bluuebunny/crossref_metadata_2025 huggingface dataset:
Is Hepatectomy Necessary in Dealing with Left Hepatolithiasis with Intrahepatic Duct Stricture?
Authors: Franco Dominique
Published: September 2007

Background: Hepatolithiasis with intrahepatic biliary strictures, more common in Southeast Asia than elsewhere, remains a difficult problem to manage. Hepatic resection has recently been advocated as one of the treatment modalities for hepatolithiasis; however, this procedure is not without risk. This study was designed to achieve complete clearance of the stones, eliminate bile stasis, and avoid the potential risks of hepatic resection in the patient with hepatolithiasis and intrahepatic biliary stricture.

Methods: In this prospective clinical trial 13 patients with retained left hepatolithiasis and intrahepatic biliary strictures were included. All the patients met the following criteria: (1) initial surgical procedure for hepatolithiasis, (2) normal gross findings of the left liver, and (3) no obvious clinical evidence of an associated intrahepatic cholangiocarcinoma. After the operation they underwent matured T‐tube tract ductal dilatation with percutaneous transhepatic cholangioscopy tube stenting. Choledoschoscopic electrohydraulic lithotripsy was used in five patients after dilatation when impacted or large stones were encountered.

Results: Complete clearance of the stones was achieved in these 13 patients. One patient had fevers develop after ductal dilatation, and another patient had mild hemobilia after electrohydraulic lithotripsy. Both recovered uneventfully with conservative treatment. These successfully treated patients remain well, with a mean follow‐up period of 20 months.

Conclusions: Postoperative matured T‐tube tract ductal dilatation and stenting, combined with endoscopic electrohydraulic lithotripsy when indicated, is an effective and safe alternative to hepatic resection for selected left hepatolithiasis with intrahepatic biliary stricture.
Postoperative Intravenous Drip Infusion is not Required after Minilaparotomy Cholecystectomy
Authors: Kumar N. , Annudath K. B. , Shukla H. S. , Singh A. , Kumar K.
Published: September 2007

Objective: To determine if drip infusion should be discontinued after full recovery of the patient from anaesthesia after minilaparotomy cholecystectomy in uncomplicated cases.

Design: A randomised controlled clinical trial on 60 patients, from the waiting list, of cholelithiasis/cholecystitis operated by minilaparotomy cholecystectomy between November 1995 to March 1996. 30 patients did not receive postoperative IV drip infusion and in 30 patients 12–24 hours of standard drip transfusion was continued according to the current practice.

Setting: Single Surgical Unit, SS Hospital, Banaras Hindu University, Varanasi, India.

Main outcome measure: Recognition of clinical indication for continuation of. IV drip infusion after full recovery from anaesthesia.

Results: In the cohorts of 30 patients each who were or were not given IV drip infusion after full recovery from anaesthesia following minilaparotomy cholecystectomy the observations on pulse rate, blood pressure, time to first voiding of urine and time to start first oral intake of fluids were identical. However postoperative urinary retention occured in 6 (20%) patients in whom the IV drip infusion was given.

Conclusion: There is no clinical indication to continue IV drip infusion after full recovery from anaesthesia in patients operated for minilaparotomy cholecystectomy.
Ciliated Foregut Cyst of the Pancreas
Authors: Munshi Imtiaz A. , Parra-Davila Eduardo , Casillas Victor J. , Sleeman Danny , Levi Joé U.
Published: September 2007

Cystic lesions of the pancreas are relatively uncommon.
We describe the case of a young man with a
complex cystic mass located within the head of the
pancreas. The patient underwent exploration with
resection of the mass. Pathology revealed a ciliated
epithelial cyst, a rare cystic lesion of the pancreas.
Liver Resection: To Drain or not to Drain?
Authors: Morris David L.
Published: September 2007

Purpose: A prospective, randomized trial was performed to determine if intra‐abdominal drainage catheters are necessary after elective liver resection.

Patients and Methods: Between April 1992 and April 1994, 120 patients subjected to liver resection, stratified by extent of resection and by surgeon, were randomized to receive or not receive operative closed‐suction drainage. Operative blood loss was not an exclusion criteria, and no patient who consented to the study was excluded.

Results: Eighty‐seven patients (73%) had resection of one hepatic lobe or more (27 lobectomies, 54 trisegmentectomies, and 6 bilobar atypical resections) and 33 had less than a lobectomy (8 wedge resections or enucleations, 9 segmentectomies, and 16 bisegmentectomies). Eighty‐four patients (70%) had metastatic cancer and 36 patients (30%) had primary liver pathology. There were no differences in outcome, including length of hospital stay (no drain, 13.4 ± 0.9 days; drain, 13.1 ± 0.8 days; P not significant [NS]), mortality (no drain, 3.3%; drain, 3.3%), complication rate (no drain, 43%; drain, 48%; n= NS), or requirement for subsequent percutaneous drainage (no drain, 18%; drain, 8%; P= NS). All infected collections (n= 3) occured in operatively drained patients. Two other complications were directly related to the operatively placed drains. One patient developed a subcutaneous abscess at the drain site, and a second developed a subcutaneous drain tract tumor recurrence as the only current site of recurrence.

Conclusion: In the first 50 consecutive resections performed since the conclusion of this trial, only 4 patients (8%) have required subsequent percutaneous drainage. We conclude that abdominal drainage is unnecessary after elective liver resection,
Bile Duct Calculi – The New Challenges
Authors: Stiegmann Gregory V.
Published: September 2007

Background: Morbidity and mortality after surgical treatment of bileduct stones increase with age and associated diseases. A proposed alternative therapy is endoscopic sphincterotomy (ES) with the gallbladder left in situ, and we elected to compare this option with standard open surgery in high‐risk patients.

Methods: 98 patients (mean age 80 years) with symptoms likely to be due to bileduct stones or a recent episode of biliary parcreatitis were randomised to be treated either by open cholecystectomy with operative cholangiography and (if necessary) bileduct exploration (n=48) or by endoscopic sphincterotomy alone (n=50).

Findings: The procedure was accomplished successfully in 94% of the surgery group and 88% of the ES group, and there were no significant differences in immediate morbidity (23% vs 16%) or mortality (4% vs 6%). During mean follow‐up of 17 months biliary symptoms recurred in three surgical patients, none of whom underwent repeat surgery, and in 10 ES patients, seven of whom had biliary surgery. By multivariate regression analysis endoscopic sphincterotomy was an independent predictor of recurrent biliary symptoms (odds ratio 6.9; 95% C11.46 to 32.54).

Interpretation: In elderly or high‐risk patients, surgery is preferably to endoscopic sphincterotomy with the gallbladder left in situ as a definitive treatment for bileduct stones or non‐severe biliary pancreatitis.
Pharmacokinetics of Octreotide in PatientsWith Cirrhosis and Portal Hypertension;Relationship Between the Plasma Levelsof the Analogue and the Magnitudeand Duration of the Reduction in CorrectedWedged Hepatic Venous Pressure
Authors: Jenkins S. A. , Nott D. M. , Baxter J. N.
Published: September 2007

In healthy subjects octreotide is largely metabolised
by the liver suggesting that the plasma half‐life of the
somatostatin analogue may be prolonged in patients
with hepatic dysfunction. The aim of this study was
therefore (a) to determine the pharmacokinetics of
octreotide following its subcutaneous injection in 6
patients with cirrhosis and portal hypertension and
(b) compare the magnitude and duration of the effects
of intravenous administration of 250 μg somatostatin
and 50 μg octreotide on corrected wedged hepatic
venous pressure (WHVP) and to relate the findings to
the plasma levels of the analogue 1h after administration
in 13 patients with cirrhosis and portal
hypertension. Following subcutaneous administration
of 50 μg octreotide the circulating half life (range
2.4 to 4.79 h) was prolonged whereas the clearance
(range 2.101 to 4.775 L/h) was decreased compared to
healthy controls. Intravenous bolus administration of
25 μg somatostatin or 50 μg octreotide resulted in a
reduction in WHVP of approximately the same
magnitude and duration despite appreciable quantities
of the analogue in the blood lh after administration
(1944 ± 226 pg/ml). These results indicate
that the circulating half‐life of octreotide is prolonged
in cirrhotics suggesting that the dosage
regimens should be modified in such patients to
avoid accumulation of the analogue in the blood
which may result in undesirable side‐effects or
toxicity. Furthermore, since the magnitude and
duration of the reduction in WHVP elicited by IV
octreotide is similar to that obseved with somatostatin,
the analogue, like the native hormone, must be
administered by continuous IV infusion to produce a
sustained response and hence a therapeutic effect in
the management of acute variceal bleeding.
Portal Decompression Using the Inferior Mesenteric Vein
Authors: Gorini Paolo , Johansen Kaj
Published: September 2007

We report five patients with variceal hemorrhage, in three cases secondary to diffuse thrombosis of the portal, superior mesenteric and splenic veins. Mesenteric angiography demonstrated patency of the inferior mesenteric vein (IMV) in each, and successful portal decompression by anastomosis of the IMV to the left renal vein (n=4) or the inferior vena cava (n=1) was accomplished. Bleeding was permanently controlled: four patients have survived from one to eight years post‐operatively. Because shunt procedures utilizing the IMV are technically straightforward, subtotally decompress the portal system and avoid the right upper quadrant, they may be advantageous in certain clinical settings.
Hepatic Cryotherapy and SubsequentHepatic Arterial Chemotherapyfor Colorectal Metastases to the Liver
Authors: Stubbs Richard S. , Alwan Majeed H. , Booth Michael W. C.
Published: September 2007

This paper presents an experience of thirty consecutive
patients with hepatic colorectal metastases
who were treated with hepatic cryotherapy and
subsequent hepatic arterial infusion (HAI) chemotherapy
using 5FU.

Patients with colorectal metastases confined to the
liver but not suitable for resection, and with liver
involvement of less than 50% were offered the
treatment. Prospective documentation of all patients
was undertaken with data being recorded on a
computerised database.

Patients had a median of 6 (2–15) lesions with
sizes ranging from 1–12 cm. There was no 30 day
mortality. Postoperative complications developed in
8 patients but were followed by full recovery in all
instances. Side effects from chemotherapy occured
in 23% of cycles. Twenty seven patients have died.
Median survival from the time of cryotherapy was
18.2 months (7–34), or 23months (9–44) from
diagnosis of liver lesions.

Hepatic cryotherapy with subsequent arterial
chemotherapy is safe and well tolerated. The results
suggest survival of patients with colorectal hepatic
metastases can be improved by the use of this
modality of treatment.
Leakage Via Aberrant Bile Duct Dueto Cholangiocarcinoma
Authors: Stanton R. , Craig P. I. , Jorgensen J. O. , Morris D. L.
Published: September 2007

The case of a male who had an open cholecystectomy
complicated by presistent bile leak from an
aberrant bile duct is presented. The persistence and
volume of bile leak resulted in subsequent investigation
of the biliary tree which demonstrated a
cholangiocarcinoma of the right hepatic duct. This
case is presented as an unusual presentation of
cholangiocarcinoma and to highlight the value of
modern techniques in imaging the biliary tree.
Spontaneous Passage of GallbladderCalculi‐Facilitation by Endoscopic Sphincterotomy
Authors: Sharma B. C. , Agarwal D. K. , Baijal S. S. , Saraswat V. A.
Published: September 2007

After Endoscopic sphincterotopy (ES) gallbladder
motility increases leading to expulsion of crystals
and stones. But this is not a universal phenomenon.
We evaluated cholangiographic findings in patients
emptying their gallbladder after ES for common
bile duct (CBD) stones. Cholangiographic features
of twenty patients expelling gallbladder calculi
after ES were studied. Controls included 20 age and
sex matched patients with gallstones and CBD
stones, who did not expel gallstones after ES. Of 20
cases in study group, 9 recovered more than 20
stones each in the stool within 7 days of ES. Repeat
ERCP showed empty gallbladder in all, whereas
CBD was full of stones in 11 of the 20 cases. In the
study group, low insertion of the cystic duct was
more common (10 vs 0, p<0.04), the cystic duct
made a narrow angle (20±5° vs 50±10°, p<0.04)
with CBD before insertion and cystic duct diameter
was higher (5 mm vs 2.5 mm, p<0.04) as compared
to controls. We conclude that in patients undergoing
ES with intact gallbladder and small gallbladder
calculi, spontaneous emptying of
gallbladder calculi occurs, if cystic duct is wider,
has low insertion and makes narrow angle with
CBD before insertion.
Band Ligation or Sclerotherapy as EndoscopicTreatment for Oesophageal Varices in SchistosomoticPatients: Results of a Randomized Study
Authors: Siqueira Eduardo Sampaio , Rohr Maria Rachel Da Silveria , Libera Ermelindo Della , Castro Rubem Robson O. , Ferrari Angelo Paulo
Published: September 2007

Endoscopic sclerotherapy and banding ligation are
the two preferred methods to treat oesophageal
variceal bleeding. There are many reports dealing
with such treatment in cirrhotic patients but we do not
know how good they are to treat varices secondary to
other forms of portal hypertension. Schistosomiais
mansoni is the main cause of portal hypertension and
oesophageal varices in Brazil. We performed a
prospective randomised study to compare: 1) the
efficacy of both treatments in eradicating oesophageal
varices, and 2) complications secondary to both
treatments. Forty patients were divided in two
Groups. Both sclerotherapy and banding ligation
were performed until variceal eradication. There were
no severe complications. Variceal eradication was
faster obtained with banding ligation than sclerotherapy
although there was no statistical difference (mean
number of sessions 3.05 vs 3.72, p=0.053). Benign
complications were equally frequent in both Groups,
although additional sedation was more common in
the sclerotherapy Group. We concluded that both
treatments are equally effective in the eradication of
oesophageal varices, although banding ligation is
better tolerated by the patient and probably faster.
Extrahepatic Portal Hypertension following Liver Transplantation: a Rare but Challenging Problem
Authors: Malassagne B. , Soubrane O. , Dousset B. , Legmann P. , Houssin D.
Published: September 2007

This study reports our experience of 8 cases of extrahepatic portal hypertension after 273 orthotopic liver transplantations in 244 adult patients over a 10‐ year period. The main clinical feature was ascites, and the life‐threatening complication was variceal bleeding. Extrahepatic portal hypertension was caused by portal vein stenosis in 6 patients, and left‐sided portal hypertension in 2 patients after inadventent ligation of portal venous tributaries or portasystemic shunts. All patients with portal vein stenosis had complete relief of portal hypertension after percutaneous transhepatic venoplasty (n=4) or surgical reconstruction (n=2), after a median follow‐up of 33 (range: 6–62) months. Of the 2 patients with left‐sided portal hypertension, one died after splenectomy and one rebled 6 months after left colectomy. This study suggests that extrahepatic portal hypertension is a series complication after liver transplantation that could be prevented by meticulous portal anastomosis and closure of portal tributaries or portasystemic shunts to improve the portal venous flow. However, any ligation has to be performed under ultrasound guidance to avoid inadventent venous ligations.
Cystic Dilation of Extrahepatic Bile Ducts in Adulthood: Diagnosis, Surgical Treatment and Long. Term Results
Authors: Belli G. , Rotondano G. , D′Agostino A. , Iannelli A. , Marano I. , Santangelo M. L.
Published: September 2007

To evaluate the long‐term results of surgery for choledohal cyst in adulthood, a series of 13 patients over the age of 16 operated on for choledochal cyst during a period of six years and followed‐up for a minimum of 3 years was analyzed. Patients with type I and IVa cysts underwent extrahepatic cyst resection and Roux‐en‐Y hepatico‐jejunostomy. Choledochoceles (type III) were managed endoscopically. No operative mortality or morbidity occurred. Type I and III cysts showed almost ideal follow‐up with no sign of stricture on HIDA scan. One type IVa cyst patients developed recurrent cholangitis due to anastomotic stricture, managed percutaneously. Whenever possible, complete cyst resection and Roux‐en‐Y reconstruction is the treatment of choice for all extrahepatic biliary cysts. Intra‐ and extrahepatic dilatations are adequately treated by extrahepatic resection and careful endoscopic or radiologic surveillance. Small choledochoceles can be safely managed by endoscopic sphincterotomy.
Lost Stones During Laparoscopic Cholecystectomy
Authors: Diez J. , Arozamena C. , Gutierrez L. , Bracco J. , Mon A. , Almeyra R. Sanchez , Secchi M.
Published: September 2007

Background: Gallbladder perforation, with loss of
calculi in the abdomen is frequent during laparoscopic
cholecystectomy. Recent publications report
complications in port sites or in the abdominal
cavity. A study of 3686 laparsocopic cholecystectomies
performed by 6 surgeons was undertaken. In
627 patients, perforation of the gallbladder occurred
and in 254 stones were spilled into the abdominal
cavity. In 214 they were retrieved and in 40 left in the
abdomen. Twelve patients developed complications.
Percutaneous drainage was successful in 2 with
serous collections. Two patients with abdominal
abscesses were reoperated, stones retrieved and the
abdomen drained.

One patient developed an intestinal obstruction
due to a stone in the ileum. One patient who had a
cholecystectomy in another hospital developed a
paraumbilical tumor. At reoperation a stone was
retrieved. In another six patients, stones were found
in port sites. Stones lost into the abdomen should be
removed because of their potential morbidity,
especially if they are large or if infection is present
in the gallbladder at the time of initial surgery.
There is no indication for routine conversion to open
surgery when stone spillage occurs, although patients
should be informed to avoid legal consequence,
and to hasten early diagnosis of later
complications.
Bilirubin as an Anti‐oxidant for Surgical Stress: APreliminary Report of Bilirubin Oxidative Metabolites
Authors: Kozaki N. , Shimizu S. , Chijiiwa K. , Yamaguchi K. , Kuroki S. , Shimoharada K. , Yamaguchi T. , Nakajima H. , Tanaka M.
Published: September 2007

Background Bilirubin has been recognized as an antioxidant.
The purpose of this study was to examine
whether bilirubin would act as an antioxidant for
surgical stress in humans. Materials and Methods
Serum bilirubin and urinary bilirubin oxidative
metabolites (BOM) were measured in 96 patients
who underwent surgery. The antioxidant activity
of bilirubin was assessed using BOM measured
by enzyme‐linked immunosorbent assay with an
anti‐bilirubin monoclonal antibody. Results Serum
bilirubin levels increased after surgery in all 96
patients (p<0.01), but did not correlate with operation
time or blood loss (p=0.53 and p=0.28, respectively).
BOM increased only in patients with major
surgeries (p=0.048). Significant correlations between
BOM and operation time and blood loss were found
(p<0.01). Conclusions Bilirubin appears to act as an
antioxidant for invasive surgery in humans. Urinary
BOM could be a reliable marker for the degree of
surgical stress.
Left Extended Hemihepatectomy With Preservation ofLarge Inferior Right Hepatic Vein: A Case Report
Authors: Texler M. L. , Jamieson G. G. , Maddern G. J.
Published: September 2007

For hepatic function to be preserved after an extended
hemihepatectomy adequate venous drainage
of the remaining liver is required. Most metastases
close to the confluence of the superior hepatic veins
are considered unresectable because hepatic venous
outflow after resection would be compromised. In
10–25% of people, the inferior right hepatic vein is
of large calibre. Thus the superior hepatic veins may
be sacrificed and hepatic function preserved if a
large inferior right hepatic vein is present.

A patient with involvement of segments 2, 4 and 8
by metastatic colorectal cancer is presented. This
patient had a large inferior right hepatic vein, and so
was able to undergo an extended left hemihepatectomy
with ligation of all superior hepatic veins. Subsequent
quality of life was maintained.

This case illustrates that an ‘unresectable’ hepatic
lesion can be actually resectable if an alternative
venous drainage is present. A pre‐operative search
for a prominent inferior right hepatic vein by ultrasound,
computerised tomography, or even magnetic
resonance imaging should be considered in these
cases.
Do Alterations in the Rate of Gastric Emptyingafter Injection Sclerotherapy for OesophagealVarices Play any Role in the Developmentof Portal Hypertensive Gastropathy?
Authors: Balan K. K. , Grime J. S. , Sutton R. , Critchley M. , Jenkins S. A.
Published: September 2007

Bleeding from portal hypertensive gastropathy
(PHG) has been estimated to account for upto 30%
of all upper gastrointestinal haemorrhage in patients
with cirrhosis and portal hypertension. Although
portal hypertension seems to be an essential prerequisite,
the precise mechanisms responsible for
the development of PHG are unknown. The aim of
this study was to examine the role of injection sclerotherapy
of oesophageal varices in the development
of PHG. Gastric emptying was studied using a
radionuclide test meal with the emptying characteristics
of a slow liquid in 57 patients with cirrhosis
and/or portal hypertension (median age 53 yrs), of
whom 34 had received injection sclerotherapy for
their oesophageal varices and 20 normal healthy
volunteers (median age 42 yrs). As vagal damage is
associated with more rapid emptying of liquids,
despite hold up of solids, this technique might be
expected to demonstrate such damage if gastric
emptying was accelerated. The results indicated that
there was no difference in the rate of gastric
emptying between normal healthy volunteers and
portal hypertensive patients. However, patients who
had received injection sclerotherapy emptied their
stomachs faster than those who had not (p<0.05).
Furthermore, the speed of gastric emptying correlated
directly with the number of injections (r=0.41;
p=0.02) and the volume of sclerosant injected
(r=0.39; p=0.03). These observations suggest that
injection sclerotherapy for oesophageal varices
results in disturbances of gastric emptying that
may contribute to the pathogenesis of portal hypertensive
gastropathy.
Endoscopic Management of Bleeding Ectopic Varices With Histoacryl
Authors: Bhasin Deepak K. , Sharma B. C. , Sriram P. V. J. , Makharia G. , Singh K.
Published: September 2007

Bleeding from antral and duodenal varices is an
uncommon feature in patients with portal hypertension.
We report a patient with cirrhosis and portal
vein thrombosis, who had a massive bleed from
antral and duodenal varices. Bleeding was controlled
with endoscopic injection of varices using
histoacryl. Endoscopic treatment and the relatively
uncommon occurrence of antral and duodenal
varices are highlighted.
Reoperations for Bleeding Portal Hypertension.Surgical Rescue of Surgical Failures
Authors: Mercado Miguel Angel , Gómez-Méndez Tito José María , Morales-Linares Julio César , Granados Jorge , Chan Carlos , Rojas Gilberto , Orozco Héctor
Published: September 2007

Background; Surgery for portal hypertension has a
low rebleeding rate. Patients that rebleed can be
grossly divided into those who die as a consequence
of the episode, those who don′t die but develop liver
failure (remaining as Child‐Pugh C) and those who,
in spite of the bleeding episode, retain good liver
function (Child‐Pugh A or B). At our hospital, the
latter group is considered for further surgical
treatment. We report here the results of surgical
rescue of surgical failures.

Methods; In a twenty year period, 36 patients (30
Child‐Pugh A, 6 Child‐Pugh B) were reoperated. The
files of these patients were reviewed.

Results; Average age was 33 years. Cirrhosis was
present in 31 cases. All patients were electively
reoperated with portal blood flow preserving procedures.
Operative mortality for the whole group
was 12% and for the Child‐Pugh A group 6.6%. Rebleeding
was observed in 5.5%. Postoperative
incapacitating encephalopathy was recorded in one
case (2.7%). Good quality of life was recorded in 84%
of the cases. Survival (Kaplan‐Meier) was 78% at 6
months and 69% at 5 years.

Conclusions; Surgical failures in low risk patients
(Child‐Pugh A or B) can be treated by means of
surgery, and a low mortality, re‐bleeding and
encephalopathy rate can be expected. The performance
of a portal blood flow preserving procedure
is recommended.
Pulmonary Lymphangitis Carcinomatosaand Acute Pancreatitis: A Rare Presentationof Choledochal Cyst
Authors: Kelly D. M. , O′Donnell P. J. , Howard E. R.
Published: September 2007

Pulmonary lymphangitis carcinomatosa is an unusal
cause of death in a young adult. This case describes
an apparently healthy young woman who presented
with severe acute pancreatitis, which is a recognized
complication of a choledochal cyst. Autopsy examination
revealed advanced malignancy with poorly
differentiated adenocarcinoma penetrating the wall
of the choledochal cyst and metastatic adenocarcinoma
in the lymph nodes, lungs and kidneys. This
case emphasises the unusual presentation of a
choledochal cyst with acute pancreatitis and the
aggressive nature of malignancy associated with this
congenital anomaly.
Adenoma of the Ampulla of Vater:A Genetic Condition?
Authors: Serafini Francesco M. , Carey Larry C.
Published: September 2007

The etiology of adenoma of the ampulla of Vater is
not well understood. Previous authors reported the
association of this neoplasm with polycystic kidney
disease of two fraternal sisters. They concluded that
these two conditions were somehow related. We
describe a case of ampullary adenoma associated
with polycystic kidney disease. This presentation
raises again the question of a possible link between
these two diseases.
Selenium Deficiency and Chronic Pancreatitis:Disease Mechanism and Potential for Therapy
Authors: Bowrey David J. , Morris-Stiff Gareth J. , Puntis Malcolm C. A.
Published: September 2007

Background: It has been suggested that antioxidant
deficiency may play a role in the pathogenesis of
chronic pancreatitis. The aim of this review was to
analyse the evidence for this relationship and to
consider the role of antioxidant supplementation in
the treatment of chronic pancreatitis.

Methods: Medline review of all English language
publications for the years 1966–1998.

Results and Conclusions: There is evidence that
patients with chronic pancreatitis have enhanced
levels of free radical production, cytochrome P450
induction and antioxidant deficiencies, in particular
selenium. The limited published literature in this
field suggests that dietary antioxidant supplementation
may ameliorate the pain associated with chronic
pancreatitis, diminish the frequency of acute exacerbations
and reduce the requirement for pancreatic
surgery. These findings await confirmation by a large
prospective placebo‐controlled study.
Recognition of Intrabiliary Hepatic MetastasesFrom Colorectal Adenocarcinoma
Authors: Povoski Stephen P. , Klimstra David S. , Brown Karen T. , Schwartz Lawrence H. , Kurtz Robert C. , Jarnagin William R. , Fong Yuman , Blumgart Leslie H.
Published: September 2007

Intrinsic involvement of bile ducts, by metastatic
colorectal adenocarcinoma growing from within or
invading the lumen of bile ducts, is not a well
recognized pattern of tumor growth. Clinical, radiographic,
operative, and histopathologic aspects of 15
patients with intrabiliary colorectal metastases were
described. Fourteen patients were explored for
possible hepatic resection. Two had jaundice, two
radiographic evidence of an intrabiliary filling
defect, 10 intraoperative evidence of intrabiliary
tumor, and six microscopic evidence of intrabiliariy
tumor. Eleven patients underwent hepatic resection.
Five of the resected patients developed hepatic
recurrence. Four patients were explored for possible
repeat resection. One had jaundice, one radiographic
evidence of an intrabiliary filling defect, all had
intraoperative evidence of intrabiliary tumor, and
three microscopic evidence of intrabiliary tumor.
Three patients underwent repeat hepatic resection.
All patients with preoperative jaundice and radiographic
evidence of an intrabiliary filling defect
were unresectable. Overall, actuarial five‐year survival
is 33% for those patients resected versus 0% for
those not resected. Intraoperative recognition of
intrabiliary tumor at exploration for hepatic resection
was more common than clinical, radiographic,
or histopathologic recognition. More diligent examination
of resected liver tissue by the surgeon and
pathologist may increase identification of bile duct
involvement and aid in achieving adequate tumor
clearance.
Giant Hepatic Hemangioma With Kasabach–MerrittSyndrome: Is the Appropriate TreatmentEnucleation or Liver Transplantation?
Authors: Hochwald Steven N. , Blumgart Leslie H.
Published: September 2007

We present a case of giant cavernous hemangioma of
the liver with disseminated intravascular coagulopathy
(Kasabach–Merritt syndrome) which was
cured by enucleation. The 51 year old woman
presented with increased abdominal girth and easy
bruisability. Workup elsewhere revealed a massive
hepatic hemangioma and she was started on radiation
therapy to the lesion and offered an orthotopic
liver transplant. After careful preoperative preparation,
we felt that resection was possible and she
underwent a successful enucleation. The operation
and postoperative course were complicated by
bleeding but she recovered and remains well in
followup after 6 months. All coagulation parameters
have returned to normal. Enucleation should
be considered the treatment of choice for hepatic
hemangiomas, including those presenting with
Kasabach–Merritt syndrome. The benefits of enucleation
as compared to liver transplantation for
these lesions are discussed.
Review: Research Toward Safer Resectionof the Cirrhotic Liver
Authors: Moser M. A. J. , Kneteman N. M. , Minuk G. Y.
Published: September 2007

Despite recent advances in hepatic surgery, resection
of the cirrhotic liver continues to be fraught
with high morbidity and mortality rates. As a result,
for many patients requiring resection of HCC the
postoperative course is complicated and the probability
of cure is diminished by coexisting cirrhosis.
In this review, we discuss the characteristics
of the cirrhotic liver which make it poorly tolerant
of resection and the most common complications
that follow such surgery. The main purpose of this
paper is to review recent attempts to identify interventions
that might be beneficial to cirrhotic patients
undergoing resection. These interventions include
assessment of liver reserve, advances in surgical
technique, and improvement in liver function and
regeneration.
Surgery for Deeply Located Hydatid Cystsof the Liver: A Simple Alternative
Authors: Kjossev Kirien T. , Losanoff Julian E.
Published: September 2007

Gaining access to deeply located hydatid cysts of the
liver using conventional surgical techniques may be
accompanied by significant intra‐ and postoperative
complications. In addition, obliteration of the cyst
cavity is still a matter of controversy. We developed
a novel method for easy access to deep hydatid cysts
using a water jet dissector (Parenchimotom 01,
TOSA, Pleven, Bulgaria). At pressure of 20 Bar
using a 0.2mm nozzle, a corridor is created through
the liver parenchyma overlying the cyst; vessels and
biliary duct are thus clearly displayed as linear structures
traversing the corridor and are ligated and divided
under direct visual control. The fibrous capsule
of the cyst is spared by the jet. Following endocystectomy
performed in the ordinary manner, the
cyst cavity is filled with gelatin sponge; a passive
tube drain is placed in contact with the liver incision.

In allowing for a selective dissection of the liver
parenchyma, the jet makes safe access to deeply located
hydatid cysts possible. On the other hand, the
gelatin sponge induces good fibroblast response
and assists in rapid and effective obliteration of the
residual cavity. This novel technique works well in
our hands but more extensive studies are necessary
before its final acceptance.
Morphine Plus Bupivacaine Vs. MorphinePeridural Analgesia in Abdominal Surgery:The Effects on Postoperative Coursein Major Hepatobiliary Surgery
Authors: Barzoi G. , Carluccio S. , Bianchi B. , Vassia S. , Colucci G. , Mangiante G. L.
Published: September 2007

Anaesthesia and surgical procedures lead to a
reduction of intestinal motility, and opioids may
produce a postoperative ileus, that might delay
postoperative feeding. The aim of this prospective
randomised study is to test whether or not different
kinds of epidural analgesia (Group A: morphine 0.00
17 mg/kg/h and bupivacaine 0.125% – 0.058 mg/kg/h;
Group B: morphine alone 0.035mg/kg/12h in the
postoperative period) allow earlier postoperative
enteral feeding, enhance intestinal motility a passage
of flatus and help avoid complications, such
as nausea, vomiting, ileus, diarrhoea, pneumonia or
other infective diseases. We included in the study 60
patients (28 males and 32 females) with a mean age
of 61.2 years (range 50–70) and with an ASA score of
2 or 3. All patients had hepato–biliary‐pancreatic
neoplasm and were candidates for major surgery.
We compared two different pharmacological approaches,
i.e., morphine plus bupivacaine (30 patients,
Group A)versus morphine alone (30 patients,
Group B). Each medication was administered by
means of a thoracic epidural catheter for the control
of postoperative pain. In the postoperative course
we recorded every 6 hours peristaltic activity. We
also noted morbidity (pneumonia, wound sepsis)
and mortality. Effective peristalsis was present in
all patients in Group A within the first six postoperative
hours; in Group B, after 30 hours. Six
patients in Group A had bowel motions in the first
postoperative day, 11 in the second day, 10 in the
third day and 3 in fourth day, while in Group B none
in the first day, two in the second, 7 in the third, 15
in the fourth, and 6 in the fifth: the difference
between the two groups was significant (P<0.05
in 1st, 2nd, 4th and 5th days). Pneumonia occurred
in 2 patients of Group A, and in 10 of Group B
(P<0.05).

We conclude that epidural analgesia with morphine
plus bupivacaine allowed a move rapid return
to normal gut activity and early enteral nutrition compared
with epidural analgesia with morphine alone.
Tracking Down Duodenopancreatic Malignancy
Authors: Samel-Westerhof Constanze , Samel Stephan , Back Walter , Gaa Jochen , Sturm Jörg
Published: September 2007

Background Malignant tumours of the duodenum
are rare and often difficult to diagnose. Due to the
small clinical experience with duodenal malignancies
their prognosis is unknown and resection is the
treatment of choice.

Case report Adding to a small series of incidental
tumours, we report the case of a 65‐year‐old patient
with primary extranodal (MALT‐) lymphoma of the
duodenum infiltrating the pancreatic head. The
patient was admitted because of anaemia and
epigastric discomfort with a history of Helicobacter‐
pylori associated gastric ulceration. Physical
examination and bloodchemical values were otherwise
normal. Endoscopy revealed duodenal ulceration
but the biopsies taken from the ulceration did
not give any evidence of malignancy or residual
Helicobacter pylori infection. But MRT showed a
circular intramural tumour of the duodenum. On
laparotomy a large duodenal tumour adherent to the
pancreatic head was found and a Whipple procedure
was performed.

Conclusion Apart from describing the case of a
rare lymphoproliferative disorder of the duodenum,
this report illustrates the diagnostic difficulties with
uncommon neoplasm′s of the duodenopancreatic
region and the value of MRT prior to resection of a
duodenopancreatic mass.
The Impairment of Wound Healing Processis Correlated With Abnormalities of TNF‐αProduction by Peritoneal Exudate Cellsin Obstructive Jaundiced Rats
Authors: Dawiskiba Janusz , Kwiatkowska Danuta , Zimecki Michał , Kornafel Pawel , Tyran Wanda , Czapiiska Elżbieta , Woźniak Zdzisław
Published: September 2007

The wound healing process and production of
tumour necrosis factor alpha (TNF‐α) by peritoneal
cells of 7‐day and 14‐day obstructive jaundice (OJ)
and sham‐operated rats were investigated. In the
study the skin wound breaking strength was measured,
In addition such histological and biochemical
parameters as fibroblast and endothelial cell proliferation,
inflammatory cell infiltration and hydroxyproline
content were evaluated in polyurethane
sponge discs implanted subcutaneously into rats.
TNF‐α production by peritoneal exudate cells (PEC),
both spontaneous and lipopolysaccharide (LPS)‐
induced was determined by a bioassay. In OJ rats the
process of both early as well as late phase of healing
was impaired. The breaking strength of skin wound
was decreased, the fibroblast and endothelial cell
proliferation and collagen deposition, as well as hydroxyproline
content were diminished. In 7 day OJ
the numbers of inflammatory cells in the implants
were lowered with a subsequent slight increase on
day 14 of OJ. The spontaneous and LPS induced TNF‐
α production by PEC were significantly higher in 7
day OJ as compared with sham‐operated controls. On
day 14 of OJ the LPS‐induced TNF‐α level was, in
contrast, much lower and did not differ much from
the spontaneous TNF‐α production. We conclude
that the impairment of wound healing in OJ results
from disturbances in functioning of the immune
system caused by systemic endotoxaemia.
Treatment Options for Villous Adenomaof the Ampulla of Vater
Authors: Hoyuela C. , Cugat E. , Veloso E. , Marco C.
Published: September 2007

Introduction: Duodenal villous adenoma arising
from the ampulla of Vater has a high risk of malignant
development. Excluding associated malignant
disease prior to resection of an adenoma of the ampulla
is not always possible. Therefore, the surgical
procedure of choice to treat this rare tumour is still
controversial.

Objective: To evaluate retrospectively results of treatment
of villous adenoma arising from ampulla of
Vater with dysplasia or associated carcinoma limited
to the ampulla.

Patients and Methods: From 1985 to 1996, eight
patients have been diagnosed with ampullary villous
adenoma suitable for resection. We have reviewed
treatment, morbidity, mortality, follow‐up and final
outcome.

Results: Pancreatoduodenectomy (PD) was performed
in 4 patients. Transduodenal ampullectomy and
endoscopic resection was performed in 2 patients
each. There was no perioperative mortality.
None of the patients had biliary, pancreatic or intestinal
leakage but two patients who underwent
PD had minor postoperative complications. The mean
follow‐up was 44 (range: 6–132) months. Villous
adenoma was associated with adenocarcinoma in
50% of the cases (4/8 patients). During the followup
both patients who underwent transduodenal
ampullectomy developed recurrent disease. All patients
initially treated by PD are alive without
evidence of recurrent disease.

Conclusions: Treatment of villous adenoma of the
ampulla must be individualized within certain limits.
In our series, PD achieve good results and it appears
to be the procedure of choice in order to treat
villous adenomas with proved presence of carcinoma,
carcinoma in situ or severe dysplasia. Endoscopic
or local resection may be appropriate for small
benign tumours in high risk patients.
Hepatobiliary Manifestationsof Inflammatory Bowel Disease
Authors: Memon Mohammed Iqbal , Memon Breda , Memon Muhammed Ashraf
Published: September 2007

Hepatobiliary manifestations occur quite frequently
in patients suffering from chronic ulcerative colitis
and Crohn′s disease and carry with them considerable
morbidity and mortality. Although the true
incidence is difficult to determine, clinically, significant
hepatobiliary disease occurs in 5%–10% of
patients. At the present moment, the aetiology and
pathogenesis of inflammatory bowel disease and its
systemic manifestations remains speculative. For
those hepatobiliary manifestations that respond to
therapy of the underlying bowel disease, medical
and/or surgical therapy must be aggressively pursued.
More urgent research is required towards
understanding the underlying cause(s) of the primary
bowel disease and its systemic manifestations
in order to improve the overall management of this
condition.
Novel Mechanism whereby Nuclear Factor κB Mediates DNA Damage Repair through Regulation of O6-Methylguanine-DNA-Methyltransferase
Authors: Lavon Iris , Fuchs Dana , Zrihan Daniel , Efroni Gilat , Zelikovitch Bracha , Fellig Yakov , Siegal Tali
Published: September 2007

O 6-Methylguanine-DNA-methyltransferase (MGMT) and nuclear factor κB (NF-κB) are two key effectors associated with the development of resistance to alkylating agent–based chemotherapy. This prompted us to hypothesize that NF-κB might be involved in MGMT regulation. Consistent with this hypothesis, we have discovered two putative NF-κB binding sites within the MGMT promoter region and showed a specific and direct interaction of NF-κB at each of these sites. Forced expression of the NF-κB subunit p65 in HEK293 cells induced an increase in MGMT expression whereas addition of the NF-κB super repressor ΔNIκB completely abrogated the induction. We also found a significant correlation between the extent of NF-κB activation and MGMT expression in the glioma cell lines and the human glial tumors tested and showed that it was independent of MGMT promoter methylation. Our results are of potential clinical significance because we show that cell lines with ectopic p65 or high constitutive NF-κB activity are less sensitive to nitrosourea treatment and that suppression of MGMT activity with O6-benzylguanine completely abolishes the chemoresistance acquired by NF-κB. The findings of our study strongly suggest that NF-κB plays a major role in MGMT regulation and that MGMT is most probably the major player in NF-κB–mediated chemoresistance to alkylating agents. [Cancer Res 2007;67(18):8952–9]
Identification and Characterization of Genetic Variation in the Folylpolyglutamate Synthase Gene
Authors: Leil Tarek A. , Endo Chiaki , Adjei Araba A. , Dy Grace K. , Salavaggione Oreste E. , Reid Joel R. , Ames Matthew M. , Adjei Alex A.
Published: September 2007

Folylpolyglutamate synthase (FPGS) catalyzes the polyglutamation of folic acid, methotrexate, and pemetrexed to produce highly active metabolites. To characterize genetic variation in the FPGS gene, FPGS, have resequenced the gene in four different ethnic populations. Thirty-four single nucleotide polymorphisms were identified including five nonsynonymous coding single nucleotide polymorphisms that altered the FPGS protein sequence: F13L and V22I polymorphisms in the mitochondrial isoform of FPGS, and R466/424C, A489/447V, and S499/457F polymorphisms, which exist in both the mitochondrial and cytosolic isoforms. When expressed in AuxB1 cells, the A447V cytosolic variant was functionally similar to the wild-type cytosolic (WT Cyt) allozyme, whereas the R424C and S457F cytosolic variants were reduced by ∼2-fold in protein expression compared with WT Cyt (P < 0.01). The intrinsic clearance of glutamate was reduced by 12.3-fold (R424C, P < 0.01) and 6.2-fold (S457F, P < 0.01), whereas the intrinsic clearance of methotrexate was reduced by 4.2-fold (R424C, P < 0.05) and 5.4-fold (S457F, P < 0.05) in these two cytosolic variants when compared with the WT Cyt isoform. Additionally, the in vitro enzyme velocity at saturating pemetrexed concentrations was reduced by 1.6-fold (R424C, P < 0.05) and 2.6-fold (S457F, P < 0.01) compared with WT Cyt. AuxB1 cells harboring these same cytosolic variant allozymes displayed significant increases in the EC50 for folic acid and in the IC50 values for both methotrexate and pemetrexed relative to the WT Cyt form of FPGS. These observations suggest that genetic variations in FPGS may alter the efficacy of antifolate therapy in cancer patients. [Cancer Res 2007;67(18):8772–82]
A Novel Nonobese Diabetic/Severe Combined Immunodeficient Xenograft Model for Chronic Lymphocytic Leukemia Reflects Important Clinical Characteristics of the Disease
Authors: Dürig Jan , Ebeling Peter , Grabellus Florian , Sorg Ursula R. , Möllmann Michael , Schütt Philipp , Göthert Joachim , Sellmann Ludger , Seeber Siegfried , Flasshove Michael , Dührsen Ulrich , Moritz Thomas
Published: September 2007

We here describe a novel xenograft model of chronic lymphocytic leukemia (CLL) generated by infusion of human primary CLL cells into immunodeficient nonobese/severe combined immunodeficient (NOD/SCID) mice. Combined i.v. and i.p. injection of peripheral blood mononuclear cells (PBMC) from 39 patients with CLL resulted in highly reproducible splenic (37 of 39) and peritoneal (35 of 39) engraftment, which remained stable over a time span of 4 to 8 weeks. By comparison, recovery of leukemic cells from bone marrow (21 of 39) or peripheral blood (8 of 22) was substantially lower. The engraftment pattern of CLL PBMC 4 weeks posttransplant was correlated with clinical disease activity: infusion of PBMC from donors with Binet stage A, lymphocyte doubling time of >12 months, and normal lactate dehydrogenase (LDH) serum levels led to marked engraftment of T cells whereas comparably few tumor cells could be detected. In contrast, NOD/SCID mice receiving PBMC from donors with advanced stage Binet C, lymphocyte doubling time of <12 months, and elevated LDH serum levels exhibited predominant engraftment of tumor cells and comparably low numbers of T cells. These results suggest that this model reflects the heterogeneity and important clinical characteristics of the disease, and thus may serve as a tool for preclinical drug testing and investigation of the pathophysiology of CLL. [Cancer Res 2007;67(18):8653–61]
Mastermind-like 1 Is a Specific Coactivator of β-Catenin Transcription Activation and Is Essential for Colon Carcinoma Cell Survival
Authors: Alves-Guerra Marie-Clotilde , Ronchini Chiara , Capobianco Anthony J.
Published: September 2007

Misregulation of the Wnt signaling pathway has been linked to many human cancers including colon carcinoma and melanoma. The primary mediator of the oncogenic effects of the Wnt signaling pathway is β-catenin. Accumulation of nuclear β-catenin and transcription activation of lymphoid enhancer factor 1 (LEF1)/T-cell factor (TCF) target genes underlie the oncogenic activity. However, the mechanism of β-catenin–mediated transcriptional activation remains poorly understood. In this study, we identified Mastermind-like 1 (Maml1), which is thought to be a specific coactivator for the Notch pathway, as a coactivator for β-catenin. We found that Maml1 participates in the Wnt signaling by modulating the β-catenin/TCF activity. We show in vivo that Maml1 is recruited by β-catenin on the cyclin D1 and c-Myc promoters. Importantly, we show that Maml1 functions in the Wnt/β-catenin pathway independently of Notch signaling. Finally, we show that the knockdown of Mastermind-like family proteins in colonic carcinoma cells results in cell death by affecting β-catenin–induced expression of cyclin D1 and c-Myc. This is the first demonstration of a role for the Mastermind-like family in another signaling pathway and that the knockdown of Mastermind-like family function leads to tumor cell death. [Cancer Res 2007;67(18):8690–8]