Las hepatectomías mayores en pacientes con colangiocarcinoma e ictericia son seguras

Background

Surgical resection is the only possibility of long term survival in patients with Klatskin tumours. However, surgical resection is a challenging problem and hepatic resection is often necessary.

Objective

The aim of our study was to assess the need for biliary drainage, resection rate and outcome of hilar cholangiocarcinoma in a single tertiary referral centre.

Patients and methods

From 2005 to 2008, 26 patients with Klatskin tumours were identified and assessed prospectively with multidetector CT and MR cholangiography in special cases. Seven patients (27%) were deemed to be unresectable in pre-operative staging. A total of 19 surgical procedures were performed, 8 left hepatectomies, 5 right hepatectomies and 6 resections exclusively of the biliary tree.

Results

Resection rate was 73%, transfusion rate 53% and preoperative biliary drainage was performed only in 7 cases (37%). Major complications occurred in 11 (58%), including two post-operative deaths (10%).There were no differences in the epidemiological data, when we separately analysed the outcomes of the 9 patients with bilirubin <15 mg/dL and the 10 patients with bilirubin >15 mg/dL. Biliary drainage was required in 6 (67%) patients in the group with low bilirubin levels vs. 1(10%) in the other group (P=0.02). The mean bilirubin level in the jaundiced group was 22.1±3.9 vs. 4.7±4.3 (P<0.001) in the other group. There were no differences in the postoperative outcome between both groups.

Conclusion

Resection and survival rates have increased recently but still carries the risk of significant morbidity and mortality. Major hepatectomies in selected patients without percutaneous biliary drainage are safe.     

Platelet function profiles in patients with type 2 diabetes and coronary artery disease on combined aspirin and clopidogrel treatment

To assess platelet function profiles in diabetic and nondiabetic patients on aspirin and clopidogrel therapy, two patient populations were included to investigate the 1) acute effects of a 300-mg clopidogrel loading dose (group 1, n = 52) and 2) long-term effects of clopidogrel (group 2, n = 120) on platelet function in diabetic compared with nondiabetic patients already on aspirin treatment. Patients were stratified according to the presence of type 2 diabetes. Platelet aggregation was assessed using light transmittance aggregometry (groups 1 and 2). Platelet activation (P-selectin expression and PAC-1 binding) was determined using whole-blood flow cytometry (group 2). Clopidogrel response was also assessed. In group 1, platelet aggregation was significantly increased in diabetic (n = 16) compared with nondiabetic (n = 36) patients at baseline and up to 24 h following a 300-mg loading dose (P = 0.005). In group 2, platelet aggregation and activation were increased in diabetic (n = 60) compared with nondiabetic (n = 60) subjects (P < 0.05 for all platelet function assays). Diabetic subjects had a higher number of clopidogrel nonresponders (P = 0.04). Diabetic patients have increased platelet reactivity compared with nondiabetic subjects on combined aspirin and clopidogrel treatment. Reduced sensitivity to antiplatelet drugs may contribute to the increased atherothombotic risk in diabetic patients.     

A comparative study of resource use and costs of renal, liver and heart transplantation

Organ transplantations are among the most expensive surgical treatments performed today, but estimates of the costs of organ transplantations vary widely between settings. The aim of this study is to estimate the costs of renal, liver and heart transplantation in a university hospital, adopting a similar costing methodology for all the three kinds of transplantation. Resource use data were collected from 803 patients transplanted between January 1995 and August 2001. Data about the time physicians and other hospital employees spent per transplantation were based on interviews. All costs from pretransplantation screening up to 3 years post-transplantation were taken into account and divided into costs of patient care and programme-related costs. Mean cost of renal transplantation varied from 70,723 Euros for cadaveric donor transplantations to 76,577 Euros for living donor transplantations. Mean costs of liver transplantation were 141,510 Euros and the mean costs of heart transplantation were 17, 828 Euros. Direct costs of patient care contributed to 79%, 87% and 92% of the costs of renal, liver and heart transplantation respectively. Inpatient hospital days were the largest contributor to the costs of patient care. The mean number of inpatient hospital days from pretransplantation screening to 3 years post-transplantation varied from 46 days for renal transplantation from a living donor to 58 days for renal transplantation from cadaveric donors, 83 days for heart transplantation and 108 days for liver transplantation. In conclusion, costs of liver and heart transplantation were approximately 2.0 and 2.5 times higher than the cost of renal transplantation. Length of inpatient hospital stay for transplantation did not change substantially over time between 1995 and 2001.     

Patient survival characteristics after routine mitral valve repair for ischemic mitral regurgitation

BACKGROUND: Ischemic mitral regurgitation has been associated with diminished survival compared with nonischemic mitral regurgitation. Conversion from mitral valve replacement to valve repair has improved prognosis, but it is unclear whether ischemic mitral regurgitation remains an independent predictor of outcome after mitral valve repair. METHODS: Five hundred thirty-five patients undergoing mitral valve repair (primarily rigid ring annuloplasty) with or without coronary bypass from 1993 through 2002 were reviewed retrospectively (ischemic mitral regurgitation, n = 141; nonischemic mitral regurgitation, n = 394). A Cox proportional hazards model evaluated survival as a function of 9 simultaneous covariates: ischemic versus nonischemic mitral regurgitation, age, sex, number of medical comorbidities, ejection fraction, New York Heart Association class, coronary disease, reoperation, and year of operation. RESULTS: According to univariable analysis, patients with ischemic mitral regurgitation had greater age, higher comorbidity, lower ejection fraction, higher New York Heart Association, and higher reoperation rate (all P < .001) compared with those having nonischemic mitral regurgitation. Univariable 30-day mortality was as follows: 4.3% for patients with ischemic mitral regurgitation versus 1.3% for patients with nonischemic mitral regurgitation (P = .01). Unadjusted 5-year mortality was as follows: 44% +/- 5% for patients with ischemic mitral regurgitation versus 16% +/- 3% for patients with nonischemic mitral regurgitation (P < .001). In the multivariable model, however, only the number of preoperative comorbidities and advanced age were independent predictors of survival (P < .0001), whereas ischemic mitral regurgitation, sex, ejection fraction, New York Heart Association class, coronary disease, reoperation, and year of operation did not achieve significance (all P > .19). After being adjusted for differences in all preoperative risk factors, survival was not statistically different between ischemic mitral regurgitation and nonischemic mitral regurgitation (P = .33). CONCLUSIONS: With routine application of rigid ring annuloplasty, long-term patient survival is more influenced by baseline patient characteristics and comorbidity than by ischemic cause of mitral regurgitation per se. Future risk assessment and decision making should be based on patient condition and should not be biased by ischemic cause of mitral regurgitation.     

Computer-based test to measure optimal visual acuity in age-related macular degeneration

PURPOSE: The authors present a computer-based method for evaluating the visual acuity of patients with age-related macular degeneration (AMD). It incorporates four features known to improve visual acuity: high contrast, white optotypes on a black background to reduce intraocular scatter, proportional layout to reduce the effects of crowding, and multiple optotypes to minimize the effects of fixation instability and to maximize the likelihood of optotype detection. METHODS: Experiment 1 evaluated the best-eye acuity of 24 patients with AMD using the ETDRS chart and three versions of the Tumbling E acuity test: multiple black optotypes on a white background, single white optotype on a black background, and multiple white optotypes on a black background. Experiment 2 compared the two White E optotype tests with the ETDRS in patients with AMD, and Experiment 3 measured probability summation in persons with normal vision. RESULTS: Multiple white optotypes on a black background yielded the highest acuity estimates and the ETDRS the lowest. The Single E test yielded a lower estimate of acuity than the two Multiple E tests. The effect of polarity-white on black was better than black on white-was consistent with results found in persons with healthy retinas. For patients with AMD, acuity measured with the Multiple E test was independent of that measured with the ETDRS, but acuity measured with the Single E test decreased as acuity worsened. For the participants with normal vision, the differences between the Multiple and Single E tests were within the known limits of test-retest variability. CONCLUSIONS: The multiple-optotype, reversed-polarity test provides a measure of the optimal visual acuity of which a person is capable and, in this sense, may be a useful tool for assessing rehabilitation progress.     

Estimation of intraocular pressure in rabbits with commonly used tonometers.

BACKGROUND AND OBJECTIVES: To validate accuracy and reproducibility of the Perkins tonometer, pneumatonometer, and Tono-Pen XL (Medtronic Solan, Jacksonville, FL) in estimating intraocular pressure (IOP) in rabbits. MATERIALS AND METHODS: IOP was increased from 5 to 50 mm Hg in 5-mm increments. Measurements were compared to readings of two digital manometers simultaneously measuring real IOP in the anterior chamber and vitreous cavity. Interobserver accuracy was evaluated using 4 eyes with the Perkins tonometer. RESULTS: The Perkins tonometer and Tono-Pen XL underestimated IOP and were more accurate at pressures less than 30 mm Hg. No statistically significant difference was found between real IOP and Tono-Pen XL readings. The pneumatonometer overestimated pressures in the low ranges but was accurate at pressures greater than 40 mm Hg. The Tono-Pen XL had more variability than the Perkins tonometer and pneumatonometer at high IOP. CONCLUSIONS: None of the tonometers are accurate or reproducible in estimating IOP in rabbits over the tested range. Pneumatonometry, although not very accurate, has the advantage of having acceptable variability.     

A novel isoform of acetylcholinesterase exacerbates photoreceptors death after photic stress

PURPOSE: To study the involvement of stress-induced acetylcholinesterase (AChE) expression in light-induced retinal damage in albino rats. METHODS: Adult albino rats were exposed for 24 hours to bright, damaging light. AChE expression was monitored by in situ hybridization, by histochemistry for AChE activity, and by immunocytochemistry. An orphan antisense agent (Monarsen; Ester Neurosciences, Ltd., Herzlia Pituach, Israel) was administered intraperitoneally to minimize light-induced AChE expression. The electroretinogram (ERG) was recorded to assess retinal function. RESULTS: Twenty-four-hour exposure to bright light caused severe reduction in the ERG responses and augmented expression of mRNA for the "read-through" variant of AChE (AChE-R) in photoreceptor inner segments (IS), bipolar cells, and ganglion cells. AChE activity increased in IS. The expressed AChE protein was a novel variant, characterized by an extended N terminus (N-AChE). Systemic administration of the orphan antisense agent, Monarsen, reduced the photic induction of mRNA for AChE-R, and of the N-AChE protein. Rats exposed to bright, damaging light and treated daily with Monarsen exhibited larger ERG responses, relatively thicker outer nuclear layer (ONL), and more ONL nuclei than did rats exposed to the same damaging light but treated daily with saline. CONCLUSIONS: The findings indicate that the photic-induced novel variant of AChE (N-AChE-R) may be causally involved with retinal light damage and suggest the use of RNA targeting for limiting such damage.