Roux-en-Y biliary reconstruction as a definitive treatment for serious complications of portal biliopathy. Case series.

INTRODUCTION AND IMPORTANCE: Portal biliopathy (PB) is an abnormality of the biliary tree wall due to extrahepatic portal hypertension. Among the complications of portal biliopathy are digestive bleeding, jaundice, and cholangitis. Surgical treatment is an exception when medical management is not possible. CASE PRESENTATION: This is a case series study of four patients with severe PB complications requiring surgical management in our center from 2005 to 2016. Two of them had previous surgical procedures related to portal hypertension. All presented with severe biliary stenosis and recurrent cholangitis, and two also had massive upper gastrointestinal bleeding. Because of endoscopic management failure, a Roux-en-Y hepaticojejunostomy was performed in all cases. Two patients presented morbidity Clavien-Dindo>IIIA, requiring reoperation. During follow-up, no one developed other complications related to PB. DISCUSSION: Surgical treatment for PB complications is a challenge and mainly implies a portosystemic shunt as a first step. When it fails, an alternative is perform a biliodigestive anastomoses, with high risk of bleeding given the prominent collaterals present in the hepatoduodenal pedicle secondary to portal cavernomatosis. CONCLUSION: Our patients after YRGB didn't present new complications due to PB. The surgery could be a definite solution for PB complications. It has only been made for selective cases because it implies high complexity and risk.

Liver resection for hepatolithiasis: A multicenter experience in Latin America.

BACKGROUND: Hepatolithiasis is a prevalent disease in Asia but rare in Western countries. An increasing number of cases have been reported in Latin America. Liver resection has been proposed as a definitive treatment for complete stone clearance. The aim of this study was to evaluate the postoperative outcomes of liver resection for the treatment of hepatolithiasis in 2 large hepatobiliary reference centers from South America. METHODS: We conducted a retrospective descriptive analysis from patients with hepatolithiasis who underwent liver resection between November 1986 and December 2018, in 2 Latin-American centers in Chile and Brazil. RESULTS: One hundred forty-nine patients underwent liver resection for hepatolithiasis (72 in Chile, 77 in Brazil). The mean age was 49 years and most patients were female (62.4%). Hepatolithiasis was localized in the left lobe (61.7%), right lobe (24.2%), and bilateral lobe (14.1%). Bilateral lithiasis was associated with higher incidence of preoperative and postoperative cholangitis (81% vs 46.9% and 28.6% vs 6.1%) and need for hepaticojejunostomy (52.4%). In total, 38.9% of patients underwent major hepatectomy and 14.1% were laparoscopic. The postoperative stone clearance was 100%. The 30-day morbidity and mortality rates were 30.9% and 0.7%, respectively. Cholangiocarcinoma was seen in 2 specimens, and no postoperative malignancy were seen after a median follow-up of 38 months. Fourteen patients (9.4%) had intrahepatic stones recurrence. CONCLUSIONS: Liver resection is an effective and definitive treatment for patients with hepatolithiasis. Bilateral hepatolithiasis was associated with perioperative cholangitis, the need for hepaticojejunostomy, and recurrent disease. Resection presents a high rate of biliary tree stone clearance and excellent long-term results, with low recurrence rates and low risk of malignancy.

Customized normothermic machine perfusion decreases ischemia-reperfusion injury compared with static cold storage in a porcine model of liver transplantation.

BACKGROUND: Liver transplantation has been demonstrated to be the best treatment for several liver diseases, while grafts are limited. This has caused an increase in waiting lists, making it necessary to find ways to expand the number of organs available for transplantation. Normothermic perfusion (NMP) of liver grafts has been established as an alternative to static cold storage (SCS), but only a small number of perfusion machines are commercially available. METHODS: Using a customized ex situ machine perfusion, we compared the results between ex situ NMP and SCS preservation in a porcine liver transplant model. RESULTS: During NMP, lactate concentrations were 80% lower after the 3-h perfusion period, compared with SCS. Bile production had a 2.5-fold increase during the NMP period. After transplantation, aspartate transaminase (AST) and alanine transaminase (ALT) levels were 35% less in the NMP group, compared to the SCS group. In pathologic analyses of grafts after transplant, tissue oxidation did not change between groups, but the ischemia-reperfusion injury score was lower in the NMP group. CONCLUSION: NMP reduced hepatocellular damage and ischemia-reperfusion injury when compared to SCS using a customized perfusion machine. This could be an alternative for low-income countries to include machine perfusion in their therapeutic options.

[Outcomes of Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Single-Center Experience]. / Resecciones Hepáticas Laparoscópicas por Hepatocarcinoma: Resultados Perioperatorios y Oncológicos.

BACKGROUND: Hepatocellular carcinoma (HCC) is the sixth most common cancer in the world. Surgery is the treatment of choice in stages 0 and A in the Barcelona Clinic Liver Cancer classification. A minimally invasive technique in this scenario has the advantage of reducing postoperative pain, blood loss, and hospital stay. We present our experience and outcomes in laparoscopic liver resection in HCC. METHODS: Retrospective descriptive analysis from all patients who underwent laparoscopic liver resection for HCC in our center between August 2006 and December 2020. RESULTS: Laparoscopic liver resection for HCC was performed in 20 patients. The median age was 70 years, and the male gender was 75%. Sixteen patients had chronic liver disease, and 87.5% were Child A. The most common liver resection was the non-anatomical (45%). 30-day morbidity was 15%, without the need for reintervention. We had no 30-day mortality and postoperative liver failure. Negative margins were achieved in 90% of patients. Median disease-free survival and overall survival were 25 and 40.5 months, respectively. CONCLUSION: Laparoscopic liver resection for the treatment of HCC in our series is safe, with no 30-day mortality, low incidence of complications, no postoperative liver failure, and suitable medium- and long-term oncological results.

Implementation and design of customized ex vivo machine perfusion. Analysis of its first results.

The lack of organs available for transplantation is a global problem. The high mortality rates on the waiting list and the high number of discarded livers are reasons to develop new tools in the preservation and transplantation process. New tools should also be available for low-income countries. This article reports the development of customized normothermic machine perfusion (NMP). An ex vivo dual perfusion machine was designed, composed of a common reservoir organ box (CRO), a centrifugal pump (portal system, low pressure), and a roller pump (arterial system, high pressure). Porcine livers (n = 5) were perfused with an oxygenated normothermic (37℃) strategy for 3 hours. Hemodynamic variables, metabolic parameters, and bile production during preservation were analyzed. Arterial and portal flow remain stable during perfusion. Total bilirubin production was 11.25 mL (4-14.5) at 180 minutes. The median pH value reached 7.32 (7.25-7.4) at 180 minutes. Lactate values decreased progressively to normalization at 120 minutes. This perfusion setup was stable and able to maintain the metabolic activity of a liver graft in a porcine animal model. Design and initial results from this customized NMP are promising for a future clinical application in low-income countries.

Cómo evitar la lesión de vía biliar en colecistectomía laparoscópica: más allá de la visión crítica de seguridad / How to avoid bile duct injury in laparoscopic cholecystectomy: beyond the critical safety view

Resumen La colecistectomía laparoscópica (CL) es el estándar de tratamiento para la patología benigna como la colelitiasis y los pólipos de la vesícula biliar y es uno de los procedimientos más frecuentes de la cirugía general. Esta intervención tiene un riesgo de 0,1%-0,3% de causar una lesión quirúrgica de la vía biliar (LQVB). En la actualidad, existen programas de sociedades científicas, estrategias de abordaje y tecnologías que nos permiten reducir las LQVB mejorando la seguridad clínica de este procedimiento. El objetivo de este documento es realizar una revisión de las estrategias, tecnologías y maniobras para realizar una CL segura más allá de la visión crítica de seguridad.

Laparoscopic cholecystectomy (LC) is the standard of treatment for benign pathologies such as cholelithiasis and gallbladder polyps. The LC is one of the most frequent procedures in general surgery, with a 0.1%-0.3% associated risk of bile duct injury. Currently, scientific society programs, surgical strategies, and new technologies allow us to reduce the risk of bile duct injuries and to increase the clinical safety of this procedure. This document aims to review the strategies, technologies, and tactics to carry out a safe LC beyond the critical vision of security.

Development of a Novel Perfusable Solution for ex vivo Preservation: Towards Photosynthetic Oxygenation for Organ Transplantation.

Oxygen is the key molecule for aerobic metabolism, but no animal cells can produce it, creating an extreme dependency on external supply. In contrast, microalgae are photosynthetic microorganisms, therefore, they are able to produce oxygen as plant cells do. As hypoxia is one of the main issues in organ transplantation, especially during preservation, the main goal of this work was to develop the first generation of perfusable photosynthetic solutions, exploring its feasibility for ex vivo organ preservation. Here, the microalgae Chlamydomonas reinhardtii was incorporated in a standard preservation solution, and key aspects such as alterations in cell size, oxygen production and survival were studied. Osmolarity and rheological features of the photosynthetic solution were comparable to human blood. In terms of functionality, the photosynthetic solution proved to be not harmful and to provide sufficient oxygen to support the metabolic requirement of zebrafish larvae and rat kidney slices. Thereafter, isolated porcine kidneys were perfused, and microalgae reached all renal vasculature, without inducing damage. After perfusion and flushing, no signs of tissue damage were detected, and recovered microalgae survived the process. Altogether, this work proposes the use of photosynthetic microorganisms as vascular oxygen factories to generate and deliver oxygen in isolated organs, representing a novel and promising strategy for organ preservation.

Severe case of post cholecystectomy vasculobiliary injury successfully treated by right hepatectomy with a jump graft to the remaining left hepatic lobe.

Vasculobiliary injuries (VBI) caused by cholecystectomies are infrequent but extremely serious. We report a case of a severe VBI successfully treated at our center. A 22-year-old woman underwent an open cholecystectomy as treatment for acute cholecystitis and bile duct stones. She was transferred to our center on postoperative Day 4 because of progressive jaundice and encephalopathy. After a proper investigation, we found an extreme VBI with infarction of the right hepatic lobe associated with complete interruption of the portal vein and proper hepatic artery flows and full section of the common hepatic duct. Right hepatectomy with portal-Rex shunt revascularization of the left hepatic lobe and Roux-en-Y hepaticojejunostomy to the left hepatic duct was done. The patient was discharged on the 60th postoperative day. Discussion: This case shows the successful surgical treatment of a severe cholecystectomy's VBI, avoiding an emergency liver transplant.

Minimally invasive tele-mentoring opportunity-the mito project.

BACKGROUND: Simulation training is a validated method for acquiring laparoscopic skills. Training sessions may be sporadic or lack continuity in oversight by instructors since traditional programs mandate in-person teaching and evaluation. This study presents the development, implementation, and results of a novel smartphone application that enables remote teacher-student interaction. This interface is used to complete a validated program that provides learner-specific feedback. Outcomes of training via Lapp were compared to outcomes of traditional in-person training. METHODS: A web-based and mobile iOS and Android application (Lapp) was developed to enable a remote student-teacher interaction. Instructors use Lapp to assess video recorded training sessions of students at distant locations and guide them through the laparoscopic skill course with specific and personalized feedback. Surgical trainees at two remote training centers were taught using Lapp. A control group was assessed during traditional simulation training at the training facility, with in-person feedback. Pre- and post-training performances were video recorded for each trainee and blindly evaluated by two experts using a global rating scale (GRS) and a specific rating scale (SRS). RESULTS: A total of 30 trainees were trained via Lapp and compared with 25 locally taught. Performance in the Lapp group improved significantly after the course in both GRS and SRS scores, from 15 [6-17] to 23 [20-25], and from 12 [11-15] to 18 [15-20], respectively. The results between both groups were comparable. CONCLUSION: Laparoscopic simulation training using a mobile app is as effective as in-person instruction in teaching advanced laparoscopic surgical skills. Lapp provides an effective method of teaching through simulation remotely and may allow expansion of robust simulation training curriculums.

CcpA and three newly identified proteins are involved in biofilm development in Lactobacillus plantarum.

The aim of this study was to identify genes involved in biofilm development in the probiotic lactic acid bacterium Lactobacillus plantarum. The ability of L. plantarum LM3 and of some derivative mutant strains to form biofilm has been investigated. Biofilm microtitre plate assays showed that L. plantarum LM3-2, carrying a null mutation in the ccpA gene, coding the CcpA master regulator, was partially impaired in biofilm production compared to wild type (LM3). Moreover, we found three genes in the L. plantarum genome, hereby named flmA, flmB, and flmC, whose deduced amino acid sequences show significant identity with the Streptococcus mutans BrpA (biofilm regulatory protein A). We investigated the role of FlmA, FlmB, and FlmC in biofilm formation by isolating strains carrying null mutations in the corresponding genes. Our results suggest involvement of the Flm proteins in biofilm development. Moreover, transcriptional studies show that expression of flmA, flmB, and flmC is under the control of CcpA. These results, together with the reduced ability of LM3-2 (ccpA1) to form biofilm, strongly suggest a positive role of the master regulator CcpA in biofilm development.

Hepatotoxicidad por drogas: reporte de un caso y revisión de literatura / Drug-induced liver injury: a case report and literature review

La Hepatotoxicidad por drogas se define como una lesión hepática asociada a deterioro de la función de éste órgano, secundaria a exposición a una droga u otro agente no infeccioso. Es un cuadro infrecuente, pero puede determinar graves lesiones hepáticas y una mortalidad considerable si no se detecta a tiempo. Es labor del clínico mantener un alto Índice de sospecha al enfrentarse a un paciente con alteraciones hepáticas de reciente comienzo y uso concomitante de medicamentos. En el presente articulo se expone el caso clínico de un paciente masculino, 48 años de edad, con Depresión Severa en tratamiento con Sertralina, Clonazepam, Risperidona, Lamotrigna y Acido Valproico. Ingresó al Hospital de Talca con diagnostico de Síndrome Colestásico cuyo estudio demostró serología para VHB y VHC negativa y ecotomografía abdominal normal. Presentó buena respuesta clínica y de laboratorio a la suspensión de las drogas. El cuadro fue compatible con Hepatotoxicidad por drogas.

Pain in early cancer of the lungs.

164 patients with early cancer of the lungs, i.e., without extrathoracic spread or distant metastasis, were examined. Subjective and objective characteristics of the pain were studied. A correlation was found between the location of the neoplasm, the location of the pain and the characteristics of the sensory changes. These observations may be a useful contribution to the early diagnosis of primary carcinomas of the lungs.