[Hepatocellular carcinoma with neoplastic thrombosis of the common hepatic duct]. / Carcinoma epatocellulare con trombosi neoplastica del dotto epatico comune: caso clinico e revisione della letteratura.

Biliary tract involvement in patients with hepatocellular carcinoma usually occurs in advanced stages and is due to tumour compression or infiltration. In a few cases, however, a tumour thrombus may grow into the biliary ducts (bile duct thrombosis). Identification of this condition is important because surgical treatment may be beneficial in selected cases. A 69-year-old man came from another hospital after repeated sessions of radiofrequency thermoablation and alcoholisation of 3 nodules of hepatocellular carcinoma. At admission to our unit, the nodule in S5-S8 was still viable and a neoplastic thrombus had invaded the right and common bile ducts. S5-S8 sub-segmentectomy, S6 wedge resection and removal of the tumour thrombus were performed. Seventeen months later the tumour thrombus recurred in the hepatic ducts without evidence of intrahepatic recurrence and was again removed. Eight months later a large metastatic lymph node appeared at the hepatic hilum, without evidence of liver recurrence or distant metastases, and the patient underwent lymphadenectomy. Eighteen months after the last procedure the patient is alive without recurrence. The appearance of bile duct thrombosis in the natural history of hepatocellular carcinoma does not necessarily entail an unfavourable prognosis. An early diagnosis is crucial to select the appropriate treatment. Biliary decompression with removal of tumour debris and blood clots and curative resection of the hepatocellular carcinoma can result in effective palliation and occasional long-term survival. Also in the presence of intrabiliary, hepatic or limited extrahepatic recurrence, surgical exeresis is the best therapeutic choice in selected cases.

Hepaticojejunostomy--analysis of risk factors for postoperative bile leaks and surgical complications.

Anastomoses between the jejunum and the bile duct are an important component of many surgical procedures; however, risk factors for clinically relevant bile leaks have not yet been adequately defined. The objective of this study was to describe the incidence of bile leaks after hepaticojejunostomy and to define predictive factors associated with this risk and with surgical morbidity. Between October 2001 and April 2004, hepaticojejunostomies were performed in 519 patients in a standardized way. Patient- and treatment-related data were documented prospectively. A bile leak was defined as bilirubin concentration in the drains exceeding serum bilirubin with a consecutive change of clinical management or occurrence of a bilioma necessitating drainage. Surgical morbidity occurred in 15% of patients, the incidence of a bile leak was 5.6%. Multivariate analysis confirmed preoperative radiochemotherapy, preoperative low cholinesterase levels, biliary complications after liver transplantation necessitating a hepaticojejunostomy, and simultaneous liver resection as risk factors for bile leakages, whereas biliary complications after liver transplantation necessitating hepaticojejunostomy, simultaneous liver resection, and diabetes mellitus were significantly associated with postoperative surgical morbidity. Our results demonstrate that hepaticojejunostomy is a safe procedure if performed in a standardized fashion. The above found factors may help to better predict the risk for complications after hepaticojejunostomy.

[Anatomic anomalies in neonatal cholestatic jaundice]. / Anatomische afwijkingen bij neonatale cholestatische icterus.

Disorders of the biliary tree are an important cause of cholestatic jaundice in infancy. For the most frequent diseases in this group, biliary atresia and choledochal cyst, prognosis is strongly dependent on timely diagnosis and treatment. In biliary atresia the bile flow is obstructed due to obliteration of the extrahepatic bile ducts. Construction of an hepatic portoenterostomy before 60 days of age will result in restoration of bile flow in the vast majority of patients. When failed, the disease is progressive and ultimately fatal, unless a liver transplantation is performed. For those patients in which restoration of the bile flow succeeds, the subsequent course is strongly dependent on the occurrence of cholangitis. For all patients fat-soluble vitamins should be supplemented and caloric intake should be carefully monitored. Presentation of a choledochal cyst can be either before or after the first year of life. It is mostly characterized by jaundice, with or without abdominal pain. Therapy consists of resection of the cyst, followed by a hepatico-jejunostomy. Paucity of bile ducts is an intrahepatic disorder, in which--almost--no bile ducts can be found in the portal tracts. This anomaly is frequently found in combination with a typical facies, a pulmonary stenosis and vertebral anomalies, a combination which is called Alagille syndrome. Prognosis is generally good.