Q fever, a rare cause of secondary hemophagocytic lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome in which Coxiella burnetii is a very infrequent etiology. We present the case of a 62-year-old male with progressive pulmonary infiltrates, fever, hepatitis, and bicytopenia despite broad spectrum antibiotics. A thorough clinical evaluation led to a high suspicion of Coxiella burnetii infection, subsequently confirmed through a positive serum polymerase chain reaction (PCR) analysis. HLH diagnosis was established based on the fulfillment of 5/8 diagnostic criteria, obviating the need for a bone marrow biopsy. Targeted antibiotic treatment and dexamethasone led to full recovery within two weeks, eliminating the need for stronger immunosuppressive therapy.

Contemporary practice and perception of autologous blood salvage in hepato-pancreatico-biliary operations: an international survey.

BACKGROUND: This study aimed to assess contemporary knowledge, attitudes and behaviors around transfusion of intraoperative salvaged blood (sRBCt) during hepato-pancreatico-biliary (HPB) operations. Findings are meant to inform the design of future studies that address provider concerns to change behaviors and improve patient outcomes. METHODS: A survey was designed and assessed for relevance, readability and content, and distributed to an international audience of surgeons performing HPB operations. RESULTS: The 237 respondents were predominantly distributed across North America (37.55%), Europe (27.43%) and Asia (19.83%). Roughly one-half (52.74%) of respondents had used sRBCt in HPB surgery before. Transplantation surgeons were more likely than HPB surgeons to have previously used sRBCt [odds ratio = 5.18 (95% CI 1.89-14.20)]. More respondents believed sRBCt was safe for non-cancer versus cancer operations (68.57% vs. 24.17%, p < 0.0001). Less than half (45.71%) of respondents believed that sRBCt was safe in clean-contaminated fields. Most did not utilize preoperative strategies to avoid donor transfusion. CONCLUSION: Practices related to sRBCt in HPB operations vary widely and there is no consensus on its use. Concerns seem primarily related to cancer-specific and infectious outcomes. While further studies are pursued, surgeons may increase their utilization of preoperative strategies to boost hemoglobin levels for at risk patients.

Prevalence of hepatitis C in patients with non-affective psychotic disorders.

INTRODUCTION: the goal of this study was to determine the prevalence of hepatitis C virus (HCV) infection in patients with non-affective psychotic disorders and to compare it with population-based data. MATERIAL AND METHODS: an observational study was performed that measured anti-HCV antibodies (HCV-RNA in case of seropositivity) in 425 serum samples from patients with non-affective psychosis. Eight patients were positive for anti-HCV (1.9 %) and five had detectable HCV-RNA (1.2 %). The prevalence of viremia was significantly higher than in the general population (OR: 5.4; 95 % CI: 1.9-14.6). CONCLUSIONS: patients with non-affective psychotic disorder have a higher prevalence of active infection than that of the general population and should undergo systematic screening.

Laparoscopic ablation therapies or hepatic resection in cirrhotic patients with small hepatocellular carcinoma.

BACKGROUND: The Barcelona Clinic Liver Cancer staging system recommends radiofrequency ablation as treatment of choice for patients with "small" (up to 2 cm in size) hepatocellular carcinoma. AIMS: Aim of the study was to assess whether laparoscopic ablation therapies or hepatic resection could be proposed as alternative option if percutaneous approach is not feasible. METHODS: Overall survival and tumour recurrence rate were compared in a retrospective cohort of 176 consecutive patients with small hepatocellular carcinoma on cirrhosis treated by laparoscopic ablation therapies or surgery. To balance the covariates between the two groups, a propensity case-matched analysis was developed to generate a matched sample, which included 76 patients in each arm. RESULTS: Local tumour progression (p=0.005), intra-segmental recurrence (p=0.0001), and 5-year recurrence rates (80% vs. 60%; p=0.0014) were significantly higher in the ablation therapies group. The 5-year survival rate were 48% after ablation therapies and 69% after hepatic resection (p=0.0006). Multivariate analysis showed that MELD score, alpha-fetoprotein value, procedure category and intraoperative restaging were associated with survival, while the surgery was the only independent predictor of intra-hepatic recurrence. CONCLUSIONS: The present study suggests that, if percutaneous ablation is not feasible, hepatic resection may be considered as a sound option in the treatment of small hepatocellular carcinoma.

Liver resection for hepatocellular carcinoma in 313 Western patients: tumor biology and underlying liver rather than tumor size drive prognosis.

BACKGROUND & AIMS: Treatment decisions for hepatocellular carcinoma are mostly guided by tumor size. The aim of this study was to analyze resection outcomes according to tumor size and characterize prognostic factors. METHODS: Patients resected at a Western center between 1989 and 2010 were grouped by largest tumor size: <50mm, 50-100mm, and >100mm. The primary end points were overall- and recurrence-free survival. Univariate associations with primary endpoints were entered into a Cox proportional hazard regression model. RESULTS: Three hundred thirteen patients underwent resection: 111 (36%) had tumors <50mm, 113 (36%) had tumors between 50 and 100mm, and 89 (28%) had tumors >100mm. Five-year overall and disease-free survival rates for the three groups were 67%, 46%, and 34%, and 32%, 27%, and 27%, respectively. Thirty-five patients, mostly from <50mm group, underwent transplantation which was associated with a 91% 5 year survival rate. Tumor size was not an independent predictor of overall or recurrence-free survival on multivariate analyses. Independent predictors of decreased overall survival were: intraoperative transfusion (HR=2.60), cirrhosis (HR=2.42), poorly differentiated tumor (HR=2.04), satellite lesions (HR=1.69), alpha-fetoprotein >200 (HR=1.53), and microvascular invasion (HR=1.48). The use of salvage transplantation was an independent predictor of improved survival (HR=0.21). Recurrence-free survival was predicted by intraoperative transfusion (HR=2.15), poorly differentiated tumor (HR=1.87), microvascular invasion (HR=1.71) and cirrhosis (HR=1.69). CONCLUSION: By studying a large group of patients across a distribution of tumor sizes and background liver diseases, it is demonstrated that size alone is a limited prognostic factor. Tumor biology and condition of the underlying liver are better prognosticators and should be given closer attention. Although hampered by recurrence rates, resection is safe and offers good overall survival. In addition, it may allow for better selection for salvage transplantation after consideration of histopathological risk factors.

A foregut cystic neoplasm with diagnostic and therapeutic similarities to mucinous cystic neoplasms of the pancreas.

CONTEXT: Greater utilization of cross-sectional abdominal imaging has increased the diagnostic frequency of cystic neoplasms of the pancreas. The "International Consensus Guidelines 2012 for the Management of IPMN and MCN of the Pancreas" illustrates a diagnostic and therapeutic algorithm for these lesions based on current knowledge. CASE REPORT: We present a case of a 49-year-old woman with two years of intermittent epigastric pain found to have an 8.5 cm head of the pancreas mass on CT. Evaluation was consistent with a mucinous cystic neoplasm for which she underwent an uneventful pancreaticoduodenectomy. Histology revealed a bronchogenic cyst of the head of the pancreas. DISCUSSION: Bronchogenic cysts are congenital anomalies of the ventral foregut that can migrate into the abdomen prior to fusion of the diaphragm. They can easily be misdiagnosed for other benign and malignant retroperitoneal lesions. Similarly to mucinous cystic neoplasms, bronchogenic cysts have been reported to undergo malignant transformation. They can also become infected and hemorrhage. Therefore, resection should be performed in appropriate risk candidates. It is possible, with increased use of high resolution cross-sectional imaging, that these lesions may be identified with greater frequency in the abdomen and confused with other pancreatic neoplasms. The presence of ciliated respiratory epithelium and cartilage on pathology provides for definitive diagnosis.

[Inflammatory pseudotumor of the liver: a case of recurrence after resection]. / Pseudotumor inflamatorio del hígado: recurrencia después de la resección.

Inflammatory pseudo-tumor of the liver is a rare benign condition. Usually presented as a large liver mass, may cause obstruction or infiltration of the main vessels or biliary tree. The clinical presentation is mostly an inflammatory syndrome with acute abdominal pain. We present a 39-year-old female patient with abdominal pain, fever and jaundice. Images showed a 15-cm liver lesion in the left lobe of the liver. Malignancy could not be discarded and the patient underwent left hepatectomy. The histologic examination reported an inflammatory pseudo-tumor of the liver. The patient recurred after one year with the same symptoms and a 10-cm new lesion occupying segment I. Considered as a recurrence, medical treatment was decided tumor size decreased 50% after the first month and completely disappeared during the follow up. Two years later, the patient was readmitted with a new episode and a new 8-cm liver lesion in segment VII. She was treated again with anti-inflammatory medication and imaging control. Although inflammatory pseudo-tumor of the liver is a benign condition, it can have a recurrent behaviour. The differentiation with other malignant tumors sometimes is impossible by clinical and imaging presentation.

Pseudotumor inflamatorio del hígado: recurrencia después de la resección / [Inflammatory pseudotumor of the liver: a case of recurrence after resection].

Inflammatory pseudo-tumor of the liver is a rare benign condition. Usually presented as a large liver mass, may cause obstruction or infiltration of the main vessels or biliary tree. The clinical presentation is mostly an inflammatory syndrome with acute abdominal pain. We present a 39-year-old female patient with abdominal pain, fever and jaundice. Images showed a 15-cm liver lesion in the left lobe of the liver. Malignancy could not be discarded and the patient underwent left hepatectomy. The histologic examination reported an inflammatory pseudo-tumor of the liver. The patient recurred after one year with the same symptoms and a 10-cm new lesion occupying segment I. Considered as a recurrence, medical treatment was decided tumor size decreased 50

after the first month and completely disappeared during the follow up. Two years later, the patient was readmitted with a new episode and a new 8-cm liver lesion in segment VII. She was treated again with anti-inflammatory medication and imaging control. Although inflammatory pseudo-tumor of the liver is a benign condition, it can have a recurrent behaviour. The differentiation with other malignant tumors sometimes is impossible by clinical and imaging presentation.

Laparoscopic resection for liver tumors: initial experience in a single center.

BACKGROUND: Laparoscopic liver resections are 1 of the most complex procedures in hepatobiliary surgery. During the last 20 years, laparoscopic liver surgery has had an important development in specialized centers. OBJECTIVE: To describe the initial experience in laparoscopic liver resection for benign and malignant tumors, to assess its indications and outcomes, and to describe technical aspects of these resections. METHODS: Review of the records of 28 patients who underwent laparoscopic liver resection between November 2000 and November 2007. Analysis of the data regarding preoperative management and postoperative outcomes. RESULTS: Twenty-six liver resections were performed laparoscopically (20 purely laparoscopic, 3 hand assisted, and 3 hybrid technique) and 2 were converted to open surgery. The laparoscopic approach was attempted in 6% (28 out of 459) of the liver resections carried out in the analyzed period. Indications for resection were: benign tumors in 22 patients (78%) and malignant tumors in 6 patients (22%). Resections were minor in 27 patients (96%) and major in 1 patient (4%). Pringle maneuver was performed in 14 patients (50%). Margins were negative in all the cases. Mean operative time was 170 minutes (range 70 to 350), and the mean length of stay was 3 days (range 1 to 6). Mortality rate was 0%. Only 2 patients (7%) had postoperative minor complications (self-limited bile leaks). CONCLUSIONS: In selected patients with benign and malignant liver tumors, laparoscopic liver resections can be safely performed. This procedure must be carried out by the surgeons trained in both the hepatobiliary and laparoscopic surgery.

Hernioplastía inguinal bilateral simultánea: nuestra experiencia / Simultaneous bilateral inguinal hernia repair: our experience

Introducción: El tratamiento de las hernias bilaterales es un tema controvertido, pues no todos adoptan el mismo abordaje. Las conductas posibles son: A) Abordaje diferido: reparación de un lado y luego de varios meses reparar el contralateral. B) Abordaje intermedio: reparción de un lado y luego de 2 a 7 días realizar la contralateral. C) Abordaje simultaneo: reparación de ambas hernias en un mismo acto. En nuestro servicio optamos, desde hace tiempo, por este último. El objetivo de este trabajo es mostrar las técnicas utilizadas, el porcentaje de complicaciones y recidivas con el abordaje bilateral simultáneo. Material y método: Se realizó el estudio de los pacientes operados de hernia inguinal bilateral simultánea en un período de 22 años. Entre enero 1984 y diciembre 2006 se realizó el fichaje retrospectivo por búsqueda de las historias clínicas y entre enero 1998 y diciembre 2006 el fichaje prospectivo. Se describen características poblacionales, tipos de hernioplastías, complicaciones y porcentaje de recidivas. Se realizó seguimiento periódico por consultorio y telefónico a los 15 y 30 días, posteriormente cada 6 meses. Resultados: Entre 1/1/1984 y 31/12/2006 se operaron un total de 4918 pacientes por patología herniaria inguinal. De esta población 365 (7,4%) fueron operados de hernia inguinal bilateral simultánea. El porcentaje de recidivas fue del 3,4%, complicaciones: 14,7%; promedio de internación: 1,9 días. Las ténicas con malla fueron las más utilizadas. Conclusión: La práctica de la hernioplastía inguinal bilateral simultánea es una técnica segura, con bajo índice de complicaciones y recidivas. Asimismo la técnica a emplearse debe seleccionarse según el tamaño y tipo de hernia.