Portoenterostomy as a Salvage Procedure for Major Biliary Complications Following Hepaticojejunostomy.

Major biliary complications that require surgical intervention after hepaticojejunostomy are rare and technically challenging. While the hepaticojejunostomy can be refashioned in most patients requiring surgical reexploration after anastomotic dehiscence, a selected few may require a portoenterostomy, which involves anastomosis of the jejunum to a decapsulated area of the liver to establish a conduit from the intrahepatic bile ducts to the intestine. Herein, we describe the technique where a portoenterostomy has been used to restore bilioenteric continuity in three patients where reconstruction with a hepaticojejunostomy was not feasible. All patients survived the procedure and two needed percutaneous transhepatic biliary dilatation after 5 years and 6 months, respectively. One patient died of unrelated causes 12 years after the initial procedure and the other two are alive with normal bilirubin and intrahepatic ducts at 14 and 4 years. In rare cases where hepaticojejunostomy is not feasible due to small, friable or inflamed hepatic ducts, portoenterostomy with transanastomotic stenting provides an effective way of saving life and restoring bilioenteric continuity. Although this is not a procedure to be recommended without due consideration of other options, we have shown it can be life-saving and provide good long-term results in combination with postoperative radiological intervention, when necessary.

Outcomes in patients with indeterminate pulmonary nodules undergoing resection for colorectal liver metastases.

OBJECTIVES: This study aimed to assess outcomes in patients who underwent hepatic resection for colorectal liver metastases (CRLM) with subcentimetre indeterminate pulmonary nodules (IPN) and to devise a management pathway for these patients. METHODS: Patients undergoing CRLM resection from January 2006 to December 2010 were included. Survival differences following liver resection in patients with and without IPN were determined. RESULTS: A total of 184 patients were included, 30 of whom had IPN. There were no significant differences between the IPN and non-IPN groups in terms of demographics, surgery and pathological factors. There were no significant differences between patients with and without IPN with respect to disease-free (P= 0.190) and overall (P= 0.710) survival. Fifteen patients with IPN progressed to metastatic lung disease over a median period of 10 months (range: 3-18 months); six of these patients underwent lung resection. Of the remaining 15 patients with IPN, eight showed no IPN progression and subsequent CT scans did not identify IPN in the remaining seven. CONCLUSIONS: Colorectal liver metastases patients with IPN who have resectable disease should be treated with liver resection and should be subject to intensive surveillance post-resection. Although 50% of these patients will progress to develop lung metastases, this does not appear to influence survival following liver resection.