2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy.

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Adrenal insufficiency in cardiothoracic patients: an evaluation of the corticotrophin stimulation test and other diagnostic methods.

PURPOSE: The purposes of the study were to determine the incidence of adrenal insufficiency (AI) using several published techniques, compare the response rates using a low-dose (LD) corticotropin (ACTH) stimulation test vs a standard dose (SD), and identify the technique that is most closely related to vasopressor use. MATERIALS AND METHODS: Consecutive adult patients who were undergoing open heart surgery for CAD or valvular disease were prospectively enrolled. Exclusion criteria included history of steroid use, operative steroid, or etomidate administration. Postoperatively, each patient underwent ACTH stimulation with 1 µg (LD) and 249 µg (SD), 60 minutes apart. Agreement among the tests was evaluated, and vasopressor use was compared between groups. RESULTS: There were 40 patients evaluated. The incidence of AI based on operative change, postoperative values, and LD-ACTH and SD-ACTH tests was 53%, 38%, 60%, and 38%, respectively. Agreement between the LD- and SD-ACTH tests was 73% (κ = 0.476, P = .001). There was a significant difference in the need for (93% vs 52%, P = .013) and duration (18.9 [0-180.6] vs 0.6 [0-73.2] hours, P = .003) of vasopressor therapy in patients with and without AI but only using the SD-ACTH definition. CONCLUSION: The incidence of AI will vary greatly based on technique used for diagnosis. The SD-ACTH stimulation test should be used to determine AI in open heart patients postoperatively because of the close association with vasopressor usage.

Induction of tolerance to composite tissue allograft in a rat model.

The goal of this study was to establish a rat model that can be used to determine the variables in influencing induction of tolerance to composite tissue allografts. An anti T-cell depleting agent (R73) and 15-deoxyspergualin were given in different doses and schedule to four groups of Lewis rats receiving a limb transplant from Brown-Norway donors. Graft survival prolongation was maximal combining a single dose of R73 and a 20-day administration of 15-deoxyspergualin. Long-term survivors accepted a skin graft from Brown-Norway donors at 80 days, but rejected grafts from an unrelated donor. Skin grafting did not influence survival of the transplanted limb. Mixed allogeneic chimerism was not detectable in peripheral blood by flow cytometry, but immunohistochemistry identified donor-derived cells in the thymus of tolerant recipients at 100 days. These results suggest a state of donor-specific, dynamic tolerance, with potential for future application in human composite tissue allotransplantation.