Gallbladder cancer who is really cured?

BACKGROUND: Although gallbladder cancer (GBCA) is characterized by a dismal prognosis, there is a proportion of patients who are cured. The aim of this study was to analyze the profile of these patients. METHODS: A database was queried for patients who underwent curative resection with a follow-up of at least 5 years. Patients were prospectively treated and registered by the same surgical team. A multivariate regression analysis was used to identify factors associated with long-term survival. RESULTS: From 1988 to 2013, 461 patients were evaluated and 112 who underwent resection were analyzed. Among the patients, five year survival was 57% while lymph node and liver compromise were the only independent factors associated with survival. On the other hand, the elapsed time between the cholecystectomy and the resection, the differentiation grade and the level of wall invasion did not have an independent effect on the prognosis. CONCLUSION: Despite its poor prognosis, a subset of patients can be cured of GBCA. R0 resection of patients without lymph and liver infiltration are key to GBCA survival.

Laparoscopic management of incidental gallbladder cancer.

BACKGROUND: The laparoscopic cholecystectomy has allowed the detection of an increasing number of incidental gallbladder cancers (IGBC). Although laparoscopy is employed in the management of a variety of abdominal tumors, its use in gallbladder cancer is reduced and controversial. This study analyzes the role of laparoscopy in gallbladder cancer with the focus in IGBC. METHOD: We evaluated our prospective series of 51 patients with an IGBC who were treated by laparoscopy between 2006 and 2016 at the Clinica Alemana in Santiago, Chile. RESULTS: The series comprised 7 men and 44 women. Age ranged from 43 to 76 years (mean age 60). Regarding wall involvement, 29 patients had a T2 tumor, which was the most common. 8 and 14 patients had T1b and T3 tumors, respectively. Of the patients, 17 underwent only laparoscopic exploration. This was due to the presence tumor dissemination not being observed in the preoperative staging. 10 patients had to be converted to complete the resection, whereas 24 patients were laparoscopically resected. The quality of the resected material was not different between those who were converted and those who were treated by laparoscopy. In the laparoscopic group, the average number of harvested lymph nodes was 7.9, not statistically different from the converted group. The mean of hospital stay in the laparoscopic group (4.3 days) was significantly lower than the converted group. CONCLUSIONS: Laparoscopy has been shown to be a safe and feasible method for the management of IGBC. This method not only allows for a complete exploration, identifying a previously unseen residual tumor, but also makes it possible to accomplish the same oncology objectives as the open procedure. Therefore, laparoscopy should be considered a valid alternative in the management of IGBC.

Enhancement in liver SREBP-1c/PPAR-alpha ratio and steatosis in obese patients: correlations with insulin resistance and n-3 long-chain polyunsaturated fatty acid depletion.

Sterol receptor element-binding protein-1c (SREBP-1c) and peroxisome proliferator-activated receptor-alpha (PPAR-alpha) mRNA expression was assessed in liver as signaling mechanisms associated with steatosis in obese patients. Liver SREBP-1c and PPAR-alpha mRNA (RT-PCR), fatty acid synthase (FAS) and carnitine palmitoyltransferase-1a (CPT-1a) mRNA (real-time RT-PCR), and n-3 long-chain polyunsaturated fatty acid (LCPUFA)(GLC) contents, plasma adiponectin levels (RIA), and insulin resistance (IR) evolution (HOMA) were evaluated in 11 obese patients who underwent subtotal gastrectomy with gastro-jejunal anastomosis in Roux-en-Y and 8 non-obese subjects who underwent laparoscopic cholecystectomy (controls). Liver SREBP-1c and FAS mRNA levels were 33% and 70% higher than control values (P<0.05), respectively, whereas those of PPAR-alpha and CPT-1a were 16% and 65% lower (P<0.05), respectively, with a significant 62% enhancement in the SREBP-1c/PPAR-alpha ratio. Liver n-3 LCPUFA levels were 53% lower in obese patients who also showed IR and hipoadiponectinemia over controls (P<0.05). IR negatively correlated with both the hepatic content of n-3 LCPUFA (r=-0.55; P<0.01) and the plasma levels of adiponectin (r=-0.62; P<0.005). Liver SREBP-1c/PPAR-alpha ratio and n-3 LCPUFA showed a negative correlation (r=-0.48; P<0.02) and positive associations with either HOMA (r=0.75; P<0.0001) or serum insulin levels (r=0.69; P<0.001). In conclusion, liver up-regulation of SREBP-1c and down-regulation of PPAR-alpha occur in obese patients, with enhancement in the SREBP-1c/PPAR-alpha ratio associated with n-3 LCPUFA depletion and IR, a condition that may favor lipogenesis over FA oxidation thereby leading to steatosis.

Liver NF-kappaB and AP-1 DNA binding in obese patients.

Oxidative stress and insulin resistance (IR) are major contributors in the pathogenesis of nonalcoholic fatty liver disease (NAFLD) and in the progression from steatosis to nonalcoholic steatohepatitis (NASH). Our aim was to assess nuclear factor-kappaB (NF-kappaB) and activating protein-1 (AP-1) activation and Toll-like receptor 4 (TLR4) expression as signaling mechanisms related to liver injury in obese NAFLD patients, and examined potential correlations among them, oxidative stress, and IR. Liver NF-kappaB and AP-1 (electromobility shift assay (EMSA)), TLR4 expression (western blot), ferric reducing ability of plasma (FRAP), and IR evolution (HOMA) were evaluated in 17 obese patients who underwent subtotal gastrectomy with gastro-jejunal anastomosis in Roux-en-Y and 10 nonobese subjects who underwent laparoscopic cholecystectomy (controls). Liver NF-kappaB and AP-1 DNA binding were markedly increased in NASH patients (n = 9; P < 0.05) compared to controls, without significant changes in NAFLD patients with steatosis (n = 8), whereas TLR4 expression was comparable between groups. Hepatic NF-kappaB activation was positively correlated with that of AP-1 (r = 0.79; P < 0.0001); both liver NF-kappaB and AP-1 DNA binding were inversely associated with FRAP (r = -0.43 and r = -0.40, respectively; P < 0.05) and directly correlated with HOMA (r = 0.66 and r = 0.62, respectively, P < 0.001). Data presented show enhanced liver activation of the proinflammatory transcription factors NF-kappaB and AP-1 in obese patients with NASH, parameters that are significantly associated to oxidative stress and IR.

Videothoracoscopic management of middle esophageal diverticulum with secondary bronchoesophageal fistula: report of a case.

Middle esophageal diverticulum is rare, but can result in bronchoesophageal fistula. Previous reports have described open surgical techniques to treat esophageal diverticula, but few have evaluated the effectiveness of a videothoracoscopy approach. We report a case of middle esophageal diverticulum associated with bronchoesophageal fistula, managed successfully with videothoracoscopy. We also review the relevant literature.

[Esophageal manometry in patients with non cardiac chest pain]. / Estudio mamométrico del esófago en pacientes con dolor torácico no cardíaco.

BACKGROUND: Non cardiac chest pain can be caused by esophageal problems such as gastroesophageal reflux or smooth muscle motor disorders. AIM: To perform esophageal manometry in patients with non cardiac chest pain. MATERIAL AND METHODS: One hundred patients with chest pain in whom coronary problems were discarded, were studied. A computerized esophageal manometry was performed in all and 24 hours esophageal pH measurement was done in 21 patients. RESULTS: Esophageal manometry was normal in eight patients. Nutcracker esophagus was the most common finding, in 36 patients. Twenty eight had a hypotensive sphincter, 16 had unspecific motor disorders, nine had diffuse esophageal spasm, two had a non achalasic esophageal aperistalsis and one had a hypertensive sphincter. CONCLUSIONS: Only eight of 100 patients referred to esophageal manometry for non cardiac chest pain, had a normal study.

Estudio mamométrico del esófago en pacientes con dolor torácico no cardíaco / Esophageal manometry in patients with non cardiac chest pain

Background: Non cardiac chest pain can be caused by esophageal problems such as gastroesophageal reflux or smooth muscle motor disorders. Aim: To perform esophageal manometry in patients with non cardiac chest pain. Material and methods: One hundred patients with chest pain in whom coronary problems were discarded, were studied. A computerized esophageal manometry was performed in all and 24 hours esophageal pH measurement was done in 21 patients. Results: Esophageal manometry was normal in eight patients. Nutcracker esophagus was the most common finding, in 36 patients. Twenty eight had a hypotensive sphincter, 16 had unspecific motor disorders, nine had diffuse esophageal spasm, two had a non achalasic esophageal aperistalsis and one had a hypertensive sphincter. Conclusions: Only eight of 100 patients referred to esophageal manometry for non cardiac chest pain, had a normal study.

[Relationship between gastroesophageal reflux symptoms and 24 h esophageal pH measurement in patients with normal or minimally abnormal upper endoscopies]. / Correlación entre síntomas de reflujo gastroesofágico y resultados de la pHmetría de 24 horas en pacientes con estudio endoscópico normal o levemente alterado.

BACKGROUND: Heartburn and regurgitation are considered highly specific symptoms of gastroesophageal reflux. A considerable number of patients with these symptoms do not have endoscopic signs of esophagitis. AIM: To study the relationship between gastroesophageal reflux symptoms and 24 h esophageal pH mesurement in patients with normal or near normal endoscopic findings. PATIENTS AND METHODS: One hundred eighty six patients with persistent reflux symptoms and absence of severe endoscopic esophagitis were studied. Pathological studies of esophageal biopsies, manometry and 24 h esophageal pH measurements were performed in all. RESULTS: Abnormal acid reflux was found in 131 patients (70%). No differences in the frequency of symptoms, gender or pathologic findings were observed between patients with or without abnormal acid reflux. However, a higher frequency of esophageal erosions and a lower resting pressure of the inferior sphincter of the esophagus was observed in patients with abnormal acid reflux. CONCLUSIONS: Thirty percent of patients with heartburn and regurgtitation did not have abnormal acid reflux. Therefore, these symptoms are not specific for gastroesophageal reflux.

Gastrectomía casi total abierta o laparoscópica en obesidad refractaria a tratamiento médico: fundamentos y resultados / Total open gastrectomy or laparoscopy in refractory obesity to medical treatment

Se presenta la experiencia protocolizada de 375 pacientes con obesidad grave refractaria a tratamiento médico, que han sido sometidos a gastrectomía casi total de 98 por ciento con reservorio de 20 ml. y asa yeyunal desfuncionalizada en Y de Roux de 150 cm. ya sea por abordaje abierto o por laparoscopía, basados en la experiencia publicada de los riesgos que representa dejar un estómago ciego abandonado. Los resultados muestran que el método es muy eficaz para manejar en forma definitiva la obesidad y que puede ser realizado por vía laparoscópica. Sin embargo, dado que tiene riesgos de morbilidad relacionados con la técnica quirúrgica, debe ser realizado por grupos con experiencia en cirugía gastro-esofágica, que sepan manejar oportuna y adecuadamente las complicaciones, bajo protocolos de estudio, con pacientes debidamente informados y en el marco de un trabajo trans-disciplinario que involucre a otros profesionales de la salud, tanto para el manejo inmediato del paciente operado como para su seguimiento y control alejado.