Using MR cholangiopancreatography to evaluate iatrogenic bile duct injury.

OBJECTIVE: The purpose of this study was to assess the role of MR cholangiopancreatography (MRCP) in the evaluation of iatrogenic bile duct injuries. SUBJECTS AND METHODS: In this prospective study, MRCP was performed in 10 postoperative patients (nine female and one male, ranging in age from 17 to 79 years) suspected of having bile duct injury as a result of surgery. Presence or absence of biliary dilatation, excision injury, stricture, fluid collection, and free fluid was noted. Excision injury was diagnosed if a segment of bile duct was not visible on any of the MRCP sequences. Positive cases were classified according to anatomic location and extent of injury. Results were compared with endoscopic retrograde cholangiopancreatography in five patients, percutaneous transhepatic cholangiography in one, surgery in four, and clinical follow-up in three. RESULTS: Three patients had normal findings on MRCP and remained asymptomatic on clinical follow-up. Four patients had bile duct excision injury on MRCP that was surgically proven, and one had stricture, confirmed by percutaneous transhepatic cholangiography. Of these five patients, one had Bismuth type I injury, two had type II, one had type III, and one had type IV. Two patients had findings suggestive of cystic duct leak on MRCP that were confirmed on cholangiography. CONCLUSION: MRCP can accurately diagnose postoperative biliary strictures and excision injuries and can characterize and anatomically classify these injuries for planning reparative surgery. It can also suggest the presence of cystic duct leaks in patients who have undergone cholecystectomy.

Dilatation of biliary strictures through the afferent limb of a Roux-en-Y choledochojejunostomy in patients with sclerosing cholangitis.

Repeated dilatation of biliary strictures in patients with sclerosing cholangitis through a subcutaneously placed afferent limb of a choledochojejunostomy is technically feasible and safe. This study is a prospective 15-year evaluation of 36 patients treated by repeat dilatation through this jejunal limb. There was one operative death and one major complication of dilatation. The 5-year survival of all patients was 74%. If patients with cirrhosis or unproven cholangiocarcinoma at the time of operation are not included, the 5-year survival is 86%. The 15-year survival of all patients was 30%; it was 64% if those with cirrhosis and unproven cholangiocarcinoma at the time of operation are not included. Six patients are presently alive with an average survival of 159 months. The study suggests that a combination of repeated dilatations combined with transplantation is the approach of choice in selected patients.

Management of hilar bile duct carcinoma.

BACKGROUND/AIMS: Hilar cholangiocarcinoma is a rare tumor with a dismal prognosis. Because proximal bile duct cancers are uncommon, outcomes related to various therapeutic interventions are not well defined. METHODOLOGY: Between 1985 and 1997, 55 patients with bile duct cancers involving the proximal third of the extrahepatic bile ducts were seen. The management of patients with resectable and unresectable disease was retrospectively reviewed. All but four patients were followed until the time of death. RESULTS: Forty patients underwent laparotomy following preoperative assessment of extent of disease and 19 patients (35%) ultimately underwent resection with curative intent. Survival was significantly longer in patients who underwent resection (2-year survival 47% vs. 18%; P = 0.027). Of those patients whose disease was resected, 11 patients received adjuvant radiotherapy. Survival for this group was not significantly different from that seen in patients who did not receive adjuvant radiotherapy. Similarly, in patients with unresectable disease, administration of radiotherapy was not associated with an improved outcome. CONCLUSIONS: Locoregional extent of disease is the greatest problem in cases of proximal bile duct cancers. Resection provides the best hope for long-term survival, but new adjuvant strategies are needed.

Large cystic lesions of the liver in adults: a 15-year experience in a tertiary center.

BACKGROUND: Cystic lesions of the liver consist of a heterogeneous group of disorders and may present a diagnostic and therapeutic challenge. Large hepatic cysts tend to be symptomatic and can cause complications more often than smaller ones. STUDY DESIGN: We performed a retrospective review of adults diagnosed with large (> or = 4 cm) hepatic cystic lesions at our center, over a period of 15 years. Polycystic disease and abscesses were not included. RESULTS: Seventy-eight patients were identified. In 57 the lesions were simple cysts, in 8 echinococcal cysts, in 8 hepatobiliary cystadenomas, and in 1 hepatobiliary cystadenocarcinoma. In four patients, the precise diagnosis could not be ascertained. Mean size was 12.1 cm (range, 4 to 30 cm). Most simple cysts were found in women (F:M, 49:8). Bleeding into a cyst (two patients) and infection (one patient) were rare manifestations. Percutaneous aspiration of 28 simple cysts resulted in recurrence in 100% of the cases within 3 weeks to 9 months (mean 4(1/2) months). Forty-eight patients were treated surgically by wide unroofing or resection (laparoscopically in 18), which resulted in low recurrence rates (11% for laparoscopy and 13% for open unroofing). Four of the eight patients with echinococcal cysts were symptomatic. All were treated by open resection after irrigation of the cavity with hypertonic saline. There was no recurrence during a followup period of 2 to 14 years. Hepatobiliary cystadenomas occurred more commonly in women (F:M, 7:1) and in the left hepatic lobe (left:right, 8:0). Seven were multiloculated. All were treated by open resection, with no recurrence, and none had malignant changes. Cystadenocarcinoma was diagnosed in a 77-year-old man, and was treated by left hepatic lobectomy. CONCLUSIONS: Large symptomatic simple cysts invariably recur after percutaneous aspiration. Laparoscopic unroofing can be successfully undertaken, with a low recurrence rate. Open resection after irrigation with hypertonic saline is a safe and effective treatment for echinococcal cysts. Hepatobiliary cystadenomas have predilection for women and for the left hepatic lobe. Malignant transformation is an uncommon but real risk. Open resection is a safe and effective treatment for hepatobiliary cystadenoma, and is associated with a low recurrence rate.

Diminished benefit from resection of cancer of the head of the pancreas in patients of advanced age.

BACKGROUND AND OBJECTIVES: The incidence of pancreatic cancer is increasing, and an increasing proportion of these patients is older than 65 years. The benefits of resection in the geriatric population, in whom major comorbidity is more likely, are poorly defined. The authors sought to determine the relative benefits of resection of cancer of the head of the pancreas in different age groups, with particular emphasis on the geriatric population. METHODS: Between 1983 and 1995, 273 patients presented to the University of Miami for evaluation of noncystic epithelial cancer of the head of the pancreas. Resection was performed in 104 patients, and these patients are the subject of this retrospective review. Mean length of follow-up for surviving patients was 37 +/- 24 months. Outcomes were compared in patients < 65 years old (group 1, n = 38), 65-74 years old (group 2, n = 47), and > 74 years old (group 3, n = 19). RESULTS: Total pancreatectomy was performed in 12 patients and pancreaticoduodenectomy was performed in 92 patients. The overall complication rate was similar in all groups, but major morbidity was highest in group 3 (P = 0.05). Median survival for patients in group 2 was 25.1 months. Survival was significantly shorter in patients from groups 1 and 3 (median survivals 12.4 months and 11.4 months, respectively; P = 0.02). Following control for Hispanic ethnicity, which was also a significant prognostic factor on univariate analysis, only the oldest age group had a significantly shorter survival than the other two groups. Age > 74 years and Hispanic ethnicity remained significant after multivariate analysis. CONCLUSIONS: Long-term survival after resection is truncated in older patients. This finding and the observation that the major complication rate is higher in the older subgroup emphasize the need to evaluate critically whether older patients should be submitted to radical resection.

Influence of Hispanic ethnicity on outcome after resection of carcinoma of the head of the pancreas.

BACKGROUND: Poor outcomes in Hispanic patients have been reported for tumors at a number of sites. The authors sought to determine whether a similar phenomenon occurs in Hispanics after the resection of solid epithelial tumors of the head of the pancreas. METHODS: Between 1983-1995, 273 patients with noncystic epithelial carcinoma of the head of the pancreas were evaluated. Resection was accomplished in 104 patients (38%); these patients were the focus of the current retrospective review. Of the patients who underwent resection, 26 (25%) were Hispanic and 78 (75%) were non-Hispanic. RESULTS: Although Hispanic patients tended to present at a significantly younger age and their serum bilirubin level was significantly higher, no other differences in clinical characteristics were observed. After resection, Hispanic patients had a median survival of only 11.4 months, whereas the non-Hispanic group had a median survival of 21.7 months (P = 0.009). Hispanic ethnicity, as well as age > 74 years and jaundice at the time of presentation also were found to be significant prognostic factors on multivariate analysis. Hispanic patients did not present with more advanced disease and no delays in assessment by a physician or in proceeding to surgery were observed. Furthermore, the rate of resection was the same in Hispanic patients and non-Hispanic patients. Long-term survival after palliative bypass was similarly worse in the Hispanic subgroup. CONCLUSIONS: Hispanic patients treated at the study center appeared to have a diminished survival after resection of a tumor of the head of the pancreas. No treatment-related factors were identified that could explain this discrepancy in outcome.

A subcutaneous or subfascial jejunostomy is beneficial in the surgical management of extrahepatic bile duct cancers.

BACKGROUND: Extrahepatic bile duct cancers are rare tumors with a dismal prognosis. Even after a resection, obstructive cholestasis and other biliary complications are the rule. To facilitate retrograde access to the biliary tree for treatment of such biliary complications, a modified Roux-en-Y hepaticojejunostomy is constructed such that the afferent limb is brought up as a subcutaneous or subfascial jejunostomy (SJ). The safety and utility of construction of an SJ was evaluated in patients with extrahepatic cholangiocarcinoma. METHODS: From 1985 to 1997, 24 patients with extrahepatic bile duct cancers received an SJ as part of their management. Demographic data, operative data, tumor characteristics, and postoperative courses were retrospectively reviewed. All but 3 patients were followed to the time of death. RESULTS: The average age of the patients was 62 +/- 9 years. The tumor was resected in 17 patients. Major complications occurred in 5 patients (21%). There was 1 operative death (4%). None of the complications could be attributed to construction of the SJ, although 1 patient had a soft tissue infection at the site of the percutaneous access of the SJ. Frequent dilatations of biliary strictures were required in 5 patients, and 1 patient eventually required insertion of an internal biliary stent. These procedures could all be accomplished through the SJ. CONCLUSIONS: The SJ is a technically simple and safe addition to the management of resectable and unresectable extrahepatic bile duct cancers, particularly proximal lesions. The procedure facilitates brachytherapy if indicated, and it allows convenient management of postoperative biliary complications, including recurrent strictures.

Imaging of nontraumatic hemorrhagic hepatic lesions.

Spontaneous hepatic bleeding is a rare condition. In the absence of trauma or anticoagulant therapy, hepatic hemorrhage may be due to underlying liver disease. The most common causes of nontraumatic hepatic hemorrhage are hepatocellular carcinoma and hepatic adenoma. Such hemorrhage can also occur in patients with other liver tumors, such as focal nodular hyperplasia, hemangiomas, and metastases. Other conditions associated with this entity include HELLP syndrome, amyloidosis, and miscellaneous causes. Imaging plays a significant role in the diagnosis and management of this potentially lethal entity. In the appropriate clinical setting, the diagnosis of a hemorrhagic liver lesion is suggested when a hyperechoic mass or a mass with hyperechoic areas is seen at ultrasonography, a hyperattenuating mass is seen at computed tomography (CT), or a mass with high-signal-intensity areas is seen at T1-weighted magnetic resonance (MR) imaging. The signal intensity of blood can be increased or decreased on MR images depending on when the hemorrhage is imaged. The presence and extent of commonly associated subcapsular hematomas and hemoperitoneum can be easily ascertained with CT. During the first 24-72 hours, acute hematomas are hyperattenuating on nonenhanced CT scans; later, they decrease in attenuation and sometimes develop a pseudocapsule.

Radical resection of periampullary tumors in the elderly: evaluation of long-term results.

Increasingly, patients of advanced age are coming for evaluation of periampullary tumors. Although several studies have demonstrated the safety of resecting periampullary tumors in older patients, few long-term survival data have been reported. Between 1983 and 1992 various periampullary masses were resected in 70 patients over age 65 (range 65-87 years). Total pancreatectomy was performed in 11 patients, and 59 patients underwent pancreaticoduodenectomy. The mean duration of hospitalization was 17 +/- 15 days. Major complications occurred in 27 patients (39%), and operative mortality rate was 8.5%. Overall median survival was 24 months; and 5-year survival was 25%. Perioperative outcome was compared in patients aged 65 to 74 years and in patients > or =75 years old. The older age group required longer periods in the surgical intensive care unit postoperatively, but the long-term survival was similar in the two age groups. Radical resection with the intent to cure periampullary tumors is safe in selected patients of advanced age, and long-term survival is in the range of expected survival for younger patients with the same tumors.

A phase I study of chemoembolization with cisplatin, thiotepa, and lipiodol for primary and metastatic liver cancer.

Thirty patients with primary hepatocellular carcinoma or liver metastases were entered into a program of chemoembolization with cisplatin, lipiodol, and escalating doses of thiotepa. Doses of cisplatin were 100/m2, and thiotepa doses ranged from 9 mg/m2 to 24 mg/m2. Two of three patients with ocular melanoma had partial responses in the liver metastases for 3+ and 16 months. In patients with either hepatocellular carcinoma (15 patients) or primary cholangiocarcinoma of the liver (three patients), there were two partial responses, for 22 and 33 months. Five patients had minor responses: four with a 40% reduction in tumor and one with a mixed response. There were four early deaths, which involved sepsis in two patients, respiratory failure in one, and acute myocardial infarction in one. Otherwise, toxicity was tolerable and reversible and included abdominal pain and transient elevation of serum creatinine, bilirubin, and transaminases. Less common toxicities included ototoxicity and peripheral neuropathy. Chemoembolization of the liver with cisplatin, thiotepa, and lipiodol can produce responses, but toxicity can be significant. The recommended starting phase II dose for future studies is thiotepa 24 mg/m2 and cisplatin 100 mg/m2.

Laparoscopic cholecystectomy in cirrhotic patients.

BACKGROUND: Reported mortality for open cholecystectomy in patients with cirrhosis ranges from 10% to 80%. Laparoscopic cholecystectomy has gained acceptance in the general population and has become the procedure of choice for symptomatic cholelithiasis. We reviewed our experience with the use of laparoscopic cholecystectomy in this group. STUDY DESIGN: We did a retrospective review of the records of 25 consecutive laparoscopic choleoystectomy procedures performed on cirrhotic patients from May 1992 to July 1996. RESULTS: There were no mortalities in our group. All procedures were completed laparoscopically. Mean length of stay was 1.7 days (range, 1 to 8 days). Morbidity consisted of wound hematomas, pneumonia, and ascites for a rate of 32%. Only patients with Child's Class A and Class B cirrhosis were operated on. CONCLUSIONS: Laparoscopic cholecystectomy can be performed safely in cirrhotic patients with well compensated liver function.

Retroperitoneal abscess as a complication of retained gallstones following laparoscopic cholecystectomy.

Retroperitoneal abscess formation secondary to retained spilled gallstones after laparoscopic cholecystectomy is a rare complication. We describe the case of a patient with this complication as well as a novel method utilizing interventional radiologic localization with subsequent operative drainage and removal of the stones. A review of the literature is provided.

Percutaneous dilatation of biliary strictures through the afferent limb of a modified Roux-en-Y choledochojejunostomy or hepaticojejunostomy.

BACKGROUND: This report is a 13-year prospective evaluation of percutaneous balloon dilatation of benign biliary strictures through the subcutaneous or subfascially positioned afferent limb of a choledocho or hepaticojejunostomy in 30 patients. DATA SOURCE: Twenty-seven strictures developed after a common duct injury sustained at the time of cholecystectomy, two after hepatectomy reconstruction for trauma and one following a gastrectomy. Twelve injuries (40%) were recognized at operation. Of the 18 patients where the injury was unrecognized at the time of operation, 8 had not been reoperated at the time of referral, 7 had late repairs by the referring physician, and 3 had late repairs at our institution. The follow-up is 1 to 13 years. RESULTS: There has been 1 late death and 6 patients are lost alive. The jejunal-limb was accessed 50 times with two minor and no major complications. There have been two parajejunal hernia repairs, but there have not been any reoperations for recurrent biliary strictures. CONCLUSIONS: Benign biliary strictures can be effectively managed by repeat balloon dilatations thru the afferent limb of a choledocho or hepaticojejunostomy, thus eliminating the need for repeat surgical interventions.

Ciliated foregut cyst of the pancreas.

Cystic lesions of the pancreas are relatively uncommon. We describe the case of a young man with a complex cystic mass located within the head of the pancreas. The patient underwent exploration with resection of the mass. Pathology revealed a ciliated epithelial cyst, a rare cystic lesion of the pancreas.

Balloon dilatation through the subcutaneously placed afferent limb of a hepaticojejunostomy in patients with resected Klatskin tumors.

It is generally conceded that palliation for proximal bile duct tumors (Klatskin) is exceptional if obstruction and the resultant infections can be prevented. Our experience with balloon dilatations thru the subcutaneously placed afferent limb of a choledocho or hepatico jejunostomy in patients with benign strictures suggests that this approach will be effective in patients with malignancies and thus provide long-term control of the obstruction without the need for external tubes. This is a report on one patient who, following a resected Klatskin tumor with positive margins, was treated with transhepatic internal external stents and was converted to a subcutaneous limb following numerous bouts of cholangitis. A schedule for repeat dilatations thru the jejunal limb was established. The patient has remained afebrile with a normal bilirubin and a moderately elevated alkaline phosphatase. Recurrent tumors or postirradiation strictures in patients with resected Klatskin tumors can be effectively controlled by repeated balloon dilatation without the need for external stents.

A phase II trial of recombinant leukocyte interferon plus doxorubicin in patients with hepatocellular carcinoma.

A Phase II trial of combination therapy with recombinant leukocyte interferon (alpha IFN) and doxorubicin was performed in patients with unresectable hepatocellular carcinoma. alpha IFN was administered at a starting dose of 20 x 10(6) U/m2 intramuscularly or subcutaneously with doxorubicin 20 mg/m2 intravenously weekly x 3 weeks followed by a 2-week period rest. There were 22 patients entered into the study. Among the 21 patients, there were 2 partial responses (10%), one minor response, and one patient had stable disease. Toxicity was generally tolerable, with fever, fatigue, and myelosuppression being the most common side effects. This combination of weekly recombinant leukocytic interferon and doxorubicin has modest and limited activity in hepatocellular carcinoma.

A phase I study of chemoembolization with cisplatin and lipiodol for primary and metastatic liver cancer.

Twenty patients with either unresectable primary hepatocellular carcinoma or hepatic metastases were entered into a chemoembolization program with cisplatin and lipiodol; 19 patients were evaluable for response. Doses of cisplatin ranged from 40 to 100 mg/m2. Toxicity was tolerable and reversible and included abdominal pain, transient elevation in serum creatinine, serum bilirubin, and serum transaminases. Less common side effects include fever, ascites or pleural effusion, and hiccups. Two of four patients with ocular melanoma had partial responses. Duration of response was 10 and 11 months. Among 8 patients with unresectable hepatoma, 2 patients had partial response for 10+ and 13 months, 2 had minor response for 2 months and 4+ months, 1 patient had stable disease for 5+ months, and 3 patients failed to respond. Of the six colon cancer patients treated, one had a partial response in the liver, but developed progressive nodal disease, and another patient had a partial response for 3 months. Chemoembolization of the liver with cisplatin and lipiodol is feasible and doses of cisplatin at least 100 mg/m2 are tolerable. Antitumor activity in metastatic ocular melanoma is encouraging but requires further study.

Giant colonic diverticulum: an unusual manifestation of a common disease.

Giant colonic diverticula are an uncommon manifestation of colonic diverticular disease. This report documents another case of this rare entity. The clinical presentation is variable, but abdominal pain and the presence of an abdominal mass are common. Their etiology is uncertain, but they are thought to originate from pulsion diverticula. Abdominal plain films and barium enema are helpful in making the diagnosis. Computerized tomography is useful when the diagnosis is unclear. Surgical resection is recommended to alleviate symptoms and avoid complications.

Laparoscopic ligation of a leaking cystic duct.

Laparoscopic cholecystectomy (LC) has rapidly become an acceptable surgical technique. Indeed it may become the preferred method for cholecystectomy, with the open method reserved for complicated cases. Early series of LC have shown a mortality rate of 0-1%, comparing favorably to the open method. However, complications such as bile duct injury, cystic duct leaks, and biliary collections may be more frequent. We report the first case of cystic duct leakage after LC successfully managed by subsequent laparoscopic ligation.

Portal hypertension. A fifteen year perspective.

Two hundred six consecutive patients were followed from 5 to 15 years after a distal splenorenal shunt operation. Nonalcoholic patients demonstrated nearly twice the survival rate when compared with alcoholic patients. The mean duration of life for the surviving nonalcoholics was 10 years and for the alcoholics, 9 years. We predict that approximately a third of the nonalcoholics will enjoy long-term survival. The operative mortality rate was similar in both groups, being about 4 percent. The risk of liver cancer was highest in the male alcoholics, and long-term survival was greater for women in both the alcoholic and nonalcoholic groups.