Determination of dietary intake of total arsenic, inorganic arsenic and total mercury in the Chilean school meal program.

The dietary intake of total arsenic (tAs), inorganic arsenic (iAs) and total mercury (tHg) in lunch and breakfast servings provided by the Chilean School Meal Program (SMP) was estimated, using the duplicate-portion variant of the total diet study. Lunch and breakfast samples were collected from 65 schools throughout the country in 2006. The population sample was a group of girls and boys between 6 and 18 years old. The tAs concentration was measured via hydride-generation atomic absorption spectrometry. The total mercury concentration was measured via cold-vapor atomic absorption spectroscopy. The estimated iAs intake was 12.5% (5.4 µg/day) of the Provisional tolerable daily intake (PTDI) as proposed by the FAO/WHO, and the tHg intake was 13.2% (1.9 µg/day) of the PTDI as proposed by the FAO/WHO. It was therefore concluded that tAs, iAs and tHg intake from food provided by the SMP do not pose risks to student health.

Assessment of total mercury levels in Clarias gariepinus from the Sagua la Grande River, Cuba.

Total mercury levels (Thg) were quantified in Clarias gariepinus captured from the Sagua la Grande River (Cuba) in the vicinity of an active chlor-alkali plant, and relationships among place of capture; fish size, weight, and sex; and THg levels were assessed. THg levels ranged from 67 to 375 ng/g ww in collected fish, never exceeding the Cuban recommended maximum limit for fish consumption of 500 ng/g ww. No significant correlation was observed between mercury levels and fish allometric characteristics (p < 0.05); however, levels were significantly higher in fish captured below the chlor-alkali facility, suggesting a connection between mercury bioaccumulation and plant discharges.

Estimate of mercury and methyl mercury intake associated with fish consumption from Sagua la Grande River, Cuba.

This paper provides an estimate of the weekly intake of total mercury (THg) and methyl mercury (MeHg) from consumption of fish from the Sagua la Grande River, Villa Clara, Cuba, by determining the THg levels in different fish species. The levels varied between 0.143 and 0.484 µ g g(-1) on a fresh weight basis. None of the analysed fish was found to have levels above the national and international regulatory levels, although THg levels over 0.2 µ g g(-1), the threshold concentration established by the World Health Organization (WHO) for the consumption by vulnerable population groups, were found in 75% of samples. The MeHg level was found to be 84% of the THg content. A Food Frequency Survey was given to 127 townspeople to estimate river fish consumption. The weekly intake of MeHg was found to be greater than the value established by the provisional tolerable weekly intake (PTWI) in 50% of children, in 80% of pregnant women, and in 75% of women in childbearing age. These weekly intakes can represent an important risk to the population's health, especially for vulnerable groups.

Intraperitoneal bile collections after laparoscopic cholecystectomy: causes, clinical presentation, diagnosis, and treatment.

BACKGROUND: Bile leakage is more common after laparoscopic cholecystectomy than after open surgery. In our department, the rate of postoperative bile collections after open surgery is 0.2% vs 0.6% after laparoscopic cholecystectomy. METHODS: We studied 13 cases of intraperitoneal bile collection without common bile duct damage drawn from a total of 5,200 laparoscopic cholecystectomies (0.23%). Clinical presentation, symptoms, method of diagnosis, causes, time of diagnosis, correlation of time of diagnosis with definitive treatment, and postoperative results were analyzed. RESULTS: The symptoms appeared between the 5th and 8th postoperative days. They were observed in patients with either chronic or acute cholecystitis. The main causes were misapplication of clips at the cystic duct and open Luschka's duct. Ultrasound failed for early recognition of bile collections. The definitive diagnosis was made by repeat ultrasonography, CAT scan, and ERCP. CONCLUSION: The ideal treatment in these cases is a minimally invasive procedure, but since the diagnosis is frequently delayed, open surgery is performed in the majority of patients. However, there were no mortalities in this group of patients.

Gallbladder carcinoma during laparoscopic cholecystectomy: is it associated with bad prognosis?

Laparoscopic cholecystectomy is the treatment of choice for gallstone disease. The ultrasonogram has failed for the early detection of gallbladder cancer, especially if inflammation (chronic or acute) is present. Incidental gallbladder could be an important cancer finding during laparoscopic cholecystectomy, due to the potential cancer cell dissemination during the procedure. In our Department, 6500 laparoscopic cholecystectomies have been performed in the last 5 years and in 15 cases (0.23%) gallbladder cancer was found during surgery or after histological examination of the resected gallbladder. In none of these 15 patients was pre-operative diagnosis of gallbladder carcinoma postulated. When re-evaluation of the pre-operative ultrasonograms was done, it was possible to observe signs suggesting the presence of neoplastic infiltration in 4 of them (28.6%). During videoscopic exploration, also in 4 patients, the suspicion of gallbladder cancer was noted. Laparoscopic cholecystectomy was completed in 9 patients. In 2 of them, in situ or mucosal invasion was demonstrated with a long survival. One patient presented recurrence at the biliary hilum 2,5 years after surgery. Six patients were re-operated and in 4 of them peritoneal or port site metastasis was found; all died early (4.5 month median survival). The other 2 patients were submitted to liver bed resection and lymph node dissection. These patients are free of cancer recurrence after 15 months of follow-up. Six patients were converted to open surgery, performing palliative procedures and died before the 12 month follow-up. The suspicion of pre-operative gallbladder cancer is generally unlikely to be confirmed based on ultrasonographic signs; but, in some cases with high suspicion, further investigation (TAC, tumor markers, etc.) must be indicated in order to avoid poor results. Laparoscopic cholecystectomy could be associated with bad prognosis, and then, when gallbladder cancer is suspected during the laparoscopic procedure, conversion to open surgery could be the best choice.

Long-term follow-up after laparoscopic cholecystectomy without routine intraoperative cholangiography.

The indications for routine intraoperative cholangiography remain controversial. We present here our recent results concerning the frequency of unknown retained common bile duct stones in 253 consecutive patients who underwent laparoscopic cholecystectomy without intraoperative cholangiography in whom the presence of preoperative choledocholithiasis had been excluded by clinical, biochemical, and ultrasonographic evaluation. These patients were followed up for at least 4 years after surgery with evaluations similar to those made preoperatively. Freedom from symptoms and normal test results were found in 96.8% of patients. Jaundice and abnormal liver function test results were demonstrated in 3.2% of patients, but retained common bile duct stones were found in only 2.3% of patients. We conclude that laparoscopic cholecystectomy without routine intraoperative cholangiography can be performed safely without the discovery of a high percentage of retained common bile duct stones at later follow-up.

Correlation among ultrasonographic and videoscopic findings of the gallbladder: surgical difficulties and reasons for conversion during laparoscopic surgery.

Laparoscopic cholecystectomy is currently the standard procedure for chronic and acute cholecystitis. The purpose of this prospective study was to evaluate the preoperative ultrasound findings of the gallbladder and correlate those aspects with surgical videoscopic and histopathologic findings and the results concerning intraoperative complications and the conversion index to open surgery. Gallbladder findings were classified into three categories according to the gallbladder wall characteristics and the presence of visible lumen and stones. Simple chronic cholecystitis (type I) and acute cholecystitis, with gallbladder wall thickness <5 mm (type IIa) presented significantly lower intraoperative complications without conversion to open surgery. Scleroatrophic (type III) and acute cholecystitis with gallbladder wall thickness >5 mm (type IIB) presented significantly more surgical difficulties and a higher conversion rate to open surgery (p < 0.01). We postulate that this classification will be useful for surgeons in predicting potential problems in individual patients, at least at the initial laparoscopic cholecystectomy experience, and in advising patients of the potential risks of and conversion to open surgery.

Gallstone ileus.

A retrospective analysis of 74 patients with gallstone ileus detected during the period between 1975 and 1987 was performed at the Surgical Department. The group comprised 55 females and 19 males, with a mean age of 64.8 years. Previous biliary symptoms had been observed in 76% of the cases and in 58% there had been concomitant disease. The main duration of symptoms previous to admission was 3.4 days. In 85% of the cases complementary diagnostic procedures were performed. The triad of air in the biliary tract, air-fluid levels and ectopic stone was found in only 9.5% of the cases. The preoperative diagnosis of gallstone ileus was made in 31% of the patients. The preoperative period was 2.2 days. The main surgical procedure was enterolithotomy in 92% of the cases, the site of impaction being the terminal ileum in 65%. Only in 1 case was simultaneous biliary tract surgery and enterolithotomy performed. Overall, the 30-day postoperative mortality rate was 13.5%, with intra-abdominal sepsis as the main cause of death. Sixteen patients were submitted to biliary surgery 2 to 6 months later, and no deaths occurred.

Histological analysis of liver parenchyma and choledochal wall, and external diameter and intraluminal pressure of the common bile duct in controls and patients with common bile duct stones with and without acute suppurative cholangitis.

The purpose of this prospective controlled study was to determine the changes in intraluminal pressure and diameter of the common bile duct in a total of 121 bile patients with choledocholithiasis, and the consequences of these alterations for choledochal mucosa and liver histology. In fact, the reflux of bacteria from the obstructed biliary tract into the bloodstream is responsible for producing the clinical syndrome of acute suppurative cholangitis. Group I (26 patients) served as controls, Group II (50) had choledocholithiasis with clear green bile, and Group III (45) were patients with acute suppurative cholangitis with pus in the biliary tract. Ultrasonography revealed gallstones in all the patients. The external diameter of the common bile duct in patients with choledocholithiasis and acute suppurative cholangitis was significantly greater than in those of the other groups. Patients with acute suppurative cholangitis also had a higher intraluminal pressure than those of Groups I or II.

Common bile duct pressure in patients with common bile duct stones with or without acute suppurative cholangitis.

Resting common bile duct pressure was measured in three groups of patients: group 1, 53 patients with gallstones but without common duct stones; group 2, 35 patients with common bile duct stones unaccompanied by cholangitis; and group 3, 36 patients with common duct stones and acute suppurative cholangitis. A significantly higher pressure in the common bile duct was documented in patients with cholangitis when compared with the other two groups. Twenty-four patients with cholangitis had common duct pressure values above 20 cm H2O, the maximal values of normal. Additionally, patients with cholangitis with pressure values over 30 cm H2O (nine patients) showed absence of green bile in the extrahepatic biliary tract, suggesting cessation of bile excretion into biliary duct. In all these cases, an impacted stone at the distal end of the common bile duct was documented.

Anomalies of extrahepatic biliary duct and gallbladder associated with intestinal malrotation: a case report.

Knowledge of congenital anomalies in abdominal viscera is important for surgeons, if they are to treat such patients and solve their problems adequately. This article presents an unusual case of reversed rotation of the intestine associated with anomalies in the biliary tract and gallbladder. This patient underwent surgery because of a bleeding duodenal ulcer. During surgery the following viscera positions were detected: the gallbladder was located to the left of the round ligament, the choledochus was in front of the first portion of the duodenum, the small intestine was in the left portion of the abdomen, and the colon was exclusively at the right side of the abdomen. This reversed rotation is a rare condition, only occasionally reported in the literature. However, the simultaneous association with anomalies in the gallbladder position (in the left lobe) and the biliary tract (the choledochus located in front of the duodenum) makes this a case unlike any other described in the medical literature.