Prognostic value of positive surgical margins after resection of cholangiocarcinoma. Experience at a high-volume hospital center specializing in hepatopancreatobiliary surgery. / Valor pronóstico del margen quirúrgico positivo tras la resección de un colangiocarcinoma. Experiencia en un centro de alto volumen en cirugía hepatopancreatobiliar.

INTRODUCTION AND AIMS: Cholangiocarcinoma accounts for 3% of gastrointestinal tumors and is the second most frequent hepatic neoplasia after hepatocellular carcinoma. The primary aim was to evaluate the median disease-free period and survival in patients with cholangiocarcinoma diagnosis through the comparison of R0 and R1 resection margins. MATERIAL AND METHODS: A retrospective analysis was conducted on 36 patients that underwent some type of surgical resection due to cholangiocarcinoma diagnosis, within the time frame of 2000-2017, at a center specializing in hepatopancreatobiliary surgery. Population, preoperative, and oncologic variables were included. The IBM Statistical Package for the Social Sciences for Mac, version 16.0, software (IBM SPSS Inc., Chicago, IL, USA) was employed. RESULTS: Thirty-one patients underwent hepatectomy, the Whipple procedure, or bypass surgery, depending on tumor location. The statistical significance of survival between patients with positive margins and those with negative margins was evaluated through the Mann-Whitney U test, with a P<.05 as the reference value. No statistically significant difference was found. The overall morbidity rate was 58.06% (n=18) and the mortality rate was 12.9% (n=4). CONCLUSIONS: No statistically significant difference in relation to the incidence of disease recurrence or general survival resulted from the comparison of microscopically positive surgical margins (R1) and negative surgical margins (R0). There was also no correlation between preoperative CA 19-9 levels and disease prognosis.

Percutaneous cholecystostomy as treatment for acute cholecystitis: What has happened over the last five years? A literature review. / Colecistostomía percutánea como tratamiento de colecistitis aguda: ¿qué ha pasado en los últimos 5 años? Revisión de la literatura.

Acute cholecystitis is one of the most frequent diseases faced by the general surgeon. In recent decades, different prognostic factors have been observed, and effective treatments described, to improve the results in patients with said pathology (lower morbidity and mortality, shorter hospital stay, and minimum conversion of laparoscopic to open procedures). In general, laparoscopic cholecystectomy is the standard treatment for acute cholecystitis, but it is not exempt from complications, especially in patients with numerous comorbidities or those that are critically ill. Percutaneous cholecystostomy emerged as a less invasive alternative for the treatment of acute cholecystitis in patients with organ failure or a prohibitive surgical risk. Even though it is an effective procedure, its usefulness and precise indications are subjects of debate. In addition, there is little evidence on cholecystostomy catheter management. We carried out a review of the literature covering the main aspects physicians involved in the management of acute cholecystitis should be familiar with.

Influence of land development on stormwater runoff from a mixed land use and land cover catchment.

Mitigating for the negative impacts of stormwater runoff is becoming a concern due to increased land development. Understanding how land development influences stormwater runoff is essential for sustainably managing water resources. In recent years, aggregate low impact development-best management practices (LID-BMPs) have been implemented to reduce the negative impacts of stormwater runoff on receiving water bodies. This study used an integrated approach to determine the influence of land development and assess the ecological benefits of four aggregate LID-BMPs in stormwater runoff from a mixed land use and land cover (LULC) catchment with ongoing land development. It used data from 2011 to 2015 that monitored 41 storm events and monthly LULC, and a Personalized Computer Storm Water Management Model (PCSWMM). The four aggregate LID-BMPs are: ecological (S1), utilizing pervious covers (S2), and multi-control (S3) and (S4). These LID-BMPs were designed and distributed in the study area based on catchment characteristics, cost, and effectiveness. PCSWMM was used to simulate the monitored storm events from 2014 (calibration: R2 and NSE>0.5; RMSE <11) and 2015 (validation: R2 and NSE>0.5; RMSE <12). For continuous simulation and analyzing LID-BMPs scenarios, the five-year (2011 to 2015) stormwater runoff data and LULC change patterns (only 2015 for LID-BMPs) were used. Results show that the expansion of bare land and impervious cover, soil alteration, and high amount of precipitation influenced the stormwater runoff variability during different phases of land development. The four aggregate LID-BMPs reduced runoff volume (34%-61%), peak flow (6%-19%), and pollutant concentrations (53%-83%). The results of this study, in addition to supporting local LULC planning and land development activities, also could be applied to input data for empirical modeling, and designing sustainable stormwater management guidelines and monitoring strategies.

Monitoring and predicting the fecal indicator bacteria concentrations from agricultural, mixed land use and urban stormwater runoff.

While the urban runoff are increasingly being studied as a source of fecal indicator bacteria (FIB), less is known about the occurrence of FIB in watershed with mixed land use and ongoing land use and land cover (LULC) change. In this study, Escherichia coli (EC) and fecal streptococcus (FS) were monitored from 2012 to 2013 in agricultural, mixed and urban LULC and analyzed according to the most probable number (MPN). Pearson correlation was used to determine the relationship between FIB and environmental parameters (physicochemical and hydrometeorological). Multiple linear regressions (MLR) were used to identify the significant parameters that affect the FIB concentrations and to predict the response of FIB in LULC change. Overall, the FIB concentrations were higher in urban LULC (EC=3.33-7.39; FS=3.30-7.36log10MPN/100mL) possibly because of runoff from commercial market and 100% impervious cover (IC). Also, during early-summer season; this reflects a greater persistence and growth rate of FIB in a warmer environment. During intra-event, however, the FIB concentrations varied according to site condition. Anthropogenic activities and IC influenced the correlation between the FIB concentrations and environmental parameters. Stormwater temperature (TEMP), turbidity, and TSS positively correlated with the FIB concentrations (p>0.01), since IC increased, implying an accumulation of bacterial sources in urban activities. TEMP, BOD5, turbidity, TSS, and antecedent dry days (ADD) were the most significant explanatory variables for FIB as determined in MLR, possibly because they promoted the FIB growth and survival. The model confirmed the FIB concentrations: EC (R(2)=0.71-0.85; NSE=0.72-0.86) and FS (R(2)=0.65-0.83; NSE=0.66-0.84) are predicted to increase due to urbanization. Therefore, these findings will help in stormwater monitoring strategies, designing the best management practice for FIB removal and as input data for stormwater models.

[Current management of benign and malignant bile duct strictures]. / Manejo de las estenosis benignas y malignas de las vías biliares.

Benign and malignant bile duct strictures require multidisciplinary management. The radiologist, endoscopist and surgeon must assess the general conditions of the patient, as well as the etiology of the stenosis and the therapeutic options (palliative, temporal, or definitive). Stenotic injuries that maintain bilioenteric continuity are susceptible to radiologic and/or endoscopic treatment, specially benign lesions, usually appearing in the postsurgical period. Injuries with loss of continuity require surgical management in almost every case. Iatrogenic bile duct injuries with preserved continuity (Strasberg A and D) may be treated by endoscopy. Types B and C, in which a liver segment loses communication with the remaining bile tree, need surgical repair and/or resection. Complete sections of the bile ducts require surgical intervention, with hepatojejunostomy being the best choice. The use of metallic endoluminal stents is almost prohibited in these types of injuries. Benign, non-iatrogenic injuries (sclerosing cholangitis, autoimmune cholangiopathy) require surgical intervention in rare occasions. Malignant injuries are extremely aggressive and only a small percentage (less than 15%) is candidate for curative resection, which unfortunately does not preclude recurrence.

Evaluation and management of the persistent/recurrent varicocele.

OBJECTIVE: To review outcomes in adolescent patients following redo varicocelectomy surgery. METHODS: The composite varicocele registry of a single surgeon was queried to identify patients who had undergone redo varicocelectomy. Variables of testicular asymmetry, testicular volume, presence and degree of retrograde venous flow, and incidence of postoperative hydrocele were evaluated. RESULTS: Nineteen boys were identified as having had a redo varicocelectomy (16 open, 1 laparoscopic, 2 radiographic embolization) with a minimum postoperative follow-up of 6 months (mean: 23.4; range: 6-53 months). No varicocele was palpable postoperatively among the 17 surgical redoes; one patient's testicle was significantly smaller after surgery, and 3 developed a hydrocele requiring repair. One of two boys who underwent radiographic embolization had a persistent varicocele. Eight of the nine boys who had asymmetry of 10% or greater before redo demonstrated catch-up growth after repair. The consistent intraoperative finding in all redo patients was the presence of large veins within the cord, just proximal to the junction with the vas and in continuity with the dilated veins distal to the internal ring. Post-redo retrograde venous flow was not identifiable in 16 and minimal in three. CONCLUSIONS: Redo varicocelectomy can be accomplished successfully and has a similar chance of achieving catch-up growth as does an initial repair. Postoperatively, there exists a small risk of testicular volume compromise and a significant risk of hydrocele development. Distal collateral veins may have a smaller role in varicocele formation and recurrence than previously thought.

[Indications of hepatectomy for iatrogenic biliary injury.]. / Indicaciones de hepatectomía en lesión biliar iatrógena.

BACKGROUND: The most efficient surgical procedure to treat bile duct injuries is a Roux en Y hepatoyeyunoanastomosis (RY-HYA). A small group of patients who have undergone a RY-HTA develop cholangitis without jaundice, with proven permeability of the anastomosis. OBJECTIVE: To describe our experience in this subgroup of patients. PATIENTS AND METHODS: 355 patients received surgical treatment for BDI with a RY-HYA. Medical charts of patients diagnosed with segmentary cholangitis involving a single hepatic lobe were reviewed. Segmentary cholangitis with intra-hepatic abscess was diagnosed through computer tomography, endoscopic retrograde cholangiopancreatography or by percutaneous transhepatic cholangiography. RESULTS: We found 10 patients with segmentary cholangitis within the 355 cases in our series. Eight of them received treatment with a right hepatectomy and two of them with a left hepatectomy. In every patient, the hepatoyeyunoanastomosis was dismantled during the reoperation, corroborating the presence of a wide and permeable anastomosis. Surgical exploration was conducted through the hepatic ducts. After the affected lobe hepatectomy a new hepatoyeyunoanastomosis was performed. Out of the 10 patients one died (mortality 10%) due to hepatic cirrhosis. In the rest of the group a satisfactory resolution of the segmentary cholangitis was observed. CONCLUSIONS: In our series, 3% of the patients required a mayor hepatectomy for the persistent cholangitis to resolve, despite the presence of a functional bilioenteric anastomosis. Segmentary cholangitis must be suspected in patients with normal levels of direct bilirubin and abnormal liver function tests with clinical manifestations of cholangitis.

[Factors associated with survival in liver resection for metastatic colorectal carcinoma]. / Factores asociados a superviviencia en la resecciónhepática por metástasis de cáncer de colon y recto. Experiencia en el Instituto de Ciencias Médicasy Nutrición "Salvador Zubirán".

BACKGROUND: The liver is the organ in which often metastasize primary tumors. Knowledge of the etiology and forms of presentation of metastatic disease is key to deciding on the different treatment options. OBJECTIVE: Describe the surgical management of liver metastases in colorectal cancer and factors that affect the survival of patients. PATIENTS AND METHODS: We reviewed 43 cases of patients with metastatic liver cancer of the colon or rectum, who underwent liver surgery, attended January 1990 to December 2007. We analyzed demographic variables and perioperative associated with the survival of patients. There was the course and type of postoperative complications as well as the direct causes of mortality. RESULTS: Were conducted mostly metastasectomies (n = 25), followed by right hepatectomy (n = 9),and left hepatectomy (n = 9). Surgical mortality was 4.6% (n = 2). The survival rate at 1, 3 and 5 year were 45% (18 patients), 42.5% (18 patients)and 12.5% (5 patients), respectively. The presence of a single metastatic lesion (p = 0.006), size of the lesion larger than 5 cm (p = 0.003), positive lymph nodes (p = 0.002), synchronous tumor (p = 0.04),presence of extra hepatic disease (p = 0.01), positive margin (p = 0.001) and blood loss >2000 mL were significantly associated with a lower survival rate. CONCLUSION: After hepatic resection for metastatic colorectal cancer the presence of more than one tumor, > of 5 cm, with presence of synchronous tumor, nodes and positive margins, extra hepatic disease, as well blood loss > 2000 mL are factors associated with a worse survival.

[Postoperative handling in biliodigestive derivation by iatrogenic bile duct injury]. / Manejo posoperatorio en derivación biliodigestiva por lesión iatrógena de vía biliar.

Bile duct injury is a severe complication related to cholecystectomy, impacting in the long-term quality of life and functional status. Bile duct repair is the first-line treatment for complex injuries. During short-term and long-term postoperative care, it is important to bear in mind the diagnostic tools, both laboratory and imaging, that will be useful to evaluate a possible surgical complication and to plan an adequate therapeutic strategy. In addition, post-surgical classification describes patients according to their complications and clinical course. In this review we describe the principal issues of postoperative care after bile duct repair, highlighting the diagnosis, severity classification and therapeutic approach of acute cholangitis.

Evidence for Ca(2+)-permeable AMPA receptors in the olfactory bulb.

alpha-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors (AMPARs), a subtype of glutamate receptor, contribute to olfactory processing in the olfactory bulb (OB). These ion channels consist of various combinations of the subunits GluR1-GluR4, which bestow certain properties. For example, AMPARs that lack GluR2 are highly permeable to Ca(2+) and generate inwardly rectifying currents. Because increased intracellular Ca(2+) could trigger a host of Ca(2+)-dependent odor-encoding processes, we used whole cell recording as well as histological and immunocytochemical (ICC) techniques to investigate whether AMPARs on rat OB neurons flux Ca(2+). Application of 1-naphthylacetyl spermine (NAS), a selective antagonist of Ca(2+)-permeable AMPARs (CP-AMPARs), inhibited AMPAR-mediated currents in subsets of interneurons and principal cells in cultures and slices. The addition of spermine to the electrode yielded inwardly rectifying current-voltage plots in some cells. In OB slices, olfactory nerve stimulation elicited excitatory responses in juxtaglomerular and mitral cells. Bath application of NAS with d,l-2-amino-5-phosphonovaleric acid (AP5) to isolate AMPARs suppressed the amplitudes of these synaptic responses compared with responses obtained using AP5 alone. Co(2+) staining, which involves the kainate-stimulated influx of Co(2+) through CP-AMPARs, produced diverse patterns of labeling in cultures and slices as did ICC techniques used with a GluR2-selective antibody. These results suggest that subsets of OB neurons express CP-AMPARs, including functional CP-AMPARs at synapses. Ca(2+) entry into cells via these receptors could influence odor encoding by modulating K(+) channels, N-methyl-d-aspartate receptors, and Ca(2+)-binding proteins, or it could facilitate synaptic vesicle fusion.

Acute bile duct injury. The need for a high repair.

BACKGROUND: An immediate repair is considered optimal in acute biliary duct injuries; however, it may prove to be a challenge, because such repairs are usually performed on small ducts whose viability cannot always be determined. METHODS: We performed a retrospective review of the charts of patients with acute bile duct injury who underwent repair at a tertiary care academic university hospital. A total of 204 patients with acute bile duct injury were seen between 1989 and 2002. Of these, 30 were repaired within minutes to hours after the injury. These patients were divided into two groups. Group I patients had a Roux-en-Y hepatojejunostomy below the hepatic junction; Group II patients had a Roux-en-Y hepatojejunostomy at the junction level. We then performed a long-term evaluation of anastomosis function in these patients, using clinical, radiological, and laboratory. RESULTS: Twenty-eight injuries were secondary to a laparoscopy; the other two resulted from open cholecystectomies. All of the patients suffered complex injuries with complete section of the duct and substance loss (Strasberg E). There were 12 patients in group I and 18 in group II. Three cases in group I (25%) and one in group II (5%) developed anastomosis dysfunction. Mean follow-up was 56 months (range, 12-80) in group I and 52 months (range, 10-76) in group II. Two cases in group I (16%) and none in group II (0) required reoperation (p < 0.05). CONCLUSIONS: In the acute setting, complex lesions should be treated with a high bilioenteric anastomosis (at the junction level) in the first attempt at repair. Lower-level anastomoses are associated with a higher dysfunction rate and the need for radiological manipulation and reoperation. Also, stenosis of the anastomosis secondary to undetected duct ischemia in the acute repair is more frequent in low bilioenteric anastomoses.

Diminished morbidity and mortality in portal hypertension surgery: relocation in the therapeutic armamentarium.

Although several effective therapeutic options are available for bleeding from portal hypertension, surgery has a well-defined role in the management of patients with good liver function who are electively operated. The aim of this investigation was to evaluate the operative mortality and morbidity of portal blood flow-preserving procedures in a highly select patient population. The records of 148 patients operated on between 1996 and 2000 using one of two techniques (selective shunts or a Sugiura-Futagawa operation [complete portoazygos disconnection]) were analyzed with particular attention to operative mortality, postoperative rebleeding, and encephalopathy. Survival was calculated according to the Kaplan-Meier method. Sixty-one patients had distal splenorenal shunts placed, and 87 patients had a devascularization procedure. Operative mortality for the group as a whole was 1.2%. In the group with selective shunts, the rebleeding rate was 4.9%, the encephalopathy rate was 9.8%, and the shunt obstruction rate was 1.6%. Survival at 24 months was 94% and at 48 months was 92%. In those undergoing devascularization, the encephalopathy rate was 5% and the rebleeding rate was 14%. Survival at 24 months was 90% and at 48 months was 86%. Portal blood flow-preserving procedures have very low morbidity and mortality rates at specialized centers. In addition, a low rebleeding rate is associated with a good quality of life. Low-risk patients with bleeding portal hypertension should be considered for surgical treatment.

[Evaluation of 20 years of experience and quality of life in patients surgically treated for liver cystic disease]. / Evaluación de 20 años de experiencia y calidad de vida en pacientes con tratamiento quirúrgico para la enfermedad quística del hígado.

UNLABELLED: Surgical treatment of liver cystic disease is reserved for symptomatic patients. The surgical approach is chosen according to the size and distribution of the cysts. In patients with massive hepatomegaly secondary to polycystic liver disease, liver transplantation is indicated with excellent results and quality of life. OBJECTIVE: To evaluate over 20-year period, the results in terms of clinical outcome of three groups of patients with cystic liver disease (EQ) who received surgical treatment and to determine postoperative quality of life. MATERIALS AND METHODS: In a 20-year period, 44 patients were operated on; 24 had simple liver cyst, 13 had polycystic liver disease, and seven cystadenomas. Using the SF36 questionnaire, self-perception of quality of life was evaluated using eight scales in two major categories: Physical component summary (PCS) and mental component summary (MCS). RESULTS: Upper abdominal pain was the main clinical symptom. Fenestration was the most frequent procedure performed. No differences in quality of life were observed in all, while good quality of life was recorded in all groups at a median follow-up of 39 months. CONCLUSIONS: Surgical treatment of cystic liver disease is reserved for symptomatic patients or complications such as rupture, infection, and hemorrhage. Therapeutic alternatives should been chosen on an individual basis. Good quality of life is obtained after surgery in these patients.

The evolution of portal hypertension surgery: lessons from 1000 operations and 50 Years' experience.

HYPOTHESIS: Surgery for portal hypertension has evolved widely in the past decades. Selection criteria and the type of operations have evolved because of the appearance of other therapeutic alternatives, such as pharmacotherapy, endoscopic therapy, transjugular intrahepatic portosystemic shunt, and liver transplantation. We believe the surgical approach has a therapeutic role in a select patient population. DESIGN: Retrospective review of the medical records of patients operated on for bleeding portal hypertension in the past 50 years. SETTING: An academic tertiary care university hospital. PATIENTS AND METHODS: In a 50-year period, 1000 operations for the treatment of bleeding portal hypertension have been done, including shunts and devascularization procedures. In the past years, in low-risk (Child-Pugh classification A) selected patients, only portal blood flow-preserving operations have been done. RESULTS: Non-portal blood flow-preserving procedures had a wide spectrum of results, with a high encephalopathy rate and short long-term survival. The results with portal blood flow-preserving procedures in the past 10 years are as follows: operative mortality, 2.7%; postoperative encephalopathy, 6%; rebleeding, 6%; and shunt obstruction, 4%. CONCLUSIONS: Portal hypertension surgery has a role in elective operations and in low-risk selected patients, when portal blood flow-preserving procedures are done. The type of operation is selected according to the individual characteristics of each patient.

Small-diameter mesocaval shunts: a 10-year evaluation.

The use of small-diameter portosystemic shunts for the treatment of bleeding esophageal varices caused by portal hypertension has emerged as an outgrowth of the development of polytetrafluoroethylene vascular grafts, which allow the use of a narrow lumen. We report our experience with this type of graft over a 10-year period. Thirty-three patients with good liver function (Child-Pugh class A) were electively operated. The average age of these patients was 45 years (range 17 to 71 years). Twenty-nine patients had liver cirrhosis, one had portal fibrosis, and three had idiopathic portal hypertension. Operative mortality was 3%, and the rebleeding rate was 15%. Postoperative encephalopathy was observed in 14 patients (11%), three of whom had grade III to IV encephalopathy. The remaining 11 patients, had mild encephalopathy that was easily controlled. Postoperative angiography showed shunt patency in 81% of the patients, reduction in portal vein diameter in 33% of the patients, and portal vein thrombosis in 6%. Good postoperative quality of life was observed in 63% of the patients. Survival according to the Kaplan-Meier actuarial method was 81% at 12 months, 56% at 60 months, and 36% at 10 years. These shunts are a good alternative for patients being considered for surgery in whom other portal blood flow preserving procedures (i.e., elective shunts, devascularization with esophageal transection) are not feasible.

A comparative study of the elective treatment of variceal hemorrhage with beta-blockers, transendoscopic sclerotherapy, and surgery: a prospective, controlled, and randomized trial during 10 years.

OBJECTIVE: To compare three options for the elective treatment of portal hypertension during a 10-year period. METHODS: Patients included in the trial were 18 to 76 years old, had a history of bleeding portal hypertension, and had undergone no prior treatment. Treatment options were beta-blockers (propranolol), sclerotherapy, and portal blood flow-preserving procedures (selective shunts and the Sugiura-Futagawa operation). RESULTS: A total of 119 patients were included: 40 in the pharmacology group, 46 in the sclerotherapy group,and 33 in the surgical group. The three groups showed no differences in terms of age, Child-Pugh classification, and cause of liver disease. The rebleeding rate was significantly lower in the surgical group than in the other two groups. The rebleeding rate was only 5% in the Child A surgical group, compared with 71% and 68% for the sclerotherapy and pharmacotherapy groups, respectively. Survival was better for the low-risk patients (Child A) in the three groups, but when the three options were compared, no significant difference was found. CONCLUSIONS: Portal blood flow-preserving procedures offer the lowest rebleeding rate in low-risk patients undergoing elective surgery.