Wilson W.C. Ng

Feasibility of liver resection without the use of the routine Pringle manoeuver: an analysis of 248 consecutive cases

BACKGROUND New instruments and techniques for hepatectomy have been shown to reduce blood loss during liver resection. The present study aims to evaluate the feasibility and result of our techniques of liver resection without routine inflow occlusion (the Pringle manoeuver). METHODS The cavitron ultrasonic surgical aspirator (CUSA) and saline-linked radio-frequency dissecting sealer (TissueLink) were used together for open hepatectomy, whereas a bipolar vessel sealing device (Ligasure) and TissueLink were used for laparoscopic hepatectomy. Between June 2003 and May 2007, 248 consecutive cases of liver resection were carried out using the above techniques without the routine Pringle manoeuver. The operative and clinical outcome data were prospectively collected and analysed. RESULTS During the study period, a total of 220 cases of open hepatectomy and 28 cases of laparoscopic hepatectomy were performed. The Pringle manoeuver was eventually applied in six patients (2.4%): two for portal vein tumour thrombus extraction and four as a result of heavy bleeding. Median blood loss was 300 ml (20-2700 ml) and the blood transfusion rate was 7.7%. In most of the cases, the liver function tests showed improvement on post-operative day 1 or 2, and the median post-operative hospital stay was 7 days. There were two post-operative deaths (0.8%). Complications occurred in 63 patients (25.4%) and most complications were minor. CONCLUSIONS Refined techniques and instruments for liver resection allow hepatectomy to be done safely without using the routine Pringle manoeuver. Most patients had a quick recovery of liver function and were discharged early.

Outcome of surgical treatment for recurrent pyogenic cholangitis: a single-centre study

BACKGROUND Recurrent pyogenic cholangitis (RPC) is still a common disease in East Asia. The present study reviews the operative results for this disease in a single centre. METHODS The records of 85 patients who underwent surgical treatment for RPC from August 1995 to March 2008 were retrospectively reviewed. RESULTS Patients included 35 men and 50 women with a median age of 61 years. Types of surgery included: hepatectomy (65.9%); hepatectomy plus drainage (9.4%); drainage alone (14.1%), and percutaneous choledochoscopy (10.6%). There was no operative mortality. Complications occurred in 40% of patients and half the complications involved wound infections. The overall incidences of residual stone, stone recurrence and biliary sepsis recurrence were 21.2%, 16.5% and 21.2%, respectively, over a median follow-up of 45.4 months. The drainage-alone group and percutaneous choledochoscopy group had higher incidences of residual stone, stone recurrence and biliary sepsis recurrence. In hepatectomy patients, regardless of whether or not a drainage procedure had been performed, rates of residual stone, stone recurrence and biliary sepsis recurrence were 15.6%, 7.8% and 9.4%, respectively, over a median follow-up of 42.7 months. CONCLUSIONS Hepatectomy is safe and yields the best treatment outcome for RPC. It should be considered as the treatment of choice for suitable patients with RPC.

Safe Modification of the Liver-Hanging Maneuver by Endoscopic-Assisted Dissection of the Retrohepatic Tunnel

As a safer approach to right hepatectomy, Belghiti et al. (J Am Coll Surg 193:109–11, 2001) described a liver-hanging maneuver. However, this procedure is performed blind, with the risks of damaging the small retrohepatic veins and consequential bleeding. To overcome this problem, we modified the procedure so that, instead of performing blind dissection using a long vascular clamp, we use a flexible choledochoscope to dissect the retrohepatic space filled by loose alveolar tissue anterior to the inferior vena cava (IVC). The avascular path is identified by a combination of saline irrigation and gentle movement of the tip of the choledochoscope. Cotton tape can then be passed around the liver parenchyma to elevate the liver away from the anterior surface of the IVC. This modification of Belghitis liver-hanging maneuver allows direct vision along the plane anterior to the IVC, thus avoiding injury to the retrohepatic veins.

A Preliminary Analysis of Combined Liver Resection With New Chemotherapy for Synchronous and Metachronous Colorectal Liver Metastasis

OBJECTIVE To compare the survival between patients with synchronous and metachronous colorectal liver metastases after hepatectomy with new generation of peri-operative chemotherapy. METHODS From October 2002 to January 2008, patients receiving hepatectomy for synchronous or metachronous colorectal liver metastasis were studied retrospectively. RESULTS Fifty-five patients (synchronous group=35, metachronous group=20) underwent hepatectomy for colorectal liver metastases. Besides younger age with male predominance, patients in the synchronous group had more tumour multinodularity and bilobe liver involvement. They had received less hepatic curative hepatectomy (81.1% vs. 100%) with a higher rate of peri-operative chemotherapy (91.4% vs. 50%) and postoperative morbidity (25.7% vs. 0%). However both groups had no statistical significant difference in median overall survival (OS) and disease free survival (DFS). Inferior OS and DFS were observed in the synchronous group for patients who had no peri-operative chemotherapy or those showing poor response to chemotherapy. The most favourable OS is observed in both groups after performing globally curative hepatectomy. CONCLUSION Synchronous colorectal liver metastasis is not a poor prognostic factor for survival when compared with the metachronous metastasis. Globally curative hepatectomy in combination of new generation of chemotherapy is recommended for the management of resectable colorectal liver metastasis.

Ruptured gastroduodenal artery pseudoaneurysm as the initial presentation of chronic pancreatitis

Gastroduodenal artery pseudoaneurysm is a rare but life threatening complication of pancreatitis. Diagnosis and management of it remain challenging. Surgical treatment was associated with a high mortality. Percutaneous transarterial embolization of bleeding artery has recently been advocated as a definitive therapy and can be attempted as the initial measure to control bleeding. We herein report a case of chronic pancreatitis presented with ruptured pseudoaneurysm of gastroduodenal artery which was successfully controlled with transarterial embolisation.

Intrahepatic cholangiocarcinoma: A diagnostic and therapeutic challenge

Objectives:  Intrahepatic cholangiocarcinoma (ICC) is a rare tumor of the liver. The diagnosis and treatment of it are difficult. The present study reviewed the diagnostic pathways and operative results for ICC.

Xanthogranulomatous cholecystitis: A rare condition with variable presentations

Aim:  Patients suffering from xanthogranulomatous cholecystitis have variable clinical presentations. The present study aims to evaluate the clinical presentations of the disease and the various surgical treatment strategies in the management of patients suffering from xanthogranulomatous cholecystitis.

Pseudocystectomy: An unusual operation for an atypical pancreatic pseudocyst

Pancreatic pseudocyst is an amylase‐rich peri‐pancreatic fluid collection devoid of epithelial lining. Occasionally, it cannot be differentiated from cystic neoplasm of pancreas and resections are required. We report a case of pancreatic pseudocyst masquerading cystic neoplasm treated with distal pancreatectomy. The investigation strategy and management of cystic lesions of the pancreas are also discussed.

Confluent hepatic fibrosis mimicking malignant hepatic neoplasm on ultrasonography

Confluent hepatic fibrosis is a special entity of liver cirrhosis that can result in gross distortion of the normal liver anatomy. Rarely, its distorted appearance can mimic malignant liver neoplasm on screening ultrasonography that might introduce diagnostic confusion. Computed tomography scanning with three‐dimensional reconstruction is crucial in making accurate diagnostic differentiation. Here, we report an unusual case of confluent hepatic fibrosis that presented as a suspicious liver mass on ultrasonography.