Role of tumour location and surgical extent on prognosis in T2 gallbladder cancer: an international multicentre study.

BACKGROUND: In gallbladder cancer, stage T2 is subdivided by tumour location into lesions on the peritoneal side (T2a) or hepatic side (T2b). For tumours on the peritoneal side (T2a), it has been suggested that liver resection may be omitted without compromising the prognosis. However, data to validate this argument are lacking. This study aimed to investigate the prognostic value of tumour location in T2 gallbladder cancer, and to clarify the adequate extent of surgical resection. METHODS: Clinical data from patients who underwent surgery for gallbladder cancer were collected from 14 hospitals in Korea, Japan, Chile and the USA. Survival and risk factor analyses were conducted. RESULTS: Data from 937 patients were available for evaluation. The overall 5-year disease-free survival rate was 70·6 per cent, 74·5 per cent for those with T2a and 65·5 per cent among those with T2b tumours (P = 0·028). Regarding liver resection, extended cholecystectomy was associated with a better 5-year disease-free survival rate than simple cholecystectomy (73·0 versus 61·5 per cent; P = 0·012). The 5-year disease-free survival rate was marginally better for extended than simple cholecystectomy in both T2a (76·5 versus 66·1 per cent; P = 0·094) and T2b (68·2 versus 56·2 per cent; P = 0·084) disease. Five-year disease-free survival rates were similar for extended cholecystectomies including liver wedge resection versus segment IVb/V segmentectomy (74·1 versus 71·5 per cent; P = 0·720). In multivariable analysis, independent risk factors for recurrence were presence of symptoms (hazard ratio (HR) 1·52; P = 0·002), R1 resection (HR 1·96; P = 0·004) and N1/N2 status (N1: HR 3·40, P < 0·001; N2: HR 9·56, P < 0·001). Among recurrences, 70·8 per cent were metastatic. CONCLUSION: Tumour location was not an independent prognostic factor in T2 gallbladder cancer. Extended cholecystectomy was marginally superior to simple cholecystectomy. A radical operation should include liver resection and adequate node dissection.

ANTECEDENTES: En el cáncer de vesícula biliar, la ubicación del tumor subdivide el estadio T2 en tumores con invasión del lado peritoneal y del lado del hígado (T2a y T2b). Para los tumores que invaden el lado peritoneal (T2a) se sugiere que se puede obviar la resección hepática sin que ello comprometa el pronóstico. Sin embargo, este argumento no ha sido validado. El estudio tuvo como objetivo investigar el valor pronóstico de la localización del tumor en el cáncer de vesícula biliar T2 y establecer la extensión adecuada de la resección quirúrgica. MÉTODOS: Se recogieron los datos clínicos de pacientes que se sometieron a cirugía por cáncer de vesícula biliar en 14 hospitales de Corea, Japón, Chile y Estados Unidos. Se realizaron análisis de la supervivencia y de los factores de riesgo. RESULTADOS: Se dispuso de datos de 937 pacientes para ser evaluados. La tasa de supervivencia global libre de enfermedad a los 5 años fue del 70,6%, y las de T2a y T2b del 74,5% y 65,5% (P = 0,028). Con respecto a la resección hepática, la colecistectomía extendida presentó una tasa mejor de supervivencia libre de enfermedad a los 5 años que la colecistectomía simple (73,0% versus 61,5%, P = 0,012). La tasa de supervivencia libre de enfermedad a los 5 años fue marginalmente mejor para la colecistectomía extendida que para la colecistectomía simple tanto en T2a (76,5% versus 66,1%, P = 0,094) como en T2b (68,2% versus 56,2%, P = 0,084). Las tasas de supervivencia libre de enfermedad a los 5 años no fueron diferentes entre la resección hepática en cuña y la segmentectomía S4b+S5 (74,1% versus 71,5%, P = 0,720). En el análisis multivariable, los factores de riesgo independientes para la recidiva fueron la presencia de síntomas (cociente de riesgos instantáneos, hazard ratio, HR 1,52, P = 0,002), la resección R1 (HR 1,96, P = 0,004) y el estadio N1/N2 (N1 HR 3,40, P < 0,001; N2 HR 9,56, P < 0,001). El 70,8% de las recidivas eran metastásicas. CONCLUSIÓN: La localización del tumor no fue un factor pronóstico independiente en el cáncer de vesícula biliar T2. La colecistectomía extendida fue marginalmente superior que la colecistectomía simple. La cirugía radical debe incluir una resección hepática y una linfadenectomía adecuada.

Laparoscopic Liver Resection: A South American Experience with 2887 Cases.

BACKGROUND: Laparoscopic liver resections (LLR) have been increasingly performed in recent years. Most of the available evidence, however, comes from specialized centers in Asia, Europe and USA. Data from South America are limited and based on single-center experiences. To date, no multicenter studies evaluated the results of LLR in South America. The aim of this study was to evaluate the experience and results with LLR in South American centers. METHODS: From February to November 2019, a survey about LLR was conducted in 61 hepatobiliary centers in South America, composed by 20 questions concerning demographic characteristics, surgical data, and perioperative results. RESULTS: Fifty-one (83.6%) centers from seven different countries answered the survey. A total of 2887 LLR were performed, as follows: Argentina (928), Brazil (1326), Chile (322), Colombia (210), Paraguay (9), Peru (75), and Uruguay (8). The first program began in 1997; however, the majority (60.7%) started after 2010. The percentage of LLR over open resections was 28.4% (4.4-84%). Of the total, 76.5% were minor hepatectomies and 23.5% major, including 266 right hepatectomies and 343 left hepatectomies. The conversion rate was 9.7%, overall morbidity 13%, and mortality 0.7%. CONCLUSIONS: This is the largest study assessing the dissemination and results of LLR in South America. It showed an increasing number of centers performing LLR with the promising perioperative results, aligned with other worldwide excellence centers.

Analgesia in patients with acute abdominal pain.

BACKGROUND: For decades, analgesia for patients with acute abdominal pain was withheld until a definitive diagnosis was established for fear of masking the symptoms, changing physical findings or ultimately delaying diagnosis and treatment of a surgical condition. This non-evidence-based approach has been challenged by recent studies demonstrating that the use of analgesia in the initial evaluation of patients with acute abdominal pain leads to significant pain reduction without affecting diagnostic accuracy. However, early administration of analgesia to such patients can greatly reduce their pain and does not interfere with a diagnosis, which may even be facilitated due to the severity of physical symptoms being reduced. OBJECTIVES: To determine if the currently available evidence supports the use of opioid analgesia in patient management with acute abdominal pain; and to assess changes in a patient comfort while awaiting definitive diagnosis and final treatment decisions. SEARCH STRATEGY: Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 4, 2006), MEDLINE (1966 to 2006) and EMBASE (1980 to 2006). Randomized controlled trial filter for MEDLINE and EMBASE search. Trials will also be identified by "related articles". The searches were not limited by language or publication status. SELECTION CRITERIA: Randomized controlled trials (RCTs) that include adult patients with acute abdominal pain, without gender restriction, comparing any opioid analgesia regime to no analgesia administered prior to any intervention regardless of outcomes. DATA COLLECTION AND ANALYSIS: Two authors looked independently at the titles and abstracts of reports. Potentially relevant studies selected by at least one reviewer were retrieved in full text versions for potential inclusion. Allocation concealment was important to avoid bias and was graded using the Cochrane approach. The data from studies included was reviewed qualitatively and quantitatively using the Cochrane Collaborations methodology and statistical software RevMan Analysis 1.0.5. In the case of homogeneity or non- worrying heterogeneity, a random effects model was used. Sensitivity analysis was performed based on quality assessment. MAIN RESULTS: Six studies fulfilled the inclusion criteria. Improvement with use of opioid analgesia was verified in variables patient comfort, reduction of pain, changes in physical examination. AUTHORS' CONCLUSIONS: The review provide some evidence to support the notion that the use of opioid analgesics in patients with acute abdominal pain is helpful in terms of patient comfort and does not retard decisions to treat.

Laparoscopic pericystectomy for liver hydatid cysts.

BACKGROUND: The laparoscopic approach for managing of liver echinococcosis is a controversial issue because of scarce experience worldwide. The aim of this report is to describe the technical details of our laparoscopic method and present our results. METHODS: Consecutive cases of liver echinococcosis managed by laparoscopic surgery are reported. Thoracic x-ray and abdominal ultrasound had been performed previously. The following aspects were considered as selection criteria: unique cyst located in segments III, IV, V, VI, and VIII; diameter less than 7 cm; and no evidence of infection or calcification. An evacuating puncture was performed, germinative membrane removed, and pericystectomy performed, which extirpated the pericystic structure with the surrounding liver parenchyma. Specimens were removed in a plastic bag through one of the ports. Surgical morbidity, hospital stay, time until return to work, and evidences of hydatid recurrence were measured. RESULTS: Surgery was performed on eight patients (5 women and 3 men) with a mean age of 44.9 years (range, 22-83 years) who had a liver hydatid cyst with a mean diameter of 6.6 cm (range, 5-7 cm). During a mean follow-up period of 30 months (range, 23-44 months), no morbidity or hydatid recurrence were verified. Hospital stay was 2 days in all cases, and return to work was within 15 days. CONCLUSION: This laparoscopic technique, applied with selective criteria, can be a useful alternative for treating patients with liver hydatidosis because its results are comparable with those for open surgery studies involving similar follow-up time.

[Cholangiohydatidosis. An evolutive complication of hepatic hydatidosis]. / Colangiohidatidosis. Una complicación evolutiva de la hidatidosis hepática.

Hydatidosis is and endemic disease in the south of Chile, especially in Region IX where remain rates of high prevalence. Cholangiohydatidosis is an infrequent complication of liver hydatidosis. The objective of this paper is to describe clinical features of a series of patients with cholangiohydatidosis. Series of cases of cholangiohydatidosis treated consecutively and the corresponding follow-up is reported. Clinical, laboratory and images characteristics are described. Descriptive statistic was used its incidence was calculated. In the studied period, 13 patients with cholangiohydatidosis were recruited, 9 men (69.2%) and 4 women (30.7%). Observed laboratory abnormalities were an increment of leukocytes in 8 patients (61.5%) and hepatic cholestasis with hepatocyte signs of cytolysis in 11 patients (84.6%). Choledocus diameter average measured by ultrasonography was 24.7 mm. All the patients had at least one liver cyst whose diameter average was of 12.1 cm. At surgery, evidence of biliary communications was detected in all patients and biliary decompression was carried out through a choledocostomy in 12 patients (92.3%) and by choledocoduodenal anastomoses in one case (7.7%). With a mean follow-up of 38.7 months morbility was 23% and mortality 7.7%. Accumulated incidence of this entity was of 0.07 cases in 5 years. Cholangiohydatidosis is an uncommon complication of liver hydatidosis that presents considerable morbidity and mortality rates.

Prevalence of esophageal disorders in patients with recurrent chest pain.

The objective of this study is to determine the prevalence of esophageal disorders (ED) associated with recurrent chest pain (RCP) and the utility of esophageal functional tests (EFT) in the study of these patients. The cross-sectional study was conducted at Hospital Clínico de La Frontera, Chile. One hundred and twenty-three patients with RCP were studied using esophageal manometry, edrophonium stimulation and 24-h pH monitoring. The performance of EFT was considered acceptable when they were capable of finding ED. To state the probability that RCP had an esophageal origin, patients were classified according to whether their pain had a probable, possible or unlikely esophageal origin. The prevalence of ED was determined according to diagnoses obtained after applying EFT and a multivariate analysis was performed to examine the association between the esophageal origin of RCP and ED. Rates of correct diagnosis of 65.9%, 56.9% and 31.7% was verified for 24-h pH monitoring, esophageal manometry and edrophonium stimulation, respectively. In 38.2% of patients with RCP, the pain was probably of esophageal origin, in 42.3% there was a possible esophageal origin and in 19.5% an unlikely esophageal origin. A 44.7% prevalence of GERD, 26.8% of GERD with secondary esophageal motor dysfunction and 8.9% of pure esophageal motor dysfunction were verified. The multivariate analysis allowed us to verify the association between the probability of esophageal origin of RCP, the variables RCP duration, esophagitis and dysphagia coexistence (P= 0.037, P= 0.030 and P= 0.024, respectively), and a statistically significant association between ED and dysphagia coexistence (P= 0.028). A high prevalence of ED was identified in patients with RCP.

The use of monensin or formaldehyde to control the digestion of the nitrogenous constituents of perennial ryegrass (Lolium perenne cv. Melle) and white clover (Trifolium repens cv. Blanca) in the rumen of cattle.

Pure swards of perennial ryegrass (Lolium perenne cv. Melle) and white clover (Trifolium repens cv. Blanca) were harvested daily as primary growth (grass in May, clover in June) or regrowths (clover only in July) and offered, in the long form, to growing cattle at a feeding rate of 22 g dry matter/kg live weight. With each forage, two treatments were compared with the untreated forage (C): monensin (100 g active ingredient/kg, 250 mg/d) addition to the rumen (treatment M) or formaldehyde (30 g/kg crude protein (nitrogen X 6.25] application to the diet (treatment F). The objective of the experiment was to examine means of manipulating N metabolism in the rumen and the duodenal non-ammonia-N (NAN) supply derived from fresh forages. The apparent digestion of ingested organic matter (g/kg) in the rumen was unaffected by treatment M (C 509, M 497) but was significantly (P less than 0.01) reduced by treatment F (443). The extent of cellulose digestion in the rumen was not affected by any of the treatments imposed and the changes in organic matter digestion were due mainly to effects on N digestion and rumen microbial synthesis. On the untreated diets, duodenal NAN supply averaged 0.74 g/g N intake and treatment M caused a small but non-significant increase (M 0.79 g/g N intake). In contrast, the effect of treatment F was much larger (F 0.91 g/g N intake; P less than 0.01). These differences were accompanied by corresponding reductions in rumen NH3 concentrations (mg/l; C 350, M 310, F 220; P less than 0.001). Of the increased flow of NAN to the small intestine observed on the white clover only diets with treatment F, 0.70 was accounted for by an increased net synthesis of microbial N, while treatment M had no effect on microbial N synthesis and a marginal reduction in feed N degradability only with the regrowth white clover diet. Treatment F reduced feed N degradability to a limited extent on both clover diets (C 0.82, M 0.81, F 0.77). No corresponding measurements were made for the ryegrass diets. It is concluded that the extensive loss of N from the reticulo-rumen of cattle fed on fresh forages can be reduced by the use of agents to reduce protein solubility. However, the study demonstrated that treatment F may in some circumstances increase N supply to the small intestine more through enhancing microbial N synthesis within the rumen than through increasing the passage of undegraded feed N to the small intestine.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of forage species and season on nutrient digestion and supply in grazing cattle.

1. A total of twenty Friesian steers were grazed on pure swards of either perennial ryegrass (Lolium perenne cv. Melle) or white clover (Trifolium repens cv. Blanca) from May to late August to examine the effect of forage species and season on nutrient digestion and supply. Within each forage species, two daily allowances of forage (i.e. 30 and 60 g dry matter (DM)/kg live weight) were given, and nutrient flow into the small intestine was measured on thirteen separate occasions (viz. seven grasses and six clovers). 2. Total nitrogen content of the grasses varied between 28 (early season), 19 (mid-) and 33 (late) g/kg DM, whilst the clovers showed a much narrower range and all values were higher (39-45 g/kg DM). In vitro organic matter (OM) digestibilities of plucked samples ranged from 742 to 809 g/kg OM (grass) and 712 to 790 g/kg OM (clover), the lowest values being noted in late June (grass) and mid-July (clover). 3. OM intakes calculated from estimated faecal OM output (using unlabelled ruthenium) and predicted OM digestibility of the consumed forage indicated mean values of 20.9 (grass) and 26.0 (clover) g/kg live weight (P less than 0.001), whilst the higher forage allowances increased OM intake by approximately 8% on both grass and clover (P less than 0.01) compared with the low allowance. OM intake was significantly (P less than 0.01) lower on the two primary growths of grass examined in May (mean 16.8 g/kg live weight) than the other five grass diets. 4. Rumen molar propionate levels declined with season but were at all times higher on the grass than on the clover diets, whilst acetate levels were unaffected by forage species. Apart from the late-season grass, mean rumen ammonia concentration was less than 100 mg NH3-N/l on all grass diets, whilst values on the clover diets ranged from 200-350 mg/l. 5. Daily duodenal OM flows in relation to animal live weight were approximately 20% higher on the clover than on the grass diets (grass 9.2, clover 11.2 g/kg live weight, P less than 0.001), but estimates of the proportion of digestible OM apparently digested in the rumen were not significantly influenced by forage species (grass 0.69, clover 0.71).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of forage species and stage of harvest on the processes of digestion occurring in the rumen of cattle.

1. Pure swards of perennial ryegrass (Lolium perenne L. cv. Melle) or white clover (Trifolium repens L. cv. Blanca) were harvested daily as either primary growth (May-June) or mid- (July) and late- (August-September) season 4-week regrowths and offered to Friesian steers at two levels of feed allowance (18 and 24 g dry matter (DM)/kg live weight), to examine the effect of forage species and stage of harvest on nutrient digestion and supply. 2. The early- and mid-season grasses had low nitrogen (23 g/kg DM) and high water-soluble carbohydrate (169 g/kg) contents whilst the late-season grass had a higher N content (28 g/kg). All clover diets had high N (average 45 g/kg) and low water-soluble carbohydrate (89 g/kg) contents, and DM digestibility on all diets ranged from 0.77 to 0.83 (mean of two feeding levels). 3. Mean total rumen volatile fatty acid concentrations were significantly (P less than 0.001) higher on the clover diets, whilst on the grass diets molar proportions of propionate showed a slight but not significant decline with advancing season and tended to be higher than those on the clover diets. Mean rumen ammonia concentrations were significantly (P less than 0.001) lower on the early- and mid-season grasses (59 mg NH3-N/l) than the late-season grass (242 mg/l) and early-season clover (283 mg/l) which were all significantly (P less than 0.01) lower than the mid- and late-season clovers (372 and 590 mg/l) respectively. 4. Rates of organic matter (OM) and N digestion in the rumen were estimated using established nylon-bag techniques and found to be high on all diets, but significant effects due to forage species (clover greater than grass; P less than 0.001) were detected, whilst overall potential degradability in the rumen exceeded 0.89 for both OM and N on all diets. 5. Significantly (P less than 0.001) more OM entered the small intestine of calves fed on white clover (10.2 g/kg live weight) than those fed on ryegrass (8.33 g/kg) and similar effects due to level of feeding (g/kg; low 7.9, high 10.6; P less than 0.05) and stage of harvest (g/kg; early 8.3 v. mid 10.0, late 9.50; P less than 0.05) were also detected.(ABSTRACT TRUNCATED AT 400 WORDS)