Posters

Liver – Transplantation

(DOI 10.1080/16515320310001075)

251

LIVER TRANSPLANTATION FOR BILIARY CIRRHOSIS DUE TO IATROGENIC BILIARY INJURY DURING CHOLECYSTECTOMY 15 YEARS AGO

Ozden I, Bilge O, Tekant Y, Acarli K, Alper A, Emre A, Ariogul O

Istanbul University, Istanbul Faculty of Medicine, Department of General Surgery, Hepatopancreatobiliary Unit, Istanbul, Turkey

A 10-year-old girl underwent open cholecystectomy and duodenoraphy for cholelithiasis in 1987 at another institution (the gallbladder was found to be fistulized to the duodenum). The postoperative course was complicated by biliary and duodenal fistulae. Roux-en-Y hepaticojejunostomy was performed. In 1994, percutaneous transhepatic cholangiography at our institution demonstrated a Bismuth III biliary stricture; at laparotomy, there were no healthy bile ducts suitable for anastomosis and portoenterostomy was performed. Until 2000, she had a relatively benign course with ursodeoxycholic acid treatment. In 2001, balloon dilation of the hilar strictures was performed. Between October 2001 and February 2002, she was hospitalized 3 times for hepatic abscesses in the right lobe. The extremely short intervals between the 3 life-threatening episodes and the rapid progression to severe sepsis were taken into consideration and liver transplantation was performed. She is leading a healthy life at 11 months post-transplantation. Iatrogenic biliary injury can usually be treated successfully by a combination of surgery, radiological and endoscopic techniques. Rarely, salvage of the liver is not possible. It is likely that as the follow-up of the already published iatrogenic biliary injury series becomes longer, liver transplantation will be a treatment modality for a small but persistent subgroup of patients.

252

THE PROTECTIVE EFFECT OF ERYTHROPOIETIN ON ISCHEMIA-REPERFUSION INJURY OF THE LIVER

Yilmaz S, Ates E, Erkasap S, Pehlivan T, Koken T

Osmangazi University Medical Faculty, Department of General Surgery, Eskisehir, Turkey

Aim: Erythropoietin (EPO) has multiple protective effects such as antiapoptotic, antioxidant and angiogenic, also neuroprotective effects of EPO aganist ischemia have been demonstrated in cell culture and animal models. The aim of the study was to evaluate the effect of EPO on liver ischemia-reperfusion injury.

Methods: 24 adult male Spraque-Dawley rats weighing 250–300 g were divided into 2 groups. Group I: hepatic ischemia; group II: EPO + hepatic ischemia. Hepatic ischemia was created by placing a microvascular clamp on the hepatic pedicule for 45 min. EPO was given to group II at a dose of 1000 U/kg 120 min before the ischemia. Blood samples and liver tissues were obtained after 45 min of reperfusion from half of the rats in each group. The remaining rats were also sacrificed after a 24-h observation period and blood and tissue samples were obtained. Blood ALT, AST, TNF-α and IL-2 levels and liver tissue MDA levels were determined.

Results: ALT, AST, TNF-α, IL-2 and tissue MDA levels were significantly higher and the histopathological score was also more severe in the HI group than in the EPO + HI group.

Conclusion: This study demonstrates that preischemic administration of EPO has protective effects on hepatic I/R injury as reflected by decreased levels of ALT, TNF-α and IL-2 values and also histopathological tissue injury.

253

LIVING DONOR LIVER TRANSPLANTATION FOR FULMINANT LIVER FAILURE

Kilic M, Arikan C, Aydogdu S, Nart D, Celebi A, Karasu Z, Zeytunlu M, Yuzer Y, Tokat Y

Department of General Surgery, Ege University Hospital, Izmir, Turkey

Background: Fulminant liver failure is a fatal condition with 80% mortality if the patient does not undergo urgent liver transplantation. In countries like ours the scarcity of cadaveric allografts has led us to use living donors as an organ source for acute liver failure. Herein, the application, safety and efficacy of living donor liver transplantation in Turkey are analyzed.

Methods: 6 fulminant liver failure patients were transplanted from living donors at this hospital between September 2000 and December 2002. The age of the patients ranged between 5 and 37 years. Etiologies were fulminant hepatitis A in 2 patients, fulminant hepatitis B in 1 patient, Wilson's disease in 1 patient, toxic hepatitis in 1 patient and unknown in 1 patient. The donors were mothers in 4 cases and siblings in 2 cases. 3 of the allografts were left lateral segments and 3 of them were right lobes.

Results: 5 of 6 patients (83%) survived and are currently alive and well with a median 9 months follow-up. One of the patients transplanted for fulminant hepatitis A was lost due to sepsis and multiorgan failure. One of the patients had temporary visual loss in the early postoperative period and a bile duct stricture developed in 1 of the right lobe recipients. None of the survivors had neurological sequelae. There was no donor morbidity or mortality.

Conclusion: Living donor liver transplantation seems to be an effective and safe alternative for fulminant liver failure patients, especially in countries that have a limited number of cadaveric donors.

254

MEASUREMENTS OF HEMODYNAMICS OF LIVER GRAFTS IN LIVING DONOR LIVER TRANSPLANTATION BY MEANS OF XENON CT

Hashimoto K, Dono K, Sakon M, Hayashi S, Kubota M, Goto K, Kobayashi S, Yamamoto S, Marubashi S, Kato T, Nagano H, Umeshita K, Nakamori S, Monden M

Department of Surgery and Clinical Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan

Aim: Measurement of hepatic hemodynamics is important to evaluate liver function of liver graft and to diagnose complications after transplantation. We developed a new Xenon CT system that can measure the hepatic arterial and portal venous tissue blood flow (HATBF/PVTBF) separately and quantitatively. The purpose of this study is to confirm the ability of quantitative assessment of sequential hepatic blood flow of postoperative graft liver with xenon CT and the usefulness for diagnosis of complications.

Methods: 15 patients who underwent a living liver transplantion using right lobe graft from July 2000 to December 2002 were reviewed. The mask was fixed to the face and connected with the xenon inhalation system (AZ-725; Anzai Medical Co. Ltd). Serial abdominal CT scan was obtained every 1 min before and during 4 min inhalation of the non-radioactive 25% xenon gas following 5 min administration of 50% oxygen. From these images, HATBF and PVTBF were calculated separately with a special imaging system using Kety-Schmidt equation based on Fick's principle.

Result: HATBF showed nearly constant flow, while PVTBF at 2 weeks after operation showed highest (85.1 ml/min/100g), and those at 4 weeks (70.6 ml/min/100 g), and 3 months (67.8 ml/min/100 g), were lower than 2 weeks. We conjectured that the decrease of portal flow was due to increase of the regenerating graft liver volume because the flow value of xenon CT is the value per unit of volume. We experienced 4 cases of complications in hepatic blood flow. 1 case had partial arterial infarction. HATBF (14.1 ml/ min/100g) in infarcted segment decreased compared with other normal segments (48.6 ml/min/100g). The other case had outflow block in anterior partial segment. HATBF (16.7 ml/min/100 g) and PVTBF (15.2 ml/min/100g) markedly decreased than posterior segments (HATBF; 46.8 ml/min/100 g, PVTBF; 114.5 ml/min/100 g).

Conclusion: Measurements of hepatic TBF by xenon CT is a safe, reliable and non-invasive method. This study suggests the ability for quantitative assessment of sequential hepatic blood flow change of postoperative graft liver and the usefulness for diagnosing complications with xenon CT.

255

LONG SURVIVAL AFTER A SIMULTANEOUS LIVER AND KIDNEY TRANSPLANTATION

Hadjiyannakis EJ¹, Stratopoulos Ch¹, Moustafellos P², Gourgiotis S², Anastasiou T²

¹Athens Medical Center 1st Surgical Department and ²Transplant Unit, Evangelismos Hospital of Athens, Greece

Aims: To present a case of a 46-year-old female patient, who remains extremely well 11 years after a simultaneous liver and kidney transplantation.

Methods: The recipient received a combined liver renal grafting on 1 September 1992.

Results: The combined liver and kidney transplantation (the first in our country and the 4th in the international literature) was performed in a 46-year-old woman suffering from complicated polycystic disease of the kidneys and liver. 4 months prior to transplantation the patient had been subjected to bilateral nephrectomy (plus hysterectomy and appendectomy) because of suppuration of the polycystic kidneys and from then on she was on regular dialysis. Owing to deterioration of the liver function, it was decided that she be promptly managed with a combined liver renal grafting. She had an excellent postoperative course, except 1 rejection episode that was treated with 1 g i.v. methylprednisolone for 3 days. She was discharged on the 28th postoperative day with good liver and kidney function. 11 years post transplantation she is in excellent condition, working in a full-time job and she is receiving an immunosuppressive regimen consisted of cyclosporine A (3°mg/kg/day), prednisolone (2.5 mg/day) and mycophenolate mofetil (2 g/day).

Conclusion: Simultaneous liver and kidney transplantation should be considered an important therapeutic option in the management of polycystic kidney disease associated with severe and disabling cystic hepatomegaly.

256

EFFECT OF ISCHAEMIA/REPERFUSION INJURY (I/R) ON THE INCIDENCE OF ACUTE CELLULAR REJECTION (ACR) IN CLINICAL ORTHOTOPIC LIVER TRANSPLANTATION (OLT)

El-Wahsh M, Fuller B, Seifalian A, Rolles K, Davidson B

Liver Transplant Unit, University Department of Surgery, Royal Free and University College Medical School, London, UK

Aim: To investigate the effect of ischaemia-reperfusion (I/R) injury on the incidence of acute cellular rejection (ACR).

Methods: 83 patients who underwent 87 orthotopic liver transplantations (OLT) had routine postoperative biopsies at day 7, and additional biopsies were taken at the end of week 2 or 3 if there was a suspicion of ongoing graft rejection. The severity of the rejection was graded into no rejection, mild, moderate and severe. AST, ALT and bilirubin levels were used to assess I/R injury and prothrombin time (PT) to assess synthetic function of the graft.

Results: According to the scoring system used in this study, 35 grafts had mild I/R injury, 33 moderate and 17 had severe injury. The incidence of early (first week post-transplant) and late (2–3 weeks post-transplant) ACR was analysed among those grafts which developed I/R injury and results are summarised in Tables 1 and Table 2.

Table 1. I/R and early ACR.

	No rejection	Mild	Moderate	Severe	Total
Mild I/R injury	8	8	15	4	35
Moderate I/R injury 9	9	11	11	2	33
Severe I/R injury	3	9	4	1	17
Total number	20	28	30	7	85

Table 2. I/R and late ACR.

	No biopsy	No rejection	Mild	Moderate	Severe	Total
Mild I/R injury	7	8	2	11	7	35
Moderate I/R injury	8	12	1	9	3	33
Severe I/R injury	1	3	2	9	2	17
Total number	16	23	5	29	12	85

Conclusion: In the present study there was no such correlation between I/R injury and either early or late ACR.

257

THE EFFECT OF REDUCED GLUTATHIONE ADDITION TO WASH OUT SOLUTION IN ISCHAEMIA-REPERFUSION INJURY (I/R) AND ACUTE CELLULAR REJECTION (ACR) IN CLINICAL ORTHOTOPIC LIVER TRANSPLANTATION

El-Wahsh M, Fuller B, Seifalian A, Rolles K, Davidson B

Liver Transplant Unit, University Department of Surgery, Royal Free and University College Medical School, London, UK

Aim: To investigate the possibility of improving the function and the outcome of transplanted liver allografts by adding the GSH to the flush out solution used just prior to reperfusion.

Methods: 87 liver allografts were prospectively randomised to GSH or saline addition to the albumin flush out solution before starting reperfusion. Routine postoperative biopsies were taken at day 7. The severity of the rejection was graded into no rejection, mild, moderate and severe. AST, ALT and bilirubin levels were used to assess ischaemia-reperfusion (I/R) injury and prothrombin time (PT) to assess synthetic function of the graft.

Results: Patients in both groups were similar regarding age, sex and indications for transplantation. There was no difference in warm ischaemia time or cold ischaemia time in either group. The I/R injury in both groups is summarised in Table 1.

Table 1. Ischaemia/reperfusion injury in GSH and saline groups.

	Mild	Moderate	Severe	Total Number
GSH	18	16	8	42
Saline	17	17	9	43

The incidence of ACR in both groups is summarised in Table 2. There was no difference in ACR incidence in either GSH or saline grafts.

Table 2. Acute cellular rejection in GSH and saline groups.

	No rejection	Mild	Moderate	Severe	Total Number
GSH	10	16	14	2	42
Saline	10	12	16	5	43

Conclusion: In the current study the addition of GSH to flush out solution did not improve the I/R injury or decrease the incidence of acute cellular rejection in the treated group.

258

DONORS’ RESIDUAL LIVER REGENERATION AFTER RIGHT LOBE HEPATECTOMY FOR LIVING-RELATED LIVER TRANSPLANTATION

Kubota M, Dono K, Hashimoto K, Kato T, Nagano H, Umeshita K, Nakamori S, Sakon M, Monden M

Second Department of Surgery, Dokkyo University School of Medicine, Tochigi, Japan

Aim: An increasing number of living-related liver transplantations are performed worldwide because it is a successful clinical approach to overcome organ shortage in liver transplantation. However, the safety of donors in living-related liver transplantation is not established yet. To investigate liver regeneration in donors, we have measured their liver volume after the hepatectomy.

Methods: 16 right lobe donors were included in this study (male:female = 14:2, mean age 30.1 years). We evaluated liver regeneration by liver-volume estimation with serial CT scans. They were taken before and after 2 weeks, 1, 3, 6 and 12 months of the surgery with a GE Light-speed CT unit (GE Medical System, Milwaukee, WI, USA) at 1.0-cm intervals. The liver edges on each CT scan image were traced, summed, and multiplied using the GE workstation, Voxtool v2.0.8 gamma. Remnant liver volume was estimated to reduce the graft weight from the original volume. To make a comparison of liver regeneration, each estimated liver volume was divided by its original volume.

Results: (1) In the first month after the surgery, liver regeneration was vigorous. (2) All donors’ livers followed-up for >1 year are larger than 90% of their original liver.

Conclusion: From the point of view of liver regeneration, the first 4 weeks after the operation is very important period in right lobe graft donors. Thus, careful management is needed, especially in this period, for right lobe graft donors.

Liver – Tumour

(DOI 10.1080/16515320310001084)

259

SURGICAL TREATMENT FOR COLORECTAL LIVER METASTASES INVOLVING THE PARACAVAL PORTION OF THE CAUDATE LOBE

Yamamoto H, Hayakawa H, Kitagawa Y, Nagino M, Kamiya J, Nimura Y Tohkai Hospital, Nagoya, Japan

Background: Hepatic tumors in the paracaval portion of the liver (S1r) are usually difficult to treat surgically, because such tumors often invade the adjacent large vessels such as hepatic veins and/or inferior vena cava.

Methods: Between July 1977 and December 2001, 74 consecutive patients with colorectal hepatic metastases underwent hepatic resection. 6 patients with liver metastases involving the 1r were enrolled in this study. There were 5 men and 1 woman with a mean age of 59.8 years (range 54–75). Metastases were located in S1r in 3 patients, and S1r + the Spiegel lobe (S1l), S1r + S1l + the caudate process (S1c) and S1r + segment 4a in 1 patient each.

Results: The surgical procedures performed were 3 independent caudate lobectomies, 1 right hepatic lobectomy and 2 right hepatic trisegmentectomies with caudate lobectomy. Combined resection included a partial resection of hepatic vein in 2 patients, a wedge resection of IVC in 2, and a segmental resection of IVC in 1. There was no postoperative mortality. The 3- and 5-year survival rates after hepatectomy were 66.6% and 66.6% for the 6 patients with S1r metastases and 47.1% and 32.0% for the remaining 68 patients. There was no significant difference between the two groups (p = 0.346).

Conclusions: Aggressive surgical approach with combined resection of the adjacent major vessels can offer a better chance of long-term survival in selected patients with caudate lobe metastases from colorectal cancer.

260

TECHNICAL ASPECTS OF THE RARELY CENTRAL PARAMEDIAL LIVER RESECTIONS

Tasev V, Gaydarski R, Dimitrova V, Popov V, Boulanov D

Department of General and Liver Pancreatic Surgery, Medical University of Sofia, U.H. “Alexandrovska”, Sofia, Bulgaria.

Aims: Resections of the central paramedial hepatic sectors are very rarely reported due to their technical complexity. We present 3 cases in which we carried out this rare operative intervention for primary hepatic neoplasm in the central hepatic segments. We describe the surgical techniques.

Methods: In 3 cases (2 of primary hepatic cancer and 1 of sarcoma) we carried out resection of the central segments in the following steps: mobilization of the liver, subhepatic approach to the inferior vena cava, preparation for vascular isolation of the liver by Pringle's maneuver, dissection of the biliary, arterial and venous vessels in the hepatic hilus, intraoperative assessment of the involvement of these structures in the neoplastic process and subsequent hepatic resection.

Results: For a period of 5–24 months of follow-up we have not established a relapse of the disease in the cases described.

Conclusions: The outcome of the hepatic resections strongly depends on various factors including accurate preoperative diagnosism and assessment of the resection volume according to the involvement of the hepatic vessels in the neoplastic process. Hepatic resection can be performed with the same degree of confidence and similar low morbidity as any other major surgical procedure.

261

BENEFITS OF CENTRAL BISEGMENTECTOMY FOR HEPATOCELLULAR CARCINOMA IN PATIENTS WITH CIRRHOSIS

Kim CH, Chae MK

Department of Surgery, Soonchunhyang University, Chunan, South Korea

Aims: Hepatic resection is a well-established treatment for hepatocellular carcinoma (HCC). In cirrhotic patients, extended hepatic resection for HCC involving both lobes of the liver is rarely recommended because of high operative mortality and morbidity, related to limited liver function. The aim of this study was to evaluate the benefits of perioperative outcomes and survival of central bisegmentectomy for HCC involving both lobes in patients with cirrhosis. Central bisegmentectomy defines resection of the left medial and right anterior segments.

Methods: Between 1998 and 2002, 7 patients with HCC involving segments underwent central bisegmentectomy. The liver was evaluated by conventional biochemical tests and by the retention of indocyanine green dye (ICG R15). The postoperative morbidity, mortality and survival of these patients were analysed.

Results: All patients had cirrhosis and positive hepatitis B serology except one. In child's classification, Group A included 2 patients and group B included 5 patients. In ICG R15, the values of each patient were 18.8%, 20.5%, 24.6%, 25.2%, 24.1%, 15.4% and 19.6%, respectively. Mean size of the tumor was 6.4×3.1 cm. Postoperatively acute renal failure developed in 1 patient, but recovered uneventfully. There were no other significant operative complications. There was no operative mortality. The length of follow-up was 21–45 months. The disease-free survival length of each patient was 21, 30, 34, 45, 47, 34 and 25 months, respectively.

Conclusions: In cirrhotic patients, extended hepatic resection for HCC is rarely indicated. Central bisegmentectomy is recommended in cirrhotic patients who have HCC involving left medial and right anterior segments, with acceptable perioperative outcomes and survival.

262

LOW CVP ANESTHESIA AND INTERMITTENT VASCULAR INFLOW OCCLUSION DURING HEPATIC RESECTION REDUCE BLEEDING AND MORBIDITY

Lim TJ, Kang KJ, Cho JH, Kim YH, Kim JM

Department of Surgery, Keimyung University, Dongsan Medical Center, Daegu, Korea

The risk of major hemorrhage is one of the principal concerns during major liver resection. Excessive bleeding and subsequent transfusions correlate with increased incidence of postoperative morbidity and mortality. Major bleeding during hepatic transection is caused by backflow of blood from fenestrated or injured hepatic vein. Therefore reducing the backflow from the hepatic vein while keeping the central venous pressure as low as possible could reduce bleeding from the hepatic vein. We analysed the results of hepatic resection as regards the amount of bleeding and postoperative complications of 58 consecutive patients who had 24 cirrhotic or fatty livers, which included 44 major resections (more than a sectionectomy) and 14 minor resections (less than a segmentectomy). We have done hepatic resection using intermittent occlusion of hepatic vascular inflow while keeping central venous pressure as low as possible using several kinds of modalities. In order to reduce the central venous pressure, we used several modalities such as restriction of fluid infusion, Trendelenberg position, keeping tidal volume as low during anesthesia and continuous infusion of nitroglycerine. The central venous pressure and systolic blood pressure was lowered to 3.4 mmHg and 98 mmHg during transection of the liver from 7.2 mmHg and 130 mmHg respectively before medication with nitroglycerine. Packed RBC were transfused in 21 patients (36.2%) and no blood or blood product was used for 37 patients (63.8%). Average total duration of intermittent vascular occlusion was 35 min, the amount of bleeding was 580 ml and average amount of packed RBC for transfusion in 21 patients was 2.3 units (920 ml). There were minor complications in a few patients, abdominal abscess in 6 patients, minor leakage of bile in 3 patients, wound infection in 2 patients with 1 mortality (1.7%). There was no deterioration of kidney function induced by hypotension. In conclusion, keeping low central venous pressure with continuous infusion of nitroglycerine and intermittent vascular inflow occlusion of the portal triad during hepatic resection is very effective for reducing blood loss and is accompanied by limited complications. Nitroglycerine-induced hypotension during hepatic transection resulted in minimal deterioration of the hepatic and renal function.

263

HEPATIC RESECTION FOR METASTATIC TUMORS FROM GASTRIC CANCER

Maeda A, Yokoi S, Kunou T , Niinomi N, Kanemoto H, Ebata Tomoki, Uesaka K

Division of Hepato-Biliary Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan

Aims: To identify prognostic determinants for hepatic metastases from gastric cancer and to evaluate the actual targets of surgical therapy.

Methods: Between 1985 and 2001, 11 patients (all men, a median age of 59.5 years) underwent 13 hepatectomies for radical treatments and were enrolled. Follow-up ranged from 6 to 62 months. Macroscopically, number, size, lobar distribution, and surgical margin of the metastases were studied. The microscopic features evaluated were histological differentiation and the presence of vascular and lymphatic invasion of gastric cancer, and fibrous pseudocapsule and peritumoral lymphocytes of metastases.

Results: 6 patients died of recurrence (3 hepatic metastases, 2 lymph node, 1 bone marrow), and 3 patients are still alive with recurrence. The overall survival was 100% at 1 year, 64% at 3 years, and 17% at 5 years. Univariate analysis revealed venous involvement of the primary tumor (in patients with venous invasion, 5-year survival of 0% vs 22% in patients without, p = 0.0026) and lymphocyte aggregation around the metastases (in patients with aggregation 22% vs 0% in patients without, p = 0.009) to be significant prognostic factors for survival. However, multivariate analysis indicated them to have no significant impact on survival. There were 3 survivors more than 4 years, and all had lymphocytes aggregation.

Conclusions: Liver resection for metastases from primary gastric cancer may contribute to better survival in selected patients. Those without venous invasion of the primary gastric lesion may be a good indication for liver resection. Peritumoral lymphatic aggregation of the liver deposits may be a good predictive factor.

264

SOMATOSTATIN ANALOGUE USE (OCTREOTIDE: ‘SANDOSTATIN’ AND ‘SANDOSTATIN LAR’ FOR THE TREATMENT OF PATIENTS WITH HEPATOCELLULAR CARCINOMA

Severtsev A, Misherjakova T, Volodin D, Pfaf V, Alexandrov V, Melkin G Surgery Department, MPS – Central Clinical Hospital, Moscow, Russia

There are papers with announcement that somatostatin analogue (octreotide: ‘Sandostatin’ and ‘Sandostatin LAR’ could be used for the treatment of hepatocellular carcinoma (HCC). The number of patients with this disease has increased in recent years in Russia, but not so much as in other countries. The aim of this study was to assess the effectiveness of Sandostatin and the first experience of the use of Sandostatin LAR in the treatment of patients with HCC. We had 4 groups (6 patients each) with: 1) curative liver resection without Sandostatin use, 2) curative liver resection with Sandostatin use in the postoperative period, 3) no surgery, but the use of Sandostatin, 4) no surgery, no Sandostatin. Plus 3 patients were treated with Sandostatin LAR (intraperitoneal; 10mg/month). All patients were given Sandostatin 0.05 µg/day subcutaneously for 4 months at least in the 2nd and 3rd groups. The best results were in the 2nd group (mean long-term results were 14±4 months). In other groups mean long-termresults were 12±1.5 months in the 1st group, 5±1.5 months in the 3rd group, and 3.5±2 months in the 4th group. The long-term results of patients with Sandostatin LAR injections were 12, 7, 6 months with complete social rehabilitation. All results are NS. Nevertheless it could be concluded that the use of Sandostatin and Sandostatin LAR benefits the course of disease of patients with HCC.

265

BENIGN BILIARY CYSTADENOMA. REPORT OF A CASE

Manouras A, Stamou MK, Markogiannakis C, Kekis BP, Apostolidis N, Papadimitriou C, Androulakis G

1st Department of Surgery, University of Athens, Hippokrateion Hospital, Athens, Greece

Background: Certain entities in surgical pathology are presented mainly as case reports or retrospective collective studies since their rarity prohibits a prospective evaluation. Biliary cystadenomas are such entities and a relative case is presented.

Case report: A 37-year-old woman complained of vague pain and increasing abdominal girth. No other signs or symptoms were evident apart from hepatomegaly on clinical examination. All blood tests were normal including serous neoplasmatic markers. Ultrasound findings of a cystic lesion of the liver were followed by a computed tomography scan that revealed a large multinodular cystic formation of the liver. The patient underwent right hepatectomy and the postoperative course was uneventful. The pathology report diagnosed a ‘benign biliary cystadenoma’. The epithelium was simple columnar and cuboidal with no atypia and underlying densely cellular mesenchymal stroma resembling ovarian.

Discussion: Less than 100 reports of intrahepatic biliary cystadenomas have been identified in the literature. Resection is the management of choice, as for most multiloculated cystic hepatic lesions. The extent of resection for biliary cystadenomas is not determined since partial resection, lobectomy and enucleation have been reported in the past. Benign biliary cystadenomas are believed to transform to cystadenocarcinomas even decades after partial resection, although <40 of these lesions have been reported. Cystadenomas should therefore be appreciated as premalignant lesions. Since complete surgical resection is the only safe way of eliminating such danger and differentiating the two entities, in any case such tumors should be excised. In addition, experience from partial resection or aspiration is disappointing since recurrence rates are as high as 90%.

266

RADIOFREQUENCY TISSUE ABLATION: INDIAN EXPERIENCE

Varshney S, Sharma S, Sewkani A, Pamecha V, Narkhede V, Patel K, Tewari V, Maudar KK

Bhopal Memorial Hospital, Bhopal, India

Aim: Radiofrequency tissue ablation (RFTA) has been tried safely and effectively in the west as percutaneous local tissue ablation therapy. We present our experiecnce of RFTA in India.

Methods: RFTA was done using a radiofrequency generator (Berchtold, Germany) generating 35–50 RF W of power output. The RF needle was placed in the tumour/tissue under image guidance USG (n=22), CT scan (n=2), or at an open operation (n=2). Over 21 months, 26 patients underwent RFTA for 76 lesions, metastatic liver secondaries n=21 (from gallbladder n=6, colorectal n=8, breast n=6, carcinoid of bronchus n=l), locally advanced inoperable carcinoma of pancreas n=2, fibroadenoma of the breast n=2, and arrhythmogenic margins of left ventricular aneurysm n=1. Around 1500 W/sec/cubiccm RF energy was delivered to the tumour.

Result: RFTA was safe with no mortality or major morbidity. We had 2 minor complications (ascites 1, pleural effusion 1). RFTA was effective, all the lesions <3 cm in size (n=17) and 39% of lesions 3–4 cm in size (17/ 44), had complete necroses. Residual tumour was seen in 27/44 lesions (61%), 3–4 cm in size and 100% (n=14) lesions, >4 cm in size. Conclusion: RFTA in the Indian setting is a safe and effective, local tissue ablative method with increasing applications.

267

PROGNOSIS OF HEPATOCELLULAR CARCINOMA WITH TUMOR THROMBUS IN THE PORTAL VEIN OR HEPATIC VEIN

Miyake H, Tashiro S, Fujii M, Sasaki K, Takamura K, Takagi T, Imura A

University of Tokushima School of Medicine, Tokushima, Japan

Aims: Prognosis of patients with hepatocellular carcinoma (HCC) with tumor thrombus (TT) in the vessel (portal vein or hepatic vein) is still poor. We investigated the prognosis of those patients and discussed the significance of surgical resection and postoperative adjuvant therapy. Methods: Of 236 patients with HCC who underwent hepatic resection at Tokushima University Hospital from February 1985 to September 2002, 224 patients whose cancerous lesion was completely removed were retrospectively studied.

Results: 90 patients (40.1%) had TT and 134 patients had no TT in the vessel (v0 group). Among 90 patients, TT existed in the distal to the second portal branches or in the peripheral branch of the hepatic vein in 58 patients (vl group) and existed in the first or second portal branches with or without extension to the trunk or the opposite side portal branch/or in the right, middle, or left hepatic vein trunk or the short hepatic vein with or without extending to the IVC in 32 patients (v2 group). Postoperative survival was significantly lower in v2 group compared with v0 and vl group (p < 0.01). There was no significant difference between v0 and vl group. Cumulative 5-year survival rates were 49.6%, 47.1% and 11.4% in v0, vl and v2 groups, respectively. Among 32 patients in v2 group, 10 patients underwent adjuvant therapy (5FU + CDDP, 5 days a week/interferon alpha, 3 days a week) at least more than 1 month after operations (IFN group) and 22 patients underwent no adjuvant therapy (control group). Disease-free survival was significantly higher in the IFN group compared with the control group.

Conclusions: Surgical resection was an effective modality for patients with v0 or v1 HCC. Resection and postoperative adjuvant therapy probably improve the prognosis of the patients with v2 HCC.

268

CONTRIBUTION OF IMAGING STUDY IN THE DIAGNOSIS AND FOLLOW-UP OF HEPATIC HEMANGIOENDOTHELIOMA IN INFANCY

Koumanidou C, Vakaki M, Manoli E, Evangelidakis E, Kekis P Agia Sofia Children's Hospital, Athens, Greece

Aim: Infantile hemangioendothelioma (IH) is a rare tumor with vascular origin. It appears in early infancy and is associated with cutaneous hemangiomas in 45% of cases. Despite its benign behavior, life-threatening complications (heart failure, intraperitoneal hemorrhage or thrombocytopenia) make early diagnosis imperative. We presentat the imaging findings that established the diagnosis and describe the course of children with IH.

Methods: 4 infants with IH before, during and after treatment. 2–5, 5–8 MHz convex and 5–12 MHz linear transducers were used. CT and MRI images were taken before and after IV contrast and gadolinium administration repectively.

Results: 4 children with hepatomegaly were examined. Cutaneous hemangiomas coexisted in 3 of the 4 cases. Diagnosis of IH was based on the imaging findings and no biopsy was ever performed. Specifically, 2 newborns, 2 and 28 days old respectively, appeared with hepatomegaly and multiple round lesions with mixed echo pattern in both liver lobes in ultrasound. CT was performed in the first case and IH was diagnosed. In the second case, typical sonographic appearance combined with clinical findings established the diagnosis. Steroid and interferon-a therapy were administered and sonographic follow-up showed rapid response. 2 more infants, 45 days and 3 months old, underwent sonography and MRI where IH was diagnosed. Spontaneous regression and total recovery after a 4-month steroid therapy course was observed, respectively.

Conclusion: Imaging studies provide diagnosis as well as assessment of treatment effectiveness and follow-up in infantile hemangioendothelioma.

269

DOES THE PSYCHOLOGICAL REQUEST OF THE PATIENT JUSTIFY THE SURGERY FOR HEPATIC HEMANGIOMA?

Di Carlo I, Russello D, Puleo S, Latteri F

Department of Surgery, University of Catania, Catania, Italy

Aim: The surgical approach to liver hemangioma is debated, due to the increasing numbers of hemangioma of the liver recognized during ultrasound scans (US), frequently performed for other abdominal signs. The aim of this work was to establish if the psychological request for surgery from patients known to have a benign tumour of the liver must be avoided or not.

Methods: Age, sex, symptoms, methods of diagnosis, surgical procedure, morbidity, mortality and follow-up of the patients affected by liver hemangioma observed in our department from 1995 to 2002 were analysed.

Results: From January 1995 to October 2002, 8 patients were submitted to surgery for hepatic hemangioma. They were 2 males and 6 females, ages ranged from 26 to 72 years (mean 44). Diagnosis was performed with US and CT scan in all cases, only 1 patient required MRI. Symptoms presented by the patients were various but the most frequent was right hypochondrium pain, except 1 patient operated for bleeding. In 6 patients there was right indication for surgery. 2 patients without indication requested surgery for psychological implications concerning the anxiety of having a benign tumor of the liver. 5 patients underwent ‘enucleation’ and 3 patients underwent surgical resection. No morbidity and no mortality were recorded. The last 2 patients respectively after 2 and 3 years of follow-up remain with their abdominal non-specific symptoms. The other 6 patients were definitively cured.

Conclusions: Our results suggest that liver hemangiomas should be operated for right indications; compression on near organs, Kasaback-Merrit syndrome and rapid increase. Psychological requests from the patients should be even avoided.

270

ORIGINAL SUPERNATANT IN TREATMENT OF INTRAHEPATIC CHOLANGIOCARCINOMA

Galperine E, Dyuzheva T, Platonova L, Shono N, Ionochkina N

Moscow Sechenov Medical Academy, Moscow, Russia

Aim: To study the anticancer activity of supernatant derived from human and pig small bowel mucosa.

Methods: Liver tumor (cholangiocarcinoma, MC-1) was induced in 93 unbred rats by intraparenchymal injection of 0.1 ml of 20% tumor suspension. Treatment began on the 12th day after tumor implantation. In group 1 (n=28) the supernatant was injected intraperitoneally (D280 protein concentration was 30 opt.U/ml, 210 opt.U per 7-day course). In group 2 (n=23) supernatant (18 opt.U per course) was injected in the lobar portal vein branch by selective-occlusive method. In control groups (n=22 and n=22) saline was injected in the same mode. Tumor volume (TV) and morphology were evaluated on day 6.

Results: Stabilization or slow tumor growth were marked in group 1 (in 23 of 28 rats vs 9 of 22 control 2 test significance p = 0.019). There were no differences in TV and rats apoptosis rate after intraperitoneal injection of supernatant derived from pig and human small bowel mucosa. In group 2 TV and apoptosis rate were significantly smaller compared with the control (p < 0.001), also the mitosis number decreased. No changes in normal organs and tissues were revealed.

Conclusion: Supernatant derived from small bowel mucosa slows down the growth of intrahepatic cholangiocarcinoma in rats and increases the apoptosis rate. Selective-occlusive technique comparing with intraperitoneal injections allows obtaining an effect after the only injection, decreasing (to 11 times) the drug dose and reducing mitosis rate.

271

HEPATOCARCINOMA CHOLECYSTOLITHIASIS AND GALLBLADDER CARCINOMA: A RARE INCIDENTAL ASSOCIATION

La Greca G, Barbagallo F, Rodolico M, Fasone M, Basile A, Rapisarda V, Rapisarda D, Scuderi M

Department of Surgical Sciences, Transplantation and Advanced Technology, University of Catania, Catania, Italy

We report a rare case of a patient operated with a diagnosis of hepatic tumor and gallbladder lithiasis which after the operation was shown to be a hepatocarcinoma (HCC) associated with gallbladder carcinoma. The female, 76-year-old, diabetic patient was admitted because of increasing recurrent epigastric pain with postprandial eructation. The spiral CT demonstrated a hepatic mass (∅︀7 cm) at the IV segment, compatible with HCC and without satellite lesions. Moreover it showed multiple calcific images inside the gallbladder referable to lithiasis. During the intraoperative observation the liver appeared cirrhotic with micronodular aspect. Cholecystectomy was performed and thereafter a wedge resection of segment IV without vascular exclusion was performed, obtaining 15 mm microscopically free resection margins. The definitive histopathological examination demonstrated a well differentiated hepatocarcinoma G2 and surprisingly an adenocarcinoma of the gallbladder limited to the mucosa. The case is relevant in our opinion because the association of HCC with adenocarcinoma is rarely reported in the literature and also suggests that cholecystectomy should be routinely performed during liver resection in patients with HCC because a successive cholecystectomy can be more difficult and also because the prognosis of gallbladder carcinoma is often very poor.

272

SURGICAL APPROACH FOR PATIENTS WITH MALIGNANT LIVER TUMORS

Stratopoulos Ch, Moustafellos P, Gourgiotis S, Anastasiou T, Hadjiyannakis EJ

1st Surgical Dept and Transplant Unit, Athens Medical Center Evangelismos Hospital, Athens, Greece

Aims: To present the results of hepatectomies performed for malignant liver tumors in Child class A patients without portal hypertension.

Methods: During the last 30 years (Athens Medical Center, Evangelismos Hospital, Tzanio hospital and Laikon Hospital), 479 patients with malignant liver tumors were treated. Median age was 60.4 years. Most patients were male (63%).

Results: 476 patients were operated upon electively and 3 under emergency conditions (due to rupture of the tumor). In 272 cases the tumor was found to be inoperable. For the remaining 207 patients, who were operated, we performed: right hepatectomy in 40 cases, right extended hepatectomy in 47 cases, left lateral lobectomy in 39 cases, left hepatectomy in 21 cases, segmentectomy in 57 cases and liver transplantation in 3 cases. The mean hospitalization time was 19.1 days. Perioperative mortality and morbidity rates were 0% and 19.8%, respectively. Postoperative jaundice occurred in 13 patients, hydrothorax in 12 patients, ascites in 9 patients, cholorrhea in 6 patients and liver failure in 1 patient. 1-year, 3-year and 5-year survival rates were 91%, 72% and 53%, respectively. The longest survival concerned a patient who was operated 27 years ago. Most of the tumors were hepatocellular carcinomas (143 cases).

Conclusion: Hepatectomy is a safe procedure and improves survival rate of patients with malignant liver tumors, when specific criteria and safety measures are considered and maintained.

273

THE ROLE OF THE EXTRACELLULAR MATRIX IN THE INVASIVENESS OF HEPATOCELLULAR CARCINOMA

Abou-Shady M

General Surgery Department, Faculty of Medicine, Um Al-Qura University, Makkah, Saudi Arabia

Aim: The aim of this study was to analyse the role of extracellular matrix (collagen type 1) and factors controlling its production; transforming growth factor-beta 1 (TGF-β1), its receptors TβR-I and TβR-II, and connective tissue growth factor (CTGF) in two distinct types (invading and expanding) of human hepatocellular carcinoma (HCC). Extracellular matrix is important for the tumor cells to move, migrate into other tissue compartments and developing metastasis. TGF-β1 may play a pathogenic role for these growth patterns by modulating cell proliferation, invasion and stroma formation, while CTGF has a role in modulating the extracellular matrix that can affect tumor cell motility.

Patients: HCC tissue samples were obtained from 10 patients undergoing partial liver resection. 6 were expanding and 4 were invading HCC. Normal liver tissues from 10 patients (4 organ donors, 6 liver resections for colorectal cancer metastases) served as controls. Methods: Northern blot analysis was done using specific cRNA or cDNA probes. The mRNA expression of TGF-β1, TβR-I and TβR-II, collagen type 1, and CTGF was analysed. In addition, cellular localization of TGF-β, TβR-I and TpR-II was assessed by immunohistochemistry using specific antibodies.

Results: TGF-β1 was markedly overexpressed in HCC in comparison with controls, and invading tumors demonstrated significantly higher mRNA levels than expanding tumors. The TGF-β receptors type I and type II were less expressed in HCC in comparison with controls. Collagen and CTGF showed also higher mRNA expression in invading HCC. By immunohistochemistry, marked TGF-β1 immunostaining was found in HCC, more intense in the invading than in the expanding type. Mild immunostaining was present in the normal controls. For TGF-β receptors types I and II, immunoreactivity in both types of HCC was mild to moderate only, less than the controls.

Conclusion: These findings suggest that differential expression of TGF-β1 and its receptors, and the higher expression of collagen and CTGF in the invading phenotype may have an important role in the pathogenesis of the distinct growth patterns characterizing invading vs expanding HCC through their effect on modulating the extracellular matrix.

274

HEPATIC HEMANGIOMAS – WHY OPERATE?

Baghai M, Farnell MB, Que FG, Donohue JH, Nairn M, Nagorney

DM Mayo Clinic, Rochester, USA

Background: Hepatic hemangioma is the most common benign tumor of the liver. Complications from hemangiomas are rare and indications for surgical resections remain poorly defined and controversial. The aim of our surgical review on hemangiomas was to define surgical indications and to evaluate our outcome.

Methods: A retrospective chart review was performed. Follow-up was documented in the medical records or by telephone contact. Statistical analysis was carried out using the Chi-square test.

Results: Between January 1983 and May 2001, 185 operative procedures were performed for hepatic hemangiomas. There were 65 men and 130 women with a mean age of 55 (range 23–86) years. 67 of 185 (36%) patients were symptomatic at presentation. Mean hemangioma size in all patients was 7.8 cm. Mean size was greater in symptomatic than in asymptomatic patients (12.5 cm vs 2.9 cm, p<0.01). Of the symptomatic patients, 87% of the hemangiomas were >4 cm in size. In asymptomatic patients, only 18% were >6 cm. Presenting symptoms ranged from pain and pressure, 84%; early satiety, 13%; and <10% fever, malaise, shortness of breath, and anemia. No patients had bleeding, rupture, or Kassalbach-Merritt syndrome. Other indications for operation were hemangioma growth (7%), diagnosis (35%), and incidental finding during another abdominal operation (58%). 80 patients had only a biopsy or were diagnosed based on gross features. There were 33 major hepatic resections (≥3 segments), 45 segmentectomies or subsegmentectomies, 22 enucleations, and 1 orthotopic liver transplantation. Major complications included bile leak, intra-abdominal abscess, or liver failure (5%). Minor complications occurred in 18% of patients. There was 1 death secondary to a pulmonary embolism. 3 asymptomatic contiguous recurrences were recognized at 4 months, 2 years, and 15 years, and two new non-contiguous hemangiomas at 2 and 8 years. Symptoms resolved in 95% of patients.

Conclusions: Hepatic resection or enucleation is justified for symptomatic patients with hepatic hemangiomas. Resolution of symptoms after resection can be expected.

Liver – Infection

(DOI 10.1080/16515320310001093)

275

GIANT LIVER ABSCESS ASSOCIATED WITH GALLBLADDER-DUODENAL FISTULA IN A PATIENT WITH MULTIPLE JEJUNAL DIVERTICULA

Glynatsis M, Stamou MK, Kekis PB, Karatzikos G, Milingos N, Androulakis G

1st Department of Surgery, University of Athens, Hippokrateion Hospital, Athens, Greece

Introduction: Pyogenic bacterial liver abscess is most commonly connected to ascending cholangitis in a biliary tract partially or completely obstructed by stone, tumor, or stricture (35% of cases). We present a case of giant liver abscess associated with bilioenteric fistula in a patient with multiple jejunal diverticula.

Case report: A 71-year-old man presented with a history of fatigue, anorexia and fever with chills of 20 days’ duration. Anti-echinoccocal IgG antibodies were found to be positive. Abdominal ultrasound findings led to a computed tomography scan where a 10×15 cm cystic formation was identified occupying the right liver lobe. Free air was visible in the biliary tree. During his hospitalization, the patient developed acute upper gastrointestinal (GI) bleeding and emergency endoscopy revealed multiple acute ulcers of the stomach and duodenum. He was operated under the diagnosis of ‘complicated hydatid cyst – upper GI bleeding’. Surgical exploration revealed a large pyogenic non-parasitic liver abscess situated in segments V, VI and VII. A bilioenteric fistula involving the gallbladder and the duodenum was discovered along with multiple jejunalileal diverticulas. The abscess was drained and a cholecystectomy was performed with disruption of the bilioenteric communication. A T-tube was used to drain the biliary tree postoperatively. The postoperative course was uneventful and the patient was discharged in 7 days. Upper GI bleeding did not recur. Cultures of the abscess's pus were dominated by Enterococcus faecium.

Conclusion: The case is presented because of the uncommon origin of the septic factor. Percutaneous drainage of liver abscesses is the treatment of choice with operative drainage indicated for cases of identified intra-abdominal focus of infection and in patients in whom percutaneous drainage is not feasible or has failed.

276

MANAGEMENT OF HEPATIC AND GALL BLADDER TUBERCULOSIS

Varshney S, Sharma S, Sewkani A, Pamecha V, Tewari V, Maudar KK Bhopal Memorial Hospital, Bhopal, India

Introduction: Tuberculosis of gallbladder (GTB) is rare, but hepatic tuberculosis (HTB) is not uncommon in tropical countries. Gallbaldder tuberculosis usually presents as chronic calculous or acalculous cholecystitis. Hepatic tuberculosis generally presents as mass lesion or liver abscess. Isolated (primary) tuberculosis of these organs is rarer. There are no clear guidelines regarding management of GTB and HTB.

Methods: We report 5 consecutive cases (2 GTB and 3 HTB) of hepatic and gallbladder tuberculosis, seen over a period of 18 months and discuss their management and outcome.

Results: The first patient with GTB presented as calculous cholecystitis with cholecystoduodenal fistula. She had tuberculosis of lumbar vertebra also. She underwent cholecystectomy and closure of fistula. She had antitubercular drug therapy (ATT) for 9 months. The second case had primary GTB presenting as calculous cholecystitis with thickened contracted gallbladder. She underwent open cholecystectomy. She had ATT for 9 months and is doing well. All the cases of HTB were primary. HTB presented as mass lesion with calculous cholecystitis n=1; recurrent hepatic abscess n=2. They were treated with cholecystectomy n=1; long-term open drainage of hepatic abscess n=1 and resection of involved hepatic segment n=1. All patients had ATT and are well on follow-up. Conclusion: Most cases are diagnosed postoperatively at the histopathological examination. Rarely, acid-fast bacilli (AFB) could be isolated on microscopy or culture or newer tests like DNA probe or PCR are required. There are no typical clinical or radiological features of hepatic or gallbladder tuberculosis. High index of suspicion when concomitant evidence is present should raise the suspicion of tubercular involvement of these organs. We suggest that HTB and GTB should be treated with resection and/or long-term drainage with a full course of ATT.

277

COLON CANCER MAY BE UNDERLYING CAUSE OF PYOGENIC HEPATIC ABSCESS

Yigitbasi R, Erturk S, Aydogan F, Karabicak I

General Surgery Department, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey

In this case we present a patient with a pyogenic liver abscess secondary to right colon cancer. A 41 -year-old male patient was admitted to our hospital with the complaints of right upper quadrant pain and fever existing for 2 weeks and anemia. Physical examination revealed tender hepatomegaly and body temparature of 39°C. Laboratory data also revealed elevated white blood cell count (19,000/mm³) and deep anemia (Htc: 21%). Abdominal US and CT showed a solitary abscess of 6 cm in diameter within the right lobe of the liver, increased cecal wall thickness and retrocecal collection possibly indicating pericolonic abscess. Meanwhile, colonoscopic examination was undertaken due to high index of suspicion of malignancy. Colonoscopy confirmed right colon carcinoma. CEA level was also elevated (27.1 IU). The liver abscess was treated by percutaneous catheter drainage and Streptococcus faecalis and Bacteroides fragilis grew in microbiological analysis of the pus drained. After complete recovery, laparotomy was undertaken. Appendix vermiformis was totally normal in appearance. Mobilization of the right colon revealed retrocecal abscess formation just in vicinity of the right colon tumor. No other source of inflammation was detected. Right hemicolectomy was performed. Postoperative course of the patient was uneventful. Control CT taken 2 months later showed complete recovery. Silent or complicated colonic cancer should also be taken in consideration when a pyogenic liver abscess is encountered.

278

CAN CHLORHEXIDINE-GLUCONATE BE AN IDEAL SCOLICIDAL AGENT IN THE TREATMENT OF INTRA-PERITONEAL HYDATOSIS?

Puryan K, Karadayi K, Topcu O, Sumer Z, Canbay E, Turan M, Karayalcin K

Department of General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey

Aim: Intra-peritoneal hydatosis (IPH) that can occur spontaneously or via traumatic rupture of leakage from the csyt still remains the most important complication of hydatid cyst surgery. In this study, we aimed to investigate the effects of chlorhexidine-gluconate (Chl-Glu), which was proved to be a scolicidal agent in vitro in the treatment of experimental IPH.

Methods: 75 Wistar-albino rats were used for this study. IPH was reproduced in rats by inoculation with 1 ml of a suspension, which contained approximately 1200 viable protoscolex of Echinococcus granulosus. Viability of protoscolex was determined in vitro by light microscopy. Scolicidal effects of Chl-Glu were detected in vitro. The rats were divided into 3 groups (Group I = 0.9% NaCl (n=25); Group II = 4% Chl-Glu (n=25); Group III = 0.4% Chl-Glu (n=25). They were subjected to a median laparotomy for the instillation of 2 ml of the scolicidal solution into the peritoneal cavity. After 6 months of follow-up, the rats were sacrificed and the number of isolated cysts, peri- and postoperative death, toxicity and adhesion formations were evaluated.

Results: Cyst formation did not occur in either 4% or 0.4% Chl-Glu groups compared to control group. Postoperative period of death was found 1 (4%) in group I, 15 (60%) in group II, and 2 (8%) in group III. The differences in the survival rate of the Group I and Group III were much higher than Group II and the results were statistically significant. Conclusion: 0.04% Chl-Glu was found to be the most potent and non-toxic agent used in this study.

279

ACTINOMYCOTIC LIVER ABSCESS

Christodoulou N, Papadakis I, Spiridakis K, Christoforakis Z, Koumendakis E, Velegrakis M

Second Surgical Department, “Venizelion” General Hospital of Iraklion, Crete, Greece

Aim: Actinomycosis is a chronic suppurative and granulomatous disease, which is characterized clinically by extensive necrosis and abscess formation, and histologically by the presence of sulfur granules. Actinomycosis is generally classified as cervicofacial, thoracic and abdominal type. The objective of this study is the presentation of a case of actinomycotic liver abscess that was treated in our department in 1998.

Methods: A male patient, 36 years old, presented with high fever, malaise, anorexia, vomiting after food ingestion and right upper quadrant pain. Leucocytosis with a left shift was present, and ultrasonography demonstrated a mass of a mixed composition in the anterior part of the right hepatic lobe, measuring 6.8×4.6 cm, suggestive of an abscess or hemangioma. MRI scan confirmed the presence of a space-occupying lesion, suggestive of an abscess.

Results: The patient was submitted to surgical drainage of the hepatic abscess. The culture of the purulent material was proven to be sterile, while the histochemical examination of the specimen demonstrated the presence of actinomycosis. The patient had an uneventful postoperative course, and after his discharge he received prolonged chemoprophylaxis.

Conclusions: Actinomycotic liver abscess is a very rare clinical entity, and only 57 cases have been reported in the English literature. Due to the rarity of the disease and the limited reported cases, we considered the presentation of this case to be useful.

Liver – Hydatid Disease

(DOI 10.1080/16515320310001101)

280

RADICAL THERAPY FOR LIVER ECHINOCOCCOSIS

Vishnevski VA, Ikramov RZ, Kaharov MA, Muhiddinov ND, Sergeeva ON

Institute of Surgery, Russian Academy of Medical Sciences, Moscow, Russia

Aim: To evaluate the short-term and long-term results of radical therapy of liver echinococcosis.

Methods: Since 1994, 253 patients with liver echinococcosis have undergone surgical procedures in this institute. 161 (63.6%) were female; the age range was 16–78 years. Multiple lesions were revealed in 72 patients and single cysts in 181 patients. Among the latter the right lobe was affected in 124 cases, the left lobe in 39 and central localization (4-5 segments) was found in 18 patients. The work-up included ultrasound, spiral computer topography, serology and gas chromatography of blood. All patients underwent open operative procedures. The radical procedures were preferred. The conventional procedures included ‘mechanic’ pericystectomy and elimination of fibrous capsula by plasma scalpel. The following procedures were performed: right hemihepatectomy (6), left hemihepatectomy (1), wedge liver resections (14), total pericystectomy (106) and subtotal pericystectomy (88). 38 patients with multiple liver lesions underwent combined procedures.

Results: Operative mortality was 0.79%. In the postoperative period the following complications were observed: liquid in the resection area in 6 (2.37%) patients, suppuration of remaining cavity and abscesses of abdominal cavity in 4 (1.58%), bleeding in 2 (0.79%) and pulmonary complication in 9 (3.6%) patients. Relapses and residual cysts in remote period (observations during 1–7 years) were observed in 2 patients.

Conclusion: Radical procedure including fibrous capsule removial is a method of choice for liver echinococcosis therapy.

281

SURGICAL MANAGEMENT OF HYDATID DISEASE OF THE LIVER

Daskalakis K, Kakavias K, Daskalaki D, Kapiris S, Diamantopoulos G

Evagelismos Hospital, Athens, Greece

Aims: Several surgical techniques have been used for the treatment of hepatic hydatidosis. The technique of choice depends on the number, size, location and complications of the cysts. The aim of this study was to review the advantages and disadvantages of these techniques. Methods: In our department 135 patients with hepatic hydatidosis were operated during the last 17 years (1986–2002). 76 were males and 59 females; age ranged between 17 and 78 years. 104 of them (77%) were operated electively and 31 (23%) urgently: 5 because of suppuration of the cyst, 25 for obstructive jaundice and cholangitis due to rupture of the cyst into the biliary ducts and 1 for rupture into the pleural cavity. We performed 11 total cystopericystectomies, 5 atypical hepatic lobectomies, 99 partial cystectomies plus omentoplasty, 15 partial cystectomies plus capitonnage and 5 external drainage. Common bile duct exploration was done in 53 patients.

Results: There were no deaths and no serious postoperative complications in this series. There were 4 biliary fistulas. Two of them healed spontaneously, 1 was managed with an endoscopic sphincterotomy and 1 with a choledocho-duodenostomy. The mean hospital stay was 17.3 days.

Conclusions: The surgical treatment of hepatic hydatidosis, especially of the complicated cases, is sometimes a serious problem which needs urgent management. Partial cystectomy and omentoplasty is the procedure that is applicable in the majority of patients with excellent results.

282

EVALUATION OF TUBE DRAINAGE METHOD IN THE TREATMENT OF HYDATID CYST OF LIVER

Arikan S, Kocakusak A, Daduk Y, Yucel A F, Gulen M, Akinci M, Sunar H, Halas F

Department of General Surgery, Haseki Education and Research Hospital, Istanbul, Turkey

Aim: It has been reported that surgical methods such as marsupialization and tube drainage were unfavourable due to their possible complications in surgical treatment of hydatid cyst in liver. We aimed to compare the tube drainage technique with other surgical modalities.

Methods: 72 patients who underwent surgical treatment due to hydatid cyst of liver in this hospital between 2000 and 2003 constituted our study group. The mean age of patients was 42±17 years, 31 were male and 41 female. Tube drainage was applied to 32 patients, whereas the remaining 40 patients were treated by other surgical methods such as omentoplasty, total cystectomy, intraflexion, capitonnage. These two groups of patients were compared with each other according to their postoperative hospitalization time and resulting complications.

Results: The complication rate was 28.1% in patients who underwent tube drainage. Their mean postoperative hospitalization time was 7.3±3.19 days. The complication rate was 17.5% in patients who underwent any kind of surgery other than tube drainage. Their mean postoperative hospitalization time was 7.4±4.5 days. No statistical significant difference was found in the comparison of these two groups concerning both the postoperative hospitalization time and the rate of complications (p > 0.05).

Conclusion: The method of tube drainage is a safe surgical modality in the treatment of hydatid cyst disease of liver if applied properly in appropiate patients according to the data we obtained.

283

SURGICAL TREATMENT OF HEPATIC ECHINOCOCCOSIS

Dervisoglou Ath, Giannakakis P, Mattheou A, Kiriazis C, Maniati P, Pinis S

2nd Department of Surgery, General State Hospital of Pireus, Pireus, Greece

Aim: Hepatic echinococcosis has a high morbidity rate in Greece. The ailment affects 9.77 in 100,000 Greek patients annually. In this study we present our experience from the surgical treatment of hepatic echinococcosis.

Methods: In the period 1992–2002 we treated 47 patients (26 male and 21 female), mean age 47.3 and 43.8 years old, respectively, affected by hepatic echinococcosis. 16 patients suffered from solitary hepatic localization (34.04%), while 31 patients (65.96%) suffered from multiple hepatic localizations. The hydative cyst was located in the right lobe in 33 patients (70.21%), in the left lobe in 9 patients (19.15%) and in both lobes in 5 patients (10.64%). 5 of these patients had been treated previously and were on recurrence. 4 patients (8.51%) were treated with non-typical hepatectomy, 21 (44.68%) with partial cystectomy and drainage and 22 (46.81%) with omentoplasty. Surgery to treat hepatic echinococcosis was followed by cholecystectomy in all cases. Due to cystic rupture in the hepatic ducts, 5 patients were fitted with a Kehr's-type tube and 3 underwent billiary-jejunal anastomosis. Postoperative complications included atelectasis in 12 patients (25.53%), urinary infection in 3 patients (6.38%), trauma suppuration in 2 patients (4.26) and sustained bile draining in 18 patients (38.3%). Mortality rate was zero. Mean hospitalization time amounted to 19.7 days.

Conclusions: Hepatic echinococcosis is a grave form of parasitism that cannot be easily treated with surgery due to the parasite's great invasive ability, which explains the extended hospitalization and the increased morbidity rate.

Liver – Miscellaneous

(DOI 10.1080/16515320310001110)

284

SURGICAL MODEL OF FULMINANT HEPATIC FAILURE IN MINIPIG

Pantoflicek T, Ryska M, Ryska O, Lipar K, Zazula R, Kieslichova E

Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic

Background: The management of fulminant hepatic failure (FHF) remains a challenge. The mortality of FHF is very high despite considerable progress in intensive care treatment. Techniques that could provide a time for the liver to regenerate (bioartificial liver support systems) have yet to be tested and optimized. It is considered useful to produce an animal model of fulminant hepatic failure with well defined clinical and biochemical criteria to allow more precise testing of bioartificial devices.

Methods: Group A: we produced a devascularized model (portocaval anastomosis – PCA and hepatic artery ligation – HAL) of fulminant hepatic failure in 10 minipigs. Group B: we performed a sham operation (laparotomy) in a control group of 10 minipigs.

Results: Confirmation of liver failure was by collecting of blood analytes and clinical parameters in the 3rd, 6th, 9th and 12th hour of experiment. Confirmation of coma was by monitoring of ammonia levels. Group A: the mean survival time was 13 h with increasing AST, ALT, prothrombin time, ammonia levels. Group B: normal values of AST, ALT, prothrombin time and ammonia during the experiment.

Conclusion: We have produced a devascularized model of FHF leading to death in a one-stage procedure – PCA, HAL. This model is good, and reproducible, with a suitable therapeutic window.

285

THE ROLE OF AMRINONE, A PHOSPHODIESTERASE INHIBITOR, IN AN EXPERIMENTAL LIVER ISCHEMIA-REPERFUSION MODEL

Kucuk C, Baskol M, Akgun M, Yazici C, Muhtaroglu S

Department Of General Surgery of Erciyes University Faculty of Medicine, Kayseri, Turkey

Aim: To assess the effect of amrinone, a phosphodiesterase inhibitor, on liver ischemia-reperfusion injury in rats.

Methods: 60 Wistar-Albino rats weighing between 200 and 250 g were used in the study. Rats were divided into 3 groups as sham, control and amrinone. After catheterization of the jugular veins of the rats, a loading dose of 2 mg/kg amrinone was administered to each rat of the g/kg/minute. Amrinone infusion was amrinone group, followed by an infusion of 10 applied for a 3-h period; 1 h ischemia and 2 h reperfusion. The rats in the sham and control groups received normal saline infusion for the same periods. Liver ischemia was induced in the amrinone and control groups for a period of 60 min. The rats in the sham group underwent exploration of the hepatoduodenal ligament only. 10 rats from each group were sacrificed 2 h and 5 days after reperfusion and blood and tissue samples were obtained. Survival rates of the the rats were evaluated. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactic dehydrogenase (LDH) were measured in the blood samples. Liver adenosine triphosphate (ATP) levels were determined and the organs were histopathologically examined.

Results: Serum AST, ALT, LDH levels and histological damage scores in the amrinone and control groups were statistically significantly higher than sham group (p<0.01). However, all these values were statistically significantly lower in the amrinone group than in the control group (p < 0.05). Liver ATP levels and rat survival rate in the amrinone and control groups were statistically significantly lower than sham group (p < 0.01). However, these values were statistically significantly higher in the amrinone group compared to control group (p < 0.01).

Conclusion: It can be concluded that amrinone, an inhibitor of phospodiesterase, may protect the liver against tissue ischemia-reperfusion damage.

286

DISTRIBUTIONS OF eNOS AND iNOS IMMUNOREACTIVITIES IN PORTAL VEIN LIGATED RAT LIVER TREATED WITH EITHER PROPRANOLOL OR OCTREOTIDE

Ozer I, Yamac E, Vatansever S, Giray G, Aydede H, Sakarya A

Celal Bayar University, Manisa, Turkey

Chronic portal hypertension is accompanied by a nitric oxide (NO)-dependent vasodilation. NO, which is synthesized enzymatically by NO synthases (NOS), is a powerful inhibitor of platelet aggregation and a potent vasodilator. 3 isoforms of NO producing synthases (NOS) are characterized; neuronal NOS (nNOS), endothelial NOS (eNOS) and inducible NOS (iNOS). The present study was undertaken to evaluate the possible interaction between endothelium and non-endothelium-derived vasodilators after 2-week octreotide and propranolol administration (2 microg/kg and 2.5 mg/kg respectively) in portal vein ligated (PVL) rats liver. We divided rats into 4 groups: (1) sham operated rats, (2) untreated control rats, (3) octreotide-treated rats and (4) propranolol-treated rats. Liver tissues from all groups were stained with primary antibodies against eNOS or iNOS using indirect biotin-streptavidine-peroxidase immunohistochemical technique. Immunoreactivities of eNOS and iNOS were detected in hepatic portal veins, but not in hepatocytes of the sham group. However, strong immunoreactivities of eNOS and iNOS were observed in hepatic portal vein and hepatocytes in untreated control group. Additionally, distribution of eNOS and iNOS were seen in both portal vein and hepatocytes in the propranolol-treated group; however, intensity of eNOS and iNOS immunoreactivity were stronger than in the octreotide-treated group but not stronger than in the untreated group. This unmarkable production in treatment groups may contribute to changes of systemic hemodynamics in PVL rats sourced from another tissues.

287

WATER JET DISSECTOR FOR LIVER SURGERY

Bagmet NN, Skipenko OG, Zavenyan ZS

Department of Liver, Bile Ducts and Pancreatic Surgery, Russian National Research Center of Surgery, Moscow, Russia

Aims: Evaluation of water-jet dissector (Helix Hydro-Jet, Andreas Pein Medizintechnik, Germany) efficacy for liver dissection.

Methods: The comparative efficacy of water-jet dissection for liver surgery was investigated by in vivo experiment in young pigs (10 pigs average 30 kg: water-jet group – 7, tissue fracture technique (control) group – 3; left medial lobe was resected). A prospective clinical study with 15 patients followed the experiment.

Results. The water-jet was easy to handle. By experiment the mean blood loss in water-jet group was less than in control (3.3 vs 5.2 ml/cm ). There were no significant differences concerning operation time and blood loss. In the water-jet group good hemostasis was achieved in a shorter time (5 vs 12 min) and with usage of less suture material. 15 patients (median age 45 years) with different liver lesions underwent left or right hepatectomy (14) and hepatojejunostomy (1) using the Hydro-Jet. Operation time was 390 min (150–680 min), total intraoperative blood loss was 970 ml (300–3200 ml), blood loss during parenchyma dissection 560 ml (150–1500 ml), hemotransfusion 651 ml (0–2595 ml), final hemostasis was achieved within 30 min (17–75 min) using coagulation, ligation and applications of hemostatic agent TachoComb (5 patients). No serious complications attributable to the use of the water-jet dissector in the experimental and clinical study were encountered.

Conclusion: The mechanical simplicity and safety of the water-jet method, and perfect control of the operative field will lead to more widespread use in liver surgery. The preliminary results suggest that blood loss and usage of suture material may be diminished.

288

NON-PARASITIC CYSTS OF THE LIVER

Economou N, Alexiou C, Siaperas P, Tsimpoukidi O, Sahin I, Karanikas I, Antsaklis G

Department of Surgery, Sismanoglion General Hospital, Athens, Greece

Aim: To present our experience in the treatment of non-parasitic liver cysts.

Methods: In the period between 1995 and 2002, 11 patients (5 males and 6 females) with mean age 55 years old, were treated in our department. These patients had solitary non-parasitic cysts, mainly found in the right lobe of the liver (70%). The majority of patients (10) complained of atypical symptoms from the right upper quadrant, fullness or dyspepsia. One of the patients was admitted with fever, due to abscess in the right hepatic lobe, probably due to contamination of preexisting solitary liver cyst. The patients were diagnosed either preoperatively by U/S, MRI or by CT scanning, which was performed in order to identify other probable or preexisting causes or intraoperatively during laparotomy. In all patients a partial roof fenestration of the cyst was done, followed by placement of a drainage tube in the cystic cavity, and the traumatic boundaries of the cyst. The content of the cyst was sent for cytological and histological evaluation.

Results: No complication occurred. Median hospital stay was 8 days. Follow-up of the patients, which was continued by CT scanning for a period of 6–12 months after surgery, showed no recurrences.

Conclusions: Solitary non-parasitic cysts of the liver account in 2–4% of the population and mainly are an accidental finding during check-up of the upper abdomen, (a) Simple drainage of the cyst is not therapeutic, (b) Surgery is the treatment of choice, (c) Laparoscopic surgery requires proper surgical expertise as well as further clinical experience in order to evaluate the results. Complications, especially contamination of the cyst, require broad-spectrum antibiotics and surgical drainage, as well as recognition of the responsible septic site and cause.

289

A CASE OF BENIGN SPLENIC EPITHELIAL CYST ACCOMPANIED BY ELEVATED CA19-9 LEVEL

Yigitbasi R, Erturk S, Aydogan F, Karabicak I

General Surgery Department, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey

True non-parasitic splenic cysts are very rare. Only 10 cases of benign true splenic cysts, with a high CA 19-9 serum level, have ever been published in the medical literature. In this case we present an epithelial cyst of the spleen associated with high CA 19-9 serum level. A 30-year-old female patient with left upper abdominal and left shoulder pain and left upper quadrant mass was admitted to our hospital. On examination, a palpable mass was found at the left upper quadrant. Laboratory data was normal except high CA 19-9 (268 U/ml) serum level. Serology for hydatid disease was negative. Abdominal computed tomography (CT) revealed a splenic cyst and no other intra-abdominal malignancy. The patient underwent laparotomy revealing a centrally located huge splenic cyst. Splenectomy was performed. CA 19-9 serum level returned to normal level within 2 months. The histological diagnosis was an epithelial splenic cyst. High CA 19-9 levels may accompany benign splenic cysts provided that any malign source is excluded. As seen in our case, elevated CA 19-9 serum level returns to normal level after surgery.

290

ERYTHROPOIETIN USE IN LIVER RESECTION

Severtsev A, Mischerkova T, Volodin D, Pfaf V, Aleksandrov V, Remizov M, Leonenko I, Melnikov G

Surgery Department, MPS – Central Clinical Hospital, Moscow, Russia

Background: One of the most important problems of liver resection is the bleeding (intra-operative and postoperative). The use of allogenic blood transfusion (because of the large volume of bleeding) could not solve this problem (infection transmission, liver insufficiency, donor absence, etc.). There are many perioperative methods to save blood. One of these methods is the use of recombinant erythropoietin. The purpose of this study was the assessment of the use of erithropoietin for liver surgery.

Methods: From December 1994 till May 2001, 135 patients with liver tumors were surgically treated (resections) at this hospital. Of these patients, 32 had major liver resections (trisectorectomies and lobectomies). In last 10 resections (main group) we used erythropoieitin (‘Eprex’; dosage 10,000 IU) during the perioperative period. The mean age of the main group was 63±5 years old and the control group (22 patients, no erythropoietin) – 66±7 years old. The male/female ratio was 5/5 and 9/13 respectively. The criteria of comparison between groups were: (1) the volume of intraoperative bleeding; (2) the volume of postoperative bleeding; (3) Hb and Ht after surgery; (4) the need for allogenic blood transfusions; (5) the duration of stay at the hospital after surgery.

Results: All criteria of assessment for criteria 1, 2, 3 were practically identical and NS. The need for allogenic blood transfusions was 2.5±1.5 units for the control group and 0.3±0.07 for the control group (NS). The duration of stay at the hospital after surgery was 7.3±5 days for the main group and 12±10 days for control (NS). The general number of postoperative complications (pulmonary, septic complications, bleedings, etc.) was 2.5 times more for the control group (p < 0.005). Long-term (up to 5 years) investigations found 1 case of development of hepatitis C in the control group after surgery.

Conclusion: The use of erythropoietie during the perioperative period (liver surgery) is an acceptable method of improvement of results for this type of surgery.

291

THE USE OF OCTREOTIDE FOR THE TREATMENT OF CHRONIC ABDOMINAL PAIN AFTER LIVER RESECTION

Severtsev A, Mischejakova T, Volodin D, Pfaf V, Aleksandrov V, Remizov M, Leonenko I, Melnikov G

Surgery Department, MPS – Central Clinical Hospital, Moscow, Russia

Background: One of the causes of the chronic abdominal pain after abdominal surgery is the development of abdominal adhesions. There are some publications about the prevention and treatment role of octreotide in case of the development of abdominal adhesions. According to various data liver resection is the ideal clinical model which gives the maximal development of abdominal adhesions. The purpose of this clinical study was to assess the use of octreotide for abdominal adhesion prevention and the treatment of chronic abdominal pain.

Methods: From December 1994 until May 2001, 135 patients with liver tumors were surgically treated (resections) at this hospital. There were the main (31) and the control (44) groups, which were compared for the use of octreotide. The mean age of patients in the groups was 57±9 and 55±14 years and the male/female ratio was 14/17 and 17/27, respectively. The mean octreotide (‘Sandostatin’) dose was 0.1 mg per day subcutaneously 3 days before surgery and 14 days after. The criteria for octreotide effectiveness were the absence of intestine obstruction and no need for postoperative laparotomy, the presence of chronic abdominal pain (1 month after surgery) which demands the use of non-opioid analgesics.

Results: All general criteria were the same for both groups. Adhesive intestinal obstruction developed in 7 patients in the control group and in no patients in the main group. Laparotomy was used in 5 patients. Postoperative pain developed in 14 patients in the control group and 1 in the main.

Conclusion: Octreotide could be used for the treatment and prevention of abdominal adhesion formation after liver resections and the subsequent treatment of chronic abdominal pain after such surgery.

292

A STUDY OF 51 PATIENTS WHO WERE TRANSFERRED WITH RUPTURED ESOPHAGEAL VARICES TO OUR EMERGENCY MEDICAL CENTER

Takahashi H, Suga H, Abe M, Soga Y, Nakagawa T

Department of Emergency Medicine, Dokkyo Women's Medical University Daini Hospital, Tokyo, Japan

Subjects: The patient group consisted of 51 patients with ruptured esophageal varices who visited our center with the chief complaint of hematemesis during the above-described period. The control group consisted of 60 patients with esophageal varices who were newly admitted to the Divisions of Gastroenterology and Gastrointestinal Surgery of our hospital because of the introduction of EST during that period.

Results: In the control group, hepatopathy was caused by hepatitis C in 40 patients (67%), i.e. the majority, and by non-B non-C hepatitis in 6 patients (10%). In the patient group, non-B non-C type hepatitis was the more frequent cause of hepatopathy, i.e. in 20 patients (40%), as compared with hepatitis C in 17 patients (34%). Thus, there was a difference in the causes of hepatopathy between the control group and the patient group. A thorough analysis revealed that all those patients with non-B non-C hepatitis who developed hepatopathy were also alcoholics.

Conclusions: The proportion of patients with ruptured esophageal varices in whom the hepatopathy was caused by alcoholic hepatitis was significantly high. One possible reason for this is that these patients often have scant knowledge regarding their disease condition, and often the medical care provider also does not provide adequate explanation about the disease process.

Acute Pancreatitis

(DOI 10.1080/16515320310001129)

293

EXPERIMENTAL ACUTE PANCREATITIS MODEL FOR CONTRAST MATERIAL EFFECT

Oksuzler M, Goktay Y, Coker A,Unek T, Sagol O, Ulukus C, Coker C

General Surgery Department, Dokuz Eylul University, Izmir, Turkey

Contrast-enhanced CT scan is still the ‘gold standard’ for detecting necrosis in acute pancreatitis. In the literature, there are some conflicting results regarding contrast material in acute pancreatitis. Some authors claim that contrast material worsens acute pancreatitis and others do not. In this study we tried to explain dose-dependent effects of contrast material on acute pancreatitis. 42 Wistar rats (average weight 250 g) were used in this study and divided into 6 groups. Rats were fasted for 6–8 h and 100 mcg cerulein was injected intra-abdominally. 12 h later than this injection non-ionic contrast material or physiologic serum was injected intravenously. While rats in Groups 1 and 3 received only physiologic serum, those in Groups 2, 4, 5 and 6 received contrast material in doses of 2 ml/kg, 1 ml/kg, 1.5 ml/kg and 2 ml/kg, respectively. 12 h later, all animals were anesthetized by ether and peripheral blood and pancreatic tissue specimens were taken. IL-6, endothelin-1 and amylase levels were determined in blood. In tissue specimens, interstitial inflammation, peripancreatic necrosis and acinar cell necrosis and vacuolization were recorded numerically. Statistical analyses were performed by SPSS statistical package for PC. Mean serum amylase levels in Groups 1–6 respectively were (IU/ml) 139.28, 125.57, 1500.28, 2050.57, 1885.28 and 2031.14. Groups 3–6 were pancreatitis groups and the results were statistically different from those in Groups 1 and 2. Mean IL-6 levels (pg/ ml) in Groups 1–6 in same manner were: 44, 78, 81.14, 100, 78 and 181. Groups 5 and 6 were statistically different from others. Similarly, mean serum endothelin 1 levels were (pg/ml): 16.21, 24, 7, 6.6, 3.4 and 5.5. Results for Groups 4, 5 and 6 were statistically different from others. Interstitial inflammation rate, acinar cell vacuolization and necrosis rates were statistically different in Groups 5 and 6 from others in all groups. We conclude that contrast material does have any harmful effect on pancreatic tissue in doses of 1 ml/kg but in doses of 1.5 and 2 ml/kg, acute pancreatitis has been affected inversely.

294

POST-TRAUMATIC PANCREATATIS AND FORMATION OF PANCREATIC PSEUDOCYST AFTER BLUNT ABDOMINAL TRAUMA

Kokkinakis Th, Michalakis M, Katsougris N, Manousakis E, Triantafyllis S, Kokkinos I, Papadakis Th, Vakonakis N, Kandylakis S

1st Department of General Surgery, “Venizelio-Pananio” General Hospital, Heraklion, Crete, Greece

Background: Isolated injuries of the pancreas after blunt abdominal trauma are rare, even more rare is the formation of a post-traumatic pancreatic pseudocyst in the immediate period following the trauma. The case of a 22-year-old female patient who developed a pancreatic pseudocyst after a blunt abdominal trauma due to a vehicle accident is presented.

Case Report: A 22-year-old female presented in the ER after a vehicle accident with the symptoms of acute abdomen. The preoperative assessment revealed the presence of free fluid in the peritoneal cavity. During the operation hemoperitoneum was observed without any gross intra-abdominal hemorrhage. The patient was hospitalized for 6 days and was discharged in a good general condition. The next day the patient was readmitted with acute mid-epigastrial pain. During the imaging investigation a pseudocyst of 5 cm in diameter was recognized on the tail of the pancreas by computed tomography. The general condition of the patient had improved and it was decided to follow her up as an outpatient with imaging studies.

Conclusion: Usually injury of the pancreas occurs during penetrating abdominal trauma rather than blunt abdominal trauma. The diagnosis of the injury of the pancreas after blunt abdominal trauma demands diagnostic acuity by the physician, as the imaging studies do not determine the extent of the damage, especially during the early post-traumatic period. The management and treatment are dependent on the clinical symptoms and findings, it is separated in conservative management and various surgical or draining techniques.

295

NECROSECTOMY, LAVAGE AND ON-DEMAND RE-LAPARATOMY FOR SEVERE PANCREATITIS. SINGLE CENTER EXPERIENCE

Coker A, Astarcioglu H, Koskderelioglu M, Olguner C, Karademir S, Astarcioglu I

Dokuz Eylul University Medical School, Department of General Surgery, Izmir, Turkey

In this study 25 consecutive cases treated and followed in this hospital between 1999 and 2002 were evaluated prospectively and the role of necrosectomy + lavage + on-demand re-laparatomy was determined. Clinical data, Ranson's prognostic criteria, Mannheim Peritonitis Index (MPI), body mass index (BMI), CT scan findings and abdominal fluid cytology were evaluated. 24 patients underwent necrosectomy + lavage and on demand re-laparotomy. All patients had applied postoperative continuous abdominal lavage. The patients’ age was 59.24 and mean Ranson score was 6.56. Male/female ratio was 1. Mean BMI was 25.12 ±4.64, and MPI was 23.41±1.66. Mean Apache II score was 12.23±2.52. 3 patients underwent ERCP + ES (12%) at admission before surgery. Detection rate of necrosis for CT scan was 100% and false-negative results were 50%. Patients received artificial nutrition support for an average of 10.59 days. Somatostatin was never used in these patients. Antibotic regimen consisted of carbapenem and ornidazole combination along with antifungal agents. 6 patients also received aminoglycosides. Mean re-laparotomy frequency for 24 patients was 2.7. Nine patients (36%) died because of multiple organ failure postoperatively. The abdominal wall was repaired by biomaterial in all patients at final operation. Microorganisms obtained from abdominal necrosis material were E. coli, P. aeruginosa and Acinetobacter spp. Myceles were observed in 14 patients. We concluded that the only chance for patients with severe acute pancreatitis was close physical examination and observation of deterioration in the clinical situation.

296

A SINGLE CENTER EXPERIENCE IN ACUTE PANCREATITIS: RANDOMIZED PROSPECTIVE STUDY

Coker A, Astarcioglu H, Topalak O, Ozkardesler S, Koskderelioglu M, Karademir S, Astarcioglu I

Dokuz Eylul University Medical School, Department of General Surgery, Izmir, Turkey

In this study, patients with acute pancreatitis had been prospectively treated according to determined multidisciplinary approach at this hospital. Ranson and APACHE II criteria, and body mass index (BMI) at admission, and contrast-enhanced CT scan and abdominal ultrasonography were obtained for all patients. Patients were classified according to the Atlanta classification. While ERCP±ES was performed in the first 72 h in severe cases, patients with mild pancreatitis underwent the same procedure at the same hospitalization. Surgical treatment modality was necrosectomy + continuous abdominal lavage + on-demand re-laparotomy in severe cases. 80 mild (76.1%) and 25 severe (23.9%) pancreatitis were tested and followed-up between 1999 and 2002. While etiological factors in mild cases were biliary stones (76.25%, n=61), drug induction (2.5%, n=2) and miscellaneous (21.25%, n=17), in severe groups those were biliary stones (80%, n=20) and other causes (20%, n = 3) like trauma and alcohol abuse. USG detected all biliary pancreatitis in the mild group. This ratio was 25% in the severe group. In the severe group 4 patients underwent ERCP + ES (16%) in the first 72 h, but in the mild group 71.25% of patients (n=57) had the same procedure. Necrosis detection rate and false-negative results for CT scan in all cases were 100% and 50%, respectively. 60 patients with mild pancreatitis (75%) underwent laparoscopic cholecystectomy (LC) in the same hospitalization. In the severe pancreatitis group, all patients but one received surgical treatment. While the mortality rate was 36% (n=9) in the severe group, there was no mortality in the mild group. Conversion rate to open surgery in LC was 5% (n = 3). In the mild group 32 patients received antibiotic treatment (40%), all patients received antimicrobial treatment in the severe group. Somatostatin was never used in these patients. NG decompression was introduced to 9 patients in the mild group (11.25%) and parenteral nutrition was given for an average of 2.5 days. In the severe group these values were 100% and 11.5 days. In conclusion, while ERCP±ES is a good choice for mild acute pancreatitis and ERCP does not cause any morbidity, necrosectomy + lavage + on-demand re-laparatomy can be safely used. Clinical evaluation is more helpful for detection of necrosis than any other diagnostic tools. Antimicrobial treatment and NG decompression have a limited role in mild pancreatitis.

297

THE ROLE OF OCTREOTIDE IN PREVENTING POST-ERCP PANCREATITIS FOR ACUTE BILIARY PANCREATITIS

Pavars M, Gvaramadze A, Gardovskis J

Department of General Surgery, Riga Stradin University, Riga, Latvia

Aims: This study evaluated the role of octreotide in preventing post-ERCP pancreatitis (PEP) in patients with acute biliary pancreatitis.

Methods: In this study we retrospectively analysed the medical records of all patients with acute biliary pancreatitis who underwent therapeutic ERCP between January 2000 and June 2002. The study included 59 patients (39 females and 20 males) with a mean age of 60 years (range 24–91). We analysed 2 groups of patients. The first group (31 patients) was treated between January 2000 and January 2001, the second group (28 patients) was between January 2001 and June 2002. Because of post-ERCP pancreatitis (10 patients) in the first group we started to use octreotide to prevent PEP. In our department octreotide has been used since January 2001 for prevention of PEP. To evaluate severe acute gallstone pancreatitis we used Ranson's score >4 and APACHE-II score >8, US and contrast-enhanced computed tomography (CT) findings. In 28 patients (48%) octreotide 0.1 mg 1 h before ERCP and two more times after 8 and 16 h was used to prevent PEP.

Results: There was no PEP in the group of patients who received octreotide. 10 of 31 patients (32%) who did not received octreotide had worsened clinical and laboratory findings, one of them had deterioration of severe acute pancreatitis.

Conclusion: Octreotide has a promising role for preventing post-ERCP pancreatitis in patients with acute biliary pancreatitis.

298

ACUTE PANCREATITIS FROM SCORPION ENVENOMATION IS CAUSED BY EXCESSIVE PANCREATIC EXOCRINE STIMULATION AND NOT PANCREATIC DUCT OBSTRUCTION

Chen JWC, Thomas AC, Shi CX, Schloithe AC, Toouli J, Saccone GTP Flinders University of South Australia, Adelaide, Australia

Aim: Scorpion envenomation can cause severe acute pancreatitis. The pathogenesis of scorpion venom-induced pancreatitis is not clear, although both hyperstimulation of the exocrine pancreas and induced sphincter of Oddi dysfunction causing pancreatic duct obstruction have been postulated. The aim of this study was to determine the pathophysiological mechanism of scorpion venom-induced acute pancreatitis in an anaesthetised animal model.

Methods: In vivo preparations using anaesthetized Australian brush-tailed possums (n=38) were subjected to scorpion venom or vehicle infusion using intravenous or closed intra-arterial (hepatic artery) routes. 4 groups of animals were subjected to closed intra-arterial scorpion venom infusion to characterise the effects of scorpion venom on pancreatic duct pressure and serum parameters of acute pancreatitis. Another 3 groups of animals were subjected to intravenous scorpion venom infusion to characterise the effects on sphincter of Oddi motility, trans-sphincteric flow, pancreatitis histology and serum markers. Pancreatic exocrine volume and enzyme output were also measured.

Results: Intravenous scorpion venom infusion causes profound transient motility disturbance with transient increase in sphincter of Oddi contraction and decrease in trans-sphincteric flow. The exocrine pancreatic amylase secretion was elevated by 70-fold. This is associated with increased serum amylase and lipase and an increase in the pancreatitis histology score. Intra-arterial infusion of scorpion venom resulted in a transient increase in pancreatic duct pressure associated with an increase in sphincter of Oddi motility and trans-sphincteric resistance. However, decompression of the pancreatic duct did not reduce pancreatic amylase rise suggesting that the transient elevation of pancreatic duct pressure secondary to induced sphincter of Oddi obstruction is not the primary cause of pancreatic damage.

Conclusion: Scorpion venom induces acute pancreatitis even when the pancreatic duct is decompressed, indicating that pancreatic hyperstimulation rather than pancreatic duct obstruction is the cause of scorpion venom-induced acute pancreatitis.

299

NITRIC OXIDE REGULATES BACTERIAL TRANSLOCATION IN EXPERIMENTAL ACUTE EDEMATOUS PANCREATITIS

Cevikel H, Ozgun H, Boylu S, Demirkiran A, Sakarya S, Culhaci N Adnan Menderes University, Faculty of Medicine, Department of General Surgery, Aydin, Turkey

Aims: The role of nitric oxide (NO) in bacterial translocation (BT) associated with acute pancreatitis is controversial. We investigated the effects of the NO synthase substrate, L-arginine, and the NO synthase inhibitor, N-nitro-L-arginine methyl ester (L-NAME), on BT in caerulein-induced acute pancreatitis in rats.

Methods: Acute pancreatitis was induced by subcutaneous injections of caerulein (12 µg/kg) at 6-h intervals for 2 days. Subcutaneous L-arginine (100 mg/kg) or L-NAME (10 mg/kg) was administered. At 48 h, pancreatic injury and BT to the mesenteric lymph nodes (MLN), liver, and peritoneum were assessed.

Results: Compared with controls, rats that received caerulein injections alone had increased BT to the MLN and pancreatic inflammatory changes. L-Arginine significantly reduced the inflammation and BT caused by caerulein. L-NAME did not significantly alter pancreatic inflammation. Although caerulein + L-NAME-treated rats had increased BT to the peritoneum, MLN, and liver compared with controls, rates of BT did not significantly differ between caerulein alone and caerulein + L-NAME-treated rats.

Conclusion: In acute edematous pancreatitis, BT is increased and is regulated by NO. NO substrates limit BT and pancreatic inflammation associated with acute pancreatitis, probably by their bactericidal actions and ability to improve pancreatic blood flow.

300

THE EFFICACY OF ERCP IN THE TREATMENT OF ACUTE BILIARY PANCREATITIS

Cag M, Altuntas YE, Kurt N, Kement M, Kucuk HF

Dr. Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey

Aims: The aim of our study was to show the efficacy of ERCP in the treatment of acute biliary pancreatitis.

Methods: The 16 patients with acute biliary pancreatitis who attended this hospital between 1 January 2002 and 31 December 2002 were assessed retrospectively by Ranson criteria. Mortality, morbidity and ERCP results were investigated in these patients.

Results: ERCP was performed in the 8 patients at acute period. The patients are divided into 5 groups by using Ranson criteria. Ranson index: 1(+) point, 3/16 patients; 2(+) points, 6/16 patients; 3(+) points, 4/16 patients; 4(+) points, 2/16 patients; 5(+) points, 2/16 patients. The mortality and morbidity rates of patients were evaluated by the Baltazar-Ranson scoring system, as follows. Index – mortality – morbidity: 0–1 index – 0 mortality – 0 morbidity, 3 index – 0 mortality – 2/16 morbidity, 4-6 index – 1/16 mortality – 1/16 morbidity, >8 index – 0 mortalitiy – 1/16 morbidity. The mean length of hospital stay was 10 days (range 8–22 days) for patients who underwent ERCP, with a mean of 18 days (range 10–32) for patients who did not undergo ERCP.

Conclusion: Despite improvements in the treatment of acute biliary pancreatitis, the mortality and morbidity rates cannot be changed; however, ERCP can decrease the lenghth of hospital stay for patients. We believe that the mortality and morbidity can be decreased by using new treatment techniques in the future.

301

MANAGEMENT OF ACUTE GALLSTONE PANCREATITIS BY LAPAROSCOPIC CHOLECYSTECTOMY

Karydakis P, Fotopoulos A, Alexiou C, Konstantinidou E, Sahin I, Siaperas P, Antsaklis G

Department of Surgery, Sismanoglion General Hospital, Athens, Greece

Aim: This retrospective study presents the experience of this clinic in etiologic management of mild acute gallstone pancreatitis by laparoscopic cholecystectomy.

Methods: During the years 1992–2001, 612 patients were admitted to our clinic with the diagnosis of acute pancreatitis. Biliary calculi was the cause in 471 cases (76%) and 431 of these were classified as mild. During first admittance, 10–20 days immediately after remission of acute symptoms and restoration of imaging, 155 cases were operated. Laparoscopic cholecystectomy was the choice for 84 of our patients (6 cases were converted to open cholecystectomy). The other 71 patients underwent open cholecystectomy, including 6 of the converted cases; open surgery was done in a total of 77 cases. Both groups (laparoscopic and open cholecystectomy) underwent intraoperative cholangiography.

Results: (1) The surgical field image comparing difficulties in recognizing anatomical elements in both ‘cold’ and ‘warm’ cases of laparoscopic cholecystectomy was similar. (2) The converted cases (6 patients) were not included in laparoscopic cholecystectomies (78 patients). (3) Intraoperative cholangiography was successful in 74 patients out of 78. (4) Median time of operation was similar in both cases excluding time of intraoperative cholangiography. (5) Increased levels of serum amylase were not detected in any of the patients in either case. (6) Postoperatively, complication such as 1 case of bile leakage and 2 cases of abdominal wall bleeding, were treated conservatively. (7) The median postoperative hospital stay was not prolonged more than 3.2 days.

Conclusion: Laparoscopic cholecystectomy in etiological management of acute gallstone pancreatitis, except from the well known advantages, is a secure method and can be the first choice of operative method for such patients, during their first admittance.

Chronic Pancreatitis

(DOI 10.1080/16515320310001138)

302

VASCULAR LESIONS IN AUTOIMMUNE PANCREATITIS

Tsuchie K, Nimura Y

Department of Surgery, Meijoh Hospital, Nagoya, Japan

To study the vascular lesions in autoimmune pancreatitis (AIP), we carefully examined HE or EV-stained resected pancreas samples of 6 patients (4 males and 2 females, median age = 62 years (range 38–66)), who were finally diagnosed as AIP according to the Japanese criteria for diagnosis after receiving total (n=4) or distal (n=2) pancreatectomy under a presumptive diagnosis of pancreatic cancer in our affiliated hospitals over 25 years. In 3 patients, round cellular infiltration was observed in the adventitia of intrapancreatic arteries; however, in the remaining 3 patients, more severe inflammation was observed with extended infiltration from the external elastic lamina all the way to the intima of the arteries. These changes were considered to cause luminal obliteration and recanalization of the arteries in patients with AIP, which may be responsible for the irregular encasement in the arteriograms. In all of the patients, diffuse infiltrations were observed in and around the walls of intrapancreatic veins including splenic and portal veins, causing complete luminal obliterations like those observed in obliterative phlebitis. Considerable thickening of the wall of the portal and the splenic veins, which is responsible for caliber change in the portogram, was observed in the 3 patients with severe arterial infiltrations. These observations revealed that intrapancreatic arteries and vein in patients with AIP are severely damaged by the characteristic dense and diffuse inflammatory round cellular infiltration like those observed in the pancreatic ducts and intrapancreatic bile duct.

Pancreas Tumour

(DOI 10.1080/16515320310001147)

303

FOUR PHENOTYPIC EXPRESSIONS OF PANCREATIC CARCINOMA

Yamasaki H, Shimamoto F, Asahara T

Department of Surgery, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima and Department of Pathology, School of Health Sciences, Hiroshima Women's University, Hiroshima, Japan

Aims: In mucinous antigens, there are gastric types, such as human gastric mucin (HGM) and pS2 protein, and intestinal types, such as MUC2 and small intestinal mucinous antigen (SIMA), which are expressed mainly in normal gastric and intestinal mucosa, respectively. These mucinous antigens have been reported not to be expressed in normal pancreatic tissues but to be expressed in pancreatic adenocarcinoma. Recently, gastric and colon cancers were classified into four phenotypes based on the expression of these mucinous antigens, but pancreatic adenocarcinoma had not yet been classified. Therefore, we studied the expression of these mucinous antigens in pancreatic adenocarcinomas immunohistochemically and classified them into 4 phenotypes.

Methods: We analysed immunohistochemical expressions of MUC2, HGM, SIMA and pS2 protein in 46 pancreatic tubular adenocarcinomas and classified them into 4 phenotypes (gastric type, intestinal type, mixed type and null type) based on the immunohistochemical expression.

Results: The incidence of gastric type, intestinal type, mixed type and null type was 17 cases (37.0%), 2 cases (4.3%), 19 cases (41.3%) and 8 cases (17.4%), respectively. There was no significant correlation of the 4 phenotypes with clinicopathological features and prognosis.

Conclusions: We could classify pancreatic tubular adenocarcinomas into 4 phenotypes based on the immunohistochemical mucinous expression, and knew that pancreatic tubular adenocarcionomas had a characteristic to express gastric phenotype.

304

SEVERE DIGESTIVE BLEEDING DUE TO GIANT CYSTIC LYMPHANGIOMA OF THE PANCREAS IN THE ELDERLY

La Greca G, Randazzo V, Latteri S, Fisichella MP, Catanuto G, Scala V, Bonaccorsi R, Russello D

Department of Surgical Sciences, Transplantation and Advanced Technology – University of Catania, Catania, Italy

We report a case of an 82-year-old woman with severe anemia for >3 years due to intermittent bleeding from the gastrointestinal tract treated in different hospital with transfusions but finally related to a polycystic lymphangioma of the pancreas. 8 years earlier the patient underwent a Billroth II resection and bilio-jejunal anastomosis for jaundice and gastric occlusion due to a pancreatic tumor of unknown origin that was considered unresectable. After admission a CT scan showed a 29×27 cm polycyclic mass involving the pancreas infiltrating the gastro-jejunal efferent loop with compression and infiltration of the superior mesenteric vein. The source of bleeding were multiple mucosal erosions of the efferent jejunal loop. The patient's age, poor general condition and the assumed diagnosis of malignancy suggested a conservative strategy, but continuous bleeding and the patient's willingness brought her to urgent surgery. The retro-peritoneal tumor involved the afferent and efferent BII loops and the colon trasversum too. An ‘en bloc’ resection, including transverse colon and jejunal loop, was performed. Reconstruction with jejuno-jejunal t-t and colo-colic anastomosis was done. The origin was the anterior surface of the pancreas but this could not be resected because a dissecting plane was evident. The patient was discharged after 8 days and was well without bleeding recurrence until 3 months follow-up. Conclusion: Cystic lymphangioma is a rare tumor, especially in elderly, that can lead to wrong diagnosis and that can produce severe bleeding. In this case surgery remains the only treatment. This is the first case in the literature presenting with a severe bleeding.

305

ASSESSMENT OF COST-EFECTIVENESS OF DIAGNOSTIC METHODS USED IN PANCREATIC MALIGNANCIES

Cag M, Kucuk HF, Sad O, Ozkan Z, Kement M, Kurt N

Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey

Aims: The dimensions and the situation of pancreas make diagnostic procedures difficult. Therefore different methods should be used for diagnosis. The aim of our study was to determine the cost-effectiveness of these methods.

Methods: All the pancreas biopsies performed at our hospital between 1 January 1996 and 30 September 2002 were considered (n=150). Age, sex, imaging methods, tumor markers, endoscopic findings, ERCP, biopsy techniques, the follow-up periods and their costs were considered.

Results: USGs sensitivity in malignant pancreatic diseases was 0.39 while the specificity was 0.66. The mean dimension of tumors measured with USG was 50.2 mm. The sensitivity of CT was 0.28 while the specificity was 0.73. The mean dimension of tumors was 48.4 mm when diagnosed by CT. The specificity of tumor markers was 0.9 while the sensitivity was 1. The sensitivity of frozen section was 1 and the specificity was 0.73. The sensitivity of FNAB was 1 and the specificity was 0.6.

Conclusion: The imaging methods combined with tumor markers are more sensitive than the biopsies. Furthermore, if we consider the costs of the operations, postoperative course, the pre-operative imaging methods in combination with tumor markers protect the patients from unnecessary operation cost.

306

MICROCYSTIC CYSTADENOMA OF THE PANCREAS

Papoulides P, Sarros Ch, Skoumis G, Pitsargiotis E, Naoum E

Department of General Surgery, General Hospital of Larissa, Larissa, Greece

Microcystic adenoma of the pancreas is a rare benign tumor of the pancreas without malignant potential and usually appears in older women. They represent 10% of pancreatic cystic masses. They appear as serous and mucinous. Pain, weight loss, palpable mass and jaundice (if the tumor is localized in the head of the pancreas) are the main symptoms. Thanks to the modern imaging techniques (ultrasonography, US; computerized tomography, CT) the tumor is discovered and even diagnosed preoperatively. Surgical excision is the treatment of choice. We present a case of microcystic (glycogen-rich) adenoma of the tail of the pancreas in a 56-year-old woman with known hyperthyroidism and hypertension. She complained of nausea, vomiting and an abdominal mass. The patient was admitted in oligaimic shock due to hemorrhage. An urgent CT and US were performed. In CT a multicystic mass of the pancreatic tail, 10×8×15 cm in diameter, was discovered accompanied by blood in the abdominal cavity, while the outcome of the US was blood in the abdominal cavity and a mass that allocated left kidney to a lower level. Serum amylase was elevated as well as the urine amylase. Later remains elevated even 2 months after the surgical excision. A distal pancreatectomy with splenectomy was performed to treat the pancreatic cystic tumor. Hemorrhage was due to lesion of the left gastroepiploic artery. Histological examination of the specimen showed a microcystic cystadenoma. 6 months later the patient is free of any symptoms with normal CT and US findings and urine amylase levels.

307

INSULINOMA: 7 CASES, C.U.T.F. EXPERIENCE

Ozgur Y, Haznedar M, Demiryurek H, Erkocak Emin U

Department of General Surgery, Medical School of Cukurova University, Adana, Turkey

Hypoglycemia caused by insulinoma can occur at any age but is most common in middle age. This syndrome occurs in both sexes equally. Unfortunately, this disease may remain unsuspected and undiagnosed for a long time because of a low index of suspicion. USG, CT, MRI, selective angiography, sampling with portal venous catheterisation, IOUS, and experienced surgeon are used for localisation of tumor. Between 1996 and 2002 at Cukurova University School of Medicine, Department of General Surgery, 7 patients were treated because of insulinoma. Mean age was 45.1 (28–70) years, mean duration of symptoms was 3.8 years (1–7). Localisation of tumor was done in 4 patients preoperatively (angiography in 1, CT and USG in 3 patients). The other 3 tumors were found during the operataion. Frozen biopsies were performed in 3 patients. Operative procedures were enucleation in 6 patients and distal subtotal splenopancreatectomy in 1 patient. In 2 patients, pancreatic fistula and pseudocyst formation developed during the postoperative course and they were treated medically. In conclusion, insulinoma is a rare endocrine tumor. Once the diagnosis of suspected hyperinsulinism is confirmed, every effort should be made to localize the source of excessive insulin production; however, it is difficult to localize the tumor in both the preoperative and operative period.

308

A SINGLE CENTER EXPERIENCE FOR PANCREATIC AND PERIAMPULLARY TUMORS

Coker A, Astarcioglu H, Obuz F, Ucar D, Karademir S, Astarcioglu I General Surgery Department, Dokuz Eylul University, Izmir, Turkey

In this retrospective study we evaluated mortality and morbidity rates along with survival rates for pancreatic and periampullary tumors in our institute between 1998 and 2002. Hospital records were reviewed in 128 consecutive cases in terms of diagnostic tools, tumor location, surgical procedures and adjuvant therapies. Selected surgical procedure for periampullary tumors was standard pancreaticoduodenectomy and distal pancreatectomy for pancreatic tumors located in body and tail. Adjuvant chemotherapy schedule was gemcitabine and 5-FU for all patients. In 2 patients concomitant chemoradiotherapy was applied. All patients followed by periodical clinical controls and health conditions were recorded by periodic phone calls. Survival analysis was performed by Kaplan-Meier methods. Location of tumors was periampullary region in 105 cases (82 %), pancreatic body in 20 patients (15.6%). 3 patients had chronic pancreatitis. The numbers of patients with resection in these groups were 71 (67.6%) (pancreaticodudoenectomy), 17 (85%) (distal pancreatectomy) and 3 (100%) (pancreaticoduodenectomy), respectively. Resectability rate was 90.4% and 73 of cases (80.2%) were in Stage 3 and 4. In 4 cases partial portal vein resection was performed along with tumor resection. Early postoperative mortality rate was 5 (5.5%) and major morbidity rate (anastomosis leak, GIT bleeding) was 5.5%. Kaplan-Meier survival analysis revealed mean survival time in pancreatic head was 1.04 months, in pancreatic and distal choledoc tumor as 13.63±1.44 months, 10.28 body tumors and 17.26±2.04 months in papilla tumors.

309

CLINICOPATHOLOGY OF PANCREATICOBILIARY MALJUNCTION

Seki M, Ninomiya Y, Ohta H, Yamamoto J, Yamaguchi T, Aruga A, Takano K, Yanagisawa A

Cancer Institute Hospital, Tokyo, Japan

Aims: In this retrospective study, we elucidated the relationship between papillary hyperplasia commonly seen in background biliary epithelium of pancreaticobiliary maljunction (PBM) patients and carcinogenesis, and so investigated appropriate operation methods for PBM. Methods: 31 patients with PBM resected in the last 14 years were classified as type I or II in Komi's classification of PBM, and type II was subclassified into IIa or IIb, according to whether the maximal diameter of the extrahepatic bile duct was >10 mm or <10 mm. Papillary hyperplasia was graded from 0 to 3 in gallbladder (GB) epithelium and from 0 to 2 in bile duct (BD) epithelium according to extent of papillary growth.

Results: (1) GB of type I (n=10): Grade (Gr.) 0 = 1, Gr.l = 1 (carcinoma), Gr.2 = 2, Gr.3 = 6. (2) BD of type I (n=10): Gr.0 = 0, Gr.l = 6 (1 dysplasia), Gr.2 = 4 (1 dysplasia). (3) GB of type Ha (n=5): Gr.0 = 0, Gr.l = 1 (carcinoma), Gr.2 = 1 (carcinoma), Gr.3 = 3. (4) BD of type IIa (n=5): Gr.0 =1, Gr.l = 4, Gr.2 = 0. (5) GB of type IIb (n=16): Gr.0 = 0, Gr.l = 4 (2 carcinomas), Gr.2 = 8 (5 carcinomas), Gr.3 = 4. (6) BD of type IIb (n=13): Gr.0 = 4 (2 carcinomas), Gr.l = 8 (4 carcinomas), Gr.2 = 1.

Conclusions: (1) There was no apparent relationship between extent of papillary hyperplasia and carcinogenesis in PBM patients. (2) In type lib patients who had no BD dilatation, the incidence of biliary tract carcinoma was rather high: GB = 7/16 (44%), BD = 6/13 (46%). Consequently, we concluded that extrahepatic bile duct resection was necessary even for PBM patients without bile duct dilatation.

310

PALLIATIVE TREATMENT OF JAUNDICE IN PANCREAS CANCER

Ovejero V, Gonzales-Pinto I, Barneo L, Miyar A, Rodriguez-Vigil R, Vazquez L, Garcia- Cosio JM, Martinez E

University of Oviedo, Hospital Central Asturas, Oviedo, Spain

Aims: Most pancreatic cancers are incurable when diagnosed, needing drainage of the biliary system as palliative treatment. The purpose of this study was to compare the techniques of drainage employed in our hospital for the treatment of jaundice.

Methods: 54 pancreatic cancers with jaundice (mean age 67.4 +/– 12.3) were treated. There were 63% males. 24 of them (group I) underwent an open bypass procedure because planned resection was not feasible. A non-surgical drainage was performed in 30 cases (group II). Analytical parameters and outcome of drainage were evaluated to establish the prognosis of the disease.

Results: A biliary and gastric bypass was performed in 70.8% of operated cases. The most used non-surgical procedure was percutaneous (83%), because the endoscopic drainage had failed to go across the papilla in 23% (7/12 cases). There were no difference between groups with respect to age, gender and biochemical parameters (except total bilirrubin – mg/dl: group I, 9.9; group II, 18.4; p <  0.05). Complications: I, 67% (surgical, 13/24; medical, 11/24); II, 50% (surgical, 13/30; medical, 5/30). Hospital death: I, 8%; I, 13%. Readmission: I, 25%; II, 27%. Survival (months – mean/ median): I, 7.9/7.1; II, 4.8/4.6 (p < 0.05). Cholangitis was the main etiology of non-tumoral death in group II.

Conclusions: Non-surgical drainage appears to offer the best outcomes at short term (less complications), with more effectiveness for the percutaneous approach. The surgical group showed better survival than the non-surgical group.

311

PANCREATOGRAPHY OF PANCREATIC CARCINOMAS INVOLVING THE WHOLE PANCREAS

Ninomiya Y, Seki M, Yanagisawa A, Ohta H

Cancer Institute Hospital, Tokyo, Japan

Aims: In the present study, we investigated whether we could predict preoperatively the indication for total pancreatectomy by pancreatography. Methods: From 1981 to 2001, a consecutive series of 8 patients with pancreatic carcinomas involving the whole pancreas underwent total pancreatectomy, followed by detailed histopathological examinations. All the patients were submitted to ERCP, CT and postoperative pancreatography for evaluation of pancreatic ducts. Pancreatographies estimated by the combination of ERCP, CT, and postoperative pancreatography were classified into 3 types: type A, diffuse and cystic dilatation type; type B, focal or segmental stenosis type with dilatation of distal main pancreatic duct; type C, diffuse and irregular stenosis type.

Results: There were 2 patients of type A. One, who died from other disease, survived without recurrence 148 months after surgery; the other survives 22 months after surgery without recurrence. They had intraductal papillary carcinoma with slightly invasive part without lymph node metastasis. All of the patients with type B died from recurrence of pancreatic cancer 17 ∼ 25 months after surgery. They had mixed features of invasive ductal carcinoma and intraductal carcinoma. 2 of them had lymph node metastasis. All of the patients with type C died from recurrence of pancreatic cancer 2–7 months after surgery. Both of them had invasive ductal carcinomas throughout the whole pancreas with lymph node metastasis.

Conclusion: Our results suggest that preoperative pancreatography could predict the outcome of surgery, and that the indication for total pancreatectomy should be decided by pancreatography.

312

CARCINOMA OF THE HEAD OF THE PANCREAS: 15 YEAR EXPERIENCE

Papavramidis Sp, Kotidis E, Ntokmetzioglou I, Kesisoglou I, Gamvros O Aristotelian University of Thessaloniki, Third Department of Surgery, Ahepa Hospital, Thessaloniki, Greece

Aims: Carcinoma of the head of the pancreas is the most frequent periampullary malignancy. Its prognosis, even after radical resection, remains poor. The aim of this study was to present our experience of the surgical treatment of carcinoma of the head of pancreas.

Methods: Between 1 January 1988 and 31 December 2002, 69 patients with carcinoma of the head of pancreas were treated in our department. 36 were men and 33 women, with a mean age of 66 years (±13 years). Histopathological confirmation was available in 53 patients (6 by percutaneous and 47 by intraoperative biopsy) while, in 16, diagnosis was based on clinical manifestations and CT findings. In 52 cases the tumor was ductal adenocarcinoma (6 well, 18 moderately and 28 poorly differentiated) and one well differentiated cystadenocarcinoma. Jaundice, body weight loss and abdominal pain were the main presenting symptoms in the majority of the patients.

Results: Only 14 of our patients (20.28%) had resectable tumor at the time of diagnosis and underwent pylorus-preserving pancreatoduodenectomy (10 patients) and Whipple operation (4 patients). 33 patients were treated by bypass operation, 16 by percutaneous and 6 by endoscopically placed biliary stents. Perioperative mortality rate was 4.3% (3 patients) and the mean hospital stay was 15.5 days. The mean survival of the patients who underwent pancreatoduodenectomy was 14 months (±3 months) and of those who were treated by palliative operation or biliary stents 6 months (±4 months). The 1 patient with cystadenocarcinoma is still alive 13 years after the operation. 4 patients were given octreotide (Sandostatin Lar) with satisfactory palliative effects.

Conclusion: Carcinoma of the head of the pancreas is an aggressive tumor with very poor prognosis. If the tumor is resectable, pancreatoduodenectomy offers a relatively better survival rate, while preservation of the pylorus and administration of somatostatin analogs improve the patients’ quality of life.

313

CYSTIC ADENOMA OF THE PANCREAS: CASE REPORT

Karatsis P, Fragiadaki E, Kostakis G, Stavrakis J, Vrekoussis Th, Mitas S, Daskalaki A, Tsarits A

Department of General Surgery, District General Hospital of Agios Nikolaos, Crete, Greece

Aim: Cystic adenoma or serous microcystic adenoma of the pancreas is a rare benign neoplasm. It is usually asymptomatic and is found randomly either during an operation or by imaging procedures. We present a case of cystic adenoma of the pancreas as well as a literature review.

Methods: A female patient, 60 years old, was admitted to the surgical department due to problems of intestinal motility. From the personal history only diabetes mellitus was found as well as gallstones. Clinical examination revealed tenderness in the upper right quandrant and the abdominal ultrasound indicated a small tumor in the pancreatic body. Computed tomography was then performed, showing a cystic formation of 3.6 cm in the body tail border.

Results: An open cholecystectomy and a distal pancreatectomy was performed. Post-surgical course was normal. The patient was discharged in 11 days.

Conclusions: (1) It is a rare neoplastic cyst of the pancreas. (2) Female/male ratio is 1.6/1 with a mean age of diagnosis 60–86 years. (3) Most cases have symptoms related to an abdominal mass or to near organ compression. (4) Procedures such as U/S, C/T, needle biopsy angiography may establish the diagnosis. (5) The treatment is distal or proximal pancreatectomy.

314

PANCREATIC RENAL CELL CARCINOMA METASTASIS PRESENTING WITH UPPER GASTROINTESTINAL BLEEDING

Pekmezci S, Kahya A, Kapan M, Durgun V, Tasci H

Department of General Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey

Aims: To present and discuss clinical features and surgical outcome of a rare case with pancreatic metastatic tumors of renal cell carcinoma who was admitted with an upper gastrointestinal bleeding bout. Methods: We investigated the patient's history as well as medical records.

Results: A 62-year-old man was admitted to our clinic with a complaint of melena. In the patient's history, there were a left nefrectomy, 9 years ago due to a renal cell carcinoma and a palliative biliary drainage procedure, a year ago, due to obstructing jaundice caused by pancreatic metastasis. Gastrointestinal bleeding was related to tumor infiltration in duodenal bulbus, found on upper endoscopic examination. Computerized tomography scans revealed two metastatic tumors that located in head and tail of the pancreas. The tumors were considered to be resectable, then total pancreaticoduodenectomy and splenectomy were performed. There were no early complications but a wound infection was encountered and the patient was referred to the oncology department for adjuvant treatment. The patient is still free of tumor, symptoms and complications on controls at the 5th month postoperatively.

Conclusion: Pancreas is an infrequent site of renal cell carcinoma metastasis. The primary or metastatic tumors of pancreas have poor prognosis but in contrast, renal cell carcinoma metastases of the pancreas are associated with high survival rates, if resected. Therefore, every effort should be made, to carry out surgical resection of this particular type of pancreatic tumor.

315

MALIGNANT FIBROUS HISTIOCYTOMA OF THE PANCREAS: A CASE REPORT

Erikoglu M, Yol S, Tavli L, Oltulu P

Selcuk University, Meram Medical School, Department of General Surgery, Konya, Turkey

Aim: Although malignant fibrotic histiocytoma (MFH) is a well known soft tissue sarcoma, malignant fibrotic histiocytoma of the pancreas is a very rare tumor. For this reason, we aimed to investigate the diagnosis and treatment of this tumor.

Methods: A 59-year-old male patient presented with epigastric pain for about 1 year radiating slightly to the back. On physical examination, there was tenderness in the left upper quadrant and a partially mobile mass of 6×8 cm in diameter with ill-defined margins. On abdominal Doppler ultrasonographic examination, there was a solid mass of 90×73 mm in diameter with cystic components extending from the tail to the body of the pancreas. Portal and splenic vein thrombosis was detected. No metastases were found. On CT examination, there was a mass of 8×10 cm in diameter in the distal pancreas and thrombosis in the portal vein. There were no significant changes in the routine hematologic and biochemical values. The patient was operated on as a case of tumor of the tail of the pancreas. Peroperatively there was a partially well defined solid mass of 8×10 cm in diameter with cystic components originating from the tail of pancreas. The portal vein was about 3 cm in diameter and was full of thrombus. There were no signs of other organ metastases. Splenectomy and distal pancreatectomy were performed. A length of 10 cm thrombus was extracted from the portal vein. The patient was discharged on the 7th postoperative day. On pathological examination, the mass was found to be a malignant fibrous histiocytoma of the pancreas. Cy (V) AIDC chemotheraphy schedule was started and radiotherapy was planned.

Conclusion: Malignant fibrous histiocytoma of the pancreas is a very rare tumor originating from acinar or ductal epithelial cells of the pancreas. As far as we determined, there were only 9 cases in the literature. In the treatment, only wide local resection with adjuvant radiotherapy with or without chemotherapy was performed. The tumor has a high local recurrence rate and agressive and poor prognosis. Postoperative radiotherapy seems to be important for increasing survival rate.

316

PANCREATIC NEUROENDOCRINE TUMOR

Christodoulou N, Papadakis I, Spiridakis K, Christoforakis Z, Koumendakis E, Velegrakis M

Second Surgical Department, “Venizelion” General Hospital of Iraklion, Crete, Greece

Aim: We present a rare case of a pancreatic neuroendocrine tumor, which was incidentally discovered in a 65-year-old patient during the performance of a laparoscopic cholecystectomy 5 years ago.

Methods: During the laparoscopic cholecystectomy multiple small metastatic lesions were identified on the upper hepatic surface, and the operation was converted into an open laparatomy in order to examine the intra-abdominal cavity more thoroughly. Besides the aforementioned findings, a large mass occupying the tail of the pancreas, the left colic flexure, the spleen and the left kidney was also identified.

Results: The mass was considered to be inoperable, and the obtained biopsy specimens demonstrated the presence of a neuroendocrine pancreatic tumor. A medical treatment with somatostatin (Sandostatin 0.5 mg, 3 times daily) was administered to the patient, who had an uneventful postoperative course and was discharged in a good general condition. The patient is still receiving somatostatin treatment (Sandostatin LAR 20 mg, once monthly, during the last year), being submitted to a clinical and laboratory examination at 6-month intervals. The patient is still in a good general condition, without any evidence of relapse of the disease.

Conclusions: We considered it useful to present this rare case, emphasizing the good responsiveness of the pancreatic neuroendocrine tumor to pharmaceutical treatment, which constitutes the treatment of choice.

317

BILIARY ENTERIC BYPASS IN CARCINOMA OF PANCREATIC HEAD

Antsaklis G, Alexiou C, Konstantinidou E, Tsimpoukidi O, Kefalogianis E, Hinopoulos G, Economou N

Department of Surgery, Sismanoglion General Hospital, Athens, Greece

Aim: To present our experience of the palliative surgical procedures for pancreatic head carcinoma, which is usually presented as an advanced disease at the time of diagnosis.

Methods: During 1995–2002, 53 patients were admitted with the diagnosis of carcinoma of the head of the pancreas. 90% of them presented with painless obstructive jaundice, weight loss and pruritus. Preoperative laboratory tests including full blood tests and cancer indicators, CT, MRI, and ERCP were performed. A palliative surgical procedure was decided as the only possible approach in 42 of the 53 patients: 38 patients underwent choledochoduodenostomy and 4 Roux-en-Y biliary enteric bypass. In addition, a concomitant gastrojejunal anastomosis was performed for 18 patients due to gastric outlet obstruction. The indications for a biliary enteric bypass were: (1) the inability to perform a curative surgical procedure with full extraction of the tumor, (2) the failure of endoscopic stenting.

Results: 5 patients had postoperative complications including bile leakage in 3 patients, rupture of the anastomosis in 1, and bleeding in 1 patient. 3 of our patients were treated conservatively and the other 2 patients underwent a second operation.

Conclusions: (1) Due to non-specific clinical symptoms, the diagnosis of cancer of the pancreatic head is usually delayed, so those lesions are inoperable in a high percentage at the preoperative period. (2) Operative procedures that bypass the tumor have longer survival rates than endoscopic stenting. (3) Endoscopic stenting is an alternative palliative method and may be well tolerated by elderly patients or in cases of patients with increased morbidity due to concomitant diseases. (4) The anastomosis must be constructed in such a way that a width of at least 15 mm must be ensured for a good and safe postoperative function.

318

PYLORIC GLAND HYPERPLASIA FORMING A NODULE IN THE MAIN PANCREATIC DUCT

Sakamoto E, Hasegawa H, Ogiso S, Igami T, Mori T, Mizuno T, Hattori K, Sugimoto M, Fukami Y

Department of Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan

We report a case of pyloric gland hyperplasia of the pancreatic duct leading to the formation of a grossly visible, polypoid lesion and dilatation of the main pancreatic duct. The patient was a 66-year-old male who presented to our hospital for early gastric cancer and pulmonary tuberculosis. Endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) showed a filling defect in the main pancreatic duct in the head of the pancreas. A diagnosis of intraductal papillary-mucinous neoplasm of the pancreas was made and pancreatoduodenectomy was performed. The cut surface of the resected specimen showed a polypoid lesion approximately 18 mm in diameter in the main pancreatic duct and its branch. Light-microscopic examination revealed closely packed, pyloric-type tubular glands lined by columnar epithelial cells with abundant clear cytoplasm but without nuclear atypia. The tubular glands were periodic acid-Schiff positive but Alcian blue negative. Mucous cell hyperplasia with focal pyloric gland metaplasia was present in the adjacent ductal epithelium. We consider this pyloric gland hyperplasia to be derived from hyperplasia of gastric foveolar mucous cells in the pancreatic ductal epithelium.

319

SPLENOPANCREATECTOMY FOR A RARE SOLID AND CYSTIC-PAPILLARY NEOPLASM OF THE PANCREAS

Karamarkovic A, Colovic R, Stefanovic B, Djukic V, Mihailovic V, Antic A

Institute for Digestive Disease, University Clinical Center, Belgrade, Yugoslavia

Aim: Solid and cystic-papillary neoplasm (SCPN) of the pancreas, described by Frantz (1959), is an uncommon clinicopathologic entity with relatively low grade malignant potential. The tumor is more frequent in the body and tail of the pancreas. The majority of the patients are young females. About 50% of the patients are asymptomatic. Complications such as rupture, bleeding or secondary infection are rare. Metastases of the tumor and local recurrence after surgical treatment are also rare.

Methods: Case 1: a 23-year-old woman with a 2-year history of upper abdominal pain and occasional fever, was addmited in our institution. US and CT examinations revealed a well defined mass of 5 cm in diameter in the tail of the pancreas. The mass was excised with limited resection of the pancreas and splenectomy. Histological findings established a solid and cystic-papillary neoplasm of the pancreas. The recovery was uneventful. Case 2: a 39-year-old woman was addmited with abdominal discomfort and palpable abdominal mass in the upper abdomen. US and CT scan revealed a round neoformation of 14 cm in diameter located in the body of the pancreas. Left spleno-hemipancreatectomy was performed. Histological examination of 14×9×6 cm brown and tan lobulated mass of 386 g with cystic areas in the body of the pancreas, established a solid and cystic-papillary tumor. The patient was discharged on the 7th postoperative day.

Conclusions: Prognosis is excellent after complete surgical removal. New imaging techniques make diagnosis of the neoplasm easy, but exact diagnosis is based on histological findings. Differential diagnosis should be made with pancreatoblastoma, non-neoplastic cysts, pancreatic pseudocysts and hydatid cyst. Surgical excision or resection is the treatment of choice.

Pancreas – Miscellaneous

(DOI 10.1080/16515320310001156)

320

TRANSGENIC MOUSE OVEREXPRESSING ANTI-IMMUNE RESPONSE GENE: A NOVEL STRATEGY FOR ISLET TRANSPLANTATION

Shen KL

Tri-Service General Hospital, Taipei, Taiwan

Aims: Type 1 diabetes (IDDM) is caused by an autoimmune destruction of the insulin-producing beta cells in islets. A widely used model for dissecting immunopathological mechanisms and for developing therapeutic strategies is the non-obese diabetic (NOD) mouse, resembling human IDDM. One obstacle preventing the survival of transplanted islets in IDDM recipient is the autoimmune attack. To overcome this problem, we generated transgenic NOD mice overexpressing soluble decoy receptor 3 (DcR3) in their beta cells and investigated the survival of transgenic islets transplanted in diabetic recipient.

Methods: DcR3 gene under insulin promoter control was microinjected directly into NOD embryo. The transgenic founders were confirmed by Southern blot. Both RT-PCR and Western blot were performed to detect the expression of transgene and to evaluate the promoter stringency.

Results: All transgenic NOD mice expressed DcR3 in pancreatic beta cells. The insulin promoter in these transgenic mice is highly stringent, as DcR3 was not detected in any other organs tested. Immunohistochemical study further confirmed the expression of DcR3 in situ. Strikingly, all of the transgenic mice overexpressing DcR3 in beta cells were prevented from autoimmune diabetes, demonstrating the protection of DcR3 in autoimmune attack. The survival and function of transgenic islets transplanted in diabetic NOD recipients are under evaluation.

Conclusion: We have successfully generated transgenic NOD mice that were protected from diseases. We are currently performing experiments to transplant the islets overexpressing DcRJ and are testing the resistance of grafts to autoimmune attack. This may provide the further basis of potential preventive/therapeutic strategies for IDDM.

321

SAFETY OF PANCREATICODUODENECTOMY IN PATIENTS WITH HYPERBILIRUBINEMIA

Chae MK, Kim CH

Soonchunhyang University Chunan Hospital, Department of General Surgery, Chungnam, South Korea

Aims: Pancreticoduodenectomy in patients with obstructive jaundice carries an increased risk of postoperative complications and mortality. The concept of preoperative biliary drainage has been developed to reduce this morbidity and mortality but the benefit of preoperative biliary drainage is still questioned for several reasons. The aim of this study was to evaluate postoperative outcomes following pancreaticoduodenectomy in relation to hyperbilirubinemia patients.

Methods: 92 patients who underwent pancreaticoduodenectomy between 1992 and 2001, were divided into 2 groups. Group A comprised 11 cases with preoperative hyperbilirubinemia (serum bilirubin >10 mg/dl), and the other 81 cases (serum bilirubin < 10mg/dl). In group A, 6 patients underwent preoperative biliary drainage. In group B, 31 patients underwent preoperative biliary drainage. Postoperative morbidity and mortality were analysed, comparing the two groups by chi-sqare test retrospectively.

Results: In group A (average values of serum bilirubin 15.2 mg/dl), wound complications were seen in 9.0%, hemorrhage in 18.1%, delayed gastric emptying in 18.1%, anastomotic leakage in 18.1%, abscess was absent, and mortality was noted in 9%. In group B, wound complication was noted in 14.8%, hemorrhage in 8.6%, delayed gastric emptying in 9.8%, anastomotic leakage in 22.1%, abscess in 4.9%, and mortality in 4.9%. There were no significant differences in morbidity and mortality between the two groups.

Conclusions: Preoperative hyperbilirubinemia did not influence the incidence of postoperative outcomes following pancreticoduodenectomy. It can be assumed that preoperative biliary drainage to reduce the level of serum bilirubin is is a meaningless procedure, except in specific situations.

322

IDIOPATHIC FIBROSING PANCREATITIS ASSOCIATED WITH ULCERATIVE COLITIS

Nve E, Montull P, Ribe D, Villanueva MJ, Navines J, Blay J, Badia JM

Hospital de Granollers, Barcelona, Spain

Background: Idiopathic fibrosing pancreatitis is characterized by infrequent attacks of abdominal pain, irregular narrowing of the pancreatic duct, and swelling of the pancreatic parenchyma. It has been associated with Sjogren's syndrome, primary biliary cirrhosis, and primary sclerosing cholangitis. This condition frequently develops in childhood and youth and has also been related to ulcerative colitis and pericholangitis. Extracolonic complications of ulcerative colitis may involve many organs, including liver, biliary tract, joints, eyes and skin. Methods: A 25-year-old man, previously treated for UC, was admitted with epigastric pain and jaundice. Bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase, and transaminase levels were increased. Abdominal ultrasonography, computed tomography, magnetic resonance and ERCP revealed diffuse enlargement of the pancreas, filiform distal stenosis of the common bile duct as well as intrahepatic bile ducts and pancreatic duct dilatation. At operation, a ‘rock-hard’ nodular pancreatic gland was noted, and a fine needle aspiration cytology was informed as chronic pancreatitis with diffuse lymphoplasmacytic infiltration. Cholecystectomy and Y-Roux hepaticoje-junostomy with an access loop was done.

Conclusion: Idiopathic fibrosing pancreatitis should be considered in young patients with obstructive jaundice, especially those affected with chronic inflammatory or autoimmune diseases. In some patients with Crohn's disease and ulcerative colitis this condition has been associated with antibodies against pancreatic juice. Other authors have found high serum IgG4 concentrations, suggesting an autoimmune pathogenesis. Glucocorticoid therapy induces clinical remisions, and would be the first line of treatment, although many patients require surgical treatment.

323

GUNSHOT INJURIES OF THE PORTAL VEIN, PANCREAS AND LIVER SUCCESSFULLY TREATED BY STIR (STAGED INJURY REPAIR CONCEPT)

Karamarkovic AR

University Center for Emergency Surgery, Belgrade, Yugoslavia

Background: Staged injury repair (STIR) is a new operative concept that has evolved in the last decade to manage severe abdominal injuries. STIR is defined as one operation performed in multiple steps to permit delayed definitive repair after initial damage control in non-stable patients.

Methods: A 37-year-old woman was admitted in our institution, with gunshot injury in the epigastric region of the abdomen, with signs of severe hemorrhagic shock. After initial reanimation emergency surgery was performed. During the initial operation we discovered a lesion of the left paramedian sector of the liver, rupture of the isthmic pancreas, and also injury of the portal vein at the level of splenic vein confluence. The portal vein was successfully reconstructed with prolene 5-0 single interrupted sutures. Then the left hemipancreatectomy with splenectomy was performed. The lesion of the liver was treated by hepatorrhaphy. Due to the unstable and hypotensive condition of the patient, perihepatic packing was done. Temporary abdominal clousure was performed utilizing a glider (ETIZIP). During the first re-exploration 24 h later, perihepatic packing was removed, and on that occasion the lesion of segmental pedicle (S3) within the umbilical fissure, with bile leakage and bleeding, was discovered. Under stable hemodynamic conditions, segment S3 of the liver was removed (segmentectomy S3). The second re-exploration was performed 48 h later. We found the resected liver and pancreas completely normal, with no signs of bleeding and leakage. The reconstructed portal vein was of normal diameter showing no signs of thrombosis. The ETIZIP was removed and abdominal wall was definitely closed. The postoperative course of the patient was excellent. The control Doppler US registered normal blood flow through the superior mesenteric and portal vein. The patient was discharged on the 8th postoperative day.

Conclusion: The STIR concept with possibilities for multiple exploration proved to be successful in the treatment of severe abdominal injuries, particularly those followed by serious hemodynamic instability.

Biliary Tumour

(DOI 10.1080/16515320310001165)

324

ANALYSIS OF GDNF, GFRALPHA1 AND COX2 EXPRESSION AS PROGNOSTIC FACTORS IN BILE DUCT CARCINOMA

Iwahashi N, Takahashi M, Nimura Y

Division of Surgical Oncology, Department of Surgery, Nagoya University School of Medicine, Nagoya, Japan

Aims: We have recently shown that expression of glial cell line-derived neurotrophic factor (GDNF) correlates with perineural invasion in bile duct carcinoma. Although perineural invasion is one of the important prognostic factors of bile duct carcinoma, preoperative diagnosis of perineural invasion is difficult. We analysed the influence of GDNF expression on the prognosis of patients with bile duct carcinoma. We also investigated expression of GDNF receptor alpha 1 (GFRalphal) and cyclooxgenase-2 (COX-2), which are suggested to play a role in the development of bile duct carcinoma.

Methods: Immunohistochemical staining of GDNF, GFRalphal and COX-2 was performed in paraffin-embedded tissue sections from 82 patients with bile duct carcinoma. The average clinical follow-up period of these patients was 843.7 days (range 57–4031). They were classified into two groups based on staining intensity of each protein.

Results: GDNF expression correlated with perineural invasion (p = 0.026) but not with the prognosis of the patients with bile duct carcinoma (p = 0.98). Neither expression of GFRalphal nor COX-2 correlated with prognosis (p = 0.90 and p = 0.48, respectively). Perineural invasion did not correlate significantly with prognosis (p = 0.061).

Conclusion: GDNF expression did not correlate with survival of patients with bile duct carcinoma, whereas it correlated with perineural invasion. It also indicated that expression of GFRalphal and COX-2 are not useful as prognostic factors in bile duct carcinoma.

325

A RESECTED CASE OF PRIMARY ADENOENDOCRINE CELL CARCINOMA OF THE LOWER BILE DUCT

Wada D, Morimoto S, Tsuyuguchi M, Sohnaka Y, Fukumoto T, Hatakeyama S, Yamasaki S, Nakano K, Ogasawara T

Tokushima Municipal Hospital, Tokushima, Japan

We report a surgical case of primary adenoendocrine cell carcinoma of the lower bile duct. A 74-year-old man was admitted to our hospital for evaluation of fever and jaundice. Abdominal ultrasonography showed a low echoic mass in the lower bile duct. Abdominal enhanced computed tomography showed a soft tissue density with staining effect at early phase in the lower bile duct. Endoscopic retrograde cholangiography (ERCP) and percutaneous transhepatic gallbladder drainage (PTGBD) revealed an inverted U-shaped filling defect with sharp margin in the lower bile duct. At surgery, a small fingertip-sized tumor was found in the common bile duct. The intraoperative pathological diagnosis was poorly differentiated adenocarcinoma. Therefore, a pancreaticoduodenectomy was performed. The resected specimen showed the triple polypoid tumors with small steel arising in the lower bile duct. Microscopically, the tumor consisted mainly of small atypical cells with a high nuclear/cytoplasmic ratio forming solid cellular nests and trabecular pattern. Atypical cells in the mucosa of the common bile duct showed gradual transition to well differentiated adenocarcinoma. Immunohistochemical findings showed positive staining of AE1/AE3, CAM5.2 and also partially positive staining of chromographin A, NSE and synaptophysin. Histopathological examination revealed adenoendocrine cell carcinoma. Adenoendocrine cell carcinoma of the bile duct is thought to be extremely rare, and only 4 cases have been reported to date in the Japanese literature. Here, we report this case with a review of the literature.

326

BILIARY CYSTADENOMA AND BILIARY CYSTADENOCARCINOMA: FIVE CASE REPORTS

Park IY, Lee JH, Hur H, Sung GY, Chin HM, Kim DG, Kim EK, Kim J

Department of Surgery, College of Medicine, Catholic University of Korea, Seoul, Korea

Biliary cystadenoma (BC) and cystadenocarcinoma (BCA) are rare intrahepatic cystic neoplasms. The clinical feature is not marked but abdominal fullness and abdominal mass are the most common symptoms. The tumor is commonly a large multilocular cystic mass which requires hepatectomy for cure. We experienced 1 case of BC and 4 cases of BCA. The BC case was a 58-year-old woman with right upper quadrant discomfort for 5 months who had a 17 cm-sized multilocular cystic mass. The serum level of CA 125 was elevated and returned to normal level after resection. Right hemihepatectomy was performed and the patient had no recurrence for 14 months after resection. The mean age of BCA patients was 53 years. The size of BCA ranged from 5 to 12 cm and all cysts except 1 were multiloculated. 3 patients with BCA underwent left hemihepatectomy and 1 underwent right hemihepatectomy. One of the BCA patients showed elevation of serum CA 125. This may be a valuable finding in the differential diagnosis. The patients had no recurrence during the follow-up period. The treatment of choice for BC and BCA is complete resection. We report 1 case of biliary cystadenoma and 4 cases of cystadenocarcinoma.

327

THE CLINICAL VALUE OF P53, C-ERBB-2 AND KI-67 EXPRESSION IN GALLBLADDER CARCINOMA

Kim KH, Lee SK, You YK, Kim JS, Chin HM, Park IY, Kim DG, Lim KW

Catholic University, Uijongbu St. Mary's Hospital, Seoul, Korea

Aim: To study the expression and prognostic importance of p53, c-erbB-2 and Ki-67 protein in gallbladder carcinoma. We investigated immunohistochemically the expression of p53, c-erbB-2 and Ki-67 protein in gallbladder carcinoma, and we evaluated the correlation between clinicopathologic features and p53, c-erbB-2 and Ki-67 protein expression in gallbladder carcinoma.

Methods: From January 1994 to July 1999, 34 cases of gallbladder carcinoma were enrolled in this study and their clinicopathologic findings were analysed. We performed p53, c-erbB-2, and Ki-67 immunohistochemical staining on formalin-fixed, paraffin-embedded histological sections with an antibody.

Results: The rate of overexpression of p53, c-erbB-2, and Ki-67 protein in gallbladder carcinoma was 47.1%, 70.6% and 55.9%, respectively. The 5-year patient survival rate significantly correlated only with tumor stage (p = 0.016). p53, c-erbB-2 and Ki-67 positive gallbladder carcinoma patients survived less than negative patients, but no statistical significance was found. There was marginal significance by subdivided intensity of expression (1+, 2+, 3 + ) in p53 positive gallbladder carcinoma patients.

Conclusion: Progressively increasing incidence of p53, c-erbB-2 and Ki-67 protein overexpression was observed in gallbladder carcinoma patients. Although this study found no correlation between the molecular markers and survival, further study will be needed to evaluate the significance of p53, c-erbB-2 and Ki-67 proteins as prognostic factors.

328

SOMATOSTATINOMA OF THE AMPULLA OF VATER – A CASE REPORT

Kim H C, Sin EJ, Cho GS

Soon Chun Hyang University Hospital, Department of General Surgery, Bucheon, Korea

Somatostatinoma is rare, one of the neuroendocrine tumors that was first described in 1977. Most tumors have involved the pancreas and unusually involve the gastrointestinal tract. Somatostatinomas of ampulla of Vater are extremely rare and there were distinct clinical and pathologic differences. Duodenal carcinoid tumors tend to be benign and mainly gastrinoma, but ampullary carcinoid tumors had malignant behavior and mainly somatostatinomas. We have experienced a case of somatostatinoma of ampulla of Vater in a 51-year-old male. He complained of generalized, non-specific abdominal pain for a few days. Gastrofiberscopically, a 1.2-cm bulging mass was observed on ampulla of Vater. Radiologically, a protruding enhancing mass was in the duodenum on abdominal CT scan. In Octrescan, there was abnormal focal increased radiouptake in the subhepatic area. He underwent a pyrolus-preserving pancreatoduodenectomy. Histologically, it showed well-defined tubular cell nets and psammoma bodies. Immunohistochemically, the tumor cells showed the neuroendocrine nature with synaptophysin immunostain.

329

SURGICAL PALLIATION OF MALIGNANT HILAR OBSTRUCTION: INTRAHEPATIC B3 CHOLANGIOENTERIC BYPASS

Karamarkovic RA¹ , Gadzijev ME²

¹Center for Emergency Surgery, University of Belgrade, Yugoslavia and ²Surgical Department, Teaching Hospital Maribor, University of Ljubljana, Slovenia

Background: In 1957 Soupault and Couinaud described bypass of malignant hilar obstruction by anastomosis of a jejunal loop to the segment (S3) bile duct (B3). The technique was further refined by Bismuth and Corlette who described an intrahepatic approach within the plane of the round ligament. The procedure is useful for palliation of non-resectable cancer of the hepatic duct confluence and gallbladder.

Methods: The confluence pattern and surgical anatomy of the segmental bile duct B3 was studied in 61 specimens (28 adult cadavers and 33 liver casts). It is important to understand the detailed anatomy of B3, and its relation to the segmental portal venous branch P3. We do not register anatomical variations of segmental biliary ducts B2 and B3. Since March 2001, at the University Center for Emergency Surgery in Belgrade we perfomed intrahepatic B3 cholangiojejunostomy by Roux-en-Y fashion, utilizing a round ligament approach, in 9 patients with malignant obstructive jaundice due to non-resectable cancer of the hepatic duct confluence (Klatskin) (6 patients) and gallbladder (3 patients). A transanastomotic stent was used in 6 cases. The jaundice resolved in all patients, with excellent quality of palliation. The rate of postoperative surgical complications (postoperative bleeding, bile leakage, abscess formation) and hospital mortality rate was 0%. During a follow-up period of 2–20 months, registered mortality rate was 22% (2 patients).

Conclusions: The intrahepatic B3 cholangioenteric bypass is a safe and effective procedure in the palliative treatment of unresectable hilar malignancies which provides enough distance from a malignant lesion.

330

CURATIVE REOPERATION FOR RECURRENT CANCER OF THE EXTRAHEPATIC BILIARY TRACT

Kim SW, Yoon YS, Jang JY, Ahn YJ, Park YH

Seoul National University College of Medicine, Seoul, Korea

Aims: Local recurrence after resection of cancer of the gallbladder (GB) and bile duct is usually not curable, and 2nd curative surgery is almost impossible. To determine the feasibility and significance of 2nd curative surgery, we present our experiences in this study.

Methods: We reviewed the medical records and clinical outcomes of 4 patients who underwent re-resection for recurrent cancer of the extra-hepatic biliary tract.

Results: The mean age of the 4 patients was 51.5 years. One patient who had recurrent disease at intrahepatic and intrapancreatic bile duct 66 months after segmental resection of bile duct for common bile duct (CBD) cancer underwent hepatopancreatoduodenectomy. The second patient who had a recurrent tumor mass in the CBD originated from cystic duct 11 months after cholecystectomy underwent segmental resection of bile duct. The third patient who had recurrent disease at distal CBD 28 months after right hepatectomy for Klatskin tumor, underwent pylorus-preserving pancreatoduodenectomy. Gross type of the above 3 cases was papillary tumor. The fourth patient who had a recurrent tumor mass at GB bed site 16 months after simple cholecystectomy at another hospital for GB cancer, underwent liver wedge resection. There was no operative mortality or morbidity. Each patient is alive 46, 63, 9 and 30 months later, respectively without recurrence after reoperation.

Conclusion: We conclude that surgical re-resection is possible in selected patients with recurrent bile duct cancer, mostly papillary type. Primary operation for bile duct cancer should be performed with wide surgical margins and second curative surgery should be considered whenever possible in case of recurrence.

Biliary – Gallstones

(DOI 10.1080/16515320310001174)

331

ERCP POST-LAPAROSCOPIC CHOLECYSTECTOMY: CONVENTIONAL VS FACILITATED

Cox MR, Kaleal F, Liem H, Martin CJ

University of Sydney, Department of Surgery, Nepean Hospital, Penrith, NSW, Australia

Aim: There are several techniques to treat stones in the common bile duct (CBD) found at laparoscopic cholecystectomy (LC). The most frequent method is post-LC ERCP. The insertion of a transcystic stent across the ampulla at the time of LC facilitates the ERCP. The aim of this study was to compare the effectiveness and morbidity of conventional ERCP to ERCP that has been facilitated with the passage of a transcystic stent.

Methods: A prospective, non-randomised study from June 1996 until June 2001. The conventional group was referred from other surgeons for a post-LC ERCP. The facilitated group had the LC done by the authors, a transcystic stent was inserted and proceeded to post-LC ERCP.

Results:

Parameter	Conventional	Facilitated
Number of patients	101	157
Post-LC pancreatitis	0	0
Successful CBD canulation	90 (90%)	155 (99%)
Need for repeat ERCP	12 (12%)	9 (6%)
CBD clearance at initial ERCP	90 (90%)	151 (96%)
Post ERCP complications
Pancreatitis	8 (8%)	1 (1%)
Cholangitis	2 (1%)	2(1%)
Bleeding	1 (1%)	0
Perforation	0	2(1%)
Total	11 (11%)	5 (3%)

Conclusions: Insertion of a transcystic stent at LC increases the rate of cannulation and clearance of the CBD with a significant reduction in the incidence of post-ERCP pancreatitis.

332

CHOLESTEROL CONTENT OF INTRAHEPATIC STONES AND ITS CLINICAL SIGNIFICANCE IN KOREAN PATIENTS

Park YC, Kim SW, Park YH

Dankook University Hospital, Chungnam, South Korea

Aims: Intrahepatic calculi or hepatolithiasis, which has unique characteristics with frequent complications and recurrence, is prevalent in East Asia. Precise compositional analysis is mandatory for appropriate management and prevention of hepatolithiasis.

Methods: We analysed the chemical composition of intrahepatic stones quantitatively, from 89 consecutive Korean patients. Quantification for cholesterol, bilirubin, calcium and phosphorus by chemical assay were performed and supplementary cholesterol quantification by infrared (FTIR) spectroscopy was also carried out.

Results: Intrahepatic stones were grouped initially by their gross appearance as 3 (3.4%) cholesterol, 84 (94.4%) brown and 2 (2.2%) black pigment stones. Chemical assay disclosed that calcium bilirubinate stones (<50% cholesterol, 10–60% calcium bilirubinate) were 89.3% (n=75) of intrahepatic brown stones, and the remainder (n=9, 10.7%) were mixed cholesterol stones (50-70% cholesterol). Brown pigment stones with cholesterol content >20% of dry weight were 56% (n=47). Intrahepatic stones, containing <5% material insoluble in solvents (n = 35), had comparable cholesterol contents determined by chemical assay and IR spectroscopy (Pearson's correlation coefficient = 0.628, p < 0.01). Intrahepatic stones (n=54) with >5% insoluble residue had a mean cholesterol content of $35.6¡/\frac{3}{4}5.4\%$ by IR spectroscopy, which was significantly greater than a mean of $19.1¡/\frac{3}{4}8.4\%$ by chemical assay (Pearson's correlation coefficient = 0.399). There were no significant differences in chemical composition of intrahepatic stones according to clinical findings such as age, sex, locations of stones, body mass index and laboratory findings.

Conclusion: A portion of intrahepatic brown stones according to gross appearance was classified as mixed cholesterol stone by chemical assay and cholesterol contents were greater than expected by gross inspection in Korean hepatolithiasis patients.

333

SURGICAL MANAGEMENT OF MIRIZZI SYNDROMA – OUR EXPIRIENCES

Jovanovic M, Zdravkovic R, Kitanovic A, Smiljkovic M, Filipovic G, Zajic S

Krusevac, Yugoslavia

The aim of our work is to present our experiences in surgical management of obstructive jaundice which is caused by Mirizzi syndrome We report a retrospective study from medical histories in which we have analysed clinical pictures, diagnostic procedures, operative managements and postoperative complications. In the period between 1 January 1994 and 31 March 2002 we have performed 1216 operations for biliary tract diseases. In that period we have found 24 (1.97%) patients with Mirizzi syndrome: 9 (37.5%) with type I, 10 (41.67%) with type II, 4 (16.67%) with type III and 2 (8.33%) with type IV. There were 14 women and 10 men. Patients in the 6th decade of life dominated. Mirizzi syndrome is rare (2% in our case), it causes obstructive jaundice, sometimes dangerous, and serious complications, and it is necessary to take into consideration before and intraoperatively the possibility of an existence of Mirizzi syndrome.

334

GALLBLADDER TORSION AS A CAUSE OF ACUTE ABDOMEN: CASE REPORT

Kayalibag E, Aydin T, Yazici S, Karatepe O, Baglar B

SSK Okmeydani Egitim Hastanesi, Istanbul, Turkey

Torsion of the gallbladder, as reported in <300 cases in the literature, is a very rare cause of acute surgical abdomen. Recently the increasing frequency of reports indicates a higher incidence than previously suspected. Accurate reporting of the actual rate of occurrence is needed so that torsion of the gallbladder can appropriately be considered in the differential diagnosis of patients with a right-sided acute surgical abdomen. The diagnosis, usually, can only be made at the time of exploration. The torsion occurs at the base of the gallbladder, around the cystic duct and cystic artery. The condition may be suspected in an elderly patient, known to suffer from acute cholecystitis, with signs and symptoms of toxemia. The only treatment, obviously, is emergency cholecystectomy. One case is presented to help define the true incidence of this process.

335

XANTHOGRANULOMATOUS CHOLECYSTITIS: IS IT POSSIBLE TO ACHIEVE A PREOPERATIVE DIAGNOSIS?

Fragiadaki E, Karatsis P, Kostakis G, Vrekoussis Th, Stavrakis J, Kounounas Th, Finokaliotis M, Kourtis D

District General Hospital of Agios Nikolaos, Department of General Surgery, Crete, Greece

Aim: The transformation of a common cholecystitis to xanthogranulomatous cholecystitis takes place when the inflammation expands into the Rokitanski-Aschoff crypts of the gallbladder mucosa. We present the differential diagnosis of xanthogranulomatous cholecystitis in comparison with gallbladder carcinoma, while we analyse 3 cases treated in the last 5 years.

Methods: Between 1997 and 2002, 455 laparoscopic cholecystectomies were performed. Of these, 3 (0.65%) cases were proved to be xanthogranulomatous cholecystitis by histological means. Female:male ratio was 2:1. In all 3 of them, severe inflammation coexisted with increased thickness of the gallbladder wall.

Results: Laparoscopic cholecystectomy was performed successfully in every patient. In one male patient histological diagnosis revealed coexistent gallbladder carcinoma. The characteristic histological lesion is diffuse infiltration by inflammatory cells as well as by foam cells.

Conclusions: (1) Preoperative diagnosis of xanthogranulomatous cholecystitis is quite impossible. (2) Symptoms mimic either acute or chronic cholecystitis. (3) U/S or CT scan do not seem to be useful in the diagnostic setting. (4) Intraoperative diagnosis is based on the local findings as well as the degree of suspicion for the referred entity. (5) Since laparoscopic cholecystectomy is the method of choice in the treatment of cholelithiasis it would be important to set a preoperative diagnosis in order to achieve an extended surgical resection.

336

LAPAROSCOPIC MANAGEMENT OF ACUTE EMPHYSEMATOUS CHOLECYSTITIS: CASE REPORT

Tzovaras G, Mantzos F, Fafoulakis F, Hatzitheofilou C

Department of Surgery, University Hospital of Larissa, University of Thessaly, Larissa, Greece

A 68-year-old man presented to the Emergency Department of our hospital with a 48-h history of deteriorating epigastric and right upper quadrant pain, associated with nausea, vomiting and fever. From his past medical history he had an aortic valve replaced 5 years earlier and was on oral anticoagulants. Clinical examination revealed a positive Murphy's sign, a temperature of 38 °C, leukocytosis (WCC 30.400 with 94% polymorphs), prothrombin time of 21 sec, a total bilirubin of 2.8 mg/dl with normal direct bilirubin and the rest of liver function tests. The clinical diagnosis of acute emphysematous cholecystitis was confirmed by an impressive picture on plain X-ray abdominal films, which showed the gallbladder full of air along with the presence of air within the gallbladder wall, a typical picture of the condition. Abdominal ultrasonography confirmed the diagnosis. The patient was treated initially with antibiotics and i.v. fluids with a view to attempting laparoscopic cholecystectomy as soon as the coagulation profile would permit. After a 36-h replacement of oral anticoagulants with heparin and prothrombin time normalization, the patient was taken to theatre. The procedure was completed laparoscopically with no particular difficulty regarding identification of the Calot's triangle structures. A corrugated drain was inserted and remained for 24 h. The patient was fed orally and was recommenced on oral anticoagulants on the first postoperative day. He was discharged on postoperative day 3 and reviewed after 10 days as an outpatient; he was extremely well at the time.

Conclusion: Laparoscopic cholecystectomy can be performed safely even in a severe form of acute cholecystitis, such as emphysematous cholecystitis. Experience with the ‘difficult case’ resulting from a policy of laparoscopic management of acute cholecystitis during the acute phase is mandatory.

337

EFFECTIVE DIAGNOSIS OF PATIENTS WITH SLUDGE CHOLECYSTOPATHY USING ULTRASOUND AND CT SCAN BEFORE LAPAROSCOPIC CHOLECYSTECTOMY

Kyriakidis A, Amet R, Panaritis V, Sioka C, Anagnostopoulou E, Alexandris H, Raffo L, Aggelidis G Amfissa, Greece

Aims: To examine if the method of computerized tomography of the abdomen is effective for diagnosis of patients with sludge cholecystopathy, complementary to ultrasound, before a cholecystectomy when necessary.

Methods: 476 patients with upper abdominal pain were evaluated in our hospital in 1 year. All the patients were examined clinically, followed by U/S and CT scan control.

Results: Using the U/S technique, among the 476 patients examined, 197 patients had gallstones, 21 patients had biliary sludge and the rest of the 258 patients had findings unrelated to GB pathology. The subsequent CT scan of the abdomen verified the results of the ultrasound. We have estimated the density values of the GB lumen in 3 different levels, both by classical approach and histogram. The mean values in GBs with dense content were between 18 and 27 HU. On the contrary, normal GBs had values of 3–10 HU. The most frequent clinical findings in the 21 patients were tenderness to palpation in the right upper abdominal region, abdominal discomfort, nausea and vomiting. The laboratory examination demonstrated increase of transaminase values. Among the 21 patients, 9 had repetitive acute symptoms and underwent cholecystectomy.

Conclusion: It seems that CT is an effective complementary method for the diagnosis of biliary sludge.

338

SUBCAPSULAR HEMATOMA OF THE LIVER: A RARE COMPLICATION OF HEPATIC HEMANGIOMA DURING LAPAROSCOPIC CHOLECYSTECTOMY (CASE REPORT)

Antsaklis G, Economou N, Fotopoulos A, Alexiou C, Konstantinidou E, Antsaklis P, Karanikas I

Department of Surgery, “Sismanoglion” General Hospital, Athens, Greece

Various complications following laparoscopic cholecystectomy have been reported. Some of them are not recognized during the laparoscopic procedure which they are detected during an open cholecystectomy. Our purpose is to present a serious and extremely rare complication of this surgical procedure. A male patient aged 73 underwent a laparoscopic cholecystectomy for cholelithiasis. Preoperatively, the hematocrit value was 38% and the US study showed, apart from cholelithiasis, the presence of 1–2 liver hemangiomas. The operation was uneventful. On the 1st postoperative day the patient developed hemodynamic instability. On physical examination he had a blood pressure 80/50 mmHg and pulse rate 120/min, while blood was noted to be present in tube drainage. The hematocrit was 19.9%. Immediate blood transfusion was carried out and CT scanning showed the presence of a large subcapsular hematoma of the right lobe of the liver. The patient was managed conservatively with transfusions of blood, fresh frozen plasma and platelets. The patient was hemodynamically stabilized on the 6th postoperative day and a new CT scan showed no changes in the subcapsular hematoma. The patient was discharged home on the 23rd postoperative day. In conclusion, serious and rare complications, which are difficult to prevent, may occur following laparoscopic cholecystectomy. Subcapsular hematoma of the liver is one of them and early recognition and management are mandatory in order to avoid lethal results, especially when the preoperative study has shown the presence of liver hemangiomas which jeopardize the patient's outcome.

339

GALLBLADDER PERFORATION

Kucuk C, Sozuer E, Ok E, Yucel M A, Yilmaz Z

Department of General Surgery, Erciyes University Faculty of Medicine, Kayseri, Turkey

Gallbladder perforation is a rare but important complication of acute cholecystitis. Traditionally, gallbladder perforations are classified as either: Type I, acute free perforation with bile-stained peritoneal fluid: Type II, subacute perforation with pericholecystic abscess: Type III, chronic perforation with formation of cholecysto-enteric fistula. Between January 1996 and October 2002, in this department, 79 cases with gallbladder perforation were evaluated retrospectively. There were 52 (65.8%) females, 37 (34.2%) males and the median age was 59.4 years (31–90). Type I was detected in 49 (62%) cases, type II in 13 (16.4%) cases and type III in 17 (21.5%). The incidence of severe systemic disease was more common in type I as compared with others (p<0.05). Cholecystectomy were performed in 41 (51.8%) cases, cholecystectomy and additional surgical procedures in 38 (48.1%). In the early postoperative period, 7 (8.8%) cases died due to sepsis. They were also Type I cases. Type I having high morbidity and mortality rate, needs an immediate preoperative diagnostic approach. Early cholecystectomy for acute cholecystitis appears to reduce the morbidity and mortality caused by a delay in diagnosis.

340

EARLY LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS: IS IT SAFE?

Karanikas I, Alexiou C, Tsimpoukidi O, Gouliamas S, Karydakis P, Antsaklis G

Department of Surgery, “Sismanoglion” General Hospital, Athens, Greece

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic uncomplicated gallstone disease. However, the application of laparoscopic procedures in the management of acute cholecystitis is still controversial. The aim of this study was to evaluate the efficacy, feasibility and safety of laparoscopic cholecystectomy applied to patients with acute cholecystitis. Laparoscopic cholecystectomy was carried out in 698 patients (307 men and 391 women), aged 25–88 years, during a 7-year period. From those 142 were operated for acute cholecystitis. A subhepatic tube drainage was inserted in all patients. Intraoperatively, in 71 cases there was difficulty in clarifying the anatomy due to inflammation. This significantly increased the mean operative time compared with the remaining cases (82 vs 108 min, p<0.05). Post-operatively, bile leaks were noted in 4 (2.8%) patients. The initial treatment was conservative and the bile leak resolved spontaneously in 2 patients. In the other 2 cases with a prolonged bile loss, ERCP and stent insertion in the common bile duct was performed with success. No other major complication occurred. The mean postoperative hospital stay was 3.8 days. Histopathology confirmed acute cholecystitis in all patients. In conclusion, the results of our series demonstrate the safety and effectiveness of laparoscopic cholecystectomy in the management of acute cholecystitis, as it was associated with a low postoperative morbidity rate and early patient discharge.

341

PROTEIN C AS EARLY MARKER OF SEPTIC CASCADE DURING SEVERE HPB INFECTIONS

Karamarkovic A, Stefanovic B, Djukic V, Mihailovic V

University Center for Emergency Surgery, Belgrade, Yugoslavia

Aim: Severe HPB infections with sepsis syndrome are still associated with high mortality rate (40–60%). Plasma proteolytic disturbances during severe HPB infections play a significant role in the pathophysiological changes seen in sepsis. In the competition among laboratory tests and modern imaging techniques, early detection of the plasma cascade system disturbances is a very important diagnostic step.

Methods: This prospective study refers to the diagnostic and predictive importance of protein C in severe hepato-biliary and pancreatic infections.

Results: In the prospective study we investigated plasmatic proteolytic cascade activity during severe HPB infections (33 patients with perforative cholecystitis, cholangitis, hepatic abscess, infected necrotic pancreatitis, peritonitis from HPB origin), and also in the control group (20 patients with inguinal hernia) by daily evaluation of aPTT, antithrombin III, protein C, plasminogen, alpha 2 antiplasmin, C5-a and C5-B9 complements, Cl inhibitor, alpha 2 macroglobulin and HMWK. The mean APACHE II score was 16 points, with actual mortality of 21% vs 36% of predictive mortality rate. All evaluated parameters were different in the HPB and control groups, with high significance (p < 0.001). The results and multivariate regression statistical analysis revealed the following parameters as very sensitive biological markers of septic cascade (p 0.0001–0.026): AT III, protein C, HMWK, C5-B9, Cl-INH, alfa-2 macrogloulin. Protein C was the most statistically significant parameter by multivariate analysis (p < 0.0001) for early diagnosis of sepsis, and as an important predictive value. Also, we made the Prognostic Plasma System (PSS) on the basis of the mentioned results.

Conclusion: The clinical difficulties of sepsis during severe HPB infections are due to inherent problems of the limited clinical signs and the complexity of the distribution of infection. The systemic inflammatory process is often well under way before the clinical signs and symptoms of sepsis are present. Early diagnosis of septic cascade is very important from the diagnostic and therapeutic point of view, and protein C plays a very significant role as an early marker of sepsis.

Biliary – Miscellaneous

(DOI 10.1080/16515320310001183)

342

TREATING OBSTRUCTION OF EXTRAHEPATIC BILE DUCTS IN ELDERLY PATIENTS

Dervisoglou Ath, Papavassileiou A, Meimaris G, Ioannidis C, Arnaoutos S, Pinis S

2nd Department of Surgery, General State Hospital of Pireus, Pireus, Greece

Aim: In this retrospective study, we present our experience from treating patients aged 65 years old and over suffering from extrahepatic billiary duct obstruction.

Methods: In 1995–2001 we treated 408 patients suffering from extra-hepatic billiary duct and pancreas ailments. 83 patients (20.3%), i.e. 51 male and 32 female, mean ages 79.5 and 73.2 years, respectively, suffered from extrahepatic billiary duct obstruction. 72 patients suffered from common bile duct obstruction due to cholelithiasis, 4 due to an adenocarcinoma in the extrahepatic ducts, 5 due to a carcinoma located on the head of the pancreas, and 2 due to a pseudocyst in the pancreas. From the aforementioned 83 patients, 48 underwent surgery (cholecystectomy + Kehr or billiary-jejunal anastomosis) while 35 were treated using ERCP.

Conclusions: Following the study of our material, and noting that ERCP has been carried out in our clinic for the past few years, we reach the conclusion that using ERCP to treat patients suffering from extrahepatic billiary duct obstruction has not only diagnostic but also therapeutic value. It is strongly recommended for elderly patients as it is a relatively simple method of intervention in comparison with laparotomy and common bile duct exploration, that will naturally be conducted whenever it is not possible to use ERCP.

343

USE OF DUODENAL STUMP AS AN ISOLATED LOOP FOR BILIARY DRAINAGE IN PATIENTS WITH PREVIOUS BILLROTH II PARTIAL GASTRECTOMY

Kotru A, Halazun K, Prasad KR, Menon K

St James’ University Hospital, Department of HPB Surgery, Leeds, UK

Background: Choledochoduodenostomy is associated with a higher risk of complications than a biliary drainage into an isolated Roux loop, due to reflux of gastric contents into the bile ducts through the anastomosis. We report 2 cases, in whom the duodenal stump was used as an isolated loop for biliary reconstruction.

Methods: Case 1: a 72-year-old lady was admitted with multiple episodes of right upper quadrant pain (RUQ). Her past surgical history includes, a Billroth II partial gastrectomy (BIIPG) for peptic ulcers, an anti-reflux and cholecystectomy. Ultrasound and MR cholangiogram showed a dilated common bile duct (CBD) with 2 stones. An ERCP was attempted but failed, and she underwent a laparotomy and CBD exploration. A biliary reconstruction was performed because of a dilated biliary tree with bile under significant pressure, as well as the fact that future endoscopic interventions would be difficult. The procedure performed was choledo-choduodenostomy using the duodenal stump from previous gastric surgery as an isolated loop. On follow-up, the patient has remained well and symptom-free for the last 8 months. Case 2: a 58-year-old gentleman was admitted with cholangitis. He has an extensive past surgical history, having had a vagotomy and gastroenterostomy in 1973, a fundoplication in 1978, revision of the gastroenterostomy in 1987, BIIPG in 1993 and an open cholecystecomy and bile duct exploration in 2001. He underwent an MRCP, which showed dilated extrahepatic ducts and filling defects in the CBD. He went on to have an ERCP which was unsuccessful. After a further admission with cholangitis, he underwent a bile duct reconstruction. At the time of surgery, he was found to have a dilated CBD and CHD with a tight stricture. He underwent a hepaticoduodenostomy involving anastomosis with the duodenal stump. At 9 months follow-up he remains symptom-free.

Conclusion: Duodenal stump, in patients who had BIIPG, can be safely used as an isolated loop for biliary reconstruction. It is also technically easier because of the close proximity of the bile duct and duodenum. This procedure also avoids pancreatico-biliary diversion.

344

HOW TO OBTAIN GOOD RESULTS IN THE TREATMENT OF BENIGN HIGH BILE DUCT STRICTURES?

Galperine E, Chevokin A, Dyuzheva T, Garmaev B

Moscow Sechenov Medical Academy, Moscow, Russia

Aim: To improve results of treatment of patients with benign high bile duct strictures.

Methods: 201 patients with benign bile duct strictures Bismuth III–V were observed (1988-2002). There was chronic cholangitis in 106 (53.4%), obstructive jaundice in 66 (32.8%), intrahepatic abscesses in 23 (11.6%), secondary biliary liver cirrhosis with portal hypertension in 17 (9%), intrahepatic cholangiolithiasis in 37 (19.6%) patients. The precise bilioenteric anastomosis was procedure of choice. To mobilize the proximal part of unaltered bile ducts the dissection and bringing down of hilar plate were used in all patients, and 31 of them also underwent IV and V segments resections. Confluence reconstruction was performed in 13 patients. Transhepatic drainage was used in 31 (19%) patients with extended cicatrical lesion.

Results: Perioperative mortality was 4.4% (7 patients): 6 patients died from abscessing cholangitis, 1 from intraperitoneal bleeding. Short-term results: complications were observed in 117 (58.2 %) patients. 16 of them required different procedures. Long-term results were studied in 140 (87.5%) patients over 1–14 years (average 6.3 years). 8 patients underwent re-laparotomy. 14 patients died in remote period: from liver cirrhosis decompensation 3, liver abscess 1, serious concomitant diseases 10. Results were estimated as ‘excellent’ and ‘good’ in 117 patients.

Conclusion: The special technique of unaltered bile duct mucosa separation allows the formation of precise bilio-enteric anastomosis for high benign bile duct strictures with good long-term results.

345

APPROACH IN OBSTRUCTIVE JAUNDICE DUE TO BILIARY HYDATIDOSIS

Ovejero V, Gonzales-Pinto I, Barneo L, Vazquez L, Miyar A, Rodriguez-Vigil R, Martinez E

University of Oviedo, Hospital Central Asturas, Oviedo, Spain

Background: Liver is the most common localization of hydatidosis. Only a few patients are asymptomatic all through their life. There are a great variety of complicated forms. Communication of a hydatid cyst with the biliary system can be observed in approximately one quarter of cases. The expulsion of hydatid sands or daughter cysts towards biliary tract may originate jaundice. The aim of this study is to present 3 cases without preoperative suspicion of hydatidosis and unsuccessful diagnosis of complicated biliary lithiasis.

Methods and Results: The age of the patients was 70, 44 and 34, respectively. One had a past medical history of liver hydatidosis, another had a traffic accident, some days before. They complained of icteric syndrome, vomiting and abdominal pain. The diagnosis was biliary lithiasis by imaging studies. We performed the following surgical procedures. Case 1: cholecystectomy, choledochotomy, drawing out of a daughter cyst and choledochoduodenostomy. Case 2: cholecystectomy, cystojejunostomy, choledochotomy, transduodenal sphincterotomy and choledochorrhaphy leaving a T-tube. Case 3: cystectomy, cholecystectomy and choledochotomy leaving a T-tube. The only post-surgical complication was a haemorrhagic gastritis.

Conclusion: The finding of biliary lithiasis is not a unique explanation of jaundice. Past medical history of hydatidosis and a recent onset of obstructive jaundice should to be a reason to suspect the diagnosis. There are several operative procedures for the management of complicated forms but exploration must be careful to reduce the risk of peritoneal soilage. Nowadays, endoscopic retrograde cholangiography and percutaneous drainage are becoming a useful approach in its treatment.

346

RIGHT SIDE HEPATIC RESECTION FOR INTRAHEPATIC DUCT STONE

Moon JI, Moon HJ, Choi SH, Joh VJ, Heo JS, Yong IK

Department of General Surgery, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea

Aim: The best treatment for primary intrahepatic duct stone is hepatic resection. Sometimes, however, in right side intrahepatic duct stone, hepatic resection has been considered an excessive treatment because of larger hepatic volume than that of the left side. The authors evaluated the effectiveness and safety of right side hepatic resection for intrahepatic duct stone.

Methods: Between Oct. 1994 and May 2002, 22 patients underwent right side hepatic resection for intrahepatic duct stone. Data on perioperative outcome and long-term recurrence were collected retrospectively.

Results: There were 15 right hepatectomies, 3 right hepatectomies with left lateral sectionectomy and 4 right posterior sectionectomies. 6 patients had left intrahepatic duct stone simultaneously. There was no hepatic dysfunction after resection. In 5 patients, operative complications developed and were resolved through conservative management. In 1 patient, a residual stone was found in the left side intrahepatic duct postoperatively and was removed by endoscopic procedure through the T-tube. During a median follow-up period of 22 months, there was 1 recurrence in the left liver without symptoms.

Conclusion: Right side hepatic resection is a safe and effective treatment modality for intrahepatic duct stone. In particular, combined resection of left lateral section is considered a safe method if patients have both intrahepatic duct stones.

347

PROBLEMS IN REOPERATIONS OF THE BILIARY TRACT

Daskalakis K, Varada E, Daskalaki D, Krassas A, Diamantopoulos G

Evagelismos Hospital, Athens, Greece

Aims: The aim of this study is to describe the problems in diagnosis and management of patients who need reoperations of the biliary tract. Methods: During the last 14 years (1989–2002), 127 patients who needed reoperations on the biliary tract were managed in our hospital. 65 were males (mean age 65.2 years) and 62 females (mean age 67.3 years). 139 reoperations were performed in these 127 patients. The cases of reoperations were: choledocholithiasis 68, pancreatic cancer 10, extra-hepatic biliary tract cancer 11, recurrence of hydatid cysts 8, injuries and stricture of the bile duct 10, bilious peritonitis 12, complications of acute pancreatitis 12 and remaining choledocholithiasis 8. The following procedures were performed: Whipple procedure 3, primary closure of the common bile duct 11, T-tube insertion 31, bilio-enteric bypass 73, transduodenal sphincteroplasty 7, end-to-end anastomosis of the common bile duct 1 and miscellaneous procedures 13.

Results: Mortality rate: 5.5% (7 patients). Reoperations for complications: 12 patients (9.5%). Morbidity rate: 19.6% (25 patients). Mean hospital stay: 13.4 days.

Conclusions: The problems in diagnosis and surgical management of the patients who had previous operations of the biliary tract and who need to submit reoperations are difficult. The surgical experience and the choice of the proper operation are critical for satisfactory results.

348

LATE COMPLICATIONS AFTER EXCISIONAL OPERATION FOR CHOLEDOCHAL CYST

Yoon YS, Kim SW, Jang JY, Ahn YJ, Park YH

Seoul National University College of Medicine, Seoul, Korea

Aims: Even after excision of choledochal cyst, different complications can develop. This study was conducted to examine the long-term outcome of cyst excision.

Methods: Of 50 choledochal cysts over a 10-year period (1991–2000), excluding cancer and rare types, 39 patients, who underwent cyst excision, were reviewed to evaluate late outcome.

Results: 35 patients (previous cystoenterostomy in 4 patients) underwent cyst excision (pancreatoduodenectomy (PD) in 3 patients). 4 patients who had a history of cyst excision, underwent reoperation during this period: excision of distal residual cyst (1) and PD (1), revision of hepaticojeju-nostomy (2). Median follow-up period was 24 months after operation. Late complications (5 cholangitis, 4 pancreatitis, 3 intrahepatic stone without cholangitis, 1 liver abscess, and 1 periampullary cancer) developed in 14 (35.9%) patients. Of 5 patients with cholangitis, 2 patients underwent balloon dilatation due to anastomotic stricture and 1 patient had left lateral sectionectomy for remaining intrahepatic cyst. The remaining 2 patients developed cholangitis because of incomplete excision and they underwent choledochoscopic stone removal for stone and conservative management. 2 patients developed pancreatitis due to pancreas divisum and probably due to residual distal cyst. The symptoms were mild and improved by conservative management. Intrahepatic stone without cholangitis and liver abscess was conservatively managed. Periampullary cancer with multiple seeding developed 18 months after cyst excision in 1 case.

Conclusion: To minimize hepatopancreatobiliary complications and malignancy after cyst excision, complete excision of extrahepatic bile duct should be performed. Moreover, long-term follow-up is necessary because of these late complications.

349

AGENESIS OF THE GALLBLADDER. A CASE AND REVIEW OF THE LITERATURE

Helavacioglu Y, Karatepe O, Battal M, Kayalibag E

SSK Okmeydani Hospital, 2. Department of Surgery, Istanbul, Turkey

Ultrasonography has evolved into a non-hazardous relatively inexpensive means of diagnosing biliary tract disease. It is considered to have a 95% sensitivity for the diagnosis of cholelithiasis. Occasionally, a small contracted gallbladder associated with stones and chronic cholcystitis will be difficult to visualize with ultrasonography. One patient with agenesis of the gallbladder was recently treated by the authors. A patient had ultrasonographic evidence suggestive of a contracted gallbladder with stones. The patient was explored and found to have absent gallbladder. Agenesis of the gallbladder with normal bile ducts is a rare congenital condition ocurring in 13–65 per 100,000 population, probably from failure of the gallbladder bud to develop or vacuolize in utero. Adults are usually asymptomatic. Approximatelly 220 cases have been reported in the literature. Most of these are from necropsy studies. Many of these were newborns with more serious anomalies. One might project an increase in adult cases on the basis of increased usage of ultrasonography in patients with abdominal problems. At the present time, only operative findings including cholangiography can be considered as diagnostic of gallbaldder agenesis. However, as more of these cases are reported, preoperative awareness of this entity will be increased.

350

FIRST CASE OF INTRAPERITONEAL BRONCHOGENIC CYST

Kim KH, Lee SK, Yoo YK, Kim JS, Chin HM, Park IY, Kim DG, Lim KW

Catholic University, Uijongbu St Mary's Hospital, Seoul, Republic of Korea

Bronchogenic cyst is derived from embryologic branchial cleft. Its origin is mainly pulmonary and it is rarely located in extrathoracic sites such as subdiaphragmatic retroperitoneal area. Most of them originate from vestiges of embryonic blastemas. Their inner lining is usually compatible with either a mesothelial or mesonephric origin. Bronchogenic cysts are developmental abnormalities of the primitive foregut that are usually found above the diaphragm, especially in the mediastinum and particularly posterior to the carina. Rarely, they can occur in a subdiaphragmatic location, and a retroperitoneal position is distinctly unusual. To our knowledge, there have been only 22 cases reported in the world literature, 16 of which have been in the English language. We present the first Korean case of intraperitoneal bronchogenic cyst, which was located at inferior surface of the liver, beside the gallbladder and clinically mimicking gallbladder tumor. A 48-year-old woman was admitted to our hospital because of intermittent, right upper quadrant abdominal pain. Computed tomography showed a large mass beside the gallbladder. During laparotomy, the mass showed ovoid cystic nature attached to normal gallbladder and liver bed. Cyst excision with cholecystectomy was performed. Histopathological diagnosis was bronchogenic cyst. Most bronchogenic cysts have a benign nature, but malignant changes have been reported. Therefore, if a cystic tumor of the abdomen is suspected in preoperative diagnosis, bronchogenic cyst should be considered as one of the differential diagnoses.

351

CASE SERIES OF BENIGN CAUSES OF PORTAL VEIN THROMBOSIS

Surash S, Kotru A, Prasad RK, Toogood G, Lodge P

St James’ University Hospital, Department of HPB Surgery, Leeds, UK

Portal vein thrombosis (PVT) is an uncommon disorder. It has a bimodal age distribution, occurring in both children and adults (mean age 6 and 40 years, respectively). The risk factors for the development of PVT include infection, cirrhosis, malignancy and inflammation. Biliary tract disease causing PVT is usually malignant in origin. Benign disease causing PVT is less common. Presented in this report is a case series of patients with documented benign causes of PVT. Case 1. A 53-year-old female was admitted to a referring hospital with upper abdominal pain. She had a history of gallstones and abnormal liver function tests alluded to a diagnosis of cholangitis. Abdominal CT showed stones in the common bile duct; however, the liver had multiple areas of infarct and a thrombosed right portal vein. At laparotomy, a stone was extracted and a T-tube inserted. Postoperatively, she deteriorated with intra-abdominal sepsis, further imaging showed more extensive infarct in the right lobe. She was transferred to us and at further laparotomy debridement of the infarcted lobe was performed. Within weeks she improved and a T-tube cholangiogram showed no leak. She was transferred back to her referring hospital and has made a good recovery. Case 2. A 79-year-old female was admitted with upper abdominal pain and weight loss. She had a previous left hepatic duct stricture stented and removed on normalisation of the liver function tests. Imaging of her liver on this admission showed dilated bile ducts, a lymph node at the hilum and a thrombosed left portal vein. A cholangiocarcinoma was suspected. Diagnostic laparotomy showed an atrophic left lobe. Lymph node biopsy showed reactive follicular hyperplasia and gallbladder pathology showed chronic cholecystitis with dense lymphoid infiltrate. She made a good recovery. Two cases of benign disease causing PVT are documented here. In both patients, surgical intervention resulted in a good outcome.

HPB – Endoscopy

(DOI 10.1080/16515320310001192)

352

PANCREAS DIVISUM: RESULTS OF A SERIES OF 3700 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHIES

Fuentes J, Uribarrena R, Serrablo A, Garcia S, Uribarrena R, Simon MA

Departments of Gastroenterology and Surgery, Miguel Servet University Hospital, Zaragoza, Spain

Background: Pancreas divisum is the most frequent congenital anomaly of the pancreas. Only 5% of patients have symptoms or complications. Aim: To evaluate associated pathology of pancreas divisum in a series of 3700 endoscopic retrograde cholangiopancreatographies (ERCP).

Methods: Retrospective analysis of ERCP carried out between 1992 and 2002. Information was obtained from the database and discharge cards when necessary. Statistical analysis comprised comparison of results with the overall results of all ERCP with the appropriate tests.

Results: Between 1992 and 2002, 3700 ERCP were performed. In 28 (0.7%) pancreas divisum was found. Pancreatits was the indication in 7 of the patients (25%). In the rest of the cases ERCP was performed because of cholestasis or jaundice, with 6 patients (21.4%) with normal ERCP. Choledocholithiasis was found in 6 cases (21.4%), benign stenosis in 1 (3.5%) and neoplasms of the biliary system in 5 (17.8%). Cannulation of choledocho lithiasis was not achieved in 2 cases and in 1 patient the indication was neoplasm, not confirmed by ERCP.

Conclusions: Prevalence of pancreas divisum in this series is lower than that communicated in the English literature (2–7%). We have found a high frequency of pancreatitis and malignant neoplasms of biliary system in patients with pancreas divisum, which is higher than the other published series.

353

INTRAHEPATIC CHOLEDOCHOJEJUNUM ANASTOMOSIS FOR BENIGN STRICTURES

Triantafyllidis S, Tsaniklides E, Vontas C, Pantazis E, Giannakakis A, Skaltsas S

1st Surgical and Endoscopy Unit, Patission General Hospital, Athens, Greece

Intrahepatic jejunum anastomoses are commonly complicated with stenosis, mainly due to bile leakage. Benign strictures are usually postoperative (90%), mainly after simple cholocystectomy (90%), when damage of bile ducts has occured. Reoperations reconstructing anastomoses or transhepatic dilatation of the stricture are associated with high percentages of morbidity and mortality. The most popular strategy is to perform a Roux-en-Y hepaticojejunostomy and fixation of the blunt end of the loop in the abdomen wall. In order to achieve easy access to the anastomosis we suggest the fixation of the access loop to the duodenum so that access to the anastomosis can easily be achieved endoscopically if needed. In our experience 3 cases with high bile duct trauma were treated by the above suggested operation. Postoperatively, these 3 patients had no complications. The anastomosis was easily accessible endoscopically for any further manipulations needed. In the follow-up 1 patient developed stenosis of the hepaticojejunostomy and endoscopic dilation of the stricture was easily performed.

354

DUODENAL VILLOUS ADENOMA CAUSING MECHANICAL JAUNDICE AND INCIDENTAL POLYPOSIS COLI

*Akaydin M,**Kalafat H, Kaplan R, Celebi F, Gunes Z, Akcakaya A

*SSK Vakif Gureba Hospital, 2. Surgical Clinic, **Istanbul University Cerrahpasa Medical Faculty, Hepatopancreatobiliary Surgery, Istanbul, Turkey

ERCP was planned for a 40-year-old mechanically obstructed female patient. Before the procedure the biochemical tests including bilirubin, alkaline phosphatase, AST, ALT and GGT were found to be elevated. Ultrasonography showed that both intra- and extrahepatic bile ducts were dilated. During the ERCP examination a mass of 3 cm diameter originating from lower papilla was observed. Also selective choledochus cannulation showed that both the choledochus and intrahepatic bile ducts were dilated. Bile flow was supplied by sphincterotomy. The pathologic diagnosis of the biopsy material taken from the mass was villous adenoma. Gastric and small intestinal examination was normal. However, colonoscopic examination revealed multiple polypoid lesions in the large bowel. The pathologic diagnosis of the biopsies was mild to severe dysplastic changes. Total proctocolectomy, j pouch ileoanal anastomosis and local excision of the duodenal lesion were performed. The histopathological examination of the duodenal villous adenoma showed no malignancy. However, at a single localization at the sigmoidal colon, well differentiated adenocarcinoma was diagnosed histopathologically. This case shows that extracolonic lesions are very important in the diagnosis of polyposis coli syndrome.

HPB – Laparoscopy

(DOI 10.1080/16515320310001219)

355

FATAL INTESTINAL ISCHEMIA AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Sevinc A, Astarcioglu H, Koskderelioglu M, Karademir S, Coker A, Astarcioglu I

DE University Hospital, Izmir, Turkey

Pneumoperitoneum during laparoscopic cholecystectomy was shown to decrease splanchnic blood flow, which may result in irreversible ischemic injury to abdominal organs. We report here a 55-year-old male who developed acute intestinal ischemia after laporoscopic cholecystectomy (LC) performed for acute cholecystitis. After an uneventfull LC, on postoperative day 2, the patient had an abdominal pain, nausea, vomiting and diarrhea. Abdominal USG and hepatobiliar scintigraphy, which were performed to detect possible biliary leakage or other injury, were normal. The patient's clinical condition deteriorated about postoperative day 5 and no amelioration was obtained despite aggressive resuscitation. Laparoscopy was performed on the 9th postoperative day. Exploration showed necrosis of all small intestinal segments till transverse colon. We converted the operation to an open procedure. Pulsation of superior mesenteric artery was absent. Total small intestinal resection and extended right colectomy were performed in the hope of performing small intestinal transplantation in case the patient's clinical condition ameliorated. On postoperative day 3, anastomotic leakage was observed and the patient was lost due to respiratory distress syndrome on postoperative day 5. In conclusion, preexisting impairment of splanchnic blood flow seems to be particularly dangerous because pneumoperitoneum during LC leads to further decompensation. Mesenteric ischemia should be considered in the differential diagnosis of patients developing abdominal symptoms after LC.

356

LAPAROSCOPIC-ASSISTED SURGERY FOR LIVER DISEASES

Fukuda Y, Nishii H, Ogasawara K, Kondo Y, Aoki Y, Toba S

Takamatsu Municipal Hospital, Takamatsu-city, Kagawa, Japan

Background: The recent advances in laparoscopic techniques and instruments enabled us to make laparoscopic approaches to hepatic diseases with minimal invasiveness. We report 2 cases of laparoscopic-assisted surgery for liver diseases.

Methods and Results: Case 1: laparoscopic-assisted hepatectomy. A 71-year-old man was admitted for liver tumor located in segment VI. CT angiography revealed hypervascular tumor 1.5 cm in diameter. Hepatic function was very good as, ICGR15 9.5%, total bilirubin 1.0 mg/dl. Before the liver dissection, a small incision was made of right subcostal lesion 6 cm in length to assist the hemostasis and remove the specimen. After the ablation of marked dissection line, using a microwave coagulation device, parenchymal transection was performed using harmonic scalpel laparoscopic coagulation shears (LCS) and Cavitron ultrasonic surgical aspiration. Algon beam coagulator (ABC) and fibrin tissue-adhesive collagen fleece (TachoComb) were administered for hemostasis of the raw surface of the liver. Case 2: laparoscopic wide deroofing of non-parasitic large liver cyst. A 58-year-old woman was admitted for non-parasitic liver cyst, which was located in lateral segment of the liver, 12 cm in diameter. After the initial decompression by aspiration, a wide deroofing using LCS was performed. KTP/YAG laser and ABC were applied for the prevention of serous discharge from the intima of the cyst.

Conclusions: Laparoscopic surgery has the advantage of less pain, less invasion compared with traditional laparotomy. Tumors located in superficial or ventral side of the liver and cystic diseases should prefer a laparoscopic- (assisted) method.

357

LAPAROSCOPIC LIVER RESECTION: DIAGNOSTIC AND THERAPEUTIC ROLE

Shah SR, Desai D, Joshi A, Abraham P

PD Hinduja Hospital, Bombay, India

Aim: Minimal access surgery is rapidly replacing laparotomy in the management of various abdominal disorders. Experience with laparoscopic liver resection is limited. The aim of this study is to present our early experience with laparoscopic liver resection in the management of liver disease.

Methods: Case 1. A 56-year-old man presented with epigastric discomfort and a large epigastric lump. Imaging revealed multiple large cystic lesions almost replacing segments 2 and 3 of the liver, and extending into segment 4b, suggestive of hydatid disease, although the serology was negative. Laparoscopic biopsy of the cyst wall obtained after sterilizing the cyst with povidone-iodine was suggestive of polycystic liver disease. A laparoscopic left lateral hepatectomy was successfully accomplished without need for transfusion, with the patient being discharged 72 h after surgery. Case 2. A 50-year-old man with chronic abdominal pain for 2 years and persistent eosinophilia had multiple small hyperechoic lesions scattered in segments 4 and 5 on ultrasonography. As these were too small to target by liver biopsy, laparoscopic wedge resection was carried out. Histopathology revealed multiple eosinophilic granulomas suggestive of visceral larva migrans. Conclusion: Laparoscopic liver resections can replace laparotomy in the management of some benign liver diseases.

HPB – Imaging

(DOI 10.1080/16515320310001228)

358

SONOGRAPHIC APPEARANCE OF THE PRESENCE OF GAS IN THE MAIN HEPATIC PORTAL VEIN

Manoli E, Vakaki M, Koumanidou C, Evangelidakis E, Kekis P Agia

Sofia Children's Hospital, Athens, Greece

Aim: The presence of air in the main hepatic portal vein in children is a finding associated with serious underlying conditions that affect the integrity of the bowel wall. In recent literature, a small number of cases with sonographic demonstration of the transient presence of gas in the portal veins as a result of benign conditions have been reported. The purpose of this study was demonstration of the imaging characteristics of the presence of gas in the main hepatic portal vein.

Methods: We describe the sonographic findings of two infants. An ATL machine with 5–8 MHz convex and 5–12 MHz linear transducers was used and the examination was combined with Doppler study. Results: Two infants, 35 days and 8 months old, respectively, were admitted to our hospital with high fever of undefined aetiology. In the abdominal sonogram, heterogeneous liver echotexture was noticed in the first place. The recognition of the portal vein revealed multiple mobile foci moving quickly in the direction of blood flow inside the vascular lumen. Doppler study showed sharp spikes superimposed on the usual Doppler tracing of the portal vein. Gas in the portal vein and main branches was diagnosed. Urinary tract infection complicated with septicemia was identified in both cases. The second sonogram, performed after appropriate therapy, was normal.

Conclusion: Sonography is undoubtedly highly sensitive in demonstrating portal vein gas, a finding not always related to ischemic bowel wall necrosis in children.

HPB – Miscellaneous

(DOI 10.1080/16515320310001237)

359

PREOPERATIVE AUTOLOGOUS BLOOD DONATION (PAD) IN ONCOLOGIC HPB SURGERY. 2 YEARS OF EXPERIENCE

Serrablo RA, Fuentes J¹, Solano VM², García-Erce JA³, Esarte JM

Unit of Hepato-Pancreato-Biliary Surgery, Department of General Surgery, ¹Digestive Illnesses Department, ²Preventive Medicine Department, ³Haematologic Department, Miguel Servet University Hospital, Zaragoza, Spain

Background: Anemia is common in cancer patients. Transfusion rates from 20 to 50%. Allogenic transfusion complications are widely known being more important in oncologic patients.

Methods and Results: A prospective study was carried out from May 2001 to November 2002 of oncologic patients remitted to our Blood Bank for their inclusion in preoperative autologous blood donation (PAD) and of those it was reserved units of allogenic blood before surgery.

Results: 41 patients were included, 25 were male and 16 women. Mean age was 60.39 years. 48.8% had hepatic metastasis, 43.9% pancreas neoplasia and 7.3% hepatocarcinoma. 39% was admitted to PAD and 31.3% were rejected. 17.1% received treatment with r-hu- erythropoietin. 65.9% were transfused (mean 3.3 units). 81.8% of those admitted were transfused vs 80% of those rejected. The overall hospital stay was 19.6 days. Preoperative hemoglobin level was smaller in those admitted to PAD (12.8% g/l vs 13.1 g/l). The mean of transfused homologous blood units in those included was 2.5 vs 3.5 in those not admitted. The length of hospital stay was 2.2 times in no rejected that admitted in PDA. The major complications occurred in allotransfused patients and alone there was mortality in this group.

Conclusions: PAD is a possible method in oncologic HPB surgery, even in pancreas cancer. It allows reduction of homologous blood transfusion and, therefore, mimimizes their adverse effects. ICU and overall hospital stay could decrease.

360

NOSOCOMIAL INFECTION IN A HEPATO-PANCREATO-BILIARY SURGERY UNIT: DESCRIPTIVE ANALYSIS

Serrablo A, Fuentes J1, Solano VM², Tirado G³, Vázquez P⁴, Uribarrena R¹, Esarte JM, Arribas JL²

Unit of HPB Surgery, Surgery Department, ¹Digestive Illnesses Department, ²Preventive Medicine Department, ³Intensive Care Unit of Miguel Servet University Hospital General Surgery of Albacete Hospital, Zaragoza, Spain

Aim: Nosocomial infections (NI) make up an important problem public health care. In our enviroment, of 3–14% of patients that enter acute hospitals they develop one NI. From an etiologic point of view they are characterized by constant evolution over time. We wanted to know the current situation in our unit regarding micro-organisms and risk factors for developing NI during 1 year.

Methods: A prospective study was carried out. We considered infection according to the CDC approaches. We counted daily during 1 year: dates of charge, discharge, surgical intervention, ASA, intrinsic and extrinsic risk factors, NI, its microbiology, reoperations and exitus.

Results: 486 patients were analysed during 1 year. The mean age was 59.78; 50.54% of the series were male and 12.45% up 80 years old. The surgery was clean-contaminated in 53.68%. There were 112 NI, what supposed an accumulated infection rate of 23.93%. The most frequent NI was surgical infection site (SI) (45.54%). In 75% of those NI it was micro-organism responsible. The most frequently isolated micro-organism was methicillin-resistant Staph. aureus (21.43%). SI was caused by gram-positive cocci in 54.35%. Male sex, time of surgery up 120 min, transfusion, number of intrinsic factors, type of surgery, principal diagnosis and central venous catheter were independent risk factors for development of NI.

Conclusions: It is appreciated a resurgence of gram-positives like reponsible for NI. This could rebound in the empiric antiobiotic policies of our unit. Transfusion is possibly the only amendable factor.

361

PRIMARY ECHINOCOCCAL CYSTS WITH EXTRAHEPATIC LOCATION. A CASE REPORT OF 3 PATIENTS

Karatsis P, Fragiadaki E, Kostakis G, Stavrakis J, Vrekoussis Th, Mitas S

Department of General Surgery, District General Hospital of Agios Nikolaos, Crete, Greece

Aim: To present 3 rare primary locations of echinococcal cysts in viscera.

Methods: Three female patients with echinococcal cysts located in (1) the spleen, (2) the great omentum, (3) the retroperitoneal area. The peritoneal cavity was clear of other echinococcal cysts.

Results: The diagnosis was verified by the pathologist. Post-surgical course was normal. There has been no relapse so far.

Conclusions: Echinococciasis is an endemic disease in Greece. Extrahepatic locations except the lung are considered to be rare. Abdominal U/S as well as CT can have a high diagnostic sensivity. Total resection guarantees the final and complete treatment of the disease.

362

SURGICAL TREATMENT FOR SPLENIC HYDATIDOSIS

Kucuk C, Sozuer E, Ok E, Yucel MA, Yilmaz Z

Department of General Surgery, Erciyes University Faculty of Medicine, Kayseri, Turkey

Hydatid disease of the spleen is a rare clinical entity even in endemic countries. A few authors have conducted specific studies for splenic hydatidosis. The first case of a hydatid cyst of the spleen was reported by Bertelot in 1790 from an autopsy. The spleen is the third most commonly involved organ after the liver and the lung. Between July 1997 and October 2002 a total of 14 patients with hydatid disease of the spleen were treated surgically in this department. During this period, a total of 263 patients with abdominal hydatid disease underwent operation. In consequence, splenic hydatid disease represents 5.3% of abdominal hydatid disease treated in our center. In 5 patients the spleen was the only location of hydatid disease; in 7 patients there was concomitant liver hydatid disease; 1 patient had disseminated intra-abdominal disease; and 1 patient had a coexisting hydatid cyst in the quadriceps femoris muscle. Plain abdominal films, ultrasonography and computed tomography scans were most useful for establishing the diagnosis. All patients underwent splenectomy alone or combined with management of cysts at other sites, except for 2 patients who underwent omentoplasty and 1 patient who underwent external drainage. 3 patients had minor complications. Splenic hydatid disease should be included in the differential diagnosis when a splenic cyst is identified, especially in patients with a history of hydatid disease. In conclusion, splenectomy remains the therapeutic procedure of choice for splenic hydatidosis, offering complete cure of splenic and perisplenic disease with a low mortality rate.

363

SPONTANEOUS ACUTE PORTAL VEIN THROMBOSIS ASSOCIATED WITH THROMBOPHILIA STATES

Shah SR, DasGupta A, Desai D, Joshi A, Abraham P

PD Hinduja Hospital, Bombay, India

Background: Spontaneous thrombosis of the portal venous axis is a rare cause of acute abdominal pain. Few data exist on thrombophilia states in this condition in the Indian population. Methods: A thrombophilia screen was carried out on 3 consecutive patients patients (all male), presenting with acute abdominal pain, documented to have spontaneous portal/superior mesenteric vein (SMV) thrombosis demonstrated on contrast-enhanced abdominal CT scanning.

Results: Factor V Leiden gene mutation with high fibrinogen levels was seen in 1 case, factor V Leiden gene mutation with raised factor VIII levels in the second and protein S deficiency with lupus anticoagulant was demonstrated in the third case.

Conclusions: Underlying thrombophilia states are prevalent in Indian patients with spontaneous portal/SMV thrombosis. The simultaneous occurrence of more than one such condition may lead to an increased risk.

364

PYLEPHLEBITIS AS A COMPLICATION OF ACUTE APPENDICITIS

Park IY, Hur H, Lee JH, Sung GY, Lee DS, Kim W, Won JM

Department of Surgery, Holy Family Hospital, Catholic University of Korea, Seoul, Korea

Pylephlebitis is defined as a septic thrombophlebitis of the portal vein or one of its tributaries, usually secondary to infection in the region drained by portal venous system. Pylephlebitis is extremely rare today but a high mortality rate is associated with this disease. It can be a severe complication of acute appendicitis and other intra-abdominal or pelvic infections. One patient was 54-year-old man. He was admitted with abdominal pain for 7 days. He underwent appendectomy with drainage for periappendiceal abscess. He was discharged on the 9th postoperative day. 4 days later after discharge, he developed high fever and chilling and was readmitted. Abdominal ultrasonography revealed intra-abdominal abscess in the right paracolic gutter and a thrombus in the portal vein. The angiography showed portal vein thrombosis and superior mesenteric vein thrombosis. Reoperation was performed. Antibiotic therapy was continued but his symptoms were not improved. 25 days after second operation, hepatic abscess developed which was treated with percutaneous drainage. He was discharged in good condition on the 45th postoperative day. The second case was 58-year-old woman. She had 3-day duration of diarrhea and high fever and right lower quadrant abdominal pain. Abdominal ultrasonography and computed tomography revealed periappendiceal mass and occlusion of the superior mesenteric vein. Appendectomy was performed and massive antibiotic therapy was applied. She was discharged with no complication. These patients had a favorable outcome with medical and surgical therapy. Early diagnosis, timely administration of antibiotics and institution of surgical therapy are most important for pylephlebitis.

365

OUR EXPERIENCE IN MANAGEMENT OF GASTROINTESTINAL STROMAL TUMORS

Mazis A, Potsis K, Sarakis P, Pappa K, Vrizaki E, Rathosis S, Vlachos C Department of Surgery, Saint Andrew General Hospital, Patras, Greece

We present our experience in management of gastrointestinal stromal tumors during a 3-year period. 4 patients, 3 females and 1 male, mean age 51.5 years, were admitted to our hospital because of a large intra-abdominal tumor and symptoms of malignant disease. One patient had a recurrence of a known stromal tumor, 9 months after the first surgical therapy. 2 patients underwent surgical excisions of the tumors and the other 2 had metastatic and unresectable tumors. 2 patients received imatinib mesylate therapy per os. In a mean follow-up 24.5 months only 1 of 4 patients survived till now. We did not use chemotherapy or radiation in the management of our patients. Gastrointestinal stromal tumors are usually unresectable or metastatic fatal disease. These mesenchymal neoplasms appear to be related to the interstitial cells of Cajal of the myenteric plexus, with which they share certain differentiation markers. These stromal tumors resist conventional cytotoxic chemotherapy and the effectiveness of radiation therapy for this disease has not been proved. Recently, some authors have suggested the use of imatinib mesylate to control the disease, with the patients having better survival rates.