Knotless choledochorraphy with barbed suture, safe and feasible.

PURPOSE: To describe the safety and feasibility of a running continuous unidirectional barbed suture (V-Loc, Covidien, Mansfield, MA) for primary common bile duct closure while performing laparoscopic common bile duct exploration (LCBDE). INTRODUCTION: LCBDE is nowadays the best approach for treating complex common bile duct lithiasis or cases where the endoscopic retrograde cholangiopancreatography has failed. It is clear that the primary closure of the common bile duct must be preferred over the T-tube drainage. The actual technical aspects offer room for improvement. We present our experience with barbed suture, for which recently, various fields of surgery have become interested in and which now has a series of studies that support it for several uses. METHODS: Between July 2012 and July 2014, 54 consecutive patients with bile duct stones underwent LCBDE by a single surgeon. Perioperative outcomes and 30-day complications were recorded. RESULTS: Upon the completion of the exploration, 50 patients had primary common bile duct closure using knotless unidirectional barbed 3-0 V-Loc 90 suture, and 4 patients were excluded. All of the sutures were performed without knot tying. The procedure in all patients was successfully performed with no intraoperative complications. There were no bile leaks in the 50 patients or other postoperative complications such as infection, need for reintervention or death. CONCLUSION: The use of unidirectional knotless barbed suture (V-Loc 90) is safe, feasible and effective on LCBDE for primary common bile duct closure. The biliary leak rate is acceptably low and comparable to the rate reported in the literature. This report is our initial experience that needs further clinical trials.

Structured reporting of multiphasic CT for pancreatic cancer: potential effect on staging and surgical planning.

PURPOSE: To compare structured versus nonstructured reporting of multiphasic computed tomography (CT) for staging of pancreatic cancer and the effects of both types of reporting on subjective assessment of resectability. MATERIALS AND METHODS: This institutional review board-approved, HIPAA-compliant retrospective study with waiver of informed consent included all patients who were referred for presurgical multiphasic CT of the pancreas between December 2006 and April 2011 at one institution before and after implementation (April 2008) of a structured reporting template. The template was created specifically for reporting multiphasic CT results to stage pancreatic cancer in patients and contained specific information relevant to surgical and oncologic planning. Multiphasic CT reports were assessed for the presence of 12 key features required for staging and surgical planning, including location, size, enhancement, node status, and vascular involvement. Three pancreatic surgeons evaluated the reports to assess resectability, surgical planning, and ease of extracting information before and after reviewing the multiphasic CT images blinded to the patient identifiers. The Student t test and χ(2) test were used for statistical analysis. RESULTS: Forty-eight (40%) structured and 72 (60%) nonstructured multiphasic CT reports were reviewed. Nonstructured reports contained a mean ± standard deviation of 7.3 key features ± 2.1 (range, 1-11) and structured reports contained 10.6 ± 0.9 (range, 9-12) features (P < .001). Information for surgical planning was deemed easily accessible in 94%, 60%, and 98% of structured and 47%, 54%, and 32% of nonstructured reports by the three surgeons, respectively (P < .001, .79, < .001). Surgeons had sufficient information for surgical planning in 96%, 69%, and 98% of structured and 31%, 43%, and 25% of nonstructured reports (P < .001, .009, and < .001). When surgeons reviewed reports in combination with multiphasic CT images, they were more likely to convert an answer of "unsure" regarding resectability to a definitive answer (ie, resectable or unresectable) when the reports were structured than when they were nonstructured. CONCLUSION: Structured reporting of pancreatic multiphasic CT provided superior evaluation of pancreatic cancer and facilitated surgical planning. Surgeons were more confident regarding decisions about tumor resectability when they reviewed structured reports before review of multiphasic CT images.

A root-cause analysis of mortality following major pancreatectomy.

INTRODUCTION: Although mortality rates from pancreatectomy have decreased worldwide, death remains an infrequent but profound event at an individual practice level. Root-cause analysis is a retrospective method commonly employed to understand adverse events. We evaluate whether emerging mortality risk assessment tools sufficiently predict and account for actual clinical events that are often identified by root-cause analysis. METHODS: We assembled a Pancreatic Surgery Mortality Study Group comprised of 36 pancreatic surgeons from 15 institutions in 4 countries. Mortalities after pancreatectomy (30 and 90 days) were accrued from 2000 to 2010. For root-cause analysis, each surgeon "deconstructed" the clinical events preceding a death to determine cause. We next tested whether mortality risk assessment tools (ASA, POSSUM, Charlson, SOAR, and NSQIP) could predict those patients who would die (n = 218) and compared their prognostic accuracy against a cohort of resections in which no patient died (n = 1,177). RESULTS: Two hundred eighteen deaths (184 Whipple's resection, 18 distal pancreatectomies, and 16 total pancreatectomies) were identified from 11,559 pancreatectomies performed by surgeons whose experience averaged 14.5 years. Overall 30- and 90-day mortalities were 0.96% and 1.89%, respectively. Individual surgeon rates ranged from 0% to 4.7%. Only 5 patients died intraoperatively, while the other 213 succumbed at a median of 29 days. Mean patient age was 70 years old (38% were >75 years old). Malignancy was the indication in 90% of cases, mostly pancreatic cancer (57%). Median operative time was 365 min and estimated blood loss was 700 cc (range, 100-16,000 cc). Vascular repair or multivisceral resections were required for 19.7% and 15.1%, respectively. Seventy-seven percent had a variety of major complications before death. Eighty-seven percent required intensive care unit care, 55% were transfused, and 35% were reoperated upon. Fifty percent died during the index admission, while another 11% died after a readmission. Almost half (n = 107) expired between 31 and 90 days. Only 11% had autopsies. Operation-related complications contributed to 40% of deaths, with pancreatic fistula being the most evident (14%). Technical errors (21%) and poor patient selection (15%) were cited by surgeons. Of deaths, 5.5% had associated cancer progression-all occurring between 31 and 90 days. Even after root-cause scrutiny, the ultimate cause of death could not be determined for a quarter of the patients-most often between 31 and 90 days. While assorted risk models predicted mortality with variable discrimination from nonmortalities, they consistently underestimated the actual mortality events we report. CONCLUSION: Root-cause analysis suggests that risk prediction should include, if not emphasize, operative factors related to pancreatectomy. While risk models can distinguish between mortalities and nonmortalities in a collective fashion, they vastly miscalculate the actual chance of death on an individual basis. This study reveals the contributions of both comorbidities and aggressive surgical decisions to mortality.

Conditional survival in pancreatic cancer: better than expected.

BACKGROUND: Traditional survival estimates after resection for pancreatic cancer are based on clinicopathological variables at the time of diagnosis. Estimates have not reflected time survived after resection, as investigated for other malignancies. The aim of the present study was to understand how survival estimates change after pancreatic resection for cancer based on time already survived (conditional survival). METHODS: Pancreatectomies performed for pancreatic ductal adenocarcinoma (PDAC) between 2001 and 2010 were reviewed. Clinicopathological variables were evaluated to identify predictors of survival. Expected survival according to a validated nomogram for pancreatic cancer as well as conditional survival estimates and actual survival were calculated. RESULTS: In all, 186 patients underwent pancreatic resection for PDAC [154 (82.8%) Whipple, 26 (14.0%) distal and 6 (3.2%) total]. Median (range) survival was 22 (3.4-107.3) months. Predictors of overall survival were: absence of nodal disease [odds ratio (OR) 8.8], age <67 years (OR 8.4) and lower stage (OR 4.3). Expected survival according to the nomogram was 70% (1 year), 39.5% (2 years) and 24% (3 years). As time passed, and overall and expected survival decreased, conditional survival increased. DISCUSSION: The available prognostic system for PDAC underestimated survival compared with actual survival in the present study. Conditional survival estimates, based on accrued lifespan, were better than either predicted or actual survival, suggesting that survival is a dynamic, rather than static, concept. Conditional survival may, therefore, be a useful tool to allow patients and clinicians to project subsequent survival based on time accrued since resection.

Voluntary and involuntary ligature of the bile duct in iatrogenic injuries: a nonadvisable approach.

BACKGROUND: Bile duct injuries related to laparoscopic and/or open cholecystectomy are a frequent finding and require surgical treatment. Complete obstruction is due to either intentionally or unintentionally placed ligatures or clips. The intentional application is usually performed to "facilitate identification of the duct by bile duct dilation." Considering that we are a national referral center for such injuries, we decided to analyze our cases of voluntary and involuntary duct ligation after iatrogenic bile duct injury. METHODS: We reviewed the files of patients with voluntary or involuntary bile duct ligation. Results of preoperative evaluation of the ducts, operative treatment, and postoperative results were analyzed. RESULTS: A total of 413 patients were included. Forty-five patients presented with complete obstruction. In 15 cases, the ligature was intentional, and in 30 cases, occlusion was involuntary. Bile duct dilation (>10 mm) was demonstrated in one case of voluntary (6%) and three cases of involuntary ligations (10%). The remaining cases in both groups had no duct dilation and developed necrosis at the blinded duct and leakage proximal to the ligature, with different degrees of bilioperitoneum and/or biloma. In all cases, a Roux-en-Y hepatojejunostomy was performed. CONCLUSION: Bile duct ligature produces dilation in a very small number of patients (less than 10%) and usually produces necrosis of the blinded stump with subsequent bile leakage. Placement of a subhepatic drain and transference of the patient to a qualified center for reconstruction is the best approach if the primary surgeon is not able to do the repair.

Manejo de la ruptura prematura de membranas ovulares: hospital General Docente Guillermo Domínguez López 2006 / Management of the premature rupture of the ovule membranes: “guillermo Domínguez López” Educational General Hospital

Se realizó un estudio epidemiológico, longitudinal y retrospectivo en el servicio de obstetricia de la maternidad del Hospital General Guillermo Domínguez López Puerto Padre 2006. Con el objetivo de determinar el comportamiento de la ruptura prematura de las membranas en el embarazo a término. Teniendo en cuenta que la ruptura prematura de membranas es una solución de continuidad de las membranas ovulares antes del inicio del trabajo de parto acompañada de la salida de líquido amniótico que puede ser pretérmino o a término. La muestra de estudio estuvo constituida por 183 mujeres con ruptura prematura de membranas a término, donde el inicio del trabajo de parto en el mayor número de gestantes fue espontáneo con un 63,3 por ciento, el mayor porciento de sepsis ovular fue la intraparto con un 7,1por ciento. La alta incidencia en nuestros casos puede estar dada por la incidencia de sepsis vaginal en nuestro medio, así por el número de exploraciones realizadas a nuestras pacientes por tanto que el mayor número de casos tuvo un período de latencia menor de 24 hs, la incidencia de sepsis ovular fue baja y existe relación directa entre el número de tactos vaginales y la aparición de sepsis ovular(AU)

An epidemiologic, longitudinal and retrospective study was carried out in the obstetricia service of the maternity area from “Guillermo Domínguez López” General Hospital in Puerto Padre in 2006. It was done with the purpose to determine the behaviour of the membrane premature rupture in the end of the pregnancy taking into account the fact that it is a solution of continuity of the ovule membrane before the chindbirth and that this solution is accomparied by the outcome of the ammniotic liquid that could be before or at the end. The scope of the study included 183 women with membrane premature rupture at the end. The beginning of the childbirth was spontaneous in most of pregnants with a 63,3 per sent. The biggest percent of ovular sepsis occurred in the middle stage of the childbirth with a 71 per sent. The high incidence in these cases could be due to the incidence of vaginal sepsis in the middle and the exploration carried out to the patients. The biggest number of cases had a suckling period minor than 24 hours. The incidence of ovular sepsis was low and there was a direc relation between the vagina examination and the ovular sepsis appearance(AU)

Angioma de células del litoral / Angioma of cells of the coast

Introducción: El Angioma de Células del Litoral (ACL) es un tumor vascular primario benigno y poco frecuente del bazo, que se origina en las células del litoral, las cuáles se ubican en los sinusoides esplénicos de la pulpa roja asociadas a marcadores histiocitarios. Los pacientes con ACL suelen presentarse con anemia y trombocitopenia y se han reportado algunos casos asociados a patología neoplásica. El objetivo es presentar un caso con datos clínicos, ecográficos, de resonancia magnética (RM), anatomopatológicos e inmunohistoquímicos. Presentación de caso: Se presenta el caso de un paciente de sexo masculino de 59 años de edad, sin antecedentes clínicos ni quirúrgicos, el cuál ingresa a la institución para la realización de una cirugía programada por una eventración subcostal izquierda, descubriéndose incidentalmente una masa esplénica por ecografía. Conclusión: Se presenta un caso poco frecuente, recientemente descripto, único y de hallazgo incidental, que corresponde a un ACL, que es un tumor vascular primario y benigno del bazo.

Comportamiento de algunas variables maternas y perinatales en el embarazo postérmino / Behaviour of some maternal and perinatal variables of post - term pregnancy

Se realizó un estudio descriptivo, retrospectivo en la maternidad del Hospital General Docente Guillermo Domínguez López, municipio Puerto Padre, provincia Las Tunas, en el año 2005, con la finalidad de precisar algunos factores maternos perinatales en el embarazo. El universo estuvo constituido por 194 gestantes. Para la recolección de la información fue elaborado un cuestionario, los datos se procesaron por la técnica de Palotes, el análisis estadístico utilizado fue el valor porcentual. Los resultados evidenciaron que el embarazo postérmino prevaleció en gestantes de 20-29 años de edad, nulípara con características favorables del cuello uterino, las pruebas de bienestar fetal realizados mostraron porcientos superiores de normalidad y la indicación principal de las cesáreas fue el sufrimiento fetal agudo(AU)

In order to determine some maternal and perinatal variables of pregnancy, a descriptive and retrospective study was done in the service of Maternity at General Teaching Hospital “Guillermo Domínguez López”, Puerto Padre, Las Tunas province during 2005. The universe was formed by 194 pregnant women. To collect information it was used a questionary and statistical analysis was percentage value. The results proved that post term pregnancy prevailed in pregnant women between 20 to 29 years old, nullipara with propitious characteristics of uterus, foetal well being tests gave superior percentage of normality and principal indication of caesarean section was acute foetal suffering(AU)

Placenta Previa y su repercusión en la morbimortalidad Prenatal y materna 2001-2005 / Praevia placenta and its repercussion in prenatal and maternal morbidity and martality 2001 2005

Se realizó un estudio retrospectivo con el objetivo de precisar algunas consideraciones y su repercusión en la morbimortalidad prenatal y materna por placenta previa a las gestantes que ingresaron en el centro y que se le diagnosticó una placenta previa durante el período comprendido entre Enero del 2001 a Diciembre del 2005 en el Hospital “Guillermo Domínguez López” de Puerto Padre. El universo de estudio estuvo constituido por 18 gestantes. El registro primario lo constituyo una encuesta confeccionada según revisión bibliográfica. Esta entidad apareció mayormente en el grupo de 20-34 años con un 78 por ciento, en la historia obstétrica el antecedente de aborto fue de un 56.0 por ciento, fue más frecuente en el tiempo de gestación de 28-36.6 semanas con un peso del producto de menos de 2500 grs. con un 56.0 por ciento y un 61 por ciento respectivamente. En cuanto a la morbilidad las cesáreas ocupan el primer lugar con 18 gestantes para un 100 por ciento(AU)

From January 2001 to December 2005 in “Guillermo Domínguez López” Hospital Puerto Padre, a retrospective study in order to determine some considerations and their repercussion in prenatal and maternal morbidity and mortality due to pra praevia placenta to pregnant women who were hospitalized and were diagnosed praevia placenta, was done. The universe of study was constituted by 18 pregnant women. The primary registration was an inquiry prepared according to bibliographic revision. This clinical condition greatly appeared in the group of 20 34 years old (78 per cent). The anteceden, of abortion had a 56.0 per cent in the obstetrical history. It was more frequent at 28 36.6 weeks of pregnancy having a smaller weight than 2 500 grs of the foetus, 56.0 per cent and 61 per cent respectively. According to morbidity caesarean section, this has the first place with 18 pregnant (100 per cent)(AU)

An unusual cause of bilioenteric anastomotic dysfunction after iatrogenic bile duct injury.

Roux en Y hepatojejunostomy is the surgery of choice for bile duct repair. Anastomotical dysfunction after reconstruction has several etiopathologies. Besides technical factors, ischemia of the duct is responsible for late obstruction. Bile colonization with secondary stones and sludge can also be identified as a cause. An unusual cause of anastomotical dysfunction secondary to ascaris biliary infestation after biliary reconstruction is reported herein. The patient had intermittent cholangitis and eosinophilia. At operation, the worm was found obstructing the anastomosis.

Aneurismas de la arteria hepática: diagnóstico por imágenes / Aneurysms of the hepatic artery: diagnostic for imagens

Los aneurismas de la arteria hepática son una patología rara, pero que pueden resultar mortales por ruptura espontánea. Desde el punto de vista clínico suelen ser asintomáticos hasta que se complican. El origen arteriosclerótico, infeccioso y traumático son las causas más frecuentes. Se comunican 3 casos de aneurismas de arteria hepática. Todos fueron estudiados con ecografía y arteriografía y, en dos casos, además con colangiografía transparietohepática y TC. Se describen las características de esta patología con los distintos métodos por imágenes, remarcándose su importancia para asegurar el diagnóstico aun con estudios no invasivos y para brindar al cirujano el detalle de la anatomía biliar y vascular, como así también las relaciones del aneurisma con las estrecturas vecinas. Se destaca la indicación de la arteriografía no solo para el diagnóstico sino también como tratamiento (embolización)

Aneurismas de la arteria hepática: diagnóstico por imágenes / Aneurysms of the hepatic artery: diagnostic for imagens

Los aneurismas de la arteria hepática son una patología rara, pero que pueden resultar mortales por ruptura espontánea. Desde el punto de vista clínico suelen ser asintomáticos hasta que se complican. El origen arteriosclerótico, infeccioso y traumático son las causas más frecuentes. Se comunican 3 casos de aneurismas de arteria hepática. Todos fueron estudiados con ecografía y arteriografía y, en dos casos, además con colangiografía transparietohepática y TC. Se describen las características de esta patología con los distintos métodos por imágenes, remarcándose su importancia para asegurar el diagnóstico aun con estudios no invasivos y para brindar al cirujano el detalle de la anatomía biliar y vascular, como así también las relaciones del aneurisma con las estrecturas vecinas. Se destaca la indicación de la arteriografía no solo para el diagnóstico sino también como tratamiento (embolización)

Diagnóstico precóz de la pancreatitis aguda biliar: valor de la ecografía comparada con la clínica / Early diagnósis of acute biliary pancreatitis: value of the echography compared with the clinical

En el presente esutdio se evalúa la exactitud de los signos clínicos y exámenes de laboratorio comparándolos con la ecografía, para establecer un diagnóstico correcto de pancreatitis aguda biliar durante sus etapas tempranas. En 32 pacientes con dolor epigástrico y signos de obstrucción biliar con elevación de la amilasa, bilirrubina y fosfatasa alcalina séricas de no más de 36 hs de evolución, se formuló el diagnóstico de pancreatitis aguda por cálculo impactado en la ampolla. A todos los pacientes se les practicó ecografía del páncreas, vía biliar y vesícula biliar, entre 5 y 48 hs (X + 34 hs) después del comienzo de la sintomatología. En 12 pacientes se observaron alteraciones ecográficas del páncreas tales como agrandamiento, disminución de la ecogenicidad o ambas; en 4 pacientes se observaron alteraciones de la vía biliar y en 30 patología vesciular, particularmente litiasis. Sobre la base del diagnóstico clínico a todos los pacientes se les efectuó laparatomía entre 2 y 15 hs (X = 8 hs) después de la ecografía. En la totalidad de los casos se constataron lesiones características de pancreatitis aguda asociada con litiasis biliar; en 27 pacientes (84%) se observó bloqueo ampular litiásico presente o reciente. La exactitud del diagnóstico clínico y bioquímico de pancreatitis aguda biliar, fue del 100%. La ecografía mostró baja sensibilidad y escasa precisión para revelar las alteraciones pancreáticas y de la vía biliar durante las etapas iniciales, pero resultó un método sensible y exacto de diagnóstico de litiasis vesicular asociada en los períodos iniciales de la pacreatitis aguda (97%)

Diagnóstico precóz de la pancreatitis aguda biliar: valor de la ecografía comparada con la clínica / Early diagnósis of acute biliary pancreatitis: value of the echography compared with the clinical

En el presente esutdio se evalúa la exactitud de los signos clínicos y exámenes de laboratorio comparándolos con la ecografía, para establecer un diagnóstico correcto de pancreatitis aguda biliar durante sus etapas tempranas. En 32 pacientes con dolor epigástrico y signos de obstrucción biliar con elevación de la amilasa, bilirrubina y fosfatasa alcalina séricas de no más de 36 hs de evolución, se formuló el diagnóstico de pancreatitis aguda por cálculo impactado en la ampolla. A todos los pacientes se les practicó ecografía del páncreas, vía biliar y vesícula biliar, entre 5 y 48 hs (X + 34 hs) después del comienzo de la sintomatología. En 12 pacientes se observaron alteraciones ecográficas del páncreas tales como agrandamiento, disminución de la ecogenicidad o ambas; en 4 pacientes se observaron alteraciones de la vía biliar y en 30 patología vesciular, particularmente litiasis. Sobre la base del diagnóstico clínico a todos los pacientes se les efectuó laparatomía entre 2 y 15 hs (X = 8 hs) después de la ecografía. En la totalidad de los casos se constataron lesiones características de pancreatitis aguda asociada con litiasis biliar; en 27 pacientes (84%) se observó bloqueo ampular litiásico presente o reciente. La exactitud del diagnóstico clínico y bioquímico de pancreatitis aguda biliar, fue del 100%. La ecografía mostró baja sensibilidad y escasa precisión para revelar las alteraciones pancreáticas y de la vía biliar durante las etapas iniciales, pero resultó un método sensible y exacto de diagnóstico de litiasis vesicular asociada en los períodos iniciales de la pacreatitis aguda (97%) (AU)