When Should We Perform Intraoperative Cholangiography? A Prospective Assessment of 1000 Consecutive Laparoscopic Cholecystectomies.

BACKGROUND: Intraoperative cholangiography (IOC) has been historically used to detect common bile duct (CBD) stones, delineate biliary anatomy, and avoid or promptly diagnose bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). We aimed to determine the usefulness of routine IOC during LC in an urban teaching hospital. METHODS: A consecutive series of patients undergoing LC with routine IOC from 2016 to 2018 was prospectively analyzed. Primary outcomes of interest were: CBD stones, BDI, and anatomical variations of the biliary tract. Secondary outcomes of interest were: IOC success rate, IOC time, and readmission for residual lithiasis. A comparative analysis was performed between patients with and without preoperative suspicion of CBD stones. RESULTS: A total of 1003 LC were analyzed; IOC was successful in 918 (91.5%) patients. Mean IOC time was 10 (4 to 30) minutes. Mean radiation received by the surgeon per procedure was 0.06 millisieverts (mSv). Normal IOC was found in 856 (93.2%) patients. CBD stones and aberrant biliary anatomy were present in 58 (6.3%) and 4 (0.4%) cases, respectively. Two patients (0.2%) underwent unnecessary CBD exploration because of false-positive IOC. Four patients (0.4%) with normal IOC were readmitted for residual CBD stones. Five (0.5%) minor BDI undetected by the IOC were diagnosed. Patients with preoperative suspicion of CBD stones had significantly higher rates of CBD stones detected on IOC as compared with those without suspicion (23.2% vs. 2.1%, P<0.0001). CONCLUSION: Routine use of IOC resulted in low rates of BDI diagnosis, aberrant biliary anatomy identification and/or CBD stones detection. Selection of patients for IOC, rather than routine use of IOC appears a more reasonable approach.

Metástasis hepática de adenoma pleomorfo / Hepatic metastasis of a pleomorphic adenoma

El adenoma pleomorfo es el tumor benigno más frecuente de las glándulas salivales. Puede sufrir transformación maligna y metastatizar a otros órganos distantes y, en otros casos, hacerlo como un tumor benigno. Se presenta el caso de un hombre de 82 años con lesión hepática detectada por ecografía en estudio urológico de rutina. La tomografía computarizada reveló una imagen sólida en los segmentos V-VI-VII del hígado. Se efectuó biopsia de la lesión de cuyo examen se informó metástasis de adenoma pleomorfo salival. Se realizó hepatectomía derecha y la anatomía patológica describió un tumor de 10 cm de diámetro, con margen libre, compatible con adenoma pleomorfo salival, 32 años después de la cirugía de su tumor primario. Luego de 8 años, en el seguimiento se hallaron cuatro nódulos hepáticos y una nueva imagen ósea en la vértebra L4 sugerente de recurrencia de la enfermedad. Se decidió administrar radioterapia corporal estereotáctica a la lesión ósea y evaluar la respuesta para decidir el futuro tratamiento de los nódulos hepáticos, debido a su lento crecimiento.

Pleomorphic adenoma is the most benign tumor of the salivary glands. It can undergo a malignant transformation to carcinoma and metastasize to distant organs, sometimes it can metastasize as a benign tumor. We present the case of an 82 years old male with hepatic lesion detected by ultrasound in routine urologic follow-up. CT scan revealed a solid image placed in segments V-VI-VII of the liver. A CT guided fine needle biopsy was made. Pathologic analysis reported a pleomorphic salivary adenoma metastasizing in the liver. Right hepatectomy was performed. Pathology study described a 10 cm diameter tumor with free margin, compatible with pleomorphic salivary adenoma, 32 years after surgery for the primary tumor. After 8 years of follow up, four hepatic nodules and a bone image in L4 vertebra that seemed to be a disease recurrence were found. It was decided to administer stereotactic body radiotherapy to the bone lesion and evaluate the response to decide the future treatment of the hepatic nodules, due to its slow growth.

[Hepatic metastasis of a pleomorphic adenoma]. / Metástasis hepática de adenoma pleomorfo.

Pleomorphic adenoma is the most benign tumor of the salivary glands. It can undergo a malignant transformation to carcinoma and metastasize to distant organs, sometimes it can metastasize as a benign tumor. We present the case of an 82 years old male with hepatic lesion detected by ultrasound in routine urologic follow-up. CT scan revealed a solid image placed in segments V-VI-VII of the liver. A CT guided fine needle biopsy was made. Pathologic analysis reported a pleomorphic salivary adenoma metastasizing in the liver. Right hepatectomy was performed. Pathology study described a 10 cm diameter tumor with free margin, compatible with pleomorphic salivary adenoma, 32 years after surgery for the primary tumor. After 8 years of follow up, four hepatic nodules and a bone image in L4 vertebra that seemed to be a disease recurrence were found. It was decided to administer stereotactic body radiotherapy to the bone lesion and evaluate the response to decide the future treatment of the hepatic nodules, due to its slow growth.

Resultados de la cirugía pancreática en pacientes mayores de 70 años / Outcomes of pancreatic surgery in patients older than 70 years

INTRODUCCIÓN: La proporción de pacientes añosos está creciendo rápidamente. Conocer los verdaderos resultados de la cirugía pancreática en este grupo etario ayudaría para la toma de decisiones terapéuticas. El objetivo es evaluar los resultados quirúrgicos de resecciones pancreáticas en pacientes mayores de 70 años. MÉTODOS: Estudio retrospectivo que incluye a pacientes tratados mediante resección pancreática en el período 2009-2014. Se dividió la muestra en 2 grupos. G1: pacientes menores de 70 años y G2: pacientes mayores de 70 años. Se compararon los resultados quirúrgicos en ambos grupos. RESULTADOS: Se realizaron 73 resecciones pancreáticas; 51 (70%) pacientes pertenecieron al G1 y 22 (30%) al G2. No hubo diferencias significativas entre G1 y G2 en cuanto al tiempo operatorio ni a los días de internación. Tampoco se obtuvo diferencia significativa en incidencia de retardo del vaciamiento gástrico, fístula pancreática ni fístula biliar. La mortalidad global de la serie fue del 4,1%: del 2% en G1 y del 13,6% en G2 (p: 0,04). Al realizar un subanálisis en G2, la mortalidad en este grupo ocurrió únicamente en pacientes con comorbilidades significativas con ASA ≥ 3 (p: 0,004). Ambos grupos con enfermedad maligna presentaron similar sobrevida global y libre de enfermedad. CONCLUSIONES: La edad no debería ser un factor limitante para realizar resecciones pancreáticas. Los pacientes añosos presentan similares resultados quirúrgicos, y su mortalidad perioperatoria aumentada se debería a la presencia de comorbilidades importantes asociadas, y no a la edad como variable independiente

INTRODUCTION: The proportion of elderly patients is growing rapidly. Knowing the results of pancreatic surgery in this group of patients would help surgeons to make therapeutic decisions. The objective is to evaluate the surgical outcomes of pancreatic resections in patients over 70 years. METHODS: Retrospective study including patients undergoing pancreatic resection during the period 2009-2014. The sample was divided into 2 groups. G1: Patients under 70 years and G2: Patients older than 70 years. Surgical results between the 2 groups were evaluated. RESULTS: Seventy three pancreatic resections were performed, 51 (70%) patients belonged to G1 and 22 (30%) to G2. There were no significant differences between G1 and G2 in terms of operative time and hospitalization days. No significant difference was obtained in the incidence of delayed gastric emptying, pancreatic fistula or biliary fistula. The overall mortality in the series was 4.1% showing difference between both groups, with 2% in G1 and 13.6% in G2 (P=.04). When a sub-analysis in G2 was made, mortality in this group occurred only in patients with significant comorbidities with ASA ≥ 3 (P=.004). Both groups with oncologic disease had similar overall survival and disease-free survival. CONCLUSIONS: Age should not be a limiting factor for pancreatic resections. The elderly have similar results as younger patients and their increased perioperative mortality is due to the presence of important associated comorbidities rather than age as an independent risk factor

Outcomes of pancreatic surgery in patients older than 70 years.

INTRODUCTION: The proportion of elderly patients is growing rapidly. Knowing the results of pancreatic surgery in this group of patients would help surgeons to make therapeutic decisions. The objective is to evaluate the surgical outcomes of pancreatic resections in patients over 70 years. METHODS: Retrospective study including patients undergoing pancreatic resection during the period 2009-2014. The sample was divided into 2 groups. G1: Patients under 70 years and G2: Patients older than 70 years. Surgical results between the 2 groups were evaluated. RESULTS: Seventy three pancreatic resections were performed, 51 (70%) patients belonged to G1 and 22 (30%) to G2. There were no significant differences between G1 and G2 in terms of operative time and hospitalization days. No significant difference was obtained in the incidence of delayed gastric emptying, pancreatic fistula or biliary fistula. The overall mortality in the series was 4.1% showing difference between both groups, with 2% in G1 and 13.6% in G2 (P=.04). When a sub-analysis in G2 was made, mortality in this group occurred only in patients with significant comorbidities with ASA ≥ 3 (P=.004). Both groups with oncologic disease had similar overall survival and disease-free survival. CONCLUSIONS: Age should not be a limiting factor for pancreatic resections. The elderly have similar results as younger patients and their increased perioperative mortality is due to the presence of important associated comorbidities rather than age as an independent risk factor.

Bile duct replacement using an autologous femoral vein graft: an experimental study. Preliminary results.

The repair of common bile duct injuries is a complex procedure with a significant rate of postoperative morbidity and mortality. The aim of this study was to demonstrate the usefulness of the autologous vein graft in replacement of the bile duct. Twelve male Sprague-Dawley rats weighing 350+/-550 g were used in the study and were divided at random into two groups: the control group (60) and the experimental group in which a 3-mm segment of the bile duct was resected and the biliary tract was replaced by a segment of vein aided by stent (G1). Both groups were subdivided into pairs of rats to study at 30, 60, and 120 days. All of the animals underwent radioisotope cholangiography, a repeat laparotomy, and blood tests for further pathologic study. The clinical evaluation and biochemical nuclear medicine and pathologic studies showed no evidence of cholestasis. The histologic study of the graft showed replacement of the endothelium by biliary-appearing epithelium. The use of an autologous vein graft with a supporting stent proves to be a feasible and alternative procedure for bile duct reconstruction. Further experimental studies should be carried out to validate these findings so they can be implemented in clinical cases.

Lymphoepithelial cysts of the pancreas: case report and review of the literature.

The aim of this report was to describe the clinical and pathologic features of lymphoepithelial cysts of the pancreas, establish the differential diagnosis of other pancreatic cysts, and review the literature. A 53-year-old man was incidentally diagnosed with a pancreatic lesion after an abdominal CT scan. This study showed a solid mass in the tail of the pancreas not enhanced by helical CT. Endoscopic ultrasound examination revealed a low-density tissue mass on the surface of the pancreas, less echogenic than the surrounding parenchyma. Distal pancreatectomy and splenectomy were performed with a suspected diagnosis of mucinous cystic tumor. The patient has had an uneventful postoperative period, and the pathologic finding was a lymphoepithelial cyst of the pancreas. Lymphoepithelial cyst of the pancreas is an unusual and benign entity that must be taken into consideration when evaluating a cystic lesion of the pancreas because a different therapeutic approach may be required.