Patients with obstructive jaundice frequently suffer postoperative complications. We have investigated
the relationship of obstructive jaundice to the neutrophil oxidase response and the “priming” of the
response by the cytokines TNFα, interleukin-1 (IL-1), IL-6, and IL-8. On stimulation with f-met-leuphe
(fmlp), the respiratory burst in neutrophils from jaundiced patients was greatly increased compared
with controls (p &lt; 0.01), jaundiced patients having the highest respiratory burst levels were those with
the poorest prognosis. Neutrophils from controls were primed by all the cytokines tested, whereas
“jaundiced” cells were primed only by IL-1, and not by TNFα, IL-6, or IL-8, which in fact produced
slight inhibition. We conclude that neutrophils from obstructive jaundiced patients have raised oxidative
responses which may be due to “pre-priming” in vivo by cytokines, such as IL-6, IL-8, or TNFα. This exaggeration of the oxidative response in circulating neutrophils may contribute to the peri-operate
complications of patients with obstructive jaundice.

W. G. Jiang

M. C. A. Puntis

M. B. Hallett

Neutrophil Priming by Cytokines in Patients With Obstructive Jaundice

We compared hemostatic changes during OLT and HLT after various periods of graft storage, toinvestigate whether the host liver in HLT protects the recipient from hemostatic deterioration inducedby severe graft storage damage. In particular, the mechanism of fibrinolytic deterioration wasinvestigated. The effect of prostaglandin E1 (PGE1) on these parameters was also studied.Material and Methods: 69 pigs underwent either OLT (N = 32) or HLT (N = 37) with a graft stored for2 hr (N = 31), 24 hr (N = 16), 48 hr (N = 7), or 72 hr (N = 15). PGE1 was given intravenously to bothdonor and recipient animals and was added to the preservation and flushing solutions. Fibrinolysis(euglobulin clot lysis time, t-PA activity and &#945;2-antiplasmin) and coagulation parameters (activated partial thromboplasmin time, prothrombin time, fibrinogen and platelet count) were measured atseveral intervals during transplantation.Statistics: Univariate non-parametric tests were used for analysis of coagulation and fibrinolysisparameters. For the three main variables- i.e., the type of transplantation, the use of PGE1, and thepreservation time, multiple regression analysis was performed.Results: Fibrinolytic activity increased during the anhepatic period of OLT. Graft reperfusion wasfollowed by a rise in t-PA in both OLT and HLT. In HLT, t-PA quickly returned to normal, whereas acontinuous increase was found in OLT. The coagulation parameters, in turn, remained unchangedduring the anhepatic period and deteriorated in OLT compared to HLT. The duration of graft storagewas directly related to the severity of the hemostatic changes, although this effect was more apparent inOLT than in HLT.Conclusions: Changes in hemostasis are more pronounced in OLT than in HLT. This suggests that thehost liver protects the recipient from the effects of graft storage damage, even after long preservationtimes. Early postreperfusion fibrinolytic activity was presumably due to t-PA release from the graft bothin OLT and HLT. The further rise t-PA in OLT might be caused by the release of cytokines from thegraft, that subsequently evoke endothelial t-PA release. In HLT, t-PA and cytokines may be cleared bythe native liver. No positive or negative effect of PGE1 on coagulation or fibrinolysis parameters wasnoticed.

C. Minke Bakker

Jan D. Blankensteijn

Peter  Schlejen

Robert J. Porte

Maria J. Gomes

Harald I. H. Lampe

Jeanne  Stibbe

Onno T. Terpstra

The Effects of Long-Term Graft Preservation on Intraoperative Hemostatic Changes in Liver Transplantation

The growing popularity of laparoscopic cholecystectomy (LC) has made extensive seriescomparing laparoscopic and conventional cholecystectomy in a prospective, randomized waynearly impossible. To evaluate LC we compared retrospectively 800 laparoscopic with 748conventional cholecystectomies (CC). Of the 800 LC, 10 (1.2&#37;) were converted to laparotomy.6 conversions were related to aberrant anatomical features or features making dissection verydifficult, 4 conversions were due to complications. There were 5 (0, 6&#37;) intraoperative complicationsduring LC and 4 (0.5&#37;) during CC. Postoperative morbidity was 2.1&#37; (n &#61; 17) after LCand 3.7&#37; (n &#61; 28) after CC. Particularly the incidence of wound problems was only 0.5&#37; (n &#61; 4)after LC while it was 1.3&#37; (n &#61; 10) after CC. Overall morbidity was 2.7&#37; (n &#61; 22) for LC and4.2&#37; (n &#61; 32) for CC. Mortality rate after CC was 0.4&#37; (n &#61; 3), there were no deaths after LC.Common bile duct-injury rate was 0.2&#37; (n &#61; 2) for both groups. Complication rates after LChave been rapidly decreasing with growing experience. Laparoscopic cholecystectomy can safelybe performed by appropriately trained surgeons in more than 90&#37; of patients suffering fromgallbladder disease. The low morbidity and mortality together with the significant advantages topatient recovery makes laparoscopic cholecystectomy the treatment of choice for symptomaticcholecystolithiasis.

Iris B. Brune

K.  Sch&#246;nleben

S.  Omran

Complications After Laparoscopic and Conventional Cholecystectomy: A Comparative Study

Outpatient Laparoscopic Cholecystectomy was attempted in 98 patients selected from 266 patientspresenting for elective cholecystectomy (37&#37;). Two patients required admission following conversion to&#8220;open&#8221; Cholecystectomy, one patient was admitted for observation because of a technically difficultLaparoscopic Cholecystectomy and 16 patients were admitted because of refractory nausea andvomiting in the early post-operative period. Seventy-nine patients (81&#37;) were able to be dischargedhome within 4 to 6 hours of surgery, with only one patient requiring readmission to hospital because ofthe onset of nausea and vomiting. There were no post-operative complications attributable to theoutpatient experience. We believe this approach to elective gallbladder pathology can be safelyaccomplished in selected patients and will be increasingly utilized in the future.

R.  Smith

D.  Kolyn

R.  Pace

Outpatient Laparoscopic Cholecystectomy

Paul  McMaster

Budd-Chiari Syndrome: Shunt or Transplant?

Kunio  Okuda

Growth and Survival in Small Hepatocellular Carcinoma

Harold O. Conn

Does Prophylactic Endoscopic Sclerotherapy Prevent Variceal Bleeding Or Not? A Question of Experimental Design

J. M. Little

Liver Trauma: New Management Trends

Biliary cystadenoma is a rare tumor of the liver. We describe a biliary cystadenoma of the left lobe of the
liver with intracystic gallstone formation. This is the first report of stone formation in biliary
cystadenoma of the liver.

Shize Lei

Don R. Domenico

John M. Howard

Intrahepatic Biliary Cystadenoma With Intracystic Gallstone Formation

Prasit  Watanapa

Robin C. N. Williamson

Have Expandable Metallic Stents Replaced Operation for Malignant Biliary Obstruction?

Gallbladder carcinoma(GBCA) is the most common malignancy of the biliary tract1 and is oftenfound seredipitiously after cholecystectomy. We report the first two cases of incidental GBCA in thenative gallbladder of two liver transplant recipients. Both patients are 2.5 years following uneventfulorthotopiic liver transplantation(OLTx) with no evidence of recurrent disease. Pathology of bothrecipients was early and favorable. Neither patient received any further therapy. Given the incidenceof GBCA and the evolution of OLTx we would anticipate this finding to be more prevalent.

W.  Kennethwashburn

W.  Davidlewis

Roger L. Jenkins

Liver Transplantation With Incidental Gallbladder Carcinoma in the Recipient Hepatectomy

Portal vein thrombosis is an unusual potential complication of liver resection. In our case it was due toligation of the right branch of the portal vein during right hepatectomy in a patient without portal veinbifurcation. Hepatic angiography can delineate this abnormality and influence the choice of surgicalmanagement.

M. K. Koh

H.  Ahmad

P.  Watanapa

R. P. Jalleh

N. A. Habib

Beware the Anomalous Portal Vein

To determine the factors responsible for therapeutic failures in acute cholangitis, a series of 127patients was analyzed. There were 64 females and 63 males whose mean age was 57.2 years. Ninetyfour(74.0&#37;) of these patients were clinically cured with initial measures, whereas 33 patients (26&#37;)failed initial therapy for an infectious reason. No differences were observed between the two groups inregard to age and gender. However, more patients in the group that failed had a malignant cause fortheir bile duct obstruction (72.7&#37; vs. 42.6&#37;, p &#60; 0.01) and had a pretreatment positive blood culture(45.5&#37; vs. 13.8&#37;, p &#60; 0.01). Patients who failed had a higher mean total bilirubin level (9.7 mg/dl vs.5.5 mg/dl, p &#60; 0.005) and more of them had a level greater than 2.2 mg/dl (97&#37; vs. 69.9&#37;, p &#60; 0.001).Also, more bile cultures were initially positive (93.9&#37; vs. 76.6&#37;, p &#60; 0.05) and more organisms wereisolated per culture (3.88 vs. 2.86, p &#60; 0.03) in the patients who failed. In addition, more patients failedwho had two or more organisms in the bile (33&#37; vs. 8.3&#37;, p &#60; 0.02). Patients in whom Candida, or anypanresistant organism was isolated also tended to fail. Multivariant analysis showed that malignancy,bacteremia, bilirubin &#8805; 2.2 mg/dl, &#8805; 2 organisms in the bile and a panresistant organism were the bestpredictors of treatment failure with a serum bilirubin level &#8805; 2.2 mg/dl being the variable that increasesa patient&#39;s log-odds ratio of failure the greatest. In conclusion, patients with acute cholangitis whohave an increased chance to fail initial therapy can be identified, and treatment altered accordingly.

Jesse  Thompson

Robert S. Bennion

Henry A. Pitt

An Analysis of Infectious Failures in Acute Cholangitis

Duodenal malformations are the third commonest cause of intestinal obstruction in infants1. Aspectrum of intrinsic obstructive lesions within the duodenum ranges from atresia to congenital bands2.Rarely, duodenal malformations may first present in adulthood. Less than 70 cases of duodenal webpresenting in an adult have been reported in the literature. In 10 patients the presentation was associatedwith pancreatitis. We report a case of congenital duodenal web associated with pancreas divisum whichfirst presented in an adult with the clinical characteristics of recurrent acute pancreatitis.

J.  Kollias

J.   Toouli

Duodenal Web and Pancreas Divisum Causing Pancreatitis in an Adult

Duodenal injury following blunt abdominal trauma is uncommon. The severity of injury can vary froman intramural haematoma to a duodenal rupture with associated transection of the pancreatic duct. Acase of duodenal rupture with avulsion of the ampulla of Vater is presented and discussed.

M. R. Cox

M. C. Eastman

Traumatic Duodenal Rupture and Avulsion of the Ampulla of Vater

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