Quicksilver cholecystitis.
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Cholecystitis↗
Biomedical subjects
Francis Sutherland
Publications and source records attributed to Francis Sutherland.
Complex hepatic surgery aided by a 1.5-tesla moveable magnetic resonance imaging system.
BACKGROUND: Resection represents the best treatment for potentially curable liver tumors; radiofrequency ablation (RFA) is an alternative. The curative potential of RFA may be hampered because the extent of burn is difficult to estimate by ultrasound. We postulated that intraoperative MRI (iMRI) would enable a more accurate assessment of ablation completeness. METHODS: We performed open hepatic surgery in an operating room equipped with a unique, retractable 1.5-T magnet. Patients were selected because it was anticipated that RFA (with or instead of resection) was likelihood and that iMRI might be helpful in making intraoperative decisions. After baseline MRI, lesions were further assessed by ultrasound at the time of open surgery. Lesions were resected and/or ablated, and further imaging confirmed the margins of the procedure. RESULTS: Nine patients underwent the procedure: 1 with metastatic carcinoid, 4 with hepatocellular carcinoma, and 4 with colorectal liver metastases. In 4 patients, iMRI had an effect on decision-making. In 5 individuals, there were nonlocal recurrences, and 1 patient who was never disease-free had a local recurrence. COMMENTS: Intraoperative MRI could potentially impact operative decision-making when ablating extensive disease. Its ability to prevent local recurrences must be determined. Moreover, the role of this technology in the overall treatment armamentarium must be defined.
Carcinoma↗
Complications of Meckel's diverticula in adults.
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Adolescent↗
Vascular occlusion to decrease blood loss during hepatic resection.
BACKGROUND: Historically, the primary hazard with liver surgery has been intraoperative blood loss. This led to the refinement of inflow and outflow occlusive techniques. The utility of the different methods of inflow and outflow techniques for hepatic surgery were reviewed. METHODS: A search of the English literature (Medline, Embase, Cochrane library, Cochrane clinical trials registry, hand searches, and bibliographic reviews) using the terms "liver," "hepatic," "Pringle," "total vascular exclusion," "ischemia," "reperfusion," "inflow," and "outflow occlusion" was performed. RESULTS: A multitude of techniques to minimize blood loss during hepatic resection have been studied. The evidence suggests that inflow occlusion techniques are generally well tolerated. These should be used with caution in patients with cirrhosis, fibrosis, steatosis, cholestasis, and recent chemotherapy, and for prolonged time intervals. CONCLUSIONS: Harmful effects of intraoperative blood loss and transfusion occur during hepatic resection. Portal triad clamping (PTC) is associated with less blood loss compared with no clamping. In procedures with ischemic times <1 hour in length, PTC-C (continuous) is likely equal to PTC-I (intermittent). In patients with chronic liver disease or undergoing lengthy operations, PTC-I is likely superior to PTC-C. PTC is superior to total vascular exclusion except in patients with tumors that are large and deep seated, hypervascular, and/or abutting the hepatic veins or vena cava and in patients with increased right-sided heart pressures.
Blood Loss, Surgical↗
Extramucosal hepaticojejunostomy.
BACKGROUND: The creation of a secure hepaticojejunostomy is an essential skill for any hepatobiliary surgeon. METHODS: We describe a refined technique of sewing the end of the common hepatic duct to the side of the jejunum. The sutures are placed to include all layers of the bowel wall except mucosa. RESULTS: One hundred eighty-five anastomoses were performed over a 6-year period. There were 3 documented leaks, 1 significant anastomotic bleed, and 2 postoperative strictures. There were no deaths. CONCLUSION: This refined technique facilitates accurate placement of sutures by improving vision and results in a well-vascularized watertight connection.
Anastomosis, Surgical↗
Training, practice, and referral patterns in hepatobiliary and pancreatic surgery: survey of general surgeons.
Subspecialization has changed the way that general surgery is practiced. Hepatobiliary and pancreatic surgery (HPB) is maturing as a subspecialty. The objective of this study was to identify the current levels of practice, self-assessments of adequacy of training, referral patterns, and perceptions regarding regionalization of HPB care to high-volume centers. A total of 240 nonstratified general surgeons from across Canada were randomly selected to receive a survey developed by an expert work group. A reference group of 10 HPB specialists were also polled for a total of 250 respondents. The overall response rate was 73% (182 responders). Subspecialty training had been completed by 65% of respondents. This included surgical oncology (15%), HPB (15%), HPB and transplant (8%), laparoscopy (7%), liver transplantation (5%), and other (50%). This training was obtained in Canada (51%), the United States (35%), Europe (11%), and Australia (3%). Ninety-five percent of responders believed that some HPB services should be regionalized. Similarly, most responders thought that they were not adequately trained to perform these procedures. The following were especially considered subspecialty procedures: major hepatectomy (93%), pancreaticoduodenectomy (90%), and biliary reconstruction (79%). The majority of non-HPB surgeons do not consider themselves adequately trained to perform complex HPB procedures. Furthermore, most surgeons think that major hepatectomy, pancreaticoduodenectomy, and biliary reconstruction should be referred to HPB specialists at high-volume centers.
Adult↗
Evaluating meta-analyses in the general surgical literature: a critical appraisal.
OBJECTIVE: To assess the methodologic quality of meta-analyses of general surgery topics published in peer-reviewed journals. SUMMARY BACKGROUND DATA: Systematic reviews and meta-analysis are used to seek, summarize, and interpret primary studies on a given topic. Accordingly, systematic reviews and meta-analyses of high-quality primary studies may be the highest level of evidence for issues of prevention and treatment in evidence-based medicine. However, not all published meta-analyses are rigorously performed. METHODS: We searched MEDLINE (from January 1, 1997, to September 1, 2002) and reference lists and solicited general surgery specialists to identify relevant meta-analyses. Inclusion criteria were use of meta-analytic methods to pool the results of primary studies in general surgery on issues of diagnosis, causation, prognosis, or treatment. Our search strategies identified 487 potentially relevant articles. After excluding articles based on a priori criteria, 51 meta-analyses fulfilled eligibility criteria. In duplicate and independently, 2 reviewers assessed the quality of these meta-analyses using a 10-item index called the Overview Quality Assessment Questionnaire. RESULTS: Overall concordance between 2 independent reviewers was good (interobserver agreement 81%, and a kappa of 0.62 (95% CI 0.55-0.69). Of 51 relevant articles, 38 were published in surgical journals. Most studies had major methodologic flaws (median score of 3.3, scale of 1-7). Factors associated with low overall scientific quality included the absence of any prior meta-analyses publications by authors and meta-analyses produced by surgical department members without external collaboration. CONCLUSIONS: This critical appraisal of meta-analyses published in the general surgery literature demonstrates frequent methodologic flaws. The quality of these reports limits the validity of the findings and the inferences that can be made about the primary studies reviewed. To improve the quality of future meta-analyses, we recommend following guidelines for the optimal conduct and reporting of meta-analyses in general surgery.
General Surgery↗
Well differentiated intrahepatic cholangiocarcinoma in the setting of biliary papillomatosis: a case report and review of the literature.
A 64-year-old man presented with long-standing, vague, epigastric abdominal pain. History, physical examination and laboratory studies were noncontributory. However, serial computed tomography scans revealed a rapidly progressive mass in segment 2 of the liver. Surprisingly, surgical pathology revealed a well-differentiated intrahepatic cholangiocarcinoma associated with biliary papillomatosis (BP). BP is a rare, benign and potentially fatal disease of the intra- and extrahepatic bile ducts. It is typified by numerous multicentric papillary fronds arising from biliary columnar epithelium. Most patients present with symptoms of jaundice and cholangitis. Although a benign disease, a review of the literature demonstrated that BP often recurs after surgical resection, carries a poor prognosis and has a moderately high malignant transformation rate. Treatment options for BP include surgical resection, transplant, ablation, stenting and/or bypass.
Bile Duct Neoplasms↗
Phase II study of neoadjuvant 5-FU + leucovorin + CPT-11 in patients with resectable liver metastases from colorectal adenocarcinoma.
BACKGROUND: Following resection of liver metastases from colorectal cancer, 5-year survivals are reportedly 30 - 39%. It can be assumed that this clinical situation represents systemic disease. Therefore, it is postulated that systemic chemotherapy would improve outcomes, particularly in those whose disease is sensitive to the agents administered. One potential advantage of neoadjuvant chemotherapy is that it provides in vivo chemosensitivity data. Response to neoadjuvant chemotherapy could therefore guide adjuvant chemotherapy following resection of liver metastases from colorectal cancer. METHODS AND DESIGN: This is a prospective Phase II evaluation of outcomes in patients with potentially resectable liver metastases. Patients will receive neoadjuvant chemotherapy and will undergo resection. Postoperative chemotherapy will be directed by the degree of response to preoperative chemotherapy. All patients with Stage IV colorectal adenocarcinoma isolated to the liver that have disease that is amenable to complete ablation by resection, radiofrequency ablation, and/or cryoablation will be candidates for the trial. Patients will receive CPT-11 180 mg/m2 IV (over 90 minutes) on day 1 with 5-FU 400 mg/m2 bolus and 600 mg/m2 by 22 hour infusion and calcium folinate 200 mg/m2 on days 1 and 2, every 2 weeks. Altogether, six cycles of chemotherapy will be administered. Patients will then undergo resection and/or radiofrequency ablation. Patients who had stable disease or a clinical response with preoperative chemotherapy will receive an additional 12 cycles of CPT-11 180 mg/m2 IV (over 90 minutes) on day 1 with 5-FU 400 mg/m2 bolus and 600 mg/m2 by 22 hour infusion and calcium folinate 200 mg/m2 on days 1 and 2 (given every 2 weeks). Patients with resectable disease who had progressive disease during neoadjuvant chemotherapy will receive best supportive care or an alternative agent, at the discretion of the treating physician. Those patients who are not rendered free of disease following the neoadjuvant chemotherapy and surgery will receive best supportive care or an alternative agent, at the discretion of the treating physician. The primary endpoint of the study is disease-free survival. Secondary endpoints include overall survival, safety and feasibility, response to chemotherapy, and quality of life.
Adenocarcinoma↗
Intestinal thromboangiitis obliterans in a woman: a case report and discussion of chronic ischemic changes.
Although traditionally regarded as a disease of distal extremities, mesenteric vasculature can also manifest thromboangiitis obliterans (TAO). There are 31 cases of intestinal TAO in the English literature and the majority of subjects are male. However, cases of women with TAO are becoming more common, coinciding with an increased incidence of smoking in this sex. We describe the sixth case of a female patient with classic extremity manifestations paralleled by paroxysms of abdominal angina. Intestinal TAO can mimic extremity disease of smoldering chronic ischemia punctuated by unpredictable acute episodes of gangrene. In the present case, chronic ischemia manifested as partial bowel obstruction due to stricture deformity of the ileum and profound adipocyte atrophy of mesentery.
Abdominal Pain↗
Soft-tissue images. Proximal jejunal gastrointestinal stromal tumour.
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Aged↗
Claude Couinaud: a passion for the liver.
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Bile Ducts↗
Intermittent hepatic vein--total vascular exclusion during liver resection: anatomic and clinical studies.
Bleeding from hepatic veins remains a problem during liver surgery. Perceived difficulties in the dissection and isolation of these retrohepatic venous structures have limited the widespread use of hepatic vein control during liver resection. The purpose of this study was to delineate the anatomy of the hepatic veins and to apply this knowledge to a series of patients undergoing liver resection with intermittent hepatic vein-total vascular exclusion (IHV-TVE). A detailed description of the hepatic venous anatomy was formulated using 20 cadaveric dissections in conjunction with anatomic descriptions during 30 hepatectomies. With the benefit of improved anatomic knowledge, we evaluated a series of 45 consecutive major liver resections in which hepatic veins were isolated and the technique of IHV-TVE was applied. The hepatocaval ligament must be divided to isolate the right hepatic vein. It was closely associated with a caudate vein 69% of the time. The hepatic veins were isolated in 45 consecutive patients who underwent a major hepatic resection. The portal triad and the hepatic veins were occluded intermittently (20 minutes with 5 minutes of reperfusion) with Rommel tourniquets. Mean total warm ischemic time was 65 +/- 24.5 minutes. Mean estimated blood loss was 864 +/- 514 ml. Eighteen percent of patients required blood transfusions. Complications were identified in 16 patients (35.5%), and the average length of hospital stay was 10.5 +/- 3.4 days. There were no deaths. Detailed anatomic knowledge of the hepatocaval ligament and the hepatic veins allows for safe extrahepatic control of the hepatic veins during major hepatic surgery. The technique was well tolerated and may have limited intraoperative blood loss.
Aged↗
Hepatic vein injury during laparoscopic cholecystectomy: the unappreciated proximity of the middle hepatic vein to the gallbladder bed.
Uncontrollable hemorrhage during laparoscopic cholecystectomy occurs in 0.1% to 1.9% of all cases, with 88% originating from the gallbladder bed. The anatomical proximity between major branches of the middle hepatic vein and the gallbladder bed, and hence the risk of intraoperative bleeding, is unclear. CT scans of 20 random patients were retrospectively reviewed to identify the closest distance between branches of the middle hepatic vein and the gallbladder bed. The vein diameter was also recorded. Risk factors for intraoperative bleeding during laparoscopic cholecystectomy were also retrospectively reviewed. Large branches (mean diameter = 2.1 mm) of the middle hepatic vein are directly adjacent to the gallbladder bed in 10% of patients. An additional 10% of cases also possess branches within 1 mm of the gallbladder bed. Chronically scarred and contracted gallbladder disease may increase the risk of significant bleeding, requiring conversion. Twenty percent of all cases will display a large branch of the middle hepatic vein adherent or immediately adjacent to the gallbladder fossa. These patients are at increased risk for intraoperative bleeding. Furthermore, contracted gallbladders with evidence of chronic disease may be at increased risk for significant hemorrhage.
Aged↗
Elevated serum interleukin 6 levels in patients with acute intestinal ischemia.
BACKGROUND/AIMS: Early diagnosis of patients with acute intestinal ischemia may be possible by measuring serum cytokine levels. METHODOLOGY: Forty-six patients presenting in emergency with an acute abdomen where intestinal ischemia was a possible diagnosis were evaluated. A single blood sample was collected in emergency prior to any intervention and the patients were then followed prospectively. Serum tumor necrosis factor-alpha and interleukin-6 levels were determined at a later date. Serum levels in patients with proven acute intestinal ischemia were compared to patients with other diagnoses. RESULTS: Serum tumor necrosis factor-alpha levels were moderately increased in patients with acute intestinal ischemia compared to controls 96.9 +/- 98.9 pg/mL vs. 60.8 +/- 63.7 pg/mL, P = 0.16. Serum interleukin-6 levels were significantly increased in patients with acute intestinal ischemia, 15.778 +/- 21.349 pg/mL vs. 2.844 +/- 5.625 pg/mL, P = 0.01. CONCLUSIONS: Serum interleukin-6 levels may prove useful in diagnosing patients with acute intestinal ischemia.
Abdomen, Acute↗
Hyperlipemic pancreatitis and pseudocyst formation in late pregnancy.
Hyperlipemic pancreatitis and pseudocyst formation late in pregnancy is a rare event. We report a case of hyperlipemic pancreatitis occurring in a G1P0 oriental woman at 32 weeks gestation. The initial serum lipase level was 1070 U/L, serum cholesterol level was 38.50 mmol/L and triglyceride level was > 57 mmol/L. She was treated conservatively with fasting, narcotic analgesia, and fluid resuscitation. Her symptoms resolved rapidly and lipase returned to normal within 2 days. During the first week in hospital she developed peripancreatic fluid collections and became symptomatic from a collection that extended down into the right pelvis. One week after admission she developed pre-term labor and delivered a healthy infant vaginally. There was an excellent outcome for both mother and infant. Serum lipid levels returned to near normal by 6 weeks post delivery.
Adult↗
A case of solid-pseudopapillary tumor of the pancreas: preoperative cyst fluid analysis and treatment by enucleation.
The authors report a case of a 26-year-old female who had a solid-pseudopapillary tumor of the pancreas. The patient had preoperative cyst fluid analysis that demonstrated low levels of carcinoembryonic antigen and moderate elevation in cyst fluid carbohydrate antigen 19-9 and lipase. Cyst fluid cytology was diagnostic. The tumor was successfully treated by complete enucleation.
Adult↗
Splenic injury following endoscopic retrograde cholangiopancreatography: a case report and review of the literature.
Endoscopy of both the upper and lower gastrointestinal tract remains one of the commonest procedures performed on patients. The common risk factors associated with this procedure are well known. However, some of the rarer complications are not known or are not considered in the immediate postprocedure time period when a patient experiences acute abdominal pain. Herein, we report a case of solid organ injury (splenic capsular tear) resulting from endoscopic retrograde cholangiopancreatography. The risk factors and presentation of this type of injury are reviewed, including its association with chronic pancreatitis, which we describe for the first time.
Adult↗