Management of an Accessory Bile Duct Leak Following Pancreaticoduodenectomy: A Novel Approach Utilizing a Percutaneous and Endoscopic Rendezvous.

Biliary leaks are uncommon but morbid complications of pancreaticoduodenectomies, which have historically been managed with percutaneous drainage, reoperation, or a combination of both. We report a de novo percutaneous-endoscopic hepaticojejunostomy from an anomalous right hepatic duct injured during pancreaticoduodenectomy to the afferent bowel limb. The percutaneous-endoscopic hepaticojejunostomy was stented to allow for tract formation with successful stent removal after 5.5 months. One year after the creation of the percutaneous-endoscopic hepaticojejunostomy, the patient remains clinically well without evidence of biliary leak or obstruction

Gd-EOB-DTPA-Enhanced MRI for Detection of Liver Metastases from Colorectal Cancer: A Surgeon’s Perspective!

Colorectal cancer affects over one million people worldwide annually, with the liver being the most common site of metastatic spread. Adequate resection of hepatic metastases is the only chance for a cure in a subset of patients, and five-year survival increases to 35% with complete resection. Traditionally, computed tomographic imaging (CT) was utilized for staging and to evaluate metastases in the liver. Recently, the introduction of hepatobiliary contrast-enhanced magnetic resonance imaging (MRI) agents including gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Eovist in the United States, Primovist in Europe, or Gd-EOB-DTPA) has proved to be a sensitive method for detection of hepatic metastases. Accurate detection of liver metastases is critical for staging of colorectal cancer as well as preoperative planning

Liver lesions in children post-oncologic therapy: Review of case reports and institutional observation

Purpose: Focal nodular hyperplasia (FNH), a benign hepatic tumor with ill-defined etiology, has been increasingly reported in children treated for extra-hepatic malignancies. Serial imaging or biopsy may be needed when survivors present with liver lesions. This study aims to review the literature, compare them with our institution’s cohort and propose a less invasive diagnostic imaging modality for FNH utilizing Magnetic resonance imaging (MRI) with gadoxetate disodium. Methods: We reviewed 13 case reports/series published over the last 20 years and compared them to our retrospective review of 16 childhood cancer survivors (CCS) found to have liver lesions on various imaging studies. Several patients underwent biopsy for diagnosis. Results: No specific generalizations could be made in terms of which specific chemotherapeutic agents cause FNH. Seven out of 11 patients underwent radiotherapy and/or hematopoietic stem cell transplant. Additionally, 36% (4/11) had been treated for neuroblastoma. From the literature review, the use of MRI with gadoxetate disodium was difficult to evaluate. Imaging was mainly accomplished using ultrasound, computerized tomography and MRI with gadolinium. The results were often indeterminate and resulted in biopsy in 6 cases in our institution. In contrast, 5 patients underwent initial MRI with gadoxetate disodium, which confirmed the diagnosis of FNH. Conclusion: CCS have an increased risk of developing liver lesions. Consistent with previously published literature, patients exposed to radiotherapy or cytoreductive agents used for hematopoietic stem cell transplants appeared to be at higher risk. A significant proportion (36%, 4/11) of our patients with FNH was previously treated for neuroblastoma. With the introduction of MRI with gadoxetate disodium, imaging may be a viable alternative to biopsy.

Clinical Presentation of Hepatocellular Carcinoma (HCC) in Asian-Americans Versus Non-Asian-Americans

The incidence of HCC is rising worldwide. Studies on ethnicity-based clinical presentation of HCC remain limited. The aim is to compare the clinical presentation and stage of HCC between Asian-Americans and non-Asian-Americans. This retrospective study assessed ethnicity-based differences in HCC presentation, including demographics, laboratory results, diagnosis of underlying liver disease, and stage of HCC. Of 276 patients, 162 were Asian-Americans and 114 were non-Asian-Americans. Compared to non-Asian-Americans, Asian-Americans had a significantly higher incidence of history of hepatitis B virus (HBV) infection (55.0% vs. 4.9%, P < 0.001), family history of HBV infection (12.5% vs. 0.0%, P < 0.001) and HCC (15.2% vs. 2.9%, P = 0.002), but lower incidence of history of hepatitis C virus (HCV) infection (37.5% vs. 61.6%, P < 0.001). At diagnosis of HCC, Asian-American patients had a significantly lower frequency of hepatic encephalopathy (8.9% vs. 29.3%, P = 0.001), and ascites (26.7% vs. 57.3%, P < 0.001). Asian-Americans had lower Child-Pugh scores (class A: 62.0% vs. 31.4%, P < 0.001), and MELD scores (9.2 ± 4.4 vs. 12.0 ± 6.4, P = 0.02), and presented with a lower stage of HCC by Okuda staging (I: 43.8% vs. 22.8%, P = 0.001). Asian-American patients with HCC presented with a higher incidence of history and family history of HBV infection, lower incidence of hepatic decompensation, lower Child and MELD scores, and an early stage HCC disease

Guidelines for the use and interpretation of assays for monitoring autophagy (4th edition)1.

In 2008, we published the first set of guidelines for standardizing research in autophagy. Since then, this topic has received increasing attention, and many scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Thus, it is important to formulate on a regular basis updated guidelines for monitoring autophagy in different organisms. Despite numerous reviews, there continues to be confusion regarding acceptable methods to evaluate autophagy, especially in multicellular eukaryotes. Here, we present a set of guidelines for investigators to select and interpret methods to examine autophagy and related processes, and for reviewers to provide realistic and reasonable critiques of reports that are focused on these processes. These guidelines are not meant to be a dogmatic set of rules, because the appropriateness of any assay largely depends on the question being asked and the system being used. Moreover, no individual assay is perfect for every situation, calling for the use of multiple techniques to properly monitor autophagy in each experimental setting. Finally, several core components of the autophagy machinery have been implicated in distinct autophagic processes (canonical and noncanonical autophagy), implying that genetic approaches to block autophagy should rely on targeting two or more autophagy-related genes that ideally participate in distinct steps of the pathway. Along similar lines, because multiple proteins involved in autophagy also regulate other cellular pathways including apoptosis, not all of them can be used as a specific marker for bona fide autophagic responses. Here, we critically discuss current methods of assessing autophagy and the information they can, or cannot, provide. Our ultimate goal is to encourage intellectual and technical innovation in the field

Spontaneous choledochoduodenal fistula in a patient with a bile duct injury following laparoscopic cholecystectomy.

We report a 67-year-old female that had a laparoscopic cholecystectomy complicated by common bile duct (CBD) and right hepatic artery injuries. A catheter was placed into the proximal common bile duct to create an external biliary fistula. The catheter eroded into the edge of the CBD and that irritation caused a choledochoduodenal fistula to form. To our knowledge, this is the first reported case in which an external biliary catheter caused the formation of a choledochoduodenal fistula after a bile duct injury from a laparoscopic cholecystectomy

Spontaneous choledochoduodenal fistula in a patient with a bile duct injury following laparoscopic cholecystectomy.

We report a 67-year-old female that had a laparoscopic cholecystectomy complicated by common bile duct (CBD) and right hepatic artery injuries. A catheter was placed into the proximal common bile duct to create an external biliary fistula. The catheter eroded into the edge of the CBD and that irritation caused a choledochoduodenal fistula to form. To our knowledge, this is the first reported case in which an external biliary catheter caused the formation of a choledochoduodenal fistula after a bile duct injury from a laparoscopic cholecystectomy