Benign Beale Gland Hyperplasia Mimicking Malignant Biliary Obstruction.

Extrahepatic bile duct obstruction can be caused by various pathologies, most of them being malignant. Painless, progressive jaundice is the usual mode of presentation. We report a case of distal Common Bile Duct (CBD) obstruction due to a Benign Intramural Beale gland hyperplasia mimicking a periampullary carcinoma. Peribiliary glands (Beale Glands) are a group of seromucinous glands, normally seen within the fibromuscular wall and periductal connective tissue in the extrahepatic and large intrahepatic ducts and also in the neck of the Gall bladder. These glands drain into the bile duct lumen through small channels referred to as sacculi of Beale. Intramural Beale ducts are lobular aggregates of mucous glands that lie within the wall of the bile duct. Beale Gland hyperplasia is uncommon, and is rarely large enough to be visible macroscopically or with imaging as an incidental finding. There are no case reports of this rare entity. It is distinguished from well differentiated bile duct adenocarcinoma by the preservation of the lobular architecture, lack of cytological atypia and lack of perineural invasion. This case is reported for its rarity.

Massive hemobilia: a diagnostic and therapeutic challenge.

BACKGROUND: Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. In this retrospective analysis, we have evaluated the challenges involved in the diagnosis and management of massive hemobilia. METHODS: Between 2001 and 2011, a total of 20 consecutive patients (14 males) who were treated in our department for massive hemobilia were included in the study and their records were retrospectively analyzed. RESULTS: Causes of hemobilia were blunt liver trauma (n = 9), hepatobiliary intervention (n = 4), post-laparoscopic cholecystectomy hepatic artery pseudoaneurysm (n = 3), hepatobiliary tumors (n = 3), and vascular malformation (n = 1). Melena, abdominal pain, hematemesis, and jaundice were the leading symptoms. All patients had undergone upper GI endoscopy, abdominal ultrasound, and computerized tomography of the abdomen. An angiogram and therapeutic embolization were done in 12 patients and was successful in nine but failed in three, requiring surgery. Surgical procedures performed were right hepatectomy (n = 4), extended right hepatectomy (n = 1), segmentectomy (n = 1), extended cholecystectomy (n = 1), repair of the pseudoaneurysm (n = 3), and right hepatic artery ligation (n = 1). CONCLUSION: The successful diagnosis of hemobilia depends on a high index of suspicion for patients with upper GI bleeding and biliary symptoms. Although transarterial embolization is the therapeutic option of choice for massive hemobilia, surgery has a definitive role in patients with hemodynamic instability, after failed embolization, and in patients requiring laparotomy for other reasons.

Isolated caudate lobe resection: technical challenges.

BACKGROUND: Isolated caudate lobe resection remains a technical challenge even in the best hands. This is due to the difficult approach and its location between major vessels. This retrospective study aims to analyze our experience with isolated caudate lobe resections. METHODS: Of the 402 patients who underwent liver resections between January 2002 and December 2011, we identified 13 caudate lobectomies. We analyzed the operative parameters, hospital stay, morbidity and follow up of these patients. RESULTS: There were nine males and four females, age ranging between 30 and 72 years. The indications were hepatocellular carcinoma in nine patients, hilar cholangiocarcinoma in two, solitary fibrous tumor in one, and a regenerative nodule in one patient. Left-sided approach was employed in seven cases, right-sided approach in three cases and a combined approach in three cases. Operating time ranged between 125 and 225 min and blood loss ranged between 210 and 630 mL. There was no mortality in the post-operative period. No local recurrence was noted in the follow-up period ranging from 6 months to 7 years. CONCLUSION: Caudate lobe resections, although technically challenging, can be successfully performed with minimal blood loss. Surgery offers potential cure in isolated caudate lobe tumors. The location and size of the tumor decides the approach.

Bleeding complication after pancreatic surgery: role of harmonic scalpel.

In this modern era of technological advancements, though many centers are contemplating complex surgical procedures on the pancreas, morbidity is still high and around 30-35 %. Post-operative bleeding complications are the most worrisome of all, which need vigilance by the operating team. Early recognition and prompt management using endoscopy, intervention radiology or urgent surgery, with a low threshold for relaparotomy is needed to avoid mortality. After successfully completing more than 500 Whipple's operations and over 300 Frey's procedures in the last 10 years, our bleeding complication, which is around 2 %, has substantially increased. This increase over the last couple of years is seen with usage of harmonic scalpel in pancreatic surgery. Here we report our recent encounter with bleeding in the post-operative period after Whipple's pancreaticoduodenectomy and Frey's procedure, where harmonic scalpel was used. We have recommended our suggestion to avoid this complication, by adopting a simple technique. We have achieved optimal results by applying this technique in our subsequent cases.

Hemosuccus Pancreaticus: 15-Year Experience from a Tertiary Care GI Bleed Centre.

Background. Hemosuccus pancreaticus (HP) is a very rare and obscure cause of upper gastrointestinal bleeding. Due to its rarity, the diagnostic and therapeutic strategy for the management of this potentially life threatening problem remains undefined. The objective of our study is to highlight the challenges in the diagnosis and management of HP and to formulate a protocol to effectively and safely manage this condition. Methods. We retrospectively reviewed the records of all patients who presented with HP over the last 15 years at our institution between January 1997 and December 2011. Results. There were a total of 51 patients with a mean age of 32 years. Nineteen patients had chronic alcoholic pancreatitis; twenty-six, five, and one patient had tropical pancreatitis, acute pancreatitis, and idiopathic pancreatitis, respectively. Six patients were managed conservatively. Selective arterial embolization was attempted in 40 of 45 (89%) patients and was successful in 29 of the 40 (72.5%). 16 of 51 (31.4%) patients required surgery. Overall mortality was 7.8%. Length of followup ranged from 6 months to 15 years. Conclusions. Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. All hemodynamically stable patients with HP should undergo prompt initial angiographic evaluation, and if possible, embolization. Hemodynamically unstable patients and those following unsuccessful embolization should undergo emergency haemostatic surgery. Centralization of GI bleed services along with a multidisciplinary team approach and a well-defined management protocol is essential to reduce the mortality and morbidity of this condition.

Embolization of liver tumors: Past, present and future.

Curative therapies for hepatocellular carcinoma (HCC), such as resection and liver transplantation, can only be applied in selected patients with early tumors. More advanced stages require local or systemic therapies. Resection of HCC offers the only hope for cure. Even in patients undergoing resection, recurrences are common. Chemoembolization, a technique combining intra-arterial chemotherapy with selective tumor ischemia, has been shown by randomized controlled trials to be efficacious in the palliative setting. There is now renewed interest in transarterial embolization/transarterial chemoembolization (TACE) with regards to its use as a palliative tool in a combined modality approach, as a neoadjuvant therapy, in bridging therapy before transplantation, for symptomatic indications, and even as an alternative to resection. There have also been rapid advances in the agents being embolized trans-arterially (genes, biological response modifiers, etc.). The current review provides an evidence-based overview of the past, present and future trends of TACE in patients with HCC.

Biliary cystadenomas: a case for complete resection.

Introduction and Objective. Biliary cystadenoma is a rare benign neoplasm of the liver with less than 200 cases being reported allover the world. We report a series of 13 cases highlighting the radiological findings and problems related to its management. Materials and Methods. Records of thirteen patients who underwent surgery for biliary cystadenomas, between March 2006 and October 2011, were reviewed retrospectively. Results. Majority of the patients were females (11 out of 13), with a median age of 46 (23-65) years. The most frequent symptom was abdominal pain (92%). Seven patients had presented with history of previous surgery for liver lesions. Five patients had presented with recurrence after partial resection for a suspected hydatid cyst and two after surgery for presumed simple liver cyst. Ten of the 13 patients had complete resection of the cyst with enucleation in 3 patients, 2 of whom in addition required T-tube drainage of the bile duct. There has been no recurrence during the follow-up period ranging from 3 months to 5 years. Conclusion. Biliary cystadenoma must be differentiated from other benign cysts. Hepatic resection or cyst enucleation is the recommended treatment option.