Left Extended Hemihepatectomy With Preservation of Large Inferior Right Hepatic Vein: A Case Report

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

Hepatic Surgery Facilitated by a New Jet Dissector

Increasing experience with major hepatic resections has stimulated the development of improved resectional techniques and tools. A new high velocity water jet dissector is reported which offers significant advances over previously developed ultrasonic and low pressure water jet machines. It has been successfully used in 8 major hepatic resections with minimal blood loss, excellent visibility and without complications. The dissector is also of value in the exposure of intrahepatic bile ducts for biliaryenteric anastomosis

Sclerosing Haemangiomas of the Liver: Two Cases of Mistaken Identity

We describe two cases where patients undergoing hepatic resection for metastatic disease of colorectal origin were found to have concomitant sclerosing haemangiomas. The typical radiological and histological appearances of these lesions are discussed

Absolute Electron Scattering Cross Sections for the CF2 Radical

Using a crossed electron-molecular beam experiment, featuring a skimmed nozzle beam with pyrolytic radical production, absolute elastic cross sections for electron scattering from the CF2 molecule have been measured. A new technique for placing measured cross sections on an absolute scale is used for molecular beams produced as skimmed supersonic jets. Absolute differential cross sections for CF2 are reported for incident electron energies of 30–50 eV and over an angular range of 20–135 deg. Integral cross sections are subsequently derived from those data. The present data are compared to new theoretical predictions for the differential and integral scattering cross sections, as calculated with the Schwinger multichannel variational method using the static-exchange and static-exchange plus polarization approximations

Painless Obstructive Jaundice Secondary to a Common Bile Duct Abscess: A Delayed Sequela of Cholecystectomy

Complications related to cholecystectomy are well described. Most occur in the early postoperative period and are recognised either at the time of, or shortly after surgery. Clinical sequelae occurring years following cholecystectomy are rare and infrequently reported. In addition, most delayed complications are related to the continuing presence or new formation of gallstones. In this paper we present a unique case of an abscess of the common bile duct wall, presenting with painless obstructive jaundice more than 30 years following an open cholecystectomy, without the presence of gallstones. The clinical presentation, investigations, and treatment are discussed with a review of other relevant reported cases in the literature

Hepatic Resection Using a Water Jet Dissector

The mortality and morbidity in major hepatic resection is often related to hemorrhage. A high pressure, high velocity water jet has been developed and has been utilized to assist in hepatic parenchymal transection. Sixty-seven major hepatic resections were performed for solid hepatic tumors. The tissue fracture technique was used in 51 patients (76%), and the water jet dissector was used predominantly in 16 patients (24%). The extent of hepatic resection using each technique was similar. The results showed no difference in operative duration (p = .499). The mean estimated blood loss using the water jet was 1386 ml, and tissue fracture technique 2450 ml (p = .217). Transfusion requirements were less in the water jet group (mean 2.0 units) compared to the tissue fracture group (mean 5.2 units); (p = .023). Results obtained with the new water dissector are encouraging. The preliminary results suggest that blood loss may be diminished

Atypical mycobacterial infection mimicking metastatic cholangiocarcinoma

Mycobacterial infections are rare in developed countries. Isolated involvement of the liver and biliary tree by mycobacterial infection is extremely rare. We report a case of a 45-year-old Caucasian female presenting with obstructive jaundice with a common bile duct stricture and multiple hypodense liver lesions raising suspicion of a metastatic cholangiocarcinoma. Percutaneous core biopsies of the liver lesions however suggested granulomatous process and histology at surgical excision confirmed this finding. Atypical mycobacteria (M. abcessus) sensitive to Amikacin were cultured from the surgical specimen proving the diagnosis. With the resurgence of tubercular and atypical mycobacterial infections in the developed world, it is important not to overlook these in differential diagnosis of various malignancies.Harsh A. Kanhere, Markus I. Trochsler, John Pierides, and Guy J. Madder

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

Stakeholders' perspectives of mobile x-ray services in support of healthcare-in-place in residential aged care facilities: a qualitative study

Background: There is interest in reducing avoidable emergency department presentations from residential aged care facilities (RACF). Mobile x-ray services may enable the delivery of healthcare in residential aged care facilities. Accordingly, the Australian Government in November 2019 introduced a Medicare Benefit Schedule rebate providing for a ‘call-out’ fee payable to radiology service providers. This study aims to understand stakeholder perspectives on the benefits of mobile x-ray services and the factors influencing their adoption by RACFs. Design, setting, participants: Twenty-two semi-structured interviews were conducted between October 2020 and February 2021 with a range of stakeholders involved in healthcare delivery to residents: a) general practitioners; b) emergency department clinicians; c) paramedic clinicians; d) a hospital avoidance clinician; e) radiology clinicians and managers; and f ) aged care clinicians and managers. Thematic analysis was conducted. Results: Mobile x-ray services were considered valuable for RACF residents. Lack of timely general practitioner in person assessment and referral, as well as staffing deficits in residential aged care facilities, reduces optimal use of mobile x-ray services and results in potentially unnecessary hospital transfers. Conclusions: The use of mobile x-ray services, as a hospital avoidance strategy, depends on the capacity of RACFs to provide more complex healthcare-in-place. However, this requires greater access to general practitioners for in-person assessment and referral, adequate staffing numbers and appropriately skilled nursing staff within residential aged care facilities.Joanne Dollard, Jane Edwards, Lalit Yadav, Virginie Gaget, David Tivey, Maria Inacio, Guy Maddern, and Renuka Visvanatha

Best practice considerations on the assessment of robotic assisted surgical systems:results from an international consensus expert panel

Background Health technology assessments (HTAs) of robotic assisted surgery (RAS) face several challenges in assessing the value of robotic surgical platforms. As a result of using different assessment methods, previous HTAs have reached different conclusions when evaluating RAS. While the number of available systems and surgical procedures is rapidly growing, existing frameworks for assessing MedTech provide a starting point, but specific considerations are needed for HTAs of RAS to ensure consistent results. This work aimed to discuss different approaches and produce guidance on evaluating RAS. Methods A consensus conference research methodology was adopted. A panel of 14 experts was assembled with international experience and representing relevant stakeholders: clinicians, health economists, HTA practitioners, policy makers, and industry. A review of previous HTAs was performed and seven key themes were extracted from the literature for consideration. Over five meetings, the panel discussed the key themes and formulated consensus statements. Results A total of ninety-eight previous HTAs were identified from twenty-five total countries. The seven key themes were evidence inclusion and exclusion, patient- and clinician-reported outcomes, the learning curve, allocation of costs, appropriate time horizons, economic analysis methods, and robotic ecosystem/wider benefits. Conclusions Robotic surgical platforms are tools, not therapies. Their value varies according to context and should be considered across therapeutic areas and stakeholders. The principles set out in this paper should help HTA bodies at all levels to evaluate RAS. This work may serve as a case study for rapidly developing areas in MedTech that require particular consideration for HTAs.</p