The management of patients with acute calculous cholecystitis has changed during recent years. The etiology of acute cholecystitis is still not fully understood. Infection of bile is relatively unimportant since bile and gallbladder wall cultures are sterile in many patients with acute cholecystitis. Ultrasonography is first choice for diagnosis of acute cholecystitis and cholescintigraphy is second best. Percutaneous puncture of the gallbladder that can be used for therapeutic drainage has also diagnostic qualities. Early cholecystectomy under antibiotic prophylaxis is the treatment of choice, and has been shown to be superior to delayed surgery in several prospective trials. Mortality can be as low as 0.5% in patients younger than 70–80 years of age, but a high mortality has been reported in octogenerians. Selective intraoperative cholangiography is now generally accepted and no advantage of routine cholangiography was shown in clinical trials. Percutaneous cholecystostomy can be successfully performed under ultrasound guidance and has a place in the treatment of severely ill patients with acute cholecystitis. Laparoscopic cholecystectomy can be done safely in patients with acute cholecystitis, but extensive experience with this technique is necessary. Endoscopic retrograde drainage of the gallbladder by introduction of a catheter in the cystic duct is feasible but data are still scarce.

Dirk J. Gouma

Huug Obertop

Acute Calculous Cholecystitis: What is new in diagnosis and therapy?

Paul H. Sugarbaker

Is Repeated Hepatic Resection Justified for Malignancy?

Objective: Morbidity and mortality involved in the resection of hilar cholangiocarcinoma were reviewed retrospectively. The clinicopathologic and laboratory parameters that might influence the patient&#39;s survival also were re-evaluated.Summary Background Data: Although much progress has been made in the diagnosis and management of hilar cholangiocarcinoma, long-term outlook for most patients remains poor. Surgical resection is usually prohibited because of its local invasiveness, and most patients can only be managed by palliative drainage. Recently, many surgeons have adopted a more aggressive resection with varying degrees of success. Several prognostic factors in bile duct carcinoma have been proposed; however, no reports have specifically focused on resected hilar cholangiocarcinoma and its prognostic survival factors using multivariate analysis.Methods: The clinical records and pathologic slides of 49 cases with resected hilar cholangiocarcinoma were reviewed retrospectively. Twenty clinical and laboratory parameters were evaluated for their correlation with postoperative morbidity and mortality, whereas 31 variables were evaluated for their significance with postoperative survival. Variables showing statistical significance in the first univariate analysis were included in the following multivariate analysis using stepwise logistic regression test for factors affecting morbidity and mortality and Cox stepwise proportional hazard model for factors influencing survival.Results: There were 5 in-hospital deaths, and the cumulative 5-year survival rate in 44 patients who survived was 14.9&#37;, with a median survival of 14.0 months. Multivariate analysis disclosed that coexistent hepatolithiasis and lower serum asparate aminotransferase levels (90 U/L) had a significant low incidence of postoperative morbidity, whereas a serum albumin of less than 3 g/dL was the only significant factor affecting mortality. Regarding survival, univariate analysis identified eight significant factors: 1) total bilirubin 10 mg/dL, 2) curative resection, 3) histologic type, 4) perineural invasion, 5) liver invasion, 6) depth of cancer invasion, 7) positive proximal resected margin, and 8) positive surgical margin. However, multivariate analysis disclosed total bilirubin &#8805; 10 mg/dL, curative resection, and histologic type as the three most significant independent variables.Conclusions: Surgical resection provides the best survival for bilar cholangiocarcinoma. An adequate nutritional support to increase serum albumin over 3g/dL is the most important factor to decrease postoperative mortality. Moreover, preoperative biliary drainage to decrease jaundice and a curative resection with adequate surgical margin are recommended if longer survival is anticipated. Patients with well differentiated adenocarcinoma seem to survive longer compared to those with moderately or poorly differentiated tumors.

Steven M. Strasberg

Resection of Hilar Cholangiocarcinoma

Fifty-seven patients with failed sclerotherapy received a mesocaval interposition shunt with an externally supported, ringed polytetrafluoroethylene prosthesis of either 10 or 12 mm diameter. Thirty-one patients had Child-Pugh gradeA disease and 26 grade B; all had a liver volume of 1000&#8211; 2500 ml. Follow-up ranged from 16 months to 6 years 3 months. Three patients (5 per cent) died in the postoperative period. There were two postoperative recurrences of variceal haemorrhage and one recurrent bleed in the second year after surgery. The cumulative shunt patency rate was 95 per cent and the incidence of encephalopathy 9 per cent; the latter was successfully managed by protein restriction and/or lactulose therapy. The actuarial survival rate for the whole group at 6 years was 78 per cent, for those with Child-Pugh grade A 88 per cent and for grade B 67 per cent. Small-lumen mesocaval interposition shunting achieves portal decompression, preserves hepatopetal flow, has a low incidence of shunt thrombosis, prevents recurrent variceal bleeding and is not associated with significant postoperative encephalopathy.

Robert  Shields

Small-Diameter PTFE Portosystemic Shunts: Portocaval vs Mesocaval

Objective: The author analyzed potential survival determinants in gastrinoma to characterize a possible uniform staging system and to determine whether complete surgical resection improves expected survival.Summary and Background Data: Gastrinoma is an indolent yet malignant neuroendocrine tumor. The associated gastric acid hypersecretion can be controlled medically. Staging of gastrinoma is inconsistent and the role Of surgical resection controversial.Methods: Seventy-four patients with gastrinoma with a minimum 5-year follow-up were assessed. Cox&#39;s proportional hazards regression model was used to examine the association of risk factors with survival.Results: The following factors had no effect on survival: age at diagnosis, sex, presence of lymph node metastases, associated multiple endocrine neoplasia, and method of ulcer treatment. The three unique determinants of survival were primary tumor size (relative risk 1.534; p&#60;0.0005), liver metastases (relative risk, 2.947; p&#60;0.0209), and complete surgical resection (relative risk 0.163; p&#60;0.0076). On the basis of these risk factors, a uniform staging system is proposed and predictive survival curves developed.Conclusions: The primary determinants of survival in gastrinoma are the size of the primary tumor and liver metastases. Complete surgical resection reduces mortality, regardless of other factors.

P. C. Bornman

K.  Radebold

Changing Therapy for Gastrinoma

Background: Morbidity and mortality after surgical treatment of bileduct stones increase with age and associated diseases. A proposed alternative therapy is endoscopic sphincterotomy (ES) with the gallbladder left in situ, and we elected to compare this option with standard open surgery in high-risk patients.Methods: 98 patients (mean age 80 years) with symptoms likely to be due to bileduct stones or a recent episode of biliary parcreatitis were randomised to be treated either by open cholecystectomy with operative cholangiography and (if necessary) bileduct exploration (n=48) or by endoscopic sphincterotomy alone (n=50).Findings: The procedure was accomplished successfully in 94% of the surgery group and 88% of the ES group, and there were no significant differences in immediate morbidity (23% vs 16%) or mortality (4% vs 6%). During mean follow-up of 17 months biliary symptoms recurred in three surgical patients, none of whom underwent repeat surgery, and in 10 ES patients, seven of whom had biliary surgery. By multivariate regression analysis endoscopic sphincterotomy was an independent predictor of recurrent biliary symptoms (odds ratio 6.9; 95% C11.46 to 32.54).Interpretation: In elderly or high-risk patients, surgery is preferably to endoscopic sphincterotomy with the gallbladder left in situ as a definitive treatment for bileduct stones or non-severe biliary pancreatitis.

Gregory V. Stiegmann

Bile Duct Calculi – The New Challenges

primary treatment for unresectable hepatocellular carcinoma (HCC). In this unit, 185 patients with a new diagnosis of HCC not amenable to surgery were seen between 1988 and 1991. Intended therapy for these patients was chemoembolisation with doxorubicin (60 mg/m2) and lipiodol, repeated at six week intervals until it was technically no longer possible o.r until complete tumour response had been obtained. Chemoembolisation was possible in 67 of the 185 (37&#x25;). Reasons for exclusion were portal vein occlusion (n&#x3D;36), decompensated cirrhosis (n 44), distant metastases (n&#x3D;5), diffuse tumour or unsuitable anatomy (tumour or vasculature) (n&#x3D;11), patient refusal (n&#x3D;11), and other (n&#x3D;11). Patients excluded from treatment survived for a median of 10 weeks (range 3 days-19 months). In patients treated, 18 had small HCC (4cm) and 49 had large or multifocal HCC. Chemoembolisation was carried out a median of two sessions for small and three sessions for large tumours. Ten of 18 patients with small HCC showed a 50&#x25; or greater reduction in tumour size. Five of 49 patients with large or multifocal tumours showed a response to treatment. Median overall survival for treated patients was 36 weeks (range 3 days&#x2013;4 years). One patient has subsequently undergone liver transplantation with no recurrence and minimal residual disease at transplantation. Two other patients are alive three years after chemoembolisation, one with no evidence of recurrent disease. No patient was thought suitable for surgery after their response to chemoembolisation. Chemotherapy related complications were seen in 22&#x25;. Complications were significantly more common in patients with larger tumours and poor liver reserve. Five patients died as a result of chemotherapy related complications. In conclusion, only one third of UK patients with unresectable HCC are treatable by chemoembolisation. Results with small tumours are encouraging, with a high response rate and the possibility of surgical intervention in previously inoperable disease. Large tumours, however, show a poor response and significant incidence of side effects, suggesting that this treatment offers little benefit in advanced disease.

Jean-Luc Raoul

Is Chemoembolisation of Value in Inoperable Primary Hepatocellular Carcinoma

Purpose: A prospective, randomized trial was performed to determine if intra-abdominal drainage catheters are necessary after elective liver resection.Patients and Methods: Between April 1992 and April 1994, 120 patients subjected to liver resection, stratified by extent of resection and by surgeon, were randomized to receive or not receive operative closed-suction drainage. Operative blood loss was not an exclusion criteria, and no patient who consented to the study was excluded.Results: Eighty-seven patients (73&#x25;) had resection of one hepatic lobe or more (27 lobectomies, 54 trisegmentectomies, and 6 bilobar atypical resections) and 33 had less than a lobectomy (8 wedge resections or enucleations, 9 segmentectomies, and 16 bisegmentectomies). Eighty-four patients (70&#x25;) had metastatic cancer and 36 patients (30&#x25;) had primary liver pathology. There were no differences in outcome, including length of hospital stay (no drain, 13.4 &#xB1; 0.9 days; drain, 13.1 &#xB1; 0.8 days; P not significant [NS]), mortality (no drain, 3.3&#x25;; drain, 3.3&#x25;), complication rate (no drain, 43&#x25;; drain, 48&#x25;; n&#x3D; NS), or requirement for subsequent percutaneous drainage (no drain, 18&#x25;; drain, 8&#x25;; P&#x3D; NS). All infected collections (n&#x3D; 3) occured in operatively drained patients. Two other complications were directly related to the operatively placed drains. One patient developed a subcutaneous abscess at the drain site, and a second developed a subcutaneous drain tract tumor recurrence as the only current site of recurrence.Conclusion: In the first 50 consecutive resections performed since the conclusion of this trial, only 4 patients (8&#x25;) have required subsequent percutaneous drainage. We conclude that abdominal drainage is unnecessary after elective liver resection,

David L. Morris

Liver Resection: To Drain or not to Drain&#x3F;

Paul G. Anderson

James  Toouli

Thomas G. Wilson

Michael  Graham

Endoscopic and Surgical Management of a Hayes Type III-G Cystic Duct Anomaly Causing a Mirizzi Type I Syndrome

Patients undergoing surgical treatment for calculous disease were considered to have had a partialcholecystectomy performed when a part of the gall bladder wall was retained for technical reasons.Forty patients underwent partial cholecystectomy: for chronic cholecystitis (20), acute cholecystitis (4),Mirizzi&#39;s syndrome (14), portal hypertension or partially accesible gall bladder (one patient each). Fourpatients (10&#37;) developed infective complications and two patients had retained common bile ductstones. In a mean follow up period of 13 months (range 1&#8211;36 mths), only 3 patients have ongoing milddyspeptic symptoms while the rest have remained asymptomatic. Partial cholecystectomy has beenfound to be a safe and effective procedure in difficult cholecystectomy situations, since it combines themerits of cholecystectomy and cholecystostomy.

Md.  Ibrarullah

L. K. Kacker

S. S. Sikora

R.  Saxena

V. K. Kapoor

S. P. Kaushik

Partial Cholecystectomy Safe and Effective

Robert E. Hermann

Pancreatic Drainage Into the Stomach After Pancreatic Resection

A series of 155 cases of hepatic hydatid disease, occurring in 121 patients, were operated on at the Navaland Veterans Hospital of Athens. Ultrasonography and computerized axial tomography provided thepreoperative diagnosis in 89 and 93 percent of the cases respectively in recent years. Thirty one percentof the cases presented with complications, the commonest of these being infection of the cyst (10percent) and rupture of the cyst into the bile ducts (17 percent). Total cystectomy was performed inthree cases and removal of the endocyst with its content in the remaining 152. The remaining cavity waseither externally drained (57 cases), or filled with omentum (omentoplasty &#8212; 95 cases). External fistulaand infection of the residual cavity occurred in 32 and 56 percent after simple drainage and in 4 and 2percent respectively after omentoplasty. Differences are statistically significant (p &#60;  0.001).Hospitalization was also significantly longer after drainage than after omentoplasty (p &#60; 0.01).Obstructive jaundice after intrabiliary rupture of the cyst was more successfully managed afteradditional choledochoduodenostomy than after simple drainage of the common bile duct.Intrapericoneal recurrence of hydatid disease occurred in two cases. The conclusion of the present studyis, that ultrasonography and computerized axial tomography provide an acceptable rate in the diagnosisand that omentoplasty offers a very low complication rate in the management of hydatid cystic disease ofthe liver.

Evaghelos  Xynos

George  Pechlivanides

Anastasios  Tzortzinis

Antonis  Papageorgiou

John S. Vassilakis

Hydatid Disease of the Liver. Diagnosis and Surgical Treatment

Squamous cell carcinoma of the liver arising from a non-parasitic cyst is a rare entity of a primary liver tumor with an unfavourable prognosis. We report a case of a patient with a cyst in the right lobe leading to upper abdominal symptoms and respiratory discomfort. Malignancy was not suspected from the clinical findings or repeated cytological examination of the cyst fluid. However, the blood stained brown color of the cyst fluid was unusual. Cyst recurrence after six attempts of conservative treatment with sonography guided drainage over a period for more than one year led to laparotomy with cyst unroofing. Because frozen section from the cyst wall revealed the unexpected finding of squamous cell carcinoma right hemihepatectomy was performed during the same operation. The patient is alive more than four years after surgery without cyst or tumor recurrence. The difficulties in establishing diagnosis are confirmed by the review ofother reports. In the diagnosis and treatment ofsymptomatic non-parasitic liver cysts possible malignancy has to be considered. In case of proven carcinoma radical surgery with partial hepatectomy should be performed.

Arved  Weimann

J&#252;rgen  Klempnauer

Michael  Gebel

Hansj&#246;rg  Maschek

Michael  Bartels

Burckhardt  Ringe

Rudolf  Pichlmayr

Squamous Cell Carcinoma of the Liver Originating from a Solitary Non-Parasitic Cyst: Case Report and Review of the Literature

Splenic arteriovenous fistula is a rare but curable cause of portal hypertension. This report describes apatient with such a disorder, presenting with bleeding esophageal varices and ascites. It emphasises theimportance of performing selective catheterization of the celiac and superior mesenteric artery in allpatients with signs of portal hypertension without evidence of chronic liver disease. Etiopathology andmanagement are discussed.

Moshe  Shleapnik

Baruch  Shpitz

Annette  Siegal

Alex  Dinbar

Bleeding Esophageal Varices and Portal Hypertension Caused by Arteriovenous Fistula of Splenic Artery

Liver Resection for Colorectal Secondaries

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