RESUMEN
BACKGROUND AND AIM: To present the experience in management of inflammatory liver pseudotumors from a specialist surgical unit and to review the medical literature on this rare manifestation. METHODS: Between 1995 and 2008, four patients were identified with this type of tumor from a total of 108 resected benign liver lesions at the Royal Infirmary of Edinburgh, Scotland UK. Two patients presented with liver abscesses, one with liver cystadenoma, and one with hilar cholangiocarcinoma. All four underwent some type of hepatectomy. We report these cases and review the literature. RESULTS: All four patients survived the operation with some morbidity. CONCLUSIONS: Inflammatory liver pseudotumors are a difficult entity to identify. Resection should be considered because it may be impossible to rule out malignancy by other means.
Asunto(s)
Granuloma de Células Plasmáticas/cirugía , Hepatectomía , Hepatopatías/cirugía , Adulto , Anciano , Errores Diagnósticos/prevención & control , Femenino , Granuloma de Células Plasmáticas/complicaciones , Granuloma de Células Plasmáticas/patología , Hepatectomía/efectos adversos , Humanos , Absceso Hepático/diagnóstico , Hepatopatías/complicaciones , Hepatopatías/patología , Neoplasias Hepáticas/diagnóstico , Masculino , Persona de Mediana Edad , Servicio de Cirugía en Hospital , Resultado del TratamientoRESUMEN
BACKGROUND: The aim of this study was to construct and validate an artificial neural network (ANN) model to identify severe acute pancreatitis (AP) and predict fatal outcome. METHODS: All patients who presented with AP from January 2000 to September 2004 were reviewed. Presentation data on admission and at 48 hours were collected. Acute Physiology and Chronic Health Evaluation (APACHE) II and Glasgow severity (GS) score were calculated. A feed-forward ANN was created and trained to predict development of severe AP and mortality from AP; 25% of the data set was withheld from training and was used to evaluate the accuracy of the ANN. Accuracy of the ANN in predicting severity of AP was compared with APACHE II and GS scores. RESULTS: A total of 664 patients with AP were identified of whom 181 (27.3%) fulfilled the clinical and radiologic criteria for severe pancreatitis and 42 patients died (6.3%). Median APACHE II score at 48 hours was 4 (range, 0 to 23). ANN was more accurate than APACHE II or GS scoring systems at predicting progression to a severe course (P < .05 and P < .01, respectively), predicting development of multiorgan dysfunction syndrome (P < .05 and P < .01) and at predicting death from AP (P < .05). CONCLUSIONS: An ANN was able to predict progression to severe disease, development of organ failure and mortality from acute pancreatitis with considerable accuracy and outperformed other clinical risk scoring systems. Further studies are required to assess its utility in aiding management decisions in patients with AP.
Asunto(s)
Redes Neurales de la Computación , Pancreatitis/diagnóstico , APACHE , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Escala de Consecuencias de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica/etiología , Pancreatitis/sangre , Pancreatitis/complicaciones , Pancreatitis/mortalidad , Pronóstico , Escocia/epidemiologíaRESUMEN
Segment III bypass can achieve excellent palliation in jaundiced patients with unresectable malignancy of the hepatic duct confluence. However, the long-term benefits are often offset by early morbidity and mortality associated with surgery. Bile leakage is a common postoperative complication. Several approaches to the segment III duct have been described. The "round ligament approach" identifies the segment III duct by following the round ligament into the recessus of Rex, in the umbilical fissure. It is the approach adopted by most units, including our own. The liver is often split to a depth of 5 to 6 cm to expose the duct. Fashioning an intrahepatic cholangiojejunostomy within the recess of the umbilical fissure can be technically difficult due to lack of space. We describe a modification of the round ligament approach, creating a long and tension-free cholangiojejunostomy, which we believe reduces the incidence of postoperative bile leakage.
Asunto(s)
Conductos Biliares/cirugía , Yeyunostomía/métodos , Humanos , HígadoRESUMEN
BACKGROUND: During orthotopic liver transplantation (OLT) for acute liver failure (ALF), some patients develop acute increases in intracranial pressure (ICP). The authors tested the hypothesis that increases in ICP during OLT for ALF can be prevented by moderate hypothermia. METHODS: Sixteen patients with ALF undergoing OLT were studied. Depending on the measured ICP before OLT, the patients were divided into three groups as follows: group I (n=6), did not require treatment for increased ICP (ICP <15 mm Hg); group II (n=5), had episodes of increased ICP that were controlled by conventional treatment (group I and group II patients were maintained normothermic during OLT); and group III (n=5), had uncontrolled increased ICP before OLT for which they had been cooled and underwent OLT with the median core temperature of 33.4 degrees C (92.1 degrees F) (range, 31.9 degrees -33.8 degrees C [89.4 degrees -92.8 degrees F]) RESULTS: There was a significant increase in ICP during the dissection and reperfusion phases in the patients in groups I and II (P=0.004 and P=0.006, respectively). Patients in group III had no significant increase in ICP during the OLT. The increase in ICP in groups I and II was associated with an increase in cerebral blood flow, which was not observed in group III. The increase in ICP was corrected during the anhepatic phase of the operation. There was no difference in the requirement of transfusions or incidence of postoperative infection between the groups. CONCLUSIONS: Moderate hypothermia is safe and successfully prevents increases in ICP during OLT for ALF.
Asunto(s)
Circulación Cerebrovascular/fisiología , Trastornos Cerebrovasculares/prevención & control , Hiperemia/prevención & control , Hipotermia Inducida , Hipertensión Intracraneal/prevención & control , Fallo Hepático Agudo/cirugía , Trasplante de Hígado/métodos , Trasplante de Hígado/fisiología , Adulto , Femenino , Humanos , Interleucina-1/sangre , Cuidados Intraoperatorios , Trasplante de Hígado/inmunología , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica , Análisis de SupervivenciaRESUMEN
BACKGROUND: It has been reported that preoperative transjugular intrahepatic portosystemic stent-shunt (TIPSS) reduces peri-operative transfusion requirements during orthotopic liver transplant, and may result in fewer episodes of poor, early graft function by reducing portosystemic shunting, thus improving portal blood supply to the graft. OBJECTIVE: To test the hypotheses that TIPSS improves early graft function and reduces transfusion requirements. METHODS: A retrospective review of 82 liver transplant recipients between 1993 and 1999 was performed. The subgroups comprised 29 patients who had TIPSS prior to first orthotopic liver transplant and 53 matched controls without TIPSS. RESULTS: There was no significant difference in the early graft function in the two groups. The prothrombin time before an orthotopic liver transplant was independently predictive of initial poor function. Transfusion requirements and total operating times were similar for both groups, although transfusion requirements were greater in those patients where TIPSS led to technical difficulties during the operation (n = 6). The TIPSS patients required a longer hospital stay than the non-TIPSS patients (41 +/- 8 vs 26 +/- 4 days, P < 0.05). There were significantly more patients needing dialysis in the TIPSS group (41.3% vs 9.4%, P < 0.001). Pulmonary infection was less common in the TIPSS group (P < 0.05), with a trend to reduced wound infections. The 12 month patient and graft survival were similar in both groups. Serum albumin levels assessed before orthotopic liver transplant independently predicted 12 month graft survival. CONCLUSIONS: TIPSS does not improve early graft function, nor reduce blood transfusion requirements perioperatively. The longer post-operative hospital stay in the TIPSS group is worthy of further study. TIPSS prior to transplantation, despite having the potential for technical operative complications, has no detrimental effects on patient and graft survival, and if required should be undertaken.