Long-term complications after extrahepatic cyst excision for type IV-A choledochal cysts

Forty-five adults with type IV-A choledochal cysts (CDC) who underwent extrahepatic cyst excision from January 2013 to December 2021 were followed up for a median interval of 25 months (range, 2 to 10 years) to observe the long-term complications in the remaining intrahepatic cyst. Late complications in varying combinations were seen in 10 patients, which included cholangitis and/or intrahepatic stones in 9 patients, intrahepatic bile duct stenosis with stones in 2 patients, anastomotic stricture in 6 patients, and left lobar atrophy with intrahepatic stones in 3 patients. Out of 6 patients who required re-do hepaticojejunostomy (HJ), three patients had left lobe atrophy with patent HJ anastomosis and a recurrent attack of cholangitis on follow-up at 3, 8, and 10 years. Complications occur frequently after extrahepatic cyst excision for type IV-A CDC and require a long-term follow-up.

Giant Adrenal Pseudocysts: An Enigma for Surgeons

Adrenal pseudocysts are cystic lesions arising within the adrenal gland enclosed by a fibrous connective tissue wall that lacks lining cells. They can attain a huge size and pose a diagnostic challenge with a broad range of differentials including benign and malignant neoplasms. There are only a few small case series and case reports describing these lesions. We report a series of five patients who presented with “indeterminate” abdominal cystic lesions and were later on found to have adrenal pseudocyst. Four out of five patients presented with non-specific abdominal symptoms, and one patient presented with symptoms suggestive of a functional adrenal tumor. The size of these tumors ranged from 6 to 30 cm. They had variable radiological features and in two cases even a percutaneous biopsy could not establish the diagnosis. In four of these “indeterminate” abdominal masses, an adrenal origin was not suspected preoperatively. Surgical excision provided a resolution of symptoms, ruled out malignancy, and clinched the diagnosis.

Analysis of outcomes of biliary reconstruction after post-cholecystectomy bile duct injuries

BACKGROUND

Post-cholecystectomy bile duct injury (BDI) is a serious complication that often requires surgical repair. This study aimed to analyze the outcomes of surgery performed for BDI and to determine the factors associated with post-surgical complications.

METHODS

A retrospective analysis was conducted using a prospectively maintained database of 105 patients who underwent surgical repair for post-cholecystectomy BDI between March 2013 and March 2020. BDI was classified based on the Strasberg-Bismuth system, and the outcomes were graded using the McDonald criteria. Multivariable logistic regression was used to identify the significant variables associated with postoperative complications.

RESULTS

In a cohort of 105 patients with post-cholecystectomy BDI who underwent bilioenteric repair, 71 (67.6%), 25 (23.8%), 2 (1.9%), and 7 (6.7%) patients had excellent, good, fair, and poor outcomes, respectively, during a median follow-up of 64 months. The incidence of recurrent biliary stricture after definitive surgical hepaticojejunostomy was 6.7% (n = 7). The presence of cholangitis, choledochoduodenal fistula, and hilar biliary strictures was among the significant variables associated with the development of both short-term and long-term complications following surgery.

CONCLUSIONS

Surgical repair of BDIs with bilioenteric anastomosis can yield excellent results when managed in a tertiary care center where expertise in the reconstruction of the biliary tree is prioritized.

Preemptive live-related renal transplantation

BACKGROUND

Preemptive transplantation (PTX) utilizes transplantation as the primary renal replacement therapy in the absence of any preceding dialysis. In developing countries, PTX may be a cost-effective option, offering additional benefits to conventional transplantation.

METHODS

Between 1989 and 1996, 43 patients who underwent live-related PTX were compared with 86 matched controls who underwent transplantation after hemodialysis. Pre- and posttransplant morbidity, and graft and patient survival rates were compared.

RESULTS

Median follow-up was 15 months in the preemptive group and 20.5 months in the control group. Controls received more transfusions (4.6+/-2.6 vs. 2.4+/-2.3), had higher hepatitis B surface antigen positivity [12 (14.6%) vs. 1 (2.4%)], and more commonly had hepatic dysfunction [5 (5.8%) vs. nil)] in the pretransplant period compared with the preemptive group. Similarly, at 6 months after transplant, the incidence of hepatitis B surface antigen positivity (13 vs. 2) and hepatic dysfunction (18 vs. 3) were higher in the control group compared with the preemptive group. The 1- and 2-year graft (preemptive: 82.8% and 77.3%; controls: 82% and 78%, respectively) and patient (preemptive: 92% and 89.5%; controls: 91% and 89.5%, respectively) survival rates were similar.

CONCLUSION

PTX offers comparable patient and graft survival to conventional transplantation. It eliminates the complications and inconvenience of dialysis. Transfusion requirements, and therefore associated morbidity, are lower. PTX is more cost effective, therefore, it should be a recommended practice in a developing country.