[Hepatic metastasis of a pleomorphic adenoma]. / Metástasis hepática de adenoma pleomorfo.

Pleomorphic adenoma is the most benign tumor of the salivary glands. It can undergo a malignant transformation to carcinoma and metastasize to distant organs, sometimes it can metastasize as a benign tumor. We present the case of an 82 years old male with hepatic lesion detected by ultrasound in routine urologic follow-up. CT scan revealed a solid image placed in segments V-VI-VII of the liver. A CT guided fine needle biopsy was made. Pathologic analysis reported a pleomorphic salivary adenoma metastasizing in the liver. Right hepatectomy was performed. Pathology study described a 10 cm diameter tumor with free margin, compatible with pleomorphic salivary adenoma, 32 years after surgery for the primary tumor. After 8 years of follow up, four hepatic nodules and a bone image in L4 vertebra that seemed to be a disease recurrence were found. It was decided to administer stereotactic body radiotherapy to the bone lesion and evaluate the response to decide the future treatment of the hepatic nodules, due to its slow growth.

Outcomes of pancreatic surgery in patients older than 70 years.

INTRODUCTION: The proportion of elderly patients is growing rapidly. Knowing the results of pancreatic surgery in this group of patients would help surgeons to make therapeutic decisions. The objective is to evaluate the surgical outcomes of pancreatic resections in patients over 70 years. METHODS: Retrospective study including patients undergoing pancreatic resection during the period 2009-2014. The sample was divided into 2 groups. G1: Patients under 70 years and G2: Patients older than 70 years. Surgical results between the 2 groups were evaluated. RESULTS: Seventy three pancreatic resections were performed, 51 (70%) patients belonged to G1 and 22 (30%) to G2. There were no significant differences between G1 and G2 in terms of operative time and hospitalization days. No significant difference was obtained in the incidence of delayed gastric emptying, pancreatic fistula or biliary fistula. The overall mortality in the series was 4.1% showing difference between both groups, with 2% in G1 and 13.6% in G2 (P=.04). When a sub-analysis in G2 was made, mortality in this group occurred only in patients with significant comorbidities with ASA ≥ 3 (P=.004). Both groups with oncologic disease had similar overall survival and disease-free survival. CONCLUSIONS: Age should not be a limiting factor for pancreatic resections. The elderly have similar results as younger patients and their increased perioperative mortality is due to the presence of important associated comorbidities rather than age as an independent risk factor.

When Should We Perform Intraoperative Cholangiography? A Prospective Assessment of 1000 Consecutive Laparoscopic Cholecystectomies.

BACKGROUND: Intraoperative cholangiography (IOC) has been historically used to detect common bile duct (CBD) stones, delineate biliary anatomy, and avoid or promptly diagnose bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). We aimed to determine the usefulness of routine IOC during LC in an urban teaching hospital. METHODS: A consecutive series of patients undergoing LC with routine IOC from 2016 to 2018 was prospectively analyzed. Primary outcomes of interest were: CBD stones, BDI, and anatomical variations of the biliary tract. Secondary outcomes of interest were: IOC success rate, IOC time, and readmission for residual lithiasis. A comparative analysis was performed between patients with and without preoperative suspicion of CBD stones. RESULTS: A total of 1003 LC were analyzed; IOC was successful in 918 (91.5%) patients. Mean IOC time was 10 (4 to 30) minutes. Mean radiation received by the surgeon per procedure was 0.06 millisieverts (mSv). Normal IOC was found in 856 (93.2%) patients. CBD stones and aberrant biliary anatomy were present in 58 (6.3%) and 4 (0.4%) cases, respectively. Two patients (0.2%) underwent unnecessary CBD exploration because of false-positive IOC. Four patients (0.4%) with normal IOC were readmitted for residual CBD stones. Five (0.5%) minor BDI undetected by the IOC were diagnosed. Patients with preoperative suspicion of CBD stones had significantly higher rates of CBD stones detected on IOC as compared with those without suspicion (23.2% vs. 2.1%, P<0.0001). CONCLUSION: Routine use of IOC resulted in low rates of BDI diagnosis, aberrant biliary anatomy identification and/or CBD stones detection. Selection of patients for IOC, rather than routine use of IOC appears a more reasonable approach.

Bile duct replacement using an autologous femoral vein graft: an experimental study. Preliminary results.

The repair of common bile duct injuries is a complex procedure with a significant rate of postoperative morbidity and mortality. The aim of this study was to demonstrate the usefulness of the autologous vein graft in replacement of the bile duct. Twelve male Sprague-Dawley rats weighing 350+/-550 g were used in the study and were divided at random into two groups: the control group (60) and the experimental group in which a 3-mm segment of the bile duct was resected and the biliary tract was replaced by a segment of vein aided by stent (G1). Both groups were subdivided into pairs of rats to study at 30, 60, and 120 days. All of the animals underwent radioisotope cholangiography, a repeat laparotomy, and blood tests for further pathologic study. The clinical evaluation and biochemical nuclear medicine and pathologic studies showed no evidence of cholestasis. The histologic study of the graft showed replacement of the endothelium by biliary-appearing epithelium. The use of an autologous vein graft with a supporting stent proves to be a feasible and alternative procedure for bile duct reconstruction. Further experimental studies should be carried out to validate these findings so they can be implemented in clinical cases.

Lymphoepithelial cysts of the pancreas: case report and review of the literature.

The aim of this report was to describe the clinical and pathologic features of lymphoepithelial cysts of the pancreas, establish the differential diagnosis of other pancreatic cysts, and review the literature. A 53-year-old man was incidentally diagnosed with a pancreatic lesion after an abdominal CT scan. This study showed a solid mass in the tail of the pancreas not enhanced by helical CT. Endoscopic ultrasound examination revealed a low-density tissue mass on the surface of the pancreas, less echogenic than the surrounding parenchyma. Distal pancreatectomy and splenectomy were performed with a suspected diagnosis of mucinous cystic tumor. The patient has had an uneventful postoperative period, and the pathologic finding was a lymphoepithelial cyst of the pancreas. Lymphoepithelial cyst of the pancreas is an unusual and benign entity that must be taken into consideration when evaluating a cystic lesion of the pancreas because a different therapeutic approach may be required.

Metástasis hepática de adenoma pleomorfo / Hepatic metastasis of a pleomorphic adenoma

El adenoma pleomorfo es el tumor benigno más frecuente de las glándulas salivales. Puede sufrir transformación maligna y metastatizar a otros órganos distantes y, en otros casos, hacerlo como un tumor benigno. Se presenta el caso de un hombre de 82 años con lesión hepática detectada por ecografía en estudio urológico de rutina. La tomografía computarizada reveló una imagen sólida en los segmentos V-VI-VII del hígado. Se efectuó biopsia de la lesión de cuyo examen se informó metástasis de adenoma pleomorfo salival. Se realizó hepatectomía derecha y la anatomía patológica describió un tumor de 10 cm de diámetro, con margen libre, compatible con adenoma pleomorfo salival, 32 años después de la cirugía de su tumor primario. Luego de 8 años, en el seguimiento se hallaron cuatro nódulos hepáticos y una nueva imagen ósea en la vértebra L4 sugerente de recurrencia de la enfermedad. Se decidió administrar radioterapia corporal estereotáctica a la lesión ósea y evaluar la respuesta para decidir el futuro tratamiento de los nódulos hepáticos, debido a su lento crecimiento.

Pleomorphic adenoma is the most benign tumor of the salivary glands. It can undergo a malignant transformation to carcinoma and metastasize to distant organs, sometimes it can metastasize as a benign tumor. We present the case of an 82 years old male with hepatic lesion detected by ultrasound in routine urologic follow-up. CT scan revealed a solid image placed in segments V-VI-VII of the liver. A CT guided fine needle biopsy was made. Pathologic analysis reported a pleomorphic salivary adenoma metastasizing in the liver. Right hepatectomy was performed. Pathology study described a 10 cm diameter tumor with free margin, compatible with pleomorphic salivary adenoma, 32 years after surgery for the primary tumor. After 8 years of follow up, four hepatic nodules and a bone image in L4 vertebra that seemed to be a disease recurrence were found. It was decided to administer stereotactic body radiotherapy to the bone lesion and evaluate the response to decide the future treatment of the hepatic nodules, due to its slow growth.

[Laparoscopic treatment of common bile duct lithiasis associated with gallbladder lithiasis]. / Tratamiento laparoscópico de la litiasis de la vía biliar principal asociada a litiasis vesicular.

INTRODUCTION: Laparoscopic bile duct exploration has become one of the main options for the treatment of choledocholithiasis associated with cholelithiasis. Our objective is to describe the results of a consecutive series of patients. PATIENTS AND METHOD: We retrospectively analyzed 101 (66 female/16 male) patients who underwent laparoscopic bile duct exploration. Age was 58 +/- 18 years. We analyzed operaion time, hospital stay and postoperative complications according to the surgical approach (transcystic or choledochotomy). Clinical follow up was carried out for 90 days after surgery and then subsequently by telephone. RESULTS: 1435 laparoscopic cholecystectomies were performed between January 1998 and December 2005. Of those, 101 of those patients underwent laparoscopic bile duct exploration for cholelithiasis and common bile duct stones. We evaluated clinical, laboratory and ultrasound predictors: 70 patients had positive and 31 negative predictors. Laparoscopic transcystic approach was successful in 78 patients and laparoscopic choledochotomy in 17 patients. Operation time was 154 +/- 59 minutes and hospital stay 4.31 +/- 3.44 days. Six patients (5.9%) were converted to open surgery. Two patients were re-operated for postoperative bile leakage. The overall effectiveness was 94%. Postoperative mortality was 0.99%. Median follow up was 51 months. Three patients died of unrelated conditions, three underwent ERCP and one had transfistular extraction for retained stones (3.96%). CONCLUSIONS: Laparoscopic treatment for common bile duct stones associated with gallbladder stones is a highly effective procedure with a low incidence of retained stones.

Metástasis hepáticas de cáncer colorrectal / Hepatic metastases from colorectal cancer

Las metástasis hepáticas ocurren entre el 20-30% de los pacientes afectaados por cáncer colorectal. la resección quirúrgica es el único tratamiento con intención curativa. El objetivo de este trabajo es describir los resultados de una serie consecutiva de pacientes.

Microcristales de colesterol en pacientes sin litiasis de la vía biliar / Cholesterol microlitiasis in patients without gallstones of the biliary tract

La prevalencia de microcristales de colesterol en la bilis coledociana o duodenal en pacientes con pancreatitis aguda de etiología indeterminada es elevada y esto ha sido la justificación para indicar la colecistectomía o esfinterotomía endoscópica. El objetivo del presente trabajo es determinar el valor de la presencia de los microcristales de colesterol en la vía biliar principal en los pacientes que no tienen síntomas ni signos de liltiasis canalicular ni pancreatitis

Utilidad del drenaje en la colecistectomía laparoscópica. Trabajo prospectivo randomizado / Usefulness of prophylactic drainage in laparoscopic cholecystectomuy. Randomized prospective report

El valor del drenaje profiláctico en diferentes cirugías abdominales se encuentra actualmente en revisión. El objetivo del trabajo es determinar la utilidad del drenaje en colecistectomía laparoscópica programada

Litiasis pulmonar secundaria a fístula colecistopleural / Secondary pulmonary lithiasis following cholecystopleural fistual

La litiasis pulmonar secundaria a fístula colecistopleural es una entidad infrecuente en la evolución de la colelitiasis que genera un potencial riesgo de vida para el paciente. Solo se ha publicado un caso en la bibiliografía angloparlante donde fue necesria una resección pulmonar para su tratamiento

Divertículo de Meckel en el adulto / Meckel diverticle in adults

En los últimos 10 años se halló divertículo de Meckel en 13 pacientes. Por complicaciones de la malformación se intervino a 4 de ellos. En los 9 restantes el divertículo fue un hallazgo incidental. Se extirpó en otros 4 pacientes y dejó in situ a los 5 restantes. No se registraron complicaciones postoperatorias inmediatas ni alejadas atribuíbles al Meckel excepto en seroma de herida. Las complicaciones más frecuentes del divertículo de Meckel son la obstrucción 46 por ciento, la inflamación 30 por ciento y la hemorragia 25 por ciento. En el 9 por ciento de los divertículos se encuentra mucosa gástrica ectópica y en el 5 por ciento tejido pancreático. El diagnóstico preoperatorio de divertículo de Meckel complicado es difícil de realizar, en revisiones importantes sólo se hizo en el 6 por ciento de los casos. A los métodos de diagnóstico por imágenes, se aconseja agregar la laparoscopia diagnóstica ante todo dolor abdominal atípico y la enteroscopia intraoperatoria ante toda hemorragia digestiva baja no localizada. Se considera la elección a la diverticulectomía extirpando en losanje la base de implantación, para no dejar heterotopia gástrica o pancreática que pudiera localizarse allí. Se cree conveniente la búsqueda sistemática del Meckel en toda apendicitis aguda, por existir, aunque rara, la asociación con diverticulitis. El divertículo encontrado en forma incidental se extirpará a cualquier edad cuando se lo palpe engrosado, se presuma la existencia de mucosa gástrica ectópica, sea de base estrecha o de longitud exagerada y siempre en los niños y adolescentes.

"By-pass" colonico en el cáncer esofágico avanzado / Colonic by-pass in advanced esophageal cancer

Se presentan 17 esofagocoloplastias izquierdas efectuadas como tratamiento paliativo de la disfagia en enfermos por cáncer esofágico avanzado. Se consideró que el cáncer era irresecable por broncoscopia. toracotomía exploradora, o por la extensión a ganglios celíacos de la enfermedad. Cinco enfermos fallecieron dentro de los primeros 2 meses por causas relacionadas con la operación, 11 pacientes sobrevivieron de 3 a 14 meses (promedio: 6,5 meses) y otro vive actualmente a los 5 meses de la cirugía. Diez enfermos toleraron una dieta oral completa desde la operación y 2 requirieron dilatación de la anastomosis cervical (1 caso por estrechez inflamatoria y 1 por estrechez neoplásica). El "by-pass" colónico es un método que se puede comparar favorablemente con otras formas más habituales de tratamiento paliativo del cáncer esofágico avanzado

Marcadores de coledocolitiasis en la patologías biliar aguda / Cheledocholithiasis markers in acute biliary pathology

En 109 enfermos con patología biliar aguda y litiatis en la ecografía al igreso, se investigó prospectivamente la sensibilidad y especificidad de las enzimas TGO, TGP, fosfatasa alcalina, amilasa sérica y bilirrubina total, como marcadores de coledocolitiasis. Los enfermos con colangitis o pancreatitis agudas fueron excluídos. presentaron al ingreso un colédoco d 0,7 cm o más de diámetro ecográfico, 69 pacientes y en todos ellos se tamizaron las materias fecales. Se halló migración transpapilar en 19; 50 presentaon en la cirugía coledocolitiasis sin migración y en los restantes 40 no existió coledocolitiasis. Con un valor umbral 3 veces superior al límite máximo normal para TGO y TGP, la sensibilidad en el diagnóstico de coledocolitiasis fue 54%, la especificidad 96%, el valor predictivo positivo 97% y el negativo 48%. Con un de 1,3 mg% o más de bilirrubina la sensibilidad fue del 51% y la especificidad 100%. La migración litiásica transpapilar ocurre a menudo en enfermos jóvenes, con escasa o ninguna elevación de la bilirrubina y marcada elevación de las transaminasas. En la coledocolitiasis sin migración, el valor diagnóstico de los marcadores tradicionales es aún más limitado, debido a la baja sensibilidad. El diámetro del colédoco medido al ingreso tiene actualmente mayor valor diagnóstico que los marcadores de laboratorio