Orhan Arıoğul

Endoscopic sphincterotomy in the treatment of postoperative biliary fistulas of hepatic hydatid disease

AbstractBackground: Ten patients with postoperative external biliary fistula treated by endoscopic sphincterotomy are reported. Methods: Nine of these patients were operated for hepatic hydatid disease and one for a liver abscess. Mean daily output of bile through the fistulae which were present for 5–39 days was approximately 500 cc. Results: Treatment was successful in nine patients with closure of the fistulae in 2–15 days (mean, 7 days). No response was obtained in one patient who was reoperated, and an intrahepatic biliary duct was found to be completely eroded by the cyst wall. Conclusions: Endoscopic sphincterotomy should be the first-line treatment for postoperative external biliary fistulae related to hepatic hydatid disease.

Mesoatrial shunt in Budd-Chiari syndrome

BACKGROUND The operations with proven effects on survival in Budd-Chiari syndrome are shunt operations and liver transplantation. PATIENTS AND METHODS Between 1993 and 1999 (June), 13 cases of Budd-Chiari syndrome have been treated surgically. Four cases had concomitant thrombosis of the inferior vena cava; the others had marked narrowing of the lumen due to the enlarged caudate lobe. Mesoatrial (n = 12) or mesosuperior vena caval (n = 1) shunts were constructed with ringed polytetrafluoroethylene grafts. RESULTS The median portal pressure fell from 45 (range 32 to 55) to 20 (range 11 to 27) cm H(2)O (P <0.001). Two patients died in the early postoperative period. One patient who did not comply with anticoagulant treatment had a shunt thrombosis in the second postoperative year. The other 10 patients are alive without problems during a median 42 (range 1 to 76) months of follow-up. CONCLUSION Mesoatrial shunt with a ringed polytetrafluoroethylene graft is effective in Budd-Chiari syndrome cases with thrombosis or significant stenosis in the inferior vena cava.

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.

Hydatid cysts of liver and portal hypertension.

Two cases of portal hypertension due to hydatid cysts of the liver are reported. In one of the patients, symptoms were secondary to obstruction of inferior vena cava and hepatic outflow tract. The other patient was operated on with a diagnosis of extrahepatic presinusoidal portal hypertension caused by extrinsic compression of the liver by an hydatid cyst. Although hydatidosis is a benign disease, it can produce serious complications as in these reported cases. Therefore hydatidosis should be remembered amongst the causes of portal hypertension in countries where the disease is endemic.

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

The role of total pericystectomy in hepatic hydatidosis

Between 1977 and 1995, 495 patients were operated on for hepatic hydatidosis. Total pericystectomy was performed in 26 patients (closed technique in 21 and open technique in 5). Twenty-one patients had single cysts and 5 had two cysts. The median cyst diameter was 8cm (range; 3–20cm). The requirements for total pericystectomy were: (1) the cyst(s) should be located away from the hepatic veins, large bile ducts, or major branches of the portal vein and hepatic artery and (2) the patient should be fit to undergo a major operation. There was no procedure-related morbidity. One patient developed a biliary fistula that closed after endoscopic sphincterotomy. The median hospital stay was 7 days (range; 3–22 days). The median follow up was 24 months (range; 9–114 months). There was disease recurrence in a non-adjacent segment in 1 patient at 4 years. Pericystectomy is a potentially dangerous operation, but it avoids problems with cavity management and has low rates of biliary fistula, spillage, and recurrence. Its success stems primarily from careful patient selection.

Hepatic atrophy-hypertrophy complex due to echinococcus granulosus

Obstruction of a major hepatic vein, or major portal vein, or biliary tree branch causes atrophy of the related hepatic region, and frequently, hypertrophy in the remaining liver—the atrophy-hypertrophy complex (AHC). Whether hydatid cysts can causeAHCis controversial. The records of 370 patients who underwent surgery for hepatic hydatid disease between August 1993 and July 2002 were evaluated retrospectively. Excluding six patients with previous interventions on the liver, AHC had been recorded in the operative notes of 16 patients (4.4%); for all patients, a cyst located in the right hemiliver had caused atrophy of the right hemiliver and compensatory hypertrophy of the left hemiliver. The computed tomography images of seven patients were suitable for volumetric analysis. The median (range) right and left hemiliver volumes were 334 (0-686) ml and 1084 (663-1339) ml, respectively. The median (range) cyst volume was 392 (70–1363) ml. AHC due to Echinococcus granulosus was confirmed by objective volumetric analysis. The presence of AHC should alert the surgeon to two implications. First, pericystectomy may be hazardous due to association with major vascular and biliary structures. Second, in patients with AHC, the hepatoduodenal ligament rotates around its axis; this should be considered to avoid vascular injury if a common bile duct exploration is to be performed.

Liver hamartoma in an adult: Report of a rare case

Liver hamartoma is a rare type of benign tumor which usually occurs in the first few years of life. Although it is the second most common benign tumor in childhood, only about 100 cases have been reported in the English literature. Thus, it is extremely rare to encounter liver hamartoma in adults. This report details the clinical presentation and surgical management of a 24-year-old woman with a rapidly growing liver hamartoma. A right hepatic lobectomy was successfully performed and the patient was discharged in good health on the 10th postoperative day.

Papillary Adenocarcinoma of the Common Bile Duct

Five patients with papillary adenocarcinoma of the common bile duct (CBD) are described. These are rare tumors and make up 5% of all malignant tumors of the biliary tract. The symptoms and signs at the time of initial diagnosis resemble benign obstructive lesions of the bile ducts. The tumor is soft, less invasive to adjacent tissues and tends to grow into the lumen. The early onset of the symptoms results in early intervention, with a better prognosis. Two of our patients are doing well after two and four years, where as three others were readmitted with recurrent disease.

Solid and cystic tumors of the pancreas: A report of two cases

Two patients operated on for solid and cystic tumors of the pancreas are presented. One of them had a history of a benign cerebral tumor (astrocytoma) for which a ventriculo-peritoneal shunt had been done 3 years previously. The operations performed were a type-I regional pancreatectomy in one patient and a Whipples procedure in the other. The patients were discharged well without complications and no recurrence has been detected 1 year after the operation