Mirizzi Syndrome-The Past, Present, and Future.

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

Laparoscopic subtotal cholecystectomy: comparison of reconstituting and fenestrating techniques.

BACKGROUND: Laparoscopic subtotal cholecystectomy (LSC) is a safe bailout procedure in situations when dissection of "critical view of safety" is not possible. After the proposed classification of subtotal cholecystectomy into "fenestrating" and "reconstituting" techniques in 2016, a comparative review of the outcomes of both methods is timely. METHODS: A literature search of the PubMed, Cochrane Library, and Web of Science database was conducted up to January 31, 2020 for studies that reported LSC. Studies reporting LSC only in patients with Mirizzi syndrome or xanthogranulomatous cholecystitis were excluded. Our analysis includes 39 studies with 1784 cases of LSC. We report a comparison of outcomes between reconstituting and fenestrating LSC on 1505 cases [935 reconstituting (62.1%) and 570 fenestrating (37.9%)]. RESULTS: Following LSC, the rate of open conversion is 7.7%, hemorrhage is 0.4%, bile duct injury is 0.3%, bile leak is 15.4%, retained stone is 4.6%, subhepatic or subphrenic collection is 2.9%, superficial surgical site infection is 2.0% and 30-day mortality is 0.2%. 8.8% of patients required postoperative endoscopic retrograde cholangiopancreatography (ERCP), 1.1% required percutaneous intervention, and 2.2% required reoperation. Compared to reconstituting LSC, fenestrating LSC has a higher incidence of open conversion (n = 58, 10.2% vs. n = 43, 4.6%, p < 0.001), retained stones (n = 38, 6.7% vs. n = 38, 4.1%, p = 0.0253), subhepatic or subphrenic collections (n = 33, 5.8% vs. n = 13, 1.4%, p < 0.001), superficial surgical site infections (n = 18, 3.2% vs. n = 14, 1.5%, p = 0.0303), postoperative ERCP (n = 82, 14.4% vs. n = 62, 6.6%, p < 0.001), and need for reoperation (n = 20, 3.5% vs. n = 12, 1.3%, p < 0.001). CONCLUSIONS: Although reconstituting LSC has better outcomes, both techniques are complementary. Intraoperative findings and surgical expertise impact the choice.

Pancreatic pseudocyst: The past, the present, and the future.

A pancreatic pseudocyst is defined as an encapsulated fluid collection with a well-defined inflammatory wall with minimal or no necrosis. The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis. The clinical presentation is often nonspecific, with abdominal pain being the most common symptom. If a diagnosis is suspected, contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst. Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty. Pseudocyst of the pancreas can lead to complications such as hemorrhage, infection, and rupture. The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications, such as biliary or gastric outlet obstruction. Management options include endoscopic or surgical drainage. The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions, diagnosis, and management of this condition.

Residency research requirements and the CanMEDS-FM scholar role: perspectives of residents and recent graduates.

OBJECTIVE: To explore the perspectives of family medicine residents and recent family medicine graduates on the research requirements and other CanMEDS scholar competencies in family practice residency training. DESIGN: Semistructured focus groups and individual interviews. SETTING: Family practice residency program at the University of British Columbia in Vancouver. PARTICIPANTS: Convenience sample of 6 second-year family medicine residents and 6 family physicians who had graduated from the University of British Columbia family practice residency program within the previous 5 years. METHODS: Two focus groups with residents and individual interviews with each of the 6 recently graduated physicians. All interviews were audiotaped, transcribed, and analyzed for thematic content. MAIN FINDINGS: Three themes emerged that captured key issues around research requirements in family practice training: 1) relating the scholar role to family practice, 2) realizing that scholarship is more than simply the creation or discovery of new knowledge, and 3) addressing barriers to integrating research into a clinical career. CONCLUSION: Creation of new medical knowledge is just one aspect of the CanMEDS scholar role, and more attention should be paid to the other competencies, including teaching, enhancing professional activities through ongoing learning, critical appraisal of information, and learning how to better contribute to the dissemination, application, and translation of knowledge. Research is valued as important, but opinions still vary as to whether a formal research study should be required in residency. Completion of residency research projects is viewed as somewhat rewarding, but with an equivocal effect on future research intentions.

A bioassay for the detection of perchlorate in the ppb range.

A bioassay for the determination of ppb (µg·L(-1)) concentrations of perchlorate has been developed and is described herein. The assay uses the enzyme perchlorate reductase (PR) from the perchlorate-reducing organism Dechloromonas agitata in purified and partially purified forms to detect perchlorate. The redox active dye phenazine methosulfate (PMS) is shown to efficiently shuttle electrons to PR from NADH. Perchlorate can be determined indirectly by monitoring NADH oxidization by PR. To lower the detection limit, we have shown that perchlorate can be concentrated on a solid-phase extraction (SPE) column that is pretreated with the cation decyltrimethylammonium bromide (DTAB). Perchlorate is eluted from these columns with a solution of 2 M NaCl and 200 mM morpholine propane sulfonic acid (MOPS, pH 12.5). By washing these columns with 15 mL of 2.5 mM DTAB and 15% acetone, contaminating ions, such as chlorate and nitrate, are removed without affecting the bioassay. Because of the effect of complex matrices on the SPE columns, the method of standard additions is used to analyze tap water and groundwater samples. The efficacy of the developed bioassay was demonstrated by analyzing samples from 2-17000 ppb in deionized lab water, tap water, and contaminated groundwater.