[Association between wound size after open cholecystectomy with severity of iatrogenic biliary tract lesions]. / Efecto del tamaño de la incisión en la gravedad de la lesin de la vía biliar iatrogénica posterior a colecistectomía abierta.

BACKGROUND: Transoperative biliary tract injury during open or laparoscopic cholecystectomy is a catastrophic event associated with significant morbidity and mortality. Our objective was to determine if wound size during open cholecystectomy is associated with more complex biliary tract injuries. METHODS: Prospective cohort study performed between March 2006 and February 2007. Sixty-six patients with biliary tract injuries after open cholecystectomy were included. Wound size was analyzed. RESULTS: Sixty six patients were included, 70% were female with a median age of 44. Seventy four percent were treated for acute cholecystitis. Most participants were overweight or had various degrees of obesity. Biliary tract injuries were not recognized during the primary surgical procedure in 76% of cases. All patients with severe biliary tract injuries (Strasberg E-3 and E-4) had a wound size less than 10 cm in length. Wound size was associated with unrecognized injuries (p=0.000), as well as with injury severity (p=0.000). We were notable to demonstrate a statistically significant association between biliary tract injuries and elective or emergency surgical procedures and midline or subcostal surgical incision for cholecystectomy. CONCLUSIONS: Our findings suggest that minor surgical access during open cholecystectomy may constitute a risk factor since smaller incisions were associated with more severe biliary tract injuries and an inability to observe this damage during the surgical procedure. We suggest to adhere strictly to the guidelines of an adequate surgical exposure during open cholecystectomy to prevent biliary tract injuries.

L-alanyl-L-glutamine-supplemented parenteral nutrition decreases infectious morbidity rate in patients with severe acute pancreatitis.

BACKGROUND: The effect of parenteral GLN on recovery from severe acute pancreatitis has not been thoroughly investigated. The aims of this study were to determine whether parenteral GLN improves nutrition status and immune function, and to determine its ability to reduce morbidity and mortality in patients with this condition. METHODS: In a randomized clinical trial, 44 patients with severe acute pancreatitis were randomly assigned to receive either standard PN (n = 22) or l-alanyl-l-glutamine-supplemented PN (n = 22) after hospital admission. Nitrogen balance, counts of leukocytes, total lymphocytes, and CD4 and CD8 subpopulations, and serum levels of immunoglobulin A, total protein, albumin, C-reactive protein, and serum interleukin (IL)-6 and IL-10 were measured on days 0, 5, and 10. Hospital stay, infectious morbidity, and mortality were also evaluated. RESULTS: Demographics, laboratory characteristics, and pancreatitis etiology and severity at entry to the study were similar between groups. The study group exhibited significant increases in serum IL-10 levels, total lymphocyte and lymphocyte subpopulation counts, and albumin serum levels. Nitrogen balance also improved to positive levels in the study group and remained negative in the control group. Infectious morbidity was more frequent in the control group than in the study group. The duration of hospital stay was similar between groups, as was mortality. CONCLUSION: The results suggest that treatment of patients with GLN-supplemented PN may decrease infectious morbidity rate compared with those who treated with nonenriched PN.

Efecto del tamaño de la incisión en la gravedad de la lesin de la vía biliar iatrogénica posterior a colecistectomía abierta / Association between wound size after open cholecystectomy with severity of iatrogenic biliary tract lesions

Antecedentes: La lesión transoperatoria de la vía biliar durante la colecistectomía abierta y laparoscópica es un evento catastrófico que se asocia con morbilidad y mortalidad significativas. El objetivo fue documentar si el tamaño de la incisión en colecistectomía abierta está asociado a lesiones más complejas de la vía biliar. Métodos: Estudio de cohorte prospectivo de marzo de 2006 a febrero de 2007. Se incluyeron 66 pacientes con lesiones de la vía biliar posterior a colecistectomía abierta. Se analizó el tamaño de la incisión. Resultados: Se incluyeron 66 pacientes, 70% del sexo femenino, con un promedio de edad de 44 años. El 70% fue tratado por colecistitis aguda. La mayoría tuvo sobrepeso o sufría diferentes grados de obesidad. En 76% de los casos, la lesión no fue advertida durante el procedimiento quirúrgico primario. Todos los pacientes con lesión de vía biliar grave (Strasberg E-3 y E-4) tuvieron incisiones menores a 10 cm de longitud. El tamaño de la incisión se asoció con lesiones inadvertidas (p=0.000), así como con el grado de lesión (p=0.000). No pudo demostrarse asociación estadísticamente significativa entre lesiones de la vía biliar y colecistectomía electiva o urgente, e incisión quirúrgica media o subcostal para la colecistectomía. Conclusiones: Nuestros hallazgos sugieren que el acceso quirúrgico menor durante la colecistectomía abierta puede ser un factor de riesgo, ya que incisiones pequeñas se asociaron con lesiones de la vía biliar más graves e imposibilidad para reconocer este daño durante el procedimiento. Sugerimos cumplir estrictamente los principios quirúrgicos de una adecuada exposición durante la colecistectomía abierta como medida para prevenir lesiones de la vía biliar.

BACKGROUND: Transoperative biliary tract injury during open or laparoscopic cholecystectomy is a catastrophic event associated with significant morbidity and mortality. Our objective was to determine if wound size during open cholecystectomy is associated with more complex biliary tract injuries. METHODS: Prospective cohort study performed between March 2006 and February 2007. Sixty-six patients with biliary tract injuries after open cholecystectomy were included. Wound size was analyzed. RESULTS: Sixty six patients were included, 70% were female with a median age of 44. Seventy four percent were treated for acute cholecystitis. Most participants were overweight or had various degrees of obesity. Biliary tract injuries were not recognized during the primary surgical procedure in 76% of cases. All patients with severe biliary tract injuries (Strasberg E-3 and E-4) had a wound size less than 10 cm in length. Wound size was associated with unrecognized injuries (p=0.000), as well as with injury severity (p=0.000). We were notable to demonstrate a statistically significant association between biliary tract injuries and elective or emergency surgical procedures and midline or subcostal surgical incision for cholecystectomy. CONCLUSIONS: Our findings suggest that minor surgical access during open cholecystectomy may constitute a risk factor since smaller incisions were associated with more severe biliary tract injuries and an inability to observe this damage during the surgical procedure. We suggest to adhere strictly to the guidelines of an adequate surgical exposure during open cholecystectomy to prevent biliary tract injuries.

[Cervical esophagogastrostomy dehiscence after gastric pull-up for type I esophageal atresia. Case report of a patient successfully treated with fibrin glue and a review of the literature]. / Dehiscencia de esófago-gastroanastomosis cervical posterior a ascenso gástrico por atresia esofágica tipo I. Reporte de un caso exitoso tratado con gel de fibrina y revisión de literatura.

INTRODUCTION: The treatment of choice for type 1 esophageal atresia is surgery to re-establish continuity of gastrointestinal tract by colon interposition or gastric pull-up. Incidence of cervical anastomosis dehiscence is 20-40%. Although it is not a serious complication, it requires a fasting period and nutritional support to achieve spontaneous closure within 2-4 weeks. AIM: To report successful treatment of cervical esophageal-gastric anastomosis dehiscence after gastric transposition using fibrin glue. CASE PRESENTATION: A 17-month-old female child, the product of a first pregnancy, was delivered by caesarean section at 35 weeks gestation in response to fetal distress; the child weighed 1,800 g at birth and had APGAR score of 6-8. At 7 h of extra-uterine life, she was diagnosed with type I esophageal atresia and cervical esophagostomy was performed. Stamm-type gastrostomy was used for enteral nutrition until she was 17 months of age. With a weight of 9 kg, the child underwent esophageal substitution with transhiatal gastric transposition, cervical anastomosis, and jejunostomy. On the seventh day postsurgery, surgical wound infection was observed, producing purulent material and saliva (45 ml in 24 h). On the 10th day, esophagogram was performed that revealed 30% anastomosis dehiscence and 2-cm fistulous tract with no abscess. On the 11th day, 3 ml of fibrinogen (80 mg/mL) activated with thrombin (1,000 uL/mL), both of human extraction (Quixil, Omrix, Tel Aviv, Israel) was applied through fistula tract. RESULT: The following day, the patient presented with cough access, expelling the fibrin glue plug. A similar dose was given that achieved a null output volume during the following 24 h. Subsequently, she began oral feeding with liquids, incorporating a normal diet over the following 2 months. At present, she is 3 years 2 months of age, weighs 15 kg, and is able to eat any kind of food without dysphagia. CONCLUSIONS: We demonstrated that use of biological adhesives can shorten time required to achieve closure of high- and low-output volume fistulas. In the present case, use of fibrin glue to obliterate the fistulous tract gave satisfactory results, reducing time to spontaneous closure and facilitating early commencement of oral feeding. Cases of enterocutaneous fistula closure reviewed in the literatura generally involve adults, but the technique can be used in children with this type of complication.