Prospective evaluation of endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis in 45 patients with normal conventional ultrasonography.

The aim of this study was to prospectively evaluate endoscopic ultrasonography and microscopic examination of duodenal bile in the diagnosis of cholecystolithiasis not detected by conventional ultrasonography. Forty five consecutive patients (26 females, 19 males, mean age: 50 years) with suspected cholecystolithiasis and at least two normal transcutaneous ultrasonography examinations were included. Endoscopic ultrasonographic criteria for the diagnosis of cholecystolithiasis were the presence of stones with or without acoustic shadowing or sludge. Criteria of microscopic examination of bile were cholesterol or bilirubinate crystals or spheroliths. Thirty three patients underwent cholecystectomy and lithiasis was found in gall bladder bile in 24. Twelve patients who were not operated on and were followed up (median: 17 months), had no evidence of cholecystolithiasis. Endoscopic ultrasonography and duodenal bile examination were 96% and 67% sensitive, respectively (p < 0.03). The specificity was not different (86 and 91%, respectively). None of the 16 patients with negative results in both procedures had evidence of cholecystolithiasis. It was found that for the diagnosis of cholecystolithiasis in patients with normal conventional ultrasonography, the sensitivity of endoscopic ultrasonography is higher than that of microscopic examination of duodenal bile. If endoscopic ultrasonography and microscopic examination of duodenal bile are negative, the risk of underdiagnosing cholecystolithiasis is negligible.     

Undifferentiated embryonal sarcoma of the liver in an adult: a case report

Undifferentiated embryonal sarcoma of the liver is rare. It is usually observed in children and adolescents. We report one case of embryonal sarcoma of the liver arising in patient without any antecedent. The only symptom was right scapular pain. The liver scan showed a multicystic lesion suspicious for infectious origin or a tumor. Serologies for ecchinococcus, schistosomiasis and brucellosis were negative. The treatment was a right hepatectomy. On gross examination, the tumor was unencapsulated, multicystic and contained large areas of necrosis admixed with gelatinous areas. Microscopically, there were epithelioid and spindle tumor cells in a myxo?d stroma. Lipoblastic-like or rhabdomyoblastic-like, giant cells and PAS positive hyaline globules in the cell cytoplasm were present. The tumor cells expressed vimentin, cytokeratin (KL1), alpha-1-antitrypsin and smooth muscle actin. This observation shows that embryonal sarcoma of the liver may develop in adult patients and should be taken into consideration in any differential diagnosis of cystic hepatic tumor.     

Mucinous cystadenoma with mesenchymal over-growth: a new variant among pancreatic mucinous cystadenomas?

We report an unusual type of mucinous cystadenoma of the pancreas, characterised by a predominantly solid gross appearance due to the presence of an abundant ovarian-type stroma. The tumour, located in the body of the pancreas, was discovered after episodes of acute pancreatitis. It was composed of several mucus-secreting benign cysts placed within a highly cellular ovarian-type stroma, composed of undifferentiated spindle cells with mild atypia but without any increase of mitotic activity and with a low proliferative index. These cells expressed oestrogen and progesterone receptors, but they did not express CD34, CD117, p53 protein or bcl-2. Recognition of this peculiar mainly solid mucinous cystadenoma containing an abundant ovarian-type stroma is difficult. It is conceivable that the mesenchymal component described in our case could represent an early stage in the development of sarcoma in mucinous cystadenoma of the pancreas.     

Anatomy of spontaneous splenorenal and gastrorenal venous anastomoses: Review of the literature

Summary Portal hypertension is characterised by the development of a collateral portocaval circulation. Among these venous reroutings, some are situated posteriorly in the left subphrenic compartment. These are the spontaneous splenorenal and gastrorenal anastomoses. Their incidence is estimated at around 16%. On the one hand, there are the direct shunts, which anastomose the spelling v. to the left renal v., of an anecdotal nature, and on the other the spontaneous indirect splenorenal shunts, characterised by the presence of a complete neurovascular pedicle traversing the gastrophrenic ligament. This relates to the gastric collateral v., which is connected to the left renal v. via the inferior v. of the left crus of the diaphragm and the middle capsular v., hence the name gastro-phreno-capsulorenal shunt. At an advanced stage of portal hypertension these splenorenal shunts may acquire a major caliber and behave like actual surgical shunts.

---

Anatomie des anastomoses veineuses spléno-rénale et gastro-rénales spontanées: revue de la littérature

Résumé L'hypertension portale se caractérise par le développement d'une circulation collatérale porto-cave. Parmi ces dérivations veineuses, certaines ont une topographie postérieure, localisée dans la loge sous-phrénique gauche. Ce sont les anastomoses spontanées splénorénales et gastro-rénales. Leur prévalence est estimée aux alentours de 16%. On distingue, d'une part, les shunts directs, qui anastomosent la v. splénique à la v. rénale gauche, de constatation anecdotique, non systématisés sur le plan anatomique ; d'autre part, les shunts splénorénaux spontanés indirects caractérisés par l'existence d'un pédicule complet vasculo-nerveux, cheminant dans le ligament gastro-phrénique. Il s'agit de la v. collatérale gastrique qui est reliée à la v. rénale gauche par l'intermédiaire de la v. inférieure du pilier gauche du diaphragme et de la v. capsulaire moyenne, d'où le nom de shunt gastro-phrénocapsulo-rénal. A un stade avancé de l'hypertension portale, ces shunts splénorénaux peuvent acquérir un calibre important et se comporter alors comme de véritables shunts chirurgicaux.

     

Continuous versus intermittent portal triad clamping for liver resection: a controlled study

OBJECTIVE: The authors compared the intra- and postoperative course of patients undergoing liver resections under continuous pedicular clamping (CPC) or intermittent pedicular clamping (IPC). SUMMARY BACKGROUND DATA: Reduced blood loss during liver resection is achieved by pedicular clamping. There is controversy about the benefits of IPC over CPC in humans in terms of hepatocellular injury and blood loss control in normal and abnormal liver parenchyma. METHODS: Eighty-six patients undergoing liver resections were included in a prospective randomized study comparing the intra- and postoperative course under CPC (n = 42) or IPC (n = 44) with periods of 15 minutes of clamping and 5 minutes of unclamping. The data were further analyzed according to the presence (steatosis >20% and chronic liver disease) or absence of abnormal liver parenchyma. RESULTS: The two groups of patients were similar in terms of age, sex, nature of the liver tumors, results of preoperative assessment, proportion of patients undergoing major or minor hepatectomy, and nature of nontumorous liver parenchyma. Intraoperative blood loss during liver transsection was significantly higher in the IPC group. In the CPC group, postoperative liver enzymes and serum bilirubin levels were significantly higher in the subgroup of patients with abnormal liver parenchyma. Major postoperative deterioration of liver function occurred in four patients with abnormal liver parenchyma, with two postoperative deaths. All of them were in the CPC group. CONCLUSIONS: This clinical controlled study clearly demonstrated the better parenchymal tolerance to IPC over CPC, especially in patients with abnormal liver parenchyma.     

In situ split liver transplantation for two adult recipients

BACKGROUND: Modifications of the in situ split liver technique are needed for safe transplantation in two adult recipients with a single donor. METHODS: The graft from a brain-dead donor, 187 cm tall and weighing 89 kg, was split in situ with a transection performed along the main portal fissure retaining the middle hepatic vein with the left graft. The right and left grafts, which weighed 985 and 760 g, respectively, were transplanted in two adult recipients weighing 70 and 56 kg, respectively. RESULTS: Both recipients had minor intraoperative blood loss and were discharged from intensive care on day 3. Both grafts were rapidly functional, and the two patients were in excellent condition with normal liver function tests 9 months after surgery. CONCLUSION: In situ split liver transplantation can be performed with the middle hepatic vein retained in the left graft to obtain a sufficient volume of the two grafts suitable for two adult recipients. This modification of the technique could expand the donor pool for adult recipients.     

Intraductal papillary mucinous tumors of the pancreas confined to secondary ducts show less aggressive pathologic features as compared with those involving the main pancreatic duct

Intraductal papillary mucinous tumors (IPMTs) of the pancreas are rare tumors characterized by a malignant potential. Because of the progress of imaging procedures, smaller cystic pancreatic lesions are now detected and some of them correspond to IPMTs that involve ectatic pancreatic branch ducts but spare the main pancreatic duct. To investigate differences in morphology and clinical behavior of branch and main duct types of IPMT, a surgical series of 43 cases was studied. All pathologic specimens of IPMT, surgically resected in our institution between October 1987 and July 1998, were analyzed. In all cases, the entire pancreatic specimen was systematically examined. IPMT of the branch type was found in 13 (30%) patients, whereas IPMT of main pancreatic duct type that involved the main pancreatic duct and branch ducts was observed in 30 (70%) patients. Patients with IPMT of the branch type were younger (median age, 55 yrs vs 64 yrs), and all but one of the lesions were located in the head and neck of the pancreas (vs 17 of 30 patients with the main duct type). The size of the cysts ranged from 4 to 55 mm, and the major duct showed a mild dilation in most cases. In contrast to the main pancreatic duct type, which showed invasive carcinoma and in situ carcinoma in 11 (37%) of 30 patients and 6 (20%) of 30 patients, respectively, IPMT of the branch type showed significantly less aggressive histologic lesions with five (39%) patients with simple hyperplasia, six (46%) patients with atypical hyperplasia, and two (15%) patients with in situ carcinoma. No invasive carcinoma was observed in this group. IPMT of the branch type occurs in younger patients and is associated with less aggressive histologic features than is the main pancreatic duct type. Our findings raise the difficult issue of clinical management of IPMT of the branch type as a distinctive group.     

Functional and morphological changes in the pancreatic remnant following pancreaticoduodenectomy with pancreaticogastric anastomosis

BACKGROUND: The aim was to evaluate pancreatic exocrine and endocrine function, pancreatic atrophy and main pancreatic duct dilatation in the pancreatic remnant following pancreaticoduodenectomy and pancreaticogastrostomy. METHODS: Nineteen patients who underwent pancreaticoduodenectomy and pancreaticogastrostomy for benign or malignant pancreatic tumours with a histologically normal pancreatic resection margin were studied prospectively. The median interval between operation and evaluation was 32 (range 12-120) months. Pancreatic exocrine insufficiency was assessed by measuring 72-h faecal fat concentrations and faecal-1 elastase. Fasting blood glucose, haemoglobin A1c, serum peptide C and insulin levels were used to assess endocrine function. Pancreatic parenchymal thickness and main pancreatic duct diameter were measured before operation and at evaluation using computed tomography (CT). RESULTS: Faecal fat excretion was raised in 16 of 17 patients; faecal-1 elastase was reduced in all 17 patients. None of the 17 non-diabetic patients had developed diabetes mellitus at follow-up. A significant decrease in pancreatic parenchymal thickness and increased dilatation of the main pancreatic duct were observed on CT at evaluation (P = 0.01 and P = 0.01 respectively). Pancreatic atrophy, assessed by subtracting the diameter of the pancreatic duct from the total gland thickness, tended to develop over time, but at the limit of statistical significance (P = 0.06). CONCLUSION: A median of 3 years following pancreaticoduodenectomy and pancreaticogastrostomy, patients remained free from diabetes but developed marked pancreatic exocrine insufficiency. Presented in part to the Societé Nationale Fran?aise de Gastroentérologie in Nantes, March 1999, and published in abstract form as Gastroenterol Clin Biol 1999; 23: A81