By Prof Steve Beningfield From Friday 13th to Sunday 15th October this year, the inaugural meeting of the Hepato-Pancreatico-Biliary Association of South African (HPBASA) was held in the Sandton Convention Centre. Organised by Professor Martin Smith and Dr Jose Ramos on behalf of the founding committee, this meeting was decidedly not dominated by any group, but was rather specifically meant as a multidisciplinary gathering of those inter- ested in liver and pancreatic disease. Radiology was represented by a number of our group, as were radiation oncologists, nuclear medicine physicians, surgeons, phy- sicians, anaesthetists, the medical funders and the ultimate arbiters, the pathologists. Regrettably, one of the liver pathology pio- neers, Professor Pauline Hall, was unable to be present. A number of interesting sessions included discussions on non-alcoholic fatty liver dis- ease (NAFLD) and non-alcoholic steato- hepatitis (NASH), and the importance in suspecting this condition, particularly before liver resection. Overt steatosis can compro- mise the residual liver postoperatively, lead- ing to potentially fatal acute liver failure. Liver biopsy and the current role of cytol- ogy were also discussed, with some of the controversy around tumour seeding of the biopsy track debated. Recurrent acute idiopathic pancreatitis and its investigation came under scrutiny, with the role of endoscopic ultrasound (EUS) and microlithiasis highlighted. Pancreatic cancer was also examined, including the various chemotherapy and radiotherapy options, but there remains little positive in this condition. Liver tumours were broadly discussed, and in particular the role that gadobenate in MRI has in resolving focal nodular hyper- plasia (FNH) versus adenoma was presented by Martin Haagensen. The thorny issue of an FNH without a scar versus well-differenti- ated hepatocellular carcinoma (HCC) could possibly be resolved by this agent, using the delayed scans to prove biliary excretion and therefore presumably a functional drainage system. The potential for delayed excretion by the nodular-type cholangiocarcinoma (and possibly HCC) would need to be con- sidered, however. Therapeutic intervention for HPB malig- nancy, including cholangiocarcinoma and metastases, was presented by Charles Sanyika. A clear overview of the radiologi- cal options in tumor oncology was given, with the relative values of radiofrequency ablation, percutaneous ethanol injection and chemoembolisation debated. The role of radioactive yttrium also has some sup- porters. The differences in behaviour of the ‘African’ versus ‘Asian’ types of HCC still has no clear resolution, but may account for the variation in reported efficacy of chemoem- bolisation. EUS is very much the up-and-coming modality, with a number of pivotal roles sup- ported for this technology, but the difficulty in learning the ultrasound component was emphasised. A thought-provoking presentation on conscious sedation focussed on the dangers of over-sedation for procedures. Pancreatic and liver cysts were covered, including management of the increasingly diagnosed intraductal papillary mucinous neoplasm (IPMN - previously also called ductectatic mucinous adenocarcinoma). Mucinous cystic neoplasms generally were also addressed by Professor Christos Dervenis from Greece. IPMN, in particular, has experienced a similar rise from obscurity that has been seen with gastrointestinal stro- mal tumours (GISTs) - the recent upsurge of IPMN has reportedly been labelled ‘a plague’. Fibro-polycystic liver disease (liver or duc- tal plate malformations) was very well pack- aged by Prof Alan Paterson from Wits, who drew the audience’s attention to a seminal article by Desmet1 attempting to link togeth- er the confusing and apparently discrete enti- ties of the polycystic liver diseases, Caroli’s (both the disease and the syndrome - did you know they were different?), plus those little nuisances better known to pathologists, the von Meyenburg complexes. In essence the proposal is that there is either an ectatic or an involutional (or necroinflammatory) process that affects the development of the ductal plate system at various levels of branching. (The ductal plate is an embryological sleeve of periportal tissue that goes on to become the biliary tree). Varying degrees of associ- ated fibrosis occur in either process. It is broken down thus: A useful pictorial review covering the same theme has recently appeared in Radiographics.2 The Johannesburg transplantation group’s activities were thoroughly covered, empha- sising some of the particular local finan- cial, political, and ethical issues around liver transplants. The present status of their pancreatic transplantation programme was also covered, detailing the move away from the use of the pancreatic duct-to-bladder implant to gut implantation. Intrahepatic islet cell transplants (injected into the portal vein), the delegates were told, had not shown good long-term results so far. Also, a number of donor pancreases are required to harvest cells for a single patient. Thrombosis and portal hypertension were also covered from medical, radiological and surgical perspectives. The transjugular intra- heptic stent (TIPS) technique has largely moved shunting activity away from surgery, but there was a strong view expressed that surgical shunting may need to be dusted off and re-introduced. Covered TIPS stents appear to offer the promise of longer patency, but there is also work at reducing flow in patients with TIPS who develop problematic hepatic encephalopathy (which can be devas- tating to personal function). All in all, this was a very useful forum to gain in-depth insights into the way the other members of a team address the diseases affecting a particular group of organs. There was strong support for making this an annual gathering, and again, with the specific intent of making it as inclusive as possible. 1. Desmet VJ. Congenital diseases of intrahepatic bile ducts: varia- tions on the theme ‘ductal plate malformation’. Hepatology 1992; 16:1069-1083 2. Brancatelli G, Federle MP, Vilgrain V, Vullierme MP, Marin D, Lagalla R. Fibropolycystic liver disease: CT and MR imaging findings. Radiographics 2005; 25: 659-670. The HPBASA inaugural meeting Hepato pancreatico biliary imaging Contributor: Steve Beningfield 39 SA JOURNAL OF RADIOLOGY • December 2006 b Table I Biliary branches Ectasia Necroinflammatory Small Autosomal- von Meyenburg dominant complexes/ polycystic kidney ‘microhamarto- disease (ADPKD) mas’ (the old adult type) Medium size Autosomal- Congenital hepatic recessive polycystic fibrosis (CHF) kidney disease (ARPKD) (the old infantile type) Central/large Caroli's disease Caroli's syndrome ducts (= Caroli's disease plus CHF) Extrahepatic Choledochal cyst Extrahepatic biliary atresia pg39.indd 39 12/11/06 11:04:05 AM