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Background: The aim of this study was to evaluate the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) for patients with unresectable pancreatic cancer and to analyze whether POSSUM can predict the long-term outcome in these patients. Such a scoring system could be useful to aid in the decision between surgical and endoscopic palliation. Methods: Between January 1993 and December 2004, 241 patients were found to have unresectable pancreatic cancer during exploratory laparotomy and underwent a double bypass procedure consisting of a gastrojejunostomy and a hepaticojejunostomy. Results: Overall, 64 of 240 patients (27%) had one or more complications after bypass surgery and 4 patients (2%) died. POSSUM predicted morbidity in 114 patients (47%). The observed:predicted (O:P) ratio for morbidity was 0.56 and the model had a significant lack of fit (p < 0.001) using a goodness-of-fit analysis. The overall median survival was 7 months. The POSSUM scoring system was, however, an independent predictor of survival in multivariate analysis. Conclusions: Overall, POSSUM overpredicted morbidity but was an independent predictor of survival. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Aim: To analyze the outcome of partial liver resection (PHx) after bile duct injury (BDI) in patients after multimodality treatment., Methods: Between 1990 and 2012, 800 BDI patients were referred to our tertiary center. Patient characteristics and long-term outcomes were described., Results: PHx was performed in 11 patients (1.4%), mean age 48.3 years (range 29.3-83.5 years), mainly because of complex injury [Amsterdam classification type D (n = 10, 91%), Strasberg type E (n = 7, 64%) and Bismuth type IV (n = 8, 73%)]. In 7 patients (64%), concomitant vasculobiliary injury had occurred in the right hepatic artery (n = 3), proper hepatic artery (n = 1), portal vein (PV; n = 2) and the right hepatic artery and PV simultaneously (n = 1). Early PHx was performed in 2 patients and delayed resection in 9 patients after a median of 57.8 months (range 3.9-183.4 months). The in-hospital mortality was 18% (n = 2) and long-term mortality 9% (n = 1). There were no significant differences in postoperative complications between early and late resection., Conclusions: Indications for PHx after BDI in patients referred to a tertiary center are relatively low (1.4%) and generally apply to vasculobiliary injury. The implications for treatment are important, so it is worthwhile to classify vascular injuries in the management of BDI., (2013 S. Karger AG, Basel.)

Aim: To identify predictors of postoperative ascites after liver resection for patients with or without preoperative portal vein embolization (PVE)., Methods: Patients undergoing PVE prior to hepatectomy (PVE group; n = 37) were compared with patients who underwent liver resection without PVE (n = 503). Ascites was defined as postoperative daily drainage of clear ascitic fluid exceeding 200 ml/day. Pre-, intra-, and postoperative variables were retrospectively analyzed using uni- and multivariate analyses., Results: Postoperative ascites was present in 13.5% (5/37) of patients who underwent PVE before hepatectomy, compared to 5.8% (29/503) in the group undergoing liver resection without PVE (p = 0.061). In all patients, cirrhosis (OR 54.505, p < 0.001), operation time (OR 1.004, p = 0.014), and the use of the Pringle maneuver (OR 2.336, p = 0.041) were independent risk predictors for ascites in multivariate analysis. In PVE patients, cirrhosis (OR 0.156, p < 0.001) was the only independent significant predictor of ascites after resection. In patients undergoing liver resection without PVE, independent risk factors with multivariate analysis were operation time (OR 1.005, = 0.001) and cirrhosis (OR 26.609, p < 0.001)., Conclusion: Operation time and the use of the Pringle maneuver were significant predictors of ascites after hepatectomy. Cirrhosis was a significant risk factor associated with postoperative ascites., (Copyright © 2012 S. Karger AG, Basel.)

Background: The repair of bile duct strictures (BDS) requires identification of healthy bile duct proximal to the stenosis. Identification may be difficult in complex bile duct injuries after cholecystectomy or partial liver resection., Aim: We describe a technique to identify the prestenotic bile duct using the sentinel light of a laser fiber passed through the catheter after percutaneous transhepatic biliary drainage (PTD)., Methods: Seven patients were seen with hepatic duct or segmental BDS after (extended) right hemihepatectomy (4), cholecystectomy (2) or previous hepaticojejunostomy (1). All patients underwent preoperative PTD for imaging of stricture site and drainage. During operation for repair, a laser fiber (0.2-0.6 mm) connected to a (low-power) red light-emitting diode laser was passed through the PTD catheter into the proximal end of the stricture., Results: In 6 patients, the prestenotic bile duct was identified and exposed with the aid of the sentinel light of the laser fiber. Roux-en-Y hepaticojejunostomy was carried out in all patients. Postoperative cholangiographies showed complete restoration of biliary continuity. In one patient, positioning of the laser fiber failed because of angulation of the PTD catheter., Conclusion: Laser-guided identification of prestenotic bile duct facilitates exposure of the stricture site without unnecessary and usually difficult dissection in complex postoperative BDS., ((c) 2009 S. Karger AG, Basel.)

Isolated resection of segment 1 is a parenchyma-sparing technique that can be used for the resection of benign or malignant tumors confined to this segment. The method of resection of segment 1 is described in relation with its complex anatomical features. Special attention is paid to prevention of damage to the hilar bile ducts and major hepatic veins during the procedure., (Copyright (c) 2005 S. Karger AG, Basel.)

Background: Granular cell tumors are rare tumors most often located in the oral cavity, skin or subcutaneous tissue. The occurrence of this tumor in the biliary tree is extremely rare., Methods: Two patients are described presenting with biliary obstruction due to a tumor at the hepatic duct confluence. One patient is a 38-year-old white male with concomitant cutaneous granular cell tumors, and the other a 50-year-old white female., Results: Hilar excision was performed in both patients. Histopathology of the tumors revealed a proliferation of cells with granular cytoplasm, diagnosed as granular cell tumor., Conclusion: At preoperative examination, hilar granular cell tumors are difficult to differentiate from cholangiocarcinoma, sclerosing cholangitis or more common benign biliary tumors. Treatment consists of surgical excision after which prognosis is favorable., (Copyright 2000 S. Karger AG, Basel)

Background: External drainage is the traditional surgical therapy for infected pancreatic pseudocyst, although associated with high morbidity and mortality rates. In this study it was determined whether internal drainage is feasible with acceptable postoperative morbidity and recurrence rates., Methods: A retrospective comparison was made of the outcome of internal versus external drainage of infected pseudocysts in 15 patients. All patients were known to have a (sterile) pseudocyst and presented with symptoms suggestive of infection of the cyst, proven by positive cultures and Gram staining., Results: Internal drainage was performed in 8 and external drainage in 7 patients. Patient characteristics appeared comparable, as was the time of sterile cyst presence before infection occurred (6 and 9 weeks, respectively). No major complications occurred, although hospital stay was prolonged after external drainage due to development of pancreaticocutaneous fistulas along the drain tract in 4 patients. Enteric microorganisms were cultured in 11 patients, of whom 10 had undergone ERCP just prior to infection. During follow-up no pseudocyst recurred., Conclusion: Surgical internal drainage of an infected pseudocyst is safe and effective and, in selected patients, is first-choice treatment. ERCP seems to play an important role in the secondary infection of pseudocysts.

Background: We found a high proportion of patients with implantation metastases during follow-up after resection of a proximal cholangiocarcinoma. A remarkable fact was that all these patients had undergone preoperative endoscopic retrograde cholangiopancreatography (ERCP) with placement of a stent. ERCP is frequently used in the assessment of the proximal extension of Klatskin tumors and is usually followed by stent insertion for biliary drainage. The aim of this study was to analyze the possible risk factors leading to implantation metastases in this series of patients., Methods: Fifty-two patients who had undergone resection of a Klatskin tumor were divided into 2 groups, comparing patients who had had preoperative ERCP and stent placement (n = 41) and patients without preoperative drainage (n = 11)., Results: Eight patients developed implantation metastases within 1 year after resection, all of whom had undergone preoperative stent placement (8/41, 20%). None of the patients without preoperative stenting developed implantation metastases. In 22 patients bile samples were taken during operation. Sixteen (72.7%) patients had malignant cells and 4 (18.2%) patients atypical cells in the bile sample. There was no difference in cytology results between the 2 groups., Conclusion: This study suggests that preoperative ERCP with biliary drainage is associated with a higher frequency of implantation metastases after resection of Klatskin tumors. A properly planned prospective study, however, is needed to determine whether bile duct stenting in patients with resectable bile duct tumors is a true risk factor for the development of implantation metastases.

Background/aims: Bacterial translocation is postulated as a risk factor in the development of a systemic inflammatory response syndrome (SIRS). Research on this topic has focused on the detection of bacteria and endotoxin in blood or mesenteric lymph nodes (MLNs). We investigated whether bacterial translocation occurs beyond the MLNs into the thoracic duct in a setting of ischemia, partial resection and reperfusion of the porcine liver., Methods: A porcine model of severe, extra-intestinal tissue injury, consisting of prolonged hepatic ischemia and reperfusion, in combination with hemihepatectomy, was used (experimental group, n = 5 pigs). To prevent venous congestion of the gut during ischemia, a temporary portal-caval shunt was created. In 5 animals (sham group) a sham portal-caval shunt was constructed while liver ischemia, partial resection and reperfusion were not induced. Thoracic duct lymph, portal blood and systemic blood were collected, and analyzed for the presence of bacteria and endotoxin., Results: In the experimental group, the incidence of bacterial translocation to the thoracic duct was significantly higher during early reperfusion compared to the sham group (5/5 animals versus 1/5 animals, p < 0.05)., Conclusion: This study demonstrates bacterial translocation into the thoracic duct. Translocation at this level leads to direct discharge of bacteria and endotoxin into the systemic circulation and therefore, may potentially enhance the development of SIRS.