento com alto campo (1,5 T), utilizando-se bobina de corpo e bomba injetora para a administração do contraste endovenoso, e interpretados por dois examinadores independentes, que avaliaram a presença de alterações morfológicas hepáticas e esplênicas. A concordância interobservador e intra-observador foram medidas pelo teste kappa e pelo teste do coeficiente de correlação intraclasses. RESULTADOS: As variáveis qualitativas e quantitativas apresentaram boa concordância interobservador e intra-observador (kapa > 0,65 e r > 0,66, respectivamente). A maior concordância interobservador foi obtida para o diâmetro ântero-posterior do baço (r = 0,98). Os observadores identificaram redução do lobo hepático direito, aumento do lobo hepático esquerdo e caudado associado a esplenomegalia em quase todos os pacientes, e alargamento de fissuras, heterogeneidade do parênquima hepático, irregularidade de contornos, vasos periféricos hepáticos e fibrose periportal em mais de 82% dos pacientes. CONCLUSÃO: As alterações morfológicas hepáticas caracterizam-se pela redução do lobo direito e aumento dos lobos caudado e esquerdo, e as esplênicas, pela presença de esplenomegalia e nódulos sideróticos. A RM apresenta elevada reprodutibilidade na avaliação dessas alterações em pacientes com esquistossomose mansônica crônica.

Liver transplantation has become mainstream surgical therapy for patient with end-stage liver disease with an operative mortality of less then 5% and 1- and 5-year survival rates 85% and 65%, respectively. 1-5 The disproportionate increase in patients awaiting liver transplant compared to the number of available organs 6,7 has led to the development of new techniques, including “living donor liver transplants” (LDLT), “split liver transplants,” and more recently, the reintroduction of “non-beating-heart liver donors.” 8 In the United States, the total number of liver transplants performed as of today is 58,507, of which 2,065 are from live donors and 56,442 are from cadavers, 9 which is a ratio of 1:27 live-donor to cadaveric liver transplants. The first successful living-donor liver transplantation was performed in 1989, with transplantation of a left hepatic lobe. Because of cultural beliefs discouraging cadaveric transplants in Asia, extensive development in the field of living-donor liver transplant was performed in the early 1990s; almost all liver transplantations performed in Asia involved living donors, whereas in the United States relatively few living-donor liver transplantations were performed until recently. It was mainly performed on children and used a left hepatic lobe (or one or more of its segments) from a parental donor. In the United States, adult lefthepatic-lobe transplantation was attempted in the 1990s, but without much success. The smaller left hepatic lobe provides insufficient hepatic mass for most adult Americans, who are physically larger than most Asians and consequently, the outcome of adult-to-adult left-hepatic-lobe transplantation in the United States was poor, and the procedure was seldom performed. 10 The first successful adult right LDLT was reported by Fan et al in 1997; 11 since then, right LDLT is the preferred adult LDLT.

A 48-year-old woman was referred for the management of an excluded left hepatic lobe (LHL) with recurrent cholangitis after right hepatectomy extended to the segment 1 and wedge resection of the segment 2 for the treatment of an occlusive metastatic adenocarcinoma of the sigmoid colon previously treated with neoadjuvant chemotherapy and local resection. The crossing of the stricture of the left intrahepatic bile ducts (LIHBDs) was not successful with endoscopic retrograde cholangiopancreatography (ERCP). A permanent percutaneous external biliary drainage was performed through segment 3 biliary branch, complicated with pain and bile leakage around the drain. A first attempt by endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS) did not succeed given the absence of dilation of the LIHBD and mostly due to an unstable position induced by a small size of the remnant LHL. Then, a hybrid procedure was performed after changing the percutaneous drain for a 5Fr Arrow-Flex introducer that permitted the puncture of the external part of the introducer with an EUS transgastric EchoTip® 19G needle and insertion of a 0.025-inch guidewire directly into the LIHBD around the introducer. The introducer was removed and the guidewire was caught in the hepatic segment 2 by a percutaneous lasso to stabilize the 0.025-inch guidewire. An EUS-HGS was done after fistulization of the transhepatic tract by 6Fr cystotome and placement of a partially-covered self-expandable metal stents. The clinical course was uncomplicated under vancomycin for an Enterococcus faecium bacteremia, and then chemotherapy was restarted. EUS-HGS is clearly established as an alternative technique for biliary drainage in case of unsuccessful ERCP or altered anatomy, based on decisional algorithm, with a pooled technical success rate of 82%, clinical success rate of 97%, and adverse event rate of 23%. The success of this procedure depends on several factors and tips like the kind and length of the intragastric part of the prosthesis, angulation of the LIHBD, oversized dilation of the transhepatic tract, access to the liver segment 3, and shearing of the guidewire. The low volume of the LHL may also be a cause of technical failure that can be resolved by new procedures as described in this case.

症例は66歳男性.胃部不快感を主訴に近医受診し,上部消化管内視鏡にて胃体上部の胃癌と診断され,平成10年12月9日に当院紹介となった.術前の腹部Computed tomography (以下CT)にて,肝左葉の欠損を認めた.血管造影では中肝動脈,左肝動脈は発達不良で,門脈造影では狭小化した門脈左枝を認めた.以上より,胃癌に合併した肝左葉形成不全と診断し,胃全摘,脾摘,胆摘,肝左葉切除を施行した.術中所見では, 9×2cmと低形成な肝左葉を認め,肝右葉は正常で肝表面肉眼所見は正常肝であり,肝転移はみられなかった.低形成肝を切除し病理学的に検索したのは本症例が初めであった.術中胆道造影では,左肝管は開存していた. 1984年以降で詳細の記載のある肝左葉形成不全について本邦報告例は25例認め,自験例を含めた26例について画像所見を中心に検討した.

In 78-year-old woman with chronic liver disease, multiple tumors in the left hepatic lobe were disclosed during a periodic ultrasound examination. She had a history of local rectal resection for a 1.5cm carcinoid with invasion of the muscularis propria, in 1985. Under the diagnosis of hepatocellular carcinoma, she underwent a laparotomy in May, 1995. Considering her age and hepatic functional reserve, lateral segmentectomy with additional microwave coagulonecrotic therapy (MCN) was selected instead of left hepatectomy. Histological findings of the resected tumors showed a structure similar to that of the previous rectal carcinoid (trabecullar growth pattern, Soga type B), thus, the hepatic tumors were diagnosed as metastatic hepatic carcinoid from the rectal primary after 12 years of dormancy. Therefore a rectal carcinoid invasion of the muscularis propria, irrespective of size, should be treated carefully. The histological structure of the carcinoid might exhibit a slow-growing behavior. Since her postoperative course was uneventful and she is doing well two years and six months after operation, hepatectomy combined with MCN was the appropriate modality in this case.