José Manuel Hermosillo-Sandoval

L-alanyl-L-glutamine-supplemented parenteral nutrition decreases infectious morbidity rate in patients with severe acute pancreatitis.

BACKGROUND The effect of parenteral GLN on recovery from severe acute pancreatitis has not been thoroughly investigated. The aims of this study were to determine whether parenteral GLN improves nutrition status and immune function, and to determine its ability to reduce morbidity and mortality in patients with this condition. METHODS In a randomized clinical trial, 44 patients with severe acute pancreatitis were randomly assigned to receive either standard PN (n = 22) or l-alanyl-l-glutamine-supplemented PN (n = 22) after hospital admission. Nitrogen balance, counts of leukocytes, total lymphocytes, and CD4 and CD8 subpopulations, and serum levels of immunoglobulin A, total protein, albumin, C-reactive protein, and serum interleukin (IL)-6 and IL-10 were measured on days 0, 5, and 10. Hospital stay, infectious morbidity, and mortality were also evaluated. RESULTS Demographics, laboratory characteristics, and pancreatitis etiology and severity at entry to the study were similar between groups. The study group exhibited significant increases in serum IL-10 levels, total lymphocyte and lymphocyte subpopulation counts, and albumin serum levels. Nitrogen balance also improved to positive levels in the study group and remained negative in the control group. Infectious morbidity was more frequent in the control group than in the study group. The duration of hospital stay was similar between groups, as was mortality. CONCLUSION The results suggest that treatment of patients with GLN-supplemented PN may decrease infectious morbidity rate compared with those who treated with nonenriched PN.

Liver fibrosis secondary to bile duct injury: correlation of Smad7 with TGF-β and extracellular matrix proteins

BackgroundLiver fibrosis is the result of continuous liver injury stemming from different etiological factors. Bile duct injury induces an altered expression of TGF-β, which has an important role in liver fibrosis because this cytokine induces the expression of target genes such as collagens, PAI-1, TIMPs, and others that lead to extracellular matrix deposition. Smad7 is the principal inhibitor that regulates the target gene transcription of the TGF-β signaling. The aim of the study was to determine whether Smad7 mRNA expression correlates with the gene expression of TGF-β, Col I, Col III, Col IV, or PAI-1 in liver fibrosis secondary to bile duct injury (BDI).ResultsSerum TGF-β concentration was higher in BDI patients (39 296 pg/ml) than in liver donors (9008 pg/ml). Morphometric analysis of liver sections showed 41.85% of tissue contained fibrotic deposits in BDI patients. mRNA expression of Smad7, Col I, and PAI-1 was also significantly higher (P < 0.05) in patients with BDI than in controls. Smad7 mRNA expression correlated significantly with TGF-β concentration, Col I and Col III expression, and the amount of fibrosis.ConclusionWe found augmented serum concentration of TGF-β and an increase in the percentage of fibrotic tissue in the liver of BDI patients. Contrary to expected results, the 6-fold increase in Smad7 expression did not inhibit the expression of TGF-β, collagens, and PAI-1. We also observed greater expression of Col I and Col III mRNA in BDI patients and significant correlations between their expression and TGF-β concentration and Smad7 mRNA expression.

Impacto del manejo con cierre asistido al vacío en abscesos profundos de cuello

BACKGROUND The presence of deep neck abscesses is potentially serious; they can lead to death in a short period of time. The vacuum-assisted closure (V.A.C.) therapy has been used in many areas of surgery for complex wound healing. This treatment modality has recently been considered in the field of head and neck surgery. OBJECTIVE Evaluate the efficacy of healing therapy using V.A.C. therapy in deep neck abscesses. MATERIAL AND METHODS Open-label trial. Patients with deep neck abscesses were included using V.A.C. therapy versus conventional therapy. Cultures were taken before and during surgery, and prior to primary wound closure. The percentages of healing, viable tissue, wound healing time, and hospital stay were evaluated. RESULTS A total of 18 patients were included. Affected neck spaces: submaxilar 29%, parapharyngeal 22%, submental 21% and masticatory 13%. The final postsurgical culture was negative in 78%. Viable tissue of the wound for the V.A.C. group was 42%, and for the control group was 36% (p=0.025). Healing time was 22±6 days and 38±15.5, respectively (p = 0.01). The mean number of hospital stay was 12 days for both groups. CONCLUSIONS Therapy with V.A.C. is useful in the treatment of deep neck abscesses; it decreased healing time as a result of more viable tissue allowing suture closure of the wound in a shorter period.

Serum oxidative stress is increased in patients with post cholecystectomy bile duct injury.

Background: post-cholecystectomy bile duct injuries are iden tified by the onset of jaundice as well as elevated bilirubin and alkaline phosphatase levels during the peri-operative period. It is unknown how serum oxidative stress markers are modified in pa tients with post-cholecystectomy bile duct injuries. Objective: to determine serum oxidative stress marker levels (lipid peroxidation by-products, nitrites/nitrates and total antioxidant capacity) in patients with post-cholecystectomy bile duct in juries. Patients and methods: a prospective, transversal and ana lytical study was designed with two groups. Group 1: 5 healthy volunteer subjects. Group 2: 52 patients with post-cholecystecto my bile duct injuries (43 female and 9 male). An elective bilio-digestive reconstruction was performed at week 8. The serum ox idative stress marker levels were quantified by colorimetric method. Results: patients with bile duct injuries had a significant in creased serum lipid peroxides (malondialdehyde and 4-hydroxyalkenals) and nitric oxide metabolites (nitrites/nitrates) levels com pared to the control group. In contrast, total antioxidant capacity in patients with bile duct injuries remained similar compared to healthy controls. Conclusions: the results show that oxidative stress is usually associated to bile duct injury.

El comportamiento del factor de necrosis tumoral alfa e interleucina 6 en lesiones de vías biliares postcolecistectomía

Introduccion. La lesion de vias biliares (LVB) post colecistectomia continua siendo un problema mayor en la practica quirurgica. Cuando se presenta una lesion hepatica se activa la produccion de las citocinas de fase aguda. Los hepatocitos poseen receptores para citocinas y las celulas de Kupffer producen TNF-? e IL-6 con el proposito de fagocitar productos toxicos. Objetivo. D eterminar el comportamiento del TNF-? y la IL-6 en LVB postcolecistectomia. Pacientes y Metodos. Se realizo un estudio transversal analitico en dos grupos de estudio; Grupo 1, 5 sujetos sanos y Grupo 2, 31 pacientes con LVB postcolecistectomia abierta o laparoscopica, con obstruccion completa de la via biliar. Mediante el metodo de ELISA se cuantificaron los niveles sericos de TNF-? e IL-6 previo a la derivacion bilio-enterica y al ano de seguimiento. Resultados. El TNF-? en los sujetos sanos fue de 0.0 ng/mL, en los pacientes con LVB fue 43.8901±2.8808 ng/mL ( p 0.0001 U de Mann-Whitney bilateral). Al ano los niveles se negativizaron. Los niveles de IL-6 en los sujetos sanos fue 3.033±1.990 pg/mL y en LVB 71.973±94.691 pg/mL, ( p 0.004 U de Mann-Whitney bilateral), 23 veces mas expresion. Al ano disminuyo a 6.4463±0.2651 pg/mL. Conclusion. Previo a la derivacion bilio-enterica los niveles de TNF-? e IL-6 estuvieron significativamente sobre expresados, a l ano la expresion de las dos citocinas disminuyo a niveles cercanos a lo normal. Consideramos que la cuantificacion periodica de los niveles de TNF-? y/o IL-6 seria de utilidad en la deteccion de complicaciones inflamatorias en los pacientes con LVB postcolecistectomia

Angiosarcoma hepático y trasplante hepático: reporte de caso y revisión de bibliografía

BACKGROUND Hepatic angiosarcoma is a rare vascular malignancy that accounts for 2% of all hepatic primary tumours. The diagnosis is difficult, especially if the patient does not have history of exposure to carcinogens, which are considered as risk factors. The diagnosis is made by histopathology, but in a considerable percentage it can only be accomplished by autopsy. The performing of fine needle aspiration biopsy can lead to bleeding, with limitations in its use. CLINICAL CASE A 41 year-old male, with no history of exposure to carcinogens, who developed abdominal pain secondary to a haemoperitoneum due to tumour rupture, was diagnosed by imaging methods with a giant cavernous hepatic haemangioma. He was initially treated with embolisation, and later with a liver transplant. After six months he developed haemoptysis secondary to lung metastasis. The autopsy reported metastatic hepatic angiosarcoma. DISCUSSION This condition has been related to carcinogen exposure, with malignant transformation from a benign vascular neoplasia being proposed as a hypothesis. The differential diagnosis can be achieved with imaging studies such as CT scan, and the definitive diagnosis is made by histopathology with immunohistochemistry tests, with 35%-100% being made in the autopsy. CONCLUSION Hepatic angiosarcoma is a malignant vascular neoplasia, the potential curative option is surgery with tumour free margins. Liver transplantation remains controversial because of its poor prognosis in the short term.

Toll-Like Receptor-1 and Receptor-2 and Beta-Defensin in Postcholecystectomy Bile Duct Injury

Postcholecystectomy bile duct injuries (BDI) produce hepatic cholestasis and cause infection of the biliary tract. The biliary cells participate in secreting cytokines and in expression of immune response receptors. Toll-like receptors (TLRs) conduct signalling and activate the innate and adaptive inflammatory response. The objective was to determine the serum levels of TLR-2 and the expression of TLR-1 and TLR-2 and β-defensin in liver biopsies of postcholecystectomy BDI patients. A transverse, analytical study with 2 groups was done. One group included healthy volunteers (control group) and other included 25 postcholecystectomy BDI patients with complete biliary obstruction. Using the Enzyme-linked Immunosorbent Assay (ELISA) technique, serum levels of TLR-2 were determined, and with immunofluorescence the morphologic analysis of TLR-1 and TLR-2 and β-defensin in liver biopsies of postcholecystectomy BDI patients was performed. The average TLR-2 serum level in the control group was 0.0 pg/mL and in the BDI group, 0.023 ± 0.0045 pg/mL (P < 0.0001, bilateral Mann Whitney U). Immunofluorescence was used to determine the expression in liver biopsies, blood vessels, bile ducts, and hepatic parenchyma where 12 hepatic biopsies were positive for TLR-1 with average of 3213057.74 ± 1071019.25 μm2; and 7 biopsies were positive for β-defensin with an average of 730364.33 ± 210838.02 μm2; and 6 biopsies positive for TLR-2, obtaining an average of 3354364.24 ± 838591.06 μm2. In conclusion, TLR-1 and TLR-2 and β-defensin play an important role in the innate antimicrobial defense of the hepatobiliary system.