bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of Endothelin‐1 on Hepatic Blood Flow
Authors: Unneberg Kjetil , Mjaaland Marianne , Helseth Elin , Revhaug Arthur
Published: September 2007

Endothelin‐1 belongs to a family of potent vasoconstrictors, recently isolated from endothelial cells.
Endothelin‐1 has a variety of hepatic effects and hepatic clearance from the circulation is important.
Elevated plasma concentrations of Endothelin‐1 are found after orthotopic liver transplantation and in
cirrhosis with ascites.

This study in piglets on hepatic bloodflow was designed to compare differences in effects between central
venous and intraportal injection of endothelin‐1, and to evaluate effects of repeated injections. Central
venous injection of endothelin‐1 caused a larger reduction in portal vein flow, while intraportal injection
caused a larger increase in portal vein pressure. Repeated injections resulted in a reduction in portal vein
flow and an increase in portal vein vascular resistance.
Unusual Tumors Causing Extrahepatic Portal Venous Obstruction
Authors: Sharma B. C. , Saraswat V. A. , Dhiman R. K. , Ghoshal U. C. , Puri A. S. , Sikora S. S.
Published: September 2007

Extrahepatic portal vein obstruction has been reported to be associated with tumors of liver, bile ducts and pancreas. We report two cases, one with gastric leiomyosarcoma and another with Non Hodgkin’s
lymphoma, complicated by portal vein block and presenting with gastric variceal bleeding. Portal vein
block in both cases was due to direct vascular infiltration. Development of portal hypertension posed
difficulties in management.
Intestinal Endotoxins as Co‐Factors of Liver Injury in Obstructive Jaundice
Authors: Menteş B. Bülent , Tatlicioğlu Ertan , Akyol Gülen , Uluoğlu Ömer , Sultan Nedim , Yilmaz Erdal , Çelebi Murat , Taneri Ferit , Ferahköşe Zafer
Published: September 2007

The concept of endotoxin‐mediated rather than direct liver injury in biliary obsruction was
investigated using the experimental rat model of bile duct ligation (BDL) and small bowel
bacterial overgrowth (SBBO). Small identical doses of intravenous endotoxin (bacterial LPS)
caused a significantly more severe liver injury in rats with BDL, compared with sham‐operated
rats, suggesting the possible contribution of LPS in this type of liver damage. BDL was then
combined with surgically created jejunal self‐filling blind loops, which resulted in SBBO. Plasma
LPS level increased significantly, and once again a more severe liver injury, determined by liver
histology and serum gamma‐glutamyl transpeptidase levels, was observed compared with the
control group of rats with BDL+self‐emptying blind loops. The data presented suggest that
small amounts of exogenous LPS and/or the ordinarily innocous amounts of LPS constantly
absorbed from the intestinal tract may be critical in the hepatic damage caused by obstruction
of the biliary tract.
Pathologic and Radiographic Studies of Intrahepatic Metastasis Hepatocellular Carcinoma; The Role of Efferent Vessels
Authors: Toyosaka Akihiro , Okamoto Eizo , Mitsunobu Masao , Oriyama Takeshi , Nakao Norio , Miura Koui
Published: September 2007

The efferent vessel of hepatocellular carcinoma (HCC) and the mechanism and pathogenesis of the high frequency of intrahepatic metastasis in HCC has not yet been clarified. Three hundred ninety‐three resected specimens of HCC were examined for tumor thrombosis in the portal vein and the hepatic vein: 231 tumors ≤5 cm in diameter were examined for the relationship between mode of tumor spread and tumor size. Efferent vessels in HCC were identified by direct injection of radiopaque material into the tumor in 23 resected liver specimens and by percutaneous infusion of radiopaque media into tumor nodules in 8 patients. The mode of tumor spread in HCC progressed from capsular invasion to extracapsular invasion, then to vascular invasion, and finally to intrahepatic metastasis. There was a strong statistical correlation between the presence of intrahepatic metastasis and portal vein thrombosis (p<0.05, R=0.998). Radiopaque material injected directly into 23 resected tumors entered only the portal vein in 17 tumors and into both the portal and hepatic veins in 6 tumors. In all 8 patients with unresectable lesions, radiopaque media injected percutaneously into tumor nodules flowed only into the portal vein. These findings suggest that intrahepatic invasion by HCC may occur through the portal vein as an efferent tumor vessel.
A Different Method of Hepaticojejunostomy for Proximal Biliary Injuries
Authors: Radford Diane M. , Schaefer Glennon
Published: September 2007

The management of proximal biliary injuries presents a surgical challenge. Anastomoses can be difficult to perform and can have poor results. We describe a method of hepaticojejunostomy done from within the Roux‐en‐Y loop, which can be utilized in this situation.
Successful Control of External Biliary Fistula by Using SMS 201‐995 in a Child
Authors: Bakhotmah Mohamad Abid
Published: September 2007

Somatostatin is a potent inhibitory hormone, it′s synthetic analogue is more potent and has a prolonged
action. It has a wide range of actions in the gastrointestinal system; among which is an anticholeritic action
on bile secretion.

The use of Sandostatin in the management of a case of complicated biliary fistula is reported; it
controlled the fistula reducing its daily output from 200 ml to less than 5 ml per day.
Techniques of Inflow Occlusion for Liver Resection
Authors: Launois B.
Published: September 2007

Limited resection can be a therapeutic approach in patients with cirrhosis with very low
remnant hepatic function after resection. In this study, two hilar vascular clamping
methods (hilar selective clamping [n=13] and hilar lobar clamping method [n=8]), which were used for resection ofhepatocellular carcinoma in patients with cirrhosis, were
compared based on cardiovascular stability during clamping, intraoperative bleeding,
operative time and postoperative course. In the past, the Pringle method had been used
(n=19) and those instances were included for comparison. The mean operation time of
the lobar clamping group was 209 ± 44 minutes, which was significantly less than that of
the selective clamping group (259 ± 44 minutes, p < 0.05). Furthermore, the mean
intraoperative blood loss of the lobar clamping group was 920 ± 400 milliliters, which
was significantly less than that of the selective clamping group (1,640 ± 590 milliliters,
p < 0.01). The postoperative total bilirubin and glutamine‐oxaloacetic transaminase
levels tended to be high in the Pringle group, but there was no significant difference
between the groups. Although the blood pressure during clamping significantly decreased
in all groups, the decrease was profound in the Pringle group as compared with those in
the other two groups. Thus, as a method for controlling afferent bloodflow during hepatic
resection in patients with cirrhosis, we recommend the lobar clamping method as a
simple, safe and effective way to minimize bleeding and maintain cardiovascular
stability.
Surglcel ® Reinforced Resection Lines in Left‐sided Hepatectomy with Linear Stapling Device. An Experimental Study on Pigs
Authors: Zilling Thomas , Holmin Torsten
Published: September 2007

Fourteen pigs underwent left‐sided hepatectomy. The resection was performed with a linear
stapling device and the pigs were randomised to either Surgicel ® reinforced resection lines or not.
The median time required for resection was 25 min (range 17‐30) in the Surgicel® reinforced
group compared to 30 min (range 21‐41) in the stapled group. This difference was, however, not
statistically significant (p=0.053).

The postoperative haemoglobin value was lower in the stapled group compared to the
Surgicel® reinforced group 69 g/1 (range 42‐85) versus 82 g/1 (range 78‐90) (p=0.018). The
estimated blood losses by weighing the compresses were 287 ml (range 166‐379) for the stapled
group and 204 ml (range 152‐264) for the Surgicel® reinforced group (p=0.053).
The median number of additional haemostatic sutures in the Surgicel® reinforced group was
7 (range 3‐11) and in the stapled group 10 (range 5‐15) (p=0.038).

The haemoglobin value was similar in the two groups week postoperatively; 100 g/1 (range
87‐104) and 102 g/1 (range 95‐114), p=0.27, in the stapled group and the Surgicel® reinforced group, respectively. In the stapled group reinforced with the Surgicel® there was one postoperative death. In the solely stapled group there was no postoperative death (p=0.5). Four out
of six pigs in the Surgicel® group had massive adhesions to the resection lines. One of these six
pigs was sacrificed postoperatively as it was ill and had small bowel obstruction secondary to
Surgicel® induced adhesions. On the other hand, no adhesions were seen in the solely stapled pigs
(p=0.09). At this point, we can not recommend the use of Surgicel® to reinforce resection lines at stapled liver resection in the clinical situation, because of the high frequency of adhesions this
material creates.
Transduodenal Sphincteroplasty and Transampullary Septectomy for Papillary Stenosis
Authors: Kelly S. B. , Rowlands B. J.
Published: September 2007

Twenty patients received transduodenal sphincteroplasty and transampullary septectomy between 1987
and 1993. Seven patients had post‐cholecystectomy pain which was much improved or abolished in 5 of 7
patients at a mean follow‐up of 4 years and 5 months. Four of five patients with chronic pancreatitis were
improved at 3 years and 2 months. Three of five patients with recurrent acute pancreatitis were improved
at 4 years and 5 months. One of three patients with chronic abdominal pain of hepatobiliary origin was
improved at 3 years. Transduodenal sphincteroplasty and transampullary septectomy can relieve pain in
patients with post‐cholecystectomy pain, recurrent acute pancreatitis, chronic pancreatitis, and chronic
abdominal pain of hepatobiliary origin, presumably by improving drainage of the obstructed ducts.
The Relationship between Portal Venous and Hepatic Arterial Blood Flow. I. Experimental Liver Transplantation
Authors: Jakab F. , Sugár I. , Ráth Z. , Nágy P. , Faller J.
Published: September 2007

The relationship between the changes in portal venous and hepatic arterial blood flows, in the liver is a much disputed question, it has tremendous significance in the practice of transplantation, and an explanation has been available since 1981, when Lautt published the so‐caled “adenosine washout theory”. According to our earlier observations the decrease of portal pressure or flow consistently led to an increase in hepatic artery flow. At the same time changes in hepatic artery flow or pressure seemed to produce only inconsistent effects on the portal circulation. In the present experiments liver transplantation (OLTX) was carried out on mongrel dogs by Starzl′s method. Electromagnetic flow probes were placed on the hepatic artery and the portal vein before removal of recipient’s liver, and after completion of all vascular anastomoses to the newly inserted liver, during the recirculatory phase of OLTX. The flow probes were connected to a Hellige electromagnetic flowmeter, portal venous and systemic arterial pressures were also recorded.

The control HAF was 241±23 ml/min, the average PVF was 517±47 ml/min before removal of the recipients′s liver. In the recirculatory phase the HAF increased, by 71±12% (p < 0.001). The PVF decreased in most animals after OLTX. The decrease was in average –40.2±3.5% (p < 0.001). The THBF calculated by adding the HAF and PVF showed a small, but not significant decrease during recirculation.

The systemic arterial pressure decreased slightly and portal vein pressure rose in most animals after OLTX. There was a substantial increase in portal inflow resistance and prehepatic arteriolar resistance and a decrease in hepatic artery resistance. The decrease of PVF after OLTX can be explained by progressive fluid accumulation in the liver parenchyma and increased sinusoidal and portal inflow resistance. The prolonged and continuous increase in hepatic artery flow during the recirculatory phase of OLTX may be due to the decrease of portal flow. The exact mechanism, by which a change in portal flow leads to arteriolar dilatation, can be most probably explained by the “adenosine washout theory” of Lautt.
Duodenum‐Preserving Resection of the Head of the Pancreas: The Significance as a Diagnostic Therapy for the Lesion in the Pancreatic Head
Authors: Watanabe Y. , Sato M. , Lee T. , Abe Y. , Nakata Y. , Kashu H. , Iseki S. , Mizukami Y. , Kimura S.
Published: September 2007

A 75‐year‐old man who was diagnosed as having mucin‐producing pancreatic cystic lesion ofthe
main pancreatic duct by duodenoscopic examination was reported. Because of the low
malignant potential of such lesions, duodenum‐preserving resection of the head of the pancreas
was performed, and the intra‐operative histological examination showed no malig‐nancy of the
resected pancreatic head and no other surgical procedures, such as lymph‐adenectomy nor
pancreato‐duodenectomy were necessary. The significance of this case report lies in that a less
invasive operation should be selected at first to diagnose whether the lesion is malignant or not,
and als0 that the selected operation itself must be sufficient to resect an adequate part of the
pancreatic tissue involving the cystic lesion, ifnot malignant. Here, we report the process to select
the procedure and the surgical technique.
Improved Results for Resection of Periampullary Adenocarcinoma
Authors: Obertop H. , Gouma D. J.
Published: September 2007

Background: This study evaluates the indications for and effects of pancreaticoduodenectomy (102 patients) or total pancreatectomy (15 patients) with extensive lymph node dissection performed upon 117 patients for treatment of periampullary adenocarcinoma.

Study Design: Presenting symptoms and postoperative morbidity and mortality rates were recorded. Cumulative survival rates were evaluated in relation to origin, size, and staging of tumor. Postoperative follow‐up of clinical symptons was done after one year.

Results: The postoperative mortality rate after Whipple’s operation was 8 percent (eight patients). The median survival period was 1.1 year and the overall five year survival rate was 15 percent (confidence limits, 5 to 25 percent). The five year survival rate for patients without tumor extension beyond the pancreas was 25 percent (confidence limits, 5 to 50 percent), and in patients with adenocarcinoma of the ampulla of Vater, 34 percent (confidence limits, 3 to 65 percent). The median survival rate in patients with adenocarcinoma of the ampulla of Vater was 3.3 years, which was significantly longer than in the other patients. Fifty‐nine patients with distant spread could be divided into 14 patients with para‐aortic lymph node metastases who had a significantly shorter survival period than 45 patients without para‐aortic lymph node metastases (p=0.004). Most patients surviving more than one year were doing well, although 60 percent needed exocrine pancreatic substitution therapy.

Conclusions: Resection of periampullary carcinoma provides a better palliation and survival rate than nonoperative biliary drainage or bypass operation. An improved preoperative verification of para‐aortic metastases could restrict resection to patients with a prognostic five year survival rate of more than 25 percent and a postoperative mortality rate of less than 5 percent.
Pancreatic Serous Cystadenomas Report of 8 Cases with a Mean Follow up of 7 Years
Authors: Fabiani Alejandro , Delía Gonzalo J. , De Rosa Roberto , Pombo María T. , Molfino Oscar , Ferraina Pedro , Laffaye Horace A.
Published: September 2007

Serous cystadenoma of the pancreas are rare tumors and have little or no malignant potential.

We report our experience in the management of eight casses of these tumors in the last 22 years. All the
patients were women with a mean age of 59 years. All the cysts caused symptoms. Ultrasound and CTscan
were useful in the diagnosis of the pancreatic cystic tumor out not in determining the nature of these
lesions clear. FNA‐biopsy was performed in 6 cases but in only one c se was the diagnosis confirmed. All
tumors were resected. Four radical pancreatoduodenectomies, two distal pancreatectomies and two
cystectomies were performed. Mean followup was 83.5 months. All patients are alive and with no signs of
recurrence. Complications include an external pancreatic fistula, an acute cholangitis and a case of
delayed gastric emptying. In all cases the histological diagnosis was serous cystadenoma of the pancreas.
We conclude that resection of these tumors is mandatory although they are supposed to be benign, in
order to avoid complications and because malignant transformations has been related to nonresective
treatment.
Monocyte and Blood Interleukin‐12 Levels Patients with Obstructive Jaundice
Authors: Jiang W. G. , Puntis M. C. A.
Published: September 2007

Patients with obstructive jaundice have an increased incidence of peri‐operative complications and
immune dysfunction. This study was to investigate interleukin (IL)‐12 (a cellular immunity stimulant),
levels in jaundiced patients. 23 jaundiced patients and 17 controls were studied. There was significantly
increased monocyte IL‐12 production in jaundice, as measured by an ELISA, compared with that in
controls (p<0.01 by Mann‐Whitney U test). A similar increase is seen in both benign and malignant
jaundice. There was no difference between plasma IL‐12 levels in the two groups. It is concluded that in
jaundice, monocytes have a significantly increased capacity to release IL‐12. This suggests that IL‐12 may
play a role in the immune dysfunction in jaundiced patients.
Squamous Cell Carcinoma of the Liver Originating from a Solitary Non‐Parasitic Cyst: Case Report and Review of the Literature
Authors: Weimann Arved , Klempnauer Jürgen , Gebel Michael , Maschek Hansjörg , Bartels Michael , Ringe Burckhardt , Pichlmayr Rudolf
Published: September 2007

Squamous cell carcinoma of the liver arising from a non‐parasitic cyst is a rare entity of a primary liver tumor with an unfavourable prognosis. We report a case of a patient with a cyst in the right lobe leading to upper abdominal symptoms and respiratory discomfort. Malignancy was not suspected from the clinical findings or repeated cytological examination of the cyst fluid. However, the blood stained brown color of the cyst fluid was unusual. Cyst recurrence after six attempts of conservative treatment with sonography guided drainage over a period for more than one year led to laparotomy with cyst unroofing. Because frozen section from the cyst wall revealed the unexpected finding of squamous cell carcinoma right hemihepatectomy was performed during the same operation. The patient is alive more than four years after surgery without cyst or tumor recurrence. The difficulties in establishing diagnosis are confirmed by the review ofother reports. In the diagnosis and treatment ofsymptomatic non‐parasitic liver cysts possible malignancy has to be considered. In case of proven carcinoma radical surgery with partial hepatectomy should be performed.
Liver resection by Ultrasonic Dissection and lntraoperative Ultrasonography
Authors: Hanna Sherif S. , Nam Robert , Leonhardt Charlene
Published: September 2007

Ultrasonic dissetion (USD) and intraoperative ultrasonography (IOUS) have shown encouraging results
in a retrospective analysis of 109 patients with benign or malignant liver disease. Of 109 patients assessed
between 1980 and 1993, 84 were resected: 27 by finger fracture technique (FFT) and 57 by USD. Hospital
mortality was 4.8% (4/84) and 30‐day mortality was 6.0% (5/84). Overall morbidity was 48.8% (41/84)
and liver related morbidity (hepatic bleeding, sepsis, and bile leak) was 34.5% (29/84); of the 29 patients,
5 required re‐operation. Liver complications occurred in 12/27 (44.4%) in the FFT group as opposed to
17/57 (29.8%) in the USD group. The incidence of postoperative hepatic bleeding was significantly less
by USD than by FFT(p=O.03). As well, intraoperative blood loss (p=O.01)number of intraoperative
blood units used (p=0.002), and postoperative length of stay (p=O.O09) have been significantly reduced
by USD. IOUS was used on 64 patients. Not only has it improved the sensitivity (99%) and specificity
(98%) for detection of hepatic neoplasms, it has also helped increase the precision and accuracy of
anatomical tumour localization. As a result, 11/64 patients (17.2%) had their preoperative plans
changed: 8 were abandoned and 3 were revised. In summary, USD has significantly reduced
intraoperative blood loss and hence reduced the number of intraoperative transfusions, incidence of
postoperative complications and postoperative length of stay. IOUS should be routinely employed in
patients undergoing liver resection since it provides critical information that could obviate oncologically
useless resections.
A Simple, Secure and Universal Pancreaticojejunostomy following Pancreaticoduodenectomy
Authors: Lin P.-W. , Lee J.-C. , Lee P.-C. , Chang T.-W. , Hung C.-J. , Chang Y.-C.
Published: September 2007

Although the operative mortality of pancreaticoduodenal resection has decreased recently, the operative morbidity resulting from a leaking pancreatic anastomosis remains high. We described our experience in 50 consecutive cases with a simple, secure end to side pancreaticojejunostomy. We used a paediatric nasogastric tube in the pancreatic remnant duct as a temporary external pancreatic drain. There were 29 men and 21 women ranging from 12 to 84 years with a median age of 61 years. Forty‐two patients underwent a standard Whipple procedure and eight a pylorus preserving pancreaticoduodenectomy. Average operating time was 270 minutes with a range of 170 to 480 minutes. The pancreaticojejunostomy could be constructed in a mean of 8 minutes. Intraoperative blood loss ranged from 150 to 3500 mL with a mean of 910mL. Twenty‐five patients (50 %) received no blood transfusion. The consistency of the pancreatic remnant was hard in 12 patients (24 %) and normal in 38 patients (76 %). The pancreatic duct was dilated (>4mm) in 15 patients (30 %). There was no operative mortality and only three (6.0 %) minor leaks from the pancreatic anastomosis which healed spontaneously. It was difficult to determine if the leaks were related to the consistency of the pancreatic remnant, the size of the pancreatic duct, the amount of intraoperative blood loss, operating time, sex of the patient or experience of the surgeon, as there were only three leaks. We concluded that our technique for pancreaticojejunal anastomosis following pancreaticoduodenectomy was safe and applicable to, standard Whipple or pylorus preserving pancreaticoduodenectomy, small or dilated pancreatic ducts, normal or fibrotic pancreas.
“Gallstone Hip” and Other Sequelae of Retained Gallstones.
Authors: Chin Peter T. , Boland Stuart , Percy John P.
Published: September 2007

The fate of gallstones spilled during laparoscopic cholecystostomy has been thought to be relatively benign. Recent experience and a review of the recent literature shows that this is not always the case. We report three cases of complications of retained stones and analyse the literature with regard to types of complications, time to presentation, and recommendations for managing spilled gallstones. Retained gallstones have been shown to cause adhesions in the rat and inflammatory reactions in dogs with no evidence of absorption. The average time to presentation of complications arising from retained gallstones is 27.3 weeks. Complications include: Intraabdominal abscess formation with or without abdominal wall sinus tract formation, persisting abdominal wall sinus tracts from port site abscess, subhepatic inflammatory masses, cholelithoptysis, microabscesses and granuloma formation, liver abscess and “dumbell” shaped abscess with one side of the “dumbell” forming a subcutaneous abscess. We recommend the judicious use of retrieval devices during the extraction phase of the laparoscopic cholecystectomy, diligent removal of any spilled stones and awareness of delayed postoperative pain and tenderness as a harbinger of symptomatic retained gallstones. Documentation of intraoperative gallstone spillage, volume, type of gallstones, and effort to retrieve is recommended.
Transhepatic Venous Angioplasty and Stenting: A Treatment Option in Bleeding from Gastric Varices Secondary to Pancreatic Carcinoma
Authors: Ferguson J. M. , Palmer K. R. , Garden O. J. , Redhead D. N.
Published: September 2007

We present a case of recurrent variceal bleeding due to subtotal occlusion of the splenoportal junction by a pancreatic carcinoma. This was effectively treated by transhepatic venous angioplasty and stenting.
Stent or Surgery for Malignant Low Bileduct Obstruction?
Authors: Ihse Ingemar , Hansson Lars , Hammarström Lars-Erik , Lindström Eva
Published: September 2007

The development of non‐surgical techniques for the relief of malignant low bileduct obstruction has cast doubt on the best way of relieving jaundice, particularly in patients fit for surgery whose life expectancy is more than a few weeks.

We did a randomised prospective controlled trial comparing endoscopic stent insertion and surgical biliary bypass in patients with malignant low bileduct obstruction. 204 patients were randomised (surgery 103, stent 101); 3 subsequently proved to have benign disease and were excluded, leaving 101 surgical and 100 stented patients for assessment. Technical success was achieved in 94 surgical and 95 stent patients, with functional biliary decompression obtained in 92 patients in both groups. In stented patients, there was a lower procedure‐related mortality (3% vs 14%, p=0.01), major complication rate (11% vs 29%, p=0.02), and median total hospital stay (20 vs 26 days, p=0.001). Recurrent jaundice occurred in 36 stented patients and 2 surgical patients. Late gastric outlet obstruction occurred in 17% of stented patients and 7% of the surgical group. Despite the early benefits of stenting there was no significant difference in overall survival between the two groups (median survival: surgical 26 weeks; stented 21 weeks; p=0.065).

Endoscopic stenting and surgery are effective palliative treatments with the former having fewer early treatment‐related complications and the latter fewer late complications.
Should the Distal Splenorenal Shunt be Combined with Gastric Disconection and Transection?
Authors: Henderson J. Michael
Published: September 2007

Background: This study was aimed at evaluating advantages of distal splenorenal shunt (DSRS) with splenopancreatic and gastric disconnection (DSRS‐SPGD) over DSRS with splenopancreatic disconnection (DSRS‐SPD) and standard DSRS (S‐DSRS).

Methods: DSRS‐SPGD, DSRS‐SPD, and S‐DSRS were performed on 62, 7, and 55 patients, respectively, from 1970 to 1992. Comparison was performed in the following aspects: (1) long‐term results in ratio of rebleeding, survival rate, and quality of life and (2) portal hemodynamics evaluated by preoperative and postoperative angiography. Portal blood flow was assessed by the ratio of the diameter of portal vein (PV) to superior mesenteric vein (SMV), and shunt selectivity was evaluated by selectivity grade.

Results: Incidence of rebleeding was significantly lower in patients who underwent DSRS‐SPGD than in those who underwent S‐DSRS (p< 0.05). Grade 0 and I performance status was better in patients who underwent DSRS‐SPGD. Accumulated survival ratio for 5 and 7 years was 78.3% and 70.5% in patients who underwent DSRS‐SPGD, 59.7% and 44.1% in patients who underwent S‐DSRS, and 75% and 75% in patients who underwent DSRS‐SPD. Hemodynamic evaluation showed significantly lower PV/SMV ratio and degree of change in PV/SMV ratio of patients who underwent S‐DSRS and DSRS‐SPD. Many patients who underwent S‐DSRS and DSRS‐SPD exhibited loss of shunt selectivity at grades II and III. In contrast, patients who underwent DSRS‐SPGD maintained satisfactory PV/SMV ratio and selectivity grade.

Conclusions: DSRS‐SPGD clearly showed advantages in decrease of rebleeding and improvement of quality of life resulting from maintenance of shunt selectivity and portal blood flow.
Mini‐Incision Versus Laparoscopic Cholecystectomy
Authors: Yeo Charles J.
Published: September 2007

Background: We report a prospective randomised comparison between laparoscopic and small‐incision cholecystectomy in 200 patients which was designed to eliminate bias for or against either technique.

Methods: Patients were randomised in the operating theatre and anaesthetic technique and pain‐control methods were standardised. Four experienced surgeons did both types of procedure. Identical wound dressings were applied in both groups so that carers could be kept blind to the type of operation.

Findings: There was no significant difference between the groups for age, sex, body mass index, and American Society of Anaesthesiologists grade. Laparoscopic cholecystectomy took significantly longer than small‐incision cholecystectomy (median 65 [range 27‐140] min vs 40 [18‐142] min, p<0.001). The operating time included operative cholangiography which was attempted in all patients. We found no significant difference between the groups for hospital stay (postoperative nights in hospital, median 3.0 [1‐17] nights for laparoscopic vs 3.0 [1‐14] nights for small‐incision, p=0.74), time back to work for employed persons (median 5.0 weeks vs 4.0 weeks; p=0.39), and time to full activity (median 3.0 weeks vs 3.0 weeks; p=0.15).

Interpretation: Laparoscopic cholecystectomy takes longer to do than small‐incision cholecystectomy and does not have any significant advantages in terms of hostital stay or 13 ostoperative recovery.
Operative vs Non‐Operative Management in Sterile Necrotizing Pancreatitis
Authors: Bradley Edward L.
Published: September 2007

Background: The clinical management of sterile pancreatic necrosis is still a matter of debate. In this study we analyzed the clinical course and outcome of patients with sterile necrotizing pancreatitis treated surgically versus nonsurgically.

Study Design: Between May 1982 and December 1993, 249 patients with necrotizing pancreatitis (NP) entered this study, of which 172 (69 percent) had intraoperatively or fine needle aspiration‐proven sterile NP. One hundred seven of 172 patients underwent surgery (S group) with necrosectomy and continuous postoperative closed lavage and 65 of 172 were treated by nonsurgical means (NS group).

Results: Median Ranson and admission APACHE II scores were 4.7 (range, 1 to 10) and 11 (range, 1 to 29) in the S group, significantly higher than those in the NS group with 3.0 (range, 0 to 6) (p=0.022) and 8 (range, 1 to 23) (p=0.036). After 48 hours of intensive care treatment, APACHE II scores persisted at 10.5 (range, 1 to 29) in the S group and decreased to 6 (range, 0 to 15) (p=0.013) in the NS patients. Median Creactive protein (CRP) levels on admission were 179 mg/L and 68.5 mg/L (p=0.023), respectively. Within 72 hours, 61 (94 percent) of 65 NS‐managed patients responded to intensive care therapy, whereas organ complications persisted or increased and thus led to surgery in the S group. Mortality rates were 13.1 percent in the surgically treated patients and 6.2 percent in the nonsurgically treated patients (p=NS).

Conclusions: Most patients with limited and sterile pancreatic necrosis respond to intensive care treatment. Indication for surgery in sterile NP should be based on persisting or advancing organ complications despite intensive care therapy. APACHE II scores and adraission CRP levels represent a helpful tool in decision making for surgical or nonsurgical management of NP.
Significance of Liver Size in Hepatic Surgery
Authors: Yanaga K. , Honda H. , Ikeda Y. , Nishizaki A. T. , Yamamoto K. , Sugimachi K.
Published: September 2007

The purpose of this study was to evaluate the significance of liver volumetry as a parameter for hepatic functional reserve in cirrhotic patients with hepatocellular carcinoma. Liver volume was calculated from preoperative computed tomograms of 44 cirrhotic patients who underwent elective hepatic resections for hepatocellular carcinoma.

The liver volume per body weight of non‐alcoholic cirrhotics was significantly smaller than that of alcoholic cirrhotics (20.9 vs. 26.7 cc/kg; p=0.03). The values for alcoholic cirrhotics was comparable with normal values. The liver volume per body weight of the cirrhotic patients demonstrated correlation with the preoperative serum albumin (p<0.01) and indocyanine green clearance (p=0.02). We conclude that the determination of hepatic atrophy by volume try can serve as a parameter for the assessment of hepatic reserve but not as a predictor of postoperative complications in elective liver surgery for cirrhotic patients.
Prediction of the First Variceal Haemorrhage
Authors: Paquet K-J
Published: September 2007

We followed 87 cirrhotic patients with esophageal varices and without previous hemorrhage for a mean period of 24 mo to prospectively evaluate the occurance of variceal bleeding within (early) or after (late) 6 mo from entry and the contribution of portal Doppler ultrasound parameters to the prediction of early and late hemorrhage. Clinical, biochemical, endoscopic and portal Doppler ultrasound parameters were recorded at entry. Variceal bleeding occurred in 22 patients (25.3%). Nine (40.9%) bled within the first 6 mo. Cox regression analysis identified variceal size, cherry‐red spots, serum bilirubin and congestion index of the portal vein (the ratio of portal vein [cross‐sectional area] and portal blood flow velocity) as the only independent predictors of first variceal hemorrhage. Discriminant analysis was used to find the prognostic index cut off points to identify patients who bled within 6 mo (prognostic group 1) or after 6 mo (prognostic group 2) or remained free of bleeding (prognostic group 3). The cumulative proportion of patients correctly classified was 73% in prognostic group 1, 47% in prognostic group 2 and more than 80% in prognostic group 3. The addition of Doppler ultrasound flowmetry to clinical, biochemical and endoscopic parameter only improved the classification of patients with early bleeding.
Multidisciplinary Conservative Treatment of Difficult Bile Duct Stones: A Real Alternative to Surgery
Authors: Masci E. , Fanti L. , Mariani A. , Spagnolo S. , Zuliani W. , Castrucci M. , Testoni P. A. , Tittobello A.
Published: September 2007

56 patients with large CBD or intrahepatic stones underwent endoscopic and/or percutaneous treatment followed by extracorporeal shock wave lithotripsy. Percutaneous access to the biliary tract was chosen when an endoscopic approach was not possible (hepaticojejunostomy in 5 patients, 1 juxtapapillary diverticulum and I inflammatory bile duct stricture). Visualization of stones was achieved radiologically in 32 patients and by ultrasound in 24. The procedure was successful in 47 of 56 treated patients (83.9%). Clearance of the biliary tract was obtained in 25 cases (53%), whereas in 22 cases (47%) complete clearing of biliary tract was obtained only after endoscopic extraction of fragments (17 cases) or percutaneous (5 cases). The median number of shock waves in each session was 1725 (range 300–3166), which were applied during one (n=30), two (n=22) or three sessions (n=4). The only complications were 1
case of symptomatic hyperamylasemia and 3 cases of macrohematuria. In conclusion, extracorporeal lithotripsy combined with endoscopic and/or percutaneous treatment is a real alternative to surgery for difficult stones.
Immune Dysfunctlon in Patients With Obstructive Jaundice, Mediators and Implications for Treatments
Authors: Jiang W. G. , Puntis M. C. A.
Published: September 2007

Patients with obstructive jaundice have an increased perioperative complication rate. Sepsis, bleeding, wound problems, renal and liver malfunction are all seen in these patients. Assessment of immune function has been an active research area in these patients. This review will examine various aspects of immune functions in obstructive jaundice, discuss the recent research results and controversies and then go on to discuss the relevant mediators of immune function and some possible implications for treatment.
Microvascular Architecture of Hepatic Metastases in a Mouse Model
Authors: Kuruppu Darshini , Christophi Chris , O′Brien Paul E.
Published: September 2007

Development of effective treatment for hepatic metastases can be initiated by a better understanding of tumour vasculature and blood supply. This study was designed to characterise the microvascular architecture of hepatic metastases and observe the source of contributory blood supply from the host. Metastases were induced in mice by an intrasplenic injection of colon carcinoma cells (106 cells/ml.) Vascularization of tumours was studied over a three week period by scanning electron microscopy of microvascular corrosion casts. Metastatic liver involvement was observed initially within a week post induction, as areas approximately 100 μm in diameter not perfused by the casting resin. On histology these spaces corresponded to tumour cell aggregates. The following weeks highlighted the angiogenesis phase of these tumours as they received a vascular supply from adjacent hepatic sinusoids. Direct sinusoidal supply of metastases was maintained throughout tumour growth. At the tumour periphery most sinusoids were compressed to form a sheath demarcating the tumour from the hepatic vasculature. No direct supply from the hepatic artery or the portal vein was observed. Dilated vessels termed vascular lakes dominated the complex microvascular architecture of the tumours, most tapering as they traversed towards the periphery. Four vascular branching patterns could be identified as true loops, bifurcations and trifurcations, spirals and capillary networks. The most significant observation in this study was the direct sinusoidal supply of metastases, together with the vascular lakes and the peripheral sinusoidal sheaths of the tumour microculature.
Abdominal Wall Sinus: A Late Complication of Gallstone Spillage During Laparoscopic Cholecystectomy
Authors: Graham Michael D. , Anderson Paul G. , Toouli James
Published: September 2007

Long term complications of laparoscopic cholecystectomy are uncommon. However, as experience with this procedure accumulates, sporadic reports of non‐biliary complication have been published. We report a case of abdominal wall sinus formation secondary to gallbladder perforation and stone spillage occurring during laparoscopic cholecystectomy.
Hepatic Arterioportal Fistula: A Curable Cause of Portal Hypertension in Infancy
Authors: Billing J. S. , Jamieson N. V.
Published: September 2007

Hepatic arterioportal fistulae are a rare cause of portal hypertension. The case is reported of a twoyear old girl with a congenital arterioportal fistula, who presented with splenomegaly and ascites. Colour doppler ultrasound showed a large shunt between the left hepatic artery and a branch of the left portal vein, producing a reversal of flow in the main portal vein. She was treated by a formal left hemihepatectomy, which has been successful in eliminating the fistula and its consequent portal hypertension in the long term. The literature regarding arterioportal fistulae and their treatment is reviewed.
Laparoscopic Cholecystectomy: Incidental Carcinoma of the Gallbladder with Abdominal Wall and Axillary Node Metastasis
Authors: Johnson Richard C. , Fligelstone Louis J. , Wheeler Malcolm H. , Horgan Kieran , Maughan Timothy S.
Published: September 2007

A case report is presented of intra‐mural gallbladder carcinoma discovered incidentally after laparoscopic cholecystectomy who subsequently developed abdominal wall recurrence at the epigastric exit port, and axillary lymph node metastases. Possible preventative steps for tumour dissemination and a management plan if incidental carcinoma is diagnosed is discussed. The use of a non‐porous retrieval bag, early recognition of the carcinoma and excision of the exit wound are advocated.
Is there a Role for Radical Surgery in Advanced Gallbladder Carcinoma?
Authors: Kemeny M. Margaret
Published: September 2007

Forty‐four patients with advanced gallbladder carcinoma (18 with stage pT3 and 26 with stage pT4 of the Union Internacional Contra la Cancrum classification) were aggressively managed by extended heptatic resection in 33 patients, bile duct resection in 28, pancreaticoduodenectomy in seven, gastrointestinal resection in eleven and portal vein resection and reconstruction in seven. Adjacent organ involvement was classified as follows: type I, hepatic involvement with or without gastrointestinal invasion (Ia, Ib); type II, bile duct involvement with or without gastrointestinal invasion (IIa, IIb); type III, hepatic and bile duct involvement with or without gastrointestinal invasion (IIIa, IIIb); type IV, gastrointestinal involvement without hepatic or bile duct invasion. Fourteen of 15 patients with type I tumours had a curative resection compared with seven of 26 with type III lesions (P< 0.0001). The surgical mortality rate was two of 15 patients with type I tumours, seven of 26 with type III tumours and nine of 44 for the whole group. The long‐term survival rate after curative resection was four and two of 23 at 3 and 5 years respectively, significantly better than two and none of 21 at I and 2 years after non‐curative resection (P<0.01). The survival rate after curative resection for patients with type I tumours was four and two of 14 at 3 and 5 years respectively, significantly better than for other types (P<0.05). This classification of advanced gallbladder carcinoma according to involvement of adjacent organs might be helpful in planning surgery for this condition; in particular, type I tumours should be treated by a radical surgical procedure to achieve a favourable outcome.
Jejunum or Stomach for the Pancreatic Anastomosis After Pancreaticoduodenectomy
Authors: Warshaw Andrew L.
Published: September 2007

Objective: The authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy after pancreaticoduodenectomy and less likely to be associated with
a postoperative pancreatic fistula.

Summary Background Data: Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastrostomy is less likely than pancreaticojejunostomy to be associated with postoperative complications.

Methods: Between May 1993 and January 1995, the findings for 145 patients were analyzed in this prospective trial at The Johns Hopkins Hospital. After giving their appropriate preoperative informed consent, patients were randomly assigned to pancreaticogastrostomy or pancreaticojejunostomy after completion of the pancreaticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50 mL of amylase‐rich fluid on or after postoperative day 10.

Results: The pancreaticogastrostomy (n=73) and pancreaticojejunostomy (n=72) groups were comparable with regard to multiple parameters, including demographics, medical history, preoperative laboratory values, and intraoperative factors, such as operative time, blood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreaticoduodenectomy was 11.7% (171145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%) groups. Pancreatisc fistula was associated with a significant prolongation of postoperative hospital stay (36±5 vs. 15±1 days) (p<0.001). Factors significantly increasing the risk of pancreatic fistula by univariate logistic regression analysis included ampullary or duodenal disease, soft pancreatic texture, longer operative time, greater intraoperative red blood cell transfusions, and lower surgical volume (p<0.05). A multivariate logistic regression analysis revealed the factors most highly associated with pancreatic fistula to be lower surgical volume and ampullary or duodenal disease in the resected specimen.

Conclusions: Pancreatic fistula is a common complication after pancreaticoduodenectomy, with an incidence most strongly associated with surgical volume and underlying disease. These data do not support the hypothesis that pancreaticogastrostomy is safer than pancreaticojejunostomy or is associated with a lower incidence of pancreatic fistula.
Emergency Portacaval Shunts: Is Orloff Correct?
Authors: Knechtle Stuart J. , Rikkers Layton F.
Published: September 2007

A prospective randomized trial was conducted in unselected, consecutive pateints with bleeding esophageal varices resulting from cirrhosis comparing (1) emergency portacaval shunt performed within 8 hr of initial contact (21 patients) with (2) emergency medical therapy (intravenous vasopressin and esophageal balloon tamonade) followed in 9 to 30 days by elective portacaval shunt in survivors (22 patients). All patients underwent the same diagnostic workup within 3 to 6 hr of initial contact, and received indentical supportive therapy initially. All patients were followed up for atleast 10 hr. The protocol contained no escape or crossover provisions. There were no statistically significant differences between the two treatment groups in the incidence of any of the clinical variables, results of laboratory tests or degree of portal hypertension. Child′s risk classes in the shunt group were A‐2 patients, B‐8 patients and C‐11 patients, whereas in the medical group they were A‐10 patients, B‐5 patients, and C‐7 patients, a significant difference (p<0.01) that might have favored emergency medical treatment. Bleeding was controlled initially and permanently by emergency shunt in every patient, but by medical therapy in only 45% (p<0.001). Mean requirement for blood transfusion was 7.1±2.6 units in the shunt group and 21.4±2.6 units in the medical group (p<0.001). Eighty‐one percent of the pateints in the shunt group were discharged alive compared with 45% in the medical group (p=0.027). Five‐ and 10‐yr observed survival rates were 67% and 57%, respectively, after emergency shunt compared with 18% and 18%, respectively, after the combination of emergency medical therapy and elective shunt (p<0.01). These survival rates produced by emergency shunt performed within 8 hr of initial contact confirm the effectiveness of this procedure observed in our previous unrandomized studies.