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Noncalculous biliary obstruction in children and adolescents
716
Letters to the Editor
orienting the surgeon in a safe plane and by protecting the hepatic vein/IVC confluence. So the use of this maneuver is compatible with all available techniques of parenchymal transection. We emphasize that this maneuver should not be used in the presence of any posterolateral tumors involving the IVC. Other limitations in our experience include dense inflammatory adhesions, discovered at operation, to the IVC (frequently seen after chemoembolization) and the atrophy-hypertrophy complex observed in some cases of cirrhosis. The “hanging maneuver,” as with other new surgical techniques (ie, extrahepatic control of hepatic veins), requires a learning curve. It may be best practiced by surgeons who frequently perform the “piggy-back” technique for liver transplantation because this plane of dissection is familiar. In addition, this technique is not only useful for difficult right hepatectomies, but also in extended hepatectomy. As an example, when right hepatectomy is extended to segment 4, the tape is switched from the right to the left side of the middle hepatic vein in front of the IVC (Fig. 1). This ensures the proper plane of transection, again protects the hepatic vein insertion onto the IVC, and is particularly important when the resected liver is from a live donor. Because we believe that good graft function depends in part on excellent venous outflow, we harvest the middle hepatic vein in the right donor liver. The “hanging maneuver” allows the surgeon to be just to the left of the middle
Figure 1. Hanging maneuver. The tape traction allows the surgeon to perform a liver parenchyma transection on the left side of the middle hepatic vein.
J Am Coll Surg
hepatic vein, preserving the maximum amount of parenchyma remaining in the donor. Again, we thank the authors for their insightful comments and look forward to future data and comments regarding this new technique.
Noncalculous Biliary Obstruction in Children and Adolescents Vinicius G Gava, Araby A Nacul-Filho, MD Passo Fundo, Brazil Pryor and colleagues1 provide an interesting review of noncalculous biliary obstruction in the child and adolescent. Four major etiologic groups were proposed: primary neoplasms, infections, inflammatory conditions, and anatomic anomalies. Regarding the infection group, discussion was limited to the causes of physical obstruction at the level of the extrahepatic system. We would like to report additional infectious agents: Ascaris lumbricoides2-6 and Fasciola hepatica.7 We will limit our arguments to ascariasis because of its greater prevalence. The ascariasis infection occurs by feco-oral route when embryonated eggs are ingested. Larvae are released from eggs in the small intestine, penetrate the gut, and migrate to the liver and then lungs by the blood or lymphatic circulation. After maturation in the lungs, the parasites ascend the respiratory tract and are swallowed. The adult parasite resides in the lumen of the small intestine.2 Ascariasis is a helminthic infection of global distribution with more than 1.4 billion persons infected worldwide.2 The majority of infections occur in developing countries of Asia, Latin America, and Africa.2 The environmental conditions associated with poverty, overcrowding, unhygienic living conditions, poor sanitation, and unsafe water supply contribute to the spread of infection.3 Although ascariasis is rare in the developed world, clinicians should be aware of complications related to it because of the increased movement of tourists, immigrants, and refugees.4 The majority of the individuals infected are asymptomatic.2 Symptomatic cases are divided in two broad
Vol. 193, No. 6, Month 2001
categories according to the site of abnormality in the pulmonary or gastrointestinal tract. In the gastrointestinal tract the worms can cause mechanical obstruction2,5 or can migrate to unusual sites such as the appendix,2,5 the pancreatic duct2-4 and the biliary tree,2-6 producing a wide spectrum of symptoms and complications. In children, ascariasis is more common and heavier, making them specially prone to biliary tree invasion.3 The diagnosis of biliary obstruction requires a high degree of suspicion. Symptoms are variable. The patient who presents with right upper quadrant pain or true biliary colic and who has a history of expulsion of parasites may be harboring one or many such helminthes in the common bile duct.5,6 Pain is frequently accompanied by vomiting; the vomitus can contain the adult Ascaris.5 The abdomen can be distended. Fever is usually late in its appearance and, once present, should make one suspect ascending cholangitis, an entity that is frequently accompanied by jaundice, a palpable gallbladder, and exquisite tenderness over the hepatic area.5 Intestinal obstruction, pancreatitis, and cholecystitis can also be the clinical presentation.2,3 Among imaging techniques, ultrasonography and endoscopic retrograde cholangiopancreatography (ERCP) are of major importance. Ultrasonography is a sensitive and specific method to identify worms in the biliary tree.2-4 The sonographic findings are described elsewhere.8 ERCP is not only an excellent diagnostic tool, but also has a major therapeutic role.2-4 Because the roundworms move freely in and out the ampulla of Vater,2-4 the management of noncomplicated cases can be done using antispasmodic drugs, intravenous fluids, nasogastric tubes, systemic antibiotics if infection is associated, and antihelminthic drugs (mebendazole, albendazole, piperazine, pyrantel pamoate, levamisole).2 The biliary tree should be monitored by serial ultrasound.2 If, in few days, the worm(s) did not exit spontaneously, biliary decompression should be carried out by ERCP with the extraction of the worm(s) from the bile duct,2 and, if the patient is not hospitalized the procedure must be performed after 3 weeks.2 Antihelminthic therapy should be given before endoscopic management. Sphincterotomy, if possible, should be avoided. Complicated patients should be treated with the prior measures plus ERCP or surgery.2-5
Letters to the editor
717
REFERENCES 1. Pryor JP, Volpe CM, Carty MG, Doerr RJ. Noncalculous biliary obstruction in the child and adolescent. J Am Coll Surg 2000;191:569–578. 2. Khuroo MS. Ascariasis. Gastroenterol Clin North Am 1996;25:553–577. 3. Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary and pancreatic ascariasis in India. Lancet 1990;335:1503–1506. 4. Khuroo MS, Zargar SA, Yattoo GN, et al. Ascaris-induced acute pancreatitis. Br J Surg 1992;79:1335–1338. 5. Ochoa B. Surgical complications of ascariasis. World J Surg 1991;15:222–227. 6. Lloyd DA. Massive hepatobiliary ascariasis in childhood. Br J Surg 1981;68:468–473. 7. Nicholas JL. Obstruction of the common bile-duct by Fasciola hepatica. Occurrence in a boy of 12 years. Br J Surg 1970;57:544–546. 8. Khuroo MS, Zargar SA, Mahajan R, et al. Sonographic appearances in biliary ascariasis. Gastroenterology 1987;93:267–272.
Obstructing Colorectal Cancers John S Spratt, MD, FACS Louisville, KY With respect to the article by Lee and colleagues in the June 2001 issue of the Journal,1 we have previously reported a large series of obstructing carcinomas of the colon. In our series,2 there were 116 (10.2% among 1137) partial obstructing and 111 (9.8%) completely obstructing carcinomas. Complete follow-up was available documenting a worse prognosis. Primary resection was tolerated. With multivariate considerations, extension of the neoplasm into the outer longitudinal muscle layer was prevalent. The outer longitudinal muscle layer of the colon is responsible for perpetuating colonic peristalisis, suggesting that there is a functional hypoperistalic component to obstruction.2 That may be as important as the mechanical obstruction from the cancer mass. REFERENCES 1. Lee YM, Law WL, Chu KW, Poon RTP. Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions. J Am Coll Surg 2001;192:719–725. 2. Ragland JJ, Londe AM, Spratt JS. Correlation of the prognosis of obstructing colorectal carcinoma with clinical and pathologic variables. Am J Surg 1971;121:552–556.
Letters to the Editor
orienting the surgeon in a safe plane and by protecting the hepatic vein/IVC confluence. So the use of this maneuver is compatible with all available techniques of parenchymal transection. We emphasize that this maneuver should not be used in the presence of any posterolateral tumors involving the IVC. Other limitations in our experience include dense inflammatory adhesions, discovered at operation, to the IVC (frequently seen after chemoembolization) and the atrophy-hypertrophy complex observed in some cases of cirrhosis. The “hanging maneuver,” as with other new surgical techniques (ie, extrahepatic control of hepatic veins), requires a learning curve. It may be best practiced by surgeons who frequently perform the “piggy-back” technique for liver transplantation because this plane of dissection is familiar. In addition, this technique is not only useful for difficult right hepatectomies, but also in extended hepatectomy. As an example, when right hepatectomy is extended to segment 4, the tape is switched from the right to the left side of the middle hepatic vein in front of the IVC (Fig. 1). This ensures the proper plane of transection, again protects the hepatic vein insertion onto the IVC, and is particularly important when the resected liver is from a live donor. Because we believe that good graft function depends in part on excellent venous outflow, we harvest the middle hepatic vein in the right donor liver. The “hanging maneuver” allows the surgeon to be just to the left of the middle
Figure 1. Hanging maneuver. The tape traction allows the surgeon to perform a liver parenchyma transection on the left side of the middle hepatic vein.
J Am Coll Surg
hepatic vein, preserving the maximum amount of parenchyma remaining in the donor. Again, we thank the authors for their insightful comments and look forward to future data and comments regarding this new technique.
Noncalculous Biliary Obstruction in Children and Adolescents Vinicius G Gava, Araby A Nacul-Filho, MD Passo Fundo, Brazil Pryor and colleagues1 provide an interesting review of noncalculous biliary obstruction in the child and adolescent. Four major etiologic groups were proposed: primary neoplasms, infections, inflammatory conditions, and anatomic anomalies. Regarding the infection group, discussion was limited to the causes of physical obstruction at the level of the extrahepatic system. We would like to report additional infectious agents: Ascaris lumbricoides2-6 and Fasciola hepatica.7 We will limit our arguments to ascariasis because of its greater prevalence. The ascariasis infection occurs by feco-oral route when embryonated eggs are ingested. Larvae are released from eggs in the small intestine, penetrate the gut, and migrate to the liver and then lungs by the blood or lymphatic circulation. After maturation in the lungs, the parasites ascend the respiratory tract and are swallowed. The adult parasite resides in the lumen of the small intestine.2 Ascariasis is a helminthic infection of global distribution with more than 1.4 billion persons infected worldwide.2 The majority of infections occur in developing countries of Asia, Latin America, and Africa.2 The environmental conditions associated with poverty, overcrowding, unhygienic living conditions, poor sanitation, and unsafe water supply contribute to the spread of infection.3 Although ascariasis is rare in the developed world, clinicians should be aware of complications related to it because of the increased movement of tourists, immigrants, and refugees.4 The majority of the individuals infected are asymptomatic.2 Symptomatic cases are divided in two broad
Vol. 193, No. 6, Month 2001
categories according to the site of abnormality in the pulmonary or gastrointestinal tract. In the gastrointestinal tract the worms can cause mechanical obstruction2,5 or can migrate to unusual sites such as the appendix,2,5 the pancreatic duct2-4 and the biliary tree,2-6 producing a wide spectrum of symptoms and complications. In children, ascariasis is more common and heavier, making them specially prone to biliary tree invasion.3 The diagnosis of biliary obstruction requires a high degree of suspicion. Symptoms are variable. The patient who presents with right upper quadrant pain or true biliary colic and who has a history of expulsion of parasites may be harboring one or many such helminthes in the common bile duct.5,6 Pain is frequently accompanied by vomiting; the vomitus can contain the adult Ascaris.5 The abdomen can be distended. Fever is usually late in its appearance and, once present, should make one suspect ascending cholangitis, an entity that is frequently accompanied by jaundice, a palpable gallbladder, and exquisite tenderness over the hepatic area.5 Intestinal obstruction, pancreatitis, and cholecystitis can also be the clinical presentation.2,3 Among imaging techniques, ultrasonography and endoscopic retrograde cholangiopancreatography (ERCP) are of major importance. Ultrasonography is a sensitive and specific method to identify worms in the biliary tree.2-4 The sonographic findings are described elsewhere.8 ERCP is not only an excellent diagnostic tool, but also has a major therapeutic role.2-4 Because the roundworms move freely in and out the ampulla of Vater,2-4 the management of noncomplicated cases can be done using antispasmodic drugs, intravenous fluids, nasogastric tubes, systemic antibiotics if infection is associated, and antihelminthic drugs (mebendazole, albendazole, piperazine, pyrantel pamoate, levamisole).2 The biliary tree should be monitored by serial ultrasound.2 If, in few days, the worm(s) did not exit spontaneously, biliary decompression should be carried out by ERCP with the extraction of the worm(s) from the bile duct,2 and, if the patient is not hospitalized the procedure must be performed after 3 weeks.2 Antihelminthic therapy should be given before endoscopic management. Sphincterotomy, if possible, should be avoided. Complicated patients should be treated with the prior measures plus ERCP or surgery.2-5
Letters to the editor
717
REFERENCES 1. Pryor JP, Volpe CM, Carty MG, Doerr RJ. Noncalculous biliary obstruction in the child and adolescent. J Am Coll Surg 2000;191:569–578. 2. Khuroo MS. Ascariasis. Gastroenterol Clin North Am 1996;25:553–577. 3. Khuroo MS, Zargar SA, Mahajan R. Hepatobiliary and pancreatic ascariasis in India. Lancet 1990;335:1503–1506. 4. Khuroo MS, Zargar SA, Yattoo GN, et al. Ascaris-induced acute pancreatitis. Br J Surg 1992;79:1335–1338. 5. Ochoa B. Surgical complications of ascariasis. World J Surg 1991;15:222–227. 6. Lloyd DA. Massive hepatobiliary ascariasis in childhood. Br J Surg 1981;68:468–473. 7. Nicholas JL. Obstruction of the common bile-duct by Fasciola hepatica. Occurrence in a boy of 12 years. Br J Surg 1970;57:544–546. 8. Khuroo MS, Zargar SA, Mahajan R, et al. Sonographic appearances in biliary ascariasis. Gastroenterology 1987;93:267–272.
Obstructing Colorectal Cancers John S Spratt, MD, FACS Louisville, KY With respect to the article by Lee and colleagues in the June 2001 issue of the Journal,1 we have previously reported a large series of obstructing carcinomas of the colon. In our series,2 there were 116 (10.2% among 1137) partial obstructing and 111 (9.8%) completely obstructing carcinomas. Complete follow-up was available documenting a worse prognosis. Primary resection was tolerated. With multivariate considerations, extension of the neoplasm into the outer longitudinal muscle layer was prevalent. The outer longitudinal muscle layer of the colon is responsible for perpetuating colonic peristalisis, suggesting that there is a functional hypoperistalic component to obstruction.2 That may be as important as the mechanical obstruction from the cancer mass. REFERENCES 1. Lee YM, Law WL, Chu KW, Poon RTP. Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions. J Am Coll Surg 2001;192:719–725. 2. Ragland JJ, Londe AM, Spratt JS. Correlation of the prognosis of obstructing colorectal carcinoma with clinical and pathologic variables. Am J Surg 1971;121:552–556.