Management of major bile duct injury after laparoscopic cholecystectomy: a case report

<p>Abstract</p> <p>Introduction</p> <p>Bile duct injury is a severe and potentially life-threatening complication of laparoscopic cholecystectomy. Several series have described a 0.5% to 0.6% incidence of bile duct injury during laparoscopic cholecystectomy. The aim of this study was to analyze the presentation, characteristics, related investigation, and treatment results of major bile duct injuries after laparoscopic cholecystectomy.</p> <p>Case presentation</p> <p>A rare case of a 48-year-old Greek woman with a triple bile duct injury (right and left hepatic duct ligation and common bile duct cross-section) is presented. A Roux en Y hepaticojejunostomy was performed after repeated endoscopic retrograde cholangiopancreatographies, percutaneous transhepatic catheterization of the ducts and magnetic resonance cholangiographies to delineate the biliary anatomy and assess the level of injury.</p> <p>Conclusion</p> <p>Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature. Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.</p

Validity of a virtual reality endoscopic retrograde cholangiopancreatography simulator: can it distinguish experts from novices?

BackgroundThere is a lack of evidence regarding the effectiveness of virtual simulators as a means to acquire hands-on exposure to endoscopic retrograde cholangiopancreatography (ERCP). The present study aimed to assess the outcome and construct validity of virtual ERCP when training on the GI II Mentor simulator.MethodsA group of seven experienced endoscopists were compared with 31 novices. After a short introduction, they were requested to carry out three virtual ERCP procedures: diagnosing and removing a common bile duct (CBD) stone; diagnosing and taking brush cytology from a hilar stenosis; and, finally, diagnosing and treating a cystic leakage with a BD stent. For each task, the total time required to complete the task, time required to correctly view the papilla, total time of irradiation, time to deep cannulation, time to define diagnosis, time to complete sphincterotomy, and time to complete the respective intervention were measured. Cannulation of the BD, correct diagnosis, sphincterotomy, and time to complete intervention were assessed by an assessor blinded to the status of the endoscopist who performed the virtual ERCP.ResultsThe time required to visualize the papilla and to cannulate deeply when removing the BD stone was significantly shorter for the experts (both p &lt; 0.05). The time to visualize the papilla, cannulate deeply, reach a diagnosis, complete sphincterotomy, and complete the intervention was significantly shorter for the experts when managing cystic leakage (all p &lt; 0.05). In diagnosing and taking brush cytology from a hilar stenosis, there was only a trend toward the experts needing less time for the deep cannulation of the BD (p = 0.077).ConclusionThe performance differed between experts and novices, especially in the management of cystic leakage. This corroborates the construct validity of the GI II Mentor simulator

Study on the pathogenetic mechanisms of acute respiratory distress syndrome (ARDS)

Background-Aims: Inhibition of neutrophil apoptosis and apoptotic death of epithelial (pneymocytes and endothelial) cells are potential pathogenic mechanisms of ALI/ARDS. The aim of this study was to evaluate the potential pathogenic role of apoptosis and its inhibition by a pan-caspase inhibitor (Z.vad.fmk or zvad) in the lung in a murine model of LPS-induced ALI/ARDS. Materials and Methods: In 43 C57B1/6 male mice ALI/ARDS was induced by LPS injection i.p. using LD45 dosage while 5 mice were the controls. Survival was observed in 15 LPS animals and in 15 LPS mice that were treated with zvad ALI/ARDS course over time was evaluated 8 hours after LPS (in 7 mice, LPS-8 group), 24 hours after LPS (6 animals, LPS-24 group) and the 8 surviving LPS animals from the survival group (LPS-72). Histological evaluation, wet lung weight per body weight and wet/dry weight ratio were used to confirm ALI/ARDS. TNF-α and MDA levels in lung tissue were measured. Using flow cytometry neutrophil, mononuclear-macrophage and epithelial counts were determined as well as their apoptotic profile and caspase-3 expression. Results: Pathologic ALI/ARDS score was the only significant prognostic factor in our study and it was significantly higher in all LPS receiving animals compared to the controls. Zvad administration significantly lowered it without adding a survival benefit. TNF-α levels were significantly lower than the controls 72 hours after LPS administration. In non-surviving LPS animals TNF-α levels were higher than the controls and zvad administration lowered them to the controls’ level. MDA did not vary significantly between study groups. Healthy and apoptotic neutrophil counts were increased by zvad in non-surviving animals due to LPS induced ALI/ARDS. Eight hours after LPS administration caspase-3 positive healthy neutrophils were doubled compared to the controls Zvad administration overall lowered them to the controls’ level. Epithelial (pneymocytes and endothelial) cells did not vary significantly over time while zvad administration increased their counts especially among mice surviving ALI/ARDS. Conclusions: Neutrophil and epithelial cell apoptosis was not the primary pathogenic mechanism in a murine LPS induced ALI/ARDS model employing LD45 as evaluated by flow cytometry. Since apoptosis inhibition significantly improved pathologic ALI/ARDS score which was the only significant prognostic factor in our study, further study is advocated.Εισαγωγή-Σκοποί: Η φλεγμονώδης διήθηση από ουδετερόφιλα πολυμορφοπύρηνα και η καταστροφή των πνευμονοκυττάρων τύπου Ι και II αλλά και των ενδοθηλιακών κυττάρων στον πνεύμονα αποτελούν βασικά στοιχεία στην πορεία του ALI/ARDS. Σκοπός της παρούσας μελέτης ήταν η διερεύνηση του ενδεχόμενου παθογενετικού ρόλου της απόπτωσης στον πνευμονικό ιστό συνολικά αλλά και στους διάφορους κυτταρικούς υποπληθυσμούς σε ένα πειραματικό μοντέλο ALI/ARDS σε μύες. Επίσης μελετήθηκαν τα αποτελέσματα της χορήγησης ενός ευρέος φάσματος αναστολέα των κασπασών (Ζ.vad.fmk). Υλικό και Μέθοδος: Χρησιμοποιήθηκαν 48 αρσενικοί μύες C57B1/6 στους 43 από τους οποίους προκλήθηκε ALI/ARDS με τη ενδοπεριτοναϊκή χορήγηση LPS σε δόση ίση με την LD45 ενώ οι υπόλοιποι 5 μύες αποτέλεσαν την ομάδα ελέγχου. Η μελέτη του ALI/ARDS έγινε στις 8 (n=7), 24 (n=6) και 72 ώρες (n=8) μετά τη χορήγηση του LPS ενώ για τη μελέτη επιβίωσης χρησιμοποιήθηκαν 30 μύες με ALI/ARDS στους 15 από τους οποίους χορηγήθηκε Ζ.vad.fmk. Η ύπαρξη και η βαρύτητα του ALI/ARDS εκτιμήθηκε παθολογοανατομικά και μετρήθηκε το περιεχόμενο υγρό πνεύμονα /ΣΒ, αλλά και ο λόγος υγρού/ξηρό βάρος. Προσδιορίστηκαν αρχικά ο TNF-α και τα επίπεδα MDA στον πνευμονικό ιστό. Ακολούθως, με τη χρήση κυτταρομετριας ροής έγινε ποσοτικός προσδιορισμός των επιθηλιακών, ουδετερόφιλων πολυμορφοπύρηνων και μακροφάγων και διακρίθηκαν οι υγιείς αποπτωτικοί και νεκρωτικοί πληθυσμοί όπως επίσης και οι θετικοί στην έκφραση της κασπάσης-3 με χρήση κατάλληλων αντισωμάτων. Έγινε μελέτη της επιβίωσης και αναζητήθηκαν προγνωστικοί παράγοντες του συνδρόμου ALI/ARDS μεταξύ των προαναφερθέντων μεταβλητών. Αποτελέσματα: Η ιστολογική βαρύτητα του ALI/ARDS ήταν υψηλότερη σε όλα τα πειραματόζωα που έλαβαν LPS σε σχέση με τους μάρτυρες και ήταν ο μοναδικός ανεξάρτητος προγνωστικός παράγοντας. Η χορήγηση Ζ.vad.fmk βελτίωσε σημαντικά την παθολογοανατομική βαρύτητα του συνδρόμου χωρίς ωστόσο να βελτιώνει την επιβίωση. Στις 72 ώρες μετά τη χορήγηση LPS οι τιμές του TNF-α έφτασαν στη χαμηλότερη τιμή τους. Στα πειραματόζωα που απεβίωσαν τα επίπεδα TNF-α ήταν αυξημένα ενώ η χορήγηση του zvad τα μείωσε στα επίπεδα των μαρτύρων. Δεν ανευρέθηκε στατιστικά σημαντική διακύμανση των επίπεδων MDA στις διάφορες στιγμές του ALI/ARDS. Η χορήγηση του zvad οδήγησε σε αύξηση των υγιών και αποπτωτικών ουδετερόφιλων στα πειραματόζωα που απεβίωσαν λόγω ALI/ARDS. Τα θετικά στην κασπάση-3 υγιή ουδετερόφιλα 8 ώρες μετά το LPS ήταν διπλάσια σε σχέση με τους μάρτυρες και το zvad τα μείωσε στο επίπεδο των μαρτύρων. Αντίθετα τα επιθηλιακά κύτταρα (πνευμονοκύτταρα και ενδοθηλιακά) δεν εμφάνισαν στατιστικά σημαντικές διακυμάνσεις στις διάφορες χρονικές στιγμές ενώ το zvad αύξησε σημαντικά το ποσοστό τους συνολικά και κυρίως στα πειραματόζωα που επιβίωσαν του ALI/ARDS. Συμπεράσματα: Η απόπτωση δεν είναι ο πρωταρχικός παθογενετικός μηχανισμός σε πειραματικό μοντέλο επιβίωσης του συνδρόμου ALI/ARDS που προσομοιάζει την επιβίωση του κλινικού συνδρόμου ανεξαρτήτως του μελετώμενου κυτταρικού υποπληθυσμού. Εφόσον η αναστολή της απόπτωσης επηρεάζει την ιστολογική βαρύτητα που είναι και ο μοναδικός ανεξάρτητος προγνωστικός παράγοντας του ALI/ARDS απαιτείται περαιτέρω μελέτη

Somatostatin versus octreotide in the treatment of patients with gastrointestinal and pancreatic fistulas

BACKGROUND AND PURPOSE: Gastrointestinal and pancreatic fistulas are characterized as serious complications following abdominal surgery, with a reported incidence of up to 27% and 46%, respectively. Fistula formation results in prolonged hospitalization, increased morbidity/mortality and increased treatment costs. Conservative and surgical approaches are both employed in the management of these fistulas. The purpose of the present study was to assess, evaluate and compare the potential clinical benefit and cost effectiveness of pharmacotherapy (somatostatin versus its analogue octreotide) versus conventional therapy

Endoscopic management of a relapsing hepatic hydatid cyst with intrabiliary rupture: A case report and review of the literature

Hydatid disease, although endemic mostly in sheep-farming countries, remains a public health issue worldwide, involving mainly the liver. Intrabiliary rupture is the most frequent complication of the hepatic hydatid cyst. Endoscopy is advocated, preoperatively, to alleviate obstructive jaundice caused by intracystic materials after a frank rupture and is also a useful and well-established adjunct in locating postoperative biliary fistulas

Granisetron versus tropisetron in the prevention of postoperative nausea and vomiting after total thyroidectomy

A b s t r A c t background: Postoperative nausea and vomiting (PONV) are frequently encountered after thyroidectomy. For PONV prevention, selective serotonin 5-hydroxytryptamine type 3 (5-HT 3 ) receptor antagonists are considered one of the first-line therapy. We report on the efficiency of granisetron and tropisetron, with that of placebo on the prevention of PONV in patients undergoing total thyroidectomy. Methods: One hundred twenty-seven patients were divided into three groups and randomized to receive intravenously, prior to induction of anesthesia, tropisetron 5 mg, or granisetron 3 mg, or normal saline. All patients received additionally 0.625 mg droperidol. All episodes of postoperative PONV during the first 24 h after surgery were evaluated. results: Nausea visual analogue scale (VAS) score was lower in tropisetron and granisetron groups than the control group at all measurements (P&lt;0.01) except for the 8-h measurement for tropisetron (P=0.075). Moreover, granisetron performed better than tropisetron (P&lt;0.011 at 4 h and P&lt;0.01 at all other points of time) apart from the 2-h measurement. Vomiting occurred in 22.2%, 27.5%, and 37.5% in granisetron, tropisetron, and control groups, respectively (P=0.43). conclusions: The combination of the 5-HT 3 antagonists with droperidol given before induction of anesthesia is well tolerated and superior to droperidol alone in preventing nausea but not vomiting after total thyroidectomy

Effects of mycophenolate mofetil vs cyclosporine administration on graft survival and function after islet allotransplantation in diabetic rats

AIM: To develop an experimental model of islet allotransplantation in diabetic rats and to determine the positive or adverse effects of MMF as a single agent. METHODS: Thirty-six male Wistar rats and 18 male Lewis rats were used as recipients and donors respectively. Diabetes was induced by the use of streptozotocin (60 mg/kg) intraperitoneally. Unpurified islets were isolated using the collagenase digestion technique and transplanted into the splenic parenchyma. The recipients were randomly assigned to one of the following three groups: group A (control group) had no immunosuppression; group B received cyclosporine (CsA) (5 mg/kg); group C received mycophenolate mofetil (MMF) (20 mg/kg). The animals were killed on the 12(th) d. Blood and grafted tissues were obtained for laboratory and histological assessment. RESULTS: Median allograft survival was significantly higher in the two therapy groups than that in the controls (10 and 12 d for CsA and MMF respectively vs 0 d for the control group, P&lt;0.01). No difference in allograft survival between the CsA and MMF groups was found. However, MMF had less renal and hepatic toxicity and allowed weight gain. CONCLUSION: Monotherapy with MMF for immunosuppression was safe in an experimental model of islet allotransplantation and was equally effective with cyclosporine, with less toxicity. (C) 2005 The WJG Press and Elsevier Inc. All rights reserved

Granisetron versus tropisetron in the prevention of postoperative nausea and vomiting after total thyroidectomy

Background: Postoperative nausea and vomiting (PONV) are frequently encountered after thyroidectomy. For PONV prevention, selective serotonin 5-hydroxytryptamine type 3 (5-HT 3 ) receptor antagonists are considered one of the first-line therapy. We report on the efficiency of granisetron and tropisetron, with that of placebo on the prevention of PONV in patients undergoing total thyroidectomy. Methods: One hundred twenty-seven patients were divided into three groups and randomized to receive intravenously, prior to induction of anesthesia, tropisetron 5 mg, or granisetron 3 mg, or normal saline. All patients received additionally 0.625 mg droperidol. All episodes of postoperative PONV during the first 24 h after surgery were evaluated. Results: Nausea visual analogue scale (VAS) score was lower in tropisetron and granisetron groups than the control group at all measurements ( P<0.01) except for the 8-h measurement for tropisetron ( P=0.075). Moreover, granisetron performed better than tropisetron ( P<0.011 at 4 h and P<0.01 at all other points of time) apart from the 2-h measurement. Vomiting occurred in 22.2%, 27.5%, and 37.5% in granisetron, tropisetron, and control groups, respectively ( P=0.43). Conclusions: The combination of the 5-HT 3 antagonists with droperidol given before induction of anesthesia is well tolerated and superior to droperidol alone in preventing nausea but not vomiting after total thyroidectomy