Chronic complications of symptomatic gallstone disease, such as Mirizzi syndrome, are rare in Western developed countries with an incidence of less than 1% a year. The importance and implications of ...this condition are related to their associated and potentially serious surgical complications such as bile duct injury, and to its modern management when encountered during laparoscopic cholecystectomy. The pathophysiological process leading to the subtypes of Mirizzi syndrome has been explained by means of a pressure ulcer caused by an impacted gallstone at the gallbladder infundibulum, leading to an inflammatory response causing first external obstruction of the bile duct, and eventually eroding into the bile duct and evolving to a cholecystocholedochal or cholecystohepatic fistula. This article reviews the life of Pablo Luis Mirizzi, describes the earlier and later descriptions of Mirizzi syndrome, discusses the pathophysiological process leading to the development of these uncommon fistulas, reviews the current diagnostic modalities and surgical approaches and finally proposes a simplified classification for Mirizzi syndrome intended to standardize the reports on this condition and to eventually develop a consensual surgical approach to this unexpected and seriously dangerous condition.
Gastrointestinal stromal tumors (GISTs) originating in the duodenal wall constitute the most challenging localization of this gastrointestinal neoplasm. Duodenal GISTs are relatively uncommon. The ...prevalence of duodenal GIST is very low, accounting for 5% to 7% or less of all surgically resected GISTs. Most published reports on duodenal GIST are case reports or small case series. Consequently, the unspecific clinical manifestations, radiologic diagnosis, appropriate surgical treatment, prognostic factors, and survival constitute a subject of current controversy. This review addresses the management of duodenal GISTs trying to establish and define surgical options according to GIST localization within the duodenum. Most articles concerning duodenal GISTs state that unlike tumors involving other sites of the gastrointestinal tract, the optimal procedure for duodenal GISTs has not been well characterized in the surgical literature. However, when carefully reviewing the published literature on the subject, it was possible to identify common surgical approaches to duodenal GISTs which are fairly standard among different authors. All approaches take into account the GIST localization within the duodenal wall and its anatomic relationships to decide whether local resection or the Whipple operation should be performed. Using this knowledge, defined surgical options for duodenal GISTs according to their localization within the duodenum are being proposed. Besides the current controversy regarding the indications for the Whipple procedure, the other most important issue remaining to be addressed is the implementation of laparoscopic surgery for this challenging tumor.
The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with ...severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.
Introduction
Solitary fibrous tumors of the liver (SFTL) are uncommon tumors; to the present day, less than 50 cases has been reported in the English scientific literature, most of which behaved as ...benign tumors. The present article reports a new case of SFTL and has the main purpose of updating the current knowledge of SFTL because due to its rarity, its clinical presentation, study, treatment, and prognosis are not well known. The clinical presentation, radiologic study, surgical treatment, immunohistochemical study, and prognosis are updated and comprehensively discussed.
Methods
Using the common search engines, a search of the English literature was conducted for “Solitary Fibrous Tumor of The Liver,” and the relevant articles were retrieved, reviewed, and analyzed.
Results
All published articles reported anecdotal SFTLs, or SFTLs were included in large series analyzing solitary fibrous tumors on different sites.
Conclusion
The SFTL is an uncommon neoplasm. The clinical presentation is habitually indolent and its behavior is uncertain. In some cases, the SFTL acts as an aggressive sarcoma with poor prognosis. Currently, only surgery offers a therapeutic opportunity for these patients. Due to the lack of current knowledge of long-term behavior of supposedly benign SFTLs and to the lack of specific therapies, methodical long-term follow-up is essential to ensure the survival of patients treated for SFTL.
Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best ...strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world.
A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery.
The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five interquartile range 4-6. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%,
< 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%).
The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.
Summary
Background
The standard technique for reconstruction of the intestinal transit after total gastrectomy for gastric cancer is the Roux-en-Y anastomosis between the esophagus and a jejunal ...loop, which prevents the reflux of alkaline intestinal juice. The purpose of this study was to analyze the esophageal body motility and the motility of the proximal jejunal loop in patients subjected to total gastrectomy.
Patients and methods
A prospective cohort of 17 total gastrectomy patients, operated on 5 years earlier, were studied using high-resolution esophageal manometry including the first 7 cm of the jejunal loop.
Results
Manometry results were similar for all patients, showing normal esophageal body motility, with the exception of the maximum intrabolus pressure that was elevated in all cases. The jejunal loop motility was disordered and ineffective.
Conclusion
Esophageal body motility was normal 5 years after total gastrectomy. However, maximum mean intrabolus pressure was elevated in all patients. The most plausible reason for this finding would be the resistance exerted by the motility of the jejunal loop. Although this abnormality might not explain the mild symptoms presented by some patients, its pathological consequences are of little relevance.
Knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction and its pathologic implications has experienced tremendous progress during the last few years.This editorial reviews the ...current knowledge on this condition and its pathological implications on gallbladder diseases.The following aspects were def ined appropriate for discussion：（1） Evidence of carcinogenesis associated with pancreaticobiliary reflux;（2） Evidence of pancreaticobiliary reflux in normal pancreaticobiliary junction;and（3） Evidence of sphincter of Oddi（SO） dysfunction as a cause of pancreaticobiliary reflux in normal pancreaticobiliary junction.The articles reviewed were selected and classif ied according to f ive levels of evidence：Level-this condition.Although an important body of research has been published regarding pancreaticobiliary reflux in normal pancreaticobiliary junction and its clinical significance,the current evidence does not fully support what has been suggested.Studies with evidence level Ι have not been undertaken.This is a fascinating subject of study,and if finally supported by evidence level Ι,the importance of this condition will constitute a major breakthrough in biliary pathology.
Background
Mirizzi syndrome and cholecystoenteric fistula with or without gallstone ileus are late complications of gallstone disease. We previously suggested that the natural history of Mirizzi ...syndrome may not end with just a cholecystobiliary fistula and that the continuous inflammation in the triangle of Calot area may result in a complex fistula involving the biliary tract and the adjacent viscera. The purpose of this study was to establish the relationship of Mirizzi syndrome with cholecystoenteric fistulas.
Methods
We retrospectively reviewed the records of all patients older than aged 18 years submitted to emergency or elective cholecystectomy from 1995 to 2006. Of 5,673 cholecystectomies performed during that period, we found 327 (5.7%) patients with Mirizzi syndrome and 105 (1.8%) patients with cholecystoenteric fistula. Ninety-four (89.5%) patients with cholecystoenteric fistula also had an associated Mirizzi syndrome.
Results
Cholecystoenteric fistula was associated with Mirizzi syndrome (
p
< 0.0001), increased age was associated with Mirizzi syndrome and cholecystoenteric fistula (
p
< 0.0001), and female gender was associated with Mirizzi syndrome (
p
< 0.0001).
Conclusion
When during surgery for gallstone disease a cholecystoenteric fistula is encountered, the possibility of an associated Mirizzi syndrome must be considered. The findings of this study confirm the association of Mirizzi syndrome with cholecystoenteric fistula.
Abstract Background/Purpose Few studies have addressed the predictive value of white blood cells (WBCs) and C-reactive protein (CRP) at different cutoff values in appendicitis. Our purpose was to ...determine the cutoff values for WBC and CRP at different periods during clinical evolution of appendicitis and to establish their use for the diagnosis of appendicitis and differentiation of simple from perforated appendicitis. Methods We studied 198 patients operated on for appendicitis, which were further divided into 4 subgroups according to the time from the onset of symptoms to diagnosis. Receiver operating characteristic curves were constructed for CRP and WBC; the best cutoff points were used to calculate the sensitivity and specificity to discriminate patients with and without appendicitis and patients with simple and perforated appendicitis. Results White blood cell and CRP individually and together had a high sensitivity to differentiate patients with and without appendicitis. The specificity of WBC and CRP taken individually and together to differentiate patients with simple and perforated appendicitis was high, but the sensitivity was low. Conclusions White blood cell and CRP could be used to support the clinical diagnosis of appendicitis, and, depending on the time from the onset of symptoms to diagnosis, to differentiate patients with and without appendicitis and discriminate simple from perforated appendicitis.
Abstract Knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction and their pathologic implications has experienced tremendous progress during the last few years. This article ...reviews the current knowledge on this condition and its pathological implications on gallbladder diseases. Many publications with different levels of evidence were found supporting biliary carcinogenesis associated with pancreaticobiliary reflux in normal and abnormal pancreaticobiliary junction. Also, there are many publications supporting the common occurrence of pancreaticobiliary reflux in normal pancreaticobiliary junction, and sphincter of Oddi dysfunction as the most plausible cause of this condition. Although an important body of research has been published regarding pancreaticobiliary reflux in normal pancreaticobiliary junction and their clinical significance, the current evidence does not fully support what has been suggested. The reflux of pancreatic enzymes into the bile tract and gallbladder is a fascinating subject of study which is open to active research. The final demonstration of the pathophysiology and consequences of PBR in NPBL and support by evidence level type I would constitute a major breakthrough in the understanding and eventually in the treatment of gallbladder diseases.
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