Reoperative Surgery After Repair of Postcholecystectomy Bile Duct Injuries: Is it Worthwhile?

Background

Repeat repair of bile duct injuries (BDIs) after cholecystectomy is technically challenging, and its success remains uncertain. We retrospectively evaluated the short- and long-term outcomes of patients requiring reoperative surgery for BDI at a major referral center for hepatobiliary surgery.

Methods

Between January 1991 and May 2011, we performed surgical BDI repairs in 46 patients. Among them, 22 patients had undergone a previous surgical repair elsewhere (group 1), and 24 patients had no previous repair (group 2). We compared the early and late outcomes in the two groups.

Results

The patients in group 1 were younger (48.6 vs. 54.8 years, p = 0.0001) and were referred after a longer interval (>1 month) from BDI (72.7 vs. 41.7 %, p = 0.042). Intraoperative diagnosis of BDI (59.1 vs. 12.5 %, p = 0.001), ongoing cholangitis (45.4 vs. 12.5 %; p = 0.02), and delay of repair after referral to our institution (116 ± 34 days vs. 23 ± 9 days; p = 0.001) were significantly more frequent in group 1 than in group 2. No significant differences were found for postoperative mortality, morbidity, or length of stay between the groups. Patients with associated vascular injuries had a higher postoperative morbidity rate (p = 0.01) and associated hepatectomy rate (p = 0.045). After a mean follow-up of 96.6 ± 9.7 months (range 5–237.2 months, median 96 months), the rate of recurrent cholangitis (6.5 %) was comparable in the two groups.

Conclusions

This study demonstrates that short- and long-term outcomes after surgical repair of BDI are comparable regardless of whether the patient requires reoperative surgery for a failed primary repair. Associated vascular injuries increase postoperative morbidity and the need for liver resection.     

Small-dose iron tolerance test and body iron content in normal subjects

Abstract: The small-dose iron tolerance test (SD-ITT) was performed in 37 healthy subjects (20 females and 17 males). The area under the curve (AUC) of serum iron variations after the test dose (10 mg of iron as iron sulphate) was corrected by the expected plasma iron disappearance rate, the expected subject's plasma volume and the measured spontaneous time-dependent serum iron variations, and was used as a summary measure of the outcome, Q-ITT. Q-ITT correlated strictly with the maximum serum iron increase (SImax). Q-ITT gave positive (greater than zero) values in only 14 out of the 37 subjects (11 females and 3 males). Serum ferritin proved to be the best discriminating parameter between positive and non-positive subjects, and was inversely correlated with Q-ITT in the positive ones. In 2 male subjects, aged 43 and 34 years, SD-ITT proved to be highly sensitive to the progressive decrease of mobilzable body iron content during repeated venesections. In these patients the threshold for a positive test result was obtained at values lower than 1050 and 950 mg of body iron content, respectively. The threshold-dependent sensitivity, simplicity, and repeatability of this method favor its becoming a useful technique for studying the up-regulation of iron absorption in normal subjects and in pathological conditions.     

Intraneural cyst of the peroneal nerve

A 15-year-old girl was referred to us because of foot drop. The motor deficit was characterized by a peculiar fluctuating course related to sporting activity: improvement of symptoms during no-sport periods and worsening during sport training. Neurophysiological examination revealed marked global impairment of muscles innervated by the peroneal nerve. Ultrasound and MRI showed a mass in close proximity to the neck of the fibula extending in a tubular fashion. At operation an intraneural lesion was found and was totally removed. Histology revealed that it was an intraneural cyst. A hypothesis on the pathogenesis was drawn up. One year after the operation a clinical and neurophysiological follow-up was performed. Received: 2 April 1997 Revised: 27 May 1997     

A Filmless Radiology Department in a Full Digital Regional Hospital: Quantitative Evaluation of the Increased Quality and Efficiency

Reggio Emilia hospital installed Picture Archiving and Communications Systems (PACS) as the final step towards a completely digital clinical environment completing the HIS/EMR and 1,400 web/terminals for patient information access. Financial benefits throughout the hospital were assessed upfront and measured periodically. Key indicators (radiology exam turnaround time, number of radiology procedures performed, inpatients length of stay before and after the PACS implementation, etc.) were analyzed and values were statistically tested to assess workflow and productivity improvements. The hospital went “filmless” in 28 weeks. Between the half of 2004 and the respective period in 2003, overall Radiology Department productivity increased by 12%, TAT improved by more than 60%. Timelier patient care resulted in decreased lengths of stay. Neurology alone experienced a 12% improvement in average patient stay. To quantify the impact of PACS on the average hospital stays and the expected productivity benefits to inpatient productivity were used a “high level” and a “detailed” business model. Annual financial upsides have exceeded $1.9 millions/year. A well-planned PACS deployment simplifies imaging workflow and improves patient care throughout the hospital while delivering substantial financial benefits. Staff buy-in was the key in this process and on-going training and process monitoring are a must.     

Continuous On-Line Optical Absorbance Recording of Blood Volume Changes during Hemodialysis

Abstract: Conventional techniques that measure blood volume changes during hemodialysis are invasive, hard to reproduce, and provide only intermittent evaluations. To overcome these drawbacks, we have developed an optoelectronic instrument that estimates intradialytic blood volume percentage changes by the optical absorbance of blood. This device is based on the absorption of light transmitted through blood, which is directly related to the hemoglobin concentration. A personal computer interfaced to the device provides a continuous on-line graphic display of the hemoglobin levels and the percentage changes in blood volume. The noninvasive measurement of dialysis blood volume changes by an optical method may be helpful in detecting the appearance of severe hypovolemia that can be dangerous in critically ill patients.     

Is the level of evidence for the use of beta-blockers in acute myocardial infarction satisfactory enough?: reply

Thanks very much for your interest in the European Society ofCardiology consensus document on beta-blockers.¹ Norwegian Timolol study, together with other early studies withbeta-blockers after an acute myocardial infarction, providedthe first convincing evidence that a drug used for cardiac diseasecould prolong life.² A large number of