Association between biliary complications and technique of hilar division (extrahepatic vs. intrahepatic) in major liver resections

BACKGROUND: Division of major vascular and biliary structures during major hepatectomies can be carried out either extrahepatically at the porta hepatic or intrahepatically during the parenchymal transection. In this retrospective study we test the hypothesis that the intrahepatic technique is associated with less early biliary complications. METHODS: 150 patients who underwent major hepatectomies were retrospectively allocated into an intrahepatic group (n = 100) and an extrahepatic group (n = 50) based on the technique of hilar division. The two groups were operated by two different surgical teams, each one favoring one of the two approaches for hilar dissection. Operative data (warm ischemic time, operative time, blood loss), biliary complications, morbidity and mortality rates were analyzed. RESULTS: In extrahepatic patients, operative time was longer (245 ± 50 vs 214 ± 38 min, p < 0.05) while the overall complication rate (55% vs 52%), hospital stay (13 ± 7 vs 12 ± 4 days), bile leak rate (22% vs 20%) and mortality (2% vs 2%) were similar compared to intrahepatic patients. However, most (57%) bile leaks in extrahepatic patients were grade II (leaks that required non-operative interventional treatment, while most (70%) leaks in the intrahepatic group were grade I (leaks that resolved and presented two injuries (4%) of the remaining bile ducts (p < 0.05). CONCLUSION: Intrahepatic hilar division is as safe as extrahepatic hilar division in terms of intraoperative blood requirements, morbidity and mortality. The extrahepatic technique is associated with more severe bile leaks and biliary injuries

Malignant potential of intrahepatic biliary papillomatosis: a case report and review of the literature

BACKGROUND: Biliary papillomatosis (BP) is a rare disease entity with a strong malignant potential. It is characterized by multiple papillary adenomas involving both the intrahepatic and extrahepatic biliary tree. BP was considered in the past to be a disease with low malignant potential. However, a current review of the English literature revealed a high rate of malignant occurrence of approximately 41% and histological analysis along with the expression pattern of mucin core proteins (MUC) and mucin carbohydrate antigens suggests that BP is a borderline or low grade malignant neoplasm with a high malignant potential. CASE PRESENTATION: A 68 year-old male patient was referred to our hospital due to the presence of sudden right upper quadrant abdominal pain, nausea and dark urine. Imaging workup demonstrated dilatation of the left hepatic duct without the presence of a space-occupying lesion. A left hepatectomy and cholecystectomy were carried out and histological analysis revealed a moderately to poorly differentiated carcinoma of the left hepatic duct in the background of biliary papillomatosis. Postoperative course was uneventful. Unfortunately, two years after initial diagnosis the patient rapidly deteriorated and died from multiple pulmonary secondary deposits. CONCLUSION: BP should not be considered to be a benign disease. The clinical behavior, the high recurrence rate and the even higher malignant transformation occurrence, as well as the presence of carcinogenetic indicators (K-ras mutation, overexpression of p53, MUC and Tn antigens) strongly support that BP is a low-grade neoplasm with high malignant potential

Enzymatic Reaction Mechanisms, pp ranca

ABSTRACT: The mechanism of the argininosuccinate lyase reaction has been probed by the measurement of the effects of isotopic substitution a t the reaction centers. A primary deuterium isotope effect of 1.0 on both Vand V / K is obtained with (2S,3R)-argininosuccinate-3-d, while a primary 15N isotope effect on V / K of 0.9964 f 0.0003 is observed. The 15N isotope effect on the equilibrium constant is 1.018 f 0.001. The proton that is abstracted from C-3 of argininosuccinate is unable to exchange with the solvent from the enzyme-intermediate complex but is rapidly exchanged with solvent from the enzyme-fumaratearginine complex. A deuterium solvent isotope effect of 2.0 is observed on the V,,, of the forward reaction. These and other data have been interpreted to suggest that argininosuccinate lyase catalyzes the cleavage of argininosuccinate via a carbanion intermediate. The proton abstraction step is not rate limiting, but the inverse 15N primary isotope effect and the solvent deuterium isotope effect suggest that protonation of the guanidino group and carbon-nitrogen bond cleavage of argininosuccinate are kinetically significant. Argininsuccinate lyase catalyzes the cleavage of argininosuccinate to arginine and fumarate. The enzyme is found in the liver where it functions in the biosynthesis of urea. The enzyme from bovine liver has been shown by Lusty and Ratner (1972) to be a tetramer of four identical subunits. No external cofactor is involved, and the enzyme apparently does not require metal ions for catalytic activity. The details of the catalytic events leading to the chemical transformation of argininosuccinate to fumarate and arginine are largely unknown. Ratner and co-workers have shown that the reaction involves the trans elimination of arginine and the pro-R hydrogen at C-3 of argininosuccinate (Hoberman et al., 1965). The kinetic mechanism of the reaction is random In this paper we report on our efforts to determine the magnitude and the timing of the bond-breaking steps in the conversion of argininosuccinate to arginine and fumarate. Th

Small-bowel herniation under the infrarenal arterial conduit in a liver transplant recipient

We report a case of herniation of the entire small bowel under an infrarenal conduit 8 months after orthotopic liver transplantation. The conduit was compressed by the mesentery and developed a stricture and thrombosis. Liver revascularization was accomplished by an urgent thrombectomy, resection of the stricture, and reanastomosis of the conduit. Suspicion of this serious complication should arise in transplant recipients who present with bowel obstruction associated with liver dysfunction

Individuals at high-risk for pancreatic cancer development: Management options and the role of surgery

Pancreatic cancer (PC) is a highly lethal disease. Despite advances regarding the safety and long-term results of pancreatectomies, early diagnosis remains the only hope for cure. This necessitates the implementation of an intensive screening program (based mainly on modern imaging), which - given the incidence of PC - is not cost effective for the general population. However, this screening program is recommended for individuals at high-risk for PC development. Indications for screening include the following three clinical settings: hereditary cancer predisposition syndromes associated with PC, hereditary pancreatitis and familial pancreatic cancer syndrome. The aim of this strategy is to identify pre-invasive (precursor) lesions, which are curable. Surgery is recommended in the presence of recognizable lesion on imaging lesions. Partial (anatomic) pancreatectomy - depending on the location of the suspicious lesion - is the most widely accepted type of surgical intervention in this setting; occasionally, however, total pancreatectomy may be required, in carefully selected patients. Despite that experience still remains limited, there is evidence that this aggressive strategy allows early detection of neoplastic lesions, thereby improving the effectiveness of surgery and prognosis. © 2010 Elsevier Ltd. All rights reserved