A preliminary study of possible prognostic factors of traumatic liver injury seen at University Hospital, 1984-1991.

A retrospective study was carried out on 42 patients (38 males, 4 females, mean age 25.9) with liver injury at the University Hospital, Kuala Lumpur from 1994 through to 1991. Prognostic factors that might help to identify those patient survival was related to pulse rate on arrival ( < or = 120 beats per minute, p = 0.027), systolic blood pressure at induction of anaesthesia ( > or = to 80 mmHg, p = 0.003) and intraoperative blood transfusion of < or = to 4 units (p = 0.05). This data were supported by the 95% confidence interval suggesting that these factors may be strong prognostic indicators individually. Increased mortality was also associated with increased total blood transfused (p = 0.002) and grade of liver injury (p = 0.02). Although the factors we have identified reflect both the severity of injury and resuscitative and surgical efforts, further studies using a prospective design are required to confirm these findings.

Retroperitoneal malignant fibrous histiocytoma with renal involvement.

Malignant fibrous histiocytoma is a mesenchymal tumour which can involve the genitourinary organs primarily or by secondary extension. Both conditions are rare. We report four cases of retroperitoneal malignant fibrous histiocytoma involving the kidney by local extension. Diagnosis was difficult because of diverse, non-specific clinical features and may only be reached at operation or post mortem. Prognosis is poor. Although en bloc tumour resection with nephrectomy was possible in two patients, they returned with recurrences.

Retroperitoneal malignant fibrous histiocytoma causing profuse bleeding per rectum.

A case is reported of retroperitoneal malignant fibrous histiocytoma (MFH) invading into the colon, causing fresh bleeding per rectum. It illustrates the difficulty encountered in the pre-operative diagnosis of this condition, especially in a patient with an atypical presentation of profuse lower gastrointestinal bleeding.

Beware the anomalous portal vein.

Portal vein thrombosis is an unusual potential complication of liver resection. In our case it was due to ligation of the right branch of the portal vein during right hepatectomy in a patient without portal vein bifurcation. Hepatic angiography can delineate this abnormality and influence the choice of surgical management.

Expression of major histocompatibility antigens in human chronic pancreatitis.

T-lymphocytic infiltration of the exocrine pancreas and liver in patients with chronic pancreatitis has suggested that cell mediated immune mechanisms may play a part in the pathogenesis of this disease. As expression of major histocompatibility (MHC) antigens is a prerequisite for organ specific autoimmunity, the expression of HLA class I (beta 2-microglobulin) and class II (HLA-DR) determinants have been analysed, together with the presence of T-lymphocytes, in 93 patients (64 men and 29 women, mean age 40.6 years) having an operation for chronic pancreatitis. Ethanol (63 patients), recurrent acute pancreatitis (12), congenital lesions (2), and unknown (16) were suggested to be the causes of the disease. Immunohistochemical staining of formalin fixed and paraffin wax embedded tissue sections used conventional immunohistochemical techniques with specific anti-serum samples. No MHC expression was identified in 10 histologically normal pancreatic control specimens or in four cases of chronic pancreatitis secondary to obstruction by neuroendocrine tumours within the head of the pancreas. beta 2-microglobulin expression by pancreatic exocrine epithelial cells was seen in 76 chronic pancreatitis specimens (82%) while HLA-DR was present in 61 (66%). Simultaneous expression of both class I and II determinants was seen in 53 (57%) of cases. MHC determinant expression was not found in 10 cases (11%) of chronic pancreatitis. In the positive specimens, expression was confined to ductal and ductular (interlobular and intralobular) epithelium with no staining of acinar cells. Staining was not related to the suspected cause of the disease or age. T-lymphocytes were more prominent in chronic pancreatitis mean (SEM) (131 (15) cells per high powered field) than controls (5 (1), p < 0.01). Aberrant MHC expression by exocrine pancreatic epithelial cells occurring in the presence of an appreciable T-cell infiltration confirmed that the appropriate cellular conditions were present for cell mediated cytotoxicity to contribute to the pathogenesis of chronic pancreatitis.

Chromosome 17 allele loss in hepatocellular carcinoma but not in synchronous liver adenoma.

A 51-year-old female underwent resection of two synchronous liver tumours, a hepatocellular carcinoma and an adenoma. DNA analysis revealed allele loss on chromosome 17 (17p13, near the locus of p53 tumour suppressor gene) in the hepatocellular carcinoma but not in the adenoma. This finding may support the view that loss of p53 tumour suppressor gene is associated with tumour progression.

Pancreatic exocrine and endocrine function after operations for chronic pancreatitis.

Exocrine and endocrine function of the pancreas was assessed in the early postoperative period (< or = 2 months) and subsequently (mean, 25 months; range, 3 to 120) in 103 patients (69 men, 34 women; mean age, 42.4 +/- 11.6 years) undergoing operation for chronic pancreatitis. Alcohol was the main causative agent (69%) and pain the most frequent indication (87%) for operation. Drainage procedures (n = 23) did not alter pancreatic function either initially or on long-term follow-up. In the early postoperative period, distal pancreatectomy (n = 42) often impaired endocrine function without affecting exocrine function; seven patients (17%) became diabetic, and results of oral glucose tolerance test showed deterioration in 23 of 28 patients (82%, p < 0.05). On subsequent follow-up, 11 patients developed exocrine failure (p < 0.01) and 10 patients endocrine (p < 0.01) failure. Proximal pancreatectomy (n = 38) precipitated clinical exocrine failure in 14 patients (37%, p < 0.01), yet pancreolauryl tests in 18 patients showed little objective change in exocrine status (0.50 > p > 0.10). Endocrine function was initially spared after proximal pancreatectomy, but six additional patients (16%, p < 0.05) required treatment for diabetes at a mean of 19 months (range, 3 to 34). Deterioration in pancreatic function is thus not an invariable immediate consequence of pancreatic drainage procedures or partial pancreatectomy for chronic pancreatitis. Progression of disease must account, in part, for failure of both exocrine and endocrine function on long-term follow-up. Drainage operations appear to delay this progressive decline in pancreatic function.

Different DNA changes in primary and recurrent hepatocellular carcinoma.

DNA restriction fragment length polymorphism analysis was carried out on a primary and recurrent hepatocellular carcinoma in a hepatitis B virus negative patient. For the primary tumour, allele losses were found on the short arm of chromosome 17 (probe: p144-D6, 17p13) and the long arm of chromosome 5 with the probe Lambda MS8 (5q35-qter); other probes showed either no allele loss or a non-informative pattern. The recurrent cancer also showed allele loss with p144-D6, but not with Lambda MS8. In addition, the recurrent tumour had allele losses with Lambda MS43 (12q24.3-qter), pYNZ22 (17p13), and DNA rearrangement revealed by the probe Lambda MS32 (1q42-43), a pattern not seen in the primary lesion. These results indicate that the second hepatocellular carcinoma was of independent clonality and probably represents a de novo neoplasm rather than a recurrence.

Morphological and immunohistochemical analysis of the human liver in chronic pancreatitis.

Morphological and immunohistological appearances of liver biopsy specimens are described in a personal series of 52 patients undergoing operation for chronic pancreatitis. The findings are compared with those in a series of 10 histologically normal liver biopsy specimens from patients without pancreatitis. Alcohol was the prime aetiological agent in 40 of the 52 patients (77%). No obvious damage to hepatic parenchymal cells or biliary structures was observed but minor morphological changes of alcohol associated liver disease were seen in 42% of specimens. The most consistent finding, present in 48 specimens (92%), was a chronic inflammatory cell infiltration of portal tracts. In all but one case, T lymphocytes predominated, but a few B cells were present. In four biopsy specimens, T cells spilled over into adjacent hepatic parenchyma, but there was no evidence of T cell mediated cytotoxic damage to the parenchymal cells or biliary epithelium. It is suggested that these inflammatory cells are in transit from the pancreas through the liver via the portal circulation and may reflect the underlying pathogenesis of chronic pancreatitis rather than alcoholic liver disease.

Pancreatic tissue and ductal pressures in chronic pancreatitis.

To assess the contribution of parenchymal hypertension to pain, pancreatic tissue pressures were measured intraoperatively in 17 patients with chronic pancreatitis and in four other patients undergoing pancreatic surgery (reference group). The technique involved direct fine needle cannulation of the pancreas using a flow infusion system, which measured parenchymal resistance to this infusion. Three to six recordings were obtained at each site. In chronic pancreatitis the pressure (mean +/- s.e.m.) was substantially elevated in all regions of the pancreas compared with reference subjects: head (257 +/- 59 versus 19 +/- 5 mmHg, P less than 0.05); body (201 +/- 51 versus 13 +/- 6 mmHg, P less than 0.05) and tail (161 +/- 45 versus 11 +/- 3 mmHg, P less than 0.05). Elevation was greater in areas of calcific disease (281-383 mmHg) than in non-calcific disease (81-120 mmHg, P less than 0.05). Mean pancreatic ductal pressure in 10 patients (seven with calcific disease) was 20 +/- 4 mmHg. Differential pressure measurements within the pancreas helped determine the extent of resection in six patients with diffuse disease. The greatly increased tissue pressures in chronic pancreatitis, especially in the presence of calcification, suggest a possible 'compartment syndrome'.

Choledochal cyst and chronic pancreatitis--treated by proximal pancreatectomy.

A 32-year-old woman with a choledochal cyst (Todani type I) developed recurrent acute pancreatitis leading to calcific chronic pancreatitis. She had previously been treated with two cyst drainage procedures and subtotal cyst excision. This association between choledochal cyst and chronic pancreatitis has not been previously reported. Severe continuing symptoms led to pylorus-preserving proximal pancreatoduodenectomy, which was undertaken to prevent future carcinoma in the cyst remnant and progression of the chronic pancreatitis.

Primary renal ganglioneuroblastoma in an adult.

A rare case of primary renal ganglioneuroblastoma in a 68 year old female is presented. The authors believe this to be the first case report of this tumour arising in the kidney of an adult patient.

Cecocolic intussusception in multiple lymphomatous polyposis of the gastrointestinal tract. Report of a case.

A rare case of recurrent cecocolic intussusception in an adult patient with multiple lymphomatous polyposis of the gastrointestinal tract is presented. Clinical features, especially the difficulty in distinguishing this entity from adenomatous polyposis on colonoscopy, and histopathology are discussed. It is important that surgeons and colonoscopists be aware of this rare form of diffuse gastrointestinal lymphoma because of therapeutic implications.

Hepatic hydatidosis: diagnostic and therapeutic aspects.

A rare case of hepatic hydatidosis in non-endemic Malaysia is reported. It is important that clinicians treating the occasional patient be familiar with current diagnostic and therapeutic modalities.