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BACKGROUND: Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7-2.5% of appendectomies performed due to suspected acute appendicitis show histologically malignant findings. The purpose of this study was to investigate the incidence of neoplasm and malignancy of the appendix in patients presenting with suspected acute appendicitis in real world setting. METHODS: This is a retrospective single-centre investigation of 457 patients undergoing appendectomy between the years 2017-2020. The patients' demographics, symptoms and diagnosis, intraoperative findings, and histopathological results were analysed. RESULTS: In 3.7% (n = 17) histological analysis revealed neoplasms or malignancies. Median age was 48 years (20-90 years), without sex predominance. Leukocytes (11.3 ± 3.7 G/l) and C-reactive protein (54.2 ± 69.0 mg/l) were elevated. Histological analysis revealed low-grade mucinous appendiceal neoplasia (n = 3), sessile serrated adenoma of the appendix (n = 3), neuroendocrine tumours (n = 7), appendiceal adenocarcinoma of intestinal type (n = 3), and goblet cell carcinoma (n = 1). Additional treatment varied between no treatment or follow-up due to early tumour stage (n = 4), follow-up care (n = 3), additional surgical treatment (n = 8), or best supportive care (n = 2). CONCLUSIONS: Preoperative diagnosis of appendiceal tumours is difficult. Nonoperative management of patients with acute, uncomplicated appendicitis potentially prevents the correct diagnosis of malignant appendiceal pathologies. Therefore, close follow-up or surgical removal of the appendix is mandatory.
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Apendicectomía , Neoplasias del Apéndice , Apendicitis , Humanos , Neoplasias del Apéndice/epidemiología , Neoplasias del Apéndice/diagnóstico , Neoplasias del Apéndice/patología , Neoplasias del Apéndice/terapia , Neoplasias del Apéndice/cirugía , Apendicitis/epidemiología , Apendicitis/cirugía , Apendicitis/diagnóstico , Apendicitis/terapia , Persona de Mediana Edad , Estudios Retrospectivos , Masculino , Femenino , Adulto , Anciano , Apendicectomía/estadística & datos numéricos , Incidencia , Anciano de 80 o más Años , Adulto Joven , Enfermedad AgudaRESUMEN
BACKGROUND: Caroli Disease (CD) and Caroli Syndrome (CS) are rare disorders presenting with dilation of the intrahepatic bile ducts. CD/CS are associated with cholangiocarcinoma (CCA). However, the true incidence of CCA is still unclear, although it may serve as an indication for surgery. In this paper, we analyzed (I) the incidence of CCA in German centers, (II) reviewed our single center population together with its clinical presentation and (III) performed a thorough literature review. METHODS: 17 large HPB-centers across Germany were contacted and their patients after surgical treatment due to CD/CS with histopathology were included. Medline search for all studies published in English or German literature was performed. Patients who underwent surgery at our department between 2012 and 2020 due to CD or CS were analyzed. RESULTS: In the multicenter study, 79 patients suffered from CD and 119 patients from CS, with a total number of 198 patients. In 14 patients, CCA was found (Overall: 7,1%; CD: 6,3%, CS 7,6%). Between 2012 and 2020, 1661 liver resections were performed at our department. 14 patients underwent surgery due to CD or CS. Histological examination showed synchronous cholangiocarcinoma in one patient. The literature review revealed a CCA-rate of 7,3% in large series, whereas in case reports a rate of 6,8% was found. CONCLUSION: There is risk of malignant transformation and patients with CD might also benefit from resection due to improvement of symptoms. Therefore, resection is strongly advised. As certain patients with CS require transplantation, treatment should not be guided by the relatively low rate of CCA but by the concomitant diseases that come along with hepatic failure.
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Neoplasias de los Conductos Biliares , Enfermedad de Caroli , Colangiocarcinoma , Neoplasias de los Conductos Biliares/diagnóstico , Neoplasias de los Conductos Biliares/epidemiología , Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Intrahepáticos/patología , Enfermedad de Caroli/complicaciones , Enfermedad de Caroli/epidemiología , Enfermedad de Caroli/cirugía , Colangiocarcinoma/diagnóstico , Colangiocarcinoma/epidemiología , Colangiocarcinoma/cirugía , Hepatectomía/efectos adversos , HumanosRESUMEN
BACKGROUND: Transurethral resection of the prostate (TUR-P) is one of the most frequent routine procedures in urology. Because of the semisterile environment, postoperative infections, including sepsis, are a common complication, with Escherichia coli, Klebsiella spp., Proteus mirabilis or Enterococcus faecalis as frequently isolated pathogens. Facklamia hominis is a gram-positive, facultatively anaerobic, alpha-hemolytic, catalase-negative coccus that was first described in 1997. To date, only a few cases of infectious complications have been described. We report the first case of postoperative bacteremia due to Facklamia hominis after TUR-P. CASE PRESENTATION: An 82-year-old man developed fever only a few hours after elective TUR-P because of benign prostate syndrome. After cultivation of blood cultures, antibiotic therapy with ceftriaxone was intravenously administered and changed to oral cotrimoxazole before discharge of the afebrile patient. One anaerobic blood culture revealed Facklamia hominis. Under antibiotic therapy, the patient remained afebrile and showed no signs of infections during follow-up. CONCLUSIONS: Fever and bacteremia are frequent complications after TUR-P. This study is the first report of Facklamia hominis in a postoperative blood culture after TUR-P. To date, there are only a few reports of patients with infectious complications and isolation of Facklamia hominis in various patient samples. Because Facklamia hominis resembles viridans streptococci on blood agar analysis, this pathogen may often be misidentified. In this case identification of Facklamia hominis was possible with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. It has been postulated that Facklamia hominis might be a facultative pathogen and that its incidence will increase in the future.
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Aerococcaceae , Bacteriemia/etiología , Infecciones por Bacterias Grampositivas/etiología , Complicaciones Posoperatorias/etiología , Resección Transuretral de la Próstata/efectos adversos , Anciano de 80 o más Años , Humanos , Masculino , Complicaciones Posoperatorias/microbiologíaRESUMEN
Acute appendicitis - recent controversies in diagnostic and therapy Abstract. Acute appendicitis is one of the most frequent surgically treated gastrointestinal diseases. For most of the patients it is supposed to be easily diagnosed and treated, but there are cases with complex diagnosis and indistinct treatment. For correct diagnosis an elaborated patients' history and clinical examination by an experienced surgeon is necessary. In many countries, patients undergo additional extensive radiological diagnostics beside of ultrasound. This fact leads to an unjustified risk of x-ray exposure and increased costs in the health care system. In contrast, delay during diagnosis and treatment and consecutive complications are often the trigger for legal dispute and the accusation of malpractice of the responsible surgeon. In addition, the treatment of acute appendicitis has undergone changes towards a non-surgical therapy, so that the routinely performed urgent appendectomy has been displaced by conservative therapy using antibiotics, percutaneous drainage, and interval surgery after a certain time in a non-inflammatory state. So far, no distinct guideline is available, as profound prospective and randomized results and subgroup analysis are still missing. In this article these problems and controversies are enlightened. Particularly, legal aspects and potential conflicts between family doctors, surgeons, relatives, and patients are discussed. Finally, nothing is easy to diagnose or treat, even potentially simple diseases as acute appendicitis is considered to be.
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Apendicitis , Enfermedad Aguda , Antibacterianos/uso terapéutico , Apendicectomía , Drenaje , Humanos , Estudios ProspectivosRESUMEN
BACKGROUND: There are numerous causes of hepatic gas formation that range from serious pathologies to incidental findings, including mesenteric infarction, liver abscess, inflammatory bowel disease or minimally invasive hepatic interventions. CASE PRESENTATION: We report a case of a 50-year-old man who was admitted to the emergency room after a car accident. The clinical examination and further diagnostics revealed a craniocerebral injury with a fracture of the skull, concomitant soft tissue lesions and subarachnoidal bleeding. Furthermore, a blunt thoracic trauma with hemopneumothorax due to rib fractures was treated with a chest tube. No obvious abdominal pathology was seen. While in the operating theatre for the surgical revision of the cranial soft tissue lesions, a femoral venous catheter was inserted without any complications. A routine ultrasound of the abdomen six hours after the trauma revealed unclear hepatic gas formation. A contrast-enhanced computer tomography (CT) scan of the abdomen was performed, and the gas formation was found to be localized within the left hepatic vein. Afterwards, there was no specific treatment of the hepatic venous gas formation, as no alterations of liver function or liver enzymes were seen. The further course of the patient was uneventful regarding the gas formation in the liver, and another ultrasound two days later revealed no further gas in the liver. CONCLUSIONS: The placement of a femoral venous catheter is a risk factor for gas formation in liver veins. No further treatment is needed in cases with stable liver function. To rule out serious pathologies, diagnostic findings (e.g., ultrasound, CT), clinical history and underlying diseases need to be analyzed carefully after the detection of intrahepatic gas formation. With contrast-enhanced CT, the localization of the gas and its potential causes might be detectable.
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Cateterismo Periférico/efectos adversos , Gases , Venas Hepáticas , Abdomen/diagnóstico por imagen , Accidentes de Tránsito , Medios de Contraste , Venas Hepáticas/diagnóstico por imagen , Humanos , Hígado/diagnóstico por imagen , Hígado/fisiología , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/complicaciones , Traumatismo Múltiple/diagnóstico por imagen , Traumatismo Múltiple/cirugía , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
PURPOSE: Liver resection in hepatic sarcoma is rare, but other alternative treatment options are scarce. Surgery offers the only aggressive approach to achieve a tumour-free state. The aim of this investigation was to evaluate the outcome and survival of these patients at a single hepato-biliary university hospital. METHODS: Between January 2004 and July 2013, 896 anatomical liver resections were performed. Eleven liver resections (1.2%) were performed due to primary hepatic sarcoma or hepatic sarcoma metastases. The demographic and clinical parameters were collected from the institutional patients' records. RESULTS: In eight patients (83%), liver resection was performed due to hepatic sarcoma metastases. The surgical procedures were as follows: two patients (18%) had segmentectomy, six patients (55%) had hemihepatectomy or extended hemihepatectomy and three patients (27%) had multivisceral resections. In nine patients (82%), the resection margins were tumour free. In 55% (n = 6) of the patients, the maximal tumour diameter was greater than 10 cm. The postoperative morbidity was low with a Clavien-Dindo score of 2 (range 0-5). One patient died on postoperative day 2 after multivisceral resection. During the follow-up of 932 days (range 2-2.220 days) the 1-, 2- and 3-year survival rates were 91, 63 and 45%, respectively. Tumour recurrence was detected in seven patients (63%). CONCLUSIONS: Liver resections in patients with primary or secondary hepatic sarcoma are rare. The main goal in these patients is to achieve complete tumour resection because chemotherapy offers no suitable alternative, but the long-term survival rates are limited because of high a recurrence rate even after aggressive surgical approaches.
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Hepatectomía , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Sarcoma/patología , Sarcoma/cirugía , Adulto , Anciano , Femenino , Humanos , Neoplasias Hepáticas/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sarcoma/mortalidad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND & AIMS: Knockout studies of the murine Nuclear Factor I-C (NFI-C) transcription factor revealed abnormal skin wound healing and growth of its appendages, suggesting a role in controlling cell proliferation in adult regenerative processes. Liver regeneration following partial hepatectomy (PH) is a well-established regenerative model whereby changes elicited in hepatocytes lead to their rapid and phased proliferation. Although NFI-C is highly expressed in the liver, no hepatic function was yet established for this transcription factor. This study aimed to determine whether NFI-C may play a role in hepatocyte proliferation and liver regeneration. METHODS: Liver regeneration and cell proliferation pathways following two-thirds PH were investigated in NFI-C knockout (ko) and wild-type (wt) mice. RESULTS: We show that the absence of NFI-C impaired hepatocyte proliferation because of plasminogen activator I (PAI-1) overexpression and the subsequent suppression of urokinase plasminogen activator (uPA) activity and hepatocyte growth factor (HGF) signalling, a potent hepatocyte mitogen. This indicated that NFI-C first acts to promote hepatocyte proliferation at the onset of liver regeneration in wt mice. The subsequent transient down regulation of NFI-C, as can be explained by a self-regulatory feedback loop with transforming growth factor beta 1 (TGF-ß1), may limit the number of hepatocytes entering the first wave of cell division and/or prevent late initiations of mitosis. CONCLUSION: NFI-C acts as a regulator of the phased hepatocyte proliferation during liver regeneration.
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Proliferación Celular , Regeneración Hepática , Hígado/metabolismo , Factores de Transcripción NFI/metabolismo , Animales , Retroalimentación Fisiológica , Regulación de la Expresión Génica , Genotipo , Hepatectomía/métodos , Factor de Crecimiento de Hepatocito/genética , Factor de Crecimiento de Hepatocito/metabolismo , Hígado/patología , Hígado/fisiopatología , Hígado/cirugía , Masculino , Ratones Endogámicos C57BL , Ratones Noqueados , Factores de Transcripción NFI/deficiencia , Factores de Transcripción NFI/genética , Fenotipo , Inhibidor 1 de Activador Plasminogénico/genética , Inhibidor 1 de Activador Plasminogénico/metabolismo , Transducción de Señal , Factores de Tiempo , Factor de Crecimiento Transformador beta1/genética , Factor de Crecimiento Transformador beta1/metabolismo , Activador de Plasminógeno de Tipo Uroquinasa/genética , Activador de Plasminógeno de Tipo Uroquinasa/metabolismoRESUMEN
BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disorder in industrialized countries, yet its pathophysiology is incompletely understood. Small-molecule metabolite screens may offer new insights into disease mechanisms and reveal new treatment targets. METHODS: Discovery (N = 33) and replication (N = 66) of liver biopsies spanning the range from normal liver histology to non-alcoholic steatohepatitis (NASH) were ascertained ensuring rapid freezing under 30 s in patients. 252 metabolites were assessed using GC/MS. Replicated metabolites were evaluated in a murine high-fat diet model of NAFLD. RESULTS: In a two-stage metabolic screening, hydroquinone (HQ, p(combined) = 3.0 × 10(-4)) and nicotinic acid (NA, p(combined) = 3.9 × 10(-9)) were inversely correlated with histological NAFLD severity. A murine high-fat diet model of NAFLD demonstrated a protective effect of these two substances against NAFLD: Supplementation with 1% HQ reduced only liver steatosis, whereas 0.6% NA reduced both liver fat content and serum transaminase levels and induced a complex regulatory network of genes linked to NALFD pathogenesis in a global expression pathway analysis. Human nutritional intake of NA equivalent was also consistent with a protective effect of NA against NASH progression. CONCLUSION: This first small-molecular screen of human liver tissue identified two replicated protective metabolites. Either the use of NA or targeting its regulatory pathways might be explored to treat or prevent human NAFLD.
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Hígado/patología , Metaboloma/fisiología , Metabolómica/métodos , Enfermedad del Hígado Graso no Alcohólico/prevención & control , Enfermedad del Hígado Graso no Alcohólico/fisiopatología , Animales , Biopsia , Suplementos Dietéticos , Cromatografía de Gases y Espectrometría de Masas , Humanos , Hidroquinonas/metabolismo , Hidroquinonas/farmacología , Ratones , Niacina/metabolismo , Niacina/farmacología , Enfermedad del Hígado Graso no Alcohólico/metabolismo , Estadísticas no ParamétricasRESUMEN
OBJECTIVE: To determine whether elevated preoperative B-type natriuretic peptide (NP) measurements are an independent predictor of atrial fibrillation (AF) in patients having thoracic surgery. DESIGN: Systematic review and meta-analysis. SETTING: In-hospital and 30 days after thoracic surgery. PARTICIPANTS: The 742 patients who participated in the 5 observational studies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: EMBASE, OVID Health Star, Ovid Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ProQuest Dissertations and Theses A&I databases were searched for all studies of noncardiac thoracic surgery patients in whom a preoperative NP was measured up to 1 month before surgery, and that measured the incidence of postoperative AF. Studies were included regardless of their language, sample size, publication status, or study design. Study quality was evaluated using the Newcastle Ottowa Scale. The combined incidence of postoperative AF was 14.5% (n=108/742), and the NP thresholds used to predict AF varied among studies. An elevated preoperative NP measurement was associated with an OR of 3.13 (95% CI 1.38-7.12; I2=87%) for postoperative AF, with the sensitivity analysis reporting an OR of 9.51 (95% CI 4.66-19.40; I2=0). CONCLUSION: Patients with an elevated preoperative NP measurement are at an increased risk of postoperative AF. There may be value in incorporating NP measurement into existing AF risk prediction models.
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Fibrilación Atrial/sangre , Péptido Natriurético Encefálico/sangre , Complicaciones Posoperatorias/sangre , Procedimientos Quirúrgicos Torácicos/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/etiología , Biomarcadores/sangre , Humanos , Estudios Observacionales como Asunto/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Valor Predictivo de las PruebasRESUMEN
Acute reduction of portal vein blood flow (Qpv) increases hepatic arterial perfusion (Qha) [the hepatic arterial buffer response (HABR)]. Angiotensin II (AT-II) reduces Qpv, but its effect on HABR is not known. We explored interactions of AT-II and enalapril with hepatic blood flow regulation. Twenty healthy anesthetized pigs were randomized to receive AT-II (n = 8) from 5 to 61 ng/kg per min, enalapril (n = 8) from 3 to 24 µg/kg per h, or saline (n = 4). HABR was assessed by occluding portal vein and expressed as 1) ratio between changes in Qha and Qpv, 2) hepatic arterial conductance (Cha). AT-II infusion increased mean arterial blood pressure from 74 (66-77) mmHg to 116 (109-130) mmHg (median, IQR; P < 0.0001) and decreased cardiac output, Qpv, and renal artery flow (-24%, -28% and -45%, respectively). The fraction of cardiac output of Qha, carotid, and femoral flows increased. With enalapril, blood pressure decreased, whereas cardiac output was maintained with flow redistribution favoring hepatic and renal arteries. In AT-II group, dQha/dQpv increased from 0.06 (0.03, 0.17) to 0.24 (0.13, 0.31) (P = 0.002), but Cha during acute portal vein occlusion decreased from 4.3 (1.6, 6.6) to 2.9 (1.2, 3.7) ml/mmHg (P = 0.003). Both variables remained unchanged in the enalapril group and in controls. AT-II infusion reduces portal flow in parallel with cardiac output and induces a dose-dependent redistribution of flow, favoring brain, hepatic artery, and peripheral tissues at the expense of renal perfusion. During HABR, AT-II decreases Cha but increases Qha compensation, likely as result of increased hepatic arterial perfusion pressure. Enalapril had no effect on HABR.
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Angiotensina II/farmacología , Inhibidores de la Enzima Convertidora de Angiotensina/farmacología , Enalapril/farmacología , Hemodinámica/efectos de los fármacos , Arteria Hepática/efectos de los fármacos , Circulación Hepática/efectos de los fármacos , Animales , Presión Arterial/efectos de los fármacos , Gasto Cardíaco/efectos de los fármacos , Arterias Carótidas/efectos de los fármacos , Arterias Carótidas/fisiología , Circulación Cerebrovascular/efectos de los fármacos , Relación Dosis-Respuesta a Droga , Arteria Hepática/fisiopatología , Masculino , Vena Porta/efectos de los fármacos , Vena Porta/fisiología , Arteria Renal/efectos de los fármacos , Arteria Renal/fisiología , Circulación Renal/efectos de los fármacos , Porcinos , Factores de TiempoRESUMEN
UNLABELLED: Nucleotides, such as adenosine triphosphate (ATP), are released by cellular injury, bind to purinergic receptors expressed on hepatic parenchymal and nonparenchymal cells, and modulate cellular crosstalk. Liver resection and resulting cellular stress initiate such purinergic signaling responses between hepatocytes and innate immune cells, which regulate and ultimately drive liver regeneration. We studied a murine model of partial hepatectomy using immunodeficient mice to determine the effects of natural killer (NK) cell-mediated purinergic signaling on liver regeneration. We noted first that liver NK cells undergo phenotypic changes post-partial hepatectomy (PH) in vivo, including increased cytotoxicity and more immature phenotype manifested by alterations in the expression of CD107a, CD27, CD11b, and CD16. Hepatocellular proliferation is significantly decreased in Rag2/common gamma-null mice (lacking T, B, and NK cells) when compared to wildtype and Rag1-null mice (lacking T and B cells but retaining NK cells). Extracellular ATP levels are elevated post-PH and NK cell cytotoxicity is substantively increased in vivo in response to hydrolysis of extracellular ATP levels by apyrase (soluble NTPDase). Moreover, liver regeneration is significantly increased by the scavenging of extracellular ATP in wildtype mice and in Rag2/common gamma-null mice after adoptive transfer of NK cells. Blockade of NKG2D-dependent interactions significantly decreased hepatocellular proliferation. In vitro, NK cell cytotoxicity is inhibited by extracellular ATP in a manner dependent on P2Y1, P2Y2, and P2X3 receptor activation. CONCLUSION: We propose that hepatic NK cells are activated and cytotoxic post-PH and support hepatocellular proliferation. NK cell cytotoxicity is, however, attenuated by hepatic release of extracellular ATP by way of the activation of specific P2 receptors. Clearance of extracellular ATP elevates NK cell cytotoxicity and boosts liver regeneration.
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Adenosina Trifosfato/metabolismo , Células Asesinas Naturales/fisiología , Regeneración Hepática/fisiología , Hígado/metabolismo , Modelos Animales , Animales , Proliferación Celular , Proteínas de Unión al ADN/metabolismo , Hepatectomía , Hepatocitos/citología , Hepatocitos/metabolismo , Proteínas de Homeodominio/genética , Proteínas de Homeodominio/metabolismo , Hidrólisis , Técnicas In Vitro , Células Asesinas Naturales/citología , Hígado/citología , Hígado/cirugía , Ratones , Ratones Endogámicos C57BL , Ratones Noqueados , Receptores Purinérgicos P2/metabolismoRESUMEN
PURPOSE: Surgical site infections (SSI) are associated with increased costs and length of hospital stay, readmission rates, and mortality. The aim of this study was to identify risk factors for SSI in patients undergoing laparoscopic cholecystectomy. METHODS: Analysis of 35,432 laparoscopic cholecystectomies of a prospective multicenter database was performed. Risk factors for SSI were identified among demographic data, preoperative patients' history, and operative data using multivariate analysis. RESULTS: SSIs after laparoscopic cholecystectomy were seen in 0.8 % (n = 291) of the patients. Multivariate analysis identified the following parameters as risk factors for SSI: additional surgical procedure (odds ratio [OR] 4.0, 95 % confidence interval [CI] 2.2-7.5), age over 55 years (OR 2.4 [1.8-3.2]), conversion to open procedure (OR 2.6 [1.9-3.6]), postoperative hematoma (OR 1.9 [1.2-3.1]), duration of operation >60 min (OR 2.5 [1.7-3.6], cystic stump insufficiency (OR 12.5 [4.2-37.2]), gallbladder perforation (OR 6.2 [2.4-16.1]), gallbladder empyema (OR 1.7 [1.1-2.7]), and surgical revision (OR 15.7 [10.4-23.7]. SSIs were associated with a significantly prolonged hospital stay (p < 0.001), higher postoperative mortality (p < 0.001), and increased rate of surgical revision (p < 0.001). CONCLUSIONS: Additional surgical procedure was identified as a strong risk factor for SSI after laparoscopic cholecystectomy. Furthermore, operation time >60 min, age >55 years, conversion to open procedure, cystic stump insufficiency, postoperative hematoma, gallbladder perforation, gallbladder empyema, or surgical revision were identified as specific risk factors for SSI after laparoscopic cholecystectomy.
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Colecistectomía Laparoscópica/efectos adversos , Costos de Hospital , Mortalidad Hospitalaria , Infección de la Herida Quirúrgica/cirugía , Adolescente , Adulto , Anciano , Colecistectomía Laparoscópica/economía , Colecistectomía Laparoscópica/métodos , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación/economía , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Reoperación/economía , Reoperación/métodos , Medición de Riesgo , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/mortalidad , Tasa de Supervivencia , Suiza , Adulto JovenRESUMEN
Objectives: Fistula formation between the duodenum and the skin of the anterior abdominal wall is a rare complication and reported most often following surgery. To the best of our knowledge, the development of a spontaneous duodenocutaneous fistula in association with duodenal ulcer has only been reported once. Case presentation: A 52-year-old female patient presented at the emergency department with a painful ulcer and erythema on the right abdominal wall. On admission, she was in extremely poor general and nutritional condition. Laboratory analysis revealed inflammation. An empiric antibiotic therapy was initiated; parenteral nutrition, fluid, and electrolyte resuscitation were started. An enterocutaneous fistula was postulated and confirmed by endoscopy identifying a perforated duodenal ulcer. Surgery was not a valuable option and a Foley catheter was inserted through the fistula. During further endoscopic interventions, the Foley catheter was first replaced by a jejunal tube and later by a percutaneous endoscopic gastrostomy with a jejunal limb for enteral nutrition. The fistula output decreased, the local infection was controlled and the nutritional status improved. Conclusions: Three months later the fistula was closed and the gastrostomy tube was removed. After 2 years the patient was in good general and nutritional condition.
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Objectives: Since its introduction as a clinical technique, robotic surgery has been extended to different fields of surgery. However, the indications as well as the number of robotic procedures varied in different institutions. The aim of this investigation was to evaluate the current use of robotic surgery in general and digestive surgery in Switzerland. Methods: All Swiss surgical departments that are recognized training institutes for postgraduate training in surgery by the Swiss Institute of Medical Education (SIWF) were queried with a detailed questionnaire regarding the use of robotic surgery techniques and were analyzed regarding hospital size and type of hospital. Results: Ninety-three departments were queried, and 67â¯% (n=63) answered the survey. Fifty-eight were public, and five were private institutions. Seventeen (26â¯%) of the queried departments used robotic surgery in digestive surgery. Four out of 17 (23â¯%) of the departments that performed robotic surgery were private hospitals, while 13 (77â¯%) were public institutions. In the majority of departments, robotic surgery of the rectum (n=12; 70.6â¯%) and colon (n=11; 64.7â¯%) was performed, followed by hernia procedures (n=8; 47.1â¯%) and fundoplication (n=7; 41.2â¯%). Less frequently, pancreatic resections (n=5; 29.4â¯%), cholecystectomy (n=4; 23.5â¯%), adrenalectomy (n=4; 23.5â¯%), gastric bypass (n=3; 17.7â¯%), gastric sleeve (n=3; 17.7â¯%), hepatic procedures (n=2; 11.7â¯%), or small bowel resections (n=1; 5.9â¯%) were performed as robotic procedures. More than 25 procedures per year per department were performed for hernia surgery (n=5 departments), gastric bypass (n=2 departments), cholecystectomy, fundoplication, and colon surgery (each n=1 department). Conclusions: The number and range of robotic procedures performed in Switzerland varied widely. Higher accreditation for general surgery or subspecialization of visceral surgery of the department was positively associated with the use of robotic techniques, reflecting an unequal availability of robotic surgery.
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Myeloproliferative neoplasms can cause primary Budd-Chiari-Syndrome with acute or chronic liver failure necessitating liver transplantation. However, preventing the recurrence remains challenging and the need for post-transplant anticoagulant and cytoreductive treatment is not sufficiently clear. We analyzed the treatment regimens for all patients who presented to our department with PBCS from MPN between 2004 and 2021. Eight patients underwent liver transplantation - 6 of them due to an acute liver failure. Post-transplant, all patients received anticoagulant and 7 patients cytoreductive medication. The mean survival after transplantation was 13.25 years. Liver transplantation shows favorable long-term outcome when combined with post-transplant anticoagulant and cytoreductive treatment.
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BACKGROUND: It is unclear whether postoperative B-type natriuretic peptides (i.e., BNP and N-terminal proBNP) can predict cardiovascular complications in noncardiac surgery. METHODS: The authors undertook a systematic review and individual patient data meta-analysis to determine whether postoperative BNPs predict postoperative cardiovascular complications at 30 and 180 days or more. RESULTS: The authors identified 18 eligible studies (n = 2,051). For the primary outcome of 30-day mortality or nonfatal myocardial infarction, BNP of 245 pg/ml had an area under the curve of 0.71 (95% CI, 0.64-0.78), and N-terminal proBNP of 718 pg/ml had an area under the curve of 0.80 (95% CI, 0.77-0.84). These thresholds independently predicted 30-day mortality or nonfatal myocardial infarction (adjusted odds ratio [AOR] 4.5; 95% CI, 2.74-7.4; P < 0.001), mortality (AOR, 4.2; 95% CI, 2.29-7.69; P < 0.001), cardiac mortality (AOR, 9.4; 95% CI, 0.32-254.34; P < 0.001), and cardiac failure (AOR, 18.5; 95% CI, 4.55-75.29; P < 0.001). For greater than or equal to 180-day outcomes, natriuretic peptides independently predicted mortality or nonfatal myocardial infarction (AOR, 3.3; 95% CI, 2.58-4.3; P < 0.001), mortality (AOR, 2.2; 95% CI, 1.67-86; P < 0.001), cardiac mortality (AOR, 2.1; 95% CI, 0.05-1,385.17; P < 0.001), and cardiac failure (AOR, 3.5; 95% CI, 1.0-9.34; P = 0.022). Patients with BNP values of 0-250, greater than 250-400, and greater than 400 pg/ml suffered the primary outcome at a rate of 6.6, 15.7, and 29.5%, respectively. Patients with N-terminal proBNP values of 0-300, greater than 300-900, and greater than 900 pg/ml suffered the primary outcome at a rate of 1.8, 8.7, and 27%, respectively. CONCLUSIONS: Increased postoperative BNPs are independently associated with adverse cardiac events after noncardiac surgery.
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Cardiopatías/sangre , Cardiopatías/epidemiología , Péptido Natriurético Encefálico/sangre , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/epidemiología , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Cardiopatías/mortalidad , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/mortalidad , Humanos , Persona de Mediana Edad , Infarto del Miocardio/sangre , Infarto del Miocardio/epidemiología , Infarto del Miocardio/mortalidad , Oportunidad Relativa , Complicaciones Posoperatorias/mortalidad , Periodo Posoperatorio , Curva ROC , Medición de Riesgo/métodos , Medición de Riesgo/estadística & datos numéricos , Factores de RiesgoRESUMEN
OBJECTIVE: The liver acts as an innate immunity-dominant organ and natural killer (NK) cells, are the main lymphocyte population in the human liver. NK cells are in close interaction with other immune cells, acting as the first line of defense against pathogens, infections, and injury. A previously developed, three-dimensional, perfused liver-on-a-chip comprised of human cells was used to integrate NK cells, representing pivotal immune cells during liver injury and regeneration. The objective of this study was to integrate functional NK cells in an in vitro model of the human liver and assess utilization of the model for NK cell-dependent studies of liver inflammation. RESULTS: NK cells from human blood and liver specimen were isolated by Percoll separation with subsequent magnetic cell separation (MACS), yielding highly purified blood and liver derived NK cells. After stimulation with toll-like-receptor (TLR) agonists (lipopolysaccharides, Pam3CSK4), isolated NK cells showed increased interferon (IFN)-gamma secretion. To study the role of NK cells in a complex hepatic environment, these cells were integrated in the vascular compartment of a microfluidically supported liver-on-a-chip model in close interaction with endothelial and resident macrophages. Successful, functional integration of NK cells was verified by immunofluorescence staining (NKp46), flow cytometry analysis and TLR agonist-dependent secretion of interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha. Lastly, we observed that inflammatory activation of NK cells in the liver-on-a-chip led to a loss of vascular barrier integrity. Overall, our data shows the first successful, functional integration of NK cells in a liver-on-a-chip model that can be utilized to investigate NK cell-dependent effects on liver inflammation in vitro.
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Interferón gamma , Células Asesinas Naturales , Humanos , Hígado , Factor de Necrosis Tumoral alfa , Inflamación , Dispositivos Laboratorio en un ChipRESUMEN
Introduction: Intestinal spirochetosis is sometimes found by chance in histological specimen of routine endoscopies. There are only a few cases described in the literature that spirochetosis of the appendix was mimicking acute appendicitis. We present a case of pseudoappendicitis with the histological finding of spirochetes and review the current literature. Case Presentation: A 72-year-old woman presented with pain of the lower right abdomen and previous systemic corticoid therapy. In clinical examination, there was a tenderness and pain in the right lower quadrant, and inflammation values were elevated. An abdominal computed tomography scan revealed no obvious inflammation of the appendix. A diagnostic laparoscopy was performed and revealed a macroscopically uninflamed appendix which was removed. Histology revealed spirochetosis of the appendix but no typical signs of appendicitis. The patient was treated with antibiotics for 5 days and was discharged without abdominal pain. In a clinical control 6 weeks later, the abdominal pain had disappeared and the patient was in good clinical condition. Discussion: Intestinal spirochetosis is randomly found in histological specimen during routine endoscopies, even in asymptomatic patients. There are only a few cases described with spirochetosis of the appendix causing pain and mimicking appendicitis; hence, this entity is an important differential diagnosis of pain in the right lower quadrant of the abdomen.
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BACKGROUND: Diagnosis of intestinal ischemia remains a clinical challenge. The aim of the present study was to use a metabolomic protocol to identify upregulated and downregulated small molecules (M(r) < 500) in the serum of mice with intestinal ischemia. Such molecules could have clinical utility when evaluated as biomarkers in human studies. METHODS: A mouse model for intestinal ischemia was established and validated using histology and serum tumor necrosis factor α concentrations. A second mouse model of peritoneal sepsis was used as a positive control. Serial serum samples were collected from these and from sham-operated animals. Sera were analyzed by gas chromatography-mass spectrometry for 40 small molecules as their trimethylsilyl and O-methyloxime derivatives. Peak areas were normalized against an internal standard and resultant peak area ratios subjected to multivariate data analysis using unsupervised principal components analysis and supervised orthogonal projection to latent structures-discriminant analysis. Upregulated and downregulated serum molecules were identified from their correlation to the orthogonal projection to latent structures-discriminant analysis model. RESULTS: Three highly significantly upregulated (fold-change) serum molecules in intestinal ischemia were inorganic phosphate (2.4), urea (4.3), and threonic acid (2.9). Five highly significantly downregulated (fold-change) serum molecules were stearic acid (1.7), arabinose (2.7), xylose (1.6), glucose (1.4), and ribose (2.2). Lactic acid remained unchanged in intestinal ischemia. CONCLUSIONS: Distinct molecular changes are reported here for the first time in intestinal ischemia. They reveal impairments of gut microbiota metabolism, intestinal absorption, and renal function, together with increased oxidative stress. In contrast to other reports, lactic acid was not significantly changed. These molecular signatures may now be evaluated in clinical studies.
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Intestinos/irrigación sanguínea , Isquemia/metabolismo , Metabolómica , Animales , Biomarcadores , Modelos Animales de Enfermedad , Cromatografía de Gases y Espectrometría de Masas , Ácido Láctico/metabolismo , Ratones , Ratones Endogámicos C57BL , Análisis de Componente PrincipalRESUMEN
PURPOSE: Standardized surgical training is increasingly confronted with the public demand for high quality of surgical care in modern teaching hospitals. The aim of this study was to compare the results of laparoscopic cholecystectomy (LC) performed by resident surgeons (RS) and attending surgeons (AS). METHODS: In this retrospective review of prospectively collected data 1,747 LC were performed in a community hospital between 1999 and 2009. Seven hundred seventy operations were performed by RS. Parameters analysed included the duration of operation and length of hospital stay, intraoperative complications, 30-day morbidity and mortality. RESULTS: Duration of operation was 88 (25-245) min for RS vs. 75 (30-190) min by AS (p = 0.001). Elective operations were shorter when performed by AS (70 (30-190) [AS] vs. 85 (25-240) [RS] min, p = 0.001). Length of hospital stay was shorter in patients treated by RS (4 (1-49) days [RS] vs. 5 (1-83) days [AS], p = 0.1). Intraoperative complications showed no differences between the groups (1.0% [RS] vs. 1.3% [AS], p = 0.6), whereas 30-day morbidity was lower in patients treated by RS (3.8% [RS] vs. 6.2% [AS], p = 0.02). Overall mortality was 0.6% and independent of surgical expertise (0.5% [RS] vs. 0.8% [AS], p = 0.5). CONCLUSIONS: Provided adequate training, supervision and patient selection, surgical residents are able to perform LC with results comparable to those of experienced surgeons.