Surgery as primary prophylaxis from variceal bleeding in patients with extrahepatic portal venous obstruction.

BACKGROUND AND AIM: In patients with extrahepatic portal venous obstruction (EHO), death is usually due to variceal bleeding. This is more so in developing countries where there is a lack of tertiary health-care facilities and blood banks. Prophylactic operations in cirrhotics have been found to be deleterious. In contrast, patients with EHO have well-preserved liver function, and we therefore investigated the role of prophylactic surgery to prevent variceal bleeding. METHODS: Between 1976 and 2010, we operated on selected patients with EHO, who had no history of variceal bleeding but had "high-risk" esophagogastric varices or severe portal hypertensive gastropathy and/or hypersplenism, and came from remote areas with poor access to tertiary health care. Following surgery, these patients were prospectively followed up with regard to mortality, variceal bleeding, encephalopathy, and liver function. RESULTS: A total of 114 patients (67 males; mean age 19 years) underwent prophylactic operations (proximal splenorenal shunts 98 [86%]; esophagogastric devascularization 16). Postoperative mortality was 0.9%. Among 89(79%) patients who were followed up (mean 60 months), hypersplenism was cured, and six (6.7%) developed variceal bleeding. The latter were managed successfully by endoscopic sclerotherapy. No patient developed overwhelming post-splenectomy sepsis or encephalopathy, and 90% were free of symptoms. CONCLUSION: In patients with EHO, prophylactic surgery is fairly safe and prevents variceal bleeding in ∼ 94% of patients with no occurrence of portosystemic encephalopathy. Patients with EHO who have not bled but have high-risk varices and/or hypersplenism, and poor access to medical facilities should be offered prophylactic operations.

Liver resection: a regional hospital experience.

BACKGROUND: Liver resection is a significant operation usually limited to large metropolitan hospitals. Liver resections were first performed at the Launceston General Hospital (LGH), a regional centre (bed capacity 280), in May 2000. This is a summary of liver resection at LGH. METHODS: Data of liver resections performed between May 2000 and March 2008 at LGH were collected retro-prospectively and reviewed with attention to patient survival, post-operative complications and mortality. RESULTS: There were 102 consecutive liver resections during the study period. Metastatic colorectal adenocarcinoma was the most frequent pathology (n = 61). Six patients had metastases from primaries other than colorectal cancer. There were 13 resections for primary liver malignancy, 2 from invasion by gallbladder carcinoma, 1 for contiguous invasion by gastric cancer and 19 were for benign conditions. Thirteen patients had post-operative wound infections and six had significant bile leaks. There were five deaths in-hospital (surgical mortality 4.9%). At the end of the study period, 51 cancer patients were still alive (14 with disease recurrences) and 30 have died (23 from recurrent diseases). Patients operated for colorectal cancer metastases achieved a 44% 5-year survival rate (median survival = 46 months). Patients with hepatocellular carcinoma had 3-year survival rate of 15% (median survival = 24 months). CONCLUSION: Resection provides the best hope of cure for patients with primary or secondary hepatic malignancy. With adequate expertise, liver resections can be performed safely in a regional hospital.

Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis.

BACKGROUND & AIMS: Organ failure is the usual cause of death in acute necrotizing pancreatitis. Our objective was to study whether the extent and infection of pancreatic necrosis correlate with organ failure and mortality. METHODS: All consecutive patients with acute pancreatitis were prospectively studied. They underwent a detailed clinical and investigative evaluation. Pancreatic necrosis, diagnosed on a computed tomography scan, was graded as <30%, 30%-50%, and >50% necrosis and characterized as either sterile or infected. Logistic regression analysis was done to find out the association of the extent and infection of pancreatic necrosis with organ failure and mortality. RESULTS: Of 276 patients (mean age, 41.25 years; 172 men), 104 had pancreatic necrosis: 30 had <30% necrosis, 37 had 30%-50% necrosis, and 37 had >50% necrosis; 74 had sterile necrosis, and 30 had infected necrosis. Of them, 37 (35%) patients developed organ failure. Two significant factors were associated with the development of organ failure, the extent of necrosis (<30% necrosis vs 30%-50% necrosis: P = .03; odds ratio [OR], 5.82; 95% confidence interval [CI], 1.15-29.45; <30% necrosis vs >50% necrosis: P = .0004; OR, 18.86; 95% CI, 3.75-94.92) and infected pancreatic necrosis (P = .02; OR, 3.29; 95% CI, 1.17-9.24). The overall mortality was 22%. Infected pancreatic necrosis (P = .006; OR, 4.99; 95% CI, 1.56-16.02) and Acute Physiology, Age, and Chronic Healthy Evaluation II score (P = .004; OR, 1.28; 95% CI, 1.08-1.52) were 2 independent predictors of mortality. CONCLUSIONS: Extent of necrosis and infected pancreatic necrosis were associated with the development of organ failure in patients with acute necrotizing pancreatitis. Infected pancreatic necrosis was the most significant predictor of mortality.

Three-dimensional helical computed tomography cholangiography with minimum intensity projection in gallbladder carcinoma patients with obstructive jaundice: comparison with magnetic resonance cholangiography and percutaneous transhepatic cholangiography.

OBJECTIVE: Computed tomography (CT) is traditionally used for evaluation and staging of gallbladder carcinoma (GC). However, in the subgroup of patients with obstructive jaundice, magnetic resonance cholangiography (MRC) is generally required to assess the level of biliary obstruction. The present study was undertaken to evaluate the diagnostic potential of three-dimensional helical CT cholangiography (3-D CTC) with minimum intensity projection (minIP), to determine the presence and level of biliary obstruction. MATERIALS AND METHODS: Twenty-five consecutive patients with proven GC, presenting with clinical and biochemical features of obstructive jaundice, over a 1-year period were included in the study. Dual phase helical CT data was obtained in the arterial and venous phases, respectively, after intravenous contrast injection using a pressure injector. Axial CT data (both arterial and venous phase) was studied for staging and resectability of tumor. Three-dimensional helical CT cholangiography using minIP obtained from the venous phase data set, was used to assess the level of biliary obstruction and isolation of hepatic segmental ducts. Three-dimensional helical CT cholangiography findings were compared with MRC and percutaneous transhepatic cholangiography (PTC) (gold standard). None of the patients were operated on as they were all considered inoperable on axial CT images due to extensive local disease or distant metastasis. RESULTS: In all patients, 3-D CTC demonstrated dilated intrahepatic ducts up to tertiary branch level. The 3-D CTC correctly diagnosed the level of biliary obstruction and demonstrated isolated segmental ducts in all patients and correlated well in all cases with MRC and PTC findings in this regard. However, the 3-D CTC did not add any additional information over the axial source images. CONCLUSION: Three-dimensional helical CT cholangiography with minIP can correctly determine the level of biliary obstruction in patients with GC and may be a strong competitor with MRC, because it gives equivalent information with regard to the level of ductal obstruction even while being a part of an overall comprehensive CT staging study. Even though 3-D CTC did not provide additional information on top of the source images, the referring physicians found them very useful for conceptualization of the 3-D biliary anatomy.

Gallbladder cancer in India: a dismal picture.

BACKGROUND: Gallbladder cancer (GBC) is one of the most common gastrointestinal malignancies. The data regarding GBC are, however, limited. METHODS: Records of 634 patients with GBC over a 10-year period were examined with regard to the clinical presentation, investigative findings, treatment, operative findings and outcome. RESULTS: The mean age of patients was 51 +/- 11 years and men : women ratio was 0.36:1.00. Pain, jaundice and hepatomegaly were seen in 81.0%, 76.0% and 61.5% patients, respectively. On imaging, a mass replacing the gallbladder was seen in 73% patients. Gallstones were present in 54% patients. Surgery was carried out in 291 (46%) patients and endoscopic treatment in 72 (19%) patients but no intervention was carried out in the remaining patients because of disseminated disease. Among the patients who were operated on, 2.0% had stage I GBC, 3.4% stage II, 17.5% stage III, 47.0% stage IVa and 29.8% stage IVb. Radical resection was possible in 133 (46%) patients. The 30-day mortality was 10% with most (90%) deaths in patients with stage IV disease. The median survival after simple cholecystectomy and radical surgery was 33.5 and 12.0 months, respectively. However, among those who underwent debulking, palliative bypass or exploratory laparotomy alone, the survival ranged between 1 and 3 months. Logistic regression analysis showed that only radical resection improved the long-term survival (P < 0.05). CONCLUSIONS: The majority of patients with GBC in India have advanced unresectable disease. Detection of GBC at an early stage is incidental and rare but is associated with long-term survival. Radical surgery, when feasible, is the only option for achieving long-term survival.

Spectrum of hemostatic derangements, in Budd-Chiari syndrome.

BACKGROUND: Hemostatic abnormalities have been reported in various hepatocellular diseases. We evaluated the hemostatic functions in patients with Budd-Chiari syndrome. METHODS: Biochemical liver function tests, and measurement of prothrombin time, activated partial thromboplastin time, and plasma levels of anti-thrombin III (antigen) and activity of protein C were done in 36 patients with Budd-Chiari syndrome. RESULTS: Liver biochemistry was abnormal in 34 patients. Plasma prothrombin time and activated partial thromboplastin time were prolonged in 17 (47%) and 23 (64%) patients, respectively. Antithrombin III antigen levels and protein C activity were reduced in 15 (50%) and 25 (83%) patients, respectively, among the 30 patients studied. Albumin levels showed significant correlation with coagulation test results, levels of anti-thrombin-III, and protein C activity. CONCLUSION: Hepatic synthesis of coagulation factors and anticoagulants is reduced in Budd-Chiari syndrome; this may play a role in recurrence of thrombosis.