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Background: In the course of oncological surgery, resection of the inferior vena cava (IVC) may be required to obtain an adequate resection margin and to offer the best opportunity of cure. The remaining defect in the IVC may be managed by: (i) primary repair which may lead to subsequent narrowing of the lumen, possibly leading to turbulent flow and thrombus formation; (ii) patch grafting of the defect, which may prevent narrowing. Several synthetic and biosynthetic materials are available as patch grafts and autologous pericardium has also been used., Methods: The harvesting and use of the autogenous peritoneo-fascial (APF) graft as an alternative caval patch graft material in the management of defects in the caval wall is proposed. Autogenous peritoneo-fascial caval patch graft repair in six patients was undertaken., Results: One patient with leiomyosarcoma secondaries in the liver eventually succumbed to the disease. The other five patients are clinically well with no evidence of IVC obstruction or venous aneurysms., Conclusion: Preliminary results show that this new technique of utilizing an APF patch graft for caval repair is clinically a suitable alternative to current biosynthetic and synthetic materials and may in fact be superior in many aspects.

Background: Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses., Methods: Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality., Results: Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%., Conclusion: Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.

Background: The aim of the present paper is to present the utility of endoluminal repair in the management of complex false aneurysms at various sites throughout the body., Methods: Between May 1992 and May 1997 the endoluminal method was used to repair 183 aneurysms at various sites throughout the body. In six patients the pathology was that of false aneurysm and these are the basis of the present report. In two of the patients the false aneurysm was situated between the renal arteries and the proximal end of a previous aortic graft. The other false aneurysms were situated in the right subclavian, the popliteal and internal carotid arteries, in addition to one situated at the junction of two longstanding bypass grafts in the groin. The technique involved delivery of an endograft into the artery from which the false aneurysm had arisen via a sheath inserted through an artery of access which was superficial and remote from the site of the aneurysm. A laparotomy was avoided in the first two cases and thoracotomy avoided in the third case. Opening of the popliteal fossa, which had been the site of a recent knee replacement in the fourth patient, was also avoided., Results: Post-procedure angiography confirmed exclusion of the false aneurysm from the general circulation in all six patients. There were no deaths and the mean length of hospital stay was 6 days., Conclusions: Endoluminal repair of false aneurysms is feasible and avoids the difficulty and morbidity associated with laparotomy, thoracotomy and operations at sites with scarring from previous interventions.

The first description of recurrent pyogenic cholangitis occurring in four occidentals is presented. While recurrent pyogenic cholangitis is a common syndrome of uncertain aetiology among orientals (also known as oriental cholangiohepatitis), it has not previously been described in occidentals. Four such patients are described. They presented with recurrent attacks of ascending cholangitis and associated hepatolithiasis, biliary stricturing and dilation. Focal hepatic involvement was treated by segmental liver resection and recurrent disease by interventional endoscopy or radiology.

During the first 3 years of the Australian National Liver Transplantation Programme, 51 liver grafts were performed in 46 patients. There were 11 major vascular complications encountered following 10 liver transplants in eight (17%) patients. They caused death in three patients and the need for retransplantation in two others. Hepatic artery thrombosis (HAT) occurred five (10%) times, producing a spectrum of clinical illness ranging from death to an asymptomatic event. Other vascular complications included hepatic artery stenosis not complicated by thrombosis (two), primary (one) and secondary (one) haemorrhage, thrombosis of a mesoportal venous graft (one) and inferior vena caval stenosis (one). Vascular complications are a significant cause of morbidity and mortality following liver transplantation. Predisposing and precipitating factors should be recognized and minimized.

Three cases of leiomyosarcoma of the duodenum are reported in this paper. The first patient demonstrated the development of a leiomyosarcoma from a leiomyoma, and also posed diagnostic problems as a Pólya gastrectomy had previously been performed. The second patient presented with acute pancreatitis--a hitherto unreported complication of this condition. The third patient showed that even though the primary tumour was unresectable, the patient remained well for more than a year after diagnosis.

Temporary control of the aorta at the level of the diaphragm above the origins of the major visceral arteries is of proven value in the management of complex aortic disease including ruptured aneurysm, 're-do' aortic surgery and for aortic trauma. The value of the technique in elective non-aortic surgery is less well known. Two patients, one with a massive leiomyosarcoma of the stomach and the other with blood loss complicating a distal splenorenal shunt, are described in which proximal aortic control was of use.

Some surgeons have advocated using polytetrafluoroethylene (PTFE) as the graft material of choice for femoropopliteal arterial bypass so that the saphenous vein could be preserved for future cardiovascular surgery. We have examined our results to see if this approach could be justified in our patient population. PTFE was used for 101 femoropopliteal reconstructions in 96 patients (56 male and 40 female). Thirty-eight (40%) complained of debilitating claudication and 58 (60%) had limb-threatening ischaemia. There were 83 primary PTFE femoropopliteal reconstructions and 18 repetitive procedures after failure of an earlier ipsilateral bypass. Twenty-nine of the 101 PTFE grafts were anastomosed distally to the popliteal artery above knee and the remaining 72 below knee. At 5 years, the cumulative patency for all grafts was only 11%. The 4 year cumulative patency was better for claudicants (40%) than for those with threatened limb loss (11%) but two of the 38 claudicants required amputation when their grafts failed. Patency rates were not significantly affected by the site of the distal anastomosis or by a previous failed ipsilateral femoropopliteal bypass. Worthwhile limb salvage was achieved only by frequent re-operation. Our results with PTFE are not good enough to use it in preference to an adequate saphenous vein for femoropopliteal bypass.