Non-hepatic surgery in patients with chronic liver disease.
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Chronic Disease↗
Biomedical subjects
N Doctor
Publications and source records attributed to N Doctor.
Results of choledochojejunostomy in the treatment of biliary complications after liver transplantation in the era of nonsurgical therapies.
Advances in radiological and endoscopic techniques have allowed many biliary complications after orthotopic liver transplantation (OLT) to be managed without surgery. The influence of nonsurgical management on the outcome of patients requiring surgical revision has not been addressed. We reviewed our 10-year experience (October 1988 to January 1998) of Roux-en-Y choledochojejunostomy (CDJ) to treat biliary complications after OLT. Forty-six patients underwent CDJ for biliary complications (32 men, 14 women; age, 22 to 65 years; median, 60 years). Biliary reconstruction at the time of OLT was duct to duct in 41 patients, primary CDJ in 3 patients, and gall bladder conduit in 2 patients. T-tubes were used only in patients with gallbladder conduit. The indication for CDJ was biliary leak (23 patients), stricture (20 patients), biliary stones (2 patients), and biliary sludge (1 patient). Two patients (4.3%) had associated hepatic artery thrombosis. The bile leaks were diagnosed at a median of 29 days post-OLT (range, 2 to 65 days) and strictures at a median of 2 years (range, 33 days to 6.5 years) post-OLT. Before surgery, 25 patients (54%) underwent an attempt at radiological or endoscopic therapeutic intervention that failed. Median follow-up was 5 years (range, 9 months to 10 years). Early complications occurred in 12 patients (26%); the most common was chest infection (4 patients). There were 3 perioperative deaths (6%); 1 death was directly related to surgery. Late complications, mainly anastomotic strictures, occurred in 10 patients (22%), half of which were successfully treated by biliary balloon dilatation. The complication rate post-CDJ was less in those who underwent a failed nonsurgical approach than those proceeding straight to surgery (9 of 25 patients; 36% v 13 of 21 patients; 62%; P =.21, not significant). The procedure-related mortality for surgical revision of biliary complications after OLT is low, but early and late complications are common. A failed attempt at nonsurgical management does not increase the complications of reconstructive surgery. Strictures after CDJ should be considered for biliary balloon dilatation.
Adult↗
Experimental study of a novel fibrin sealant for achieving haemostasis following partial hepatectomy.
BACKGROUND: Ensuring adequate haemostasis is a major difficulty in the field of liver surgery. This study aimed to evaluate a novel fibrin sealant (Vivostat), designed for autologous preparation, in a porcine model of partial hepatectomy. METHODS: Thirty-six Large White Landrace pigs underwent partial left hepatectomy by finger fracture under portal vascular inflow occlusion. Animals were randomized to treatment of the resected surface with either fibrin sealant (Vivostat, n = 12) or regenerated oxidized cellulose gauze (Surgicel, n = 12), or were left untreated (controls, n = 12). Blood loss from the resection margin was measured at 2-min intervals for 10 min, and the time to haemostasis was recorded. Following complete haemostasis the animals recovered for 7 days. RESULTS: Median (range) blood loss in the control group was 94.3 (17.3-467.0) g, and was significantly reduced with Vivostat (13.8 (5.5-150.9) g) and Surgicel (22.8 (5.8-67.3) g). Median (range) time to haemostasis in controls (31 (12-52) min) was also significantly reduced by Vivostat (8 (0-32) min) and Surgicel (10 (0-19) min) (both P < 0.001 versus controls, Kruskal-Wallis test). CONCLUSION: The novel fibrin sealant, Vivostat, is as effective as Surgicel cellulose gauze in achieving haemostasis after porcine partial hepatic lobectomy.
Animals↗
Predicting early mortality following percutaneous stent insertion for malignant biliary obstruction: a multivariate risk factor analysis.
BACKGROUND: Percutaneous stent placement is an accepted method of palliation in malignant biliary obstruction. Factors predicting early mortality after this procedure have not been identified. METHODS: We performed a retrospective study of 141 patients with malignant biliary obstruction who underwent percutaneous stent placement for biliary decompression to identify the risk factors associated with early mortality (< or = 30 days). RESULTS: Of 14 clinicopathological and laboratory variables analysed blood urea, albumin, haemoglobin and alkaline phosphatase were found to be significant on univariate analysis. The age and gender of the patient along with cancer type, level of obstruction, presence of pyrexia and bilirubin level had no influence on early mortality. Stepwise logistic regression identified the haemoglobin level and blood urea to be independently significant in predicting early mortality. Overall 30-day mortality was 20.5% (29/141). Patients with blood urea over 4.3 mmol/l and a haemoglobin less than 10.9 g/dl had a mortality rate of 52% (12/23) compared with 14% (17/118) in the remainder. Using these two variables a regression equation has been derived which allows calculation of the probability of survival at 30 days after the percutaneous procedure. CONCLUSIONS: Laboratory variables in patients with malignant obstructive jaundice can be used to predict mortality following percutaneous stent insertion.
Adult↗
Results of percutaneous plastic stents for malignant distal biliary obstruction following failed endoscopic stent insertion and comparison with current literature on expandable metallic stents.
BACKGROUND: Endoscopic stenting is an effective method of relieving biliary obstruction in patients with unresectable malignancy. If this fails, optimal management is controversial. Percutaneous insertion of plastic or mesh metal stents has been advocated. AIM: To review the outcome of percutaneous plastic stents and compare this with contemporary data from the literature on mesh metal stenting. PATIENTS AND METHODS: Over a period of six years, 400 patients had attempted endoscopic stenting for distal malignant biliary obstruction which failed in 54 (13.5%). These 54 patients were treated with percutaneously placed plastic stents. RESULTS: Percutaneous stenting was technically successful in 48 patients (89%). Early complications occurred in 13 patients (24%), the commonest being acute cholangitis in seven (12%). There was no procedure-related mortality but a 30-day mortality of 11 % (n = 6). Ten patients (18%) required re-admission after 30 days for stent block (mean period 4 months). Forty-seven patients (87%) were followed up until death. The median survival for the patients undergoing palliative stenting was 3 months (5 days to 17 months). CONCLUSIONS: These results suggest that percutaneous plastic stents can be used safely and effectively in patients who have failed endoscopic stenting.
Adult↗
Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy.
BACKGROUND: Bile leaks and bile duct strictures are major complications of cholecystectomy which increased in incidence after the introduction of laparoscopic surgery. The management and outcome of these complications following the introduction of laparoscopic cholecystectomy was reviewed. METHODS: Eighteen patients of median age 45 (range 22-70) years were treated between January 1992 and December 1995. Six patients had a common hepatic duct (CHD) stricture, four following a failed previous repair. Nine patients had bile leaks from bile duct transection (four), cystic stump (four) or segment V duct (one). Two patients had partial bile duct damage with primary sutured repair at time of cholecystectomy. One patient had recurrent haemobilia from a hepatic artery pseudoaneurysm. RESULTS: Cystic stump or segment V leaks were treated successfully by endoscopic stenting (median follow-up 42 months). Roux loop biliary reconstruction was carried out in nine patients: two CHD strictures, three of the four failed primary CHD repairs and four bile duct transections. All had normal liver function test results at median follow-up of 30 months. The two patients with partial duct injuries repaired at initial surgery required no further intervention. The right hepatic artery aneurysm was successfully embolized. There have been no deaths or major complications of endoscopic, radiological or surgical intervention. CONCLUSION: Endoscopic stenting successfully treats cystic stump and segment V duct leaks. Duct strictures, including failed initial repairs and transections, have a good outcome with Roux-en-Y loop reconstruction.
Adult↗
Primary squamous carcinoma of liver: presentation as liver abscess.
Primary keratinizing squamous carcinoma of the liver has been reported as arising in a hepatic cyst, in association with prolonged cholestasis or chronic biliary sepsis. We describe the occurrence of such a tumor without predisposing factors, with presentation similar to that of hepatic abscess.
Aged↗
Peritoneal seeding of pancreatic head carcinoma following percutaneous transhepatic drainage and stenting.
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Cholangiopancreatography, Endoscopic Retrograde↗
Liver resection.
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Carcinoma, Hepatocellular↗
Assessment of pancreatic duct damage following trauma: is endoscopic retrograde cholangiopancreatography the gold standard?
A 12-year-old girl was admitted as an emergency with blunt pancreatic trauma. Computed tomography (CT) showed an intact pancreas. She failed conservative treatment. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated division of the pancreatic duct at the neck of pancreas. At laparotomy, however, there was complete necrosis of the pancreatic head. She recovered well following enteric drainage of the body of pancreas. CT and ERCP are considered the optimal imaging for pancreatic trauma but the findings may be misleading.
Child↗
Abdominal cocoon--the cauliflower sign on barium small bowel series.
We report a case of abdominal cocoon encasing the small bowel diagnosed pre-peratively on radiology. Barium small bowel series showed the ileal loops clumped together as within a sac, giving a cauliflower-like appearance on sequential films. At surgery, the membrane enclosing the loops was thin and flimsy.
Adolescent↗
Letter: The use of blood patch for post-spinal headaches.
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Anesthesia, Epidural↗
Treatment of symptomatic polycystic liver disease with resection-fenestration.
Polycystic liver disease with severe symptoms is difficult to treat. We report a 35-year-old man with advanced disease, who had a successful outcome after resection and fenestration.
Adult↗
Hyperbaric oxygen therapy in diabetic foot.
To study the effect of hyperbaric oxygen therapy in chronic diabetic foot lesions, a prospective controlled study was undertaken. Thirty diabetics with chronic foot lesions were randomised to study group (conventional management and 4 sessions of hyperbaric oxygen therapy) and control group (conventional management). The patients were assessed for average hospital stay, control of infection and wound healing. The control of infection spread was quicker. Positive cultures decreased from initial 19 to 3 in study group as against from 16 to 12 in the control group. (p < 0.05). This difference was most pronounced for Escherichia coli. Also, the need for major amputation was significantly less in the study group (n = 2) as against the control group (n = 7) (p < 0.05). The average hospital stay was not affected. We conclude that hyperbaric oxygen therapy can be safely used and is beneficial as an adjuvant therapy in chronic diabetic foot lesions.
Aged↗