Liver regeneration after major hepatectomy. Evaluation of dogs hepatectomy

OBJECTIVES: The aim of our study is to evaluate anatomic regeneration and metabolic derangement of the liver after major resection in dogs. METHODS: This is an experimental study on 9 dogs; we divided the dogs in two groups: the first group (5 dogs) underwent at one go major hepatectomy (90% of the liver).The second group (4 dogs) underwent successively a resection of 75% of the liver and a second resection of 90% of the restored liver six months later. All dogs underwent a metabolic and morphologic studies of the liver and of their kidney function. RESULTS: In the first group; all dogs which underwent 90% hepatic resection died 48 hours after the surgical resection of hepatic insufficiency. The ultra microscopic study showed the role of portal hypertension in hepatic degeneration on the first group. In the second group, the dogs survived the first resection, and our study shows a regeneration of the liver after resection and sub normal hepatic function. CONCLUSION: The liver is able to regenerate after minimally resection but major resection must be done by successively resection to avoid hepatic dysfunction, but the time between resection must be evaluate later.     

Painful traumatic neuroma after a finger stick

In this case report we present a patient with a painful traumatic neuroma after a finger stick by lancet. The patient benefited from surgical excision of the lesion, and her symptoms were completely abolished with additional sympathetic nerve blocks.     

Coronal thick CT reconstruction: an alternative for initial chest radiography in trauma patients

It has been proposed that the imaging workup of trauma patients be accelerated by omitting the initial chest radiography (CR) and directly performing a computed tomography (CT); however, the baseline CR is then lacking. The purpose of this study was to assess if coronal thick reconstructions generated from chest CT could present an adequate alternative for CR. Sixty trauma patients underwent bedside CR and multidetector row chest CT in the emergency room. The image quality of thoracic anatomical structures, the diagnostic accuracy for chest pathology, and the depiction of indwelling devices were assessed on both modalities. Main pulmonary arteries and perihilar bronchi were equally visualized with both modalities. Central bronchi, retrocardial lung parenchyma, diaphragm, descending aorta, and vertebral pedicles were better visualized on thick CT reconstructions, whereas peripheral lung vessels were better depicted on CR (p<0.05). The accuracy to delineate various pathological findings did not differ between both modalities, except for a higher sensitivity to diagnose bronchial cuffing on CR (p<0.05). The location of indwelling devices was similarly and correctly depicted with both modalities. Coronal thick CT reconstructions provide a similar image quality and diagnostic accuracy compared with CR. These reconstructions may serve as an equivalent baseline image in trauma patients in whom emergency radiological evaluation has to be accelerated.     

Amyand’s hernia: a case report of prospective ct diagnosis in the emergency department

The diagnosis of Amyands hernia, the development of acute appendicits within an inguinal hernia, is rarely made preoperatively and is often confused clinically with an incarcerated right inguinal hernia. The use of CT to prospectively diagnose Amyands hernia and corresponding imaging findings are not well described in the literature. We report a case of Amyands hernia, which was correctly diagnosed by CT in a female patient presented to the emergency department with right lower quadrant pain and clinical suspicion of a strangulated omentocele.     

A prognostic index (bladder prognostic index) for bilharzial-related invasive bladder cancer

PURPOSE: Bladder cancer is still the most common solid tumor among adult males in Egypt because of the prevalence of bilharzial infestation, especially in the countryside. In this prospective study, we have recorded the prognostic factors for 180 patients with invasive bladder cancer for whom standard radical cystectomy had been performed to develop a prognostic index (bladder prognostic index) that defines high risk patients who are more vulnerable to disease relapse after surgery and who may benefit from additional therapy. PATIENTS AND METHODS: The study was performed between January 1997 and December 1999, in which 180 patients with histopathologically proved invasive bladder cancer associated with bilharziasis underwent radical cystectomy or anterior pelvic exenteration. After surgery, patients were regularly followed for a minimum of 2 years. RESULTS: Our patients included 141 males and 39 females. Squamous cell carcinoma was the most common type (53.3%), and most of the tumors were grade II (61.1%). A total of 173 patients had their tumors operable, while 7 were inoperable. We had 5 (2.8%) operative related mortalities. At 5 years postoperatively, free and overall survival rates for the whole group of patients were 31.44%+/-5.9% and 32.5%+/-6.8%, respectively. Tumor pathologic stage, grade, and nodal affection were the only significant factors with impact on survival (P=0.008, 0.051, and 0.004, respectively). These 3 prognostic indexes were used to design a model to predict an individual patient's risk factor for recurrence. Patients were then assigned to one of the 4 risk groups according to the score achieved in this prognostic index (0=low risk, 1=intermediate risk, and 2 or 3=higher risk). These 4 risk groups had distinctly different rates of disease-free survival, i.e., 91.7%, 53%, 13%, and 7% for low, intermediate, and higher risk groups, respectively. CONCLUSION: Although this prognostic index appears to be of a significant clinical relevance, it needs to be more validated on a larger number of patients, and it could be a surrogate variable for biologic factors responsible for the heterogeneity of bladder cancer.     

Treating pain related to inoperable pancreatic cancer in tropical areas: the advantage of CT-guided celiac plexus block and splanchnic nerves neurolysis

Many sub-Saharan African countries have recently acquired computed tomography scanners that make interventional radiology possible, especially for the treatment of cancer pain. We report the case of a patient with severe abdominal pain related to advanced pancreas cancer. After unsuccessful morphine treatment, he underwent CT-guided alcohol injection for neurolysis of the celiac plexus and splanchnic nerves. This report describes the technique and discusses its potential applications in tropical countries.     

Gastrointestinal manifestations in severe scorpion envenomation

OBJECTIVES: To evaluate the type and incidence of gastrointestinal manifestations secondary to scorpion envenomation and their prognostic significance. PATIENTS AND METHODS: All patients admitted to our ICU for scorpion envenomation were included in this retrospective chart review of a 13-year period (1990 - 2002). RESULTS: During the study period, 951 patients were admitted for scorpion envenomation and 72 (7.6%) died. Ages ranged from 0.5 to 90 years with a mean of 14.7 +/- 17.4 years. Gastrointestinal symptoms were present in 700 patients (73.6%): nausea in 24 (2.5%), vomiting in 687 (72.2%) and diarrhea in 41 patients (4.3%). At univariate analysis, the presence of diarrhea was associated with a fatal outcome (P < 0.05). Diarrhea was also correlated with other indicators of severe envenomation and poor prognosis: respiratory failure (P = 0.01), neurological failure (P < 0.0001), liver failure (P < 0.0001) and low blood pressure requiring catecholamine support (P = 0.02). The multivariate analysis showed that young age (age less than 5 years), fever > 38.5 degrees C, neurological failure and pulmonary edema were independent factors of severity. Digestive disorders were more frequent in children and in this subgroup diarrhea appeared to be associated with poor outcome. In a subset of patients for whom data were available, fatal cases demonstrated significantly higher liver enzymes levels on admission. CONCLUSION: In Tunisia, gastrointestinal symptoms are often observed in severe scorpion envenomations, especially in young patients. In children, diarrhea and elevated liver enzymes are associated with poor prognosis.     

Biliary disease after liver transplantation: the experience of the King Faisal Specialist Hospital and Research Center, Riyadh

BACKGROUND AND AIM: The biliary tract has been referred to as the "Achilles heel" of liver transplantation. The aim of this study was to document the frequency, clinical presentation and management of biliary complications after liver transplantation in the King Faisal Specialist Hospital and Research Center (KFSH&RC), Riyadh, Saudi Arabia. METHODS: The liver transplant clinic at KFSH&RC has registered and followed 220 patients (150 male and 70 female patients; age 40.6 +/- 18.6 years; pediatric 33, adult 187) during the period from 1987 to June 2003. A total of 235 transplants were carried out on these patients. Cadaveric liver transplants had been carried out on 202 patients, non-heart beating liver transplant in three patients, live donor liver transplants in 11 and split transplant in four. Biliary reconstruction was duct-to-duct anastomosis in 147 patients and Roux-en-Y in 73. Biliary complications were suspected on clinical and biochemical parameters and confirmed using imaging techniques. RESULTS: Forty patients (18.2%) developed 53 biliary complications. These included bile leak in 16, strictures in 25, calculi in eight, and sphincter of Oddi dysfunction and possible recurrence of primary sclerosing cholangitis in the donor duct in two patients each. Bile leaks were observed in the early postoperative period (median period 30 days, range 1-150 days, 95% confidence interval [CI] 8-51). Leakage occurred at the anastomotic site in 13 patients. Patients presented with bilious drainage (n = 6), abdominal pain at T-tube removal (n = 3), fever (n = 2), sepsis (n = 1), dyspnea (n = 1) and abnormal liver tests (n = 3). Eleven patients had intra-abdominal bilious collections. Two patients were treated conservatively, eight patients had ultrasound-guided aspiration of biloma, five had biliary stenting at endoscopic retrograde cholangiopancreatography and two patients needed surgery. There were four deaths, two of which were related to bile leak, one patient was left with permanent external biliary drainage and four patients had biliary strictures in the follow-up period. Biliary strictures occurred at a median period of 360 days (range 4-2900 days; 95% CI 50-670) after the transplant. Hepatic artery thrombosis caused biliary strictures in three, while 21 strictures were localized to the anastomotic site. Biliary strictures presented with elevated liver tests in five patients, progressive cholestasis in five, cholangitis (with septicemia in five) in 11, abdominal pain in two and acute pancreatitis in three patients. Repeat sessions of endoscopic or percutaneous dilatation and stenting (mean sessions 4.4/patient, range 3-7) were attempted in 20 patients to relieve strictures, with success in only nine patients. Seven patients had surgery. Four patients with biliary strictures died. Biliary calculi developed late in the follow-up period and had the appearance of biliary casts in five and sludge in three patients. Eleven (27.5%) patients with biliary disease died compared with 35 (19.4%) patients without biliary disease. CONCLUSIONS: Biliary complications occurred in 18.2% of patients after liver transplantation and included biliary leak and biliary strictures with or without calculi. Management involved a combination of endoscopic, radiologic and operative procedures. Biliary complications caused considerable morbidity and mortality in liver transplant patients.     

Multislice CT in the pre- and postinterventional evaluation of mesenteric perfusion

Multislice computed tomography angiography (CTA) has been found feasible for the evaluation of visceral vasculature. The development of multislice technology has overcome past limitations. First, the faster scanning speed increases volume coverage during a single breath-hold and improves the exploitation of contrast medium. Second, the better spatial resolution results in nearly isotropic voxels allowing reconstruction of high-resolution three-dimensional images with different algorithms. Volume rendering is capable of displaying the visceral vasculature from any external vantage point. Compared to conventional angiography, CTA not only delineates vessels but also depicts the anatomical relationship to adjacent structures and allows the evaluation of perfused organs. CTA also has become an emerging tool for the pre- and postinterventional assessment of vascular anatomy. The purpose of this pictorial essay is to present a spectrum of visceral vascular diseases and interventional and surgical therapies, and to highlight the role of postprocessing for their evaluation.