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Steatosis predicts postoperative morbidity following hepatic resection for colorectal metastasis

The Transplantation Unit of Leeds Hospita, England published a very interesting article in November’s issue of BJS, regarding the importance of steatosis and liver surgery.

They reviewed patients undergoing resection for CRLM from January 2000 to September 2005 identified from a hepatobiliary database. Data analysed included laboratory measurements, extent of hepatic resection, blood transfusion requirements and steatosis.

There were 386 patients with a median age of 66 (range 32–87) years, of whom 201 had at least one co-morbid condition and 194 had an American Society of Anesthesiologists grade of I. Anatomical resection was performed in 279 patients and non-anatomical resection in 107; 165 had additional procedures. Steatosis in 194 patients was classified as mild in 122, moderate in 60 and severe in 12. The overall morbidity rate was 36 per cent (139 patients) and the mortality rate was 1·8 per cent (seven patients). Admission to the intensive care unit, morbidity, infective complications and biochemical profile changes were associated with greater severity of steatosis. Independent predictors of morbidity were steatosis, extent of hepatic resection and blood transfusion.

Molecular Physiopathology of Cholestasis

Cholestasis is the result of a diminution of biliary secretion to the intestine. Biliary secretion is carried out through transporters located in the hepatocytes and cholangiocytes (N Engl J Med 1998; 339: 1217-1227).

A cholestatic syndrome may overcome after a mechanical obstruction of the common bile duct or secondary to biliary tree diseases or hepatocyte diseases (genetic diseases, infectious, autoimmune, metabolic, neoplastic, or toxins).

The consecuences of this syndrome are related to biliary acid toxicity that accumulates in the liver and body, or to their absence in the digestive tube, interrupting the enterohepatic cycle.

Biliary Secretion

The bile produced by the hepatocyte inside the canalicular duct, enters the bile ducts, then to the larger bile ducts until it reaches the duodenum. The biliary canalicular duct is the smallest structure in the biliary tree, it’s wall is constituted by the heaptocyte’s canalicular membrane. On this membrane there are transport proteins that allow the transport of osmotically active substances against a concentration gradient in the hepatocyte towards the bile duct.

Bile formation by the hepatocytes is done by a difference in osmotic pressures, which appears from the bile acid concentration inside the bile ducts and from other substances such as gluthathion. Water and electrolyte movements occur esentially through a paracellular mechanism, through intercellular junctions.

Bile acids, phospholipids, and cholesterol, all associate inside the bile under the form of mixed mycelles. Maintenance of the hepatocytes’s polarity (canalicular membrane and basolateral membrane) is esential for biliary secretion.

Endoscopic treatment of post-surgical bile duct injuries

The Department of Gastroenterology at the Amsterdam Medical Center published in November’s issue of Gut a very insightful article regarding bile duct injuries.

Their goal was to analyse the short and long term outcome of endoscopic stent treatment after bile duct injury (BDI), and to determine the effect of multiple stent treatment.

They performed a retrospective cohort study in a tertiary referral centre to analyse the outcome of endoscopic stenting in 67 patients with cystic duct leakage, 26 patients with common bile duct leakage and 110 patients with a bile duct stricture.

Virchow’s Node

Gastric Cancer is very prevalent in Costa Rica, and because of the rarity of finding a nodule as big as this one, I thought this could serve as an example for semiological studies. This case was published in this month’s issue of The Lancet.

The case is about a 70-year-old man presented to his primary care physician with postprandial epigastric pain. He was prescribed antacids, which were ineff ective; his weight then decreased by 11 kg in 3 months. Oesophagogastro duodenoscopy showed a mass in the antrum; histo pathological analysis of a biopsy sample established that the mass was a signet-ring adenocarcinoma. Even before the biopsy was analysed, examination of the neck supported the diagnosis of cancer: the left supraclavicular lymph node was firm and enlarged. The left supraclavicular lymph node is near the junction of the thoracic duct and the left subclavian vein, where the lymph from much of the body drains into the systemic circulation.