The effect of communication between the right and left liver on the outcome of surgical drainage for jaundice due to malignant obstruction at the hilus of the liver

Debate continues regarding the optimal management of irresectable malignant proximal biliary obstruction. Controversy exists concerning the ability of unilateral drainage to provide adequate biliary decompression with tumors that have occluded the communication between the right and left hepatic ductal systems. Between October 1986 and October 1989, 18 patients with malignant proximal biliary obstruction were treated by an intrahepatic biliary enteric bypass. Patients were divided into two groups based on the presence or absence of a communication between the right and left biliary systems. In Group I (n = 9), there was free communication; and in Group II (n = 9) there was no communication. There were two perioperative deaths (11%) one due to persistent cholangitis and the other to myocardial insufficiency both with one death in each group. The median survival (excluding perioperative deaths) was 5.6 months. Comparison of pre- and postoperative serum levels of bilirubin and alkaline phosphatase showed a significant decrease in each group, but no difference between the groups in the size of the reduction. Sixteen patients survived at least three months and the palliation was judged as excellent in eight, fair in five, and unchanged in three. These results demonstrate the effectiveness of biliary enteric bypass regardless of communication between the left and right biliary ductal systems.H. U. Baer, M. Rhyner, S. C. Stain, P. W. Glauser, A. R. Dennison, G. J. Maddern, and L. H. Blumgar

Investigating the Mechanisms Behind Moth Declines: Plants, Land-use and Climate

Moth populations have declined across large areas of north-western Europe since the mid-20th century, mirroring similar declines in other insect groups. The mechanisms behind these declines are likely manifold, but it is believed that agricultural intensification is a key factor. There were two aims of this thesis: (1) to elucidate the mechanisms behind moth decline in the UK, and (2) to determine ways in which farmland habitats could be improved for moths. Counter to expectations, between 1968 and 2016, the declines in total moth abundance were least severe in the most agriculturally intensive areas and were most severe in semi-natural habitats, as well as in urban environments. Species richness, while remaining stable at the national level, declined in only one habitat type: broadleaf woodland. No evidence was found to support the hypotheses that habitat loss, shading of the understory by canopy-closure, or overgrazing by deer had driven these declines within broadleaf woodland. Evidence was found that warm winters negatively impacted moth abundance, but this effect was consistent across all habitats. Although declines were least severe in improved grassland and arable land, the declines in total abundance were significant and ongoing, despite widespread and increasing adoption of agri-environment schemes (AES) since the early 1990s. In this thesis, the role of nectar resources and larval hostplants were explored within AES field margins on arable land, with the aim of determining how these small areas of habitat could be best managed to enhance moth abundance and diversity. It was found that the diversity of moths was greatly increased, and abundance moderately so, when margins were sown with a wide range of wildflowers and grasses, in comparison to only grasses. The evidence suggested that this was due primarily to the provision of larval hostplants, with nectar resources playing a secondary role. Overall, this thesis demonstrates that, in order to improve the environment for moths, AES wildflower margins should be encouraged over and above plain grass margins. This thesis also demonstrates that while agricultural intensification is likely responsible for some of the observed declines in moths, there are other mechanisms, as yet unknown, at work in both semi-natural habitats and urban areas

Isolated Resection of Segment I (Caudate Lobe): Is it Justified?

Background: Isolated caudate lobectomy is a challenging surgical procedure for which safe and reliable techniques have yet to be developed

Resection of the liver for colorectal carcinoma metastases - A multi-institutional study of long-term survivors

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to 1-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primarycarcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized. © 1988 American Society of Colon and Rectal Surgeons

Giant Hepatic Hemangioma With Kasabach–Merritt Syndrome: Is the Appropriate Treatment Enucleation or Liver Transplantation?

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

Mucobilia in Association With a Biliary Cystadenocarcinoma of the Caudate Duct: A Rare Cause of Malignant Biliary Obstruction

Mucobilia is a rare condition characterized by the accumulation of abundant mucus within the intra- or extrahepatic biliary tree. A variety of hepatobiliary and pancreatic neoplasms are mucin producing and have been associated with the development of mucobilia including biliary mucinosis, biliary papillomatosis, mucin-producing cholangiocarcinoma (MPCC), or cystic neoplasms of the pancreas or biliary tree (cystadenoma or cystadenocarcinoma). We report the case of 46 year-old male with a biliary cystadenocarcinoma of the caudate lobe which resulted in chronic biliary obstruction and relapsing cholangitis. A review of the literature for both mucobilia and biliary cystadenocarcinoma is provided along with a discussion addressing the clinical presentation, diagnosis, treatment, and prognosis for this rare entity

Isolated Hepatic Splenosis: First Reported Case

Splenosis is the autotransplantation of splenic tissue, most commonly seen after traumatic splenic rupture and splenectomy. Post-traumatic splenosis is often considered a rare entity, but is probably underreported because of its asymptomatic nature. We describe the first reported case of splenosis presenting as a liver mass, indistinguishable from a liver tumor by standard preoperative evaluation. The pathophysiology, evaluation and management of splenosis is discussed as well as the decision to resect a benign appearing liver mass

Investigating the mechanisms behind moth declines:Plants, land-use and climate

Moth populations have declined across large areas of north-western Europe since the mid-20th century, mirroring similar declines in other insect groups. The mechanisms behind these declines are likely manifold, but it is believed that agricultural intensification is a key factor. There were two aims of this thesis: (1) to elucidate the mechanisms behind moth decline in the UK, and (2) to determine ways in which farmland habitats could be improved for moths. Counter to expectations, between 1968 and 2016, the declines in total moth abundance were least severe in the most agriculturally intensive areas and were most severe in semi-natural habitats, as well as in urban environments. Species richness, while remaining stable at the national level, declined in only one habitat type: broadleaf woodland. No evidence was found to support the hypotheses that habitat loss, shading of the understory by canopy-closure, or overgrazing by deer had driven these declines within broadleaf woodland. Evidence was found that warm winters negatively impacted moth abundance, but this effect was consistent across all habitats. Although declines were least severe in improved grassland and arable land, the declines in total abundance were significant and ongoing, despite widespread and increasing adoption of agri-environment schemes (AES) since the early 1990s. In this thesis, the role of nectar resources and larval hostplants were explored within AES field margins on arable land, with the aim of determining how these small areas of habitat could be best managed to enhance moth abundance and diversity. It was found that the diversity of moths was greatly increased, and abundance moderately so, when margins were sown with a wide range of wildflowers and grasses, in comparison to only grasses. The evidence suggested that this was due primarily to the provision of larval hostplants, with nectar resources playing a secondary role. Overall, this thesis demonstrates that, in order to improve the environment for moths, AES wildflower margins should be encouraged over and above plain grass margins. This thesis also demonstrates that while agricultural intensification is likely responsible for some of the observed declines in moths, there are other mechanisms, as yet unknown, at work in both semi-natural habitats and urban areas

Thrombotic side-effects of lower limb venography The use of heparin-saline flush

In a prospective study of 256 postoperative patients, bilateral lower limb venography was performed using meglumine iothalamate followed by heparin-saline flushing of the deep veins, and the complications of the procedure were assessed. No patient developed clinical evidence of deep-vein thrombosis after the venogram. In 117 patients fibrinogen uptake was performed 24 hours after the venogram. A new positive area on the uptake scan developed in 3 patients (2,6%). Local swelling or haematoma at the injection site occurred in 15 patients (5,9%), cellulitis in 2 (0,8%) and minor contrast reactions in 6 (2,3%). There were no major reactions and no procedure-related mortality. The reasons for the wide variation in the reported incidence of post-venogram thrombosis are considered and the importance of heparin-saline flushing of the deep veins to prevent this complication is discussed