HCC : PE-079 ; Two cases of hepatic carcinoma post-hepatic resection presenting with chylous ascites: a case report

( Billy James Uy ),( Catherine Teh ) 대한간학회 2012 춘·추계 학술대회 (KASL) Vol.2012 No.-

Background: Chylous ascites is a rare phenomenon characterized by milky turbid ascitic fluid usually caused by ruptured lymphatics associated with a variety of causes. The main causes are usually malignant tumors, hepatic cirrhosis and tuberculosis. This case report aims to present two cases of chylous ascites post-hepatic resection that presented with significantly different outcomes. Presentation: Case No. 1. A 53 year old male alcoholic drinker presented with a right hepatic mass during appendectomy. Segmental (segment VII) hepatic resection revealed hepatic carcinoma with a cirrhotic background. One year after, CT scan revealed left hepatic mass wherein patient underwent left lateral segmentectomy. A year after the 2nd hepatic resection, patient developed globular abdomen where paracentesis revealed the presence of chylous ascites. Patient`s ascites was refractory to diuretics, octreotide and other medical management leading to his eventual demise. Case No. 2. A 48 year male diagnosed with hepatitis B presented with a 19 cm liver tumor involving segment V, VII and VII infiltrating the pleura and right lower lung lobe. CT scan revealed multiple lymphadenopathy on the portal and suprapancreatic area. Right hemihepatectomy with enbloc resection of the diaphragm, left lower lung resection and radical lymph node dissection was done. Patient developed chylous ascites 8 days post-op but eventually subsided with dietary fat restriction and intravenous octretide for 7 days. Patient recovered well. Conclusion: Hepatic resection of hepatocellular carcinoma could lead to the development of chylous ascites. However, the presence of liver cirrhosis could have led to the development of liver failure leading to intractable ascites that was refractory to treatment.

LT, Others : PE-130 ; Laser lithotripsy in a diffucult case of hepatocholedocholithiasis with distal common bile duct stricture done at the national kidney and transplant institute: a case report

( Billy James Uy ),( Kristine Trocio ),( Catherine Teh ) 대한간학회 2012 춘·추계 학술대회 (KASL) Vol.2012 No.-

Introduction: The presence of intrahepatic lithiasis is an operative dilemma for surgeons. Not all cases are amenable to endoscopic retrograde cholangiography (ERCP) extraction, and intraoperative biliary extraction is fraught with difficulties. A usual option is to insert a t-tube to allow percutaneous choledoscope extraction post-operatively. Hepatic resection is also another option but has a higher morbidity. Recent studies have shown the applicability of laser lithotripsy in the removal of intrahepatic stones. Methods: We report a case of intrahepatic lithiasis not amenable to ERCP and intraoperative biliary extraction that was done in a center specialized in urologic cases. Summary: A 52 year old male presented colicky abdominal pain where ultrasound showed calculous cholecystitis. Patient was initially treated with antibiotics but developed jaundice with acolic stools after a week. Patient was admitted and repeat ultrasound revealed calculous cholecystitis with suspicious obstructing calculus in the proximal CBD, distal CBD stricture was noted. Ductal dilatation and stone extraction failed, hence a F10 stent was inserted and scheduled for surgery. Intraoperative ultrasound revealed multiple stones in the CBD and was extracted through a choledochotomy. A 0.5 cm stone was impacted in the secondary radicles of the right hepatic duct. A nephroscope was inserted and stone basket extraction done but failed. Laser lithotripsy was used to break the stone into smaller fragments, flushed out and extracted more proximally. A roux-en-y hepaticojejunostomy was done to bypass the distal CBD stricture. Patient recovered and was eventually discharged. Conclusion: In intrahepatic stones that have failed ERCP and biliary extraction, the combination of a surgical enterotomy, biliary endoscopy, and laser lithotripsy could provide a viable option for stone removal. However, for centers not specialized in hepatobiliary surgery with lack of equipment, this could pose a significant challenge on its applicability.

HCC : Two Cases of Hepatic Carcinoma Post-Hepatic Resection Presenting with Chylous Ascites

( Billy James Uy ),( Catherine The ) 대한간학회 2013 춘·추계 학술대회 (KASL) Vol.2013 No.1

Background: Chylous ascites is a rare phenomenon characterized by milky turbid ascitic fluid caused by ruptured lymphatics usually associated with malignant tumors, cirrhosis and tuberculosis. Our aim is to present two cases of chylous ascites post-hepatic resection with significantly different outcomes. Presentation: Case No. 1. A 53 year old male alcoholic drinker with cirrhosis presented with one month history of gradual abdominal enlargement, jaundice and dyspnea. Two years earlier, he underwent segment VII hepatic resection for hepatocellular carcinoma. One year after, he underwent left lateral segmente c tomy for s egment 2-3 met ast asis, then had chemoradiotherapy for mediastinal and left axillary lymph nodes metastasis six months after. Abdominal paracentesis revealed chylous ascites. Patient`s ascites was refractory to diuretics, octreotide and other medical management leading to his eventual demise 19 days after. Case No. 2. A 48 year male with hepatitis B was diagnosed with a 19cm liver tumor involving segment V, VII and VIII infiltrating the pleura, right lower lung, and multiple lymphadenopathy on the peripancreatic and paraaortic area. Right hemihepatectomy with enbloc resection of the diaphragm, right lower lung, and radical lymph node dissection was done. Patient developed chylous ascites eight days post-op but eventually subsided with NPO, dietary fat restriction and intravenous octreotide for seven days. Patient recovered well. Conclusion: Cirrhosis with chylous ascites could have led to liver failure causing intractable ascites that was refractory to treatment, while prolonged multimodal conservative therapy aiming at decreasing lymph production amidst optimal nutritional supplement may help resolve post hepatectomy chylous ascites.

LT, Others : PE-130 ; Laser lithotripsy in a diffucult case of hepatocholedocholithiasis with distal common bile duct stricture done at the national kidney and transplant institute: a case report

( Billy James Uy ),( Kristine Trocio ),( Catherine Teh ) 대한간학회 2012 춘·추계 학술대회 (KASL) Vol.2012 No.1

Introduction: The presence of intrahepatic lithiasis is an operative dilemma for surgeons. Not all cases are amenable to endoscopic retrograde cholangiography (ERCP) extraction, and intraoperative biliary extraction is fraught with difficulties. A usual option is to insert a t-tube to allow percutaneous choledoscope extraction post-operatively. Hepatic resection is also another option but has a higher morbidity. Recent studies have shown the applicability of laser lithotripsy in the removal of intrahepatic stones. Methods: We report a case of intrahepatic lithiasis not amenable to ERCP and intraoperative biliary extraction that was done in a center specialized in urologic cases. Summary: A 52 year old male presented colicky abdominal pain where ultrasound showed calculous cholecystitis. Patient was initially treated with antibiotics but developed jaundice with acolic stools after a week. Patient was admitted and repeat ultrasound revealed calculous cholecystitis with suspicious obstructing calculus in the proximal CBD, distal CBD stricture was noted. Ductal dilatation and stone extraction failed, hence a F10 stent was inserted and scheduled for surgery. Intraoperative ultrasound revealed multiple stones in the CBD and was extracted through a choledochotomy. A 0.5 cm stone was impacted in the secondary radicles of the right hepatic duct. A nephroscope was inserted and stone basket extraction done but failed. Laser lithotripsy was used to break the stone into smaller fragments, flushed out and extracted more proximally. A roux-en-y hepaticojejunostomy was done to bypass the distal CBD stricture. Patient recovered and was eventually discharged. Conclusion: In intrahepatic stones that have failed ERCP and biliary extraction, the combination of a surgical enterotomy, biliary endoscopy, and laser lithotripsy could provide a viable option for stone removal. However, for centers not specialized in hepatobiliary surgery with lack of equipment, this could pose a significant challenge on its applicability.

HCC : PE-079 ; Two cases of hepatic carcinoma post-hepatic resection presenting with chylous ascites: a case report

( Billy James Uy ),( Catherine Teh ) 대한간학회 2012 춘·추계 학술대회 (KASL) Vol.2012 No.1

Background: Chylous ascites is a rare phenomenon characterized by milky turbid ascitic fluid usually caused by ruptured lymphatics associated with a variety of causes. The main causes are usually malignant tumors, hepatic cirrhosis and tuberculosis. This case report aims to present two cases of chylous ascites post-hepatic resection that presented with significantly different outcomes. Presentation: Case No. 1. A 53 year old male alcoholic drinker presented with a right hepatic mass during appendectomy. Segmental (segment VII) hepatic resection revealed hepatic carcinoma with a cirrhotic background. One year after, CT scan revealed left hepatic mass wherein patient underwent left lateral segmentectomy. A year after the 2nd hepatic resection, patient developed globular abdomen where paracentesis revealed the presence of chylous ascites. Patient’s ascites was refractory to diuretics, octreotide and other medical management leading to his eventual demise. Case No. 2. A 48 year male diagnosed with hepatitis B presented with a 19 cm liver tumor involving segment V, VII and VII infiltrating the pleura and right lower lung lobe. CT scan revealed multiple lymphadenopathy on the portal and suprapancreatic area. Right hemihepatectomy with enbloc resection of the diaphragm, left lower lung resection and radical lymph node dissection was done. Patient developed chylous ascites 8 days post-op but eventually subsided with dietary fat restriction and intravenous octretide for 7 days. Patient recovered well. Conclusion: Hepatic resection of hepatocellular carcinoma could lead to the development of chylous ascites. However, the presence of liver cirrhosis could have led to the development of liver failure leading to intractable ascites that was refractory to treatment.