Liver cell adenomas (LCA) can present during pregnancy with abdominal pain and bleeding. Assessment and management at this time are complicated by concerns over fetal well-being. We reviewed cases from our own institution, including the only laparoscopic liver resection reported in pregnancy, and systematically reviewed the literature to identify successful management strategies for this clinical dilemma. Two cases of surgery for bleeding liver adenoma were identified in our own institution. One case was managed with an elective laparoscopic segmental resection at 16 weeks and 1 with open surgery and successful fetal delivery at 32 weeks gestation. In the second case hepatic rupture of a 3.5-cm lesion was precipitated by diagnostic biopsy. In the world literature, spontaneous rupture of an LCA during pregnancy has been reported in 19 cases and is associated with maternal mortality and fetal loss approaching 50%. We advocate an aggressive approach to management of LCA in pregnancy owing to the high mortality associated with rupture. Biopsy of LCA in pregnancy is unsafe and can be complicated by rupture. Hence, patients presenting de novo with clinical or radiologic signs of bleeding or large (>5 cm) undiagnosed lesions should be offered laparoscopic resection if feasible.

Pseudoaneurysms after visceral transplantation represent a significant risk to patients. We report the successful treatment of three transplant (pancreas, liver and kidney) artery anastomotic pseudoaneurysms using physician-modified fenestrated endovascular stent grafts. In all cases, surgical repair was considered high risk and would have compromised the arterial supply to the graft. The endovascular approach in all cases obviated the need for surgical intervention and maintained graft arterial supply.

Fibrin sealants could potentially protect against the occurrence of pancreatic fistula after distal pancreatectomy (DP). Fourteen relevant clinical studies (11 open and 3 laparoscopic DP) were identified using an extensive customized literature search, including 4 randomized controlled trials. Data from the 1 prospective randomized controlled trial with reasonable patient numbers found that fibrin reinforcement of the pancreatic stump suture line in open DP was associated with a significant reduction in fistula rate compared with suturing alone. Three other studies failed to show a significant difference in fistula rate. Two small scale nonrandomized retrospective studies each reported a reduced fistula rate associated with use of fibrin sealant in laparoscopic DP. On the basis of the current studies to evaluate the use of fibrin sealants in open and laparoscopic DP, application of fibrin glue to the pancreatic stump could help to reduce the incidence of troublesome pancreatic fistulas associated with this procedure.