Endoscopic and Percutaneous Preoperative Biliary Drainage in Patients with Suspected Hilar Cholangiocarcinoma

INTRODUCTION: Controversy exists over the preferred technique of preoperative biliary drainage (PBD) in patients with hilar cholangiocarcinoma (HCCA) requiring major liver resection. The current study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD) in patients with resectable HCCA. METHODS: One hundred fifteen consecutive patients were explored for HCCA between 2001 and July 2008 and assigned by initial PBD procedure to either EBD or PTBD. RESULTS: Of these patients, 101 (88%) underwent PBD; 90 patients underwent EBD as primary procedure, and 11 PTBD. The technical success rate of initial drainage was 81% in the EBD versus 100% in the PTBD group (P = 0.20). Stent dislocation was similar in the EBD and PTBD groups (23% vs. 20%, P = 0.70). Infectious complications were significantly more common in the endoscopic group (48% vs. 9%, P < 0.05). Patients in the EBD group underwent more drainage procedures (2.8 vs. 1.4, P < 0.01) and had a significantly longer drainage period until laparotomy (mean 15 weeks vs. 11 weeks in the PTBD group; P < 0.05). In 30 patients, EBD was converted to PTBD due to failure of the endoscopic approach. CONCLUSIONS: Preoperative percutaneous drainage could outperform endoscopic stent placement in patients with resectable HCCA, showing fewer infectious complications, using less procedure

A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial)

Background. Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects. Methods. A randomized multicenter pragmatic clinical trial comparin

Transcatheter arterial embolization as a safe and effective treatment for focal nodular hyperplasia of the liver

When surgical treatment is being considered for focal nodular hyperplasia, the risk of liver surgery must be carefully balanced against the benefit of resection, especially in the case of a large or centrally located lesion. However, when resection is contraindicated or even impossible, transcatheter arterial embolization should be considered as a safe and less invasive alternative treatment. We describe two cases of young women who presented with abdominal pain and a hypervascular enhancing mass with the radiologic features of focal nodular hyperplasia. Arterial embolization was the therapy selected due to the risk of surgery. In both cases the procedure was successful, and the lesion showed shrinkage during follow-u

Survival in bile duct injury patients after laparoscopic cholecystectomy: a multidisciplinary approach of gastroenterologists, radiologists, and surgeons

BACKGROUND: Bile duct injury (BDI) after laparoscopic cholecystectomy (LC) has an enormous socioeconomic impact on patients. BDI has been associated with severe morbidity, impaired survival, and poor long-term quality of life. This study was performed to analyze the impact of a multidisciplinary approach in BDI patients on survival. METHODS: A prospective cohort study was performed in a tertiary referral center to determine the effect of a multidisciplinary treatment on survival in 500 bile duct injury patients. Referral pattern and patient survival after bile duct injury are analyzed, and a survey was performed on the prevalence of medical litigation in bile duct injury patients. RESULTS: The number of patients referred to the Amsterdam Medical Center increased to 0.3% of the total number of patients, yearly undergoing laparoscopic cholecystectomy in the Netherlands. The referral rate to the departments of gastroenterology (n = 329), surgery (n = 146), and radiology (n = 25) was, respectively, 66%, 29%, and 5%. After referral to the tertiary center, 150 patients (30%) were internally referred to a different department to optimize treatment. The 10-year survival rate in bile duct injury patients is not significantly worse compared with the age-matched general Dutch population (89% vs 88%, P = .7). Overall, 19% of the patients submitted a medical litigation claim against the initial surgeon or hospital. In total, 40% of these claims were resolved in the favor of the patients through settlement or verdict. CONCLUSIONS: BDI is a severe complication in modern surgical practice. BDI is associated with major morbidity and high rates of litigation claims. The detrimental effect of BDI on survival can be prevented if gastroenterologists, radiologists, and surgeons work together in a multidisciplinary tea

Results of percutaneous sclerotherapy and surgical treatment in patients with symptomatic simple liver cysts and polycystic liver disease

AIM: To evaluate the results of the treatment of simple liver cysts (solitary and multiple) and polycystic liver disease (PLD) using percutaneous sclerotherapy and/or surgical procedures in a single tertiary referral centre. METHODS: Retrospective analysis of 54 patients referred for evaluation and possible treatment of simple liver cysts (solitary and multiple) and PLD, from January 1997 to July 2006. RESULTS: Simple liver cysts were treated in 41 pts (76%) with a mean size of 12.6 cm. The most common reason for referral was abdominal pain or discomfort (85%). Percutaneous sclerotherapy was performed as initial treatment in 30 pts, showing cyst recurrence in 6 pts (20%). Surgical treatment was initially performed in 11 pts with cyst recurrence in 3 pts (27%). PLD was treated in 13 pts (24%) with a mean size of the dominant cyst of 13 cm. Percutaneous sclerotherapy for PLD was performed in 9 pts with recurrence in 7 pts (77.8%). Surgical treatment for PLD was undertaken in 4 pts (30.8%) with recurrence in all. Eventually, 2 pts with PLD in the presence of polycystic kidney disease underwent liver- and kidney transplantation because of deterioration of liver and kidney function. CONCLUSION: The majority of patients with simple liver cysts and PLD are referred for progressive abdominal pain. As initial treatment, percutaneous sclerotherapy is appropriate. Surgical deroofing is indicated in case of cyst recurrence after percutaneous sclerotherapy. However, the results of percutaneous sclerotherapy and surgical treatment for PLD are disappointing. Partial liver resection is indicated when there is suspicion of a pre-malignant lesio

Short-term Effects of Combined Hepatic Vein Embolization and Portal Vein Embolization for the Induction of Liver Regeneration in a Rabbit Model

Purpose: Alternative methods to optimize the hypertrophy response after portal vein embolization (PVE) are desired. This study assessed the effect of hepatic vein embolization (HVE) in addition to PVE on liver hypertrophy response in a standardized rabbit model. Materials and Methods: Thirty rabbits were allocated to groups according to intervention: PVE alone, HVE alone, and a combination of HVE and PVE. The liver regeneration response of the nonembolized, caudal liver was assessed by computed tomographic volumetry, liver to body weight index, and the amount of proliferating hepatocytes. Results: The caudal liver volume (CLV) increased significantly more in the PVE and combined PVE/HVE group than in the HVE group at 3 and 7 days after the procedure (P <.01). There were no significant differences in CLV increase or degree of hypertrophy between the PVE and combined embolization groups. The caudal liver to body weight index was significantly higher in the PVE and combined embolization groups than in the FIVE group on day 7 (P <.01). The index was also significantly higher in the combined PVE/HVE group compared with the PVE group (P = .008). The caudal liver tissue of the PVE and combined groups contained a significantly higher number of proliferating hepatocytes compared with the HVE group on day 7 (P <.01). Conclusions: Although histologic and additional regenerative changes are seen, HVE in addition to PVE has no additional short-term effect on hypertrophy response. The combination of HIVE and PVE may therefore have little use in a clinical settin

Crystal meth: Europe could now see a surge in supply and use.

For many people in Europe, the closest they will have got to methamphetamine will be the TV series Breaking Bad. But that could be about to change, as a result of developments in the international supply chain for cocaine and a new potential alliance between Mexican drug cartels and illegal European laboratories. Other members of the amphetamine family have been used in Europe for years. A number are used in medicine, such as methylphenidate in the treatment of attention deficit hyperactivity disorder (ADHD); while “speed” or d-amphetamine has had a steady following among recreational drug users.......