Indeterminate biliary strictures: a simplified approach

Introduction: Pre-operative evaluation of biliary strictures remains challenging. The dilemma that exists is how to balance the risk of failing to detect malignancy and the potential morbidity caused by unnecessary surgery in patients with benign etiologies. With emerging novel diagnostic modalities, this study aims to assess the efficacy of diagnostic techniques and facilitate a clinical approach to indeterminate biliary strictures.

Areas covered: Conventional imaging modalities are crucial in identifying the location of a stricture and are helpful for choosing further diagnostic modalities. Utilization of endoscopic techniques, including endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), is key in establishing a diagnosis. The emergence of novel diagnostic modalities, such as fluorescence in-situ hybridization (FISH), peroral cholangioscopy (POC), intraductal endoscopic ultrasound (IDUS) and confocal laser endomicroscopy (CLE), enhance the diagnostic yield in the evaluation of indeterminate biliary strictures.

Expert commentary: More reliable and validated visual criteria for differentiating malignancy from benign biliary conditions, utilizing advanced imaging modalities such as POC and CLE, need to be established. It is of significance to further evaluate these novel diagnostic modalities through ongoing trials and to develop a diagnostic algorithm that reconciles cost-effectiveness with diagnostic accuracy.     

Temporary silastic mesh closure for adult liver transplantation: a safe alternative for the difficult abdomen.

Primary fascial closure is often difficult after adult orthotopic liver transplantation (OLT), complicated by donor-to-recipient graft size mismatch, post-reperfusion hepatic edema, coagulopathy, or intestinal edema. Attempts at closing the abdomen under these circumstances can cause increase in intra-abdominal pressures, resulting in significant complications, including graft loss. Temporary closure with silastic mesh has been used as a viable option in children receiving transplants, but there is no experience recorded with its use in adults. A retrospective review was conducted on 200 consecutive liver transplantations performed over 42 months (October 2002 to February 2006). Records were evaluated for patient and donor demographics, perioperative factors including Model for End-Stage Liver Disease and Child-Turcotte-Pugh scores, indications for OLT, ischemic times, blood product administration, and use of temporary silastic mesh closure. Patients requiring silastic mesh were further evaluated for indication, time to primary fascial closure, duration of intubation, length of stay, graft function, and complications (infectious, vascular, biliary, and hernia development). Comparisons were made with a cohort of patients undergoing OLT over the same time period but who were closed primarily, without the use of temporary silastic mesh. Fifty-one liver transplantations (25.5%) of the 200 total transplant cohort used silastic mesh closure. Comparison of the cohorts (primary closure vs. temporary mesh) revealed that no differences existed, except the requirement of all blood products was significantly greater in the silastic mesh group (P < 0.001). Bowel edema (47.1%) and coagulopathy (37.3%) were the most common indications for mesh closure, with less frequent reasons including donor to recipient size mismatch (11.8%), hemodynamic instability, and a large preexisting fascial defect (2.0% each). The average time from transplant to final fascial closure was 3.4 days (range 2-9 days). In the silastic cohort, 41 transplants where closed primarily, 3 required the addition of synthetic mesh, and 6 had component separation and flap closure. After fascial closure, the mean time to extubation was 1 day. The median length of follow-up was 1.3 years for the silastic closure group. Long-term wound complications in the silastic closure group included 1 instance of colonic fistula, 2 incisional hernias, and 2 wound infections. The 30-day and 1-year patient survival for this group were 93.6 and 82.4%, respectively, and the graft survival for those same periods were 90.2 and 77.7%, respectively. Wound complications, rates of hepatic artery thrombosis or stricture, portal vein thrombosis or stricture, biliary complications, and allograft and patient survival were no different than those in patients undergoing initial primary closure. In adult liver transplantation with a difficult (or potentially difficult) abdomen, temporary closure with silastic mesh was found to allow for uncomplicated fascial closure in a short period of time, with rapid extubation times, excellent graft function, and minimal instances of infectious or wound complications. In circumstances where large amounts of blood products are required, where a size mismatch exists, or where bowel edema is present during adult liver transplantation, temporary closure with silastic mesh is an ideal strategy.     

Gastrosplenic fistula: etiologies, diagnostic studies, and surgical management

A gastrosplenic fistula is a rare event. Reported causes include a spontaneous malignant fistula, chemotherapy for gastric or splenic malignancies, peptic ulcer disease, Crohn disease, and trauma. We report a case of a gastrosplenic fistula discovered on abdominal computed tomography with contrast, performed in a patient with a history suspicious for malignancy. In this case, no etiology was identified prior to the surgical repair of the lesion despite extensive workup. Due to continued gastrointestinal blood loss requiring multiple transfusions, the patient was taken to surgery for splenectomy and partial gastrectomy. It was at that time that the diagnosis of a large B-cell lymphoma was made. Postoperative chemotherapy was initiated and led to remission of the malignancy. Though most cases require definitive surgical repair, the treatment plans for gastrosplenic fistulas depend largely on the etiology of the lesion.     

Transplantation for type I diabetes: comparison of vascularized whole-organ pancreas with isolated pancreatic islets

OBJECTIVE: We sought to compare the efficacy, risks, and costs of whole-organ pancreas transplantation (WOP) with the costs of isolated islet transplantation (IIT) in the treatment of patients with type I diabetes mellitus. SUMMARY BACKGROUND DATA: A striking improvement has taken place in the results of IIT with regard to attaining normoglycemia and insulin independence of type I diabetic recipients. Theoretically, this minimally invasive therapy should replace WOP because its risks and expense should be less. To date, however, no systematic comparisons of these 2 options have been reported. METHODS: We conducted a retrospective analysis of a consecutive series of WOP and IIT performed at the University of Pennsylvania between September 2001 and February 2004. We compared a variety of parameters, including patient and graft survival, degree and duration of glucose homeostasis, procedural and immunosuppressive complications, and resources utilization. RESULTS: Both WOP and IIT proved highly successful at establishing insulin independence in type I diabetic patients. Whole-organ pancreas recipients experienced longer lengths of stay, more readmissions, and more complications, but they exhibited a more durable state of normoglycemia with greater insulin reserves. Achieving insulin independence by IIT proved surprisingly more expensive, despite shorter initial hospital and readmission stays. CONCLUSION: Despite recent improvement in the success of IIT, WOP provides a more reliable and durable restoration of normoglycemia. Although IIT was associated with less procedure-related morbidity and shorter hospital stays, we unexpectedly found IIT to be more costly than WOP. This was largely due to IIT requiring islets from multiple donors to gain insulin independence. Because donor pancreata that are unsuitable for WOP can often be used successfully for IIT, we suggest that as IIT evolves, it should continue to be evaluated as a complementary alternative to rather than as a replacement for the better-established method of WOP.     

Open versus laparoscopic liver resection: looking beyond the immediate postoperative period

Background  

Laparoscopic liver resection for malignant disease has shown short-term benefit. This study aimed to compare in-house, 30-day, and 1-year morbidity between laparoscopic and open liver resections.     

Short-Term Outcomes of Ablation Therapy for Hepatic Tumors: Evidence from the 2006–2009 Nationwide Inpatient Sample

Background

Radiofrequency ablation (RFA) for the treatment of hepatic tumors has been increasingly used across the United States. Whether treatment-related morbidity has remained low with broader adoption is unclear. We conducted this study to describe in-hospital morbidity associated with RFA for hepatic tumors and to identify predictors of adverse events in a nationally representative database.

Methods

Using the 2006?C2009 Nationwide Inpatient Sample, we evaluated all patients aged ??40?years who underwent an elective RFA for primary or metastatic liver tumors (N?=?1298). Outcomes included in-hospital procedure-specific and postoperative complications. Multivariable logistic regression analyses were performed to identify patient and facility predictors of complications.

Results

Most patients underwent a percutaneous (39.9?%) or laparoscopic (22.0?%) procedure for metastatic liver tumors (57.5?%). Procedure-specific complications were frequent (18.2?%), with transfusion requirements (10.7?%), intraoperative bleeding (4.3?%), and hepatic failure (2.8?%) being the most common. Arrhythmias [adjusted odds ratio (AOR)?=?1.93 (1.23?C3.04)], coagulopathy [AOR?=?4.65 (2.95?C7.34)], and an open surgical approach [AOR?=?2.77 (1.75?C4.36)] were associated with an increased likelihood of procedure-specific complications, whereas hospital RFA volume ??16/year was associated with a reduced likelihood [AOR?=?0.59 (0.38?C0.91)]. Postoperative complications were also common (12.0?%), with arrhythmias, heart failure, coagulopathy, and open surgical approach acting as significant predictors.

Conclusions

In-hospital morbidity is common after RFA for hepatic tumors. While several patient factors are associated with more frequent procedure-specific complications, treatment at hospitals with an annual volume ??16 cases/year was associated with a 41?% reduction in the odds of procedure-specific complications.