The impact of externalized pancreatic stents in our practice: A comparison of outcomes after pancreaticoduodenectomy in two time periods.

BACKGROUND: Postoperative pancreatic fistula is a severe complication of pancreaticoduodenectomy. Using an externalized pancreatic stent is a potential mitigation strategy not previously studied in Latin America. METHODS: Pancreaticoduodenectomies performed in a single center between 2006 and 2019 were retrospectively analyzed. Clinical variables were collected with a 90-day follow-up according to stent intervention: externalized stent (ES), internal stent (IS), or no stent. Before and after ES implementation (2016) periods were also compared. RESULTS: Out of 237 patients, 77 (32.5 â€‹%) had an ES, 24 (10.1 â€‹%) an IS, and 136 (57.4 â€‹%) none. No difference was found in the overall incidence of POPF. The use of an ES was associated with less type C POPF, despite having an increased risk for fistula development. PD performed after 2016 were also associated with a reduced incidence of type C POPF, surgical reintervention requirement, POPF-associated mortality, and intrahospital stay. CONCLUSIONS: The use of an ES is a low-cost intervention that can mitigate POPF severity in high-risk patients.

Primary abandonment of the sac in the management of scrotal hernias: a dual-institution experience of short-term outcomes.

PURPOSE: Management of scrotal hernias presents as a common challenge, with operative interventions to address these hernias associated with higher rates of morbidity compared to those of less-complex pathology. Surgeons have advocated for the use of techniques such as primary abandonment of the distal sac as a potential means to reduce complications for operative intervention, with preliminary findings demonstrating feasibility. We sought to assess outcomes related to primary sac abandonment among patients undergoing minimally invasive (MIS) repair of scrotal hernias. METHODS: A review of prospectively maintained databases among two academic hernia centers was conducted to identify patients who underwent MIS inguinal hernia repairs with primary sac abandonment. Patient demographics, hernia risk factors, intraoperative factors, and postoperative outcomes were evaluated. Short-term outcomes related to patient-reported experiences and surgical-site occurrences requiring procedural intervention were queried. RESULTS: Sixty-seven male patients [median age: 51.6 years; interquartile range (IQR): 45-65 years] underwent inguinal hernia repair with primary sac abandonment. Anatomic polypropylene mesh was used in 98.5% cases. Rates of postoperative complications were low and included postoperative urinary retention (6%), clinically identified or patient-reported seromas/hematomas within a 30-day follow-up period (23.9%), deep venous thrombosis (1.5%), and pelvic hematoma (1.5%). No seromas or hematomas necessitated procedural interventions, with resolution of symptoms within three months of their operation date. CONCLUSION: We report a multi-center experience of patients managed with primary abandonment of the sac technique during repair of inguinoscrotal hernias. Utilization of this technique appears to be safe and reproducible with a low burden of short-term complications.

Concomitant midline ventral and inguinal hernia repair: can we create an algorithmic approach?

PURPOSE: International guidelines exist for surgical treatment of either ventral or inguinal hernias repair (VHR; IHR). However, approach for managing both of them remains unestablished and is further complicated by newly developed surgical techniques and modalities (namely, robotic). This highlights the need for a tailored, algorithmic strategy to streamline surgical management. METHODS: An algorithm was developed by the directors of the NYU Langone Abdominal Core Health program of which four treatment groups were described: Group 1: open VHR and either laparoscopic or robotic IHR; Group 2: robotic transabdominal pre-peritoneal (TAPP) approach for both VHR and IHR; Group 3: robotic retro-muscular VHR and IHR; and Group 4: open repair for both. Demographics, comorbidities, operative characteristics, and surgical outcomes from November 2021 to July 2023 were retrospectively compared. RESULTS: Ninety-two patients were included with a median age of 64 years, 90% (n = 83) were white, 85% (n = 78) were male, median BMI was 27 kg/m2, and 73% (n = 67) were ASA class II. Distribution of groups was: 48% (n = 44) in 1A, 8% (n = 7) in 1B, 8% (n = 7) in 2A, 3% (n = 3) in 2B, 23% (n = 21) in 3A, 8% (n = 7) in 3B, and 3% (n = 3) in 4. Ventral hernia size, OR time, and postoperative length of stay varied across groups. Postoperative outcomes at 30 days including emergency consults, readmissions, and complications, showed no differences across groups. CONCLUSION: Access without guidance to new minimally invasive surgical approaches can be a challenge for the general surgeon. We propose an algorithm for decision-making based on our experience of incorporating robotic surgery, when available, for repair of concomitant VHR and IHR with consistent favorable outcomes within a small sample of patients.

Trocar shortening for pediatric vitreoretinal surgery with a 3D printed trocar spacer: Report of two cases.

PURPOSE: To show the results of a trocar spacer for pediatric vitreoretinal surgery with a 3D printed trocar spacer in 2 cases. METHODS: We used standard 27 gauge (ga) and 25 ga trocars and cannulae, and prototyped 1.5 mm × 3 mm spacers with a Prusa MK3 3D printer (0.4 mm nozzle) with Fuse deposition melting (FDM) technology. Parts were printed with a 50 µm layer height in polylactic acid or polylactide (PLA). The spacer was placed in two places: between the blade's base and the trocar, and between the trocar and the sclera depending on the desired amount of shortening. This prototype was used in 2 vitrectomy cases in pediatric patients. RESULTS: We used this trocar spacer in 2 cases with positive results. CONCLUSIONS: This 3D printed spacer has proved to effectively shorten the introduced trocar into two different small eyes. More studies are needed to validate the efficacy and safety of this spacer in clinical practice.

Asociación Mexicana de Hepatología A.C. Clinical guideline on hepatitis B.

Hepatitis B virus (HBV) infection continues to be a worldwide public health problem. In Mexico, at least three million adults are estimated to have acquired hepatitis B (total hepatitis B core antibody [anti-HBc]-positive), and of those, 300,000 active carriers (hepatitis B surface antigen [HBsAg]-positive) could require treatment. Because HBV is preventable through vaccination, its universal application should be emphasized. HBV infection is a major risk factor for developing hepatocellular carcinoma. Semi-annual liver ultrasound and serum alpha-fetoprotein testing favor early detection of that cancer and should be carried out in all patients with chronic HBV infection, regardless of the presence of advanced fibrosis or cirrhosis. Currently, nucleoside/nucleotide analogues that have a high barrier to resistance are the first-line therapies.

Asociación Mexicana de Hepatología A.C. Clinical guideline on hepatitis B. / Asociación Mexicana de Hepatología A.C. Guía Clínica de Hepatitis B.

Hepatitis B virus (HBV) infection continues to be a worldwide public health problem. In Mexico, at least three million adults are estimated to have acquired hepatitis B (total hepatitis B core antibody [anti-HBc]-positive), and of those, 300,000 active carriers (hepatitis B surface antigen [HBsAg]-positive) could require treatment. Because HBV is preventable through vaccination, its universal application should be emphasized. HBV infection is a major risk factor for developing hepatocellular carcinoma. Semi-annual liver ultrasound and serum alpha-fetoprotein testing favor early detection of that cancer and should be carried out in all patients with chronic HBV infection, regardless of the presence of advanced fibrosis or cirrhosis. Currently, nucleoside/nucleotide analogues that have a high barrier to resistance are the first-line therapies.

Differences in the presentation and treatment of primary liver tumors at a hepatology center and an oncology center.

INTRODUCTION AND AIMS: Primary liver cancer is a public health problem in Mexico and the world. Liver transplantation (LT) is the ideal treatment for early hepatocellular carcinoma (HCC). Our aim was to evaluate the characteristics of patients with HCC and cholangiocarcinoma (CC) at two centers and identify transplantation candidates. MATERIALS AND METHODS: A retrospective observational study was conducted at the Hepatology Center (HC) and the University Center Against Cancer (UCAC), within the time frame of 2012-2018. HCC or intrahepatic CC was confirmed in 109 patients. Staging classifications, transplant selection models, and a predictive model for post-LT recurrence were applied to the HCC patients. RESULTS: Of the total population, 93% (n=102) presented with cirrhosis, 86% (n=94) had HCC (HC: 58%, UCAC: 42%), and 14% (n=15) had intrahepatic CC (HC: 40%, UCAC: 60%). Of the HC patients with HCC, Okuda I-II, BCLC A-B, and AFP levels <100ng/m predominated, whereas Okuda II-III, BCLC C-D, and AFP levels >1000ng/mL predominated in the UCAC patients. Half of the HC population with HCC met the criteria for LT, in contrast to 23% of the UCAC patients. Fifteen patients were evaluated for LT, and at present, six have undergone transplantation. CONCLUSIONS: The most frequent primary liver tumor was HCC. Patients from the HC presented with earlier-stage disease and a high number of them met the criteria for LT. Only patients from the HC underwent transplantation.

Differences in the presentation and treatment of primary liver tumors at a hepatology center and an oncology center. / Diferencias de la presentación y tratamiento en las neoplasias primarias de hígado en un centro de hepatología y un centro oncológico.

INTRODUCTION AND AIMS: Primary liver cancer is a public health problem in Mexico and the world. Liver transplantation (LT) is the ideal treatment for early hepatocellular carcinoma (HCC). Our aim was to evaluate the characteristics of patients with HCC and cholangiocarcinoma (CC) at two centers and identify transplantation candidates. MATERIALS AND METHODS: A retrospective observational study was conducted at the Hepatology Center (HC) and the University Center Against Cancer (UCAC), within the time frame of 2012-2018. HCC or intrahepatic CC was confirmed in 109 patients. Staging classifications, transplant selection models, and a predictive model for post-LT recurrence were applied to the HCC patients. RESULTS: Of the total population, 93% (n = 102) presented with cirrhosis, 86% (n = 94) had HCC (HC: 58%, UCAC: 42%), and 14% (n = 15) had intrahepatic CC (HC: 40%, UCAC: 60%). Of the HC patients with HCC, Okuda I-II, BCLC A-B, and AFP levels < 100 ng/m predominated, whereas Okuda II-III, BCLC C-D, and AFP levels > 1,000 ng/mL predominated in the UCAC patients. Half of the HC population with HCC met the criteria for LT, in contrast to 23% of the UCAC patients. Fifteen patients were evaluated for LT, and at present, six have undergone transplantation. CONCLUSIONS: The most frequent primary liver tumor was HCC. Patients from the HC presented with earlier-stage disease and a high number of them met the criteria for LT. Only patients from the HC underwent transplantation.

Consenso Mexicano para el Tratamiento de la Hepatitis C / The Mexican consensus on the treatment of Hepatitis C

El objetivo del Consenso Mexicano para el Tratamiento de la Hepatitis C fue el de desarrollar un documento como guía en la práctica clínica con aplicabilidad en México. Se tomó en cuenta la opinión de expertos en el tema con especialidad en: gastroenterología, infectología y hepatología. Se realizó una revisión de la bibliografía en MEDLINE, EMBASE y CENTRAL mediante palabras claves referentes al tratamiento de la hepatitis C. Posteriormente se evaluó la calidad de la evidencia mediante el sistema GRADE y se redactaron enunciados, los cuales fueron sometidos a voto mediante un sistema modificado Delphi, y posteriormente se realizó revisión y corrección de los enunciados por un panel de 34 votantes. Finalmente se clasificó el nivel de acuerdo para cada oración. Esta guía busca dar recomendaciones con énfasis en los nuevos antivirales de acción directa y de esta manera facilitar su uso en la práctica clínica. Cada caso debe ser individualizado según sus comorbilidades y el manejo de estos pacientes siempre debe ser multidisciplinario.

The aim of the Mexican Consensus on the Treatment of Hepatitis C was to develop clinical practice guidelines applicable to Mexico. The expert opinion of specialists in the following areas was taken into account: gastroenterology, infectious diseases, and hepatology. A search of the medical literature was carried out on the MEDLINE, EMBASE, and CENTRAL databases through keywords related to hepatitis C treatment. The quality of evidence was subsequently evaluated using the GRADE system and the consensus statements were formulated. The statements were then voted upon, using the modified Delphi system, and reviewed and corrected by a panel of 34 voting participants. Finally, the level of agreement was classified for each statement. The present guidelines provide recommendations with an emphasis on the new direct-acting antivirals, to facilitate their use in clinical practice. Each case must be individualized according to the comorbidities involved and patient management must always be multidisciplinary.

Deficiencia de vitamina D en el paciente quemado / Deficiency of vitamin D in the burn patient

Resumen: Las quemaduras son un escenario especial de trauma grave que condiciona osteopenia, alteraciones del metabolismo del calcio, miopatía e inmunosupresión, entre otras. Los pacientes quemados tienen elevado riesgo de hipovitaminosis D debido a que condicionan incremento en la pérdida de calcio, disminución de su captación en hueso e importantes alteraciones en la síntesis de vitamina D. En este contexto la suplementación con vitamina D en el paciente con quemaduras pudiera compensar su deficiencia y los efectos nocivos secundarios. El objetivo de este trabajo es revisar los conceptos actuales relacionados con el metabolismo de la vitamina D y el efecto de su deficiencia en los enfermos con quemaduras.

Abstract: Severe burn injury represents a special trauma leading to major systemic dysfunctions such a bone loss, mineral disruptions, myopathy and immunosuppression. Burn patients are at high risk of hypovitaminosis D. Burn injury gives rise to calcium wasting, failure of bone to take up calcium, and vitamin D insufficiency. In this context vitamin D supplementation could help counteract post-burn sequelae. The aim of this paper is to review the current concepts on vitamin D metabolism with special focus in burn patients.

Hemorragia cerebelosa a distancia. Presentación de un caso y revisión bibliográfica / Cerebellar hemorrhage a distance. Presentation of a Case and literature review

La hemorragia cerebelosa a distancia y, en su principal forma de presentación, los hematomas cerebelosos remotos constituyen una complicación poco frecuente de las cirugías que involucran el sistema nervioso central y la columna vertebral. Algunas publicaciones estiman su frecuencia entre el 0,2 y el 4,9%. Este porcentaje quizás esté subestimado, debido, por una parte, al gran abanico de manifestaciones clínicas que incluyen los casos asintomáticos y, por otra parte, al desconocimiento de esta inusual patología. Su fisiopatología no ha sido del todo definida; sin embargo, la teoría con más fuerza involucra el papel preponderante de la pérdida de líquido cefalorraquídeo durante el acto quirúrgico. La sintomatología puede incluir cefalea, síntomas cerebelosos y alteración del estado de conciencia. El tratamiento de los hematomas cerebelosos remotos debe ser acorde a la magnitud del sangrado y a las complicaciones asociadas. El pronóstico, en general, es bueno. Aproximadamente una tercera parte de los pacientes no tiene secuelas permanentes y la tasa de mortalidad es de alrededor 12%.(AU)

Remote cerebellar hemorrhage constitutes a rare complication of surgeries involving the central nervous system and the spine. Some publications estimate its frequency between 0.2% and 4.9%. This percentage may be underestimated, due, on the one hand, to the wide range of clinical manifestations that include asymptomatic cases and, on the other hand, to the unknown of this unusual pathology. Its pathophysiology has not been completely defined; however, the main theory involves the predominant role of cerebrospinal fluid loss during surgery. Symptoms may include headache, cerebellar symptoms and altered state of consciousness. Treatment of remote cerebellar hematomas should be commensurate with the magnitude of bleeding and the associated complications. Prognosis, in general, is good. Approximately one third of patients do not have permanent sequelae and mortality rate is around 12%.(AU)

Effects of melatonin on the acute inflammatory response associated with endoscopic retrograde cholangiopancreatography: A randomized, double-blind, placebo-controlled trial. / Efectos de la melatonina en la respuesta inflamatoria aguda asociada con la colangiopancreatografía retrógrada endoscópica: un ensayo clínico aleatorizado, doble ciego y controlado con placebo.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with an acute inflammatory response and melatonin has a variety of immunomodulatory and antioxidant effects studied experimentally in pancreatobiliary pathology. AIMS: The aim of our study was to evaluate the effects of peri-procedural administration of melatonin on the inflammatory response and lipid peroxidation associated with ERCP. METHODS: In this proof-of-concept clinical trial, 37 patients with a high probability of choledocholithiasis were randomized to receive peri-procedure (ERCP) melatonin or placebo. We measured the serum concentration of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), vascular endothelial growth factor (VEGF), lipid peroxidation, amylase, and liver function tests 24h before and after the procedure. RESULTS: We found no pre-procedure or post-procedure differences between the melatonin group or the placebo group (P>.05) in the serum concentrations of TNF-alpha (melatonin: 153.8 vs. 149.4ng/m; placebo: 103.5 vs. 107.3ng/ml), IL-6 (melatonin: 131.8 vs. 133.3ng/ml; placebo: 177.8 vs. 197.8ng/ml), or VEGF (melatonin: 157.3 vs. 157.8pg/ml; placebo: 97.3 vs. 97.8pg/ml), or in relation to lipid peroxidation (melatonin: 39.2 vs. 72.3µg/ml; placebo: 66.4 vs. 90.5µg/ml). After ERCP, a significant decrease in the AST, ALT, and total bilirubin levels was found only in the melatonin group (P<.05). The administration of melatonin was safe and tolerable. CONCLUSIONS: Melatonin is safe and tolerable in patients undergoing ERCP, but it does not appear to affect inflammatory cytokine concentrations or lipid peroxidation.

ß-Catenin is required for T-cell leukemia initiation and MYC transcription downstream of Notch1.

Notch activation is instrumental in the development of most T-cell acute lymphoblastic leukemia (T-ALL) cases, yet Notch mutations alone are not sufficient to recapitulate the full human disease in animal models. We here found that Notch1 activation at the fetal liver (FL) stage expanded the hematopoietic progenitor population and conferred it transplantable leukemic-initiating capacity. However, leukemogenesis and leukemic-initiating cell capacity induced by Notch1 was critically dependent on the levels of ß-Catenin in both FL and adult bone marrow contexts. In addition, inhibition of ß-Catenin compromised survival and proliferation of human T-ALL cell lines carrying activated Notch1. By transcriptome analyses, we identified the MYC pathway as a crucial element downstream of ß-Catenin in these T-ALL cells and demonstrate that the MYC 3' enhancer required ß-Catenin and Notch1 recruitment to induce transcription. Finally, PKF115-584 treatment prevented and partially reverted leukemogenesis induced by active Notch1.

Non-conventional functions for NF-κB members: the dark side of NF-κB.

NF-κB pathway exerts an essential function in the regulation of the immune response, which has been the nucleus of numerous studies for the past 25 years. Both activation of the pathway and termination of the NF-κB response are tightly regulated events, which is essential to prevent exacerbated inflammatory responses. Thus, alterations in NF-κB regulatory elements might result in tissue damage and cancer in different systems. In addition, several of the proteins involved in NF-κB regulation display additional, and much less studied, functions that connect with specific NF-κB-unrelated pathways. Many of these pathways are in turn regulators of particular physiologic and/or pathologic responses. Which are the principal non-conventional functions that have been identified for specific NF-κB elements, how they connect with other signaling pathways and what is their potential impact on cancer is the focus of this review.

Novel functions of chromatin-bound IκBα in oncogenic transformation.

The nuclear factor-κB (NF-κB) signalling pathway participates in a multitude of biological processes, which imply the requirement of a complex and precise regulation. IκB (for Inhibitor of kappaB) proteins, which bind and retain NF-κB dimers in the cytoplasm, are the main contributors to negative regulation of NF-κB under non-stimulation conditions. Nevertheless, increasing evidences indicate that IκB proteins exert specific nuclear roles that directly contribute to the control of gene transcription. In particular, hypophosphorylated IκBß can bind the promoter region of TNFα leading to persistent gene transcription in macrophages and contributing to the regulation of the inflammatory response. Recently, we demonstrated that phosphorylated and SUMOylated IκBα reside in the nucleus of the cells where it binds to chromatin leading to specific transcriptional repression. Mechanistically, IκBα associates and regulates Polycomb Repressor Complex activity, a function that is evolutionary conserved from flies to mammals, as indicate the homeotic phenotype of Drosophila mutants. Here we discuss the implications of chromatin-bound IκBα function in the context of tumorigenesis.

Does bladder augmentation negatively affect renal transplant outcome in posterior urethral valve patients?

OBJECTIVE: Although renal transplant (RT) is a safe and effective treatment for end-stage renal disease, the outcome of RT has been mixed for posterior urethral valve (PUV) patients. In addition, some PUV patients need an augmentation cystoplasty (AC), which may negatively affect their RT outcome. The aim of this study is to compare RT outcome between PUV children with and without AC. MATERIALS AND METHODS: Between 1985 and 2012 a total of 309 children received 369 RTs at our institution. Among these patients, 36 were had classified as having PUV. Of these, 12 underwent an AC before RT (AC group) and 24 did not (controls). Data, including age at transplant, allograft source, urological complications, urinary tract infection (UTI) incidence, the presence of vesicoureteral reflux (VUR), and patient and graft survival, were compared between groups. RESULTS: Mean age at RT and mean follow-up were 7.6 versus 7.9 years and 8.9 versus 7.9 years in the AC group and in the control group, respectively (not significant [NS]). Allografts were from living donors in 50% of the AC group and in 41.6% of the controls (NS). The rate of UTI was 0.02 UTI/patient/year and 0.004 UTI/patient/year in the AC and control group, respectively (p = 0.001). Of the nine patients with UTI in the augmented group, five (55.5%) had VUR, while 5/8 (62.5%) patients in the control group with UTI had VUR. All patients with VUR in either group had UTIs previously. Of the five AC patients with more than three UTIs, two (40%) were non-compliant with clean intermittent catheterization (CIC), and UTI incidence was not associated with either a Mitrofanoff conduit or the urethra being used for CIC. Graft function at the end of study was 87.8 ± 40.5 ml/min/m(2) in the AC group and 88.17 ± 28.20 ml/min/m(2) in the control group (NS). The 10-year graft survival rate was 100% in AC group and 84.8% in controls. Two patients in the AC group lost their grafts (mean follow-up 13.3 ± 0.8 years) and five in the control group (mean follow-up 7.1 ± 4.7 years). CONCLUSIONS: Bladder augmentation does not negatively affect renal outcome in PUV patients undergoing transplantation. However, recurrent UTIs are more frequent in transplanted PUV patients with an AC than in those without AC, and they are generally related to non-compliance with CIC or the presence of VUR but, mostly, they will not result in impaired graft function.

Bupropion reduces the inflammatory response and intestinal injury due to ischemia-reperfusion.

Intestinal ischemia-reperfusion (I/R) causes severe organ failure and intense inflammatory responses, which are mediated in part by the cytokine tumor necrosis factor-alpha (TNF-alpha). Bupropion is an antidepressant known to inhibit TNF-alpha production. We sought to examine the protective effects of bupropion on intestinal I/R injury in 15 male Sprague-Dawley rats that were randomized to sham surgery, 45 minutes of intestinal ischemia followed by 180 minutes reperfusion, or bupropion (100 mg/kg) before the intestinal I/R injury. To evaluate the systemic inflammatory response induced by intestinal I/R, we measured serum levels of TNF-alpha, interleukins-1 and -6, lipid peroxidation, and transaminases. Histologic analysis evaluated intestinal injury using the Chiu muscosal injury score. After I/R, Chiu score in control animals was 3.6 ± 1.2 vs 2.6 ± 0.53 in animals that received bupropion (P < .05). Bupropion pretreatment reduced intestinal. I/R injury and blunted serum elevations of TNF-alpha (0.96 ± 1.1 ng/mL vs 0.09 ± 0.06 ng/mL, P < .05) and interleukin-1 (0.53 ± 0.24 ng/mL vs 0.2 ± 0.11 ng/mL, P < .05). Bupropion in reduced intestinal I/R injury through immunomodulatory machanisms that involve inflammatory cytokines such as TNF-alpha.

Long-term consequences of posterior urethral valves.

Posterior urethral valves (PUV) are the most common congenital cause of bladder outlet obstruction in infancy, and it is the effect of this obstruction on the bladder and the kidneys that will decide a patient's prognosis. With the improvements in diagnosis and treatments, what was previously a poor prognosis for boys with PUV has improved, and more patients will encounter the long-term sequelae of PUV during puberty and adulthood. In these patients the long-term prognosis in terms of renal and bladder function and fertility, as well as the risk of malignancy in those whose bladders were augmented with gastrointestinal segments, is still a matter of great concern and all of these topics will be discussed in this article.