Modern imaging in patients with obstructive jaundice

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Ciliated hepatic foregut cyst: a rare cystic liver lesion

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A cost analysis of operative repair of major laparoscopic bile duct injuries

Background. Major bile duct injuries occur infrequently after laparoscopic cholecystectomy, but may result in life-threatening complications. Few data exist on the financial implications of duct repair. This study calculated the costs of operative repair in a cohort of patients who underwent reconstruction of the bile duct after major ductal injury.Objective. To calculate the total in-hospital cost of surgical repair of patients referred with major bile duct injuries.Methods. A prospective database was reviewed to identify all patients referred to the University of Cape Town Private Academic Hospital, South Africa, between 2002 and 2013 for assessment and repair of major laparoscopic bile duct injuries. The detailed clinical records and billing information were evaluated to determine all costs from admission to discharge. Total costs for each patient were adjusted for inflation between the year of repair and 2013.Results. Forty-four patients (33 women, 11 men; median age 48 years, range 30 - 78) underwent reconstruction of a major bile duct injury. First-time repairs were performed at a median of 24.5 days (range 1 - 3 662) after initial surgery. Median hospital stay was 15 days (range 6 - 86). Mean cost of repair was ZAR215 711 (range ZAR68 764 - 980 830). Major contributors to cost were theatre expenses (22%), admission to intensive care (21%), radiology (17%) and specialist fees (12%). Admission to a general ward (10%), consumables (7%), pharmacy (5%), endoscopy (3%) and laboratory costs (3%) made up the balance.Conclusions. The cost of repair of a major laparoscopic bile duct injury is substantial owing to prolonged hospitalisation, complex surgical intervention and intensive imaging requirements

Outcome of liver resection for small bowel neuroendocrine tumour metastases

Background Small bowel neuroendocrine tumours frequently metastasise to the liver. While liver resection improves survival and provides symptomatic relief, multifocal bilobar disease adds complexity to surgical management. Objectives This study evaluated outcome in patients with small bowel neuroendocrine liver metastases who underwent liver resection at Groote Schuur Hospital and UCT Private Academic Hospital. Methods All patients with small bowel neuroendocrine liver metastases treated with resection from 1990-2015 were identified from a prospective departmental database. Demographic data, operative management, morbidity and mortality using the Accordion classification were analysed. Survival was assessed using the Kaplan-Meier method. Results Seventeen patients (9 women, 8 men, median age 55 years, range 31-76) underwent resection. Each patient had all identifiable liver metastases resected and/or ablated (median n = 3, range 1-20). Ten patients had major anatomical liver resections. Three patients had five segments resected, and seven had four resected. Nine patients (53%) had a concurrent bowel resection of the small bowel NET primary and a regional mesenteric lymphadenectomy. Median operating time was 255 min (range 150-720). Median blood-loss was 800 ml (range 200-10,000). Five patients required intraoperative blood transfusion. Hepatic vascular inflow control was used in ten patients (56.5 min median, range 20-150 min), which included hepatic inflow control n = 8, total hepatic exclusion n = 1, and selective hepatic exclusion n = 1. Median postoperative hospital stay was 9 days (range 2-28). Thirteen complications occurred in seven patients. Accordion grades were 1 n = 3, 2 n = 4, 3 n = 3, 4 n = 2, 6 n = 1. One patient required reoperation for bleeding and a bile leak. One patient died of a myocardial infarction 36 hours postoperatively. Sixteen patients (94%) had symptomatic improvement. Five-year overall survival was 91% (median follow-up 36 months, range 14-86 months. Conclusion Our data show that liver resection can be safely performed for small bowel NET metastases with a good 5-year survival. However, a substantial number of patients require a major liver resection and these patients are best managed at a multidisciplinary referral centre</p

Outcome of liver resection for small bowel neuroendocrine tumour metastases

Background Small bowel neuroendocrine tumours frequently metastasise to the liver. While liver resection improves survival and provides symptomatic relief, multifocal bilobar disease adds complexity to surgical management. Objectives This study evaluated outcome in patients with small bowel neuroendocrine liver metastases who underwent liver resection at Groote Schuur Hospital and UCT Private Academic Hospital. Methods All patients with small bowel neuroendocrine liver metastases treated with resection from 1990-2015 were identified from a prospective departmental database. Demographic data, operative management, morbidity and mortality using the Accordion classification were analysed. Survival was assessed using the Kaplan-Meier method. Results Seventeen patients (9 women, 8 men, median age 55 years, range 31-76) underwent resection. Each patient had all identifiable liver metastases resected and/or ablated (median n = 3, range 1-20). Ten patients had major anatomical liver resections. Three patients had five segments resected, and seven had four resected. Nine patients (53%) had a concurrent bowel resection of the small bowel NET primary and a regional mesenteric lymphadenectomy. Median operating time was 255 min (range 150-720). Median blood-loss was 800 ml (range 200-10,000). Five patients required intraoperative blood transfusion. Hepatic vascular inflow control was used in ten patients (56.5 min median, range 20-150 min), which included hepatic inflow control n = 8, total hepatic exclusion n = 1, and selective hepatic exclusion n = 1. Median postoperative hospital stay was 9 days (range 2-28). Thirteen complications occurred in seven patients. Accordion grades were 1 n = 3, 2 n = 4, 3 n = 3, 4 n = 2, 6 n = 1. One patient required reoperation for bleeding and a bile leak. One patient died of a myocardial infarction 36 hours postoperatively. Sixteen patients (94%) had symptomatic improvement. Five-year overall survival was 91% (median follow-up 36 months, range 14-86 months. Conclusion Our data show that liver resection can be safely performed for small bowel NET metastases with a good 5-year survival. However, a substantial number of patients require a major liver resection and these patients are best managed at a multidisciplinary referral centr

Variceal recurrence, rebleeding and survival after injection sclerotherapy in 306 alcoholic cirrhotic patients with bleeding oesophageal varices: original

Endoscopic therapy is the treatment of choice for bleeding oesophageal varices. This study tested the validity of the hypothesis that eradication of oesophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding oesophageal varices in a high risk cohort of patients with portal hypertension and cirrhosis. Patients and Methods: 306 alcoholic cirrhotic patients who presented to hospital with endoscopically proven variceal bleeding were assessed prospectively between 1984 and 2001. Data were entered into a computer based proforma and analysed in April 2004 to allow a minimum 26 months follow-up. The data presented is based on an endoscopic protocol using a standard injection technique, with eradication of varices the predetermined end point. The 306 patients (239 men, 67 women; mean age 51.6, range 24-87 years) underwent 387 emergency and 1067 elective injection treatments with 5% ethanolamine oleate using a combined intra and paravariceal technique during the study period. All patients undergoing endoscopic band ligation were excluded. The Child's grades were A:42, B:122, C:142. All oesophageal complications which occurred during the subsequent 2380 endoscopies following the index sclerotherapy treatment were documented. Results: Before eradication of varices was achieved 111 (36.2%) of the 306 patients had a total of 191 bleeding episodes after the initial endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 156 (81.6%) of 191 patients who survived more than 3 months, varices were eradicated after a mean of 5 injections and remained eradicated in 69 (mean follow-up: 34.6 months; range: 1-174 months). Varices recurred in 83 patients and rebled in 43 of these patients. 830 oesophageal complications were identified during follow-up in 249 (81.3%) patients. Mucosal ulceration was noted on 584 occasions in 216 patients. 27 patients developed an oesophageal stenosis of whom 15 required dilatation. Eight patients had an oesophageal perforation after repeated sclerotherapy for recurrent bleeding. Cumulative survival by life table analysis was 56%, 40%, and 24% at 1, 3 and 5 years. 213 patients (69.6%) died during follow-up. Liver failure was the most common cause of death. Conclusion: Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Complications related to sclerotherapy were common and were mostly of a minor nature but were cumulative and life-threatening in some patients. Despite control of variceal bleeding, survival at 5 years was only 24% because of death due to liver failure in most patients. SA Gastroentorology Review Vol.2(2) 2004: 8-1