Oestrogen hormone receptors in focal nodular hyperplasia

BACKGROUND

The role of hormones in focal nodular hyperplasia (FNH) has been investigated with conflicting results.

OBJECTIVE

The aim of this study was to evaluate oestrogen and progesterone receptor immunohistochemical expression in FNH and surrounding normal liver (control material).

METHODS

Biopsy materials from FNH and control tissue were investigated using an immunostainer. Receptor expression was graded as the proportion score (percentage of nuclear staining) and oestrogen receptor intensity score.

RESULTS

Study material included tissue from 11 resected FNH lesions and two core biopsies in 13 patients (two male). Twelve samples showed oestrogen receptor expression. The percentage of nuclear oestrogen receptor staining was <33% in eight FNH biopsies, 34-66% in two FNH biopsies, and >67% in both core biopsies. The better staining in core biopsies relates to limitations of the staining technique imposed by the fibrous nature of larger resected FNH. Control samples from surrounding tissue were available for nine of the resected specimens and all showed oestrogen receptor expression. Progesterone receptor expression was negligible in FNH and control samples.

CONCLUSIONS

By contrast with previous studies, the majority of FNH and surrounding liver in this cohort demonstrated oestrogen receptor nuclear staining. The implications of this for continued oral contraceptive use in women of reproductive age with FNH remain uncertain given the lack of consistent reported growth response to oestrogen stimulation or withdrawal.

Anticoagulation policy after venous resection with a pancreatectomy: a systematic review

BACKGROUND

Portal vein (PV) resection is used increasingly in pancreatic resections. There is no agreed policy regarding anticoagulation.

METHODS

A systematic review was performed to compare studies with an anticoagulation policy (AC+) to no anticoagulation policy (AC-) after venous resection.

RESULTS

There were eight AC+ studies (n = 266) and five AC- studies (n = 95). The AC+ studies included aspirin, clopidogrel, heparin or warfarin. Only 50% of patients in the AC+ group received anticoagulation. There were more prosthetic grafts in the AC+ group (30 versus 2, Fisher's exact P < 0.001). The overall morbidity and mortality was similar in both groups. Early PV thrombosis (EPVT) was similar in the AC+ group and the AC- group (7%, versus 3%, Fisher's exact P = 0.270) and was associated with a high mortality (8/20, 40%). When prosthetic grafts were excluded there was no difference in the incidence of EPVT between both groups (1% vs 2%, Fisher's exact test P = 0.621).

CONCLUSION

There is significant heterogeneity in the use of anticoagulation after PV resection. Overall morbidity, mortality and EPVT in both groups were similar. EPVT has a high associated mortality. While we have been unable to demonstrate a benefit for anticoagulation, the incidence of EPVT is low in the absence of prosthetic grafts.

Falciform ligament abscess from left sided portal pyaemia following malignant obstructive cholangitis

Abscess formation of the falciform ligament is incredibly rare and perplexing when encountered for the first time. It is reported to occur in the setting of cholecystitis and cholangitis, but the pathophysiology is poorly understood.

In this case report, we present a 73-year-old man with falciform ligament abscess following cholangitis from an obstructive ampullary carcinoma. The patient was referred to the Royal Adelaide Hospital from a country hospital, with progressive jaundice, anorexia and nausea. Prior to transfer, he deteriorated with cholangitis, dehydration and renal failure. On arrival, his abdomen was exquisitely tender along the course of the falciform ligament. His blood tests revealed an elevated white cell count of 14.9 x 10³/μl, bilirubin of 291μmol/l and creatinine of 347 μmol/l. His CA 19-9 was markedly elevated at 35,000 kU/l. A non-contrast computed tomography (CT) demonstrated gross biliary dilatation and a collection tracking along the path of the falciform ligament to the umbilicus.

The patient was commenced on intravenous antibiotics and underwent an urgent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy and biliary stent drainage. Cholangiogram revealed a grossly dilated biliary tree, with abrupt transition at the ampulla, which on biopsy confirmed an obstructing ampullary carcinoma. Following ERCP, his jaundice and abdominal tenderness resolved. He was optimized over 4 weeks for an elective pancreaticoduodenectomy.

At operation, we found abscess transformation of the falciform ligament. Copious amounts of pus and necrotic material was drained. Part of the round ligament was resected along the undersurface of the liver. Histology showed that there was prominent histiocytic inflammation with granular acellular eosinophilic components. The patient recovered slowly but uneventfully.

A contrast CT scan undertaken 2 weeks post-operatively (approximately 7 weeks after the initial CT) revealed left portal venous thrombosis, which was likely to be a delayed discovery and was managed conservatively.

We present this patient’s operative images and radiographic findings, which may explain the pathophysiology behind this rare complication. We hypothesize that cholangitis, with secondary portal pyaemia and tracking via the paraumbilical veins, can cause infectious seeding of the falciform ligament, with consequent abscess formation.

Biliary access in technically difficult biliary cannulation: the mucosal bridge technique

BACKGROUND

The use of precut sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) facilitates selective bile duct access in difficult procedures. However, it is also associated with high rates of complications. Several techniques for precut sphincterotomy have been described in the literature. This paper reports our experience with a non-needle-knife technique for precut sphincterotomy, namely, the mucosal bridge technique.

METHODS

We analysed the experience of a single surgical endoscopist at our centre in performing precut sphincterotomies by retrospectively examining information in the database for January 2002 to February 2008, which had been stored prospectively using Endoscribe.

RESULTS

The mucosal bridge technique was performed in 16 (3.19%) of 501 patients. Success rates were 75% and 100% after first and second ERCPs, respectively. The failure of initial procedures was caused by bleeding, tissue oedema, poorly visualized papilla or a poorly distensible duodenum and oedematous papilla. There were four cases of complications, which included periductular extravasation of contrast, bleeding, and sepsis in two patients. However, these complications were not a direct consequence of the precut sphincterotomy.

CONCLUSIONS

The mucosal bridge technique can be used to increase the likelihood of successful bile duct cannulation, thus preventing the need for a second intervention.

Pancreatic stents in the management of chronic pancreatitis

BACKGROUND

Elevated pancreatic duct pressure is a potential source of pain in patients with chronic pancreatitis. Endoscopic pancreatic duct stenting is a minimally invasive way of reducing this pressure and may be a useful adjunct to surgery in these patients.

METHODS

We prospectively reviewed a series of nine symptomatic patients with obstructive chronic pancreatitis and relative contraindications to open surgery, who were managed by attempted endoscopic placement of a pancreatic stent.

RESULTS

Stents were successfully inserted endoscopically into the main or accessory duct in six patients and into a pseudocyst, transduodenally, in one patient. Of the two unsuccessful insertions, one proceeded to longitudinal pancreato-jejunostomy and in the other a stent was inserted at distal pancreatic cyst-jejunostomy. Median follow up was 21 months (range 14-43). In all eight cases with stent insertion there was rapid pain resolution, pain scores falling from 9/10 (8-10) to 2 (1-5) after 2 days (1-7). Associated symptoms of weight loss, nausea and vomiting settled in all eight cases. In one patient with a persistent pancreatic fistula, the fistula resolved. In the three with pseudocysts, the cysts resolved on computed tomography (CT) (one recurred). Five patients subsequently proceeded to stent removal after 6 months (5-23). In three of these, the stent was removed endoscopically, and replaced endoscopically in two cases, with pain resolution. Two patients underwent transduodenal pancreatic duct septectomy (one had stent change prior) and one proceeded to pseudocyst-gastrostomy, with pain resolution. the remaining three patients with stents in situ remain symptom-free. No patient suffered acute pancreatitis.

CONCLUSIONS

In selected patients with obstructive chronic pancreatitis, insertion of a pancreatic stent is a safe procedure, which can lead to rapid symptomatic control over the intermediate period. A significant proportion will need further intervention.

Primary duct closure versus T-tube drainage following exploration of the common bile duct

T-tube drainage of the common bile duct (CBD) following duct exploration has become standard surgical practice. This randomized prospective study has compared primary closure versus T-tube drainage of the CBD following exploration for calculous disease. Thirty-seven patients underwent primary closure and 26 underwent closure over T-tube. Both groups were comparable in terms of age, indications for surgery, associated illnesses, pre-operative bilirubin, amylase and white cell count. Forty-three per cent of operations were performed by a consultant in the primary closure group and 65% in the T-tube group. There was no significant difference in the duration of operation, incidence of wound infection, surgical or other complications following operation between the two groups. However, the postoperative stay was significantly prolonged in the T-tube group, to a median of 11 days, compared to 8 days in the primary closure group (P = 0.0001). This prolongation in stay was unrelated to whether admission was as an emergency or elective. T-tube drainage of the bile continued for a median of 7 days postoperative, whereas the bile drained via a wound drain in only 13 (35%) of the primary closure group, for a median of 5 days in these 13 patients. Long-term follow up was achieved in 48 patients, by a questionnaire sent at a median of 2.8 years following operation. Abdominal pains following recovery from the operation were experienced by 18% of the primary closure group and 20% of the T-tube group. No patient developed jaundice or pancreatitis, nor needed further biliary surgery following operation.(ABSTRACT TRUNCATED AT 250 WORDS)

High or low hepaticojejunostomy for bile duct strictures?

The 19 patients who underwent 22 postoperative repairs of bile duct stricture in our institution between 1973 and 1984 were evaluated to assess whether the recognition of the tenuous blood supply of the supraduodenal bile duct in 1979 had improved the results thereafter. Thirteen of these 22 operations followed a previous biliary tract repair; in 10 of the operations a low anastomosis had been performed without taking blood supply into account. Follow-up was complete and ranged from 5 to 15 years. There were no operative deaths and minimal morbidity. There were three deaths at a later time. Five of the 11 patients treated by surgery to 1979 had a clinically unsatisfactory result: recurrent strictures developed in all five patients. All but one of the eight patients receiving a high hepaticojejunostomy from 1980 had a clinically satisfactory result with no recurrent strictures. The one exception was the patient who had a second repair with separate high right and left hepatic duct anastomoses and who has ongoing symptoms from preexisting secondary sclerosing cholangitis. The results in the five high repairs performed for low strictures were particularly striking: All five were asymptomatic. This study lends support to the hypothesis of an ischemic basis for biliary strictures and to the recommendation that strictures be repaired with a high hepaticojejunostomy.

Endoscopic decompression for acute cholangitis due to stones

The prognosis in patients with acute cholangitis is poor, particularly when the cholangitis is 'severe' as defined by the presence of hypotension and/or confusion. This prospective study evaluates 16 elderly patients with acute cholangitis ('severe' in 11) due to stones in whom endoscopic biliary decompression was attempted. It was technically successful on 13 (81%) of the 16 occasions and the cholangitis rapidly resolved in these patients. In seven of 13, this was the definitive treatment while six underwent subsequent surgery consisting of: cholecystectomy or cholecystostomy (five) and secondary bile duct exploration (one). Two patients died following laparotomy for stones that were not amendable to endoscopic removal. Urgent endoscopic retrograde choledochography is recommended in elderly patients with acute cholangitis, because it confirms the diagnosis and allows decompression of the biliary tract by sphincterotomy. This stabilizes the patient's general condition and facilitates subsequent open surgery when required.

Severe juxtahepatic venous injury: survival after prolonged hepatic vascular isolation without shunting

Survival following major juxtahepatic venous injury is rare in blunt liver trauma despite the use of intracaval shunting. Prolonged liver arterial inflow control, total hepatic venous isolation and lobectomy without shunting was used in a patient to repair a combined vena caval and hepatic venous injury after blunt liver injury. An extended period of normothermic hepatic ischemia was tolerated. Early recognition of retrohepatic venous injury and temporary liver packing to control bleeding and correct hypovolemia are essential before caval occlusion. Hepatic vascular isolation without shunting is an effective simple alternative technique allowing major venous repair in complex liver trauma.

Treatment of postcholedochoduodenostomy symptoms

Upper abdominal symptoms after side-to-side choledochoduodenostomy (CDDY) may be attributed to stagnant bile, food and calculi pooling in the distal bile duct 'sump' with resultant biliary or pancreatic duct obstruction and sepsis. Endoscopic sphincterotomy (ES) provides a means of draining this sump. The aim of this study was to assess outcome following endoscopic retrograde choledochopancreatography (ERCP) and ES in patients with post-CDDY symptoms. Eight such patients (M: F = 1:7) underwent ERCP between September 1981 and March 1987. Their median age was 60 years (range: 37-72 years) and the median period since CDDY was 11 years (range: 1-28 years). The median follow-up after ERCP was 18 months (range: 14-94 months). Presenting symptoms comprised postprandial (one) or intermittent (seven) abdominal pain, cholangitis (three), pancreatitis (one) and jaundice (one). ERCP revealed bile duct abnormalities in four, consisting of filling defects alone (two), anastomotic narrowing with filling defects (one) and sclerosing cholangitis. ES was performed in seven, of whom three (all with filling defects at ERCP) remain asymptomatic and three are significantly improved. One had recurrent pancreatitis for which a sphincteroplasty and pancreatic duct septectomy was performed. ES was not performed in one because of technical difficulties (there being no subsequent improvement). It is concluded that, in patients with post-CDDY biliary symptoms, endoscopic sphincterotomy relieves the symptoms by either producing drainage of the sump at the distal bile duct, or dividing a dysfunctioning sphincter of Oddi.

Human fasting and postprandial sphincter of Oddi motility

Sphincter of Oddi motility was evaluated in post-cholecystectomy patients with indwelling T tubes during fasting and after feeding. A triple-lumen catheter was positioned to record from the sphincter of Oddi and duodenum. The sphincter of Oddi was characterized by phasic contractions independent of duodenal contractions. During fasting duodenal wave frequency exhibited four phases, whereas only two phases could be identified from the sphincter of Oddi. A prolonged phase A in the sphincter of Oddi corresponded to duodenal phases I, II and IV. A short phase B in the sphincter of Oddi just preceded the onset of duodenal phase III and was temporally related to it. Sphincter of Oddi basal pressure increased during duodenal phases III and IV. After ingestion of food, sphincter of Oddi basal pressure, wave amplitude and duration decreased, but the frequency remained unchanged. Conversely, duodenal frequency increased but there was no change in amplitude. Thus, the human sphincter of Oddi and duodenum exhibited independent motility demonstrating distinct phases during the interdigestive period. After food, sphincter of Oddi motility altered in a manner which would facilitate the passive flow of fluid into the duodenum.

Common duct exploration or endoscopic sphincterotomy for choledocholithiasis?

The relative indications for operative common duct exploration (CDE) and endoscopic sphincterotomy (ES) in treating common duct stones are often unclear. This prospective study compared CDE and ES in treating choledocholithiasis after excluding patients with acute cholecystitis, idiopathic pancreatitis, sphincter of Oddi dysfunction and malignant disease. One hundred and two patients had 105 CDE and a further 50 patients had 57 ES. Of the patients having CDE, 76 also had cholecystectomy for gall-bladder (GB) disease while 26 had prior cholecystectomy. With ES, in 16 the GB was present and not removed while 34 patients had had prior cholecystectomy. Hospitalization was significantly less following ES. There was one peri-operative death after CDE and none after ES. There were two late biliary-related deaths, 3 and 27 months after ES, in patients who developed acute cholecystitis. In post-cholecystectomy patients having ES, complications were fewer and less severe after ES (15%) than CDE (41%). In patients with an intact GB, peri-operative complications occurred in 30% after cholecystectomy and CDE. Following ES alone, complications occurred in 33% with the majority of these complications arising from the diseased GB. It is concluded that the optimal treatment for post-cholecystectomy patients with bile-duct stones is ES. In elderly patients with an intact GB, the bile-duct stones can be treated by ES; whether subsequent cholecystectomy is necessary should be assessed on the likelihood of future GB complications.

Evaluation of Tc-99m-DTPA for renal clearance studies in the pig

Conventional creatinine clearance studies in the pig are complicated by difficulties with catheterisation, infection, accurate collection and active creatinine renal tubular reabsorption. We compared a single injection, 99mTc-DTPA elimination method with creatinine clearance. Nineteen pairs of GFR estimations were performed in 10 pigs: 7 in normal pigs and 12 following bile duct ligation and/or nephrectomy. Red cell and plasma protein binding of the isotope and its hepatobiliary excretion was assessed. Absolute and weight normalised endogenous creatinine clearances correlated significantly with 99mTc-DTPA elimination. 99mTc-DTPA red cell binding and hepatobiliary excretion were negligible. Thus, 99mTc-DTPA elimination is a valid indicator of changes in renal function in grouped porcine studies, particularly in the biliary obstruction model. However, isotope plasma protein binding was high in the 2 normal pigs assessed. Individual accuracy would be improved by routine protein binding correction, unless consistently low for a particular preparation.

Gallbladder non-filling: an indication for cholecystectomy after endoscopic sphincterotomy

The place of endoscopic sphincterotomy in the treatment of common duct stones leaving the gallbladder in situ remains controversial. Over a 3-year period, 20 elderly high-operative-risk patients with stones in the common duct and intact biliary tree were treated by endoscopic sphincterotomy leaving the gallbladder in situ. Two patients underwent cholecystectomy for persistent symptoms after endoscopic sphincterotomy, and 18 patients were discharged from hospital, with the gallbladder intact. Of the 18 patients, 6 developed recurrent gallbladder problems, with 3 of the 6 dying as a result of these problems. On review of our data, these six patients were in a group of eight who, at the time of original endoscopic retrograde cholangiography (ERC), were shown to have an obstructed cystic duct. The other 10 patients, with a patent cystic duct and discharged with gallbladder in situ, remained symptom free over a median follow-up period of 9 (range 2-42) months. We conclude that if the gallbladder does not fill at ERC (indicating probable cystic duct obstruction), cholecystectomy is warranted. When the gallbladder fills, regular follow-up alone is justified in the absence of symptoms.

Exploration of the common bile duct for benign conditions: an analysis of 413 patients

The morbidity and mortality following exploration of the common duct for benign conditions has been analysed retrospectively in 413 patients from the Royal Adelaide Hospital. Follow up ranged from one to 110 months (median 47 months). The major complication rates in patients having biliary "drainage procedures" (choledochoduodenostomy (56 patients), sphincterotomy or sphincteroplasty (65 patients) compared favourably with those having choledochotomy with T-tube insertion alone (307 patients). This was despite a greater incidence of potentially adverse factors in the former group. Problems related to retained or recurrent stones were effectively reduced by drainage procedures which were performed safely in the presence of acute inflammation. Symptomatic cholangitis was not more frequent after drainage procedures.