Choledochal cysts: Management and long-term follow-up

BACKGROUND

Choledochal cysts are congenital anomalies that can occur at any level of the biliary tree. They carry long-term risk of biliary complications and cancer development. Complete excision of all involved bile ducts is recommended.

METHODS

Patients treated between 1995 and 2019 were reviewed retrospectively.

RESULTS

Sixty patients; 46 female and 14 male with a median age of 41 years (range 13-83) were included in the study. Mild abdominal pain was the most common presenting symptom (60%). Majority of the patients had Todani type I cysts (67%). Concomitant biliary malignancy was diagnosed in five patients (9%). Eight patients were followed-up conservatively (13%). Twenty-five patients were treated by excision of the extrahepatic bile ducts and Roux-en-Y hepaticojejunostomy, liver resection was added in seven, pancreatoduodenectomy was done in three and liver transplantation in one. There was no perioperative mortality. Postoperative complications developed in 17 patients (34%), two requiring surgical treatment. Four of the five patients with malignancies died at a median 42 months (range 6-95) following surgery. Median 62 months (range 8-280) follow-up was available in 45 surgically treated patients, 19 followed-up for more than 10 years. None of the patients developed malignancy during follow-up. Four patients (17%) were readmitted for anastomotic strictures requiring treatment.

CONCLUSION

The majority of choledochal cysts are Todani type-I and early cyst excision is the mainstay of management, which may decrease the risk of malignant transformation.

Curative Chemoradiotherapy of Primary Pancreatic Lymphoma with Vertebral Metastasis: Palliation of Persistent Biliary Stricture by Roux-en-Y Hepaticojejunostomy

Primary pancreatic lymphoma (PPL) is a rare tumor that usually presents with the clinical picture of advanced adenocarcinoma but has a much better prognosis. A 38-year-old man was referred after percutaneous transhepatic external biliary drainage for obstructive jaundice. Abdominal magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography had revealed a 5-cm pancreatic head mass that caused biliary tract dilation. Computed tomography angiography showed that the mass encased the celiac trunk as well as the common hepatic and splenic arteries. MRI also revealed a metastatic lesion at the third lumbar vertebra. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were within normal range. The initial diagnosis was inoperable pancreatic adenocarcinoma; however, Tru-Cut pancreatic biopsy showed a large B cell lymphoma. After 6 sessions of chemotherapy and 21 sessions of radiotherapy, both the pancreatic mass and the vertebral metastasis had disappeared. However, he had persistent distal common bile duct stricture that could not be negotiated by either the endoscopic or percutaneous route. A Roux-en-Y hepaticojejunostomy was performed. The patient stayed alive without recurrence for 52 months after the initial diagnosis and 45 months after completion of oncologic treatment. In conclusion, a large pancreatic mass with grossly involved peripancreatic lymph nodes, without ascites, liver or splenic metastasis, should alert the clinician to the possibility of PPL. Cure is possible by chemoradiotherapy even in the presence of vertebral metastasis. Persistent stricture in the distal common bile duct may require a biliodigestive anastomosis.

Assessment of living donors with respect to pre- and posttransplant psychosocial properties and posttransplant family functioning in pediatric liver transplantation

BACKGROUND/AIMS

We aimed in this study to investigate pre- and posttransplant clinical and psychosocial features of the donors and the effects of living-related liver transplantation and possible relevant factors on psychosocial outcome and family functioning.

METHODS

Thirty-two living donors (19 females, age 31.84 ± 7.10 years) were evaluated. Medical records of donors regarding pre- and posttransplant clinical and psychological features and family life were evaluated.

RESULTS

The donors were parents (n=28, 87.6%) in most. In the pretransplant evaluation, 5 donors (19.3%) had anxiety regarding postoperative complications and quality of life. Donors were discharged from the hospital in a median of 7 days (range, 5-30 days). Return to work and feeling of complete well-being were accomplished in a median of 4 weeks (range, 1-32 weeks) and 10 weeks (range, 4-48 weeks), respectively. Sixteen recipients (50.0%) suffered from major complications, and 3 (9.4%) required invasive intervention. Fourteen donors (43.4%) reported pain around the surgical incision and nonspecific gastrointestinal problems postoperatively. Psychological problems were observed in 8 donors (25.0%); 2 (6.3%) had depression requiring drug and psychotherapeutic intervention. Psychological disruption was found to be correlated with the presence of problems in the recipient (p<0.01, r=0.487). The donors' relationship with the recipient was negatively affected in 1 (3.1%), but improved in 15 (46.9%) cases. Nine donors (34.6%) displayed nervous behavior toward their spouses, and 2 (7.7%) later divorced. Life of the other family members was negatively affected in 8 (30.7%). Two donors' spouses (7.7%) failed to carry out domestic responsibilities.

CONCLUSIONS

Psychological disturbance and abnormal family functioning are frequently observed during the posttransplant period. Therefore, psychologic assessment and evaluation of family functioning should be regularly repeated during the posttransplant period.

Investigation of impaired carbohydrate metabolism in pediatric liver transplant recipients

OGTT was performed in 28 liver transplants maintained with tacrolimus to investigate carbohydrate metabolism and assess risk factors for development of PTDM. None had PTDM that was detected by OGTT. Early PTDM in four cases (14.3%) resolved in follow-up. Five new cases (17.9%) demonstrated DCM (DCM = IGT +/- hyperinsulinemia). Fasting measurements were normal in two hyperinsulinemic cases. With one (20%, p > 0.05) exception none of the children with DCM were overweight or had a family history of diabetes. All five (100%) children with DCM had been given high cumulative dosage of steroids 18 (78.3%)--without DCM (p > 0.05). The median age of children with DCM was greater [4.3 (12.7-18.0) vs. 7.0 (2.3-18.0) yr, p < 0.01] and duration of follow-up longer [5.3 (2.3-7.0) vs. 2.5 (0.7-7.3) yr, p < 0.05]. Four children (80%) with DCM were pubertal (p < 0.05). However, neither age nor duration of follow-up or pubertal stage had significant effect on DCM development. Early PTDM is a transient phenomenon and is not predictive for future development of diabetes. DCM is frequently observed in liver transplanted children. Albeit the children with DCM were given high cumulative dose of steroids, were older, mostly were pubertal, and had longer duration of follow-up, we cannot draw firm conclusions on effects of the risk factors on carbohydrate metabolism because of the small sample size and relatively short duration of follow-up. Unlike fasting measurements, OGTT can detect all children with DCM.

Necrotizing pancreatitis after transcatheter arterial chemoembolization for hepatocellular carcinoma

A patient who developed necrotizing pancreatitis after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) is presented. A 55- year-old man had been followed for chronic hepatitis B infection for 10 years at another institution. He presented with multiple masses in the right lobe of the liver and a metastasis in the left adrenal gland. He was referred after a percutaneous liver biopsy which revealed a moderately differentiated HCC. He was treated by TACE. At the third session of TACE, the right hepatic artery was found to be thrombosed; however, angiography also demonstrated collateral feeder vessels (arising from the pancreaticoduodenal artery) which were used for treatment. He developed necrotizing pancreatitis, possibly due to regurgitation of the chemotherapeutic agents to the pancreas. He recovered without complications with imipenem-cilastatin prophylaxis. Acute pancreatitis is a rare but severe complication of TACE. Selective catheterization of the tumor vessels is the established standard in TACE. A careful risk-benefit analysis is mandatory in patients with abnormal collateral vessels. Treatment of acute necrotizing pancreatitis (ANP) after TACE is the same as the accepted approach to ANP due to other causes.

Somatostatin and propranolol to treat small-for-size syndrome that occurred despite splenic artery ligation

We report our success with somatostatin and propranolol to treat small-for-size syndrome that occurred despite splenic artery ligation. A 48-year-old woman with cirrhosis due to autoimmune hepatitis underwent living-donor liver transplant; her graft-to-body weight ratio of the right lobe was 0.91%. After arterial reperfusion, portal pressure and flow were 24 cm H20 and 2.22 L/min (ie, 360 mL/100g graft/min), respectively. Following splenic artery ligation, the portal pressure decreased to 16 cm H20 and portal flow to 1.74 L/min (ie, 282 mL/100g graft/min). On the second postoperative day, small-for-size syndrome was diagnosed based on the marked prolongation of prothrombin time (international normalized ratio, 4.4), hyperbilirubinemia (359.1 micromol/L), rapid escalation of transaminases (alanine aminotransferase 2488 U/L, aspartate aminotransferase 1075 U/L) and very high portal flow rate (> 90 cm/sec). Oral propranolol (40 mg/day b.i.d.) and somatostatin infusion (250-microgram bolus followed by perfusion at a rate of 250 microgram/h for 5 days) were started. Prothrombin time and transaminase levels began to decrease the following day, although the bilirubin level increased to 495.9 micromol/L before returning to normal. The patient was discharged in excellent health 5 weeks after surgery. Despite reduction of portal pressure by splenic artery ligation, small-for-size syndrome may develop in patients with persistent high portal flow. To the best of our knowledge, this is the first report of the successful treatment of small-for-size syndrome by somatostatin and propranolol in the clinical setting.

Intraductal growth-type mucin-producing peripheral cholangiocarcinoma associated with biliary papillomatosis

A 64-year-old woman with upper abdominal pain, nausea, and vomiting was admitted. The magnetic resonance imaging revealed marked dilation and "crowding" of the segment 4 bile ducts with an area suspicious for a stone or tumor. Ultrasonography-guided percutaneous transhepatic cholangiography revealed multiple filling defects in the segment 4 bile ducts, the left and common hepatic ducts. A left hepatectomy and cholecystectomy was performed. Dilated bile ducts containing mucinous material and a mass in the cystically dilated bile ducts of segment 4 were detected in the gross examination. It showed continuity within the surrounding dilated bile ducts. The dilated bile ducts of the segments 2 and 3 contained mucinous material without any apparent mass formation. Microscopically, the bile ducts were lined by biliary epithelium displaying simple and complex papillary structures with moderate to severe degree of dysplastic changes. The mass was composed of complex papillary structures filling the bile duct with a few foci of invasion. The papillary structures were composed of mucin-producing columnar cells as well as cells with oncocytic appearance. Patchy cytokeratin 7, cytokeratin 19, hepatocyte paraffin 1, MUC2, and CDX2 immunopositivities were observed. Biliary papillomatosis, mucin-producing intrahepatic cholangiocarcinoma, and intraductal papillary-type peripheral cholangiocarcinoma are in the same disease spectrum of papillary biliary neoplasm and termed as intraductal papillary neoplasm of the liver. Mucinous hypersecretion and signs of mucobilia are considered specific and should raise the suspicion of lesions in this spectrum.

Bile duct injury during cholecystectomy requiring delayed liver transplantation: a case report and literature review

Major bile duct injury during cholecystectomy represents potentially severe complications with unpredictable long-term results. If these lesions are not treated adequately, they can lead to hepatic failure or secondary biliary cirrhosis therefore requiring liver transplantation. We report a patient who required liver transplantation 15 years after open cholecystectomy. A l0-year old girl underwent open cholecystectomy and duodenal repair for cholelithiasis and cholecystoduodenal fistula. She required two surgical interventions, hepaticojejunostomy which was performed in another center and portoenterostomy for biliary stricture at our institution seven years after the cholecystectomy. Eight years after the third operation, she required recurrent hospitalization for treatment of hepatic abscesses. The extremely short intervals between the three life threatening episodes and the rapid progression to severe sepsis were taken into consideration and liver transplantation was performed at the age of 25. She is leading a healthy life at 4 years post transplantation. Although iatrogenic biliary injury can usually be treated successfully by a combination of surgery, radiological and endoscopic techniques, patients with severe injuries develop irreversible liver disease. This case report and review of the literature suggest that liver transplantation is a treatment modality for a selected group of patients with end-stage liver disease secondary to bile duct injury.

Successful living-donor liver transplantation and retransplantation with cavoportal hemitransposition: a case report

An 11-month-old female infant underwent living-donor liver transplantation for secondary biliary cirrhosis 8 months after Kasai operation. The portal vein was hypoplastic, and its diameter was only 4 mm at the level of the splenomesenteric confluence. End-to-end anastomosis of the recipient suprarenal vena cava to the graft portal vein (a left lateral section from the patient's mother) was performed. An end-to-side portocaval shunt with the recipient portal vein was constructed to mitigate portal hypertension. The early postoperative course was relatively uneventful. However, persistent hepatitis caused by infection with Cytomegalovirus and chronic rejection resulted in progressive hepatic dysfunction. Nine months after the initial operation, a living-donor retransplantation (a left lateral section from the patient's grandmother) was performed. One month after retransplantation, severe acute rejection that eventually required OKT3 treatment developed. The patient was in excellent health until 4 months after retransplantation, when another acute rejection episode (for which she was successfully treated) developed. Cavoportal hemitransposition should be included in the armamentarium of the transplant surgeon for the management of extensive portal system thrombosis and portal vein hypoplasia. An additional shunt may be useful in mitigating portal hypertension.

Obstructive jaundice due to a textiloma mimicking a common bile duct stone

A foreign body is a rare cause of obstructive jaundice. We report a 19-year-old woman with jaundice caused by a surgical gauze in the common bile duct (CBD). Four yours earlier, she had undergone a cholecystectomy and drainage for hydatid disease of the liver. Her postoperative course was complicated by a biliary fistula that healed after 50 days. She now presented with obstructive jaundice of 2 weeks' duration. Magnetic resonance cholangiopancreatography (MRCP) showed a signal-void mass, consistent with a CBD stone. Surgical exploration of the CBD revealed a surgical gauze as the cause of the obstruction. To the best of our knowledge, this is the first case of a surgical gauze obstructing the CBD requiring surgical removal.

Hepatic atrophy-hypertrophy complex due to Echinococcus granulosus

Obstruction of a major hepatic vein, or major portal vein, or biliary tree branch causes atrophy of the related hepatic region, and frequently, hypertrophy in the remaining liver-the atrophy-hypertrophy complex (AHC). Whether hydatid cysts can cause AHC is controversial. The records of 370 patients who underwent surgery for hepatic hydatid disease between August 1993 and July 2002 were evaluated retrospectively. Excluding six patients with previous interventions on the liver, AHC had been recorded in the operative notes of 16 patients (4.4%); for all patients, a cyst located in the right hemiliver had caused atrophy of the right hemiliver and compensatory hypertrophy of the left hemiliver. The computed tomography images of seven patients were suitable for volumetric analysis. The median (range) right and left hemiliver volumes were 334 (0-686) ml and 1084 (663-1339) ml, respectively. The median (range) cyst volume was 392 (70-1363) ml. AHC due to Echinococcus granulosus was confirmed by objective volumetric analysis. The presence of AHC should alert the surgeon to two implications. First, pericystectomy may be hazardous due to association with major vascular and biliary structures. Second, in patients with AHC, the hepatoduodenal ligament rotates around its axis; this should be considered to avoid vascular injury if a common bile duct exploration is to be performed.

A rare intraabdominal tumor: giant hepatic artery aneurysm

A 55-year-old man was investigated for right upper abdominal quadrant pain. He had no history of abdominal trauma or surgery. Imaging studies showed a common hepatic artery aneurysm involving the gastroduodenal artery. Following aneurysmectomy, examination with a hand Doppler apparatus yielded clear arterial signals from the liver surface. Therefore, vascular reconstruction was not performed. He had an uneventful postoperative course.

Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center

BACKGROUND

Iatrogenic factors became the leading mechanisms of severe cholangitis in a referral center.

PATIENTS AND METHODS

The records of the 58 patients treated for severe cholangitis between 1996 and May 2004 (inclusive) were evaluated.

RESULTS

The most frequent underlying diseases were periampullary tumors and mid-bile duct carcinomas (22), followed by proximal cholangiocarcinomas (14). The triggering mechanism was an incomplete endoscopic retrograde cholangiopancreatography (ERCP) in 32 patients, incomplete or inappropriate percutaneous transhepatic biliary drainage (PTBD) in 6, apparently successful ERCP and stenting in 1, and percutaneous transhepatic cholangiography in 1. PTBD was the treatment of choice (38). Mortality was 29% (17/58); the major causes were refractory sepsis (8) and incomplete biliary drainage (advanced tumor, technical failure, or hemobilia) (8).

CONCLUSIONS

In this series composed predominantly of patients referred after development of sepsis, ERCP and PTBD complications were the leading mechanisms of severe cholangitis. Nonoperative biliary manipulations are invasive procedures with potentially fatal complications. The decisions to perform such procedures and periprocedural management are responsibilities of an experienced multidisciplinary team.

Spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis

BACKGROUND

Autoimmune pancreatitis is an evolving entity.

METHODS

A patient who had spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis is presented.

RESULTS

A 58-year-old diabetic woman with jaundice was referred for pancreatic head carcinoma diagnosed by magnetic resonance imaging (MRI). At laparotomy, a pancreatic head mass (4 x 3 cm) that involved the transverse mesocolon and two other hard masses (1 cm) in the pancreatic body and tail were found. The gallbladder was palpated as a hard tumor mass. Frozen section examination of the gallbladder and pancreatic biopsies revealed cholecystitis and pancreatitis with lymphoplasmacytic infiltration. The common bile duct was brittle and unsuitable for anastomosis. Starting 1 month after the operation, drainage from the biliary catheter decreased gradually and stopped. There was no parenchymal lesion on MRI examination in the 2nd postoperative month. Cholangiography from the percutaneous catheter showed flow of contrast agent into the duodenum. Serum immunoglobulin G, G4 and E levels were increased.

CONCLUSION

To the best of our knowledge, this is the first report of spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis.

Strong coupling of nonlinear electronic and biological oscillators: reaching the "amplitude death" regime

Interaction between an electronic and a biological circuit has been investigated for a pair of electrically connected nonlinear oscillators, with a spontaneously oscillating olivary neuron as the single-cell biological element. By varying the coupling strength between the oscillators, we observe a range of behaviors predicted by model calculations, including a reversible low-energy dissipation "amplitude death" where the oscillations in the coupled system cease entirely.

Definitive treatment of traumatic biliary injuries

BACKGROUND

We presented our experience with definitive treatment of traumatic biliary injuries.

METHODS

Six male patients (mean age 13 years; range 2 to 32 years) who were referred to our unit for definitive treatment of traumatic biliary injuries were retrospectively evaluated. Data were analyzed in terms of demographic characteristics, mechanisms of injuries, associated injuries, previous treatments, symptoms on admission, treatment at our unit, and the results of treatment. Outcome was assessed using modified Schweiser and Blumgart criteria.

RESULTS

The injuries were due to blunt abdominal trauma in all the patients but one who had a gunshot wound. In three patients, biliary injuries were missed at the initial operation. On admission, three patients had external biliary fistulas, two had biliary strictures. One patient was sent following inadvertent ligation of the hepatoduodenal ligament during attempts to control hemorrhage. Roux-en-Y hepaticojejunostomy was performed in three patients. Percutaneous biloma drainage was performed in two patients, resulting in fistula closure in 13 and 40 days, respectively. One patient was treated by endoscopic retrograde cholangiopancreatography and papillotomy, which enabled fistula closure in three days. One patient was lost to follow-up. One patient died from hepatic failure 11 years after the trauma. At the end of a mean follow-up of 49 months (range 15 to 75 months), three patients were in excellent condition, while one patient experienced occasional attacks of cholangitis.

CONCLUSION

In patients with undetected biliary injuries and in those with unsuccessful repair attempts, biliary reconstruction should be performed in experienced hepatopancreatobiliary surgery units.

Alveolar echinococcosis in Turkey. Experience from an endemic region

BACKGROUND

Radical resection is the only potentially curative treatment for hepatic alveolar echinococcosis (AE). Although Turkey is an endemic region, population screening is not performed and early diagnosis is rare. Consequently, surgeons are compelled to explore possibilities such as near-total resection and biliodigestive anastomosis for palliation of jaundice.

METHODS

Surgery was performed in 32 patients with hepatic AE with the following indications: (1) resection; (2) palliation of jaundice; (3) definite assessment of operability; (4) failure in the management of cavity infection by percutaneous methods. Curative resection (R0 = complete resection of all parasitic mass [n = 9], and R1 = a resection in which a small remnant was left on a vital structure [n = 8]) were performed in 17 patients, intrahepatic cholangiojejunostomy in 7, laparotomy-external drainage in 7, and debulking in 1.

RESULTS

Perioperative mortality rates were 2/17, 0/7, 2/7 and 1/1, respectively. Twelve patients in the curative resection group are alive without recurrence/progression of the small remnant during a median follow-up of 59 (range 27-116) months. One patient developed an inoperable recurrence that was treated with albendazole. One patient was lost to follow-up. Long-term albendazole treatment was effective in all R1 patients except a patient who had slow asymptomatic progression. Successful palliation of jaundice was achieved in 5 of the 7 intrahepatic cholangiojejunostomy patients.

CONCLUSIONS

The results of R1 resection in alveolar hydatid disease are similar to those of R0 resection; a small remnant is successfully controlled by albendazole. In patients with jaundice due to hilar invasion, biliary diversion from segment 3 or 5 is effective for palliation of the jaundice and facilitates albendazole treatment.

The effect of concomitant vascular disruption in patients with iatrogenic biliary injuries

BACKGROUND AND AIMS

To evaluate treatment results in iatrogenic biliary injuries with concomitant vascular injuries.

PATIENTS/METHODS

Between January 1998 and May 2002 (inclusive), angiography was performed in 45 of the 105 patients treated for iatrogenic biliary tract injury. The charts of these 45 patients and 5 other patients in whom vascular injury was diagnosed at operation were evaluated retrospectively. Twenty-nine patients had concomitant vascular injury, the biliovascular injury group (BVI), and the remaining 21 patients had isolated biliary tract injury (IBTI).

RESULTS

The most frequent initial operation was a cholecystectomy. The frequency of high-level (Bismuth III or IV) strictures was 90% in the BVI group and 62% in the IBTI group ( P<0.05). Perioperative mortality was 7% in the BVI group and 5% in the IBTI group ( P>0.05). The morbidity in the BVI group was significantly higher ( P<0.05). Two patients in each group were lost to follow up. During a median (range) follow up of 31 months (5-51 months), a successful functional outcome was achieved in 96% of the BVI group and 100% of the IBTI group with a multimodal approach ( P>0.05).

CONCLUSIONS

The frequency of high-level biliary injury and morbidity were significantly higher in the BVI group. However, concomitant vascular injury had no significant effect on mortality and medium-term outcome of biliary reconstruction. Thus, routine preoperative angiography is not recommended.

Endolumenal ultrasonography in the diagnosis of pancreatic diseases

We evaluated the usefulness and limitations of endoscopic ultrasonography (EUS) in pancreatic mass lesions. EUS was useful in detecting small pancreatic mass lesions, especially ductal adenocarcinomas smaller than 20 mm and small islet cell tumors smaller than 10 mm. In some of these cases, characteristic echo patterns were specific and useful for differential diagnosis from focal pancreatitis. However, when EUS did not clearly delineate a tumor at the stenotic area of the main pancreatic duct, transpapillary pancreatoscopy and biopsy/cytology were sometimes effective to obtain a definitive diagnosis. EUS fine-needle aspiration should be performed in conjunction with imaging modalities when the differential diagnosis of a pancreatic mass is difficult to make. Although the value of EUS in cancer staging was overestimated, EUS in conjunction with spiral computed tomography or magnetic resonance imaging should be performed for such a purpose. Usefulness and limitations of intraductal ultrasonography (IDUS) also were evaluated. IDUS was useful in detecting carcinoma in situ and small tumors and in assessing parenchymal invasion and the intraductal spread of the tumor. IDUS was also useful in accurately localizing islet cell tumor and in differentiating benign from malignant cases of localized stenosis of the main pancreatic duct. Thus, EUS and IDUS are indispensable modalities in the diagnosis of pancreatic diseases.

Five years and 4 months of recurrence-free survival in hepatic angiosarcoma

A 54-year-old woman was referred with the diagnosis of hepatic angiosarcoma, made by percutaneous biopsy under ultrasonographic guidance. Ultrasonography (US) had revealed a 48 x 42 x 35 mm mass in the right lobe. Standard biochemical tests and whole blood count had yielded normal results. At our institution, magnetic resonance imaging demonstrated a hypervascular mass in the right lobe. Alpha-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19-9 levels were normal. Serological tests were negative for hepatitis B and C viruses. There was no evidence of metastasis. A right hepatectomy was performed. Histopathological examination confirmed the diagnosis of angiosarcoma. However, there was a suspicion of microscopically positive margins. Relaparotomy and resection of a 1-cm-thick slice of hepatic parenchyma was performed. Histopathological examination revealed necrotic tumor cells at the previous margin. The new surgical margin was tumor free. Due to the expected poor prognosis, prophylactic chemoembolization of the remnant liver (lipiodol + adriamycin + mitomycin) was performed at 3 and 7 months postoperatively. She has been alive without recurrence for 5 years and 4 months. Hepatic angiosarcoma has two distinct presentations: multiple tumors and a solitary tumor. The reported poor results largely stem from the predominance of the multiple tumors and consequent unresectability. Long-term survival is possible in solitary resectable hepatic angiosarcomas.

Cystic duct carcinoma: a proposal for a new "working definition"

BACKGROUND

Farrar's criteria for cystic duct carcinoma (histopathological diagnosis of a carcinoma strictly limited to the cystic duct) have practical limitations. We propose new "working definition": a gallbladder tumor, the center of which is located in the cystic duct.

PATIENTS AND METHODS

Between 1980 and 2000 we diagnosed cystic duct carcinoma in 31 patients, 28 of whom (90%) had increased serum bilirubin concentrations. Extrahepatic bile duct resection and cholecystectomy were performed in 10 patients; in others, extended right hepatectomy (16), right hepatectomy (3), and liver bed resection (2) were necessary as well for a potentially curative resection. Additional procedures were portal vein resection (10) and pancreatoduodenectomy (7).

RESULTS

All tumors were adenocarcinomas. Depth of invasion was T2 in 3 patients, T3 in 12, and T4 in 16. Thirteen patients (42%) had lymph node metastasis. Curative resection was performed in 24 patients (77%). Hospital mortality was 5 of 31 (16%). Actuarial 5-year survival rate excluding hospital deaths was 22%.

CONCLUSIONS

The proposed "working definition" avoids the problems associated with Farrar's criteria and describes a distinct patient group with an approximately equal proportion of men and women, advanced T stage, but a lower than expected frequency of lymph node metastasis. It establishes a basis for standard reporting of results.

Clinicoanatomical study on the infraportal bile ducts of segment 3

In some patients, bile ducts of segments 2 and 3 (B2 and B3) run caudally to the umbilical portion of the left portal vein (UP)--an infraportal course. We aimed to evaluate the frequency and clinical implications of this variation. Between January 1992 and October 2000, 108 patients underwent resection for hilar cholangiocarcinoma. The records of the 6 patients with infraportal left hepatic ducts were evaluated. An infraportal B3 was diagnosed in 6 patients (6%). No patient had an infraportal B2. An infraportal B3 could be demonstrated by computed tomography (CT) before biliary drainage, percutaneous transhepatic or endoscopic cholangiography, portography after percutaneous transhepatic biliary drainage (PTBD) via B3 and CT after PTBD via B3. Four patients (4/6) had a liver bridge covering Rex's recess (B3 not in the bridge). The incidence of the bridge in 75 comparable patients was 9/75. In conclusion, common radiologic methods are sufficient for diagnosis of abnormal biliary anatomy. The presence of a liver bridge over Rex's recess is suggestive of this variation. Separate biliary reconstruction for an infraportal branch is mandatory in an extended right hepatectomy for biliary tract cancer and may be necessary in liver transplantation with segments 2+3 grafting.

Anatomical variations and surgical strategies in right lobe living donor liver transplantation: lessons from 120 cases

BACKGROUND

Anatomical variations in right liver lobe are common. However, clinical implications and surgical management of these variations in living donor liver transplantation have not been analyzed systematically.

METHODS

Surgical anatomy of vascular and biliary structures in 120 right lobe grafts were reevaluated by reviewing the results of preoperative (computerized tomography and Doppler ultrasonography) and intraoperative (cholangiography) imaging as well as surgical findings. The data were analyzed in relation to surgical management of anatomical variations.

RESULTS

The incidence of variants leading to multiple portal vein anastomoses was 7.5%. The incidence of dual right hepatic veins was 0.8%; 30% of the grafts had significant accessory hepatic veins (>5 mm) and 13.9% of these were multiple. All of them were successfully reconstructed with technical modifications including venoplasty and venous grafts, except for two cases with multiple intraparenchymal portal vein branches to the anterior segment. The incidence of dual hepatic arteries was 1.7%, but only one of them was reconstructed without negative sequelae. The incidence of variants potentially leading to multiple bile duct anastomoses was 35.0%, and eventually 39.2% of the grafts had multiple orifices. With a variety of techniques including ductoplasty, hepaticohepaticostomy, and biliary stent, total incidence of leakage and stenosis was 10.8% and 9.2%, respectively. Although ductoplasty, internal stent or no stenting, seemed to be associated with increased risk of complications, anatomical variants, multiple bile ducts, and duct-to-duct reconstruction did not bear a significant risk.

CONCLUSIONS

Anatomical variations of vascular and biliary structures in right lobe grafts are common. However, most can be managed safely with technical modifications. Only cases with intraparenchymal origin of the anterior portal vein(s) may form a relative contraindication, especially when combined with similar biliary variants. Otherwise, intraoperative assessment of biliary anatomy was enough for successful management. Detailed and precise assessment of vascular and biliary anatomy is vital for appropriate surgical management.

Solitary pancreatic tuberculosis mimicking advanced pancreatic carcinoma

A 40-year-old woman was referred for pancreatic head carcinoma invading the portal vein. The dichotomy between the radiological findings and the general condition of the patient, as well as the laboratory results (no evidence of cholestasis), cast doubt on the diagnosis. There was no history of tuberculosis. The chest radiograph revealed no pathological findings. The anatomic relationships of the lesion entailed a high risk of vascular injury if tissue biopsy were to be done; therefore, diagnostic laparotomy was performed. Biopsy revealed granulomas with caseous necrosis, consistent with tuberculosis. After 6 months of antituberculosis treatment, the lesions had completely resolved. Tuberculosis should be considered in the differential diagnosis of pancreatic masses, particularly in regions where the disease is endemic. The condition usually resembles an advanced pancreatic tumor. Performing a biopsy of inoperable lesions and maintaining a reasonable skepticism in regard to the evaluation of operable lesions (attention to nonexclusive but helpful clues, such as young patient age, history of tuberculosis, absence of jaundice) will lead to the diagnosis in most patients. Diagnostic laparotomy may be required in a small subset of patients. The response to antituberculosis treatment is very favorable. The role of resection (e.g., pancreatoduodenectomy) is very limited.

Vena cava stenting and portorenal shunt in Budd-Chiari syndrome: combination of the 'modern' and the 'classical'

We have treated a 33-year-old Budd-Chiari patient (due to antiphospholipid syndrome) with a history of myocardial infarction by placing a vascular stent in the inferior vena cava and performing a portorenal shunt with three objectives: (1) to perform a shunt operation on a Budd-Chiari patient with good hepatic functional reserve, (2) to avoid a thoracotomy and manipulation of the heart in a patient with a cardiac thrombus and a history of myocardial infarction and (3) to avoid a synthetic graft in a patient with antiphospholipid syndrome. Vena cava stenting and portorenal shunt make a useful combination which should be included in the armamentarium of the hepatobiliary surgeon.

Evaluation of various imaging methods in the differential diagnosis of intraductal papillary-mucinous tumor (IPMT) of the pancreas

BACKGROUND/AIMS

IPMT (intraductal papillary-mucinous tumor) of the pancreas has unique clinicopathological characteristics. The lesions which show characteristic clinical features of IPMT exhibit a wide spectrum of histological types ranging from atypical hyperplasia to invasive cancer. Therefore, surgical treatment cannot be recommended for all patients with IPMT. It is necessary to assess the malignant potential of IPMT in individual patients in order to select an appropriate approach. The aim of this study was to evaluate the effectiveness of endoscopic ultrasonography and intraductal ultrasonography as compared with ultrasonography and computed tomography for this purpose.

METHODOLOGY

Ultrasonography, computed tomography, endoscopic ultrasonography and intraductal ultrasonography were performed in 49 cases of IPMT (atypical hyperplasia 7, adenoma 23, noninvasive 7 and invasive adenocarcinoma 12). On the basis of the histopathological analysis of another 28 cases of resected IPMT specimens, criteria for differential diagnosis by imaging modalities were defined as follows: Nonneoplastic lesion (atypical hyperplasia): no wall thickening or nodule; noninvasive IPMT (adenoma and intraductal carcinoma): a nodule or wall thickening is present; and invasive IPMT with pancreatic parenchymal invasion: a mass with a heterogenous pattern or interruption of the pancreatic duct wall by the mass.

RESULTS

The diagnostic accuracy rate for differentiating nonneoplastic lesion noninvasive IPMT, and invasive IPMT was 33% by ultrasonography, 38% by computed tomography, 77% by endoscopic ultrasonography, and 67% by intraductal ultrasonography. Sensitivity, specificity and accuracy rates for differentiating neoplastic and nonneoplastic IPMT by ultrasonography was 33%, 100%, 42%, by computed tomography 36%, 100%, 44%, by endoscopic ultrasonography 90%, 71%, 88%, by intraductal ultrasonography 94%, 29%, 84%, respectively. Sensitivity, specificity and accuracy rates for differentiating invasive and noninvasive IPMT by ultrasonography was 25%, 100%, 80%, by computed tomography 33%, 100%, 83%, by endoscopic ultrasonography 55%, 97%, 88%, by intraductal ultrasonography 56%, 91%, 84%, respectively. Diagnostic accuracy for invasive IPMT except minimally invasive cases by endoscopic ultrasonography and intraductal ultrasonography was 80%, based on the results of the examination which demonstrated a higher grade lesion.

CONCLUSIONS

With these criteria, ultrasonography and computed tomography showed high specificity, but low sensitivity for the differential diagnosis of neoplastic/nonneoplastic and invasive/noninvasive IPMT. However, endoscopic ultrasonography and intraductal ultrasonography had high sensitivity and diagnostic accuracy for the differential diagnosis of neoplastic/nonneoplastic lesions. Combination of endoscopic ultrasonography and intraductal ultrasonography showed a high accuracy rate in the diagnosis of invasive IPMT. Thus endoscopic ultrasonography and intraductal ultrasonography contributed significantly to the choice of the treatment for IPMT.

The transhepatic route for the placement of a duodenojejunal stent: application in a postoperative closed loop obstruction of the duodenum

A patient who had undergone gastric resection for carcinoma, had closed loop obstruction of the duodenum due to neoplasia at the duodenojejunal junction. The obstruction was relieved successfully by transhepatic placement of a duodenojejunal stent. We were compelled to use the transhepatic route because a Roux-Y reconstruction had been performed. Transhepatic placement may be the only chance of palliation in a small subset of patients with malignant intestinal obstruction.

Pancreatobiliary adenosquamous carcinoma (report of two cases)

Adenosquamous carcinomas are rare malignant tumors of the pancreas and periampullary region. We present two cases of pancreatic and periampullary adenosquamous carcinoma with clinicopathologic, histo- and immunohistochemical findings. A 51-year-old and a 48-year-old man presented with right upper quadrant pain of three months duration and jaundice for two weeks. Both cases had an elevation of liver enzymes and CA 19-9. In the first case, computerized tomography showed a 3 cm-mass at the pancreatic head. In the second one, endoscopic retrograde choledocopancreatography (ERCP) revealed a mass at the ampulla Vateri localization. A pancreatoduodenectomy was performed for both cases. Gross pathologic examination displayed a solid, gray-white colored 4 cm-tumor at the pancreatic head and a solid, pink-white colored, 2 cm-tumor at the periampullary region bulging into the duodenal lumen. Microscopically, both tumors were composed of solid nests of squamous cells with pearl formation and mucin-containing glandular cells and diagnoses were adenosquamous carcinoma. Furthermore, histo- and immunohistochemical findings were consistent with microscopic diagnoses.

Long-term results of surgery for liver hemangiomas

BACKGROUND

Elective surgery for liver hemangiomas is still controversial.

HYPOTHESIS

Long-term results show that elective surgery for liver hemangiomas is safe and effective.

SETTING

A tertiary care university hospital in Istanbul, Turkey.

PATIENTS

Forty-two patients underwent surgery for liver hemangiomas between January 1988 and December 1998; 41 were symptomatic. The primary indications for surgery were abdominal pain in 33 patients, diagnostic uncertainty in 6, and enlargement in 3. The median largest dimension of the major lesion was 10 cm (range, 7-45 cm).

MAIN OUTCOME MEASURES

(1) Patients' assessment of the effects of surgery on preoperative symptoms, (2) determination of whether any other pathological conditions were missed in the preoperative evaluation, (3) operative mortality and morbidity, and (4) recurrences.

DESIGN

Retrospective cohort study.

RESULTS

Enucleation was the most frequent operation (33 patients). Hospital mortality and morbidity were 2.4% (bleeding from the biopsy site on a lesion evaluated as inoperable at laparotomy; 1 patient) and 12% (5 patients), respectively. Thirty-three patients could be followed up for a median of 53 months (range, 6-135 months). Of the 32 preoperatively symptomatic patients, surgery was successful in symptom control in 28 (88%) (complete resolution or significant amelioration). No other cause of pain could be identified during follow-up in the other patients. Control ultrasonography revealed no recurrences.

CONCLUSIONS

Elective surgery is indicated in a small subset of patients with hemangiomas because of abdominal pain, enlargement, and diagnostic uncertainty. The results of surgery in symptom control are gratifying in approximately 90% of patients. Recurrences are rare. Enucleation can be performed rapidly and safely in most patients and should be preferred to resection.

Primary lymphoma of the liver: report of a case

We describe herein a female patient with non-Hodgkin's lymphoma of the liver and present a review of the related literature. The patient was referred with the diagnosis of malignant hemangiopericytoma (with an open biopsy). The physical examination, standard laboratory test results and tumor marker levels were all normal. A nonstandard left lobectomy was performed. Histopathological and immunohistochemical examinations revealed non-Hodgkin's lymphoma of B-cell type. The findings of a peripheral blood smear and bone marrow biopsy were normal. There was no other site of involvement based on physical or radiological examinations. These findings established the diagnosis of primary hepatic lymphoma. Fewer than 100 cases have been reported in the world literature. The best treatment results have been obtained by a resection followed by chemotherapy when feasible.

Hepatic alveolar echinococcosis: MRI findings

The purpose of this study was to describe the magnetic resonance imaging (MRI) appearance of hepatic alveolar echinococcosis (HAE) on T(1)-weighted, T(2)-weighted and postgadolinium images. A total of 13 lesions were demonstrated in 13 patients. All patients underwent MR examination at 1 T imager. MR examinations included precontrast T(1)-weighted breathing averaged spin echo (SE), breath-hold spoiled gradient echo, T(2)-weighted TSE sequences with and without fat suppression, and T(1)-weighted breath-hold spoiled gradient echo (SGE) sequence following i.v. after gadolinium administration. All lesions were confirmed with histopathology. HAE hepatic lesions revealed geographic patterns of variable signal intensities on noncontrast T(1)- and T(2)-weighted images. Slightly hyperintense, iso- and hypointense signal on T(1)-weighted images corresponded to calcified regions, which appeared hypo-isointense signal on T(2)-weighted images. Necrotic areas were hypointense signal on T(1)-weighted and hyperintense signal on T(2)-weighted images. On postgadolinium images, lesions did not reveal enhancement. Dilatation of intrahepatic bile ducts distal to HAE abscesses were observed in five patients and portal vein invasion or compression was observed in four patients, lobar atrophy of the liver was coexistent finding in cases with portal vein compression. The MRI appearance of HAE abscesses included large irregularly marginated masses with heterogenous signal on T(1)- and T(2)-weighted images and lack of enhancement with gadolinium.

Mesoatrial shunt in Budd-Chiari syndrome

BACKGROUND

The operations with proven effects on survival in Budd-Chiari syndrome are shunt operations and liver transplantation.

PATIENTS AND METHODS

Between 1993 and 1999 (June), 13 cases of Budd-Chiari syndrome have been treated surgically. Four cases had concomitant thrombosis of the inferior vena cava; the others had marked narrowing of the lumen due to the enlarged caudate lobe. Mesoatrial (n = 12) or mesosuperior vena caval (n = 1) shunts were constructed with ringed polytetrafluoroethylene grafts.

RESULTS

The median portal pressure fell from 45 (range 32 to 55) to 20 (range 11 to 27) cm H(2)O (P <0.001). Two patients died in the early postoperative period. One patient who did not comply with anticoagulant treatment had a shunt thrombosis in the second postoperative year. The other 10 patients are alive without problems during a median 42 (range 1 to 76) months of follow-up.

CONCLUSION

Mesoatrial shunt with a ringed polytetrafluoroethylene graft is effective in Budd-Chiari syndrome cases with thrombosis or significant stenosis in the inferior vena cava.

Phantom steatosis of the liver: report of a case

A patient, referred under a diagnosis of metastatic liver tumors, was found to have multiple areas of focal fatty change (FFC) which, during follow-up, exhibited discordant evolutions. To our knowledge, this phenomenon-regression of a FFC lesion with concurrent appearance or progression of other similar lesions in the same patient, has been reported in only one previous case. FFC can be strongly suggested by clinical, biochemical and radiologic criteria. However, an exact diagnosis can only be made with biopsy. To avoid misdiagnosing a malignancy as FFC and vice versa, biopsy should be performed without hesitation in all patients in whom a change in approach is possible.

Elective repair of abdominal wall hernias in decompensated cirrhosis

BACKGROUND/AIMS

Abdominal wall hernia is a common feature of decompensated cirrhosis. However, literature on elective hernia repair in these patients is limited. Here we report the experience of our center.

METHODOLOGY

Eleven hernias (seven umbilical, three inguinal and one incisional) in nine patients with decompensated cirrhosis were repaired. The indication for operation was repeated incarceration in two patients and significant pain in four; three patients with umbilical hernias had ulceration and necrosis of the overlying skin. Pre-operatively, medical therapy of ascites was conducted at the hepatology unit. Umbilical hernias were treated with the classic Mayo repair; in all cases but two, this was buttressed with a prolene graft. One inguinal hernia was repaired with the plication-darn technique; the other two and the incisional hernia were repaired with prolene grafts.

RESULTS

There was no mortality. One patient had a scrotal hematoma; two patients had leakage of ascites into the wound. Seven patients were followed up. Four patients died without recurrence after a median period of 12 months (range 6-22). The other patients have no recurrence at 1, 10 and 40 months post-operatively.

CONCLUSIONS

Umbilical and inguinal hernias in patients with decompensated cirrhosis may be repaired safely on an elective basis. Control of ascites is vital for success.

Laparoscopic treatment of hepatic hydatid disease

Surgery is still the main modality in the treatment of hepatic hydatid disease. Laparoscopic methods, with their low morbidity, have gained prominence in many fields and, in some cases, have nearly replaced open surgery. In this report, a laparoscopic method for the treatment of hepatic hydatid disease is described and the results in the first six cases are presented. The method involves the use of an aspirator-grinder apparatus designed specifically for laparoscopic surgery. The postoperative courses of the patients were very comfortable and no complication related to the laparoscopic technique occurred. The method achieves evacuation of all viable cyst contents with the patient benefits of laparoscopic surgery. The apparatus practically eliminates the risk of spillage. The postoperative parameters and the early follow-up results (21-27 months) are very encouraging.

Laparoscopic surgery of hepatic hydatid disease: initial results and early follow-up of 16 patients

Surgery is the main modality in the treatment of hepatic hydatid disease. In this report, a laparoscopic surgical method is described, and the results in the first 16 cases are presented. The method involves the use of an aspirator-grinder apparatus that achieves effective evacuation of viable cyst contents with the patient benefiting from the laparoscopic approach. Cavity infection occurred in two patients and was treated conservatively. In another patient, postoperative ultrasonography revealed a thick-walled cavity containing a dense fluid. Because the patient was symptomatic, pericystectomy was performed during the sixth postoperative month. Early postoperative parameters and the early follow-up results in other patients (2-17 months) are encouraging. The method is particularly suitable for uncomplicated, early-stage cysts located in laparoscopically accessible locations.

Immunoprotection in spontaneous remission of type 1 diabetes: long-term follow-up results

This prospective pilot study was undertaken to test the efficacy of oral methyl-prednisolone (MP) therapy at spontaneous remission phase of type 1 diabetes in intervening the course of the disease. Twenty-five type 1 diabetic patients who were classified as having a spontaneous remission (honeymoon) were divided into treatment and non-treatment groups on voluntary basis. Fifteen patients thus making up the treatment group (13 males and 2 females, mean age 23.8 +/- 6.2 years) received 0.7-1.0 mg/kg/day of MP p.o. for 2 weeks. The dose of the drug was then gradually diminished every week until 5 mg/day (approx. 0.1 mg/kg/day) and discontinued at 10 +/- 2 weeks. In case of hyperglycemia occurring in 12 of 15 patients due to the administration of steroid, insulin was used to normalize blood glucose levels (average 0.47 +/- 0.21 IU/kg/day). The non-treatment group (8 males and 2 females, mean age 21.8 +/- 8.9) did not receive any special medication or placebo except for insulin whenever necessary to regulate glycemia. Upon completion of protocol, all patients in treatment group displayed clinical remission with 10 still in non-insulin requiring remission for follow-up periods ranging between 16 and 91 months. The remaining 5 patients relapsed within 3-15 months of therapy. Other metabolic (including basal and stimulated C-peptide levels) and immunological indices that have spontaneously ameliorated with the occurrence of honeymoon were also maintained within normal range in the NIR patients. Meanwhile, natural remission in the non-MP-treated group terminated at 3.4 +/- 0.6 months with deterioration of all metabolic and immunological markers as well as increasing requirements for insulin. In conclusion, the spontaneous remission of the patients could be prolonged significantly by MP therapy as opposed to no therapy (P < 0.001). These results suggest that the spontaneous remission phase may be a crucial point of intervention in immunotherapy of type 1 diabetes and that randomized trials with MP at this particular phase would be worthwhile.

The effect of vitamin E on glycosylated hemoglobin levels in diabetic rats: a preliminary report

The effect of vitamin E (D-alpha-tocopherol acetate) on glycosylated hemoglobin levels was investigated in streptozotocin-diabetic rats. The animals were divided into four groups: (a) Group 1: control group, (b) Group 2: diabetic group, (c) Group 3: diabetic group treated with low-dose vitamin E and (d) Group 4: diabetic group treated with high-dose vitamin E. Starting 24 hr after streptozotocin injections (60 mg/kg), Groups 3 and 4 received intraperitoneal injections of vitamin E on days 1, 4, 7, 11, 14, 18 and 21 at doses of 500 mg/kg and 1,000 mg/kg respectively. Vitamin E treatment did not prevent weight loss or improve glycemic control in diabetic animals but significantly suppressed the increase in glycosylated hemoglobin in Group 4 (7.7 +/- 0.6 mumols fructose/g hemoglobin versus 5.5 +/- 0.2 mumols fructose/g hemoglobin in Group 2 and Group 4 respectively). These levels were still significantly higher than the levels in healthy control group animals (2.6 +/- 0.1 mumols fructose/g hemoglobin). Further studies on the suppressive effect of vitamin E are warranted.