Diagnostic uncertainty of hepatobiliary cystadenoma: report of 11 cases and review of the literature

Objectives: This research was conducted to highlight the pre-operative diagnostic uncertainty of hepatobiliary cystadenomas and to suggest strategies to improve its diagnostic yield

Methods: All consecutive patients admitted with hepatobiliary cystadenomas from July 2007 to July 2014 were recruited in this study. The following information was retrieved from the medical records of eligible patients: demographics, clinical features, laboratory tests, imaging results, operative procedures, frozen sections, complications, histopathology, outpatient follow-up, and morbidity and mortality

Results: Eleven total patients with a diagnosis of hepatobiliary cystadenomas were treated in our unit. Abdominal ultrasounds and computed tomography [CT] scans were performed in all patients; magnetic resonant imaging [MRI] was performed in three patients with suspicion of hepatobiliary cystadenomas. Six patients underwent a definitive surgery; five patients were incorrectly diagnosed with non-hepatobiliary cystadenoma liver cysts [2 hydatid cysts and 3 simple cysts] by the pre-operative ultrasound and CT scan. These five patients underwent surgical deroofing. The frozen section was positive in two patients and was falsely negative in one patient who was diagnosed with simple cysts. The final histopathology results identified hepatobiliary cystadenomas in all patients

Conclusions: Hepatobiliary cystadenomas are rare and are frequently misdiagnosed as hepatic cystic lesions with resultant inadequate surgical treatments. A diagnosis of hepatobiliary cystadenomas should be considered in all patients with atypical liver cystic lesions. Further pre-operative assessment with MRIs and intra-operative frozen sections may improve the diagnostic yield and provide an opportunity for a definitive radical resection

Day-case laparoscopic cholecystectomy

To assess the safety and feasibility of laparoscopic cholecystectomy as a day-case procedure. All consecutive patients who were admitted to the day-surgery unit for laparoscopic cholecystectomy at the Department of Surgery, King Saud Medical City, Riyadh, Saudi Arabia from July 2009 to June 2013 were considered for this retrospective study. The medical records were reviewed for age, gender, presenting symptoms, laboratory findings, imaging studies, American Society of Anesthesiology [ASA] grade, anesthesia, conversion to open cholecystectomy, complications, the operating surgeons, pain management, nausea, and vomiting, overnight stay, readmission, morbidity, mortality, and outpatient follow up were collected and analyzed. A total of 487 patients underwent laparoscopic cholecystectomy as a day case [ASA I=316, ASA II=171]. Surgery was performed by high surgical trainees [HSTs] [n=417] and consultants [n=70] with conversion to open cholecystectomy in 4 patients. Twenty-two [5%] patients were admitted for overnight stay for different reasons, while 465 [95%] patients were discharged before 8 pm. Two patients [0.4 %] were re-admitted to the hospital due to abdominal pain. Five patients developed umbilical port site infection [1%]. A total of 443 patients were satisfied [97%], while 14 [3%] were unsatisfied. There was no mortality or intra-abdominal septic collection. Day-case laparoscopic cholecystectomy is safe and feasible with optimal patient selection, education, and planned postoperative antiemetic and analgesia management

Hemobilia due to liver abscess. A rare cause of massive upper gastrointestinal bleeding

Massive hemobilia is a rare complication of liver abscess. A 48-year-old male presented with massive hemobilia due to liver abscess. He had been complaining of right upper quadrant abdominal pain, fever, and jaundice for 10 days. This was followed by hematemesis and melena prior to emergency presentation. Upper gastrointestinal endoscopy showed fresh blood and clots coming from the orifice of the ampulla of Vater. The CT showed multiple liver abscesses, the largest one in the right lobe. Selective angiography revealed bleeding from a branch of the right hepatic artery into the biliary radicles. The bleeding was controlled by coil embolization. Drainage of the large liver abscesses was achieved under ultrasound guidance. Diagnostic modalities and management of hemobilia are discussed along with a review of the literature. A high index of suspicion, and the use of appropriate diagnostic tools can help diagnose and treat this rare cause of upper gastrointestinal bleeding

Arterioenteric fistula on a kidney graft site a rare cause of massive lower gastrointestinal bleeding

Arterioenteric fistula [AEF] on a kidney graft site is a rare cause of massive lower gastrointestinal bleeding [LGIB]. Emergency angiography with concomitant endovascular repair is an efficient and safe approach in controlling the acute bleeding and stabilizing patients with life-threatening bleeding from AEF. We report a 42-year-old male who underwent allograft renal transplantation in the right iliac fossa 8 months before presenting with massive LGIB. Preoperative localization of the source of bleeding with mesenteric angiography was unsuccessful. He underwent laparotomy and intraoperative endoscopy, which localized the source of bleeding from the site of the grafted kidney. An anastomotic pseudoaneurysm was found connecting the ileum and the external iliac artery at the site of transplanted kidney. Resection of an ileal loop, nephrectomy of the rejected transplanted kidney, and primary repair of the external iliac artery were performed. Such patients should undergo selective mesenteric angiogram with aorto-iliac angiogram for better localization and endovascular intervention

Early endoscopic retrograde cholangiopancreatography in mild gallstone pancreatitis with deranged liver function test. A 7-year experience in central Saudi Arabia

To determine the use of liver function tests [LFTs] as a selection tool for preoperative endoscopic retrograde cholangiopancreatography [ERCP] in patients with mild gallstone pancreatitis. All patients admitted with mild gallstone pancreatitis with deranged LFTs in King Saud Medical City, Riyadh, Kingdom of Saudi Arabia between January 2006 and February 2013 were studied retrospectively. Patients' demography, symptoms, laboratory values, imaging studies, ERCP findings, complications and its treatment, surgical intervention, intraoperative and postoperative findings, mortality, and outpatient follow up were collected and analyzed. A total of 245 patients were admitted as mild gallstone pancreatitis with admission day deranged LFTs. Pre-operative ERCP was performed in 74 patients based on admission day LFTs [Group A]. Endoscopic retrograde cholangiopancreatography was normal in 65 patients, revealed stones in 5, and sludge in 4 patients. Six patients developed ERCP complications. Endoscopic retrograde cholangiopancreatography was deferred in 171 patients [Group B] until the LFTs were repeated in 3-4 days. Liver function tests remained persistently high in 8 patients. They were submitted to preoperative ERCP, which revealed stones [n=5] and sludge [n=3]. Patients with normalized LFTs [n=163] were not submitted to ERCP. Three of them developed gallstone related complications. Patients admitted with predicted mild gallstone pancreatitis, deranged LFTs, and no evidence of cholangitis should not be submitted to ERCP unless a repeat LFT within 3-4 days shows persistently deranged LFTs. This will reduce unnecessary ERCP and its complications

experience of laparoscopic sleeve gastrectomy in obese, morbidly obese, and super morbid obese patients

To report experience with laparoscopic sleeve gastrectomy [LSG] in obese, morbidly obese, and super morbid obese patients, and to evaluate comparative efficacy of LSG among these patient groups. A total of 147 patients underwent LSG between March 2008 and December 2011 at the Department of Surgery, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia. Patients were grouped according to the preoperative body mass index [BMI] into obese [35-39.9 kg/m[2]], morbidly obese [40-49.9 kg/m[2]], and super morbid obese [>50 kg/m[2]]. Patients who did not have a regular follow-up [n=38] were excluded, and 108 patients were included in this prospective study. The mean total weight loss [TWL] among the super morbid obese group [41.31 +/- 21.23 kg] was statistically significantly greater compared to the obese group [24.31 +/- 13.00 kg, p=0.009] and morbidly obese group [26.81 +/- 15.56 kg, p=0.001]. The mean percentage excess weight loss [EWL] was clinically significant among obese [57.8%], morbidly obese [42.5%], and super morbid obese patients [45.7%], however, it was not statistically significant between the groups [F[2,105] =2.132, p=0.124]. There was no mortality; however, 6 major complications occurred including intra-abdominal collection with suspected leak, staple line bleeding, bowel ischemia, and inferior vena cava injury. Laparoscopic sleeve gastrectomy resulted in satisfactory and effective EWL in all 3 groups of obesity patients at 30-months follow-up

Cholecystectomy without intraoperative cholangiogram in gallstone pancreatitis

To determine the long term outcome of cholecystectomy without intraoperative cholangiogram [IOC] in patients recovering from acute gallstone pancreatitis with normal preoperative liver function tests and imaging. The medical records of all patients who underwent cholecystectomy without IOC for gallstone pancreatitis at King Saud Medical City, Riyadh, Saudi Arabia between January 2005 and December 2009 were studied retrospectively. Patients with severe pancreatitis and those who had preoperative endoscopic retrograde cholangio-pancreatography [ERCP] were excluded from the study. Data on patients' demography, symptoms, laboratory findings, intraoperative and postoperative findings, length of hospital stay, and outpatient follow up were collected and analyzed. A total of 160 patients were treated for acute gallstone pancreatitis. Forty-four patients with preoperative ERCP [n=39], and severe pancreatitis [n=5], were excluded. The remaining 116 patients initially underwent conservative treatment followed by cholecystectomy without IOC. All were followed up for an average of 2-4 visits. Five patients [4.3%] were re-admitted with gallstone related bilio-pancreatic complications. They underwent ERCP and CBD stone clearance. Four patients were lost to follow up. The remaining 107 patients have remained asymptomatic 12-55 months after cholecystectomy. The incidence of bilio-pancreatic complications from unsuspected CBD stones in patients of biliary pancreatitis that underwent cholecystectomy without IOC is very low. Therefore, a routine IOC in these patients can be omitted safely

Biliopleural fistula with cholethorax. A rare complication of percutaneous transhepatic biliary drainage

Biliopleural fistula leading to cholethorax formation is a rare complication of percutaneous transhepatic cholangiography [PTC]. Ideally it should be treated conservatively as it closes spontaneously in most patients. However, in complicated cases it may require surgical intervention. We report a 35-year-old male with right biliopleural fistula with cholethorax following PTC. The patient complained of shortness of breath, right pleuritic chest pain, and cough after removal of PTC catheter. Chest radiograph showed an extensive right pleural effusion. The diagnosis was confirmed by drainage of dark green pleural fluid with high bilirubin content. The initial treatment with chest tube and drainage was unsuccessful. He underwent video assisted thoracoscopic intervention. Diagnostic modalities and management options for biliopleural fistula are discussed along with a review of literature

rare cause of recurrent acute pancreatitis

Duodenal duplication cysts [DDC] are rare congenital anomalies. They are usually seen in infancy and childhood. However, rarely it can also present in adulthood. It presents as a cystic or tubular mass, which can be communicating or non-communicating. Total excision is the ideal surgical procedure. However, if total excision is not feasible, subtotal excision and cystoduodenostomy should be carried out. We present a 13-year-girl with recurrent attacks of acute pancreatitis. The diagnosis of DDC was suspected by abdominal CT, and endoscopic retrograde cholangiopancreatography. She was successfully treated with subtotal excision and intraduodenal cystoduodenostomy. Operative findings and histopathology confirmed the diagnosis. Diagnosis modalities and management options for DDC are discussed along with recommendations and review of the literature

Perforated appendicitis within paraumbilical hernia

The appendix is not uncommonly encountered within an external hernial sac. However, acute appendicitis in hernia is quite rare. We report a female patient who was admitted and operated as a case of incarcerated, strangulated paraumbilical hernia and the hemial sac was found to contain part of the greater omentum, pus and acutely inflamed, gangrenous appendix, perforated at the tip. Appendicectomy and hernial repair were carried out through the same incision