Subhepatic Region Research Articles

Complicated duplication cysts on the ileum presenting with a mesenteric inflammatory mass

Mesenteric inflammation caused by complicated duplication cysts rarely occurs. We present and discuss the imaging findings of a mesenteric inflammatory mass caused by complicated duplication cysts in an infant. Sonography showed a complex, echogenic cystic mass occupying the right subhepatic region containing two thick-walled cystic lesions inseparable from the normal bowel loop. On CT images a large, heterogeneously enhancing, hypodense peritoneal mass was observed to infiltrate the mesentery, which contained small cystic masses with enhancing thick walls. At surgery a mesenteric inflammatory mass caused by two complicated duplication cysts was found to be firmly fixed by surface contact with the ileum. A review of the literature relating to the etiologic relationship between a mesenteric inflammatory mass and complicated duplication cysts is presented.

Variant anatomy of the cystic artery in adult Kenyans

Knowledge of the variant vascular anatomy of the subhepatic region is important for hepatobiliary surgeons in limiting operative complications due to unexpected bleeding. The pattern of arterial blood supply of 102 gallbladders was studied by gross dissection. The cystic artery originated from the right hepatic artery in 92.2% of cases. The rest were aberrant and originated from the proper hepatic artery. Accessory arteries were observed to originate from proper hepatic artery (n = 5), left hepatic artery (n = 2), and right hepatic artery (n = 1). Most of the arteries approached the gallbladder in relation to the common hepatic duct (anterior 45.1%, posterior, 46.1%). The other vessels passed anterior to common bile duct (2.9%), posterior to common bile duct (3.9%), or were given off in Calot's triangle. Cystic arteries in this data set show wide variations in terms of relationship to the duct systems. In about one tenth of patients, an accessory cystic artery may need to be ligated or clipped during cholecystectomy.

Sub-hepatic ectopic pregnancy in a fallopian tube of a non-communicating rudimentary uterine horn

Ectopic pregnancy in a non-communicating rudimentary uterine horn is a rare occurrence. The authors describe a case of ectopic pregnancy in a fallopian tube of a non-communicating uterine horn. The unusually high position of the ectopic gestation into the sub-hepatic region affects the early clinical presentation. The patient had been treated successfully by laparoscopic salpingectomy.

An alternative surgical approach to a difficult case of Mirizzi syndrome: A case report and review of the literature

Mirizzi syndrome (MS) is an uncommon complication of gallstone disease and occurs in approximately 1% of all patients suffering from cholelithiasis. The syndrome is characterized by extrinsic compression of the common hepatic duct frequently resulting in clinical presentation of intermittent or constant jaundice. Most cases are not identified preoperatively. Surgery is the indicated treatment for patients with MS. We report here a 71-year-old male patient referred to the surgical outpatient department for diffuse upper abdominal pain and mild jaundice (bilirubin rate: 4.2 mg/dL). Ultrasound examination revealed a stone in the cystic duct compressing the common hepatic duct. The patient had a history of gastrectomy for gastric ulcer 30 years ago. MRCP revealed a stone impacted in the cystic duct causing obstruction of the common hepatic duct by extrinsic compression. With these findings the preoperative diagnosis was indicative of MS. At laparotomy a moderately shrunken gallbladder was found embedded in adhesions containing a large stone which was palpable in the common bile duct. The anterior wall of the body of the gallbladder was opened by an incision which extended longitudinally along the gallbladder towards the common bile duct. The stone measuring 3.0 cm in diameter, was then removed setting astride a large communication with the common bile duct. A Roux-en-Y cholecysto-choledocho-jejunostomy was performed. The subhepatic region was drained. The patient had an uneventful recovery. He was discharged eleven days after operation and remained well after a 30-mo follow-up.

211 Intraluminal high dose rate brachytherapy in the treatment of carcinomas of the subhepatic region

The −863 C/A polymorphism in the tumor necrosis factor-α (TNF-α) promoter has been suggested to influence TNF-α expression. Here we elucidated the molecular mechanisms underlying the allele-specific regulation of TNF-α gene expression under basal and LPS-stimulated conditions in THP-1 cells and in human primary macrophages. We show that the binding of two NF-κB complexes, the p50/p50 homodimer and the p50/p65 heterodimer, was upregulated upon LPS stimulation. Both complexes bound to the C-allele whereas the A-allele only bound the p50/p65 complex. Two DNase I hypersensitive sites appeared in the TNF-α promoter after LPS stimulation of THP-1 cells. DNase I hypersensitivity of the TNF-α promoter was also analyzed in human monocytes prepared from individuals of different −863C/A genotype. Hypersensitivity was increased in the promoter harboring the mutant A-allele, particularly after LPS stimulation. In summary, binding of transcription factor NF-κB to the TNF-α promoter is associated with allele-specific remodeling of chromatin structure.

Laparoscopic Excision of an Intra-Abdominal Schwannoma

While under investigation for symptomatic cholelithiasis, a32-year-old Saudi female was incidentally found to have a 4.7cm solid and cystic mass in the right subhepatic region on anultrasound scan. A plain abdominal X-ray and routinehematological and biochemical investigations were all normal.Barium enema demonstrated extrinsic pressure on the hepaticflexure of the colon. Contrast-enhanced CT scan confirmedthe presence of a well-defined round, low density,heterogenous mass related to the anterior and mesentericaspect of the hepatic flexure (Figure 1). This was confirmedby MR imaging (Figure 2).Laparoscopy was performed using a 10-mm umbilicalport, a 10-mm epigastric port and two 5-mm ports; one in theright midclavicular line and another in the right anterioraxillary line. The mass was found to be arising from thegreater omentum and adherent to, but not infiltrating, the wallof the hepatic flexure of the colon. A routine laparoscopiccholecystectomy was performed first. The mass was thenmobilized from the colon and the greater omentum withrelative ease, using a combination of sharp dissection andelectrocautery, and a large feeding vessel was clipped anddivided. Once free, the tumor was placed in an endopouchintroduced through the epigastric port. The epigastric portincision was extended to 4 cm and the tumor was deliveredthrough it intact. The patient made an uneventful recovery

Traumatic transection of the intrapancreatic common bile duct due to blunt injury: a case report and literature review

An N-year-old previously healthy man was brought by the Emergency Medical Team to our hospital, an hour after being beaten up by a gang of young men. He had been beaten all over his body including several blows to his abdomen. He was conscious (Glasgow Coma Scale 13), although agitated. Vital signs were, heart rate 116 beats/ min and BP 110/‘70 mmHg. His only complaint was of diffuse abdominal pain. On physical examination, ecchymoses and contusions were absent, no penetrating wounds were present and a small laceration of 3 cm on the lower lip was noted. Lung examination was normal. The abdomen was flat with diffuse tenderness in all four quadrants. There were no other abnormalities. Because of his intoxicated and agitated state the patient was sedated and anaesthetized and an elective intubation was performed. At this point a nasogastric tube was inserted and brought up 300 cm3 of coffee-ground material. A urinary catheter was inserted with good urine output and no signs of haematuria. X-Rays of the chest, pelvis and cervical spine were normal. Computed tomography (CT) of the head revealed findings of a small frontal intracerebral bleed. There were no signs of increased intracranial pressure (Figure 2). CT of the abdomen showed free fluid in the abdominal cavity extending from the subhepatic region to the pelvis. The spleen and liver were intact (Figure 2). Because of the intact spleen and liver and the presence of free fluid in the abdomen, the abdomen was explored. A large subcutaneous haematoma was observed in the epigastric regtion, and 500 cm3 of fresh blood was aspirated from the peritoneal cavity. A large haematoma was detected in the retroperitoneum extending from the duodenum down to the sacral region. A blotch of bile was found staining the upper portion of the first part of the duodenum. A Cattell procedure was performed and the duodenum was mobilized using the Kocher manoeuvre, at which time a blowhole of 2 mm by 3 mm was observed in the duodenum, approximately in the middle of the 1st to 2nd division of the organ. Exploration of the common bile duct showed an intact duct. During the procedure bile was noticed to exude from

Clinical significance of periportal tracking on computed tomographic scan in patients with blunt liver trauma

This study was undertaken to evaluate the clinical significance of periportal tracking on computed tomography (CT) in patients with blunt liver trauma. The clinical records and CT findings of 88 patients were reviewed. Angiographic study revealed potential injury to portal triads in patients with periportal tracking on CT. Extrahepatic injuries beneath the liver were associated in 22 of 28 patients with periportal tracking and in 2 of 17 without periportal tracking (P < 0.01, chi-square = 16.38). Hepatic complications such as bile leak, biloma, hemobilia, and infected hematoma were evaluated separately in 43 patients treated conservatively and 45 patients treated surgically. The incidence of complications in patients with periportal tracking was significantly higher in both groups (nonoperative; P < 0.01, chi-square = 8.46 and operative; P < 0.01, chi-square = 8.48). We conclude that periportal tracking on CT implies injury to the subhepatic region and intrahepatic portal triads and that it requires careful examination for extrahepatic injuries in the initial management and late hepatic complications in the follow-up management.

Auxiliary Liver Transplantation: A Negative Viewpoint

Auxiliary heterotopic liver transplantation is theoretically attractive because it leaves the recipient's liver in place. The surgical trauma of hepatectomy is avoided, and failure of the graft does not necessarily lead to the death of the patient or a second, emergency transplantation. Another advantage is that matching the body sizes of the donor and the recipient is not mandatory, which increases the number of possible donors. However, previous clinical results of auxiliary liver transplantation have been poor. We performed auxiliary partial liver transplantation in six consecutive patients with end–stage chronic liver disease who were not accepted for orthotopic liver transplantation because they had massive ascites, deficient clotting function, cachexia, or poor pulmonary reserve. The donor liver was transplanted to the right subhepatic region after removal of segments II and III, and it was provided with portal and arterial blood. There were no major changes in hemodynamic measurements during surgery. The mean hospital stay after transplantation was 22.7 days (range, 14 to 29). After a mean follow–up period of 14 months (range, 5 to 23), all patients were alive, with good graft function as demonstrated by scintigraphy, Doppler ultrasonography, and synthesis of clotting factors. From these observations we conclude that auxiliary partial liver transplantation is an attractive alternative to orthotopic liver transplantation in high–risk patients. Its role in other patients who need liver transplants remains to be defined.

Auxiliary Partial Liver Transplantation for End-Stage Chronic Liver Disease

Auxiliary heterotopic liver transplantation is theoretically attractive because it leaves the recipient's liver in place. The surgical trauma of hepatectomy is avoided, and failure of the graft does not necessarily lead to the death of the patient or a second, emergency transplantation. Another advantage is that matching the body sizes of the donor and the recipient is not mandatory, which increases the number of possible donors. However, previous clinical results of auxiliary liver transplantation have been poor. We performed auxiliary partial liver transplantation in six consecutive patients with end-stage chronic liver disease who were not accepted for orthotopic liver transplantation because they had massive ascites, deficient clotting function, cachexia, or poor pulmonary reserve. The donor liver was transplanted to the right subhepatic region after removal of segments II and III, and it was provided with portal and arterial blood. There were no major changes in hemodynamic measurements during surgery. The mean hospital stay after transplantation was 22.7 days (range, 14 to 29). After a mean follow-up period of 14 months (range, 5 to 23), all patients were alive, with good graft function as demonstrated by scintigraphy, Doppler ultrasonography, and synthesis of clotting factors. From these observations we conclude that auxiliary partial liver transplantation is an attractive alternative to orthotopic liver transplantation in high-risk patients. Its role in other patients who need liver transplants remains to be defined.

Ileal band in northwest Indian subjects.

The incidence of the ileal band was recorded in 1,040 northwest Indian subjects varying in age from 1 day to 100 years on whom a medicolegal postmortem had been performed by the author. The band was present in 31.8% of male and 17.5% of female subjects (P less than .05) and was either quadrilateral (60%) or triangular in shape. In addition 25 foetuses, each above 250 mm in crown-rump length, 25 neonates, 25 monkeys (Macaca mulatta), and an equal number of dogs, rabbits, guinea pigs and rats were also dissected, but the band was found to be absent. In all the foetuses dissected and in 24 out of 25 newborns the caecum was found to be either in the subhepatic or right lumbar region. The earliest age at which the band was found was 7 months. As the band was absent in the animals and the newborns, it appears that it develops in man on account of attaining an erect posture.

Saline microbubbles monitoring sonography-assisted abscess drainage.

The objective of this study was to assess the use of saline microbubbles as a sonographic contrast medium in monitoring abscess drainage. Seven abscesses were localized and drained with sonographic guidance. Four were in the brain and three were small abscesses in the liver, the subhepatic region, and the pancreas. After aspiration of the purulent material, irrigation with saline produced a highly echogenic sonographic pattern that was free of artifacts and distinctly different from the abscess contents and capsule, and the surrounding parenchyma. In one case, previously unsuspected loculation was detected, requiring repositioning of the needle for complete drainage. All abscesses were resolved and no untoward effects, such as sepsis, were encountered. In one additional patient, microbubble sonographic evaluation was used to monitor the progress of an abscess in which a percutaneous catheter was placed. Saline microbubbles may be used as a sonographic contrast medium to monitor sonography-assisted abscess drainage.

Hepatobiliary scintigraphy in congenital cystic dilatation of biliary tract.

Six preoperative and five postoperative hepatobiliary scans in children having cystic dilatation of the biliary tract were analyzed. The preoperative hepatobiliary scans revealed three distinct patterns. The type 1 pattern showed, in early scans, good hepatic uptake of radioactivity, and photon deficient area(s) around the porta hepatis or in the subhepatic region. These area(s) showed progressive accumulation of radio activity in the delayed scans. The type 2 pattern revealed poor hepatic uptake, nonvisualization of major biliary channels, and photon deficient area(s) in the porta hepatis or subhepatic region which persisted throughout the study. Preoperatively, it was possible to diagnose cystic dilatation of biliary tract in cases that showed type 1 and type 2 patterns. No preoperative diagnosis was possible when the scans showed a type 3 pattern. Analysis of results revealed a correct pre-operative diagnostic rate of 83.3% for the cystic dilatation of biliary tract. It was also possible to provide correct functional information regarding the patency of the bile outflow tract in all 11 cases, both pre- and postoperatively, with a diagnostic rate of 100%. On the basis of the overall accuracy of results obtained in this series, hepatobiliary scintigraphy is strongly advocated in suspected cases of cystic dilatation of the biliary tract for the initial diagnosis and for the assessment of the status of the bilioenteric bypass postoperatively.

Coronal upper abdominal anatomy: Technique and gastrointestinal applications

The coronal approach to the upper abdomen provides a valuable additional ultrasonographic view of the subphrenic and perirenal area bilaterally, and the hepatic and subhepatic region on the right. In patients with large amounts of overlying gas-filled bowel loops, it may provide the only ultrasonographic view into the high abdominal region. Reformatted coronal computed tomography may be used as a teaching aid and in demonstrating upper abdominal coronal anatomy. However, because of limited spatial resolution coronal computed tomography may be available and may be helpful in the evaluation of the upper abdomen.

Radiological method in the diagnosis of ectopic pregnancy

An radiology examination of 59 women with ectopic pregnancies was carried out. 44 of them (group 1) had a tubal pregnancy in the ampulla, 8 (group 2) had a non-developing pregnancy in the accessory horn of the uterus (pregnancy duration from 12 to 20 weeks) and 7 (group 3) Abdominal pregnancy (in 6 secondary at 16 to 24 weeks and in 1 primary with a full-term dead fetus in the subhepatic region). The diagnosis of abdominal pregnancy was confirmed by X-ray examination using fractional cervicohysterosalpingography. Iodolipol, urotrast, and verografin were used as contrast agents.