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Assesses a series of patients with pyloric channel ulcers (PCU) to determine their clinical characteristics and outcome of management. Mean duration of symptoms; Bleeding as the main presenting symptom; Endoscopic findings; Surgical therapy received; High incidence of ulcers among males; Results of the surgical treatment of PCUs.

This case report details the use of a pulsed tunable-dye laser lithotripter in the endoscopic management of recurrent intrahepatic stones in a patient with Oriental cholangitis. A 42-year-old Chinese man had a cholecystectomy and choledochoduodenostomy in 1980. Subsequently he had three episodes of recurrent cholangitis which responded to medical treatment. The patient presented in April 1989 with a fourth attack of cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) and ultrasound demonstrated a large mass of stones in the right intrahepatic ductal system. A flexible upper gastrointestinal endoscope was passed into the right hepatic duct via the choledochoduodenostomy. The stones were fragmented with a tunable-dye laser and the residual fragments were removed endoscopically. [ABSTRACT FROM AUTHOR]

Background: Sump syndrome is one of the rare long-term complications of side-to-side choledochoduodenostomy (CD) leading to attacks of cholangitis due to accumulation of food and debris in the common bile duct distal to the anastomosis is one of the rare long-term complications after CD. Methods: Fifteen patients treated with the Sump syndrome in our institution between 1996 and 2023 were retrospectively evaluated for long-term outcome. Results: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and bile duct clearance was done in 11 patients, while four were subjected to revisional surgery in the form of a Roux-en-Y hepaticojejunostomy. No complications were recorded. There were 5 (38%) recurrences in a median follow-up period of 8 years (10 months-23 years). Of those, 3 patients were treated surgically and two with repeat ERCP. None of the patients developed any cholangiocarcinoma during follow-up. Conclusion: We conclude that although a high recurrence rate was observed, endoscopic treatment may be a valid approach in the treatment of Sump syndrome, with revisional surgery in the form of a Roux-en-Y hepaticojejunostomy as salvage therapy in recurrences.

Background: A single-institution retrospective analysis was undertaken to assess long-term results of definitive surgical reconstruction for major bile duct injuries and risk factors for restenosis., Methods: Patients treated between January 1995 and October 2020 were reviewed retrospectively. The primary outcome measure was patency., Results: Of 417 patients referred to a tertiary center, 290 (69.5%) underwent surgical reconstruction; mostly in the form of a hepaticojejunostomy (n = 281, 96.8%). Major liver resection was undertaken in 18 patients (6.2%). There were 7 postoperative deaths (2.4%). Patency was achieved in 97.4% of primary repairs and 88.8% of re-repairs. Primary patency at three months (including postoperative deaths and stents removed afterwards) in primary repairs was significantly higher than secondary patency attained during the same period in re-repairs (89.3% vs 76.5%, p < 0.01). The actuarial primary patency was also significantly higher compared to the actuarial secondary patency 10 years after reconstruction (86.7% vs 70.4%, p = 0.001). Vascular disruption was the only independent predictor of loss of patency after reconstruction (OR 7.09, 95% CI 3.45-14.49, p < 0.001), showing interaction with injuries at or above the biliary bifurcation (OR 9.52, 95% CI 2.56-33.33, p < 0.001)., Conclusions: Long-term outcome of surgical reconstruction for major bile duct injuries was superior in primary repairs compared to re-repairs. Concomitant vascular injury was independently associated with loss of patency requiring revision., Competing Interests: Declaration of competing interest None declared., (Copyright © 2022 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background and Aim: To derive lessons from the data of patients who were followed for various periods with the misdiagnosis of liver hemangioma and eventually found to have a malignancy. Material and Methods: The records of 23 patients treated between 2003 and 2018 were analyzed retrospectively. Results: Twelve patients were men and 11 were women; median (range) age was 55 (35-80). The principal diagnostic modality for the initial diagnosis was ultrasonography ( n :8), magnetic resonance imaging (MRI) ( n :13), and computed tomography (CT) ( n :2). At our institution, MRI was performed in 16 patients; the diagnosis was made with the available MRI and CT studies in five and two patients, respectively. In other words, the ultrasonography interpretations were not confirmed on MRI; in others, the MRI or CT examinations were of low quality or they had not been interpreted properly. Fifteen patients underwent surgery; the other patients received chemotherapy ( n :6) or chemoembolization ( n :2). The misdiagnosis caused a median (range) 10 (0-96) months delay in treatment. The final diagnoses were hepatocellular carcinoma in 12 patients, cholangiocarcinoma in four patients, metastatic mesenchymal tumor, metastasis of colon cancer, metastatic neuroendocrine carcinoma, sarcomatoid hepatocellular carcinoma, angiosarcoma, thoracic wall tumor, and metastatic tumor of unknown primary in one patient each. Conclusions: High-quality MRI with proper interpretation and judicious follow up are vital for the accurate differential diagnosis of liver lesions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Yıldırım, Şahiner, Poyanlı, Acunaş, Güllüoǧlu, İbiş, Tekant and Özden.)

Background: Choledochal cysts are congenital anomalies that can occur at any level of the biliary tree. They carry long-term risk of biliary complications and cancer development. Complete excision of all involved bile ducts is recommended., Methods: Patients treated between 1995 and 2019 were reviewed retrospectively., Results: Sixty patients; 46 female and 14 male with a median age of 41 years (range 13-83) were included in the study. Mild abdominal pain was the most common presenting symptom (60%). Majority of the patients had Todani type I cysts (67%). Concomitant biliary malignancy was diagnosed in five patients (9%). Eight patients were followed-up conservatively (13%). Twenty-five patients were treated by excision of the extrahepatic bile ducts and Roux-en-Y hepaticojejunostomy, liver resection was added in seven, pancreatoduodenectomy was done in three and liver transplantation in one. There was no perioperative mortality. Postoperative complications developed in 17 patients (34%), two requiring surgical treatment. Four of the five patients with malignancies died at a median 42 months (range 6-95) following surgery. Median 62 months (range 8-280) follow-up was available in 45 surgically treated patients, 19 followed-up for more than 10 years. None of the patients developed malignancy during follow-up. Four patients (17%) were readmitted for anastomotic strictures requiring treatment., Conclusion: The majority of choledochal cysts are Todani type-I and early cyst excision is the mainstay of management, which may decrease the risk of malignant transformation., (Copyright © 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background: Iatrogenic factors persist as leading mechanisms of cholangitis at a referral center., Methods: The records of 51 patients treated for cholangitis due to incomplete or inappropriate nonoperative biliary interventions between 2005-2016 were evaluated retrospectively., Results: Twenty-nine patients were men; median (range) age was 60 (30-90). An incomplete or inappropriate ERCP and percutaneous transhepatic biliary drainage (PTBD) had been performed in 45 and 6 patients respectively. Inappropriate endoscopic stenting for hilar obstruction (perihilar cholangiocarcinoma: 22 and gallbladder carcinoma:3) was the most common scenario (n: 25, 49%). Twenty other patients had undergone an ERCP with incomplete (n: 12) or no (n:8) drainage. The errors in the PTBD group were passage of the catheter to the duodenum in patients with hilar obstruction (n: 4) and incomplete drainage in patients with perihilar cholangiocarcinoma (n: 2). Two patients (4%) died of infection. The surgery of 6 operable tumor patients was delayed for median (range) 5 (1-7) months., Conclusions: Incomplete or inappropriate nonoperative biliary interventions put patients' lives at risk and delay radical treatments.

Purpose: To investigate the long-term results of shunt surgery in the treatment of Budd-Chiari Syndrome., Methods: Medical records of patients treated with Budd-Chiari Syndrome between 1993 and 2006 were reviewed., Results: Thirty-seven patients (26 female, 11 male) were identified, with a median age of 30 years (range 14-51). Median duration of symptoms was 3 months (range 1 month to 10 years). Twenty-five patients, all in acute or subacute stages of disease, were treated surgically. Constructed shunts were mesoatrial in 17, portocaval in five (one was converted from a failed portorenal shunt) and mesocaval in three. Median portal pressure decreased from 44 cm H 2 O (range 31-55) to 20 cm H 2 O (range 5-27). Seven patients (28%) died in the perioperative period. Eighteen patients (72%) were followed up for a median of 186 months (24-241 months). Seven patients died during follow-up, five due to reasons related to the underlying cause and treatment. Remaining 11 patients (61%) were alive at a median of 18 years (13-25 years) with patent shunts. One-, 5-, and 10-year survival rates in patients undergoing shunt surgery were 78%, 72%, and 66%, respectively., Conclusion: Portosystemic shunts may still be considered when expertise for transjugular intrahepatic portosystemic shunt or liver transplantation is not available.

Objective: To highlight the role of albendazole hepatotoxicity in the choice between drainage versus a resection procedure in hepatic hydatidosis. Methods: The charts of four patients were reviewed retrospectively. In three patients, albendazole caused more than 10-fold increases in transaminase levels and was stopped. One patient had concomitant autoimmune hepatitis. Results: In the first case, two large hydatid cysts involving the right and the left hepatic veins were detected. First, left lateral sectionectomy and ligation of the right posterior portal vein branches were performed. Hypertrophy of the remnant liver allowed a safe right posterior sectionectomy two months later. In the second patient, a 9-cm cyst in segments 6 and 7 was treated with pericystectomy. The third patient had a 6-cm centrally located cyst. Pericystectomy, removal of small vesicles from the anterior section bile duct, common bile duct exploration with a T-tube placement were performed. In the patient with auto-immune hepatitis, pericystectomy was chosen for two objectives: 1) to eliminate a cavity prone to recurrence in an immunosuppressed patient 2) to avoid albendazole that may complicate the interpretation of liver function tests. The postoperative period and early follow up of all patients was uneventful. The second and the fourth patients have been followed for 56 and 17 months respectively and no recurrence has been detected. Conclusions: A resection procedure eliminates the cavity and the need for adjuvant albendazole treatment. This is a vital advantage for the small subset of patients with severe albendazole hepatotoxicity., (Celsius.)

Background/aims: To investigate the safety and long-term results of endoscopic retrograde cholangiopancreatography (ERCP) in children with a literature review., Materials and Methods: All patients within the age range of 6-17 years who underwent ERCP between 1994 and 2014 at our institution were retrospectively evaluated., Result: Twenty-four patients with a median age of 15 years underwent ERCP. Cannulation of the papilla was achieved in all patients (100%) without the use of needle-knife papillotomy. Before 1999, ERCP was used as a diagnostic method only in 7 patients (29%). In 17 (71%) patients, the procedure was used for therapeutic purposes. The indications were choledocholithiasis (10 cases, 42%), postoperative complications (5 patients, 21%), and recurrent pancreatitis (2 cases, 8%). In 2 patients (8%), the therapeutic effect was not achieved, thus requiring subsequent operations. There were no major complications. Mild pancreatitis occurred in only 1 patient (4%). Long-term follow-up information was obtained in 16 (67%) patients (median, 18 years; range, 3.5-22.5 years), and no long-term complications were detected., Conclusion: Endoscopic retrograde cholangiopancreatography is a valuable tool in the diagnosis and treatment of pancreatobiliary disorders in the pediatric population. Large-scale studies are required to create evidence-based guidelines specific to children.

Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

Obstructive jaundice is a rare condition due to foreign body in common bile. In this article we report a 69 year-old man who was diagnosed obstructive jaundice secondary to the endoscopic clip migration. The patient had been performed laparoscopic cholecystectomy 5 years ago and had recovered without any complications. He presented with abdominal pain and jaundice. The magnetic resonance cholangiopancreatography (MRCP) revealed filling defect in choledoch consistent with a bile duct stone. The endoscopic retrograde cholangiopancreatography (ERCP) exhibited an endoclip migration into the common bile duct which caused bile duct stone. Endoclips can migrate into bile duct and cause obstructive jaundice. ERCP is the first option for its treatment.

Background: Pregnant women may experience an acute presentation of hepatic hydatid disease. The available literature is limited to case reports., Methods: The charts of 7 patients who underwent urgent treatment for hepatic hydatid disease during pregnancy between 1992 and 2010 were reviewed., Results: The median patient age was 27 (range 23-39) years and median gestational age was 18 (range 13-24) weeks. The symptoms were severe abdominal pain (4), vomiting (2), jaundice (2), pruritus (2) and severe dyspepsia (1); in the asymptomatic patient, a closed intraperitoneal rupture had been detected during gynecologic ultrasonography. Surgical drainage of the cysts was performed in all cases. The two patients with frank biliary rupture underwent choledochoduodenostomy or Roux-Y hepaticojejunostomy. Four patients required postoperative tocolysis. Albendazole was not used. All mothers gave birth to healthy babies at term. The patients were followed for a median of 9 (range 4-19) years. Two patients developed recurrences at 2 and 7 years; these were treated with surgical drainage and albendazole., Conclusion: This entity entails the responsibility of two human beings. Although it imposes limitations on the routine diagnostic and therapeutic options due to risk of premature labor or teratogenicity, acceptable results can be obtained in collaboration with the department of obstetrics and gynecology.

Aim: To investigate the eligible management of the cystic neoplasms of the liver., Methods: The charts of 9 patients who underwent surgery for intrahepatic biliary cystic liver neoplasms between 2003 and 2008 were reviewed retrospectively. Informed consent was obtained from the patients and approval was obtained from the designated review board of the institution., Results: All patients were female with a median (range) age of 49 (27-60 years). The most frequent symptom was abdominal pain in 6 of the patients. Four patients had undergone previous laparotomy (with other diagnoses) which resulted in incomplete surgery or recurrences. Liver resection (n = 6) or enucleation (n = 3) was performed. The final diagnosis was intrahepatic biliary cystadenoma in 8 patients and cystadenocarcinoma in 1 patient. All symptoms resolved after surgery. There has been no recurrence during a median (range) 31 (7-72) mo of follow up., Conclusion: In spite of the improvement in imaging modalities and increasing recognition of biliary cystadenoma and cystadenocarcinoma, accurate preoperative diagnosis may be difficult. Complete surgical removal (liver resection or enucleation) of these lesions yields satisfying long-term results.

Major bile duct injury during cholecystectomy represents potentially severe complications with unpredictable long-term results. If these lesions are not treated adequately, they can lead to hepatic failure or secondary biliary cirrhosis therefore requiring liver transplantation. We report a patient who required liver transplantation 15 years after open cholecystectomy. A l0-year old girl underwent open cholecystectomy and duodenal repair for cholelithiasis and cholecystoduodenal fistula. She required two surgical interventions, hepaticojejunostomy which was performed in another center and portoenterostomy for biliary stricture at our institution seven years after the cholecystectomy. Eight years after the third operation, she required recurrent hospitalization for treatment of hepatic abscesses. The extremely short intervals between the three life threatening episodes and the rapid progression to severe sepsis were taken into consideration and liver transplantation was performed at the age of 25. She is leading a healthy life at 4 years post transplantation. Although iatrogenic biliary injury can usually be treated successfully by a combination of surgery, radiological and endoscopic techniques, patients with severe injuries develop irreversible liver disease. This case report and review of the literature suggest that liver transplantation is a treatment modality for a selected group of patients with end-stage liver disease secondary to bile duct injury.

Background: Iatrogenic factors became the leading mechanisms of severe cholangitis in a referral center., Patients and Methods: The records of the 58 patients treated for severe cholangitis between 1996 and May 2004 (inclusive) were evaluated., Results: The most frequent underlying diseases were periampullary tumors and mid-bile duct carcinomas (22), followed by proximal cholangiocarcinomas (14). The triggering mechanism was an incomplete endoscopic retrograde cholangiopancreatography (ERCP) in 32 patients, incomplete or inappropriate percutaneous transhepatic biliary drainage (PTBD) in 6, apparently successful ERCP and stenting in 1, and percutaneous transhepatic cholangiography in 1. PTBD was the treatment of choice (38). Mortality was 29% (17/58); the major causes were refractory sepsis (8) and incomplete biliary drainage (advanced tumor, technical failure, or hemobilia) (8)., Conclusions: In this series composed predominantly of patients referred after development of sepsis, ERCP and PTBD complications were the leading mechanisms of severe cholangitis. Nonoperative biliary manipulations are invasive procedures with potentially fatal complications. The decisions to perform such procedures and periprocedural management are responsibilities of an experienced multidisciplinary team.

Background: Oncolytic adenoviral therapy is a promising new approach for cancer treatment. The aim of this study was to improve the conditionally replicative adenoviruses (CRAds) for gallbladder cancer therapy by modifying the fiber-knob region for infectivity enhancement and by incorporating tumor-specific promoters (TSPs) for enhanced specificity., Methods: For promoter-controlled replication, in vitro efficacy of eight TSPs was investigated in two gallbladder cancer cell lines (NOZ and OCUG-1). Infectivity enhancement was analyzed by two different fiber modifications: Arg-Gly-Asp (RGD) incorporation into the HI loop (RGD modification) and a chimeric construct with a serotype 5 shaft and a serotype 3 knob (5/3 fiber modification). Comparisons were made by infectivity analysis and cytotoxicity assays in vitro, followed by tumor suppressive effects tested in vivo., Results: Among TSPs, highest potency was exhibited by the cyclooxygenase-2 (COX-2), Midkine, and vascular endothelial growth factor promoters in both cell lines tested. Fiber chimera (Ad5/3Luc1) conferred significant enhancement of Ad infectivity in comparison with unmodified and RGD-modified vectors. COX-2 CRAds demonstrated selective cytocidal effect in gallbladder cancer cells in vitro. COX-2 promoter-based Ad5/3 CRAds showed significantly enhanced tumor-suppressive effect compared with nonreplicative and RGD-modified CRAd vectors in vivo., Conclusions: The 5/3 fiber-modified, COX-2 promoter-driven CRAds may prove to be a new agent for the treatment of gallbladder carcinoma.

Background: We presented our experience with definitive treatment of traumatic biliary injuries., Methods: Six male patients (mean age 13 years; range 2 to 32 years) who were referred to our unit for definitive treatment of traumatic biliary injuries were retrospectively evaluated. Data were analyzed in terms of demographic characteristics, mechanisms of injuries, associated injuries, previous treatments, symptoms on admission, treatment at our unit, and the results of treatment. Outcome was assessed using modified Schweiser and Blumgart criteria., Results: The injuries were due to blunt abdominal trauma in all the patients but one who had a gunshot wound. In three patients, biliary injuries were missed at the initial operation. On admission, three patients had external biliary fistulas, two had biliary strictures. One patient was sent following inadvertent ligation of the hepatoduodenal ligament during attempts to control hemorrhage. Roux-en-Y hepaticojejunostomy was performed in three patients. Percutaneous biloma drainage was performed in two patients, resulting in fistula closure in 13 and 40 days, respectively. One patient was treated by endoscopic retrograde cholangiopancreatography and papillotomy, which enabled fistula closure in three days. One patient was lost to follow-up. One patient died from hepatic failure 11 years after the trauma. At the end of a mean follow-up of 49 months (range 15 to 75 months), three patients were in excellent condition, while one patient experienced occasional attacks of cholangitis., Conclusion: In patients with undetected biliary injuries and in those with unsuccessful repair attempts, biliary reconstruction should be performed in experienced hepatopancreatobiliary surgery units.

Background and Aims: To evaluate treatment results in iatrogenic biliary injuries with concomitant vascular injuries., Patients/methods: Between January 1998 and May 2002 (inclusive), angiography was performed in 45 of the 105 patients treated for iatrogenic biliary tract injury. The charts of these 45 patients and 5 other patients in whom vascular injury was diagnosed at operation were evaluated retrospectively. Twenty-nine patients had concomitant vascular injury, the biliovascular injury group (BVI), and the remaining 21 patients had isolated biliary tract injury (IBTI)., Results: The most frequent initial operation was a cholecystectomy. The frequency of high-level (Bismuth III or IV) strictures was 90% in the BVI group and 62% in the IBTI group ( P<0.05). Perioperative mortality was 7% in the BVI group and 5% in the IBTI group ( P>0.05). The morbidity in the BVI group was significantly higher ( P<0.05). Two patients in each group were lost to follow up. During a median (range) follow up of 31 months (5-51 months), a successful functional outcome was achieved in 96% of the BVI group and 100% of the IBTI group with a multimodal approach ( P>0.05)., Conclusions: The frequency of high-level biliary injury and morbidity were significantly higher in the BVI group. However, concomitant vascular injury had no significant effect on mortality and medium-term outcome of biliary reconstruction. Thus, routine preoperative angiography is not recommended.

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., (Copyright 2003 S. Karger AG, Basel)

Background: Elective surgery for liver hemangiomas is still controversial., Hypothesis: Long-term results show that elective surgery for liver hemangiomas is safe and effective., Setting: A tertiary care university hospital in Istanbul, Turkey., Patients: Forty-two patients underwent surgery for liver hemangiomas between January 1988 and December 1998; 41 were symptomatic. The primary indications for surgery were abdominal pain in 33 patients, diagnostic uncertainty in 6, and enlargement in 3. The median largest dimension of the major lesion was 10 cm (range, 7-45 cm)., Main Outcome Measures: (1) Patients' assessment of the effects of surgery on preoperative symptoms, (2) determination of whether any other pathological conditions were missed in the preoperative evaluation, (3) operative mortality and morbidity, and (4) recurrences., Design: Retrospective cohort study., Results: Enucleation was the most frequent operation (33 patients). Hospital mortality and morbidity were 2.4% (bleeding from the biopsy site on a lesion evaluated as inoperable at laparotomy; 1 patient) and 12% (5 patients), respectively. Thirty-three patients could be followed up for a median of 53 months (range, 6-135 months). Of the 32 preoperatively symptomatic patients, surgery was successful in symptom control in 28 (88%) (complete resolution or significant amelioration). No other cause of pain could be identified during follow-up in the other patients. Control ultrasonography revealed no recurrences., Conclusions: Elective surgery is indicated in a small subset of patients with hemangiomas because of abdominal pain, enlargement, and diagnostic uncertainty. The results of surgery in symptom control are gratifying in approximately 90% of patients. Recurrences are rare. Enucleation can be performed rapidly and safely in most patients and should be preferred to resection.

Background/aims: Abdominal wall hernia is a common feature of decompensated cirrhosis. However, literature on elective hernia repair in these patients is limited. Here we report the experience of our center., Methodology: Eleven hernias (seven umbilical, three inguinal and one incisional) in nine patients with decompensated cirrhosis were repaired. The indication for operation was repeated incarceration in two patients and significant pain in four; three patients with umbilical hernias had ulceration and necrosis of the overlying skin. Pre-operatively, medical therapy of ascites was conducted at the hepatology unit. Umbilical hernias were treated with the classic Mayo repair; in all cases but two, this was buttressed with a prolene graft. One inguinal hernia was repaired with the plication-darn technique; the other two and the incisional hernia were repaired with prolene grafts., Results: There was no mortality. One patient had a scrotal hematoma; two patients had leakage of ascites into the wound. Seven patients were followed up. Four patients died without recurrence after a median period of 12 months (range 6-22). The other patients have no recurrence at 1, 10 and 40 months post-operatively., Conclusions: Umbilical and inguinal hernias in patients with decompensated cirrhosis may be repaired safely on an elective basis. Control of ascites is vital for success.

Laparoscopic colon resection is a viable alternative to open colectomy. For non-malignant lesions, laparoscopic resection of the affected large bowel is attractive. For malignant lesions, where resection for cure is highly dependent on lymph node clearance, laparoscopic resection has met with criticisms regarding the adequacy of nodal clearance that can be achieved laparoscopically. Several published studies have shown that the operation though technically demanding, does not compromise the extent of resection. We report a series of 43 cases of laparoscopic colon resection done sequentially and successfully from January 1992 to June 1995. The operative time averaged 180 minutes (range 120 to 300 minutes). Five patients developed postoperative complications, which were mainly pulmonary and wound infections. There were no anastomotic leaks or perioperative deaths. The mean hospital stay was 5.3 days (range 4 to 9 days). By the third postoperative day, all patients were feeding and ambulatory. Long-term complications included one small bowel obstruction and one port site recurrence. In our selected group of patients, laparoscopic colon resection has not shown any adverse outcome. Prospective randomised studies are underway in various centres and their preliminary results are favourable.

Two patients who underwent laparoscopic cholecystectomy had postoperative cystic duct leak from slipped metallic clips. One patient presented with biliary ascites and the other with biliocutaneous fistula. Open surgery done in the first patient was not successful in controlling the fistula. Rapid closure of the fistulae was achieved in both cases using endoscopic sphincterotomy.

The surgical world is experiencing a revolution brought about by the proliferation of minimally invasive techniques. These developments have had most impact on abdominal surgery and chest surgery, but there are ramifications affecting other fields as well. One feature of this change is the increasing dependence of surgeons on technology. Developments in video imaging, ultrasound and robotics are required to make complex endoscopic procedures surgeon-friendly, just as the minimally invasive approach has made surgery more patient-friendly. In the future, integration of stereo imaging systems, computers, microrobots and robotic manipulators will result in technically sophisticated but ergonomic operating systems that will allow surgeons to perform endoscopically almost any type of surgery that can be done today.