Nonoperative Techniques Research Articles

Endoclipping of iatrogenic colonic perforation to avoid surgery

Colonoscopy is an established tool for the diagnosis and management of colonic and rectal pathology. Even though colonic perforation is rare after colonoscopy, it is a serious and typical complication. The definitive management remains controversial. Both operative and nonoperative techniques have been described in the literature, though the standard treatment for these patients is still an operative repair of the perforation site. Recently, endoscopic clip application was recommended, particularly for iatrogenic perforations, but less is known about the effectiveness of endoluminal repair of colonic perforations with clips. In this series, 7589 colonoscopies were performed over a 34-month period in a tertiary-level referral center. Three perforations occurred during 5413 diagnostic colonoscopies. Therapeutic colonoscopy was under taken in 2176 patients, resulting in a total of 27 perforations. Out of 30 patients with colonic perforation, five patients underwent operative management and 25 patients were subsequently treated nonoperatively. In 27 patients, endoscopic application of inert metallic clips was used for closure of iatrogenic perforation. Twenty-five of these patients were treated non-operatively, while two patients underwent surgery. The mean postoperative length of hospitalization for patients was 12.2 days, compared to 3.5 days for patients treated conservatively. Endoluminal repair of colonic perforations with clips and further conservative treatment seems to provide a tool that avoids the major additional trauma associated with laparotomy or laparoscopy and minimizes the length of hospitalization.

Palliation of malignant hilar obstruction at a single centre--review of operative and non-operative techniques.

Jaundice secondary to a malignant hilar obstruction can be relieved by operative bypass or percutaneous stenting. Comparative trials involving these techniques are scarce. We reviewed our experience with these competing techniques in the palliation of malignant hilar obstruction. All patients with malignant hilar obstruction managed at our institution during the period 1992-2002 were identified for review. A total of 36 deeply jaundiced patients with hilar obstruction were identified. Twenty-two patients underwent exploration with the intention of performing an operative bypass and 14 patients underwent percutaneous transhepatic cholangiography (PTC) with intention to stent. Procedure-related mortality was similar in both groups. Morbidity was much higher in the operative group. Effective symptom relief was achieved with both techniques. In the PTC group recurrent biliary obstruction in 2 patients necessitated salvage non-operative procedures. Although survival rates were slightly longer in the operative group, this was not significant. There were no long-term survivors. Operative bypass provides better sustained relief of jaundice than PTC. However long-term survival in both groups is poor and operative bypass is best reserved for younger patients with no technical contraindications. Despite early and late procedural failures PTC is the method of choice for patients with advanced-stage disease and those with significant co-morbidities.

Managing the Stiff Elbow: Operative, Nonoperative, and Postoperative Techniques

Elbow contracture may be caused by intrinsic or extrinsic limitations or a combination of both. Evaluation of the specific structures guides the development of an effective therapy treatment program. Intrinsic contractures are by definition due to joint/intra-articular incongruency, and therefore therapy and splinting cannot provide increase in joint motion. Nonoperative therapy treatment options include heat modalities, myofascial soft tissue mobilization, joint mobilization, muscle energy techniques, passive range of motion, active range of motion, extensive use of corrective splinting, and strengthening exercise. All operative candidates must participate in a preoperative therapy program of six to eight weeks to reduce extrinsic contractures as feasible and to assess patient compliance with an intensive postoperative therapy program. Corrective splinting may be needed for as long as six months to maintain gains made in surgery. The therapy following manipulation under anesthesia and open contracture release is similar. The therapist must know the details of the procedure. Operative treatment for the stiff elbow progresses in a sequential fashion to progressively release tissue structures limiting motion and reconstruct any structures as needed to provide joint stability. Postoperative therapy consists of continuous passive motion , corrective splinting, modalities, and specific exercise techniques to maintain passive gains achieved in surgery. The therapy is extensive and requires full participation from the patient to maximize motion and function. Complications of elbow contracture release include nerve palsy or nerve injury, seroma, joint instability, heterotopic ossification, and recurrence of elbow contracture.

A safer and more reliable technique for cast wedging

Non-operative techniques for the management of closed tibial fractures are well accepted and proven to be very successful. Cast wedging itself is somewhat of a dying art with a move towards operative intervention in many cases traditionally managed successfully by cast immobilisation. Much debate has ensued as to the best method of calculating the size of the wedge required. Further discussion on the merits of the opening wedge, closing wedge and the opening-closing wedge have all tried to refine the technique including the precise positioning of the wedge. None of these papers have discussed the materials used for providing the wedge itself. Traditionally a piece of cork has been used with varying size pieces inserted into the gap created. There are two problems with this:

Lumbar Disc Herniations

Lumbar disc herniation is among the most common causes of lower-back pain and sciatica. The cause(s) of lumbar disc herniation and the relation of lumbar disc herniation to back pain and sciatica have not been fully elucidated, but most likely comprise a complex combination of mechanical and biologic processes. Furthermore, the natural history of lumbar disc herniation seems generally to be favorable, leaving the optimum treatment for lumbar disc herniation a debate in the literature. Various nonoperative and operative treatment strategies have been tried with varying degrees of success. Treatment often involves patient education, physical therapy, alternative medicine options, and pharmaco-therapy. If these fail, surgical intervention is usually recommended. A literature search was conducted to evaluate the currently known effectiveness of traditional and novel non-operative and surgical techniques for the treatment lumbar disc herniation and to determine if there are substantive new advantages in these newer contemporary treatments or combinations thereof. A structured approach to treatment of a patient who may have a symptomatic lumbar disc herniation is presented, based on analysis of the current literature. No one method of nonoperative or operative treatment would seem definitively to be superior to another. Appropriate multidisciplinary treatment including behavioral analysis and support may offer the hope of improved outcomes for patients with lumbar disc herniation. Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence.

Evaluation and Management of Valgus Impacted Four-part Proximal Humerus Fractures

A valgus impacted, four-part humerus fracture is an uncommon but important injury to recognize in patients with orthopaedic trauma. Recognizing this fracture pattern and understanding the pathoanatomy of it are essential to providing appropriate care. The treatment options for valgus impacted, four-part humerus fractures range from nonoperative care to hemiarthroplasty. The peer-reviewed literature provides insight into the important factors to consider in deciding how to treat patients with valgus impacted, four-part humerus fractures. Recently, less invasive surgical techniques have been reported as a way to preserve the blood supply to the articular fracture fragment, which decreases the risk of developing avascular necrosis. Even though these techniques are becoming more popular, they are not indicated for all patients. Surgeons must use an individualized approach for each patient with this fracture. Satisfactory results have been reported for the nonoperative and operative techniques used to treat valgus impacted, four-part humerus fractures. However, less invasive procedures may help to achieve a more favorable clinical outcome. Limiting the surgical approach and achieving stabilization with minimal fixation helps to preserve the viability of the humeral head and to prevent postoperative morbidity related to osseous and soft tissue healing. Hemiarthroplasty becomes a reasonable treatment option in older patients with substantial displacement of the fracture fragments and poor bone quality that would not support internal fixation. Therapeutic study, level V (expert opinion). See Guidelines for Authors for a complete description of levels of evidence.

Dissolution of common bile duct stones.

Retained common duct stones can now be treated by a number of non-operative techniques, including dissolution by cholesterol solvents, simple irrigation, stone extraction via the T tube tract and by endoscopic sphincterotomy. This paper reviews the various solvents available for stone dissolution and its physicochemical basis. When a retained stone is found simple irrigation with saline will be successful in about 50 per cent of patients. If this fails, stone extraction via the T tube tract or by endoscopic sphincterotomy are now the methods of choice, with a 90--95 per cent chance of success. Stone dissolution by cholic acid is slow and is only successful in about 60 per cent of patients but can be of value when stone extraction is unavailable or unsuccessful.

Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results

Many operative and non-operative treatments of dorsal fracture dislocations of the proximal interphalageal (PIP) joint have been described. Return of good joint function requires anatomical reduction of the articular fragments and restoration of joint congruity and a stable functional arc of motion, with the fixation construct stable enough for early mobilization. To prevent recurrent dorsal subluxation, the attachments of the ligamentous palmar restraints and the bony buttress provided by the palmar lip of the middle phalanx base must be restored. Open reduction and internal interfragmentary screw fixation using 1.5 or 1.3mm screws was employed in 12 fingers in 10 patients with unstable dorsal fracture dislocations of the PIP joints of Schenck grades III and IV. At an average follow-up of 8.7 months, all patients in this series achieved good to excellent results and an average total active interphalangeal motion of 132 degrees (range 105 degrees -165 degrees). Additional benefits over non-operative techniques included improved patient comfort and simplified nursing care and therapy supervision.

The advancing art and science of endoscopy

Flexible endoscopy continues to advance encompassing treatment of a variety of diseases traditionally managed surgically. This review describes and evaluates many of these new endoscopic approaches with an eye toward the future. Gastroesophageal reflux disease is now treated with several endoscopic, non-operative techniques. A procedure using radiofrequency energy delivered by a peroral catheter with small needles inserted into the wall of the esophagus causes collagen deposition and ablates transient lower esophageal sphincter relaxation, both of which reduce reflux. With this treatment, >80% of patients will reduce or stop their medication for reflux. Trials involving new injectable materials show promise with a 75–80% improvement in heartburn-related quality-of-life scores and reduced medication use. Endoscopic suture and stapling devices restore the antireflux barrier with sutures that create a pleat or plication at the gastroesophageal junction. Early results indicated that 62–74% of patients had significant improvement. Long-term results are not available for any of these new techniques and there seems to be a drop off in effectiveness over time. Gastrointestinal bleeding has been more effectively managed with the recent introduction of small clips and detachable snares to control bleeding vessels. Banding and sclerotherapy for variceal bleeding has all but eliminated urgent operation for that diagnosis. In the biliary-pancreas realm, endoscopic management of pancreatic pseudocysts, stenting of pancreatic or biliary strictures and fistulae have reduced operative indications in those disease processes. Pseudocyst drainage involves creation of a transenteric communication between the pseudocyst and the stomach or duodenum. Complete cyst resolution without recurrence can be expected in 85% of patients. While endoscopic pallation of malignant biliary strictures has been accepted for years, experience with endoscopic management of iatrogenic strictures indicates that it may serve as an alternative option without surgery in many patients. Enteric stenting using metallic self-expanding stents in the esophagus, duodenum, and colon allows alleviation of obstruction without surgery for palliantation and in the colon may relieve obstruction to avoid colostomy prior to an elective resection. On the horizon stands the flexible endoscopic route to the abdominal cavity via the transgastric route and the promise of combined endoscopic-laparoscopic approaches to complex abdominal problems. General surgeons should rekindle their interest in flexible endoscopy or risk losing entire categories of disease to other specialties or to a small specialized group of endoscopic surgeons.

Surgical management of complications associated with percutaneous and/or endoscopic management of pseudocyst of the pancreas.

To study the magnitude of complications associated with the nonoperative management of peripancreatic fluid collections and pseudocysts and to assess the surgical management of these complications. These are compared with complications associated with operative management. Pancreatic pseudocysts and peripancreatic fluid collections associated with acute pancreatitis have been managed with success using nonoperative techniques for more than a decade. When successful, these techniques have clear advantages compared with operative management. There has, however, been little focus on the magnitude and outcomes after complications sustained by nonoperative management. Our report focuses on these complications and pseudocysts and on the surgical management. We have been struck by the high percentage of patients who sustain significant and at times life-threatening complications related to the nonoperative management of fluid collections. We further define an association between the main pancreatic ductal anatomy and the likelihood of major complications after nonoperative management. Between 1992 and 2003, all patients admitted to our service with peripancreatic fluid collections or pseudocysts were monitored. We evaluated complications patients managed with percutaneous (PD) or endoscopic drainage (E). Data were collected regarding patient characteristics, need for intensive care unit (ICU) stays, hemorrhage, hypotension, renal failure, and ventilator support. We further focused on the duration of fistula drainage from patients who have had a percutaneous drainage, and we assessed the necessity for urgent or emergent operation. By protocol, all patients had pancreatic ductal anatomy evaluated by means of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP). Patients with complications of E and PD were compared with 100 consecutive patients who underwent operative management of pseudocyst and fluid collections as their sole mode of intervention. A total of 79 patients with complications of PD, E, or both were studied. There were 41 males and 38 females in the group of patients who sustained complications (mean age 49 years). Sixty-six of the 79 subsequently required operation to manage their peripancreatic fluid collection, 37 urgent or emergent. The mean elapsed time from diagnosis to nonoperative intervention was 18.1 days. This group of 79 patients had mean 3.1 +/- 0.7 hospitalization (range, 1-7) and length-of-stay 42.7 +/- 4.1 days. ICU stays were required in 36 of the 79 (46%). A defined episode of clinical sepsis was identified in 72 of 79 (91%) and was by far the most common complication. Hemorrhage requiring transfusion was identified in 16 of the 79 (20%), clinical shock 51 of the 79 (65%), renal failure 16 of the 79 (20%), ventilator support for longer than 24 hours 19 of the 79 (24%). A persistent pancreatic fistula occurred in 66 of the 79 patients (84%); mean duration was 61.4 +/- 9.6 days. Sixty-three of the 79 patients with complications of E or PD had ductal anatomy (ERCP/MRCP) which predicted failure because of significant disruption or stenosis of the main pancreatic duct. Among the 100 operated patients, 69 complications occurred in 6 of the 100 (6%). Operation was initiated electively a mean interval of 42.7 days after diagnosis of pseudocyst. Hemorrhage, hypotension, renal failure, sepsis, persistent fistula, or urgent operation all were not seen in the complications associated with operated patients. CT imaging obtained at least 6 months after intervention documented complete resolution after surgery alone in 91 and 9 with cystic structures less than 2 cm. In patients with operation after failed nonoperative therapy, 6 patients had persistent cystic lesions less than 2 cm in diameter. These data support the premise that a choice between operative and nonoperative management for peripancreatic fluid collections and pseudocysts should be made with careful assessment of the pancreatic ductal anatomy, with a clear recognition of the magnitude of complications which are likely to occur should nonoperative measures be used in patients most likely to sustain complications. It is vital to recognize the magnitude and severity of complications of nonoperative measures as one chooses a modality. Ductal anatomy predicts patients who will have complications or failure of management of their peripancreatic fluid collection.

Nonoperative Management of Pediatric Upper Extremity Fractures or ‘Don’t Throw Away the Cast’

With the exception of fractures involving the distal humerus, almost all fractures of the upper extremity can be successfully treated by noninvasive methods. The surgeon treating upper extremity fractures in children in areas of developing nations where the medical and surgical resources are limited should have a good knowledge of the nonoperative techniques available. He or she should also be skilled in administering local and regional anesthesia. Fortunately, in the pediatric age group, there is a considerable remodeling potential. This fact determines the adequacy of the best reduction that can be obtained by nonoperative methods. Knowledge of the limits of satisfactory remodeling for the various fracture patterns is also essential. Anyone treating fractures in these areas needs to be flexible with their approach and innovative in their methods. Although these fractures often present challenges for the treating physician, they can provide a great deal of satisfaction when they are conquered and the patient’s fracture treatment has a successful outcome. The specific techniques for the nonoperative management of upper extremity fractures in the pediatric patient are discussed in detail. It must be emphasized, however, that the treating surgeon should both teach and perform procedures to achieve as satisfactory a reduction as possible within the resources of the local area.

Endoscopic Treatment of the Buried Bumper Syndrome

Endoscopic Treatment of the Buried Bumper Syndrome Bernhard Rieder, Albrecht Pfeiffer Introduction: The buried bumper syndrome is a rare but serious complication in patients with percutaneous endoscopic gastrostomy (PEG). While a variety of non-operative techniques have been used to manage buried bumper syndrome, in most cases surgical intervention is necessary to rectify the problem. We report on an endoscopic method using a Savary dilator over a guidewire for the treatment of the buried bumper syndrome. Method: 8 patients (4 females, 4 males, 60-90 years) were admitted to our gastroenterology unit with buried bumper syndrome. The PEG-tubes had been placed 4 (2-6) years earlier. The manifestations of the buried bumper syndrome included inability to infuse feeding solutions and swelling, pain and leakage above the PEG tube. All attempts to grasp the bumper with a snare or to dislodge it by applying pressure on the PEG tube externally proved futile. The PEG tube was cut 2 to 3 cm above the skin level. Under endoscopic visualization, a Savary dilator guidewire was inserted through the gastrostomy tube into the lumen of the stomach. The guidewire was grasped with a snare and withdrawn through the mouth. The endoscope was reinserted into the stomach. In 4 patients, where the bumper was overgrown by gastric mucosa, endoscopic incision using a needle knife was necessary. Savary dilators (24 F) were passed over the guidewire to displace the bumper together with the remnant of the tube into the stomach. The bumper was snared and removed endoscopically. Results: The buried bumpers could be removed in all 8 patients. In 7 patients, the procedure was tolerated without any incident. In one patient, a bleeding episode induced by the needle knife procedure was treated endoscopically. A new PEG was placed in all 8 patients within 6 days. Conclusion: The described endoscopic method using Savary dilators over a guidewire allows safe removal of embedded PEG bumpers and might replace surgery in the treatment of the buried bumper syndrome.

Changing Paradigm for the Treatment of Clubfeet

Clubfoot is one of the most common pediatric orthopaedic conditions. Until recently, surgical management was the treatment of choice. Nonoperative treatment techniques, including the Ponseti casting and French physical therapy methods, have peeked interest of orthopaedists eager to find a less aggressive treatment method that can assure a lasting, good result. Both methods have proven successful in reducing the number of patients requiring extensive surgical release and, as a result, have become an integral part of pediatric orthopaedic practice. A clear understanding of both treatment methods is important for the orthopaedic nurse to allow quality nursing care and help assure a successful outcome for young patients.

Combined pectoralis major and latissimus dorsi tendon transfer for massive rotator cuff deficiency

This report is a retrospective review of 11 consecutive patients treated with a combined transfer of the latissimus dorsi and pectoralis major tendons for massive rotator cuff deficiency. Each patient's chief complaint was diminished shoulder function and motion with little or no accompanying pain. The primary operative objective was to increase active shoulder motion. All 11 patients were followed up for at least 2 years (range, 24 to 42 months). The mean active elevation improved from 42 degrees preoperatively to 86 degrees postoperatively. The mean active external rotation improved from 0 degrees to 13 degrees. On the basis of the Medical Research Council scale, the mean abduction strength improved from 2.3 to 3.1 and the mean external rotation strength improved from 2.1 to 2.7. Overall, 4 patients made no improvement, 2 improved slightly, and 5 improved significantly. We conclude that a combined transfer of the latissimus dorsi and pectoralis major is a reasonable and safe procedure that may restore active elevation and external rotation in some patients' shoulders with a massive rotator cuff deficiency that have not responded favorably to traditional nonoperative and operative techniques. However, it is difficult to conclude, based on our experience, for which patients this surgery can be predictably successful.

Circumcision

Circumcision is one the most frequently performed operations in males worldwide and is an integral part of several religions, including Judaism and Islam. Circumcision rates in the UK have reduced over the last few decades from 24% of males in the 1950s to an estimated 6% today. This reduction is largely as a result of better understanding of the physiology of the normal foreskin as well as rationalization of healthcare provision. The normal foreskin is non-retractable at birth and gradually separates spontaneously such that 90% of foreskins are retractable by three years of age. Medical indications for circumcision are few. Circumcision is contraindicated in a number of congenital penile disorders, including hypospadias, epispadias, chordee, buried penis, and micropenis,. Various techniques are available for performing circumcision, including non-operative techniques for use in neonates using devices such as the Plastibell, as well as operative circumcision. Complications of circumcision include haemorrhage, infection, meatal stenosis, removal of incorrect amount of foreskin, penile injury, urethral injury, and painful scarring. However, many of these complications can be prevented using precise surgical techniques, including avoidance of monopolar diathermy and meticulous haemostasis.

ANTERIOR RELEASE OF THE ELBOW FOR EXTENSION LOSS

There are many causes of elbow contracture. When nonoperative techniques fail to increase the arc of motion of the elbow, surgical intervention may be indicated. The purpose of this study was to report the outcomes of surgical correction, predominantly with an anterior release, of elbow flexion contractures. In addition, we evaluated the efficacy of continuous passive motion in the immediate postoperative period. We retrospectively reviewed the outcomes of 106 consecutive patients who had undergone anterior elbow release for the treatment of a flexion contracture between July 1975 and June 2001. Twenty-nine patients were excluded because they had been followed for less than twelve months, leaving a study group of seventy-seven patients. Postoperatively, fifty-four of the seventy-seven patients were treated with continuous passive motion and the other twenty-three patients were treated with extension splinting. The average duration of follow-up was thirty-three months. The average patient age was thirty-four years. The results were evaluated on the basis of both preoperative and postoperative radiographs as well as clinical measurements of elbow motion, all performed by the same examiner using the same large (47-cm-long) goniometer. The mean preoperative extension in the seventy-seven patients was 52 degrees, which decreased to 20 degrees postoperatively. The mean flexion increased from 111 degrees preoperatively to 117 degrees postoperatively, and the mean total arc of motion increased from 59 degrees to 97 degrees. The total arc of motion in the patients treated with continuous passive motion increased 45 degrees, compared with an increase of 26 degrees in those treated with extension splinting. There were eleven complications in ten patients. The majority were traction neuropathies. There were two infections (one superficial and one deep), both of which resolved following treatment. Release of a pathologically thickened anterior elbow capsule through a predominantly anterior approach to correct diminished elbow extension is a safe and effective technique. Furthermore, compared with splinting in extension alone, the utilization of continuous passive motion during the postoperative period increases the total arc of motion.

Colorectal cancer presenting as surgical emergencies

Colorectal Cancer (CRC) is a major cause of cancer morbidity and mortality. Surgery is considered the first line therapy for CRC, and is generally encountered by many surgeons under elective conditions. Unfortunately, colorectal cancer may present acutely as a surgical emergency. These conditions include, but are not limited to perforation, hemorrhage, and obstruction. The presentation of a patient with these conditions can lead to higher morbidity and mortality. The choice of operation depends mainly on the site of the disease (left-sided versus right-sided), the patient's physical condition, nutritional status, and age. The treatment for right-sided lesions is a right hemicolectomy. However, treatment of left-sided lesions is still undecided. There are many therapeutic options such as primary or staged resections, Hartman's procedure, subtotal colectomy, or colostomy. Other therapies involve non-operative techniques such as laser therapy, colonic stenting, emergency endoscopy, and comfort measures.

Sacral insufficiency fracture surgically treated by fibular allograft.

Sacral insufficiency fractures have been known to occur distally after long instrumentation to the sacrum. Most such fractures are treated nonoperatively, but surgery is indicated for patients who have nonunions, persistent pain, neurologic deficits, or gross displacement. The current report elucidates the potential complication of sacral fracture after long lumbar arthrodesis, reviews the pertinent literature, presents three patients with sacral fractures after long instrumented lumbar spinal arthrodesis to the sacrum, and describes a new surgical technique for stabilizing such fractures. One patient was treated nonoperatively, and two patients were treated with arthrodesis from a posterior approach and augmentation with a strut fibular allograft. All three patients were followed to radiographic and clinical union. The authors conclude that sacral fracture is a potential complication after a long lumbar arthrodesis. Nonoperative techniques are often successful, but when they are not, a new technique using fibular allografts can be successful.

Traumatic acromioclavicular joint separation – Current concepts

BACKGROUND: The concept of treatment strategies in dislocations of the acromioclavicular joint has changed in recent years. The recommended indication for operative treatment of complete dislocations has been questioned due to the lack of evidence-based results indicating the superiority of such treatment. Although the traumatic acromioclavicular joint separation is a well-known topic, there are different classifications, diagnostic procedures, concepts of intervention and a great variety of implants. Therefore, a comparison of the numerous papers dealing with this topic is difficult. METHODS: An overview of the recent literature is given in this paper. The different therapeutical methods, ranging from nonoperative techniques to different operative procedures such as percutaneous K-wires or other transarticular techniques, extra-articular techniques or secondary procedures like tendon transfers are compared. RESULTS: The current therapeutical algorithms that help to decide on whether operative or nonoperative treatment is the best solution are oriented on the morphological classification, the clinical appearance of the injury and the individual patient's expectations. The wide range of implants available demand a decision based on anatomical and biomechanical considerations. CONCLUSIONS: In this paper an overview of current concepts is given and possible treatment options for acute and chronic cases are discussed. The indication for operative intervention is restricted to the young and physically active patient with a high-grade dislocation of the AC-joint.

Non-Hodgkin lymphoma presenting with obstructive jaundice.

Obstructive jaundice is a rare presenting feature of non-Hodgkin lymphoma (NHL). Lymphomatous masses in the peripancreatic and hepatic hilar regions are potentially difficult to diagnose. A retrospective analysis was undertaken of patients presenting with obstructive jaundice secondary to NHL at a tertiary care hepatobiliary unit. Over a 7-year period, six adults and three children with NHL were managed. The site of the lymphomatous mass was at the hepatic hilum in six patients and the peripancreatic area in three. Diagnostic procedures included a laparotomy and biopsy in four patients, hepatic trisectionectomy in two, percutaneous biopsy in two and lymph node biopsy in one patient. Percutaneous biopsy confirmed the diagnosis in both the patients in whom it was attempted. One patient died following liver resection. Chemotherapy was the mainstay of treatment and achieved complete remission in four patients, partial remission in three and no response in one patient. Two patients subsequently required operation for a benign biliary stricture after achieving complete remission. NHL must be considered in the differential diagnosis of obstructive jaundice in adults and children. Attempts must be made to diagnose the condition using non-operative techniques. Chemotherapy is the mainstay of treatment. Late benign strictures of the bile duct requiring operation may develop.