Case Report: Intraductal Papillary Mucinous Neoplasms of the Biliary Tract.

The present case report describes intraductal papillary mucinous neoplasms of the biliary tract (IPMN-BT), a rare neoplasm of the biliary tract that is described as the biliary counterpart of intraductal papillary mucinous neoplasms of the pancreas (IPMN-P). The importance of appropriate diagnosis and awareness of the clinical manifestations is highlighted. IPMN-BT has a more favorable prognosis and is easier to resect than other forms of intrahepatic cholangiocarcinomas; therefore, early and accurate diagnosis is required for planning of the best treatment strategies for this neoplasm.

Short-term outcomes of ablation therapy for hepatic tumors: evidence from the 2006-2009 nationwide inpatient sample.

BACKGROUND: Radiofrequency ablation (RFA) for the treatment of hepatic tumors has been increasingly used across the United States. Whether treatment-related morbidity has remained low with broader adoption is unclear. We conducted this study to describe in-hospital morbidity associated with RFA for hepatic tumors and to identify predictors of adverse events in a nationally representative database. METHODS: Using the 2006-2009 Nationwide Inpatient Sample, we evaluated all patients aged ≥40 years who underwent an elective RFA for primary or metastatic liver tumors (N = 1298). Outcomes included in-hospital procedure-specific and postoperative complications. Multivariable logistic regression analyses were performed to identify patient and facility predictors of complications. RESULTS: Most patients underwent a percutaneous (39.9 %) or laparoscopic (22.0 %) procedure for metastatic liver tumors (57.5 %). Procedure-specific complications were frequent (18.2 %), with transfusion requirements (10.7 %), intraoperative bleeding (4.3 %), and hepatic failure (2.8 %) being the most common. Arrhythmias [adjusted odds ratio (AOR) = 1.93 (1.23-3.04)], coagulopathy [AOR = 4.65 (2.95-7.34)], and an open surgical approach [AOR = 2.77 (1.75-4.36)] were associated with an increased likelihood of procedure-specific complications, whereas hospital RFA volume ≥16/year was associated with a reduced likelihood [AOR = 0.59 (0.38-0.91)]. Postoperative complications were also common (12.0 %), with arrhythmias, heart failure, coagulopathy, and open surgical approach acting as significant predictors. CONCLUSIONS: In-hospital morbidity is common after RFA for hepatic tumors. While several patient factors are associated with more frequent procedure-specific complications, treatment at hospitals with an annual volume ≥16 cases/year was associated with a 41 % reduction in the odds of procedure-specific complications.

Temporary silastic mesh closure for adult liver transplantation: a safe alternative for the difficult abdomen.

Primary fascial closure is often difficult after adult orthotopic liver transplantation (OLT), complicated by donor-to-recipient graft size mismatch, post-reperfusion hepatic edema, coagulopathy, or intestinal edema. Attempts at closing the abdomen under these circumstances can cause increase in intra-abdominal pressures, resulting in significant complications, including graft loss. Temporary closure with silastic mesh has been used as a viable option in children receiving transplants, but there is no experience recorded with its use in adults. A retrospective review was conducted on 200 consecutive liver transplantations performed over 42 months (October 2002 to February 2006). Records were evaluated for patient and donor demographics, perioperative factors including Model for End-Stage Liver Disease and Child-Turcotte-Pugh scores, indications for OLT, ischemic times, blood product administration, and use of temporary silastic mesh closure. Patients requiring silastic mesh were further evaluated for indication, time to primary fascial closure, duration of intubation, length of stay, graft function, and complications (infectious, vascular, biliary, and hernia development). Comparisons were made with a cohort of patients undergoing OLT over the same time period but who were closed primarily, without the use of temporary silastic mesh. Fifty-one liver transplantations (25.5%) of the 200 total transplant cohort used silastic mesh closure. Comparison of the cohorts (primary closure vs. temporary mesh) revealed that no differences existed, except the requirement of all blood products was significantly greater in the silastic mesh group (P < 0.001). Bowel edema (47.1%) and coagulopathy (37.3%) were the most common indications for mesh closure, with less frequent reasons including donor to recipient size mismatch (11.8%), hemodynamic instability, and a large preexisting fascial defect (2.0% each). The average time from transplant to final fascial closure was 3.4 days (range 2-9 days). In the silastic cohort, 41 transplants where closed primarily, 3 required the addition of synthetic mesh, and 6 had component separation and flap closure. After fascial closure, the mean time to extubation was 1 day. The median length of follow-up was 1.3 years for the silastic closure group. Long-term wound complications in the silastic closure group included 1 instance of colonic fistula, 2 incisional hernias, and 2 wound infections. The 30-day and 1-year patient survival for this group were 93.6 and 82.4%, respectively, and the graft survival for those same periods were 90.2 and 77.7%, respectively. Wound complications, rates of hepatic artery thrombosis or stricture, portal vein thrombosis or stricture, biliary complications, and allograft and patient survival were no different than those in patients undergoing initial primary closure. In adult liver transplantation with a difficult (or potentially difficult) abdomen, temporary closure with silastic mesh was found to allow for uncomplicated fascial closure in a short period of time, with rapid extubation times, excellent graft function, and minimal instances of infectious or wound complications. In circumstances where large amounts of blood products are required, where a size mismatch exists, or where bowel edema is present during adult liver transplantation, temporary closure with silastic mesh is an ideal strategy.