The Mirizzi syndrome refers to benign obstruction of the common hepatic duct by a stone impacted within
the neck or cystic duct of the gallbladder, which causes extrinsic compression of the common hepatic duct
and obstructive jaundice. Although a rare cause of obstructive jaundice, it remains a clinically and
surgically challenging problem. Five patients with the Mirizzi syndrome were culled from over 9000
patients undergoing operation for gallstone disease. The management of these patients was detailed.
Diagnosis requires a high index of clinical suspicion but can be confirmed with the use of ultrasonography
and percutaneous transhepatic cholangiography. Cholecystectomy and common duct exploration are
essential components of operative therapy, but additional procedures to repair non-circumferential bile
duct defects or strictures must be anticipated.

Thomas C. Bower

David M. Nagorney

Mirizzi Syndrome

Unsatisfactory immediate function of the transplanted liver together with technical complications
contribute to a persisting early mortality for hepatic transplantation in the 20% range. We report our
initial clinical experience with methods, one not previously used clinically, that resulted in uniformly well-functioning
liver grafts in 11 patients and contributed to a satisfactory success rate for the procedure.
Donors were heart-beating. During the donor operation all manipulations of the liver were avoided until
after cold preservation, achieved by external cooling at the same time as circulatory interruption, donor
exsanguination and perfusion of the liver with cold oxygenated fluid of “extracellular̵ type. The organs
were then gently dissected. At transplantation the livers were revascularized with arterial blood shunted
from the recipient iliac artery to the graft portal vein after completion of the suprahepatic IVC
anastomosis. The infrahepatic IVCs and hepatic arteries were then joined, the iliac artery shunts
discontinued and the portal veins joined. Total ischaemic intervals for the allografts were 3½–8 (average
5). Anhepatic intervals were 1–2¼ (average 2). The arterio-portal shunts were operating for 18–85 (mean
46) min. Blood loss and haemodynamic, acid-base and electrolyte abnormalities at revascularization were
minimal. All grafts secreted bile immediately and all parameters reflected continuing improvement of
liver function thereafter. Nine patients (82%) are alive between 4 and 18 (mean 11) months after
transplantation. We conclude that these methods offer effective avoidance of serious organ damage
during donor hepatectomy and preservation, reduced allograft ischaemic interval and reduced recipient
anhepatic time. They result in avoidance of blood loss at the time of revascularization, together with
minimal haemodynamic, acid-base or biochemical changes. In addition, they allow the surgeon to
perform and test all anastomoses without time constraints, provide the capability to deal with unexpected
complications, and assure good early graft function.

A. G. R. Sheil

J. F. Thompson

M. S. Stephen

J. C. Graham

A. A. Eyers

M. Bookallil

M. Kalpokas

G. W. McCaughan

S. F. A. Dorney

H. B. N. Ekberg

D. Mears

G. E. Kelly

K. Woodman

Liver Graft Revascularization by Donor Portal Vein Arterialization Following “No Touch” Donor Hepatectomy

Major hepatic resection was carried out on 23 adult patients with hepatocellular carcinoma (HCC) and
underlying cirrhosis of the liver (macronodular in six cases, micronodular in 11, and mixed type cirrhosis
in six). Pre-operative liver functional state was Child&#x27;s class A in 19, class B in three, and class C in one.
The operations performed were extended right lobectomy in four patients, right lobectomy in 10, left
lobectomy in one, and left lateral segmentectomy in eight. Fifteen postoperative complications were
found in 10 patients, five of whom had duplicated complications and finally died of liver failure 15&#x2013;65 days
after operation. In three of those five patients, other complications (hemorrhagic shock in two and portal
thrombosis in one) had preceded liver failure. Eighteen patients tolerated the resection and were
discharged from hospital. However, among 13 noncirrhotic patients with HCC who had undergone major
hepatic resection during the same period of time, only two had postoperative complications and all
patients were discharged from hospital. The 1-, 2- and 3-year survival rates in the 23 cirrhotics were
60.9&#x25;, 37.5&#x25; and 24.9&#x25; respectively, whereas the 1&#x2013;5-year survival rates were all 61.5&#x25; in the 13
noncirrhotics. Thus, major hepatic resection may be indicated in selected patients with HCC and
associated cirrhosis, but meticulous managements during and after operation are mandatory to prevent
fatal postoperative liver failure.

Naofumi Nagasue

Hirofumi Yukaya

Hitoshi Kohno

Yu-Chung Chang

Teruhisa Nakamura

Morbidity and Mortality After Major Hepatic Resection in Cirrhotic Patients with Hepatocellular Carcinoma

Twenty patients with ultrasonographic or computed tomographic diagnosis of pancreatic pseudocyst werereferred for endoscopic retrograde cholangiopancreatography (ERCP). Two of these were found atlaparotomy not to have pseudocysts and were excluded. Pancreatography was successful in 15 out of 18cases (83&#37;) and cholangiography in 12 out of 18 cases (67&#37;). Three types of pseudocysts were noticedaccording to the communication of the pseudocyst to the main pancreatic duct and the presence ofpancreatic duct stensosis. Successful treatment included two spontaneous resolutions, two internaldrainages and three left pancreatic resections. In the eight percutaneous external drainages fourrecurrences (50&#37;) occurred, one after closure of temporary pancreatocutaneous fistula. All therecurrences occurred in Type III pseudocysts with communication of the pseudocysts to stenotic mainpancreatic duct. In these cases internal drainage would have been the preferable treatment method. Webelieve that by ERCP one can identify pseudocysts not suitable for external drainage.

I.  Nordback

O.  Auvinen

I.  Airo

J.  Isolauri

O.  Teerenhovi

ERCP in Evaluating The Mode of Therapy in Pancreatic Pseudocyst

In order to assess the patency and function of biliary-enteric anastomoses performed in our Department ofSurgery, 21 patients entered the following study, provided an informed consent was obtained. All thepatients were affected by benign biliary tract diseases and underwent either Roux-en-Yhepaticojejunostomy (11 cases), or side-to-side choledochoduodenostomy (10 cases). The 21 patientswere evaluated with Tc-99m-HIDA scanning at intervals of 20 days&#8211;36 months after the surgicalprocedure (mean 14 months). The images were obtained after intravenous injection of the radioactivemedium (5 mCi) and the scans were taken at 1 min (1 frame/s), 3 min (1 frame/10 s), and 56 min (1 frame/2min). The data were analyzed by a Digital PDP 11/34 Computer System. This method allowed us to assesseach individual patient for the patency of the anastomosis and, by computer analysis, to build up a profileof the timing of the passage of the radioactive medium through the anastomosis; a delayed passage acrossthe anastomosis was always pathological.In conclusion, the 99m-Tc-HIDA scanning used in our study for long-term follow-up of biliary-entericanastomoses is reliable and allows an assessment of prognosis.

G.  Belli

G.  Romano

A.  Monaco

M. L. Santangelo

Hida Scan in The Follow-Up of Biliary-Enteric Anastomoses

Systemic endotoxaemia is associated with postoperative renal dysfunction in obstructive jaundice, and
can be prevented by the pre-operative administration of certain bile salts. In order to find the most
effective bile salt for use in this condition, a comparison of the anti-endotoxic activities of different bile
salts was performed. Bile salts were incubated in vitro with endotoxin and the resultant endotoxin level
was measured with a quantitative limulus assay. The in vivo effects of different oral bile salts on the
intestinal absorption of radiolabelled endotoxin from rats with obstructive jaundice were compared. The
in vitro and in vivo anti-endotoxic activities of bile salts related to their known detergent activities.
Deoxycholic acid and its conjugates were the most effective and should be the bile salts of choice for
further clinical evaluation in obstructive jaundice in man.

J. A. Pain

M. E. Bailey

Prevention of Endotoxaemia in Obstructive Jaundice &#x2014; A Comparative Study of Bile Salts

We describe the histological and histochemical changes of the common bile-duct mucosa in specimensobtained by means of peroral cholangioscopy, 1&#8211;12 years after choledochoduodenal anastomosis. Ourfindings &#8212; hyperplasia of the superficial epithelium, metaplastic goblet cells containing predominantlyacid sialomucins, and pyloric-like gland formation containing neutral mucins &#8212; express a morphologicaland functional differentiation of the common bile-duct mucosa that probably facilitates its survival in adifferent environment. We consider that these adaptive changes may explain the uneventful long-termpostoperative period of choledochoduodenostomized patients.

E.  Eleftheriadis

V.  Tzioufa

K.  Kotzampassi

H.  Aletras

Common Bile-Duct Mucosa in Choledochoduodenostomy Patients &#8212; Histological and Histochemical Study

For treatment of malignancies, physical and metabolic differences between tumour cells and host cellshave guided the development of new approaches. In this review, two new approaches to be used in thetreatment of liver malignancies are outlined: ischaemic therapy and interferences with the glucosemetabolism. Ischaemic therapy of liver malignancies has been used in different forms during the last 20years: from ligation of the hepatic artery, embolization of the arterial tree, transient occlusion of thehepatic artery to the present day use of temporary, intermittent, transient hepatic arterial occlusion. Thebeneficial effect of ischaemic therapy on malignancies is supposed to depend on oxygen and nutritionaldeficiency, formation of oxygen-derived free radicals and loss of function in cellular enzymes. The tumourcells seem thereby to be more sensitive than the host cells. Also, ischaemia might potentiate the effect ofcytotoxic drugs. Intereferencies with glucose metabolism might be directed either towards theexaggerated tumour glycolysis, for example by glucose analogues like 2-deoxy-glucose, or towards theexaggerated host gluconeogenesis, for example by hydrazine sulphate. These treatments result inreduction of the glucose availability in the intracellular glucose metabolism in the tumour cells and haveexperimentally been demonstrated to be correlated to reduced tumour growth. It is concluded that boththese approaches, ischaemic therapy and manipulations with the glucose metabolism, seem promising forthe future. What is needed now is research to clarify the mechanims behind the effects, to establish theirfull consequences, and to identify the clinical use of these treatments and their possible combinations.

Bo  Ahr&#233;n

Stig  Bengmark

Ischaemic and Metabolic Treatment of Hepatic Tumours

John  Terblanche

Shunt Surgery Versus Endoscopic Sclerotherapy for Long-Term Treatment of Variceal Bleeding&#8212;Early Results of a Randomized Trial

Five cases of massive hemoperitoneum caused by spontaneous rupture of liver tumors, collected during a27-year period, are reported. Four patients had a primary liver malignancy and one patient a liver cyst withhemangioma. Initial symptoms were obscure and hemoperitoneum was suspected pre-operatively in onlyone patient. At operation, a mean of 3100 ml of blood was found in the abdomen. Hemostatis wasachieved by liver resection in four patients and by suture ligation in one. Two patients died during orshortly after operation. The three patients surviving the operation had primary liver cancer and lived for6 months to 6.5 years. It is concluded that liver resection, whenever possible, is the treatment of choice andthat pre-operative delay and mortality may be diminished by increased awareness of this condition.

Roland  Andersson

Karl-G&#246;ran  Tranberg

Hemoperitoneum After Spontaneous Rupture of Liver Tumor: Results of Surgical Treatment

The first Japanese case of fibrolamellar carcinoma (FLC) of the liver is described. The 17-year-oldJapanese male affected died of the disease 25 months after palliative operation. The diagnosis of FLC hadnot been confirmed before autopsy. Pre-operative diagnosis of FLC is important to surgeons. Acccordingto the literature, FLC is rare in Asia. The endemic discrepancy may suggest that the carcinogenic factorsare different from those of general hepatocellular carcinoma.

Hitoshi  Kohno

Naofumi  Nagasue

Hiroyuki  Taniura

Teruhisa  Nakamura

Sabro  Nagaoka

Fibrolamellar Carcinoma of The Liver &#8212; A Case Report From Japan and a Review of The Literature

Stig Bengmark

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