Analysis of 5 patients with gallbladder tuberculosis who had open cholecystectomy and review of literature have shown that, although still rare it presents as a part of systemic miliary tuberculosis, abdominal tuberculos...Analysis of 5 patients with gallbladder tuberculosis who had open cholecystectomy and review of literature have shown that, although still rare it presents as a part of systemic miliary tuberculosis, abdominal tuberculosis, isolated gallbladder tuberculosis and as a calculus cholecystitis in anergic patients. There are no pathognomonic signs, the diagnosis depends on suspicion of tuberculosis, peroperative findings and histological examination.
Anaesthesia and surgical procedures lead to a reduction of intestinal motility, and opioids may produce a postoperative ileus, that might delay postoperative feeding. The aim of this prospective randomised study is to te...Anaesthesia and surgical procedures lead to a reduction of intestinal motility, and opioids may produce a postoperative ileus, that might delay postoperative feeding. The aim of this prospective randomised study is to test whether or not different kinds of epidural analgesia (Group A: morphine 0.0017 mg/kg/h and bupivacaine 0.125%-0.058 mg/kg/h; Group B: morphine alone 0.035 mg/kg/12h in the postoperative period) allow earlier postoperative enteral feeding, enhance intestinal motility a passage of flatus and help avoid complications, such as nausea, vomiting, ileus, diarrhoea, pneumonia or other infective diseases. We included in the study 60 patients (28 males and 32 females) with a mean age of 61.2 years (range 50-70) and with an ASA score of 2 or 3. All patients had hepato-biliary-pancreatic neoplasm and were candidates for major surgery. We compared two different pharmacological approaches, i.e., morphine plus bupivacaine (30 patients, Group A) versus morphine alone (30 patients, Group B). Each medication was administered by means of a thoracic epidural catheter for the control of postoperative pain. In the postoperative course we recorded every 6 hours peristaltic activity. We also noted morbidity (pneumonia, wound sepsis) and mortality. Effective peristalsis was present in all patients in Group A within the first six postoperative hours; in Group B, after 30 hours. Six patients in Group A had bowel motions in the first postoperative day, 11 in the second day, 10 in the third day and 3 in fourth day, while in Group B none in the first day, two in the second, 7 in the third, 15 in the fourth, and 6 in the fifth: the difference between the two groups was significant (p<0.05 in 1st, 2nd, 4th and 5th days). Pneumonia occurred in 2 patients of Group A, and in 10 of Group B (p < 0.05). We conclude that epidural analgesia with morphine plus bupivacaine allowed a move rapid return to normal gut activity and early enteral nutrition compared with epidural analgesia with morphine alone.
Intrinsic involvement of bile ducts, by metastatic colorectal adenocarcinoma growing from within or invading the lumen of bile ducts, is not a well recognized pattern of tumor growth. Clinical, radiographic, operative, a...Intrinsic involvement of bile ducts, by metastatic colorectal adenocarcinoma growing from within or invading the lumen of bile ducts, is not a well recognized pattern of tumor growth. Clinical, radiographic, operative, and histopathologic aspects of 15 patients with intrabiliary colorectal metastases were described. Fourteen patients were explored for possible hepatic resection. Two had jaundice, two radiographic evidence of an intrabiliary filling defect, 10 intraoperative evidence of intrabiliary tumor, and six microscopic evidence of intrabiliary tumor. Eleven patients underwent hepatic resection. Five of the resected patients developed hepatic recurrence. Four patients were explored for possible repeat resection. One had jaundice, one radiographic evidence of an intrabiliary filling defect, all had intraoperative evidence of intrabiliary tumor, and three microscopic evidence of intrabiliary tumor. Three patients underwent repeat hepatic resection. All patients with preoperative jaundice and radiographic evidence of an intrabiliary filling defect were unresectable. Overall, actuarial five-year survival is 33% for those patients resected versus 0% for those not resected. Intraoperative recognition of intrabiliary tumor at exploration for hepatic resection was more common than clinical, radiographic, or histopathologic recognition. More diligent examination of resected liver tissue by the surgeon and pathologist may increase identification of bile duct involvement and aid in achieving adequate tumor clearance.
Thirteen patients underwent hepatic cryotherapy and synchronous colonic resection. Two of the nine patients developed hepatic abscess--this is a rare complication of cryotherapy alone.Thirteen patients underwent hepatic cryotherapy and synchronous colonic resection. Two of the nine patients developed hepatic abscess--this is a rare complication of cryotherapy alone.
BACKGROUND: Faced with a difficult laparoscopic cholecystectomy the surgeon may feel that conversion to open operation would risk greater complications because of the laparotomy. Information on the effect of conversion i...BACKGROUND: Faced with a difficult laparoscopic cholecystectomy the surgeon may feel that conversion to open operation would risk greater complications because of the laparotomy. Information on the effect of conversion is lacking. The purpose of this study is to measure the complications of laparoscopic cholecystectomy and observe the effect of the conversion rate. METHODS: A total of 957 patients were studied. There were three consecutive series of patients; the first undergoing open cholecystectomy (384 patients), the second laparoscopic cholecystectomy with a 5.8% conversion rate (412 patients) and the third laparoscopic cholecystectomy with a 1.3% conversion rate (161 patients). Data was collected prospectively using a continuous audit, and the complication rate compared on an intention to treat basis. In addition a panel of experienced surgeons was asked to score the complications depending on their severity and a composite complication score calculated. Comparison between the 3 groups was then undertaken. RESULTS: Open cholecystectomy produced a post-operative complication rate of 6%. Initially this appeared to fall to 3.1% with the introduction of laparoscopic cholecystectomy, but when the complications occurring in the converted patients were included (i.e., on an intention to treat basis) the rate increased to 5.6% in the first group of laparoscopically-treated patients and 3.1% in the second. These differences were not statistically significant. A similar pattern emerged when scoring the severity of the complications as judged by the expert panel. The inclusion of intra-operative complications appears to remove any small advantage for laparoscopic cholecystectomy. The reduction in the conversion rate between the two laparoscopic groups from 5.8% to 1.2% was statistically significant. CONCLUSION: When considered on an intention to treat basis laparoscopic cholecystectomy offers no advantage over open operation in terms of the frequency or severity of complications. Reducing the frequency of conversion from a laparoscopic to an open procedure also has no significant effect on the complications encountered. We conclude, therefore, that the complication rate is independent of the conversion rate and that the surgeon, when faced with difficulty at laparoscopic cholecystectomy, should not be deterred from converting to open operation for fear of the post-operative consequences.
Hepatobiliary manifestations occur quite frequently in patients suffering from chronic ulcerative colitis and Crohn's disease and carry with them considerable morbidity and mortality. Although the true incidence is diffi...Hepatobiliary manifestations occur quite frequently in patients suffering from chronic ulcerative colitis and Crohn's disease and carry with them considerable morbidity and mortality. Although the true incidence is difficult to determine, clinically significant hepatobiliary disease occurs in 5%-10% of patients. At the present moment, the aetiology and pathogenesis of inflammatory bowel disease and its systemic manifestations remains speculative. For those hepatobiliary manifestations that respond to therapy of the underlying bowel disease, medical and/or surgical therapy must be aggressively pursued. More urgent research is required towards understanding the underlying cause(s) of the primary bowel disease and its systemic manifestations in order to improve the overall management of this condition.
BACKGROUND: Reports of better results at national referral centers than at low-volume community hospitals have prompted calls for regionalizing pancreaticoduodenectomy (the Whipple procedure). We examined the relationshi...BACKGROUND: Reports of better results at national referral centers than at low-volume community hospitals have prompted calls for regionalizing pancreaticoduodenectomy (the Whipple procedure). We examined the relationship between hospital volume and mortality with this procedure across all US hospitals. METHODS: Using information from the Medicare claims database, we performed a national cohort study of 7,229 Medicare patients more than 65 years old undergoing pancreaticoduodenectomy between 1992 and 1995. We divided the study population into approximate quartiles according to the hospital's average annual volume of pancreaticoduodenectomies in Medicare patients: very low (<1/y), low (1-2/y), medium (2-5/y), and high (5+/y). Using multivariate logistic regression to account for potentially confounding patient characteristics, we examined the association between institutional volume and in-hospital mortality, our primary outcome measure. RESULTS: More than 50% of Medicare patients undergoing pancreaticoduodenectomy received care at hospitals performing fewer than 2 such procedures per year. In-hospital mortality rates at these low- and very-low-volume hospitals were 3- to 4-fold higher than at high-volume hospitals (12% and 16%, respectively, vs. 4%, P<.001). Within the high-volume quartile, the 10 hospitals with the nation's highest volumes had lower mortality rates than the remaining high-volume centers (2.1% vs. 6.2%, P<.01). The strong association between institutional volume and mortality could not be attributed to patient case-mix differences or referral bias. CONCLUSIONS: Although volume-outcome relationships have been reported for many complex surgical procedures, hospital experience is particularly important with pancreaticoduodenectomy. Patients considering this procedure should be given the option of care at a high-volume referral center.
Peliosis hepatis is defined as the appearance of blood filled lakes in the hepatic parenchyma. It has been associated with various pharmacological agents and infections. Treatment has been primarily symptomatic and inclu...Peliosis hepatis is defined as the appearance of blood filled lakes in the hepatic parenchyma. It has been associated with various pharmacological agents and infections. Treatment has been primarily symptomatic and includes discontinuation of offending medications, partial hepatectomy or occasionally liver transplantation. We report a 58 year old white female on hormone replacement therapy who developed symptomatic peliosis hepatis and underwent successful superselective hepatic artery embolization with control of bleeding.
Mucobilia is a rare condition characterized by the accumulation of abundant mucus within the intra- or extrahepatic biliary tree. A variety of hepatobiliary and pancreatic neoplasms are mucin producing and have been asso...Mucobilia is a rare condition characterized by the accumulation of abundant mucus within the intra- or extrahepatic biliary tree. A variety of hepatobiliary and pancreatic neoplasms are mucin producing and have been associated with the development of mucobilia including biliary mucinosis, biliary papillomatosis, mucin-producing cholangiocarcinoma (MPCC), or cystic neoplasms of the pancreas or biliary tree (cystadenoma or cystadenocarcinoma). We report the case of 46 year-old male with a biliary cystadenocarcinoma of the caudate lobe which resulted in chronic biliary obstruction and relapsing cholangitis. A review of the literature for both mucobilia and biliary cystadenocarcinoma is provided along with a discussion addressing the clinical presentation, diagnosis, treatment, and prognosis for this rare entity.
Eleven patients with a preoperative diagnosis of adenoma of the papillae of Vater were followed up during the fifteen-year period from 1984 till 1998 in the Oulu University Hospital. Seven patients were treated primarily...Eleven patients with a preoperative diagnosis of adenoma of the papillae of Vater were followed up during the fifteen-year period from 1984 till 1998 in the Oulu University Hospital. Seven patients were treated primarily by transduodenal excision without any recurrences so far. One of these seven patients was found to have adenocarcinoma in a histological examination. Active surgery for adenoma of the papillae of Vater is recommended because of the precancerous nature of the lesion, and because malignancy cannot always be detected by endoscopic biopsies. Transduodenal excision could be recommend for patients at high operative risk, especially in cases with small adenomas and low-grade dysplasia, where histologically free resection margins can be achieved, but pancreaticoduodenectomy should still be performed on patients at low operative risk.
BACKGROUND: Pancreatic pseudocyst endoscopic drainage has been described as a good treatment option, with morbidity and mortality rates that are lower than surgery. The aim of our study is to describe the efficacy of dif...BACKGROUND: Pancreatic pseudocyst endoscopic drainage has been described as a good treatment option, with morbidity and mortality rates that are lower than surgery. The aim of our study is to describe the efficacy of different forms of endoscopic drainage and estimate pseudocyst recurrence rate after short follow up period. PATIENTS AND METHODS: We studied 30 patients with pancreatic pseudocyst that presented some indication for treatment: persistent abdominal pain, infection or cholestasis. Clinical evaluation was performed with a pain scale, 0 meaning absence of pain and 4 meaning continuous pain. Pseudocysts were first evaluated by abdominal CT scan, and after endoscopic retrograde pancreatography the patients were treated by transpapillary or transmural (cystduodenostomy or cystgastrostomy) drainage. Pseudocyst resolution was documented by serial CT scans. RESULTS: 25/30 patients could be treated. Drainage was successful in 21 (70% in an 'intention to treat' basis). After a mean follow-up of 42 +/- 35.82 weeks, there was only 1 (4.2%) recurrence. A total of 6 complications occurred in 37 procedures (16.2%), and all but 2 were managed clinically and/or endoscopically: there was no mortality related to the procedure. Patients submitted to combined drainage needed more procedures than the other groups. There was no difference in the efficacy when we compared the three different drainage methods. CONCLUSIONS: We concluded that pancreatic pseudocyst endoscopic drainage is possible in most patients, with high success rate and low morbidity.
INTRODUCTION: Duodenal villous adenoma arising from the ampulla of Vater has a high risk of malignant development. Excluding associated malignant disease prior to resection of an adenoma of the ampulla is not always poss...INTRODUCTION: Duodenal villous adenoma arising from the ampulla of Vater has a high risk of malignant development. Excluding associated malignant disease prior to resection of an adenoma of the ampulla is not always possible. Therefore, the surgical procedure of choice to treat this rare tumour is still controversial. OBJECTIVE: To evaluate retrospectively results of treatment of villous adenoma arising from ampulla of Vater with dysplasia or associated carcinoma limited to the ampulla. PATIENTS AND METHODS: From 1985 to 1996, eight patients have been diagnosed with ampullary villous adenoma suitable for resection. We have reviewed treatment, morbidity, mortality, follow-up and final outcome. RESULTS: Pancreatoduodenectomy (PD) was performed in 4 patients. Transduodenal ampullectomy and endoscopic resection was performed in 2 patients each. There was no perioperative mortality. None of the patients had biliary, pancreatic or intestinal leakage but two patients who underwent PD had minor postoperative complications. The mean follow-up was 44 (range: 6-132) months. Villous adenoma was associated with adenocarcinoma in 50% of the cases (4/8 patients). During the follow-up both patients who underwent transduodenal ampullectomy developed recurrent disease. All patients initially treated by PD are alive without evidence of recurrent disease. CONCLUSIONS: Treatment of villous adenoma of the ampulla must be individualized within certain limits. In our series, PD achieve good results and it appears to be the procedure of choice in order to treat villous adenomas with proved presence of carcinoma, carcinoma in situ or severe dysplasia. Endoscopic or local resection may be appropriate for small benign tumours in high risk patients.
The timing of laparoscopic cholecystectomy following an attack of acute biliary pancreatitis is controversial. The traditional approach of interval cholecystectomy has been challenged recently. The present study was desi...The timing of laparoscopic cholecystectomy following an attack of acute biliary pancreatitis is controversial. The traditional approach of interval cholecystectomy has been challenged recently. The present study was designed to evaluate the benefits of interval laparoscopic cholecystectomy for patients with mild acute pancreatitis (Ranson less than 3). Nineteen patients with mild pancreatitis underwent ultrasonographic evaluation to confirm the biliary etiology. ERCP was performed in all patients on the first available endoscopy list, and endoscopic sphincterotomy was performed in two patients with calculi or dilated common bile duct on ultrasonographic examination. Medical treatment was administered and laparoscopic cholecystectomy was scheduled after 8-12 weeks to allow the inflammatory process to settle. There were no recurrent attacks of pancreatitis during this period. The degree of difficulty of the laparoscopic procedure was assessed by the presence of adhesions to the gallbladder area, difficulty of dissection in the Calot's triangle, intraoperative bleeding and the need for a drain. Six patients (31.5%) had severe adhesions, difficult dissection of the cystic duct and artery, bleeding and prolonged operating time. In two of these patients (10.5%) the procedure was converted to open cholecystectomy. In conclusion, our results suggest that postponing laparoscopic cholecystectomy in acute pancreatitis patients is not advantageous surgically and does not justify the risk of further morbidity caused by the gallbladder disease.
The wound healing process and production of tumour necrosis factor alpha (TNF-alpha) by peritoneal cells of 7-day and 14-day obstructive jaundice (OJ) and sham-operated rats were investigated. In the study the skin wound...The wound healing process and production of tumour necrosis factor alpha (TNF-alpha) by peritoneal cells of 7-day and 14-day obstructive jaundice (OJ) and sham-operated rats were investigated. In the study the skin wound breaking strength was measured. In addition such histological and biochemical parameters as fibroblast and endothelial cell proliferation, inflammatory cell infiltration and hydroxyproline content were evaluated in polyurethane sponge discs implanted subcutaneously into rats. TNF-alpha production by peritoneal exudate cells (PEC), both spontaneous and lipopolysaccharide (LPS)-induced was determined by a bioassay. In OJ rats the process of both early as well as late phase of healing was impaired. The breaking strength of skin wound was decreased, the fibroblast and endothelial cell proliferation and collagen deposition, as well as hydroxyproline content were diminished. In 7 day OJ the numbers of inflammatory cells in the implants were lowered with a subsequent slight increase on day 14 of OJ. The spontaneous and LPS induced TNF-alpha production by PEC were significantly higher in 7 day OJ as compared with sham-operated controls. On day 14 of OJ the LPS-induced TNF-alpha level was, in contrast, much lower and did not differ much from the spontaneous TNF-alpha production. We conclude that the impairment of wound healing in OJ results from disturbances in functioning of the immune system caused by systemic endotoxaemia.
Gaining access to deeply located hydatid cysts of the liver using conventional surgical techniques may be accompanied by significant intra- and postoperative complications. In addition, obliteration of the cyst cavity is...Gaining access to deeply located hydatid cysts of the liver using conventional surgical techniques may be accompanied by significant intra- and postoperative complications. In addition, obliteration of the cyst cavity is still a matter of controversy. We developed a novel method for easy access to deep hydatid cysts using a water jet dissector (Parenchimotom 01, TOSA, Pleven, Bulgaria). At pressure of 20 Bar using a 0.2 mm nozzle, a corridor is created through the liver parenchyma overlying the cyst; vessels and biliary duct are thus clearly displayed as linear structures traversing the corridor and are ligated and divided under direct visual control. The fibrous capsule of the cyst is spared by the jet. Following endocystectomy performed in the ordinary manner, the cyst cavity is filled with gelatin sponge; a passive tube drain is placed in contact with the liver incision. In allowing for a selective dissection of the liver parenchyma, the jet makes safe access to deeply located hydatid cysts possible. On the other hand, the gelatin sponge induces good fibroblast response and assists in rapid and effective obliteration of the residual cavity. This novel technique works well in our hands but more extensive studies are necessary before its final acceptance.
In 11 years and 3 months, 2,037 patients with HCC were seen and 48 patients (2.4%) were diagnosed to have obstructive icteric type HCC. Five patients were terminally ill and were not investigated further. Forty three pat...In 11 years and 3 months, 2,037 patients with HCC were seen and 48 patients (2.4%) were diagnosed to have obstructive icteric type HCC. Five patients were terminally ill and were not investigated further. Forty three patients were initially investigated by endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic cholangiogram (PTC) and classified as having obstructive icteric type 1, 2, or 3 HCC based on the cholangiographic findings. The obstruction in type 1 HCC was due to intraluminal tumour casts and/or tumour fragments obstructing the hepatic ductal confluence or common bile duct, while intraluminal blood clots, from haemobilia, filling the biliary tree was the cause in type 2 HCC. The pathology in type 3 HCC was extraluminal obstruction by extensive tumour encasement of the intra-hepatic biliary ductal system and/or extrinsic compression of the hepatic and common bile ducts by tumour(s) and/or malignant lymph nodes. At the initial ERC/PTC, 10 patients (5 resected, 50%) had obstructive icteric type 1 and 23 patients (0 resected) had obstructive icteric type 3 HCC. Of the 10 patients initially classified according to cholangiography to have obstructive icteric type 2 HCC, subsequent investigations revealed that 6 patients had type 1 HCC (4 resectable,67%) and 4 patients had type 3 HCC (0 resectable). The classification of the obstructive icteric type HCC into types 1, 2, and 3, based on the initial cholangiographic appearances has simplified and rationalized our management strategy for this condition.
Despite recent advances in hepatic surgery, resection of the cirrhotic liver continues to be fraught with high morbidity and mortality rates. As a result, for many patients requiring resection of HCC the postoperative co...Despite recent advances in hepatic surgery, resection of the cirrhotic liver continues to be fraught with high morbidity and mortality rates. As a result, for many patients requiring resection of HCC the postoperative course is complicated and the probability of cure is diminished by coexisting cirrhosis. In this review, we discuss the characteristics of the cirrhotic liver which make it poorly tolerant of resection and the most common complications that follow such surgery. The main purpose of this paper is to review recent attempts to identify interventions that might be beneficial to cirrhotic patients undergoing resection. These interventions include assessment of liver reserve, advances in surgical technique, and improvement in liver function and regeneration.
Fibrolamellar hepatocellular carcinoma (FHCC) is a variant of hepatocellular carcinoma, which mainly affects a young age group and carries a relatively good prognosis. It is widely accepted that aggressive curative resec...Fibrolamellar hepatocellular carcinoma (FHCC) is a variant of hepatocellular carcinoma, which mainly affects a young age group and carries a relatively good prognosis. It is widely accepted that aggressive curative resection is still the best option for FHCC. We report here a case of successful arterialisation of the portal vein with an aortoportal jump graft for portal vein thrombosis, which developed postoperatively in an already comprised portal vein with tumour invasion following an extensive liver resection for FHCC.
Caroli's Disease (CD) is a rare congenital disorder characterized by cystic dilatation of the intrahepatic bile ducts. This report describes a patient with cholangiocarcinoma arising in the setting of monolobar CD. In sp...Caroli's Disease (CD) is a rare congenital disorder characterized by cystic dilatation of the intrahepatic bile ducts. This report describes a patient with cholangiocarcinoma arising in the setting of monolobar CD. In spite of detailed investigations including biliary enteric bypass and endoscopic retrograde cholangiography, the diagnosis of mucinous cholangiocarcinoma (CCA) was not made for almost one year. The presentation, diagnosis and treatment of monolobar CD and the association between monolobar CD and biliary tract cancer are discussed. Hepatic resection is the treatment of choice for monolobar CD.