Nonparasitic cysts of the liver: results and options of surgical treatment

Nonparasitic cysts of the liver (NPHC) are highly variable in respect to appearance and therapeutic approach. The treatment of these cysts varies according to the nature and appearance of the disease. Based on the variable nature of disease and the various therapeutic options, all of which were attempted in our patients, the most suitable mode of treatment for different forms of NPHC are discussed. Ninety-one patients with NPHC who had been treated surgically from 1977 through 1995 were examined retrospectively. Asymptomatic peripheral cysts measuring up to 10 cm do not require further treatment. Computed tomography (CT)-guided aspiration (n = 9) should be regarded as a palliative measure. Within a short period, CT-guided aspiration led to recurrence of symptoms in seven of our patients. Standard treatment of NPHC is fenestration with widest possible excision of the cystic wall, which can be performed laparoscopically (n = 10) or by the conventional surgical mode (n = 54). One patient was initially operated by the laparoscopic technique but developed bleeding, which necessitated conversion to the open mode. Three patients underwent synchronous laparoscopic cholecystectomy. Recurrence rates were similar: 11% in the laparoscopically treated group and 13% in the group that underwent conventional open surgery. Conventional surgical treatment was always successful in cases of solitary cysts. However, in cases of multiple cysts measuring more than 5 cm, conventional surgery was followed by recurrence of symptoms in 26% of patients (7/27), who then had to undergo a second operation. Partial resection of the liver (n = 9) was successfully performed in cases of polycystic disease (n = 5) with concomitant enlargement of the organ as well as in cases of large solitary cysts of the left lobe of the liver (n = 4). In patients in whom we found that the cysts communicated with the ductal system (n = 3), we performed a cystojejunostomy to drain the bile. The complication rate was low. In addition to frequent postoperative ascites, which necessitated no further intervention, we observed infectious complications in four patients. Twenty patients (22%) expired during a mean follow-up period of 6.2 years. Interestingly, deaths were frequently associated with malignancy (11/20). After fenestration of multiple cysts measuring > 5 cm, the patients are at high risk for recurrence. Hence partial resection of the liver is an excellent therapeutic alternative in selected patients with polycystic disease and massive enlargement of the organ in whom the disease could not be controlled by simple fenestration. The results of this study show that laparoscopic fenestration should replace the conventional surgical technique as the gold standard in cases of NPHC because the laparoscopic technique is less stressful for the patient and is associated with a rate of success similar to that of the conventional technique.

Sublingual nitroglycerine: effects on contractile activity of the distal oesophagus and lower oesophageal sphincter in healthy men

BACKGROUND AND AIMS

Nitric oxide plays an important role in the control of gastrointestinal motility. This study assessed the effects of graded doses of the nitric oxide-releasing agent, nitroglycerine, on distal oesophageal motor activity and lower oesophageal sphincter resting pressure.

METHODS

Eight healthy young men received at 1-week intervals placebo, 0.2 mg, 0.4 mg or 0.8 mg nitroglycerine sublingually under random double-blind conditions. Sphincter pressure was recorded using a Dent sleeve and oesophageal motility using sensors 1, 4, 7 and 10 cm orad the sleeve during two 15-min periods before and four 15-min periods after drug administration. In minutes 4 to 6 of each period, subjects swallowed 5 mL water at 30 s intervals.

RESULTS

After 0.2 mg and 0.4 mg nitroglycerine, amplitude, duration and area under curve of swallow-initiated contractions were smaller than after placebo. After 0.8 mg nitroglycerine, amplitude, duration and area under curve were slightly greater than after placebo and significantly greater than after the lower nitroglycerine doses. No effects were discernible on onset latency and propagation velocity of contractions as well as on lower oesophageal sphincter resting pressure.

CONCLUSIONS

Sublingual nitroglycerine had modest, dose-dependent effects on oesophageal peristaltic amplitude and duration, but did not affect the tone of the lower oesophageal sphincter.

[Nonparasitic liver cysts. Overview of therapy with long-term results]

Symptomatic nonparasitic cysts of the liver require surgical intervention. Seventy-one patients were treated between 1977 and 1993 at the Department of General Surgery, University of Vienna. Different surgical treatments were compared with regard to complications and recurrence. Interventional puncture led to recurrences in nearly all cases and represents only a palliative procedure. Surgical treatment consisted of either laparoscopic (n = 7) or conventional (n = 44) fenestration or excision. The rates of recurrence did not differ significantly (14% vs 9%). The laparoscopic procedure is successful not only in polycystic disease but also in solitary cysts. Wide deroofing and excision were equally effective. Laparoscopic therapy should be tried in all cysts initially, because it causes less stress than celiotomy. Because of the small number of laparoscopically treated patients in the literature and in the authors' own experience, the significance of the difference in outcome between the two methods could not be established. In more patients, further investigations should be carried out to ascertain whether the laparoscopic method is superior regarding surgical stress and recurrence. Cystojejunostomy (n = 3) and hepatic resection (n = 2) are reserved for special indications. One homologous liver transplantation was successfully carried out 6 months after cystojejunostomy because of a cholangiocellular carcinoma. Frequent postoperative ascites represented a persistent problem in only one patient. Two of three cases of postoperative infection with intraabdominal abscesses led to death. Altogether, 16 patients died, including seven because of malignancy and three because of septic complications of a Potter III syndrome.