Percutaneous cholecystostomy is an alternative to cholecystectomy in patients with acute calculous cholecystitis who are at high risk for surgical mortality and morbidity. It appears to have a low complication rate and good clinical success. Because a significant number of patients suffer recurrent attacks, elective cholecystectomy should be considered routinely. Unfortunately, firm criteria for selecting percutaneous cholecystostomy over cholecystectomy are lacking, and the surgeon's clinical judgment is critically important.

In vitro1 H MRS of human bile has shown potential in the diagnosis of various hepatopancreatobiliary (HPB) diseases. Previously, in vivo 1 H MRS of human bile in gallbladder using a 1.5 T scanner demonstrated the possibility of quantification of choline-containing phospholipids (chol-PLs). However, other lipid components such as bile acids play an important role in the pathophysiology of the HPB system. We have employed a higher magnetic field strength (3 T), and a custom-built receive array coil, to improve the quality of in vivo 1 H MRS of human bile in the gallbladder. We obtained significant improvement in the quality of 1D spectra (17 healthy volunteers) using a respiratory-gated PRESS sequence with well distinguished signals for total bile acids (TBAs) plus cholesterol resonating at 0.66 ppm, taurine-conjugated bile acids (TCBAs) at 3.08 ppm, chol-PLs at 3.22 ppm, glycineconjugated bile acids (GCBAs) at 3.74 ppm, and the amide proton (ÀNH) arising from GCBAs and TCBAs in the region 7.76-8.05 ppm. The peak areas of these signals were measured by deconvolution, and subsequently the molar concentrations of metabolites were estimated with good accuracy, except for that of TBAs plus cholesterol. The concentration of TBAs plus cholesterol was overestimated in some cases, which could be due to lipid contamination. In addition, we report the first 2D L-COSY spectra of human gallbladder bile in vivo (obtained in 15 healthy volunteers). 2D L-COSY spectra will be helpful in differentiating various biliary chol-PLs in pathological conditions of the HPB system.

Recently some have called for randomized controlled trials comparing RFA to hepatic resection, particularly for patients with only a few small metastases. The objectives were to compare local recurrence and survival following RFA and hepatic resection for colorectal liver metastases. This was a retrospective review of open RFA and hepatic resection for colorectal liver metastases between January 1998 and May 2007. All patients who had RFA were considered to have unresectable disease. 58 patients had hepatic resection and 43 had RFA. A 5-year survival after resection was 43% compared to 23% after RFA. For patients with solitary lesions, a 5-year survival was 48% after resection and 15% after RFA. Sixty percent of patients suffered local recurrences after RFA compared to 7% after hepatic resection. RFA is inferior to resection. The results observed in this study support the consensus that RFA cannot be considered an equivalent procedure to hepatic resection.

To determine whether hepatocyte membrane potential differences (PDs) are depolarized in human HCC and whether depolarization is associated with changes in GABA A receptor expression, hepatocyte PDs and ␥-aminobutyric acid (GABA) A receptor messenger RNA (mRNA) and protein expression were documented in HCC tissues via microelectrode impalement, real-time reverse-transcriptase polymerase chain reaction, and Western blot analysis, respectively. HCC tissues were significantly depolarized (؊19.8 ؎ 1.3 versus ؊25. In recent in vitro studies, we demonstrated that restoration of depolarized malignant hepatocyte cell membrane potential differences (PDs) toward those documented in nonmalignant hepatocytes results in a loss of malignant features, including decreased proliferative activity, absence of colony formation in soft agar, and normalization of phenotypic appearance. 2 Whether HCC tissues are depolarized relative to adjacent nontumor tissues and the mechanisms whereby such depolarization might exist have yet to be reported.

Primary sclerosing cholangitis (PSC) has been considered to be either an "autoimmune disease" or a "bile acid-induced injury." In vitro MRS studies on PSC patients have limitations due to the contamination of bile with contrast agent (commonly administered during endoscopic retrograde cholangiopancreatography) and/or the use of patient cohorts with other diseases as controls. The objective of this study was to quantify biliary metabolites using in vivo 1 H MRS and gain insight into the pathogenesis of PSC. Biliary metabolites in 10 PSC patients and 14 healthy controls were quantified in vivo using 1 H MRS on a 3 T MR scanner. The concentrations of total bile acids plus cholesterol, glycine-conjugated bile acids, taurine-conjugated bile acids, and cholinecontaining phospholipids (chol-PLs) were compared between the two groups. There were statistically significant decreases in the levels of the above mentioned biliary metabolites in the PSC patients compared with controls. The reduction in bile acid secretion in bile of PSC patients indicates accumulation of bile acids in hepatocytes.Moreover, reduction in the levels of chol-PLs in bile may increase the toxic effects of bile acids. Our findings suggest that the bile duct injury in PSC patients is most likely due to "bile acid-induced injury." KEYWORDS choline-containing phospholipids, glycine-conjugated bile acids, human bile, in vivo 1 H MRS, L-COSY, pathogenesis, primary sclerosing cholangitis, taurine-conjugated bile acids

Prior to the advent of somatostatin conservative therapy for pancreatic fistulas, treatment included intravenous nutritional therapy with nothing per mouth and therapeutic agents to diminish pancreatic secretions. None of these modalities were uniformly successful. A prospective study to evaluate the efficacy of a long-acting somatostatin analogue (Sandostatin) was carried out. 18 patients – 10 with pancreatic ascites and 8 with external pancreatic fistulas -were treated. The ascites resolved in 9 of 10 patients in a mean period of 22 days ( ± 3 days). The external fistulas were all high output fistulas and resolved in 7 of 8 patients. Mean period for closure was 23 days [5]. There were no side effects associated with Sandostatin. Sandostatin has made a major impact on the conservative treatment of pancreatic ascites and is an important adjunct to the management of external pancreatic fistulas. It is emphasised however that surgery may be required for the underlying pancreatic disease. In this regard close surveillance of these patients is necessary.

Emergency gallbladder surgery in the elderly was not associated with higher mortality or complication rate compared with the elective setting. Elderly patients with gallbladder-related emergencies should be offered urgent surgery when feasible.

BackgroundSurgery appears to be an underutilized treatment option for pancreatic cancer. Nihilistic physician attitudes may be partly responsible. The study objectives were to analyze physician attitudes towards this disease and determine treatment patterns and outcomes including rates of surgical referral.MethodsA survey was administered to 420 physicians in Manitoba to document general knowledge and attitudes. Population based administrative data was accessed for all patients diagnosed with pancreatic cancer between 2004 and 2006 to examine treatment patterns and outcomes.Results181 physicians responded to the survey. Most (73%) believed that surgical resection was worthwhile. Of the 413 Manitobans diagnosed with pancreatic cancer, only 11% underwent an attempt at surgical resection. There were 124 patients with stage I or II disease (i.e. potentially resectable), 85 of these patients received no treatment and 39% were not referred to a surgeon. These patients were older than those referred, but did not have more comorbidities.ConclusionMost physicians were insightfully aware of both the survival benefit and potential risks of surgical resection. However, some did overestimate the surgical mortality and underestimate the associated survival benefit. Although advanced age may justly account for some of the patients not receiving a referral, it is reasonable to assume that nihilistic physician attitudes is contributing to the apparent underutilization of surgery for pancreatic cancer. Efforts should be made to ensure that eligible patients are at least offered surgery as a potential treatment option.