Biliary stenting versus surgical bypass for palliation of periampullary malignancy.

BACKGROUND: Patients with periampullary cancers may not be suitable for curative resection due to locally advanced disease, metastases, or poor health. Biliary stenting and surgical bypass are utilized for symptom control, but the true benefit of one technique over the other is not clear. METHODS: A retrospective analysis of case records was undertaken of patients with periampullary (pancreatic head/uncinate process, distal bile duct, and ampulla of Vater and surrounding duodenum) malignancy treated between June 2004 and June 2010 in a tertiary center by palliative biliary stenting or palliative surgical bypass. RESULTS: Of the 69 patients included in the analysis, combined biliary and gastric bypass was performed on 28, while 41 underwent biliary stent (metallic, n = 39) insertion. Patients undergoing stenting were significantly older and less likely to be offered chemotherapy than those from the surgical bypass group. Overall, there were significantly more complications in the stent insertion group (85 %) than the surgical bypass group (36 %) (p = 0.003). The stent group required significantly more subsequent procedures than the surgical bypass group. Metal stent obstruction occurred in 16 of 39 (41 %) patients, with a median stent patency of 224 days. The overall median survival of patients in this study was 7 months with no significant difference between the groups (p = 0.992). The presence of metastases at presentation was the only independent factor associated with decreased survival. CONCLUSION: There was no survival difference between stenting vs. surgical bypass for palliation of periampullary cancer. There was, however, a high rate of stent occlusion and need for repeat procedures in patients treated by metal stenting, suggesting that stenting may be best suited to patients predicted as having the shortest survival.

Outcomes of patients with histologically proven acute acalculous cholecystitis.

BACKGROUND: Acute acalculous cholecystitis (AAC) is traditionally described in the setting of critical illness, where the diagnosis is based on clinical assessment and imaging criteria. Very few studies have assessed the features and outcomes of AAC in patients treated by cholecystectomy. METHODS: Patients with histologically confirmed acute cholecystitis treated in a specialized unit in a tertiary hospital between 2005 and 2011 were identified from prospectively maintained database. Retrospective review of data was undertaken and patients with AAC were compared with those patients with acute cholecystitis and confirmed gallstones. RESULTS: AAC was identified in 35 of 412 (8.5%) patients with acute cholecystitis. These patients were older (69 years versus 61 years; P = 0.004) and were more likely to be febrile (46% versus 21%; P = 0.001) and hypotensive (23% versus 5%; P < 0.001) at initial presentation. There was a higher incidence of chronic obstructive airways disease (COAD) in the AAC group (26% versus 6%; P < 0.001). Other co-morbidities were similar among the groups. Operative outcomes were similar between the groups. There were no overall differences in postoperative complications between AAC and calculous acute cholecystitis patients (17% versus 16%; P = 0.063). However, the postoperative length of stay was higher in the AAC group (5 days versus 3 days; P = 0.026). CONCLUSION: AAC more commonly occurs in older patients and those with COAD. The operative outcomes and complications of AAC treated by cholecystectomy are similar to cases of acute calculous cholecystitis.

Lymphatic patterns of colorectal liver metastases.

BACKGROUND: Hematogenous spread is considered the predominant pathway for development of colorectal liver metastases (CRLM) and subsequent further tumor dissemination portal nodal involvement is also frequently observed in such cases, suggesting that lymphatics may have a role in the spread of CRLM. The role of lymphatics in the development of liver metastases is, however, controversial. The lymphatic patterns of CRLM were determined using a well established murine model. METHODS: CRLM were induced using a well established murine intrasplenic colorectal cancer model. Tumors were assessed at varying stages of development, and lymphatic patterns were determined in tumors and liver by immunohistochemistry staining for podoplanin and LYVE-1. Blood vessels were characterized using the vascular marker CD-34. Assessment was undertaken using digital microscopy and image analysis. RESULTS: Peri- and intratumoral lymphatic vessels were identified by podoplanin staining in all metastases and significantly increased with tumor growth. LYVE-1 staining was also noted but was variable. There was a concurrent significant increase in portal lymphatic staining within the normal liver with increasing growth of CRLM. CONCLUSION: There is increased expression of lymphatics within CRLM and normal liver with increasing tumor growth. Lymphatic development is likely to play a significant role in the intrahepatic and periportal dissemination of CRLM.

Pseudoaneurysm of the hepatic artery.

INTRODUCTION: Hepatic artery pseudoaneurysms are a rare complication of biliary tract surgery and have an associated mortality that approaches 50%. CASE REPORT: A case of massive haemobilia caused by a hepatic artery pseudoaneurysm several months following laparoscopic cholecystectomy is described. DISCUSSION: It was successfully managed by angiographic embolisation, with the patient making a complete recovery.