Hepatopulmonary syndrome (HPS) in stable patients with cirrhosis can easily be overlooked. We report on the presenting symptoms, disease progression, and outcomes after liver transplantation (LT) in children with HPS. Twenty patients were diagnosed with HPS between 1996 and 2016. The etiologies were as follows: biliary atresia (n = 9); alpha-1-antitrypsin deficiency (n = 2); cryptogenic liver disease (n = 3); and others (n = 6). HPS presentations were as follows; dyspnea (n = 17) and pneumonia (n = 3). For diagnostic confirmation, the following techniques were used: technetium-99m-labeled macroaggregated albumin lung perfusion scan (n = 13) or contrast echocardiogram (n = 7). There were 16 patients listed for LT, with a median age at HPS diagnosis of 10 years and an average wait from listing to LT of 9 weeks. A marked rise in hemoglobin (Hb; median, 125-143.5 g/L) and modest decrease in oxygen saturation (SpO ; median 91% to 88% room air) were evident over this time. Patients' need for assisted ventilation (1 day), pediatric intensive care unit (PICU) stay (3 days), and total hospital stay (20 days) were similar to our general LT recipients-the key difference in the postoperative period was the duration of supplementary O requirement. Hb of ≥130 g/L on the day of LT correlated with a longer PICU stay (P value = 0.02), duration of supplementary O (P value = 0.005), and the need for the latter beyond 7 days after LT (P value = 0.01). Fifteen patients had resolution of their HPS after LT. The 5-, 10-, and 20-year survival rates were unchanged at 87.5%. None had a recurrence of HPS. In conclusion, HPS is a life-threatening complication of cirrhosis which usually develops insidiously. This combined with the often-stable nature of the liver disease leads to delays in diagnosis and listing for LT. Progressive polycythemia extends the need for supplementary O and PICU stay. We advocate screening for HPS with a combination of SpO and Hb monitoring to facilitate earlier recognition, timely LT, and shortened recovery periods.

Introduction Management of posttraumatic bile leak has evolved over time in our unit, from endoscopic retrograde cholangiopancreatography (ERCP) stenting to intraperitoneal drainage (IPD) alone as first-line treatment for intraperitoneal bile leak. Materials and Methods Retrospective review of liver trauma patients from 2002 to 2017. Demographics, time and mode of diagnosis of bile leak, management, and outcome were analyzed of the box plot. Results In 118 patients, there were 28 traumatic bile leaks. Eighteen were free intraperitoneal and 10 were localized bilomas. The median time of diagnosis was 6 days following injury. The modes of diagnosis were preemptive hepatobiliary scintigraphy (18), computed tomography (CT) or ultrasound (7), and laparotomy (3). Free intraperitoneal biliary leak management included 11 IPD alone, 3 IPD plus ERCP, 2 IPD plus transcystic biliary stent (TBS), 1 operative cholangiogram, and 1 no intervention. Median time of IPD duration was 7 days (4–95) in IPD alone versus 14 days (6–40) in IPD + ERCP/TBS (p = 0.3). Median inpatient length of stay was 13 days (8–44) in IPD alone versus 12 days (8–22) in IPD + ERCP/TBS (p = 0.4). Conclusion Placement of IPD alone, as first-line treatment, is safe and effective in the management of intraperitoneal bile leaks, avoiding the costs and potential complications of ERCP.

Background: Laparoscopic Cholecystectomy (LC) is the gold standard surgical procedure for removal of gall bladder. However in difficult situations, it is customary to convert it to an open procedure. Methods: A prospective data analysis was done for 208 consecutive cases of LC performed in a surgical unit at National Hospital of Sri Lanka from September 2012 to January 2017. Results: Out of 208 patients, 152 were women (73.1%) with a mean age of 47.6 years (range 21-79). Biliary colic (37.5%), chronic cholecystitis (31.6%) and acute cholecystitis (10.1%) were the commonest indications for LC. Eighteen patients who had CBD stones underwent CBD exploration simultaneously. Among 208 cases 19 had empyema, 8 had mucocoele and 1 had choledochoduodenal fistula. In 31 difficult cases retrograde cholecystectomy was performed and out of them 9 patients underwent subtotal cholecystectomy. All cases were successfully managed laparoscopically with zero conversion rate. Bile spillage was the commonest complication (21.4%) and average postoperative hospital stay was 2.9 days. Conclusion: With safe dissection and timely resorting to retrograde cholecystectomy in experienced hands, there seems to be no reason for conversion to open cholecystectomy. Most of the complicated cases can be successfully managed laparoscopically without conversion to open procedure.

Background: Laparoscopic Cholecystectomy (LC) is the gold standard surgical procedure for removal of gall bladder. However in difficult situations, it is customary to convert it to an open procedure. Methods: A prospective data analysis was done for 208 consecutive cases of LC performed in a surgical unit at National Hospital of Sri Lanka from September 2012 to January 2017. Results: Out of 208 patients, 152 were women (73.1%) with a mean age of 47.6 years (range 21-79). Biliary colic (37.5%), chronic cholecystitis (31.6%) and acute cholecystitis (10.1%) were the commonest indications for LC. Eighteen patients who had CBD stones underwent CBD exploration simultaneously. Among 208 cases 19 had empyema, 8 had mucocoele and 1 had choledochoduodenal fistula. In 31 difficult cases retrograde cholecystectomy was performed and out of them 9 patients underwent subtotal cholecystectomy. All cases were successfully managed laparoscopically with zero conversion rate. Bile spillage was the commonest complication (21.4%) and average postoperative hospital stay was 2.9 days. Conclusion: With safe dissection and timely resorting to retrograde cholecystectomy in experienced hands, there seems to be no reason for conversion to open cholecystectomy. Most of the complicated cases can be successfully managed laparoscopically without conversion to open procedure.