Hatem Khalaf

Granulosa cell tumor (GCT) is a unique form of sex cord tumor that is mostly unilateral and of low-grade malignancy. Most GCT recurrence is with pelvic or peritoneal dissemination. Liver metastasis is rarely reported. This study reports a rare case of GCT with liver metastasis nine years post initial presentation. We also discuss surgical intervention, radiological findings, histology, treatment approaches, and review of similar reported cases.

Schistosomiasis is one of the most prevalent parasitic infections in the developing world. When it affects the gastrointestinal system specifically the liver, it causes periportal fibrosis followed by cirrhosis. Cholecystitis however is a rare presentation, and associated liver abscess has certainly never been reported to date. We report a case of acute cholecystitis complicated by cholangitis and liver abscess in a 46-year-old man. After complex course of treatment, he had laparoscopic cholecystectomy, and the histology report confirmed schistosomiasis. Gallbladder schistosomiasis is an uncommon disease that is associated with dense fibrotic changes that strongly mimics xanthogranulomatous cholecystitis. Liver abscess may occur during the disease evolution especially in patient originating from endemic backgrounds. We present the case and a comprehensive literature review.

Background: Gallbladder cancer (GC) is a relatively rare disease. To date, there are no studies describing the epidemiology of this disease in Qatar. Objective: To study the epidemiology of Gallbladder Cancer in Qatar. Methods: A retrospective analysis of the cases of GC in Hamad General Hospital in Qatar from 2009 to 2016. Results: Thirty-five patients presented with GC during the study period, 10 females (28.6%) and 25 males (71.4%). Fourteen patients (40%) were diagnosed incidentally after laparoscopic cholecystectomy, 16 (48.6%) were diagnosed pathologically, and 4 (11.4%) were diagnosed radiologically. The median age at diagnosis was 54 years (31–78). 74.3% of the disease occurred in patients less than 60 years old. Metastatic disease was discovered in 25 patients (71.4%) versus no metastasis in 10 patients (28.6%). The most common sites for metastasis were the liver (42.9%), peritoneum (25.7%), and lymph nodes (25.7%). Curative central hepatic resection was done in 8 patients (22.9%). Pathology showed adenocarcinoma in 27 patients (77.1%), neuroendocrine tumor in 3 patients (8.6%) and high-grade dysplasia in 1 patient (2.9%). No histopathology was available for 4 patients (11.4%). Twenty-eight patients (80.0%) had regular follow up, with 22 (62.9%) still alive. Six patients (17.1%) died during follow up with survival after diagnosis ranging from 42 days to 6.8 years. Conclusions: In Qatar, due to the unique demographics, GC is more common in males and younger age groups. Most of the patients present late with metastasis, but curative resection is associated with long-term survival.

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.

Pancreatic fistula remains the main cause for postoperative morbidity following pancreaticoduodenectomy. The coincidence of sentinel bleed prior to post pancreatectomy haemorrhage (PPH) and pancreatic fistula is associated with very high mortality. We report a case of pancreaticoduodenectomy complicated by postoperative leak and hematemesis. Severe delayed haemorrhage from the pancreatico-jejunostomy necessitated re-laparotomy and complete disconnection of the pancreatic anastomosis. Hemodynamic instability precluded a pancreatectomy or creation of a new anastomosis. A follow up MRI done 3 weeks after the patient's discharge demonstrated a fistulous tract causing a communication between both the pancreatic and biliary systems and the enteric loop. Spontaneous development a pancreatico-enteric fistula despite ligation of the pancreatic duct and complete disconnection of the pancreatic anastomosis has never been reported in literature to date. Pancreatic duct occlusion may be considered over a completion pancreatectomy or revisional pancreatic anastomosis in hemodynamically unstable and challenging cases.

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:

Hepatocellular adenomas (HCA) are rare benign liver tumors. Recent technological advancements have helped in the early identification of such lesions. However, precise diagnosis of hepatocellular incidentalomas remains challenging. Studies at the molecular level have provided new insights into the genetics and pathophysiology of these lesions. These in turn have raised questions over their existing management modalities. However, the rarity of the tumor still restricts the quality of evidence available for current recommendations and guidelines. This article provides a comprehensive review on the etiology, molecular biology, patho-physiology, clinical manifestations, and complications associated with HCA. It also elaborates on the genetic advancements, existing diagnostic tools and current guidelines for management for such lesions.

Background: Severe liver trauma (grade 4 and 5) carries mortality greater than 40%. It represents a major surgical challenge in patients with hemodynamic instability who require an immediate exploratory laparotomy. Perihepatic packing and damage control can sometimes work, but for severe liver injuries, adjunct maneuvers might be needed (such as early embolization or hepatic artery ligation). During a patient’s first operation for severe liver trauma, anatomic resection is rarely tolerated. Materials and methods: We managed a 31 year-old male with a blunt grade 5 right-lobe liver injury in severe hypovolemic shock. Results: As part of the initial damage control operation, concurrently with intermittent Pringle maneuver, he underwent intra- and perihepatic packing; selective isolation and ligation of the right portal vein, right hepatic artery, and right hepatic vein; and repair of the retrohepatic inferior vena cava. Then, 36 h later, the patient underwent a right hepatectomy. Conclusion: For patients with severe liver injuries, selective vascular isolation and ligation may be considered as part of damage control (in addition to intermittent Pringle maneuver) and might enable anatomic resection at a later stage. Highlights: