Choledochal cysts occur most frequently in East Asian children and rarely in Western adults. Over the past two decades, pediatric treatment has been standardized, but relatively little information is available on the management of Western adults with choledochal cysts. Therefore the aims of this analysis were to compare the presentation, management, and late results of Western adults and children with choledochal cysts. Records were reviewed of patients with choledochal cysts at three academic institutions in Wisconsin. Fifty-seven patients were identified, and 51 of these patients (89%) were managed surgically. Thirty-one patients (54%) were adults, and the adults were more likely to be male (29% vs. 4%, P<0.02). Pain (81% vs. 42%, P<0.01) and cholangitis (35% vs. 15%) were more common in adults. Forty-one patients (71%) had type I cysts, but type IVa or V cysts with dilated intrahepatic ducts were more common in adults (39% vs. 15%, P=0.05). Seventeen adults had undergone biliary surgery prior to referral compared to only four children (59% vs. 15%, P<0.01). Preoperative endoscopic or percutaneous stents were employed more commonly in adults (42% vs. 15%, P<0.01). Hospital mortality was 0%, and morbidity was low in both adults and children (25% vs. 8%). An associated biliary malignancy correlated with age (P<0.05): 0 to 30 years (0%), 31 to 50 years (19%), and 51 to 70 years (50%). In addition, adults were more likely to have late problems with cholangitis (19% vs. 4%, P<0.07) and secondary biliary cirrhosis (13% vs. 4%). This analysis suggests that compared to children, Western adults with choledochal cysts are more likely to have (1) type IVA or V cysts, (2) undergone prior surgery, (3) preoperative biliary stents, (4) an associated biliary malignancy, and (5) late hepatobiliary problems. We conclude that surgery in Western adults with choledochal cysts is frequently complicated and should be performed by specialists in complex biliary surgery.

Adult↗

PubMedDate not supplied

Current management of portal hypertension.

Portal hypertension can lead to life-threatening hemorrhage, ascites, and encephalopathy. This paper reviews the pathophysiology and multidisciplinary management of portal hypertension and its complications, including the indications for and techniques of the various surgical shunts. Variceal bleeding is the most dreaded complication of portal hypertension. It may occur once the portal-systemic gradient increases above 12 mm Hg, occurs in 30% of patients with cirrhosis, and carries a 30-day mortality of 20%. Treatment of acute variceal bleeding includes resuscitation followed by upper endoscopy for sclerosis or band ligation of varices, which can control bleeding in up to 85% of patients. Medical therapies such as vasopressin and somatostatin can also be useful adjuncts. Shunt therapy, preferably the placement of a TIPS, is indicated for refractory acute variceal bleeding. Recurrent variceal bleeding is common and is associated with a high mortality. Therapies to prevent recurrent variceal bleeding include chronic endoscopic therapy, nonselective beta-blockade, operative or nonoperative (TIPS) shunts, devascularization operations, and liver transplantation. Recommendations and a treatment algorithm are provided, taking into account both the etiology and the manifestations of portal hypertension.

Endoscopy, Gastrointestinal↗

PubMedDate not supplied

Should suspected early gallbladder cancer be treated laparoscopically?

Early gallbladder cancer (EGC), defined as T1 and T2 disease, is frequently curable when completely excised without bile spillage. The objective of the present study was to determine what effect initial laparoscopic cholecystectomy has on outcome in patients with EGC. Of 89 patients referred to our institution with gallbladder cancer over an 11-year period, 26 had undergone initial laparoscopic cholecystectomy. Sixteen of the 26 patients had T1 or T2 disease and are the subjects of this report. These patients were reviewed retrospectively to assess preoperative diagnosis, intraoperative bile spillage, and outcome (recurrence and survival). In addition, the Western literature was reviewed to determine the impact of initial laparoscopic cholecystectomy on recurrence and survival of patients with EGC. Six patients had a preoperative ultrasound consistent with a mass in the gallbladder wall. Seven (44%) had documented bile spillage during the laparoscopic cholecystectomy. T stage based on the laparoscopic cholecystectomy was T1 (n = 1) and T2 (n = 15). Twelve patients underwent reexploration of whom seven underwent further radical excision (gallbladder liver bed resection and extensive lymphadenectomy). After a mean follow-up of 20.1 months (range 4 to 39 months), 69% of patients have had a recurrence or died. Three patients had a port-site recurrence. Five (71%) of seven patients with bile spillage at laparoscopic cholecystectomy have had a recurrence or died of disease. A review of the Western literature on EGC initially removed by laparoscopic cholecystectomy (including the present series) yielded 21 patients with T1 and 42 patients with T2 disease. One-year Kaplan-Meier survival (T1 = 89%, T2 = 71%) and 3-year Kaplan-Meier survival (T1 = 47%, T2 = 40%) of these patients is worse than prior reports for open cholecystectomy. An initial laparoscopic cholecystectomy with its potential for bile spillage can convert potentially curable EGC to incurable disease. Patients with preoperative findings suspicious for gallbladder cancer should undergo open exploration with intent to perform a radical cancer operation as a primary procedure if the diagnosis is confirmed intraoperatively.

Adult↗

PubMedDate not supplied

Scientific data from clinical trials: investigators' responsibilities and rights.

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Authorship↗

PubMedDate not supplied

The bandwagon effect.

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Digestive System Surgical Procedures↗