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We report the case of a 53-year-old patient subjected to percutaneous embolization of right and middle hepatic veins to induce liver segments 2–3 hypertrophy before extended right hepatic resection for a locally advanced type IIIa perihilar cholangiocarcinoma. Hepatic vein embolization (HVE) was performed 3 weeks after surgical recanalization of left portal vein (severely narrowed at its origin due to tumor infiltration) interposing an internal jugular vein graft between main and distal left portal vein. Nine days after HVE, future liver remnant volume increased from 395 to 501 cc, i.e. 25.1% of standardized total liver volume, allowing to perform a radical right hepatic trisectionectomy plus caudatectomy. He was discharged home on postoperative day 15th after an uneventful postoperative course, with no sign of posthepatectomy liver failure.

Background The aim of this study was to evaluate the safety and efficacy of percutaneous ablation for hepatocellular carcinoma (HCC) hepatic recurrence along surgical resection margins to achieve complete cure or bridge for additional treatment. No current recommendations exist for these lesions. Methods Retrospective review of post-surgical recurrent HCC located along surgical margins treated by percutaneous ultrasound-guided ablation from 2006-2014. Ablation was performed by radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI), selected for recurrence in proximity to extrahepatic organs. Results In total, nine patients (49-82 y, mean 73.8±8.3) were treated for 13 recurrent HCC nodules (9-35 mm, mean 21.5±8.1) located along resection margins by RFA (11 nodules) and PEI (2 nodules). Mean time between surgery and percutaneous ablation was 64 months (range 10-149). At a mean follow-up of 17 months (±9), complete ablation was achieved in 9 nodules (69.2%, 8 after RF, 1 after PEI) and partial ablation was achieved in 4 nodules (3 after RFA, 1 after PEI). Complications were limited to minor abdominal pain in 2 patients requiring medical therapy (15.3%). Of the 4 partially ablated nodules, subsequent therapy achieved complete response in 3 nodules (1 patient with TACE, 1 patient with stereotactic radiotherapy, and one with liver transplantation), while the last nodule progressed despite subsequent TACE. Conclusions HCC recurrence along the surgical margin can be safely and effectively treated by percutaneous therapy, despite the misconception of the surgical margin as a hostile location. Percutaneous treatment may bridge the patient for additional therapy.

Pyogenic abscesses in grafts after liver transplantation (LT) are observed in 0.5% to 1% of patients, with mortality rates up to 45%. Predisposing factors are hepatic artery thrombosis, presence of hepaticojejunostomy, biliary obstruction, ascendant cholangitis, bacteremia, and percutaneous procedures (liver biopsy and biliary drainage). Therapeutic options include antibiotics, immunosuppression withdrawal, percutaneous or surgical drainage, liver resection, and retransplantation. However, in extreme situations, treatments can fail and retransplantation can be contraindicated because of sepsis, a complex surgical history, or both. In this setting, a salvage approach to abscesses located in the right hepatic area was devised, inspired by the open window thoracostomy described by Clagett in 1963 for postpneumonectomy empyema. Similar to the Clagett procedure, the so-called open window hepatostomy (OWH) is based on transthoracic surgical drainage of the septic cavity and secondary wound healing. With over 1820 consecutive LT procedures performed from 1990 to 2008, the technique was applied in only 3 cases (0.2%), always resulting in control of infection and preservation of life. Repeated dressings and further interventions were needed without exception because an external biliary fistula invariably appeared. Complete skin closure was obtained in 2 cases in 12 years and 7 months, respectively. The most recent patient, whose case is illustrated here, is now at an advanced stage of the healing process. CASE REPORT

Remedial biliary surgery most often entails a Roux-en-Y hepaticojejunostomy. Sometimes the duct wall at the porta hepatis has been so damaged by inflammatory changes that the postoperative external drainage of bile away from a biliodigestive suture at risk of dehiscence is advisable. A technique of intraoperative placement of transparietohepatic biliary drainage was devised. The maneuver implies retrograde cannulation of a major intrahepatic duct with a vascular irrigation needle that is pushed to create the transhepatic path. Of 220 remedial hepaticojejunostomies performed in 211 patients (including 151 liver transplant recipients), the technique was applied in 49 (22%) of the most difficult cases in which the preoperative radiologic approach to the biliary tree had failed, was unsafe, or was unfeasible. The only major complication was a parenchymal tear needing perihepatic packing when the maneuver was performed too early after liver transplantation. Postoperative biliary fistula occurred in 2 patients (4%) and access to the biliary tract for percutaneous bilioplasty was provided in the short-term follow-up evaluation of 14 patients (29%).

a b s t r a c t INTRODUCTION: Chronic biliary obstruction consequence of a bile duct injury may require liver transplan- tation (LT) in case of secondary biliary cirrhosis, intractable pruritus or reiterate episodes of cholangitis. "Mass-forming" sclerosing cholangitis leading to secondary portal vein thrombosis and pre-sinusoidal portal hypertension has not been reported so far. PRESENTATION OF CASE: We present the case of a patient who underwent laparoscopic cholecystectomy for Mirizzi syndrome. The persistent bile duct obstruction due to a residual gallstone fragment was treated by a prolonged biliary stenting. Following repeated bouts of cholangitis, a fibrous centrohepatic scar developed, conglobating and obstructing the main branches of the portal vein and of the biliary tree. The patient developed secondary portal vein thrombosis and portal hypertension. After an extensive diagnostic work-up, including surgical exploration to rule out malignancy, the case was successfully managed by liver transplantation. DISCUSSION: Mass-forming sclerosis of the bile duct and biliary bifurcation may develop as a conse- quence of chronic biliary obstruction and prolonged stenting. Secondary portal vein thrombosis and pre-sinusoidal portal hypertension represents an unusual complication, mimicking Klatskin tumor. CONCLUSION: A timely and proper management of post-cholecystectomy complications is of mainstay importance. Early referral to a specialized hepato-biliary center is strongly advised. © 2013 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

Biliary cystadenoma is a rare benign cystic tumor of the liver. The mainstay of treatment is complete resection, either by enucleation or by formal hepatectomy, since incomplete removal entails not only constant recurrence but also the risk of malignant transformation to cystadenocarcinoma. A case of symptomatic centrohepatic biliary cystadenoma involving the main vasculobiliary structures of the liver is reported. After an unsuccessful attempt at resection resulting in an intrahepatic biliary injury, relief of jaundice and radical excision were achieved by total hepatectomy and liver transplantation. The patient is now alive and well 4 years after transplant, disease-free, with normal liver and renal function while receiving everolimus monotherapy. This is the first report of liver transplantation performed for the treatment of this tumor. With the case on the background, diagnostic aspects and available therapeutic strategies for biliary cystadenoma are reviewed and discussed.

We report herein a domino orthotopic liver transplantation (LT), from a 38-year-old woman undergoing liver-kidney transplantation (LKT) for primary hyperoxaluria type I (PH1) to a recipient with cirrhosis and hepatocellular carcinoma. Delayed onset of PH1 and renal failure and 10% residual alanine-glyoxylate aminotransferase (AGT) activity in domino liver justified its use for domino procedure. The clinical course after LKT was similar to that described in other series, including ours. Renal function started promptly and maintained despite sustained hyperoxaluria from dissolution of oxalotic deposits. Conversely, the domino recipient manifested severe hyperoxaluria and developed nephrolithiasis and renal insufficiency with rapid progression over 2 months. A new LT resulted in slow decrease of oxaluria and improvement of renal function. Therefore, PH1 behaved quite differently in these two patients, leading us to conclude that domino LT using livers from PH1 patients should be considered very carefully, only as a bridge to definitive LT in recipients with critical clinical conditions.