Biliary leakage from gallbladder bed after cholecystectomy: Luschka duct or hepaticocholecystic duct?

Anatomic variations in the biliary tract are common and can cause difficulties when a cholecystectomy is performed. One of the most common ones are hepaticocholecystic ducts and Luschka ducts, connecting the gallbladder or its bed to the bile ducts but distinction between these two types of ducts can be difficult. We do discuss here the differences between these anatomical variations, their origin and their clinical implications. These aberrant ducts may go unnoticed and may require further complementary procedures in case of postoperative biliary leakage. In addition to a careful surgical procedure and an examination of the cystic bed in the end of the intervention, an intraoperative cholangiography should be performed as often as possible.

Useulness of B Natriuretic Peptides and Procalcitonin in Emergency Medicine.

Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presented to an emergency department (ED), and it is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes directly proportional to wall tension, for lowering renin-angiotensin-aldosterone activation. For diagnosing CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in elderly population, and in patients with renal dysfunction. They might have also a prognostic value. Studies demonstrated that the use of BNP or NT-proBNP in dyspneic patients early in the ED reduced the time to discharge, total treatment cost. BNP and NT-proBNP should be available in every ED 24 hours a day, because literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients.Etiologic diagnosis of febrile patients who present to an ED is complex and sometimes difficult. However, new evidence showed that there are interventions (including early appropriate antibiotics), which could reduce mortality rate in patients with sepsis. For diagnosing sepsis, procalcitonin (PCT) is more accurate than C-reactive protein. Thus, because of its excellent specificity and positive predictive value, an elevated PCT concentration (higher than 0.5 ng/mL) indicates ongoing and potentially severe systemic infection, which needs early antibiotics (e.g. meningitis). In lower respiratory tract infections, CAP or COPD exacerbation, PCT guidance reduced total antibiotic exposure and/or antibiotic treatment duration.