Simon W. Banting

Phaeochromocytoma in pregnancy

Hypertension during pregnancy is a common problem, causing significant maternal and fetal morbidity and mortality. Pre‐eclampsia is by far the most common cause, affecting 5–10% of primigravid women. Phaeochromocytoma is a rare endocrine tumour causing hypersecretion of noradrenaline, adrenaline and/or dopamine. It is extremely rare during pregnancy and may be misdiagnosed with potentially catastrophic consequences. Delayed diagnosis remains a significant source of maternal and fetal morbidity and mortality. Recognition is critical, as the majority of maternal deaths have occurred when the diagnosis has been overlooked. Diagnosis of phaeochromocytoma is achieved by detecting increased catecholamines and metabolites (metanephrine and normetanephrine) on 24‐h urine collection, as these levels are unaffected by pregnancy or pre‐eclampsia. Definitive treatment of phaeochromocytoma is surgical and the laparoscopic approach has been shown to be safe and is preferred for most phaeochromocytomas. Medical preparation and treatment of hypertension is essential for safe surgery. Timing of adrenalectomy is either during the second trimester or as a staged procedure after Caesarean section delivery.

Percutaneous cholecystostomy in the management of acute cholecystitis.

Background:  Percutaneous cholecystostomy (PC) has been used in managing acute cholecystitis in the setting of a patient with severe comorbidities where emergency cholecystectomy would carry significant mortality. The present study aims to assess the role, efficacy and complications of PC in acute cholecystitis.

Diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration.

Background:  Endoscopic ultrasound (EUS) with fine‐needle aspiration (FNA) is increasingly being used in the staging algorithm for pancreatic carcinoma. This allows for a tissue diagnosis, which was previously difficult to obtain. The aim of this study is to assess the utility of EUS–FNA in establishing the diagnosis of solid pancreatic mass lesions in an Australian population.

The developing clinical problem of chemotherapy‐induced hepatic injury

Chemotherapy is being administered to an increasing number of patients with colorectal liver metastases (CRLM), whether they have resectable disease or not. Although this may be appropriate to downstage patients with unresectable disease, and offers theoretical advantages to those who have resectable disease, there is a price to be paid in the development of chemotherapy‐induced hepatic injuries (CIHI). These include chemotherapy‐associated fatty liver diseases and sinusoidal injuries. The main chemotherapeutic agents currently used in the adjuvant setting for colorectal carcinoma, and the neoadjuvant treatment of CRLM include 5‐flurouracil, oxaliplatin and irinotecan, and while there are non‐specific and overlapping injury profiles, oxaliplatin does appear to be primarily associated with sinusoidal injury and irinotecan with steatohepatitis. In this review, the rationale for administering chemotherapy to patients with CRLM is presented, and the problems this brings are outlined. The specific injury patterns will be detailed, as well as the data correlating specific chemotherapy regimens to these injury patterns. Finally, the clinical outcomes of patients with CRLM who undergo neoadjuvant chemotherapy followed by hepatic resection will be considered. The need for methods to identify patients at risk of CIHI and to recognize established CIHI prior to surgery will be emphasized.

Laparoscopic adrenalectomy for phaeochromocytoma: with caution.

Introduction:  Laparoscopic adrenalectomy is well described and many series include patients with phaeochromocytoma. Our aim was to establish whether laparoscopic adrenalectomy for phaeochromocytoma was a safe and feasible technique at our institution.

COMPONENT SEPARATION IN THE REPAIR OF A GIANT INGUINOSCROTAL HERNIA

Uncommon in the developed countries today, giant inguinoscrotal hernias typically present after years, even decades of neglect, often following the development of complications or significant impairment of the patient’s quality of life. A number of techniques for the repair of giant inguinoscrotal hernias have been reported.1–10 Although the use of scrotal skin flaps has been described for repair of these hernias, the case under review illustrates a new technique involving component separation of the hernial sac.1 In this case, a peritoneal flap was raised from the sac and reinforced using a polypropylene (Marlex) mesh, with redundant scrotal skin fashioned as a myocutaneous flap to provide skin coverage.

Recognition and management of biliary complications after laparoscopic cholecystectomy.

Introduction:  Injuries to the extrahepatic biliary tree at laparoscopic cholecystectomy cause major morbidity and are a major source of litigation. Injuries are often diagnosed late, leading to further complications and decreasing the chance of a successful repair.

mRNA gene expression correlates with histologically diagnosed chemotherapy-induced hepatic injury

INTRODUCTION Chemotherapy-induced hepatic injuries (CIHI) are an increasing problem facing hepatic surgeons. It may be possible to predict the risk of developing CIHI by analysis of genes involved in the metabolism of chemotherapeutics, previously established as associated with other forms of toxicity. METHODS Quantitative reverse transcriptase-polymerase chain reaction methodology (q-RT-PCR) was employed to quantify mRNA expression of nucleotide excision repair genes ERCC1 and ERCC2, relevant in the neutralization of damage induced by oxaliplatin, and genes encoding enzymes relevant to 5-flurouracil metabolism, [thymidylate synthase (TS), thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD)] in 233 hepatic resection samples. mRNA expression was correlated with a histopathological injury scored via previously validated methods in relation to steatosis, steatohepatitis and sinusoidal obstruction syndrome. RESULTS Low-level DPD mRNA expression was associated with steatosis [odds ratio (OR) = 3.95, 95% confidence interval (CI) = 1.53-10.19, P < 0.003], especially when stratified by just those patients exposed to chemotherapy (OR = 4.48, 95% CI = 1.31-15.30 P < 0.02). Low expression of ERCC2 was associated with sinusoidal injury (P < 0.001). There were no further associations between injury patterns and target genes investigated. CONCLUSIONS Predisposition to the development of CIHI may be predictable based upon individual patient expression of genes encoding enzymes related to the metabolism of chemotherapeutics.

Endoscopic management of post-cholecystectomy biliary fistula.

OBJECTIVE Bile duct injury is an uncommon but potentially serious complication in cholecystectomy. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion. The aim of this study was to assess the effectiveness of ERCP in the management of minor biliary injuries. METHODS A retrospective review of medical records at a tertiary referral centre identified 36 patients treated for postoperative minor biliary injuries between 2006 and 2010. Management involved establishing a controlled biliary fistula followed by ERCP to confirm the nature of the injury and decompress the bile duct with stent insertion. RESULTS Controlled biliary fistulae were established in all 36 patients. Resolution of the bile leak was achieved prior to ERCP in seven patients, and ERCP with stent insertion was successful in 27 of the remaining 29 patients. Resolution of the bile leak was achieved in all patients without further intervention. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. No other complications were seen. CONCLUSIONS This review confirms that postoperative minor biliary injuries can be managed by sepsis control and semi-urgent endoscopic biliary decompression.

GUIDELINES FOR THE MANAGEMENT OF BILE DUCT STONES

There are various ways of managing bile duct stones with the two main variables that determine management being the mode of presentation and local expertise/preference. Therefore although it is difficult to be prescriptive about the management of duct stones, there are guiding principles. If there is a suspicion that the patient may have a stone in the bile duct a decision needs to be made as to whether the stone should be removed preoperatively or intraoperatively (not postoperatively). If the decision is to remove the stone preoperatively by endoscopic retrograde cholangiopancreatography (ERCP) in some patients it is advisable to confirm the presence of the stone by magnetic resonance cholangiopancreatography (MRCP). This applies particularly if the evidence for a bile duct stone is equivocal. Patients with malignant obstruction of the bile duct frequently have coexistent gallstones. Therefore patients presenting with jaundice should have the cause of the jaundice established before surgery. Where a diagnosis of bile duct stones is made preoperatively and the decision is to remove them intraoperatively, facilities and expertise to perform that laparoscopically should ideally be available. Without entering the debate relating to routine operative cholangiography versus selective cholangiography, operative cholangiogram facilities should always be available at cholecystectomy. If the surgeon does not carry out routine operative cholangiograms, then at least his indication for carrying out an operative cholangiogram should be liberal, for example, slightly abnormal liver function tests (LFTs), mildly dilated duct on ultrasound, history of acute pancreatitis. If an unsuspected stone is diagnosed at operation removal of the stone by either laparoscopic or open exploration or postoperatively at ERCP are acceptable alternatives. This can be summarized as follows: (1) Common bile duct stones diagnosed preoperatively should be dealt with either preoperatively or intraoperatively. A decision to leave the stones for postoperative ERCP extraction is unacceptable. (2) Jaundiced patients should not be operated on without a firm diagnosis being established beforehand. (3) MRCP is a very useful and safe method of imaging the biliary tree. Where MRCP is unavailable, CT cholangiography is an alternative. (4) If operative cholangiography is carried out selectively rather than routinely the indications for it should be liberal. (5) Unsuspected bile duct stones diagnosed intraoperatively may either be dealt with at surgery or by ERCP postoperatively. ERCP is facilitated by the insertion of a transcystic biliary stent at operation. Of course, ERCP may not be possible in patients who have had previous gastric surgery.