İlgin Özden

Spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis.

Background: Autoimmune pancreatitis is an evolving entity. Methods: A patient who had spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis is presented. Results: A 58-year-old diabetic woman with jaundice was referred for pancreatic head carcinoma diagnosed by magnetic resonance imaging (MRI). At laparotomy, a pancreatic head mass (4 × 3 cm) that involved the transverse mesocolon and two other hard masses (1 cm) in the pancreatic body and tail were found. The gallbladder was palpated as a hard tumor mass. Frozen section examination of the gallbladder and pancreatic biopsies revealed cholecystitis and pancreatitis with lymphoplasmacytic infiltration. The common bile duct was brittle and unsuitable for anastomosis. Starting 1 month after the operation, drainage from the biliary catheter decreased gradually and stopped. There was no parenchymal lesion on MRI examination in the 2nd postoperative month. Cholangiography from the percutaneous catheter showed flow of contrast agent into the duodenum. Serum immunoglobulin G, G4 and E levels were increased. Conclusion: To the best of our knowledge, this is the first report of spontaneous regression of a pancreatic head mass and biliary obstruction due to autoimmune pancreatitis.

Intrahepatic biliary cystic neoplasms: Surgical results of 9 patients and literature review

AIM To investigate the eligible management of the cystic neoplasms of the liver. METHODS The charts of 9 patients who underwent surgery for intrahepatic biliary cystic liver neoplasms between 2003 and 2008 were reviewed retrospectively. Informed consent was obtained from the patients and approval was obtained from the designated review board of the institution. RESULTS All patients were female with a median (range) age of 49 (27-60 years). The most frequent symptom was abdominal pain in 6 of the patients. Four patients had undergone previous laparotomy (with other diagnoses) which resulted in incomplete surgery or recurrences. Liver resection (n = 6) or enucleation (n = 3) was performed. The final diagnosis was intrahepatic biliary cystadenoma in 8 patients and cystadenocarcinoma in 1 patient. All symptoms resolved after surgery. There has been no recurrence during a median (range) 31 (7-72) mo of follow up. CONCLUSION In spite of the improvement in imaging modalities and increasing recognition of biliary cystadenoma and cystadenocarcinoma, accurate preoperative diagnosis may be difficult. Complete surgical removal (liver resection or enucleation) of these lesions yields satisfying long-term results.

Hepatic alveolar echinococcosis: MRI findings

The purpose of this study was to describe the magnetic resonance imaging (MRI) appearance of hepatic alveolar echinococcosis (HAE) on T(1)-weighted, T(2)-weighted and postgadolinium images. A total of 13 lesions were demonstrated in 13 patients. All patients underwent MR examination at 1 T imager. MR examinations included precontrast T(1)-weighted breathing averaged spin echo (SE), breath-hold spoiled gradient echo, T(2)-weighted TSE sequences with and without fat suppression, and T(1)-weighted breath-hold spoiled gradient echo (SGE) sequence following i.v. after gadolinium administration. All lesions were confirmed with histopathology. HAE hepatic lesions revealed geographic patterns of variable signal intensities on noncontrast T(1)- and T(2)-weighted images. Slightly hyperintense, iso- and hypointense signal on T(1)-weighted images corresponded to calcified regions, which appeared hypo-isointense signal on T(2)-weighted images. Necrotic areas were hypointense signal on T(1)-weighted and hyperintense signal on T(2)-weighted images. On postgadolinium images, lesions did not reveal enhancement. Dilatation of intrahepatic bile ducts distal to HAE abscesses were observed in five patients and portal vein invasion or compression was observed in four patients, lobar atrophy of the liver was coexistent finding in cases with portal vein compression. The MRI appearance of HAE abscesses included large irregularly marginated masses with heterogenous signal on T(1)- and T(2)-weighted images and lack of enhancement with gadolinium.

Alveolar Echinococcosis in Turkey

Background: Radical resection is the only potentially curative treatment for hepatic alveolar echinococcosis (AE). Although Turkey is an endemic region, population screening is not performed and early diagnosis is rare. Consequently, surgeons are compelled to explore possibilities such as near-total resection and biliodigestive anastomosis for palliation of jaundice. Methods: Surgery was performed in 32 patients with hepatic AE with the following indications: (1) resection; (2) palliation of jaundice; (3) definite assessment of operability; (4) failure in the management of cavity infection by percutaneous methods. Curative resection (R0 = complete resection of all parasitic mass [n = 9], and R1 = a resection in which a small remnant was left on a vital structure [n = 8]) were performed in 17 patients, intrahepatic cholangiojejunostomy in 7, laparotomy-external drainage in 7, and debulking in 1. Results: Perioperative mortality rates were 2/17, 0/7, 2/7 and 1/1, respectively. Twelve patients in the curative resection group are alive without recurrence/progression of the small remnant during a median follow-up of 59 (range 27–116) months. One patient developed an inoperable recurrence that was treated with albendazole. One patient was lost to follow-up. Long-term albendazole treatment was effective in all R1 patients except a patient who had slow asymptomatic progression. Successful palliation of jaundice was achieved in 5 of the 7 intrahepatic cholangiojejunostomy patients. Conclusions: The results of R1 resection in alveolar hydatid disease are similar to those of R0 resection; a small remnant is successfully controlled by albendazole. In patients with jaundice due to hilar invasion, biliary diversion from segment 3 or 5 is effective for palliation of the jaundice and facilitates albendazole treatment.

Immunoprotection in spontaneous remission of type 1 diabetes: long-term follow-up results

This prospective pilot study was undertaken to test the efficacy of oral methyl-prednisolone (MP) therapy at spontaneous remission phase of type 1 diabetes in intervening the course of the disease. Twenty-five type 1 diabetic patients who were classified as having a spontaneous remission (honeymoon) were divided into treatment and non-treatment groups on voluntary basis. Fifteen patients thus making up the treatment group (13 males and 2 females, mean age 23.8 +/- 6.2 years) received 0.7-1.0 mg/kg/day of MP p.o. for 2 weeks. The dose of the drug was then gradually diminished every week until 5 mg/day (approx. 0.1 mg/kg/day) and discontinued at 10 +/- 2 weeks. In case of hyperglycemia occurring in 12 of 15 patients due to the administration of steroid, insulin was used to normalize blood glucose levels (average 0.47 +/- 0.21 IU/kg/day). The non-treatment group (8 males and 2 females, mean age 21.8 +/- 8.9) did not receive any special medication or placebo except for insulin whenever necessary to regulate glycemia. Upon completion of protocol, all patients in treatment group displayed clinical remission with 10 still in non-insulin requiring remission for follow-up periods ranging between 16 and 91 months. The remaining 5 patients relapsed within 3-15 months of therapy. Other metabolic (including basal and stimulated C-peptide levels) and immunological indices that have spontaneously ameliorated with the occurrence of honeymoon were also maintained within normal range in the NIR patients. Meanwhile, natural remission in the non-MP-treated group terminated at 3.4 +/- 0.6 months with deterioration of all metabolic and immunological markers as well as increasing requirements for insulin. In conclusion, the spontaneous remission of the patients could be prolonged significantly by MP therapy as opposed to no therapy (P < 0.001). These results suggest that the spontaneous remission phase may be a crucial point of intervention in immunotherapy of type 1 diabetes and that randomized trials with MP at this particular phase would be worthwhile.

Primary Lymphoma of the Liver: Report of a Case

Abstract: We describe herein a female patient with non-Hodgkins lymphoma of the liver and present a review of the related literature. The patient was referred with the diagnosis of malignant hemangiopericytoma (with an open biopsy). The physical examination, standard laboratory test results and tumor marker levels were all normal. A nonstandard left lobectomy was performed. Histopathological and immunohistochemical examinations revealed non-Hodgkins lymphoma of B-cell type. The findings of a peripheral blood smear and bone marrow biopsy were normal. There was no other site of involvement based on physical or radiological examinations. These findings established the diagnosis of primary hepatic lymphoma. Fewer than 100 cases have been reported in the world literature. The best treatment results have been obtained by a resection followed by chemotherapy when feasible.

Does HepPar-1 immunoexpression have a role in differential diagnosis of periampullary cancer?

Aims: Histological subtyping of periampullary carcinomas is considered as a criterion for prognosis and therapeutic implications of these tumours. We assessed the immunoexpression rates of HepPar‐1, CDX2 and MUC2 antibodies in different subtypes of periampullary adenocarcinomas (PAC), intestinal and pancreatobiliary, in order to assess their impact on differential diagnosis of this group of cancers. The expression of antibodies was also measured in ductal adenocarcinoma of the pancreatic head (DAPH). Methods: Sixty‐five patients with PAC and DAPH who underwent pancreatic Whipple resection constituted the study cohort. Of these, 46 (71%) had PAC, and 19 (29%) had DAPH. Among PACs, 20 (44%) were intestinal and 26 (56%) were pancreatobiliary type. Results: HepPar‐1 immunoreactivity was detected in 18 (39%) of all PACs. The rate of HepPar‐1 expression was significantly higher in intestinal type PAC (75%) than it was in pancreatobiliary type (12%). The sensitivity, specificity, and accuracy of HepPar‐1 immunoexpression for diagnosing intestinal type PAC were 75%, 89%, and 83%, respectively. Similarly, the rates of both CDX2 and MUC2 expressions were significantly higher in intestinal type PAC (80%) than they were in pancreatobiliary type (8%). The sensitivity, specificity, and accuracy of both CDX2 and MUC2 immunoexpressions for intestinal type PAC were 80%, 92%, and 87%, respectively. Conclusion: HepPar‐1 antibody was found to be a highly sensitive and specific marker for distinguishing intestinal type from pancreatobiliary type among PACs. In addition to CDX2 and MUC2 antibodies, HepPar‐1 immunoexpression seems to have a potential role in differential diagnosis of PACs.

Vena cava Stenting and Portorenal Shunt in Budd-Chiari Syndrome: Combination of the ‘Modern’ and the ‘Classical’

We have treated a 33-year-old Budd-Chiari patient (due to antiphospholipid syndrome) with a history of myocardial infarction by placing a vascular stent in the inferior vena cava and performing a portorenal shunt with three objectives: (1) to perform a shunt operation on a Budd-Chiari patient with good hepatic functional reserve, (2) to avoid a thoracotomy and manipulation of the heart in a patient with a cardiac thrombus and a history of myocardial infarction and (3) to avoid a synthetic graft in a patient with antiphospholipid syndrome. Vena cava stenting and portorenal shunt make a useful combination which should be included in the armamentarium of the hepatobiliary surgeon.

The transhepatic route for the placement of a duodenojejunal stent : Application in a postoperative closed loop obstruction of the duodenum

A patient who had undergone gastric resection for carcinoma, had closed loop obstruction of the duodenum due to neoplasia at the duodenojejunal junction. The obstruction was relieved successfully by transhepatic placement of a duodenojejunal stent. We were compelled to use the transhepatic route because a Roux-Y reconstruction had been performed. Transhepatic placement may be the only chance of palliation in a small subset of patients with malignant intestinal obstruction.

Liver transplantation in the management of iatrogenic biliary tract injury.

We read with great interest the article by Thomson et al. on the role of resection and transplantation in the management of iatrogenic biliary tract injury [1]. In the discussion part, the authors stated that ‘‘The English literature reports ten patients requiring hepatic transplantation in the management of biliary injury after cholecystectomy... Of these ten patients, four have died while awaiting a transplant... and the other from Kaposi’s sarcoma posttransplantation.’’ For the sake of completeness and adequate emphasis on this serious health problem, we wish to draw your attention to the other reported 14 patients who were treated by liver transplantation after iatrogenic injury during cholecystectomy (mostly biliary injury, sometimes associated with vascular injury) [2–6]. Although a combined surgical and radiologic approach achieves high success rates in biliary repair, progression to biliary cirrhosis cannot be always prevented [1]. It is likely that liver transplantation will continue to be a life-saving option in a selected group of patients with iatrogenic injury during cholecystectomy. References