PURPOSE: Review the safety and long-term success with portosystemic shunts in children at a single institution. METHODS: An IRB-approved, retrospective chart review of all children ages 19 and undergoing surgical portosy...PURPOSE: Review the safety and long-term success with portosystemic shunts in children at a single institution. METHODS: An IRB-approved, retrospective chart review of all children ages 19 and undergoing surgical portosystemic shunt from January 1990-September 2008. RESULTS: Ten patients were identified, 8 females and 2 males, with a mean age of 15 years (range 5-19 years). Primary diagnoses were congenital hepatic fibrosis (5), hepatic vein thrombosis (2), portal vein thrombosis (2), and cystic fibrosis (1). Primary indications were repeated variceal bleeding (6), symptomatic hypersplenism (2), and significant liver dysfunction (2). Procedures performed were distal splenorenal bypass (4), side-to-side portocaval shunt (3), proximal splenorenal shunt (2), and an interposition H-graft portocaval shunt (1). There was no perioperative mortality and only minor morbidity. Seventy percent of patients had improvement of their symptoms. Eighty percent of shunts remained patent. Two were occluded at a median follow-up of 50 months (range 0.5-13.16 years). Two patients underwent subsequent liver transplantation. Two patients died at 0.5 and 12.8 years postoperatively, one from multisystem failure with cystic fibrosis and one from post-operative transplant complications. CONCLUSIONS: The need for portosystemic shunts in children is rare. However, in the era of liver transplantation, portosystemic shunts in selected patients with well-preserved liver function remains important. We conclude that portosystemic shunts are safe and efficacious in the control of variceal hemorrhage and symptoms related to hypersplenism.
AIM: Determination of first line treatment with limited hepatectomy or Anatomical hepatectomy provides better clinical outcome. METHODS: Immediate and long-term outcomes of 106 patients who underwent partial hepatectomy...AIM: Determination of first line treatment with limited hepatectomy or Anatomical hepatectomy provides better clinical outcome. METHODS: Immediate and long-term outcomes of 106 patients who underwent partial hepatectomy for RH at our institution from January 2001 to February 2005 were analyzed retrospectively. Clinical end-points included time to recovery of hepatic function, residual stones, infection of the liver remnant, bile leakage, recurrent stones, morbidity, and mortality. RESULTS: LH was performed in 59 patients and AH in 47 patients as first-line treatment. The time of hepatic function recovery was not statistically different between the two groups (P > .05). However, Patients in AH group suffered from less residual stones (P < .05), less infection of the raw surface of liver remnant (P < .05), and less bile leakage (P < .05), with a median follow-up of 40.3 +/- 0.8 months (range 3-48), and AH group suffered a less recurrent stone rate (P < .05). No difference in morbidity, and mortality rates between the two groups. CONCLUSION: AH is a safe and effective treatment for RH, with a fair rate of surgical complications, it should be considered as first-line treatment of RH.
Recently some have called for randomized controlled trials comparing RFA to hepatic resection, particularly for patients with only a few small metastases. The objectives were to compare local recurrence and survival foll...Recently some have called for randomized controlled trials comparing RFA to hepatic resection, particularly for patients with only a few small metastases. The objectives were to compare local recurrence and survival following RFA and hepatic resection for colorectal liver metastases. This was a retrospective review of open RFA and hepatic resection for colorectal liver metastases between January 1998 and May 2007. All patients who had RFA were considered to have unresectable disease. 58 patients had hepatic resection and 43 had RFA. A 5-year survival after resection was 43% compared to 23% after RFA. For patients with solitary lesions, a 5-year survival was 48% after resection and 15% after RFA. Sixty percent of patients suffered local recurrences after RFA compared to 7% after hepatic resection. RFA is inferior to resection. The results observed in this study support the consensus that RFA cannot be considered an equivalent procedure to hepatic resection.
BACKGROUND/AIMS: Early prediction of the severity of acute pancreatitis would lead to prompt intensive treatment resulting in improvement of the outcome. The present study investigated the use of C-reactive protein (CRP)...BACKGROUND/AIMS: Early prediction of the severity of acute pancreatitis would lead to prompt intensive treatment resulting in improvement of the outcome. The present study investigated the use of C-reactive protein (CRP), interleukin IL-8 and tumor necrosis factor-alpha (TNF-alpha) as prognosticators of the severity of the disease. METHODS: Twenty-six patients with acute pancreatitis were studied. Patients with APACHE II score of 9 or more formed the severe group, while the mild group consisted of patients with APACHE II score of less than 9. Serum samples for measurement of CRP, IL-8 and TNF-alpha were collected on the day of admission and additionally on the 2nd, 3rd and 7th days. RESULTS: Significantly higher levels of IL-8 were found in patients with severe acute pancreatitis compared to those with mild disease especially at the 2nd and 3rd days (P = .001 and P = .014, resp.). No significant difference for CRP and TNF-alpha was observed between the two groups. The optimal cut-offs for IL-8 in order to discriminate severe from mild disease at the 2nd and 3rd days were 25.4 pg/mL and 14.5 pg/mL, respectively. CONCLUSIONS: IL-8 in early phase of acute pancreatitis is superior marker compared to CRP and TNF-alpha for distinguishing patients with severe disease.
We describe two cases where patients undergoing hepatic resection for metastatic disease of colorectal origin were found to have concomitant sclerosing haemangiomas. The typical radiological and histological appearances...We describe two cases where patients undergoing hepatic resection for metastatic disease of colorectal origin were found to have concomitant sclerosing haemangiomas. The typical radiological and histological appearances of these lesions are discussed.
Complications related to cholecystectomy are well described. Most occur in the early postoperative period and are recognised either at the time of, or shortly after surgery. Clinical sequelae occurring years following ch...Complications related to cholecystectomy are well described. Most occur in the early postoperative period and are recognised either at the time of, or shortly after surgery. Clinical sequelae occurring years following cholecystectomy are rare and infrequently reported. In addition, most delayed complications are related to the continuing presence or new formation of gallstones. In this paper we present a unique case of an abscess of the common bile duct wall, presenting with painless obstructive jaundice more than 30 years following an open cholecystectomy, without the presence of gallstones. The clinical presentation, investigations, and treatment are discussed with a review of other relevant reported cases in the literature.
BACKGROUND: A comprehensive care package for patients undergoing hepatectomy was developed with the aim of minimal physiological disturbance in the peri-operative period. Peri-operative analgesia with few gastrointestina...BACKGROUND: A comprehensive care package for patients undergoing hepatectomy was developed with the aim of minimal physiological disturbance in the peri-operative period. Peri-operative analgesia with few gastrointestinal effects and reduced requirement for intravenous (IV) fluid therapy was central to this plan. METHODS: Data on 100 consecutive patients managed with continuous epidural infusion (n = 50; bupivicaine 0.125% and fentanyl 2 microg/mL at 0.1 mL/kg/hr) or intrathecal morphine (n = 50; 300 microg in combination with oral gabapentin 1200 mg preoperatively and 400 mg bd postoperatively) was compared. RESULTS: The epidural and intrathecal morphine groups were equivalent in terms of patient demographics, procedures and complications. Patients receiving intrathecal morphine received less intra-operative IV fluids (median 1500 mL versus 2200 mL, P = .06), less postoperative IV fluids (median 1200 mL versus 4300 mL, P = .03) than patients receiving epidural infusion. Patients managed with intrathecal morphine established a normal dietary intake sooner (16 hours versus 20 hours, P = .05) and had shorter hospital stays than those managed with epidural infusions (4.7 +/- 0.9 days versus 6.8 +/- 1.2 days, P = .02). CONCLUSIONS: Single dose intrathecal morphine is a safe and effective means of providing peri-operative analgesia. Patients managed with intrathecal morphine have reduced peri-operative physiological disturbance and return home within a few days of hepatic resection.
We have previously demonstrated that uPA is overexpressed in pancreatic tumors. In an attempt to diagnose these tumors earlier, we sought to determine whether uPA could be identified in endoscopic retrograde cholangiopan...We have previously demonstrated that uPA is overexpressed in pancreatic tumors. In an attempt to diagnose these tumors earlier, we sought to determine whether uPA could be identified in endoscopic retrograde cholangiopancreatography obtained brushings in patients with malignant pancreatic and biliary strictures. Secondarily, uPA was measured in the serum of this patient population. uPA overexpression was identified in the cytologic tissue in 8 of 11 patients (72.7%). Serum analysis demonstrated a 2-fold higher concentration of uPA in the pancreaticobiliary cancer patients (1.27 versus 0.56 ng/mL; P = .0182). Also, uPA overexpression correlated with serum levels (P < .0001). This study confirms that uPA can be detected in the ERCP cytologically obtained tissue and is frequently present in a higher concentration in the serum of pancreaticobiliary cancer patients. A larger sample size will be required to address its value as a sensitive marker for the diagnosis of pancreatic or biliary cancers.
BACKGROUND: Choledochal cysts are uncommon biliary lesions. Due to the evolution of imaging and laparoscopic surgery, we sought to describe our last 3 years experience with the presentation and management of choledochal...BACKGROUND: Choledochal cysts are uncommon biliary lesions. Due to the evolution of imaging and laparoscopic surgery, we sought to describe our last 3 years experience with the presentation and management of choledochal cysts in adults. METHODS: A retrospective review of a prospectively established database of adults who were managed for primary choledochal cyst disease between 2005 and 2008 was performed. RESULTS: Between 8/2005 and 8/2008, 14 adults were managed for primary choledochal cyst disease. The average age was 41 years (range 17-86) and 79% were female. Presentations included biliary sepsis (3), pancreatitis (2), abdominal pain (3), or painless jaundice (1). Three patients had the cyst found during laparoscopic cholecystectomy, and two had an incidental finding after CT scan for an unrelated issue. The length of stay for those who had the cyst removed was 7.8 days (range 5-11). There were no operative or post-operative complications. CONCLUSIONS: Over the last 3 years 36% of our patients with choledochal cysts presented after incidental finding, either during a laparoscopic operation or after a CT scan for an unrelated problem. Increasing utilization of laparoscopy and CT scan for abdominal complaints has lead to a change in the pattern of presentation.
We report herein the case of a patient successfully treated by transhepatic portal venous stent placement for malignant portal vein obstruction with associated gastric and small bowel varices and repeated gastrointestina...We report herein the case of a patient successfully treated by transhepatic portal venous stent placement for malignant portal vein obstruction with associated gastric and small bowel varices and repeated gastrointestinal bleeding. CT angiography and portography showed severe portal vein obstruction from recurrent pancreatic cancer 15 months following pancreaticoduodenectomy with tumor encasement and dilated collateral veins throughout the gastric and proximal small bowel wall as the suspected cause of the GI bleeding. Successful transhepatic endovascular stent placement of the splenic vein at the portal vein confluence followed by balloon dilation was performed with immediate decompression of the gastric and small bowel varices and relief of GI hemorrhage in this patient until his death four months later. The treatment for patients with this dilemma can prove to be difficult, but as we have shown endovascular stenting of the portal system is an effective treatment option.
OBJECTIVE: The minimal amount of liver mass necessary for regeneration is still a matter of debate. The aim of the study was to analyze liver regeneration factors after extended resection with or without portosystemic sh...OBJECTIVE: The minimal amount of liver mass necessary for regeneration is still a matter of debate. The aim of the study was to analyze liver regeneration factors after extended resection with or without portosystemic shunt. METHODS: An extended left hemihepatectomy was performed in 25 domestic pigs, in 15 cases after a portosystemic H-shunt. The expression of Ki-67, VEGF, TGF-alpha, FGF, and CK-7 was analyzed in paraffin-embedded tissue sections. RESULTS: The volume of the remnant liver increased about 2.5-fold at the end of the first week after resection. With 19 cells/10 Glisson fields versus 4/10, Ki-67-expression was significantly higher in the H-shunt group. VEGF- and CK-7-expressions were significantly higher in the control group. No significant change was found in FGF-expression. The expression of TGF-alpha was higher, but not significantly, in the control group. CONCLUSIONS: The expression of Ki-67, and therefore hepatocyte regeneration, was increased in the shunt group. The expression of CK-7 on biliary epithelium and the expression of VEGF, however, were stronger in the control group.
Although laparoscopic cholecystectomy (LC) has been widely accepted as the standard of care, it continues to have a higher complication rate than open cholecystectomy. Bile duct injury with LC has often been attributed t...Although laparoscopic cholecystectomy (LC) has been widely accepted as the standard of care, it continues to have a higher complication rate than open cholecystectomy. Bile duct injury with LC has often been attributed to surgical inexperience, but it is also clear that aberrant bile ducts are present in a significant number of patients who sustain biliary injuries during these procedures. We present three cases of right sectoral hepatic duct injuries which occurred during LC and provide a discussion of the conditions which are likely to lead to these injuries, as part of a strategy to prevent them.
INTRODUCTION: Increased preoperative platelet and neutrophil counts are risk factors for decreased survival in several different malignancies. Our aim was to investigate the relationship between overall or disease-free s...INTRODUCTION: Increased preoperative platelet and neutrophil counts are risk factors for decreased survival in several different malignancies. Our aim was to investigate the relationship between overall or disease-free survival after resection of CRLM and the preoperative haematological parameters. METHODS: We reviewed a cohort of 140 patients who underwent resection of CRLM with curative intent, utilising prospectively maintained databases. Patient demographics, operative details, FBC, CRP, INR, histopathology results, and survival data were examined. Kaplan-Meier survival and Cox regression analyses were used to determine the impact of all variables on survival. RESULTS: 140 patients (96 males) with a median age of 67 years (range 33-82 years) underwent resection of CRLM. A significant correlation was exhibited between preoperative platelet count and neutrophil count (rho = 0.186, P = .028). When modelled as continuous covariates in a Cox regression hazards, an increased preoperative platelet (P = .02) and neutrophil counts (P <or= .001) were significantly associated with overall survival. Of the haematological parameters assessed only preoperative platelet count showed a strong trend of association with disease free survival; however this failed to reach statistical significance (P = .076). CONCLUSIONS: Increased preoperative platelet and neutrophil counts are independent risk factors for decreased survival in patients undergoing resection of CRLM in our series of patients. These findings require validation in larger studies to determine their relationship with survival. Further research into the role of these cell types in tumour progression, particularly in the development and inhibition of angiogenesis, is warranted.
Few cases of malignant rhabdoid tumour (MRT) of the liver are reported in literature and always in paediatric patients. We report the first two cases of young adults submitted to hepatic resection for MRT of the liver. A...Few cases of malignant rhabdoid tumour (MRT) of the liver are reported in literature and always in paediatric patients. We report the first two cases of young adults submitted to hepatic resection for MRT of the liver. A major liver resection was performed in both cases. The histology showed round or fusiform, loosely cohesive cells. The cytoplasm contained abundant eosinophilic inclusions, which caused the nuclei to be located in eccentric locations, giving the characteristic rhabdoid appearance. The immunohistochemical study was performed, and characteristic lack of nuclear INI1 protein expression was found. In a case surgery was associated to chemoradiotherapy. One patient died at 48 months followup for tumour recurrence. The other is still alive at 25 months followup. MRTs are rare tumours of pediatric age with poor prognosis. Hypothetical less malignant behaviour in the young adults could be supposed. Therefore an aggressive surgical and oncological treatment seems justified.
We discuss a patient who had poorly differentiated HCC with pyrexia and high CRP in laboratory data, which are not commonly observed in the usual HCC. A 50-year-old man with a history of liver dysfunction was admitted wi...We discuss a patient who had poorly differentiated HCC with pyrexia and high CRP in laboratory data, which are not commonly observed in the usual HCC. A 50-year-old man with a history of liver dysfunction was admitted with a chief complaint of a prolonged fever and general fatigue. Preoperative diagnosis was HCC with portal vein tumor thrombus. Posterior segmentectomy of the liver and thrombectomy was performed. Rapid tumor recurrence occurred after surgery, and he died 79 days after the operation. Immunohistochemical stain of HCC in this patient revealed the production of proinflammatory cytokine, interleukin-8 (IL-8). IL-8 production may have contributed to the high fever, high inflammatory reaction, and poor prognosis in this case.
Hydatidosis due to Echinococcus granulosus is an endemic parasitic zoonosis characterized by worldwide distribution particularly in Mediterranean countries. The most commonly involved anatomical locations are the liver a...Hydatidosis due to Echinococcus granulosus is an endemic parasitic zoonosis characterized by worldwide distribution particularly in Mediterranean countries. The most commonly involved anatomical locations are the liver and lung. Occasionally the cyst may progressively increase in size, mimicking gross ascites or intrabdominal tumor. Herein, are reported a case of a 40-year-old patient with a giant exophytically expanded hepatic echinococcus cyst, misdiagnosed as an abdominal malignancy during formal investigation. The patient was admitted to the hospital complaining for mild diffuse abdominal tenderness, moderate abdominal pain, nausea, diarrhoea, and vomiting. A CT scan revealed the presence of a giant abdominal mass 25 x 21 x 14 cm, resembling a tumor, adherent to the liver edges and parietal peritoneum, displacing intestinal loops. During the ensuing days the patient's clinical condition worsened, and he became febrile. Exploratory laparotomy was performed, and an exophytically grown giant liver hydatid cyst was removed, despite the radiological findings and the preoperative clinical suspicion.
BACKGROUND: Acute biliary diseases during pregnancy have been classically managed conservatively. Advances in minimally invasive surgery and the high recurrence rate of symptoms observed changed this management. METHODS:...BACKGROUND: Acute biliary diseases during pregnancy have been classically managed conservatively. Advances in minimally invasive surgery and the high recurrence rate of symptoms observed changed this management. METHODS: This is a prospective observational study. Initial management was medical. Unresponsive patients were treated with minimally invasive techniques including gallbladder percutaneous aspiration or cholecystostomy, endoscopic retrograde cholangiography, and laparoscopic cholecystectomy, depending on the pregnancy trimester and underlying diagnosis. RESULTS: 122 patients were admitted. 69 (56.5%) were unresponsive to medical treatment. Recurrent gallbladder colic was the most frequent indication for minimally invasive intervention, followed by acute cholecystitis, choledocholithiasis, and acute biliary pancreatitis. 8 patients were treated during the first trimester, 54 during the second, and 7 during the last trimester. There was no fetal morbidity or mortality. Maternal morbidity was minor with no mortality. CONCLUSION: Acute biliary tract diseases during pregnancy may be safely treated with minimally invasive procedures according to the underlying diagnosis and to the trimester of pregnancy.
BACKGROUND: Intraparenchymal endometriosis of liver is rare. It may present as liver tumour and the diagnosis is not usually established till after surgery. CASE OUTLINE: A 48-year-old postmenopausal woman presented with...BACKGROUND: Intraparenchymal endometriosis of liver is rare. It may present as liver tumour and the diagnosis is not usually established till after surgery. CASE OUTLINE: A 48-year-old postmenopausal woman presented with right upper quadrant pain and a cystic liver mass. Liver function tests and tumour markers (alphaFP, CEA, CA 19-9, and CA 125) were normal. Radiological imaging (USS, CT and MRI) suggested a thick walled cystic mass involving segments IV and VIII with complex intracystic septations. Frozen section at operation suggested a benign cystadenoma. The cyst was enucleated using a CUSA (Cavitron ultrasonic aspirator). The final histology confirmed endometriosis. DISCUSSION: Eleven cases of hepatic endometrioma have been reported and only four in postmenopausal women. Preoperative diagnosis poses a challenge and so far none of the cases have been diagnosed preoperatively. Surgery remains the treatment of choice. Accurate diagnosis at time of operation may avoid extensive liver surgery and its associated morbidity.
Portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis, is commonly followed by the development of an abnormal periportal and pericholedochal variceal network, which form a portal cavern...Portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis, is commonly followed by the development of an abnormal periportal and pericholedochal variceal network, which form a portal cavernoma. This may exert extrinsic pressure on the adjacent biliary ducts and gallblader, causing morphologic abnormalities, termed portal biliopathy, which is usually leading to asymptomatic cholestasis, while less frequently it can be associated with obstructive jaundice, gallstone formation, and cholangitis. Endoscopic stone extraction can effectively treat portal biliopathy when cholangitis is associated with common bile duct stones. Portosystemic shunts are indicated in cases of disease recurrence as they can achieve regression of portal cavernoma and usually relieve symptomatic portal biliopathy. This case describes an alternative partial portosystemic shunt that utilizes the right ovarian vein as an autologous conduit for the surgical treatment of symptomatic portal biliopathy.
UNLABELLED:BACKGROUNDS AND STUDY AIMS: Common bile duct (CBD) injury is one of the most serious complications of laparoscopic cholecystectomy (LC). Misidentification of the CBD during dissection of the Calot's triangle...UNLABELLED:BACKGROUNDS AND STUDY AIMS: Common bile duct (CBD) injury is one of the most serious complications of laparoscopic cholecystectomy (LC). Misidentification of the CBD during dissection of the Calot's triangle can lead to such injuries. The aim of the authors in this study is to present a new safe triangle of dissection. PATIENTS AND METHOD: 501 patients under went LC in the following approach; The cystic artery is identified and mobilized from the gall bladder (GB) medial wall down towards the cystic duct which would simultaneously divide the medial GB peritoneal attachment. This is then followed by dividing the lateral peritoneal attachment. The GB will be unfolded and the borders of the triangle of safety (TST) are achieved: cystic artery medially, cystic duct laterally and the gallbladder wall superiorly. The floor of the triangle is then divided to delineate both cystic duct and artery in an area relatively far from CBD. RESULTS: There were little significant immediate or delayed complications. The mean operating time was 68 minutes, nearly equivalent to the conventional method. CONCLUSIONS: Dissection at TST appears to be a safe procedure which clearly demonstrates the cystic duct and may help to reduce the CBD injuries.