Colecistectomía con exploración de vías biliares laparoscópica en paciente con situs inversus totalis

Se presenta el caso de un paciente varón de 77 años con diagnóstico de colecistitis crónica calculosa y coledocolitiasis, con antecedente de situs inversus totalis. Se le realizó una colecistectomía con exploración de vías biliares laparoscópica, utilizando la "técnica francesa en espejo", con extracción de los cálculos. El paciente evolucionó favorablemente. El objetivo del presente trabajo es dar a conocer el caso clínico que es poco frecuente su reporte en la literatura mundial (solo 9 casos). Su importancia radica en que sería el primer reporte de caso clínico publicado de una colecistectomía y exploración de vías biliares laparoscópica con retiro del cálculo en colédoco en un paciente con situs inversus totalis, realizado en el Perú.

We present the case of a 77-year-old male patient with a diagnosis of chronic calculous cholecystitis and choledocholithiasis, with a history of situs inversus totalis. Therefore, a laparoscopic cholecystectomy with common bile duct exploration were performed, using the "french mirror technique", with stone extraction. Patient evolved favorably. The aim of this study is to present this clinical case that is rarely reported in the world literature (only 9 cases). Its importance lies in the fact that it would be the first published clinical case report of a laparoscopic cholecystectomy and bile duct exploration with removal of the common bile duct stones in a patient with situs inversus totalis, performed in Peru.

Íleo biliar: descripción de dos casos / Gallstone ileus: Description of two cases

Introducción. El íleo biliar es una complicación rara de la colelitiasis y su incidencia varía del 1 al 4 %. Consiste en la migración de un cálculo de la vesicular biliar al tracto gastrointestinal, generando obstrucción intestinal. Presenta síntomas inespecíficos dependiendo del nivel de la obstrucción, lo que hace que su diagnóstico no suela ser precoz, repercutiendo en el deterioro clínico del paciente. Es especialmente grave en pacientes de edad avanzada y con comorbilidades. Casos clínicos. Se reportan los casos de dos pacientes con dolor abdominal difuso, en quienes se diagnosticó íleo biliar por tomografía. Se realizó manejo quirúrgico, el primero mediante técnica abierta y estrategia de dos pasos, y el otro mediante técnica laparoscópica. Discusión. El íleo biliar es una etiología rara de obstrucción intestinal. El cálculo migra debido a una fistula colecisto-entérica y el nivel de obstrucción es con mayor frecuencia la válvula ileocecal. Los síntomas son inespecíficos y dependen del nivel de obstrucción: dolor abdominal difuso mal caracterizado, náuseas, vómito, ausencia de flatos. El diagnóstico se hace mediante tomografía abdominal, en la cual se evidencia la tríada de Rigler. El manejo es quirúrgico, con enterotomía para extraer el cálculo y resolver la obstrucción. Conclusión. El íleo biliar es una patología que debe ser considerada en el abordaje de la obstrucción intestinal, aunque sea poco frecuente. El manejo quirúrgico es clave para resolver el cuadro de obstrucción intestinal; aún así genera importante morbimortalidad en especial en pacientes de avanzada edad.

Introduction. Gallstone ileus is a rare complication of cholelithiasis, its incidence varies from 1% to 4%. It consists of the migration of a stone from the gallbladder to the gastrointestinal tract, causing intestinal obstruction. It presents with non-specific symptoms depending on the level of the obstruction, which means that its diagnosis is not usually early, with repercussions on the clinical deterioration of the patient, being serious especially in elderly patients and with comorbidities. Clinical cases. Two patients with diffuse abdominal pain are reported. A tomographic diagnosis was made showing gallstone ileus. Surgeries were performed, in the first case using an open technique and a 2-step strategy, and on the second one using a laparoscopic technique. Discussion. Gallstone ileus is a rare etiology of intestinal obstruction. Symptoms are usually poorly characterized: diffuse abdominal pain, nausea, vomiting, absence of flatus. The diagnosis is made by abdominal tomography in which Rigler's triad is evident. Management is surgical through enterotomy to remove the stone and resolve the obstruction. Conclusion. Gallstone ileus is a rare pathology that should be considered in the approach to intestinal obstruction. Surgical management is key to resolving intestinal obstruction. Even so, it generates significant morbidity and mortality, especially in elderly patients.

Factores asociados con la conversión a técnica abierta en la colecistectomía laparoscópica / Factors associated with conversion to open technique in laparoscopic cholecystectomy

Introducción. La colecistectomía laparoscópica es el estándar de oro para el manejo de la patología de la vesícula biliar con indicación quirúrgica. Durante su ejecución existe un grupo de pacientes que podrían requerir conversión a técnica abierta. Este estudio evaluó factores perioperatorios asociados a la conversión en la Clínica Central OHL en Montería, Colombia. Métodos. Estudio observacional analítico de casos y controles anidado a una cohorte retrospectiva entre 2018 y 2021, en una relación de 1:3 casos/controles, nivel de confianza 95 % y una potencia del 90 %. Se caracterizó la población de estudio y se evaluaron las asociaciones según la naturaleza de las variables, luego por análisis bivariado y multivariado se estimaron los OR, con sus IC95%, considerando significativo un valor de p<0,05, controlando variables de confusión. Resultados. El estudio incluyó 332 pacientes, 83 casos y 249 controles, mostrando en el modelo multivariado que las variables más fuertemente asociadas con la conversión fueron: la experiencia del cirujano (p=0,001), la obesidad (p=0,036), engrosamiento de la pared de la vesícula biliar en la ecografía (p=0,011) y un mayor puntaje en la clasificación de Parkland (p<0,001). Conclusión. La identificación temprana y análisis individual de los factores perioperatorios de riesgo a conversión en la planeación de la colecistectomía laparoscópica podría definir qué pacientes se encuentran expuestos y cuáles podrían beneficiarse de un abordaje mínimamente invasivo, en búsqueda de toma de decisiones adecuadas, seguras y costo-efectivas

Introduction. Laparoscopic cholecystectomy is the gold standard for the management of gallbladder pathology with surgical indication. During its execution, there is a group of patients who may require conversion to the open technique. This study evaluated perioperative factors associated with conversion at the OHL Central Clinic in Montería, Colombia. Methods. Observational analytical case-control study nested in a retrospective cohort between 2018 and 2021, in a 1:3 case/control ratio, 95% confidence level and 90% power. The study population was characterized and the associations were evaluated according to the nature of the variables, then the OR were estimated by bivariate and multivariate analysis, with their 95% CI, considering a value of p<0.05 significant, controlling for confounding variables. Results. The study included 332 patients, 83 cases and 249 controls, showing in the multivariate model that the variables most strongly associated with conversion were: the surgeon's experience (p=0.001), obesity (p=0.036), gallbladder wall thickening on ultrasonography (p=0.011), and a higher score in the Parkland classification (p<0.001). Conclusions. Early identification and individual analysis of the perioperative risk factors for conversion in the planning of laparoscopic cholecystectomy could define which patients are exposed, and which could benefit from a minimally invasive approach, in search of making safe, cost-effective, and appropriate decisions

Unusually large number of gall stones removed through laparoscopic cholecystectomy from a single patient- A case report

Gallstone disease is characterized by the formation of calculi in the gall bladder or the biliary tract. It may be asymptomatic or present as biliary colic or with complicated disease. Laparoscopic cholecystectomy is the mainstay of treatment for symptomatic gall stones. We describe a case of Gallstone disease in a 43-year-old female, where over seven thousand stones were removed through a Laparoscopic procedure. This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Colecistectomía laparoscópica en una paciente con situs inversus totalis. Reporte de un caso y revisión de la literatura

Introducción: El situs inversus totalis es una condición congénita en la cual los órganos torácicos y abdominales se encuentran en posición contraria a la posición habitual. En la literatura quirúrgica internacional se encuentran publicados no más de 55 casos de colecistectomía en pacientes con situs inversus totalis. La resolución laparoscópica de una paciente en nuestra Institución nos permite revisar esta particular condición patológica. Caso Clínico: Paciente femenino de 43 años de edad hospitalizada por una colecistitis aguda la cual es resuelta por vía laparoscópica sin incidentes. Material y Método: Se resume la literatura actual mediante una extensa revisión en PubMed de los reportes más relevantes. Considerando que todos los artículos publicados son casos clínicos o pequeñas series de casos, se presentan los resultados de esta revisión en tablas con estadística descriptiva básica. Discusión: Se discuten las características generales de estos pacientes, la presentación clínica, diagnóstico y técnica quirúrgica. Conclusión: La colecistectomía laparoscópica constituye el estándar de oro en pacientes con situs inversus y patología biliar, la cual debe ser realizada por un cirujano experimentado acomodando los trocares apropiadamente, debido a las dificultades técnicas que se encuentran en estos pacientes por las anomalías anatómicas propias de esta condición. El diagnóstico radiológico actual permite la planificación del abordaje y del procedimiento quirúrgico apropiado para cada paciente.

Introduction: Situs inversus totalis is a congenital condition in which the thoracic and abdominal organs are in the opposite position from normal anatomy. We found no more than 55 cases of cholecystectomy in patients with situs inversus totalis published in the international surgical literature. The laparoscopic resolution of a patient in our Institution allows us to review this particular pathological condition. Clinical Case: A 43-year-old female patient was admitted for acute cholecystitis and was resolved laparoscopically without any incidents. Material and Method: We summarized the current literature through an extensive PubMed review of the most relevant reports. Considering that all published articles are clinical cases or small case series, we present the results of this review in a table with basic descriptive statistics. Discussion: We discuss the general characteristics of these patients, clinical presentation, diagnosis, and surgical technique. Conclusions: Laparoscopic cholecystectomy is the gold standard in patients with situs inversus and biliary pathology, which must be performed by an experienced surgeon, properly accommodating the trocars due to the technical difficulties in these patients secondary to anatomical anomalies typical of this condition. Current radiological diagnosis allows planning the appropriate approach and surgical procedure for each patient.

Helicobacter pylori e as doenças hepatobiliares: atualização 2023 / Helicobacter and hepatobiliary diseases: update 2023

ABSTRACT Helicobacter Pylori (H. pylori) is one of the main infectious causes of gastroduodenal diseases, however, its role in developing different extragastric diseases has been proven. The possible involvement of H. pylori in the pathogenesis of cardiovascular, metabolic, neurodegenerative, skin, and hepatobiliary diseases is suggested. The bacterium has been found in tissue samples from the liver, biliary tract, and gallstones of animals and humans. However, the role of H. pylori infection in the pathogenesis of liver and biliary diseases has not been finally established. The histopathological confirmation of the positive effect of H. pylori eradication is needed. In addition, there are discussions on the clinical significance of other Helicobacter species. The review presents the data available for and against the involvement of H. pylori in hepatobi­liary disease development and progression.

RESUMO Helicobacter pylori (H. pylori) é uma das principais causas infecciosas de doenças gastroduodenais, no entanto, seu papel no desenvolvimento de diferentes doenças extragástricas tem sido comprovado. Sugere-se o possível envolvimento do H. pylori na patogênese de doenças cardiovasculares, metabólicas, neurodegenerativas, cutâneas e hepatobiliares. A bactéria tem sido encontrada em amostras de tecido do fígado, trato biliar e cálculos biliares de animais e humanos. No entanto, o papel da infecção por H. pylori na patogênese de doenças do fígado e das vias biliares ainda não foi estabelecido definitivamente. A confirmação histopatológica do efeito positivo da erradicação do H. pylori é necessária. Além disso, existem discussões sobre a importância clínica de outras espécies de Helicobacter. A revisão apresenta os dados disponíveis a favor e contra o envolvimento do H. pylori no desenvolvimento e progressão das doenças hepatobiliares.

Íleo biliar, causa no habitual de oclusión intestinal

El íleo biliar es una rara complicación de la litiasis vesicular, que se comporta como un cuadro de obstrucción intestinal mecánica, cuya causa es la impactación de uno o más cálculos biliares en su luz. Es evidente que, por lo infrecuente de esta entidad en los servicios quirúrgicos, el diagnóstico de la misma es demorado o no se realiza, incidiendo en la evolución del paciente de manera desfavorable. El objetivo de este trabajo es considerar que un diagnóstico precoz del íleo biliar -basado en el análisis de los antecedentes del enfermo, las manifestaciones clínicas y la interpretación correcta en busca de los signos de la tríada de Rigler- permite una mejor evolución de los pacientes. Los estudios imagenológicos y su interpretación son fundamentales en el diagnóstico de esta entidad.

Biliary ileus is a rare complication of gallbladder lithiasis, which behaves like a mechanic intestinal obstruction, the cause of which is the impaction of one or more gallstones in its lumen. It is evident that because of the infrequency of this entity in the surgical services, its diagnosis is delayed or not carried out, affecting the patient's evolution in an unfavorable way. The aim of this paper is to consider that a precocious diagnosis of biliary ileus-based on the analysis of the patient's history, the clinical manifestations and correct interpretation in search of the signs of Rigler's triad-allows a better evolution of patients. Imaging studies and their interpretation are fundamental in the diagnosis of this entity.

Duración de la antibioticoterapia en pacientes con colecistitis aguda manejados con colecistostomía. ¿Afecta los desenlaces clínicos? / Duration of antibiotic therapy in patients with acute cholecystitis managed with cholecystostomy. Does it affect clinical outcomes?

Introducción. En pacientes con diagnóstico de colecistitis aguda tratados con colecistostomía, el tiempo óptimo de duración de la terapia antibiótica es desconocido. El objetivo de este trabajo fue comparar los resultados clínicos en pacientes con diagnóstico de colecistitis aguda manejados inicialmente con colecistostomía y que recibieron cursos cortos de antibióticos (7 días o menos) versus cursos largos (más de 7 días). Métodos. Se llevó a cabo un estudio de cohorte observacional, retrospectivo, que incluyó pacientes con diagnóstico de colecistitis aguda manejados con colecistostomía, que recibieron tratamiento antibiótico. Se hizo un análisis univariado y de regresión logística para evaluar la asociación de variables clínicas con la duración del tratamiento antibiótico. El desenlace primario por evaluar fue la mortalidad a 30 días. Resultados. Se incluyeron 72 pacientes. El 25 % (n=18) recibieron terapia antibiótica por 7 días o menos y el 75 % (n=54) recibieron más de 7 días. No hubo diferencias significativas en la mortalidad a 30 días entre los dos grupos ni en las demás variables estudiadas. La duración de la antibioticoterapia no influyó en la mortalidad a 30 días (OR 0,956; IC95% 0,797 - 1,146). Conclusión. No hay diferencias significativas en los desenlaces clínicos de los pacientes con colecistitis aguda que son sometidos a colecistostomía y que reciben cursos cortos de antibióticos en comparación con cursos largos

Introduction.In patients with acute cholecystitis who receive treatment with cholecystostomy, the optimal duration of antibiotic therapy is unknown. The objective of this study is to compare short courses of antibiotics (7 days or less) with long courses (more than 7 days) in this population. Methods. We performed a retrospective observational cohort study which included patients diagnosed with acute cholecystitis, who received antibiotic therapy and were taken to cholecystostomy. Univariate analysis and logistic regression were performed to evaluate the association between clinical variables and the duration. The main outcome evaluated was 30-day mortality. Results. Seventy-two patients were included, 25% (n=18) were given 7 or fewer days of antibiotics while 75% (n=54) were given them for more than 7 days. Demographic data between both groups were similar (age, severity of cholecystitis, comorbidities). There were no significant differences in 30-day mortality between both groups. Antibiotic duration did not influence mortality at 30 days (OR 0.956, 95% CI 0.797 - 1.146). Conclusion. There are no significant differences in the clinical outcomes of patients with acute cholecystitis who undergo cholecystostomy and receive short courses of antibiotics compared to long courses

Presiones de la vía biliar en pacientes con y sin colelitiasis

Introducción: El reflujo de enzimas pancreáticas hacia la vía biliar extra-hepática y la vesícula biliar es un fenómeno anormal que tiene un rol en la litogénesis y carcinogénesis. Debido a que la presión de la vía biliar depende entre otros factores, de las presiones del esfínter de Oddi. La disfunción de éste se vería reflejada en presiones elevadas de la vía biliar en pacientes con colelitiasis. Objetivo: El objetivo de este estudio es el de medir las presiones de la vía biliar extra-hepática en pacientes con y sin colelitiasis y relacionarlas con la presencia de reflujo pancreáticobiliar. Material y Método: Se diseñó un estudio pros-pectivo de casos y controles. La muestra está constituida por todos los pacientes operados con gastrectomía total por cáncer gástrico estadios I y II durante 30 meses. La medida de resultado primaria fue establecer diferencias en las presiones de la vía biliar entre pacientes con y sin colelitiasis. Resultados: Las presiones de la vía biliar extra-hepática en pacientes con colelitiasis fueron más elevadas (16,9 mmHg) que en los pacientes sin colelitiasis (3,3 mmHg) (p < 0,0001). Estas presiones se correlacionan con la presencia de amilasa y lipasa en la bilis de la vesícula; se encontraron niveles elevados de enzimas pancreáticas en pacientes con colelitiasis (p < 0,0001). Conclusiones: Las presiones de la vía biliar en pacientes con colelitiasis fueron, significativamente, mayores comparadas con las presiones de la vía biliar en pacientes sin colelitiasis. En los pacientes con colelitiasis, la presión elevada de la vía biliar se asocia a la presencia de reflujo pancreáticobiliar.

Background: The reflux of pancreatic enzymes into the bile duct and the gallbladder is an abnormal phenomenon that plays a role in lithogenesis and carcinogenesis. Because the pressure of the common bile duct depends on the pressures of the sphincter of Oddi, its dysfunction would be reflected in an increase in the pressure of the common bile duct in patients with cholelithiasis. Aim: The objective of this study was to measure the pressures of the common bile duct in patients with and without cholelithiasis and to relate them to the presence of pancreatobiliary reflux. Material and Method: A prospective case-control study was designed. The universe was constituted by all patients undergoing total gastrectomy for gastric cancer stages I and II during 30 months. The primary outcome measure was to establish differences between common bile duct pressures in patients with and without cholelithiasis. Results: Common bile duct pressures in patients with gallstones showed a significant elevation (16.9 mmHg) compared to patients without gallstones (3.3 mm Hg) (p < 0.0001). These pressures correlated with the levels of amylase and lipase in gallbladder bile; higher levels were found in patients with gallstones compared to patients without gallstones (p < 0.0001). Conclusions: Common bile duct pressure in patients with cholelithiasis was significantly higher compared to patients without cholelithiasis leading to pancreatobiliary reflux.

HISTOMORPHOLOGICAL STUDY OF CHOLECYSTECTOMIES IN A TERITIARY CARE CENTER

Introduction: Cholecystectomy is the most common surgical procedure performed for cholelithiasis (gall stones). Cholelithiasis is one of the most common gastro intestinal disorder worldwide. Usually asymptomatic, but commonly encountered symptoms may be right upper quadrant pain, dyspepsia and belching. The incidence of cholelithiasis is 2-4 times more in women than in men. The aim of the present study is to identify various morphological patterns and frequency of gall bladder lesions in cholecystectomy specimens. The Materials And Methods: present study was a cross sectional descriptive study of all cholecystectomy specimens received in the department of pathology, NRI Institute of Medical Sciences, Sangivalasa, Visakhapatnam, Andhra Pradesh; conducted over a period of 12 months from September 2021 to August 2022. The relevant and detailed clinical history were taken and processing was done in these specimens for histopathological examination. A total of 80 cholecystectomy specimens were received in the Results: department. Out of which, 79 were in?ammatory gall bladder lesions and only one case was reported as malignancy. The most common age group affected were in 4th to 5th decade with female preponderance comprising of 47cases (58.75%) while the gall bladder carcinoma was reported in 72 years of age. Among the in?ammatory lesions, most common one was chronic cholecystitis comprising of 64 cases, 80.5% (63.6% associated with gall stones) were chronic cholecystitis, followed by 10 cases (12.5%) of acute cholecystitis (100% associated with gall stones), 2cases (2.5%) of polyps & Adenomyomatosis each. Only one case (1.25%) of each Cholesterolosis & gall bladder adenocarcinoma was reported. Chronic cholecystitis is the Conclusion: most common gall bladder disease for which cholecystectomies are being done. The present had reported various morphological patterns encountered in the cholecystectomy specimens received in the department

Risk factors of acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone and construction of prediction model / 中华消化外科杂志

Objective:To investigate the risk factors of acute biliopancreatic complica-tions in patients of pregnancy combined with gallbladder stone and construction of prediction model.Methods:The retrospective case-control study was constructed. The clinical data of 98 patients of pregnancy combined with gallbladder stone who were admitted to the First Hospital of Lanzhou University from September 2011 to October 2022 and 53 patients of pregnancy combined with gallbladder stone who were admitted to Gansu Provincial Hospital May 2014 to October 2021 were collected. The age of 151 patients was 29(25,32)years. Observation indicators: (1) situations of patients of pregnancy combined with gallbladder stone; (2) risk factors of acute biliopancreatic com-plications in patients of pregnancy combined with gallbladder stone; (3) construction of prediction model for acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent t test. Measurement data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Comparison of ordinal data was conducted using the rank sum test. Univariate and multi-variate analyses were conducted using the Logistic regression model. Nomogram prediction model was conducted, and the receiver operating characteristic (ROC) curve was used to evaluate discri-mination of the nomogram predic-tion model. The calibration curve and clinical decision curve were used to evaluate calibration and net clinical benefit of the nomogram prediction model. Internal validation of the prediction model was performed by applying 10-fold cross-validation. Results:(1) Situations of patients of pregnancy combined with gallbladder stone. The total cholesterol, triglyceride, high density lipoprotein cholesterol, low density lipoprotein cholesterol, prepregnancy body mass index (<18.5 kg/m 2, 18.5?24.0 kg/m 2, >24.0 kg/m 2), gesta-tional period (early, mid, late), primipara (positive, negative), stone type (solitary, non solitary), diameter of stone (≤10 mm, >10 mm), gallbladder wall thickness (≥4 mm, <4 mm) were (4.9±1.4)mmol/L, 1.88(1.22,2.93)mmol/L, 1.48(1.22,1.83)mmol/L, (2.8±0.9)mmol/L, 13, 75, 58, 37, 45, 69, 86, 65, 37, 114, 89, 62, 38, 113 in the 151 patients of pregnancy combined with gallbladder stone. Of the 151 patients, the age, prepregnancy body mass index (<18.5 kg/m 2, 18.5?24.0 kg/m 2, >24.0 kg/m 2), primipara (positive, negative), stone type (solitary, non solitary), diameter of stone (≤10 mm, >10 mm), gallbladder wall thickness (≥4 mm, <4 mm) were 31(28,37)years, 3, 30, 36, 29, 40, 32, 37, 26, 43, 4, 65 in 69 cases without symptom, versus 27(24,31)years, 10, 45, 22, 57, 25, 5, 77, 63, 19, 34, 48 in 82 cases combined with acute biliopancreatic complications, showing significant differences in the above indicators between them ( Z=?3.636, ?2.385, χ2=11.544, 32.862, 23.729, 25.310, P<0.05). Five of the 82 patients of pregnancy combined with gallbladder stone missed data of prepregnancy body mass index. Of the 82 patients, there were 42 patients of simple acute cholecystitis, 40 patients of common bile duct stone and/or acute biliary pancreatitis including 18 cases of common bile duct stone, 13 cases of acute biliary pancreatitis and 9 cases of common bile duct stone combined with acute biliary pancreatitis. (2) Risk factors of acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone. Results of multivariate analysis showed that primipara, non solitary stone, diameter of stone ≤10 mm, gallbladder wall thickness ≥4 mm were independent risk factors of acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone ( odds ratio=3.102, 6.305, 3.674, 6.686, 95% confidence interval as 1.280?7.519, 1.886?21.080, 1.457?9.265, 1.984?22.528, P<0.05). Results of multivariate analysis in further analysis showed that primipara, non solitary stone, gallbladder wall thickness ≥4 mm were independent risk factors of simple acute cholecystitis in patients of pregnancy combined with gallbladder stone ( odds ratio=3.671, 8.905, 7.137, 95% confidence interval as 1.386?9.723, 2.332?34.006, 1.902?26.773, P<0.05), and age, non solitary stone, diameter of stone ≤10 mm, gallbladder wall thickness ≥4 mm were independent risk factors of common bile duct stone and/or acute biliary pancreatitis in patients of pregnancy combined with gallbladder stone ( odds ratio=0.883, 5.361, 5.472, 8.895, 95% confidence interval as 0.789?0.988, 1.062?27.071, 1.590?18.827, 2.064?38.325, P<0.05). (3) Construction of prediction model for acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone. The nomogram prediction model for acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone was constructed based on the clinical factors of age, primipara, stone type, diameter of stone and gallbladder wall thickness. The area under the curve (AUC) of ROC curve of prediction model was 0.869 (95% confidence interval as 0.813?0.923), indicating that the prediction model with good predictive ability. Results of Hosmer-Lemeshow test showed a good fit ( χ2=5.680, P>0.05), indicating that the prediction model with good calibration. Results of decision curve analysis showed the prediction model with high net clinical benefit. Results of internal validation of the prediction model based on 10-fold cross-validation showed the AUC of ROC curve for the cross-validation sample was 0.833, indicating that the prediction model with good stability. Conclusions:Primigravida, non solitary stone, diameter of stone ≤10 mm, gallbladder wall thickness ≥4 mm are independent risk factors of acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone. The prediction model for acute biliopancreatic complications has good predictive ability.

Preclinical evaluation of Hibiscus cannabinus Linn. in the treatment of urolithiasis and cholelithiasis / 数字中医药（英文）

@#【Objective】  To investigate the therapeutic effect of Hibiscus cannabinus Linn. (H. cannabinus) leaves on cholelithiasis and urolithiasis. 【Methods】  The study evaluated the effect of aqueous leaf extract of H. cannabinus on thiouracil and cholesterol cholic acid diet induced cholelithiasis in BALB/c mice and ethylene glycol induced urolithiasis in Wistar rats. Three doses of aqueous extract (40, 80, and 160 mg/kg) were selected to evaluate the effectiveness in cholelithiasis in mice; another three doses of aqueous extract (400, 800, and 1 600 mg/kg) were administered for evaluating the effect on urolithiasis in rats. Biochemical parameters such as biliary cholesterol, biliary phospholipid, and bile acid were determined in cholelithiasis model. Similarly, 24-hour urine output, urinary parameters such as creatinine, uric acid, protein, urea, presence of calcium oxalate crystals, red blood cells (RBCs), and pyuria were determined in urolithiasis model. 【Results】  Statistically significant differences were noted in the biliary and urinary parameters after administrating three test doses of H. cannabinus aqueous extract (P < 0.05). 【Conclusion】 H. cannabinus was found to be effective against high fat lithogenic diet urolithiasis and cholelithiasis.

Effect of Dahuang Lingxian Formula（大黄灵仙方）on miRNA-30b Expression and Inflammation-fibrosis Related Factors in Biliary Duct Tissue of Cholecystitis Model Rats / 中医杂志

ObjectiveTo explore the possible mechanism of reducing cholecystitis and preventing cholelithiasis by Dahuang Lingxian Formula（大黄灵仙方， DLF）. MethodsFifty SD rats were randomly divided into blank group， model group， DLF group， DLF + blank inhibitor group， and DLF + inhibitor group， with 10 rats in each group. The rat model of cholecystitis was established by lipopolysaccharide （LPS） induction in all the groups except for the blank group. Rats in DLF group， DLF + blank inhibitor group and DLF + inhibitor group received intragastric administration of 320 mg/ （kg·d） of DLF 3 days before the preparation of cholecystitis model， while those in blank group and model group were given 2 ml/100 g of distilled water by gastric， twice a day， for 6 consecutive days. Hematoxylin-eosin （HE） staining was used to observe the histopathologic changes of bile duct tissues in each group. The expression of nuclear factor κB （NF-κB） protein in bile duct tissues was detected by immunohistochemistry. The expression levels of interleukin1β （IL-1β） and tumor necrosis factor α （TNF-α） in serum of rats were detected by enzym-linked immunosorbent assay （ELISA）. The mRNA expression levels of miRNA-30b， transforming growth factor β1 （TGF-β1）， nucleotide-binding oligomerization domain-like receptor protein 3 （NLRP3） and bone morphogenetic protein 2 （BMP2） in bile duct tissues were detected by real-time PCR， and the protein expression levels of TGF-β1， NLRP3 and BMP2 were detected by Western blot. ResultsCompared to those in the blank group， the structure of the bile duct in the model group was abnormal， and a large number of lymphocytes， plasma cell infiltration and bile canaliculi dilation were seen in the portal area； the positive expression of NF-κB protein increased； there was nuclear infiltration； the expressions of serum inflammatory factors IL-1β and TNF-α， as well as the mRNA and protein expressions of TGF-β1， NLRP3 and BMP2 in bile duct tissue significantly increased， while the expression level of miRNA-30b significantly decreased （P＜0.01）. Compared to those in the model group， the pathological morphology of the bile ducts in the DLF group and DLF + blank inhibitor group was improved， and the infiltration of inflammatory cells was reduced， with decreased positive expression of NF-κB and nuclear infiltration； expression levels of serum inflammatory factors IL-1β and TNF-α， and the mRNA and protein expressions of TGF-β1， NLRP3 and BMP2 in bile duct tissue decreased， while the expression level of miRNA-30b significantly increased （P＜0.05 or P＜0.01）. Compared to the model group， those indicators in the DLF + inhibitor group was not significantly improved （P＞0.05）. There was no significant difference in the indicators between the DLF group and the DLF + blank inhibitor group （P＞0.05）. ConclusionDLF may play a role in delaying the progression of cholelithiasis by regulating the expression of miRNA-30b and inflammation-fibrosis related factors.

Asymptomatic cholelithiasis: expectant or cholecystectomy. a systematic review / Colelitíase assintomática: expectante ou colecistectomia. revisão sistemática

ABSTRACT BACKGROUND: Asymptomatic cholelithiasis is a highly prevalent disease, and became more evident after the currently greater access to imaging tests. Therefore, it is increasingly necessary to analyse the risks and benefits of performing a prophylactic cholecystectomy. AIMS: To seek the best evidence in order to indicate prophylactic cholecystectomy or conservative treatment (clinical follow-up) in patients with asymptomatic cholelithiasis. METHODS: A systematic review was performed using the PubMed/Medline database, according to PRISMA protocol guidelines. The review was based on studies published between April 26, 2001 and January 07, 2022, related to individuals older than 18 years., The following terms/operators were used for search standardization: (asymptomatic OR silent) AND (gallstones OR cholelithiasis). RESULTS: We selected 18 studies eligible for inference production after applying the inclusion and exclusion criteria. Also, the Tokyo Guideline (2018) was included for better clarification of some topics less or not addressed in these studies. CONCLUSIONS: Most evidence point to the safety and feasibility of conservative treatment (clinical follow-up) of asymptomatic cholelithiasis. However, in post-cardiac transplant patients and those with biliary microlithiasis with low preoperative surgical risk, a prophylactic cholecystectomy is recommended. To establish these recommendations, more studies with better levels of evidence must be conducted.

RESUMO RACIONAL: A colelitíase assintomática é uma doença altamente prevalente, e atualmente tornou-se mais evidente, após o maior acesso a exames de imagem. Portanto, é cada vez mais necessário analisar os riscos e benefícios de realizar uma colecistectomia profilática. OBJETIVOS: Buscar as melhores evidências para indicar colecistectomia profilática ou tratamento conservador (acompanhamento clínico) em pacientes com colelitíase assintomática. MÉTODOS: Foi realizada revisão sistemática, no PubMed/Medline, de acordo com as diretrizes do protocolo PRISMA, selecionando estudos publicados entre 26/04/2001 e 01/07/2022, relacionados a indivíduos maiores de 18 anos, com padronização de busca usando os seguintes termos/operadores: (Assintomático OU Silencioso) E (Cálculos biliares OU colelitíase). RESULTADOS: Foram selecionados 18 estudos elegíveis após a aplicação dos critérios de inclusão e exclusão. Além disso, a Tokyo Guideline (2018) foi incluída para melhor esclarecimento de alguns tópicos menos ou não abordados nestes estudos. CONCLUSÕES: A maioria das evidências aponta para a segurança e viabilidade do tratamento conservador (acompanhamento clínico) da colelitíase assintomática. Entretanto, em pacientes com transplante pós-cardíaco e aqueles com microlitíase biliar com baixo risco cirúrgico pré-operatório, a colecistectomia profilática é recomendada. Para estabelecer completamente estas recomendações, mais estudos com melhores níveis de evidência devem ser conduzidos.

Aplicación de guías tokio 2018 para diagnóstico y tratamiento de colangitis aguda en hospital escuela, honduras

Antecedentes: Las Guías Tokio 2018 son un conjunto de directrices médicas actualizadas y reconocidas que ofrecen recomendaciones detalladas para el diagnóstico y tratamiento de la colangitis aguda, una inflamación aguda de los conductos biliares que puede ser potencialmente grave. Objetivo: Examinar la utilidad de la aplicación de las Guías Tokio 2018 para el diagnóstico y tratamiento en pacientes con Colangitis Aguda ingresados al Hospital Escuela durante 2018-2019. Métodos: Estudio descriptivo transversal, se revisaron 54 expedientes clínicos que registraron datos sociodemográficos, antecedentes personales y patológicos, laboratoriales e imagenológicas. Los resultados se presentaron como frecuencias, porcentajes, promedios y rangos. Resultados: Las Guías de Tokio 2018 (TG18) fueron implementadas en un 94%. La colangitis aguda leve fue más frecuente en 48.1%. La concordancia en la estatificación de los casos según TG18 erró con mayor proporción en las colangitis grado 2 (15% No, 7% Si); la lesión renal siendo la falla orgánica más frecuente 25.9% (14). El manejo antibiótico concordó en el 70.0%. El drenaje biliar se realizó de forma oportuna en 14.0%. La causa más frecuente de colangitis fue la litiasis en un 48.2%. El promedio de hospitalización fue de 5-9 días en 31.5%. El 63.0% (34) de los pacientes egresó mejorado y el 24.0% (13) fallecieron. Conclusión: La utilización de lasTG18 por parte del Hospital Escuela demostró un enfoque en mejorar la precisión del diagnóstico y optimizar la administración de antibióticos. Sin embargo, su eficacia parece comparativamente disminuida cuando se aplica al aspecto fundamental del drenaje de los conductos biliares.

Background: The Tokyo 2018 Guidelines are a set of recognized and up-to-date medical guidelines that provide detailed recommendations for the diagnosis and treatment of acute cholangitis, an acute inflammation of the bile ducts that can be potentially serious. Objective: To examine the usefulness of the application of the Tokyo 2018 Guidelines for the diagnosis and treatment of patients with Acute Cholangitis admitted to the Hospital Escuela during 2018-2019. Methods: Cross-sectional descriptive study, reviewing 54 clinical records that recorded sociodemographic data, personal and pathological, laboratory and imaging history. Results were presented as frequencies, percentages, means, and ranges. Results: The Tokyo 2018 Guidelines (TG18) were implemented by 94%. Mild acute cholangitis was more frequent in 48.1%. The concordance in the staging of the cases according to TG18 erred with a greater proportion in grade 2 cholangitis (15% No, 7% Yes); kidney injury being the most frequent organic failure 25.9% (14). The antibiotic management agreed in 70.0%. Biliary drainage was performed in a timely manner in 14.0%. The most frequent cause of cholangitis was lithiasis in 48.2%. The average hospitalization was 5-9 days in 31.5%. 63.0% (34) of the patients discharged improved and 24.0% (13) died. Conclusion: The use of TG18 by the Hospital Escuela demonstrated a focus on improving diagnostic accuracy and optimizing the administration of antibiotics. However, its efficacy appears comparatively diminished when applied to the fundamental aspect of bile duct drainage.

Colecistectomia laparoscopica en el hospital municipal los pinos, 2012 - 2022 / Laparoscopic cholecystectomy at Los Pinos municipal hospital, 2012 - 2022

La colecistectomía laparoscópica es el estándar de oro para el tratamiento de la litiasis vesicular. El presente estudio tiene por objetivo difundir la experiencia de 10 años en colecistectomía laparoscópica del Hospital Municipal Los Pinos de La Paz, Bolivia. Se realizó la revisión de historias clínicas de pacientes internados y sometidos a colecistectomía laparoscópica de junio 2012 a julio 2022, la serie de casos estuvo compuesta por 1095 pacientes; 866 (79.3%) mujeres y 229 (20.7%) varones; el grupo etáreo con mayor casuística fue 31 a 40 años con 256 casos (23.3%), la edad promedio fue de 50,5 (10 a 81 años). La vía de ingreso de los pacientes fue por consulta externa 72.5% y emergencias 27.4%. El tiempo operatorio promedio fue de 85 min. (20 a 150 min.). El diagnostico de ingreso de mayor prevalencia fue la colecistitis crónica litiasica con 766 (69.9%). El factor de conversión a cirugía abierta fue la falta de identificación de estructuras anatómicas, con un índice de conversión de 6.9%. La estancia postoperatoria promedio fue de 3.5 días (1 a 6 días). Basado en los resultados obtenidos la colecistectomía laparoscópica demuestra ser aun el tratamiento seguro y efectivo en pacientes con colelitiasis.

Laparoscopic cholecystectomy is the Gold standard for the treatment of vesicular lithiasis. The present study aims to describe the experience in laparoscopic cholecystectomy of 10 years at Los Pinos Municipal Hospital in La Paz, Bolivia. A review of medical records of hospitalized patients undergoing laparoscopic cholecystectomy from June 2012 to July 2022 was carried out. Case series were 1095 patients; 866 (79.3%) female and 229 (20.7%) male; the age group with higher casuistry was 31 to 40 years (256 cases, 23.3%), the average age was 50.5 (10 to 81 years). The admission of patients was by outpatient 72.5% and emergency unit 27.4%. The average surgery time was 85 min. (20 to 150 min.). The highest prevalence diagnosis at admission was chronic lithiasic cholecystitis (766 cases, 69.9%). The conversion factor to open surgery was the anatomical structures identification difficulty, conversion rate of 6.9 %. The postoperative hospital stay average was 3.5 days (1 to 6 days). Based on the results obtained, laparoscopic cholecystectomy still proves to be the safe and effective treatment in patients with cholelithiasis.

The use of serum alkaline phosphatase as a choledocholithiasis marker to mitigate the cost of magnetic resonance cholangiography

ABSTRACT Objective To assess the predictive value of preoperative serum laboratory test results for identifying choledocholithiasis and reduce the use of cholangioresonance and its inherent costs. Methods Patients aged 21-69 years who underwent preoperative cholangioresonance examination at our institute were included. Patients with a history of fluctuating jaundice or biliary pancreatitis, bile duct dilatation on ultrasonography, and elevated levels of canalicular enzymes (alkaline phosphatase >100U/L and gamma-glutamyl transferase >50U/L) underwent cholangioresonance-guided surgery. Cases of choledocholithiasis confirmed by cholangioresonance were compared with those without choledocholithiasis. Serum laboratory data were evaluated and the diagnostic capabilities of these examinations were analyzed. Results A total of 104 patients were included. For detecting choledocholithiasis using alkaline phosphatase, the cut-off point was 78U/L, sensitivity was 97.6% (95%CI: 87.4-99.9), and specificity was 72.6% (95%CI: 59.8-83.1). In the binary logistic regression analysis, age (OR= 0.92; 95%CI: 0.86-0.98) and alkaline phosphatase level (OR= 1.02; 95%CI: 1.01-1.05) were selected for the final model. Conclusion Serum alkaline phosphatase levels may aid preoperative diagnosis of asymptomatic choledocholithiasis. After a global clinical assessment of the patient, serum laboratory findings may contribute to a reduction in cholangioresonance-related heathcare costs.

Comparison of bacterial profile of gallbladder with gallstones from patients undergoing cholecystectomy due to complicated and uncomplicated cholelithiasis: changes in the epidemiological scenario / Perfil bacteriano da vesícula biliar e dos cálculos biliares de pacientes submetidos à colecistectomia por colelitíase complicada e não complicada: mudanças no cenário epidemiológico

ABSTRACT Introduction: cholelithiasis is a highly prevalent disease of the digestive system in the world. In Brazil, it is a routine condition, whose studies suggest a prevalence of around 10% of adults. Colonization of bile and gallstone pathogens can occur when there is bacterial stasis and proliferation. This proliferation is facilitated by the adhesion and biofilm formation capacity of some bacteria. There are also lithogenic processes that involve bacterial participation. Studies have shown changes in the microbiota of the gallbladder of patients undergoing cholecystectomy, which may impact empirical treatment with antibiotics. Methodology: microbiological analyzes of the sonication fluid of the gallstones and of two samples with bile were performed. Identification and antimicrobial susceptibility testing were performed according to a standard routine. Results: of the 34 patients, 76.4% were female. The age group was 48 years +/- 16.61. Acute cholecystitis occurred in 50% of cases. Bactobilia was evidenced in 32.1% of the cases. Klebisiella pneumoniae was noted as the most prevalent pathogen in acute cholecystitis; and Enterobacter sp, in cases of uncomplicated cholelithiasis. Greater sensitivity was obtained in the search for microorganisms in the sonication fluid samples of the stones in relation to the bile samples (p=0.0058). Conclusion: there was a higher prevalence of bactobilia in patients with acute cholecystitis compared to those with uncomplicated cholelithiasis. The use of sonication in bacterial investigation proved to be superior to the conventional method and can be considered.

RESUMO Introdução: a colelitíase é uma doença do sistema digestivo de alta prevalência no mundo. No Brasil, trata-se de uma condição rotineira, cujos estudos sugerem uma prevalência em torno de 10% dos adultos. A colonização de patógenos da bile e do cálculo biliar pode ocorrer quando há estase e proliferação bacteriana. Esta proliferação é facilitada pela capacidade de adesão e de formação de biofilme de algumas bactérias. Também há processos litogênicos que envolvem a participação bacteriana. Estudos evidenciaram mudanças na microbiota da vesícula biliar de pacientes submetidos à colecistectomia, o que pode impactar no tratamento empírico com antibióticos. Metodologia: Realizou-se análises microbiológicas do fluido de sonicação dos cálculos biliares e de duas amostras com bile. A identificação e o teste de sensibilidade aos antimicrobianos foram realizados de acordo com uma rotina padrão. Resultados: Nos 34 pacientes, 76,4% deles foram do sexo feminino. A faixa etária foi de 48 anos +/- 16,61. A colecistite aguda ocorreu em 50% dos casos. A bactobilia foi evidenciada em 32,1% dos casos. Notou-se Klebisiella pneumoniae como o patógeno mais prevalente em quadros de colecistite aguda; e Enterobacter sp, nos casos de colelitíase não complicada. Obteve-se maior sensibilidade na pesquisa de microrganismos nas amostras de fluido de sonicação dos cálculos em relação às de bile (p=0,0058). Conclusão: Houve maior prevalência de bactobilia nos pacientes com colecistite aguda em relação àqueles com colelitíase não complicada. A utilização da sonicação na investigação bacteriana se mostrou superior ao método convencional e pode ser considerada.