Evolución natural de la fístula biliar externa post cirugía del quiste hidatídico hepático / External biliary fistula after surgery for hydatid cyst: retrospective analysis of 58 patients

Background: External biliary fistula is the most common complication of surgery for liver hydatid cysts. Aim: To report the experience with the conservative management of external biliary fistula. Material and Methods: Retrospective analysis of medical records of patients operated for hydatid cysts, complicated with external biliary fistula, between 1985 and 2004. Results: In the study period, 554 patients were operated for liver hydatid cysts and in 58 (10.5 percent), an external biliary fistula appeared. In 90 percent of these patients, cysts were located in the right lobe and 30 percent were multiple cysts. Seventy seven percent of cysts were multivesicular, 10 percent were infected and 52 percent had a concealed cysto-biliary rupture. In 84 percent of patients, a conservative surgical approach such as marsupialization and partial excision of the peri cystic region was used. Mean hospital stay of these patients was 36.8 days, compared with 11.4 days among patients without fistulae. Conclusions: Among patients that require surgery for hydatid cysts, risk factors for biliary fistula should be sought and conservative surgical approaches should be avoided whenever possible.

La fístula biliar externa (FBE) es la complicación más frecuente en la cirugía del quiste hidatídico hepático (QHH). En esta oportunidad se quiere dar a conocer la experiencia en el manejo conservador de la fístula biliar secundaria a la cirugía del QHH. Se revisa en forma retrospectiva los registros clínicos de 554 pacientes tratados por hidatidosis hepática, desde enero 1985 a diciembre de 2004, en el Servicio de Cirugía del Hospital Regional de Coyhaique. De acuerdo a los hallazgos clínicos preoperatorios, estudio de imágenes, hallazgos operatorios y seguimiento de los pacientes, se encontraron 58 pacientes (10,5 por ciento) portadores de fístula biliar postoperatoria. En los 554 pacientes tratados durante este período, se encontró 91 con filtración biliar (16,4 por ciento) y en 58 (10,5 por ciento) se constató la presencia de FBE. Los hallazgos anatomopatológicos indicaron que el 76,6 por ciento de los quistes eran multivesiculares, que sólo el 10 por ciento estaba infectado y que la ruptura cistobiliar oculta estaba presente en el 51,7 por ciento de los casos. Las técnicas quirúrgicas conservadoras fueron las más utilizadas. El promedio de estadía de los pacientes con fístula biliar fue de 36,8 días y de 11,4 en aquellos que no la presentaban. Es importante en el preoperatorio pesquisar los factores predictores de una probable ruptura franca, ser acuciosos en la pesquisa de las comunicaciones cistobiliares ocultas y tratar de evitar, dentro de lo posible, la realización de técnicas quirúrgicas conservadoras. Todo lo anterior disminuirá la frecuencia de la FBE, cuya evolución natural aumenta en más de tres veces la estadía postoperatoria.

Endocarditis de válvula aórtica nativa y absceso septal por un bacilo gram negativo: capnocytiphaga sputigena / Native aortic valve endocarditis and septal abscess by a gram negative bacilli: capnocytophaga sputigena

A male patient aged 32 developed infectious endocarditis on a congenital (and repaired) stenotic aortic valve defect. He presented with prolonged fever and wasting symptoms and also referred recurrent gingivitis. At admission, fever, systolic and diastolic aortic murmurs, and periodontitis were registered. Ultrasound imaging showed aortic vegetations reaching a maximal diameter of 49 mm and a severe aortic stenosis and insufficiency. Patient received treatment with vancomycin and gentamycin due to penicillin allergy but developed a progressive non-oliguric acute renal failure. Blood cultures revealed bacilli of uncertain gram stain that were recognized as gram negative bacilli and identified as Capnocytophaga sputigena at the National Reference Laboratory. Patient remained stable but murmurs increased and new imaging studies revealed the development of a unique septal abscess despite antibiotic therapy with intravenous ciprofloxacin. Intraoperative finding showed a perforated aortic coronary leaflet