Periesophageal Tuberculosis Abscess Post-Liver Transplantation Successfully Treated With Lumen-Apposing Metal Stent Cyst Esophagostomy.

The therapeutic utility of ultrasound-guided endoscopy has grown significantly in recent years. In this report, we describe a case of extrapulmonary tuberculosis in a liver transplant recipient found to have an encapsulated fluid collection in the inferior mediastinum, which was drained with an endoscopic ultrasound-guided technique, precluding the need for percutaneous or surgical intervention.

Heads or tails: confusion about "proximal" and "distal" terminology for pancreaticobiliary anatomy.

BACKGROUND AND STUDY AIMS: The anatomical meaning of the terms "proximal" and "distal" in relation to the pancreaticobiliary anatomy can be confusing. We aimed to investigate practice patterns of use of the terms "proximal" and "distal" for pancreaticobiliary anatomy amongst various medical specialties. MATERIALS AND METHODS: An online survey link to a normal pancreaticobiliary diagram was emailed to a multispecialty physician pool. Respondents were asked to label various parts of the common bile duct (CBD) and pancreatic duct (PD) using the terms "proximal," "distal," "not sure," or "other." Variability in use of these terms between specialties was assessed. RESULTS: We received 370 completed surveys from 182 gastroenterologists (49.2 %), 97 surgeons (26.2 %), 68 radiologists (18.4 %), and 23 other physicians (6.2 %). There was overall consensus in describing the upper/sub-hepatic CBD as "proximal CBD" (73.8 %, P  = 0.1499) and the lower/pre-ampullary portion as "distal CBD" (84.6 %, P  = 0.1821). CONCLUSIONS: Although use of the terms "proximal" and "distal" is still very common to describe pancreaticobiliary anatomy, there is a discordance about its meaning, particularly for the PD. Use of descriptive terminology may be a more accurate alternative to prior ambiguous terminologies such as "proximal" or "distal" and can serve to improve communication and decrease the possibility of medical errors.

Hepatectomy cures a cough: giant cavernous hemangioma in a patient with persistent cough.

Cavernous hemangiomas are the most common type of benign liver tumor. Although these tumors are often asymptomatic, they can occur with an array of symptoms. The authors describe a case of a 51-year-old man who presented to the emergency department with a relentless cough, nausea, and abdominal pain. Results of a computed tomography scan suggested the patient had a giant cavernous hemangioma on his liver; microscopic evaluation confirmed this diagnosis. The hemangioma was initially deemed unresectable and the patient was treated with one session of hepatic artery embolization. The embolization was unsuccessful at easing the patient's symptoms, however, and a hepatic lobectomy and resection was performed. After surgical intervention, the patient's symptoms resolved. The present case illustrates an unusual instance in which chronic cough was cured through hepatectomy for giant cavernous hemangioma. To our knowledge, no reports of coughing as a primary symptom of giant cavernous hemangioma have been previously reported in the literature.

Hemoperitoneum secondary to rupture of cystic artery pseudoaneurysm.

BACKGROUND: Spontaneous hemoperitoneum of hepatobiliary origin is commonly due to hemorrhage from a liver tumor. It is rarely caused by spontaneous rupture of aneurysm in visceral arteries. METHODS: We report an unusual case of hemoperitoneum caused by rupture of cystic artery pseudoaneurysm, and also outline the approach to its management through surgical and radiological methods. RESULTS: In our patient, the pseudoanurysm was initially treated with percutaneous thrombin injection. However this method of treatment failed after initial success. The pseudoanurysm was finally obliterated successfully using microcoil embolization. CONCLUSIONS: The mainstay of treatment of cystic artery pseudoaneurysm is cholecystectomy and ligation of the aneurysm. Recent publications showed success in using microcoil embolisation. In this case we also outline the use of percutaneous thrombin injection as a definitive treatment method and discuss its success or failure as a new method of treatment.

Liver transplantation and chemotherapy in children with unresectable primary hepatic malignancies: development of a management algorithm.

OBJECTIVES: Total surgical excision and adjunctive chemotherapy are cornerstones of treatment of primary hepatic malignancies in children. Recent studies suggest that transplantation is a viable option for unresectable tumors, but there are questions concerning decision making regarding resectability and timing of transplantation in relation to chemotherapy. We developed a management algorithm based on our experience, with reference to recently published multicenter transplantation outcomes. RESULTS: Nine patients underwent transplantation (median age, 38 months; 7 hepatoblastoma, 2 undifferentiated mesenchymal sarcoma). All were assessed unresectable at presentation. After chemotherapy, 7 remained unresectable and had primary transplantation, 1 developed chemotherapy-related liver failure, necessitating emergent transplantation, and 1 was deemed resectable, requiring rescue transplantation after local recurrence. Using a timely living/cadaver donor graft acquisition strategy relative to chemotherapy, median waiting time from listing was 8 days. After transplantation, 3 of 9 had chemotherapy, with side effects dictating discontinuation in 2; 6 of 9 had no chemotherapy, with 2 developing distant metastases, 1 of whom died 12 months posttransplantation. Median follow-up was 3.08 years. Overall survival was 89%. CONCLUSIONS: Primary transplantation can be highly successful in children with hepatic tumors. These outcomes compare favorably with multicenter studies, where waiting-list deaths are reported and survival after rescue transplantation is poor. We encourage timely transplantation in the setting of questionably resectable tumors or evidence of chemotherapy resistance. The necessity of posttransplantation chemotherapy is questioned. Consultation with a transplantation program before chemotherapy should avoid inappropriate attempts at resection and allow appropriate planning of transplantation in relation to chemotherapy.

Left hepatic trisectionectomy for hepatobiliary malignancy: results and an appraisal of its current role.

OBJECTIVE: To analyze results of 70 patients undergoing left hepatic trisectionectomy and to clarify its current role. SUMMARY BACKGROUND DATA: Left hepatic trisectionectomy remains a complicated hepatectomy, and few reports have described the long-term results of the procedure. METHODS: Short-term and long-term outcomes of 70 consecutive patients who underwent left hepatic trisectionectomy from January 1993 to February 2004 were analyzed. RESULTS: Of the 70 patients, 36 had colorectal liver metastasis, 24 had cholangiocarcinoma, 4 had hepatocellular carcinoma, and the remaining 6 had other tumors. Overall morbidity, 30-day and 90-day mortality rates were 46%, 7%, and 9%, respectively. Multivariate analysis disclosed that preoperative jaundice and intraoperative blood transfusion were positive independent predictors for postoperative morbidity; however, there were no independent predictors for postoperative mortality. Postoperative morbidity (87% versus 35%, P < 0.001) and mortality (20% versus 5%, P = 0.108) were observed more frequently in patients with preoperative obstructive jaundice than in those without jaundice. Each survival according to tumor type was acceptable compared with reported survivals. Survival for patients with colorectal liver metastasis undergoing left hepatic trisectionectomy with concomitant partial resection of the remnant liver was similar to those without this concomitant procedure. This concomitant procedure was not associated with postoperative morbidity and mortality. CONCLUSIONS: Left hepatic trisectionectomy remains a challenging procedure. Preoperative obstructive jaundice considerably increases perioperative risk. Concomitant partial resection of the remaining liver appears to be safe and offers the potential for cure in patients with colorectal metastasis affecting all liver segments.

Current techniques and results of liver resection for colorectal liver metastases.

Colorectal cancer remains the second most common cause of cancer death in the West. Every year in the UK alone, around 14 000 patients develop secondary hepatic deposits from a primary colorectal cancer. Surgery remains the mainstay of treatment for liver metastases. Although not every patient is a candidate for surgery, earlier referral and rapid assessment are required to improve outcome. With the use of most recent technologies and radical surgery, increasing numbers of patients should have therapy with curative intent. This paper reviews preoperative patient evaluation and selection, surgical strategies, adjuvant therapy and postoperative follow-up. Other treatment modalities to increase tumour resectability are also described.