Bilioenteric anastomotic stricture in patients with benign and malignant tumors: prevalence,risk factors and treatment

BACKGROUND: Stricture formation at the bilioenteric anastomosis is a rare but important postoperative complication. However, information on this complication is lacking in the literature. In the present study, we aimed to assess its prevalence and predictive factors, and report our experience in managing bilioenteric anastomotic strictures over a ten-year period. METHODS: A total of 420 patients who had undergone bilioenteric anastomosis due to benign or malignant tumors between February 2001 and December 2011 were retrospectively reviewed. Univariate and multivariate modalities were used to identify predictive factors for anastomotic stricture occurrence. Furthermore, the treatment of anastomotic stricture was analyzed. RESULTS: Twenty-one patients (5.0%) were diagnosed with bilioenteric anastomotic stricture. There were 12 males and 9 females with a mean age of 61.6 years. The median time after operation to anastomotic stricture was 13.6 months (range, 1 month to 5 years). Multivariate analysis identified that surgeon volume (<30 cases) (odds ratio:-1.860; P=0.044) was associated with the anastomotic stricture while bile duct size (>6 mm) (odds ratio: 2.871; P=0.0002) had a negative association. Balloon dilation was performed in 18 patients, biliary stenting in 6 patients, and reoperation in 4 patients. Five patients died of tumor recurrence, and one of heart disease. CONCLUSIONS: Bilioenteric anastomotic stricture is an uncommon complication that can be treated primarily by interventional procedures. Bilioenteric anastomosis may be performed by a surgeon in his earlier training period under the guidance of an experienced surgeon. Bile duct size >6 mm may play a protective role.

Predictors of incidental gallbladder cancer in elderly patients

BACKGROUND： At the time of diagnosis, most patients with gallbladder cancer are in advanced stage and the cancer is unresectable. Long-term survivors are usually seen in a small number of patients with incidental gallbladder cancer. This study aimed to identify preoperative predictors of incidental gallbladder cancer in elderly patients.METHODS： A total of 4014 patients of more than 44 years old who had undergone cholecystectomy at our department from January 2000 to December 2010 were retrospectively reviewed Univariate and multivariate modalities were used to identify the predictive factors of incidental gallbladder cancer.RESULTS： Twenty-nine of the 4014 patients who had under gone cholecystectomy for benign gallbladder diseases were histologically diagnosed as having incidental gallbladder can cer. Multivariate analysis identified that elevated carbohydrate antigen 19-9 combined with carcinoembryonic antigen and/or carbohydrate antigen 125 （P=0.045）, a gallbladder polyp greater than or equal to 1.2 cm （P=0.043） and focal gallblad der wall thickening of more than or equal to 5 mm （P=0.002）were predictive factors of incidental gallbladder cancer.CONCLUSION： Cholecystectomy is suggested for patients with these predictive factors and intraoperative frozen section should be considered to rule out carcinoma.

Resection of a retrohepatic leiomyosarcoma of the inferior vena cava combined with caudate lobectomy and reconstruction with an allogenic vein

Primary leiomyosarcoma of the inferior vena cava(IVC)is a rare disease,accounting for 0.5%of soft tissue sarcomas in adults[1].A diversity of therapeutic methods have been applied to treat this type of tumor.The average survival time of patients who are not treated is merely 3-4 months[2].The effect of radiotherapy and chemotherapy remains unclear and controversial[3].On the other hand,the en-bloc resection with negative margins may be the only potentially curative treatment and therefore,can contribute to the long-term survival of the patients[4].During the operation,a reconstruction graft for the defected IVC needs to be chosen[5]as the graft-related complications are the surgeons’major concern,which include graft thrombosis and infection[6].Growing evidence has suggested that an allogeneic vein from donation after brain death or cardiac death is a better choice to avoid these complications[7].An allogeneic vein has been reported to be safely used in patients with pancreatic cancer in case of the portal vein and/or superior mesenteric vein invasion[8].A cryopreserved allograft can even be applied in the management of native and prosthetic aortic infections[7].Herein,we present a case of resection of a retrohepatic leiomyosarcoma of the IVC combined with partial caudate lobectomy and reconstruction with an allogeneic vein.

Liver transplantation benefits selected patients with hilar cholangiocarcinoma and colorectal liver metastases

Hilarcholangiocarcinoma(HCCA)isanaggressivemalignancy with a dismal prognosis. The 5-year survival rate has been reported to range from 39%to 50%if an R0 resection is obtained [1]. Approximately 25%patients with early stage HCCA of all cases can be treated with radical surgical resection [2], while most patients do not have a chance to receive a surgical procedure due to the advanced stage at the time of diagnosis. The poor prognosis is gen-

Deceased donor liver transplantation for Budd–Chiari syndrome:Long-segmental thrombosis of the inferior vena cava with extensive collateral circulation

Budd–Chiari syndrome(BCS)is an infrequent clinical disease resulting from obstruction of the hepatic venous outflow tract anywhere from small hepatic veins to the inferior vena cava(IVC)[1].Currently,step-wise treatment strategy has been proposed and widely adopted based on the patient's status,which contains anticoagulation,thrombolysis,percutaneous recanalization,transjugular intrahepatic portosystemic shunt(TIPS)and surgical shunt[2].