Surgical and nonsurgical management of primary and metastatic liver tumors.

The medical records of 267 patients who had liver tumors, primary and metastatic, from 1988 to 1995 were retrospectively reviewed. Two hundred thirteen patients (80%) had metastatic disease, and 54 patients (20%) had primary liver disease. Their clinical manifestations and laboratory values were evaluated as factors predictive of diagnosis and survival. There was a significant increase in the occurrence of upper abdominal pain, weight loss, extrahepatic symptoms due to the metastatic origin, and hepatomegaly. Metastases from colorectal primary lesions were synchronous in 34 patients and metachronous in 31 patients. Stomach, lung, and pancreatic primaries were more commonly synchronous. Breast metastases were more commonly metachronous. Elevated serum glutamic-oxaloecetic transaminase and alkaline phosphatase and decreased albumin were the most common liver test abnormalities at diagnosis. Carcinoembryonic antigen values were elevated in the majority of colon cancer patients. Eighty-one percent of patients with primary liver cancer had elevated levels of alpha-fetoprotein, 40 per cent were seropositive for hepatitis B, and 23 per cent were seropositive for hepatitis C. Seventy-nine patients (30%) underwent surgery for their cancer, 37 (47%) had resections, 38 (48%) were unresectable, and 4 (5%) underwent liver transplantation. The patients who underwent surgery had a 32 per cent 5-year survival rate compared to a 0 per cent 5-year survival in the patients who did not have surgery (p = 0.0001). The patients who had resections had a better survival rate than those deemed unresectable at surgery (62% versus 0% at 5-years with p = 0.0008). The perioperative morbidity rate was 16 per cent, with lobectomies having the best rate and trisegmentectomies having the worst. Perioperative mortality rate was zero for all liver resections. Hepatic resection and, in selected patients, liver transplantation are the only two available therapeutic modalities that produce long-term survival with a possible cure in patients with primary and metastatic liver tumor.

Suspected biliary complications after laparoscopic and open cholecystectomy leading to endoscopic cholangiography: a retrospective comparison.

To study how suspected postoperative biliary complications are influenced by surgical technique, we compared clinical profiles of 63 patients referred for ERCP after open (OC) and laparoscopic cholecystectomy (LC) over a four-year period. ERCP was not performed for postoperative pain alone and only six (9.5%) studies were normal. Referrals after LC were younger (mean 39.1 vs 53.6 years, P < 0.001) and ERCP was requested earlier (mean 71.6 vs 2360 days, P < 0.001) in the postoperative course. Choledocholithiasis (CDL) alone, the most common finding, was successfully managed with a single ERCP in 97.2% of cases. CDL after LC occurred in younger patients (35.5 vs 58.9 years, P < 0.01) who presented earlier (mean 98.6 days vs 5.1 years, P < 0.01), without biliary ductal dilatation (P < 0.01). Although CDL after LC was associated with higher ALT and bilirubin levels than after OC, the difference was not statistically significant. Cystic duct leaks (LC: six patients, OC: four patients) were typically associated with CDL after OC and 90% resolved with endoscopic therapy. Biliary ligation (four cases) was managed successfully with choledochojejunostomy. We conclude that findings at ERCP for suspected biliary obstruction or injury after OC or LC are similar and usually can be endoscopically managed. After LC, referrals currently are younger, present much earlier, and retained stones are less likely to be associated with ductal dilatation than after OC.

Chronic hepatitis C with normal aminotransferase levels: a clinical histologic study.

OBJECTIVE: To define chronic hepatitis C virus (HCV) infection among patients with persistently normal aminotransferase levels (PNAL). DESIGN: Retrospective chart review of all patients encountered during 1-yr with positive hepatitis C antibody (anti-C100-3 ELISA), no alternative cause for their liver disease and PNAL for 6 or more consecutive months prebiopsy. Blinded review of liver histology. SETTING: Outpatient hepatology clinics of two academic centers. PATIENTS: Fifty patients with PNAL among 303 with hepatitis C. MEASUREMENTS: Epidemiologic profiles, reasons for seroscreening and confirmatory analyses were tabulated. Histology was reviewed and grading of inflammatory activity and stage of fibrosis was determined by protocol. RESULTS: Among 50 patients with PNAL, 35 (70%) were female, 34 (68%) had parenterally acquired HCV, 44 (88%) abstained (> 2 yr) from ethanol, all were HIV-negative and none pharmacologically immunosuppressed. HCV infection was uniformly confirmed by RIBA II or HCV-RNA assay. The mean level of HCV-RNA by quantitative PCR was 3.79 x 10(5) copies/ml (range, 500 to 1.8 x 10(6) copies/ ml) and by B-DNA, 53 x 10(5) copies/ml (range, 3.5-230 x 10(5) copies/ml). Traditional histoevaluation yielded chronic hepatitis ("active", n = 15; "persistent", n = 25), cirrhosis (n = 7), and normal histology (n = 3). Blinded protocol review of histology (inflammatory grade/fibrotic stage) revealed 0/0 (n = 4), 1/0 (n = 6), 2/0 (n = 17), 2/1 (n = 3), 2/4 (n = 1), 3/0 (n = 2), 3/1 (n = 6), 3/2 (n = 2), and 3/3 (n = 9). CONCLUSIONS: In chronic HCV infection, active inflammation, fibrosis, and variable circulating HCV-RNA levels may coexist with PNAL, particularly among female nondrinkers. Asymptomatic carriers with normal histology comprise 6 to 8% of chronic hepatitis C with PNAL. Management guidelines for this group of patients need to be developed.

Needle knife papillotomy in a university referral practice. Safety and efficacy of a modified technique.

To study the utility of needle knife papillotomy (NKP), we retrospectively reviewed 575 consecutive endoscopic retrograde cholangiopancreatography (ERCP) procedures performed over a 3.5-year period. Seventy patients (12.2%) underwent NKP utilizing a shallow ampullary mucosal incision followed by probing with a taper-tipped cannula. Usually a prelude to anticipated therapeutic intervention, NKP was also performed purely for diagnosis in 15 patients (21.4%). The incised ampulla was normal-sized in the majority (53 of 70, 75.7%), and ductal dilatation was present in 49 of 70 cases (70%). NKP was performed de novo in 63 patients, one of whom had Billroth II anatomy, and stent-guided NKP was performed in seven patients (10%), two of whom had Billroth II anatomy. Biliary access was immediate in 68 patients (97.1%) and successful 24 h later in two cases. The NKP incision was completed with a traction sphincterotome in 45 patients (64.3%). Complications occurred after NKP in five patients (7.1%), compared with 11 complications (4.2%) among a concurrent 261 patients who underwent standard ES without NKP. All complications following NKP were selflimited, including pancreatitis (n = 2) and bleeding (n = 2). Our experience indicates that NKP is versatile, effective, and safe with broad applicability in an academic referral practice.

Endoscopic diagnosis and management of biliary complications following orthotopic liver transplantation.

Nonoperative management of biliary complications (BC) with endoscopic retrograde cholangiopancreatography (ERCP) is a natural sequel to the emergence of choledochocholedochostomy as the preferred biliary reconstruction for orthotopic liver transplantation (OLT). Overall, therapeutic ERCP's efficacy for posttransplant BC is difficult to assess because most published data are retrospective, anecdotal, or in abstract form, and there are no prospective, randomized studies. Thus, endoscopic management of posttransplant BC must be individualized. While T-tube-related late bile leaks and ductal calculi are amenable to endoscopic therapy, its efficacy for strictures is more difficult to define. Refined surgical technique has prevented many unifocal anastomotic lesions, while multifocal strictures (for which endoscopic therapeutic experience is minimal) are increasingly prevalent. Whether endoscopic sphincterotomy is appropriate for posttransplant sphincter of Oddi dysfunction is controversial, because the disorder may be transient and the risk significant. Multicenter, prospective studies are needed to determine more accurately the optimal role of endoscopic therapy after OLT.

Delayed hemorrhage following endoscopic retrograde sphincterotomy for choledocholithiasis.

To define the clinical significance of delayed postsphincterotomy hemorrhage, we reviewed 476 consecutive ERCP procedures performed over a three-year period. Of 250 patients who underwent endoscopic sphincterotomy (ES), five (2%) developed postprocedure hemorrhage, two of whom had immediate, self-limited bleeding that resolved after endoscopic injection of epinephrine and did not require transfusion. The other three had delayed hemorrhage characterized by: onset 20-48 hr after the procedure, melena without hematemesis as the index clinical manifestation of bleeding, and atraumatic balloon extraction of common duct stones. Transfusion of 2-6 units of packed erythrocytes was necessary in each and one patient required surgical hemostasis. Delayed hemorrhage following ERS is an important, frequently severe complication to remember when contemplating performing ERS as an outpatient procedure.

A retrospective study of the efficacy of transjugular intrahepatic portosystemic shunts.

Transjugular intrahepatic portosystemic shunts (TIPS) are being used increasingly for complications of portal hypertension, including active and recurrent variceal hemorrhage and intractable ascites, as well as for portal decompression in patients awaiting orthotopic liver transplantation. We reviewed the initial 2-year experience with TIPS at Louisiana State University Medical Center-Shreveport and Willis-Knighton Medical Center, Shreveport, Louisiana, which involved 31 patients. Clinical findings (with some patients having more than one finding) revealed that 16 per cent (five) of the patients had active hemorrhage; 61 per cent (19), multiple episodes of (recurrent) variceal hemorrhage; and 48 per cent (15), ascites. The mean follow-up period was 6.2 months, with a patient mortality of 13 per cent. Results showed that in 87 per cent (27 of 31) of patients the TIPS procedure was successfully placed. There was 100 per cent control of active variceal hemorrhage (five patients) and ascites (12 patients; excludes three patients who died). Rebleeding occurred in 18 per cent (four of 22) of patients, all related to stenosis or occlusion of the TIPS. The overall incidence of occlusion and stenosis was 11 per cent and 22 per cent, respectively. Seventy-seven per cent (seven of nine) of the patients experiencing the latter complications underwent successful angioplasty or revision of their TIPS. The results of our experience indicate that TIPS placement can be performed successfully with low procedural morbidity. The procedure is effective in controlling active variceal hemorrhage refractory to endoscopic sclerotherapy. The use of TIPS may be particularly beneficial for patients who are either awaiting liver transplantation or poor candidates for surgical shunt procedures. TIPS may not be a long-term solution for patients with portal hypertension, given the current rates of occlusion and stenosis.

Sequential endoscopic/laparoscopic management of sickle hemoglobinopathy-associated cholelithiasis and suspected choledocholithiasis.

We reviewed the medical records of 17 patients with sickle hemoglobinopathy-associated cholelithiasis who were candidates for laparoscopic cholecystectomy (LC) between 1991 and 1994. Eight patients with suspected choledocholithiasis (CDL) were identified, all of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP), which revealed CDL in 3 patients (18%), all of whom had endoscopic ductal clearance. Choledocholithiasis was suspected because of hyperbilirubinemia or serum liver enzyme abnormalities. Incremental hyperbilirubinemia exceeding "baseline" values by > 5 mg/dL was the best predictor of CDL. Subsequent LC was successful with discharge within 2 days of LC in all but one patient, who was converted to open cholecystectomy. This small series suggests that in sickle hemoglobinopathy patients with cholelithiasis (1) CDL is relatively common among patients with an increase above baseline hyperbilirubinemia, (2) bile duct dilatation, alkaline phosphatase, and serum aminotransferase levels are poor predictors of CDL, and (3) sequential endoscopic/laparoscopic management of cholelithiasis and suspected CDL is successful.

Diagnostic considerations in evaluation of patients presenting with melena and nondiagnostic esophagogastroduodenoscopy.

Proper evaluation of patients with melena and nondiagnostic esophagogastroduodenoscopy is comparatively undefined. We sought to determine the percentage of patients with melena and nondiagnostic upper endoscopy and assess the yield of further evaluation. Of 209 patients presenting with melena, 180 underwent esophagogastroduodenoscopy as the initial study, which was nondiagnostic in 43 cases (24%). Further evaluation was pursued in 30. A presumed source of melena was found in 11 patients (37%), identified by colonoscopy in seven, bleeding scan in three, and barium enema plus flexible sigmoidoscopy in one. Nearly all such defined cases originated from the right colon. Small bowel contrast studies, flexible sigmoidoscopy of barium enema alone, and angiography failed to reveal a source. Our findings suggest that many (24%) patients presenting with melena will have nondiagnostic upper endoscopy; further evaluation reveals a potential source in 37% of this group, with the right colon being the most likely location of pathology; and colonoscopy is the test of choice in this cohort.

A critical review of the Couinaud technique of hepatic resection.

The Couinaud technique of left hepatic lobectomy involves the isolation and division of portal vein, hepatic artery, and biliary tributaries as a unit within the liver parenchyma. It saves time and minimizes blood loss by virtue of the common investment of the portal structures in a thick connective tissue sheath. Right hepatic lobectomy can be performed in a similar manner based on the same assumption that the biliary and vascular tributaries maintain a constant anatomic relationship with one another. We describe a patient who underwent right hepatic lobectomy by the Couinaud technique who (in retrospect) had congenital absence of a left hepatic duct. Because small bile ducts from the left lobe drained into the right hepatic duct deep to the sight of resection, obstructive jaundice resulted postoperatively, necessitating orthotopic liver transplantation. Presently, the patient is doing well 1 year after transplantation. When the Couinaud technique is used in the setting of a biliary anatomic variant, the results can be disastrous. This case illustrates that the Couinaud technique is unsafe unless biliary anatomic variants are excluded prior to hepatic lobectomy.

Choledocholithiasis in patients with normal serum liver enzymes.

Retrospective chart review of 330 patients undergoing ERCP over a two-year period yielded five patients with choledocholithiasis whose serum liver enzyme and total bilirubin levels were repeatedly normal. All were female, three were elderly, and the gallbladder was in situ in three of the five, one of whom had a large gallbladder remnant. In four patients, the common bile duct was dilated (> 10 mm), whereas none had intrahepatic duct dilatation. Four patients had a prominent ampulla, and stone size varied widely. Each patient was managed with endoscopic sphincterotomy and stone extraction followed by cholecystectomy for the four patients with the gallbladder or its remnant in situ. This small series proves that common duct stones may exist in patients with repeatedly normal serum liver enzyme and total bilirubin levels. We hypothesize that marked dilatation of the common bile duct or gallbladder may serve as a pressure sump and blunt liver enzyme elevation. Normal liver enzymes should not dissuade one from performing cholangiography in patients with suspected choledocholithiasis.

Liver transplantation. When is it indicated and what can be expected afterwards?

Orthotopic liver transplantation is an established form of therapy for selected patients who have chronic parenchymal liver disease with cirrhosis, a chronic cholestatic syndrome, fulminant hepatic failure, or unresectable hepatic malignant disease. In most centers with experienced staff, 5-year survival rates exceed 70%. For a good outcome, it is essential that the patient be referred to a transplant center early, before overt clinical deterioration occurs. Following transplantation, lifelong immunosuppression is required to prevent allograft rejection, and extensive follow-up is necessary for early reversal of complications. The primary care physician plays a critical role in identifying organ donors.

Chronic abdominal pain as the initial manifestation of pancreatic injury due to remote blunt trauma of the abdomen.

Three patients were admitted with severe abdominal pain that began after an asymptomatic latent period following blunt trauma to the abdomen. During initial medical evaluation 3 months to 1 year after the trauma, serum amylase levels were normal or minimally elevated, and computed tomography scanning revealed edema and/or pseudocyst formation in the tail of the pancreas. Pancreatography showed ductal stenosis or obstruction in the midbody of the pancreas in each patient. At surgery, chronic pancreatitis in the tail was clearly demarcated from the normal head of the gland. Distal pancreatectomy was curative. Blunt traumatic pancreatic ductal injury may occur without typical immediate posttraumatic acute pancreatitis. Chronic distal pancreatitis following an asymptomatic latent period may culminate in delayed admission months to years after the initial injury. Endoscopic retrograde cholangiopancreatography should be considered for evaluation of patients with chronic abdominal pain and prior blunt trauma to the abdomen.

Recent advances in the management of gallstones.

Demands for less invasive, more cost-effective therapy have revolutionized the management of gallstones over the past 10 years. There are no reliable methods of permanently reversing the pathophysiologic defects that cause gallstones. Open cholecystectomy (OC), the gold standard for managing symptomatic cholelithiasis, has been largely replaced by laparoscopic cholecystectomy (LC), which has the advantages of a minimal hospital stay and quicker return to work. Other adjunctive therapies, limited in applicability to selected patients, include oral bile acid therapy (BAT), dissolutional agents, and extracorporeal shock wave lithotripsy. Choledocholithiasis (CDL), formerly managed exclusively with surgical common duct exploration, is increasingly treated with therapeutic biliary endoscopy. Methods of laparoscopic common bile duct exploration are being developed. Optimal algorithms for applying these techniques to patients undergoing LC are evolving. In a sense, the solution to all, or certainly most, gallstones now can be seen through a scope.

Acute suppurative cholangitis associated with choledochal sludge.

Three patients with acute cholangitis who lacked cholangiographic evidence of common bile duct stones are reported. One presented 7 yr after cholecystectomy, and the other two had gallbladder sludge but no gallstones. The clinical features were mild, consisting of biliary pain, low grade fever without chills, and with modest leukocytosis. In each case, free cannulation of the bile duct was not possible, necessitating needle-knife papillotomy. After endoscopic sphincterotomy, balloon retrieval yielded purulent bile and sludge, but no stones. Prompt clinical improvement resulted in all three patients. Cultures of bile obtained at endoscopic retrograde cholangiopancreatography grew Escherichia coli in two patients and Enterobacter aeruginosa in the other. These observations suggest a link between intermittent obstruction due to biliary sludge in the common bile duct and bacterial cholangitis. We hypothesize that recurrent passage of biliary sludge may precipitate obstructive inflammation and fibrosis of the ampulla of Vater. Acute cholangitis should be added to the differential of potential complications of biliary sludge.

Traumatic pancreatitis in a patient with pancreas divisum: clinical and radiographic features.

A previously healthy patient with chronic hyperamylasemia and epigastric pain following blunt abdominal trauma complicated by retroperitoneal hematoma is reported. Endoscopic retrograde cholangiopancreatographic and computerized tomographic examinations revealed pancreatographic characteristics of pancreas divisum with traumatic disruption of the duct of Santorini and adjacent pseudocyst formation. Distal pancreatectomy with cystjejunostomy resulted in total recovery. This represents the first documented case of traumatic pancreatitis in a patient with pancreas divisum.