Ahmed Mahfouz

Introduction: Associating Liver Partition and Portal Vein Ligation for Staged -hepatectomy (ALPPS) is an evolving procedure that allows rapid hypertrophy of the future liver remnant (FLR). We describe the first two cases performed in Qatar. Case presentations: Case 1: A 53 -year old male with sarcoma metastases to the liver 8 years after resection of an abdominal wall tumor, requiring an extended right hepatectomy but with in an inadequate FLR. ALPPS was done and he achieved 147% increase in the volume of the FLR within 6 days (from 15.9%-34.2%). The second stage was completed successfully on day 7. Case 2: A 59-year old male patient had colorectal liver metastases that required an extended right liver resection and had inadequate FLR of 19.8%. Seven days after the first stage, the FLR hypertrophied to 37.7% (90.2% increase in volume) and the second stage was completed successfully on day 8. Both patients had uneventful recovery and no recurrence or complications on follow up. Discussion: ALPPS allows large liver resections while circumventing the long delay in the conventional two staged hepatectomy and portal vein ligation/embolization. The reported morbidity and mortality in earlier series was high, but recent selection criteria and technique refinements reduce this morbidity. Many variations are still being reported. Conclusion: ALPPS is an evolving technique that adds to the armamentarium of the liver surgeon to allow larger liver resections in a timely manner. It is feasible and safe to be performed with careful selection. Highlights:

Most patients with pancreatic masses pose a diagnostic challenge when a benign lesion is suspected, and often, resection is needed before a benign diagnosis is confirmed. A 57 years old male patient presented with a pancreatic head mass, obstructive jaundice and submandibular lymph node enlargement. He also had a history of recurrent eye pain and redness, skin lesions, and benign prostatic hypertrophy. MRI showed a pancreatic head mass with double duct sign, aortic thickening, bilateral renal lesions, diffuse lymph node enlargement, and prostatic enlargement. FDG-PET/CT demonstrated abnormal uptake corresponding to the MRI lesions, and there were elevated IgG4 levels on blood investigations. Biopsy of an inguinal lymph node revealed infiltrates with IgG4 plasma cells, consistent with the diagnosis of IgG4 disease. The patient was treated with IV steroids and showed significant improvement. IgG4 related disease is a rare entity that is characterized by lesions that show heavy infiltration with IgG4 positive plasma cells, storiform fibrosis, and obliterative phlebitis. The pancreas is the most commonly involved organ, but several other organ systems are involved, and this helps in clinical suspicion of the diagnosis. A biopsy from any easily accessible site that shows the characteristic histological features is sufficient for diagnosis. Patients respond quickly to steroids, but recurrence is frequent. IgG4 related disease is a rare cause of pancreatic tumorous lesions that need a high index of suspicion for diagnosis and should be differentiated from pancreatic neoplastic lesions.

INTRODUCTION: Intramural duodenal hematoma (IDH) is a rare pathological entity that occurs as a complication of trauma, pancreatitis, peptic ulcer disease or endoscopic biopsy procedures. In this report, we present a case of IDH related to a duodenal diverticulum that was complicated by intra-abdominal bleeding and peritonitis. PRESENTATION OF CASE: We report a 31-year old male who presented with pancreatitis that was complicated with IDH, as diagnosed using endoscopy and CT scan of the abdomen. The condition was related to a duodenal diverticulum as appears on imaging. The patient was treated conservatively over a course of 1 week when he started to have intra-abdominal bleeding and developed peritonitis. The patient was successfully treated with laparotomy, drainage of intra-abdominal abscess, evacuation of IDH and repair of duodenal perforation. We discuss this case in the context of the current indications of surgery in cases of IDH. CONCLUSION: Despite shift towards conservative management of IDH cases over last few decades, these cases should be handled carefully as they might develop life-threatening complications. Highlights: