Choledocholithiasis at the hepatic confluence mimicking a hilar cholangiocarcinoma

Adenocarcinomas of the bifurcation of the hepatic ducts (Klatskin tumors) are a relatively rare cause of obstructive jaundice. Differential diagnosis includes other neoplastic lesions, sclerosing cholangitis, Mirizzi's syndrome and benign strictures. We present a 46 year-old white female with a 2 month history of epigastric pain and progressive jaundice. Endoscopic retrograde cholangiopancreaticography (ERCP) revealed a filiform stenosis of the right hepatic duct and an obstructed left hepatic duct, an image strongly suggestive of a Klatskin tumor. The correct diagnosis was achieved, however, by percutaneous transhepatic cholangiography (PTC), which disclosed a gallstone at the common hepatic duct bifurcation and multiple small concrements in the left hepatic duct. After endoscopic removal of the gallstones in the biliary tree and laparoscopic cholecystectomy, the patient was discharged on the third post-operative day. Protuberant tumors and round biliary stones may be confused at ERCP.     

Surgical treatment of extrahepatic bile duct carcinoma

OBJECTIVE: To evaluate the experience in the diagnosis and surgical treatment of the extrahepatic bile duct carcinomas. METHODS: 242 patients with extrahepatic bile duct carcinoma over the past 20 years was retrospectively studied. RESULTS: The origin points were carcinomas of the upper bile duct in 168, of the middle bile duct in 18, and of the lower bile duct in 56 patients. The preoperative diagnostic rates for the location and the nature of the lesion were respectively raised to 97.2% and 94.5% by combination of ultrasonography and CT. The curative resection rates for the tumors in the upper, middle, and lower bile duct over the recent five years reached to 50.0%, 50.0% and 71.4%. respectively. Follow-up of patients with curative resection showed a one year recurrent rate of 73.9% and a three year recurrent rate of 100.0% with a mean recurrent time of 9.6 months in patients with local metastasis, in contrast to 13.3%, 71.4% and 17.5 months in those without metastasis. Metastasis was mainly responsible for the recurrence. Liver or multiple organ failure, intra-abdominal infection and gastrointestinal hemorrhage were the common and serious complications. CONCLUSION: The case number of the bile duct carcinoma presented a remarkable increment tendency. Ultrasonography and CT were satisfactory enough for diagnosis. To reduce the recurrent rate, resection of the tumor together with the lymph, nervous, fatty and connective tissues in the hepatic hilus, even the right celiac ganglia, should be considered the necessary procedure. Monitoring and protecting the main organs to prevent the multiple organ failure, controlling the gastrointestinal hemorrhage and the intra-abdominal infection are important to decreasing the mortality.     

Surgical treatment of hepatic hydatid cysts

Ciliated cells from the nasal mucosa of normal persons were collected in culture medium and exposed to either oxymetazoline without preservatives, oxymetazoline with preservatives, xylometazoline with preservatives, or sham (culture medium). There was a significant decrease in ciliary beat frequency only by the two drugs with preservatives after 20 min. After substitution of the test media with culture medium ciliary action did not recover in any group.     

Spontaneous rupture of the left hepatic duct

A previously well 24-year-old man complained of persistent epigastric pain after a session of intensive muscle building exercise especially of the abdominal muscles. The abdomen was diffusely tender without guarding. There was an increased concentration of bilirubin (64.7 mumol/l), GOT (117 U/l), GPT (529 U/l) and alkaline phosphatase (150 U/l). Ultrasound examination showed a widening of the choledochal duct to 11 mm without signs of gallstones. Endoscopic retrograde cholangiography additionally revealed contrast-medium extravasation from the left hepatic duct. Computed tomography, performed immediately afterwards, confirmed the extravasation, while liver and pancreas were unremarkable. Laparoscopy revealed a 5 mm tear in the left hepatic duct, close to the hepatic duct bifurcation with bile effusion into the peritoneal cavity. The latter was rinsed endoscopically with Ringer's solution and drains were placed in the omental bursa and subhepatically in the region of the bile leak. To relax the sphincter Oddi glycerol trinitrate was administered postoperatively, for the first five days 72 mg/24 h intravenously, then for nine days twice daily 20 mg by month. No more bile drained as early as the second postoperative day and the patient was free of symptoms 2 weeks later.     

Surgical treatment in proximal bile duct cancer. A single-center experience

OBJECTIVES: The authors evaluated the experience and results of a single center in surgical treatment of proximal bile duct carcinoma. SUMMARY BACKGROUND DATA: Whenever feasible, surgery is the appropriate treatment in proximal bile duct carcinoma. To improve survival rates and with special regard to liver transplantation, the extent of surgical radicalness remains an open issue. PATIENTS AND METHODS: Retrospective analysis of 249 patients who underwent surgery for proximal bile duct carcinoma via the following procedures: resection (n = 125), liver transplantation (n = 25), and exploratory laparotomy (n = 99). Survival rates were calculated according to the Kaplan-Meier method, uni- and multivariate analysis of prognostic factors, and log rank test (p < 0.05). RESULTS: Survival rates after resection and liver transplantation are correlated with international Union Against Cancer (UICC) tumor stage (resection: overall 5-year, 27.1%; stage I and II, 41.9%; stage IV, 20.7%; liver transplantation: overall 5-year, 17.1%; stage I and II, 37.8%; stage IV, 5.8%). Significant univariate prognostic factors for survival after liver resection were lymph node involvement (N category), tumor stage, tumor-free margins, and vascular invasion; for transplantation, they were local tumor extent, N category, tumor stage, and infiltration of liver parenchyma. For resection and transplantation, a multivariate analysis showed prognostic significance of tumor stage and tumor-free margins. CONCLUSION: Resection remains the treatment of choice in proximal bile duct carcinoma. Whenever possible, decisions about resectability should be made during laparotomy. With regard to the observation of long-term survivors, liver transplantation still can be justified in selected patients with stage II carcinoma. It is unknown whether more radical procedures, such as liver transplantation combined with multivisceral resections, will lead to better outcome in advanced stages. With regard to palliation, surgical drainage of the biliary system performed as hepatojejunostomy can be recommended.     

Diagnosis and treatment of iatrogenic ureteral injury

Diagnosis and treatment of 17 patients who sustained 20 iatrogenic ureteral injuries were analyzed. Primary operations in which ureteral injury occurred are almost gynecologic procedures and general surgery. Injuries were managed by ureteroureterostomy in four, ureteral stent in one, removal suture ligation and ureteral double J-catheter in one, ureteroneocystostomy in ten, psoas-hitch technique and ureteroneocystostomy in one, nephrectomy in two. All patients with appropriate repair were followed-up periods of three to five years. Renal function of these patients had optimal results. When ureteral injury occurs, B-US, IVU, cystoscopy, retrograde ureterography or infusion of dye may be useful. An appropriate repair should be chosen according to length and position of ureteral injuries. Reoperation was optimal in two to three weeks. Immediate recognition of accidental ureteral injury provides optimal results. Patients with unrecognized injuries had suboptimal results.     

Surgical treatment for the recurrence of colorectal cancer

Analysis by two-dimensional gel electrophoresis of the N-laurylsarkosinate(Sarkosyl)-insoluble envelope complexes of L-[35]S-cysteine-labeled elementary bodies of Chlamydia pneumoniae strain IOL-207, Chlamydia trachomatis serovar LGV2, D, and F, and Chlamydia psittaci strain 6BC showed differences in the molecular charges of chlamydial outer membrane proteins. The apparent isoelectric point (pI) of the major outer membrane protein of C. pneumoniae strain IOL-207 was 6.4, whereas the pI of the major outer membrane protein of the C. trachomatis and C. psittaci strains differed little from one another, ranging from 5.3 to 5.5. The 60-kDa cysteine-rich protein of C. pneumoniae was the only 60-kDa chlamydial protein with a pI value (5.9) more acidic than that of the corresponding major outer membrane protein. As a general rule, the charges of both the 60-kDa and the low-molecular-mass (12-15 kDa) cysteine-rich proteins were widely variable, depending on the strain. However, in each individual strain, the variation of the charge of the 60-kDa protein had a compensatory change in the low-molecular-mass cysteine-rich protein.     

Surgical correction of recurrent stenosed submandibular duct orifice

Ten patients complaining of recurrent stone formation in submandibular stenosed duct orifice were diagnosed and evaluated. Surgical technique for removal of the stones and widening of the orifice to heal by secondary intention was discussed. Irrigation of the duct and wound with 5% diluted hydrogen peroxide was done to remove all desquamated epithelial cells and microliths to prevent narrowing the lumen of the duct. One year post operative follow up revealed no recurrence of stone formation in the submandibular duct and normal salivary flow for all patients.     

65例患者结肠肝曲癌侵犯十二指肠的外科治疗及预后

Objective:The aim of the study was to discuss surgical treatment of right colon carcinoma of hepatic flexure invading the duodenum.Methods:The 65 patients with right colon carcinoma of hepatic flexure invading the duodenum,treated in our department from 1987 to 2007,were included in this study.Their clinicopathological data were retrospectively reviewed and analyzed.All the cases were divided into three types (local invasion,regional invasion,and cancer with internal fistula) according to duodenal defect,including local invasion (< 2.0 cm),wide invasion (> 2.0 cm) and the presence of internal fistula.Results:The 25 patients with local invasion underwent en bloc resection of the duodenal wall.Pedicled ileal flap was used to cover the large duodenal defect measuring 2.0–3.0 cm in 5 patients.Dudenojejunostomy was used to reconstruct the large defect measuring more than 5 cm in 3 patients.Conservative resection of right-sided colon was performed in 18 patients with wide invasion.Four patients underwent pancreaticoduodenectomy combined with right hemicolectomy for colon cancer involving the pancreatic head.Ten cases underwent duodenal diverticularization.One patient with anastomotic leak-age healed within 3 weeks.Other patients were cured without postoperative complications.The total 3- and 5-year survival rates after surgery were 53.8% and 9.2%,respectively.Conclusion:The surgical procedure to be performed is usually de-cided according to the cancer location,extent,and duodenal defect and invasion,which are important for prolonging life time,improving of quality of life and prognosis in these patients.     

Surgical treatment for advanced carcinoma of the gastric remnant

BACKGROUND/AIMS: Carcinoma of the gastric remnant has increased in recent years, but a therapeutic strategy for this disease has not been established. This retrospective study was performed to determine the most appropriate surgical procedure for carcinoma of the gastric remnant. METHODOLOGY: A total of 25 patients who underwent operation for advanced carcinoma of the gastric remnant that had developed after distal gastrectomy (13 for benign gastric diseases, B group; 12 for gastric carcinoma, M group) were studied. Clinicopathological features, as well as the status of lymph node metastasis, were investigated in the B and M groups. RESULTS: There were more patients with carcinoma invading other organs, stage IV disease, and with N2 or more lymph node metastasis (especially, with a high metastatic rate to lymph nodes along the splenic artery) in the M group than in the B group. Forty percent of patients in the M group were treated by left upper abdominal evisceration (LUAE), but only 8% in the B group. The survival rate (5-year, 46.0%) of the B group was significantly higher than that (5-year, 11.9%) of the M group. When we compared the survival rate of carcinoma of the gastric remnant with that of primary carcinoma of the upper third of the stomach, there was no difference between the two groups in the curative resection cases. CONCLUSIONS: Almost the same surgical strategy can be adopted for the B group as for primary gastric carcinoma. On the other hand, for the M group, a radical surgical procedure, LUAE, should be recommended.     

Sibling spacing and intellectual development: A closer look at the confluence models.

Discusses the 3 confluence models developed by R. B. Zajonc et al (1975, 1976, 1979, 1980) that attempt to explain variations in intellectual development by the size and spacing of an individual's sibship and by the age of the individual at testing. A closer look at 2 of these models revealed several major problems of internal consistency and external correspondence to data. The use of the child spacing variable in both models was particularly suspect. In addition, the most recent confluence model appears to have little applicability to within-families data due to the model's inability to account for individual differences in intellectual growth functions among siblings. The past use of between-families data for substantiating within-families models is also discussed. Finally, new between- and within-families data from 15,000 (predominantly Mormon) university students showed essentially no relationship between sibling spacing and intellectual development. (35 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)