Cáncer incidental de vesícula: incidencia y factores asociados en pacientes de una institución de la ciudad de Medellín / Incidental gallbladder cancer: Incidence and associated factors in patients from an institution in the city of Medellín

Introducción. El cáncer de vesícula biliar es una de las neoplasias más frecuentes de la vía biliar y la mayoría de los casos se diagnostican de forma incidental o en estadios avanzados. En Colombia existen pocas publicaciones acerca de la prevalencia y características clínicas de pacientes con cáncer insospechado de vesícula biliar. El objetivo de este trabajo fue actualizar la información existente. Métodos. Estudio de tipo transversal basado en registros médicos. Como variable de resultado se definió el hallazgo incidental de patología maligna reportado por un patólogo y el subtipo histológico. Se midieron variables demográficas, clínicas y quirúrgicas. Se calcularon OR con sus respectivos intervalos de confianza (IC95%). Resultados. De los 2630 casos analizados, en cuatro se hizo diagnóstico de cáncer incidental de vesícula, con una prevalencia del 0,15 %. Se encontraron como características asociadas al cáncer incidental de vesícula, la edad, el antecedente de cáncer y la presencia de pólipos. Conclusiones. Esta es una patología poco frecuente en la población evaluada, lo que permite afirmar que no es necesario realizar estudios prequirúrgicos más amplios de forma rutinaria, a menos que el paciente presente alguno de los factores asociados.

Introduction. Gallbladder cancer is one of the most common neoplasms of the bile duct and most cases are diagnosed incidentally or in advanced stages. In Colombia, there are few publications about the prevalence and clinical characteristics of patients with unsuspected gallbladder cancer. The objective of this work was to update the existing information. Methods. Cross-sectional study based on medical records. The incidental finding of malignant pathology reported and the histological subtype were defined as the outcome variable. Demographic, clinical and surgical variables were measured. ORs were calculated with their respective 95% CI. Results. Of the 2630 cases analyzed, four were diagnosed with incidental gallbladder cancer, with a prevalence of 0.15%. Characteristics associated with incidental gallbladder cancer were age, history of cancer and the presence of polyps. Conclusions. This is a rare pathology in the population evaluated, which allows us to recommend that it is not necessary to routinely perform more extensive presurgical studies, unless the patient presents any of the associated factors.

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

Adenocarcinoma de vesícula biliar: un caso de presentación temprana

El cáncer de la vesícula biliar es una enfermedad rara, con una incidencia mundial de 2 casos por cada 100 000 individuos con un pronóstico desfavorable. Con el aumento de colecistectomías por causas benignas, se ha incrementado la detección incidental de neoplasias vesiculares en las piezas quirúrgicas, siendo este el método diagnóstico más frecuente, generando retrasos en el manejo y requiriendo reintervenciones extensas. Debido a lo anterior, se resalta la importancia de un diagnóstico temprano preoperatorio, con el objetivo de ofrecer un tratamiento quirúrgico potencialmente curativo. Se presenta el caso de un paciente masculino de 72 años con un cuadro intermitente de dolor abdominal y pérdida de peso de un año de evolución, el cual fue diagnosticado con cáncer vesicular en etapa temprana y sometido a una colecistectomía laparoscópica extendida con linfadenectomía y hepatectomía parcial con una evolución a 6 meses sin complicaciones y bajo un protocolo de vigilancia periódica.

Gallbladder cancer is a rare disease, accounting a global incidence of 2 cases per 100 000 individuals with an unfavorable prognosis. The rise in cholecystectomies for benign causes has increased an incidental detection of vesicular neoplasms in the surgical specimens, being the main diagnostic method, therefore it generated delay in the management, requiring extensive re-interventions. It is important to improve early preoperative diagnosis, with the aim of offering a potentially curative surgical treatment. We present a case of a 72-year-old male with intermittent abdominal pain and weight loss of one year of evolution, who was diagnosed with early stage gallbladder cancer and underwent an extended laparoscopic cholecystectomy with lymphadenectomy and partial hepatectomy with a 6 months evolution without complications and under a periodic surveillance protocol.

Colecistectomía Laparoscópica difícil: tratamiento quirúrgico / The surgical management of difficult LaparoscopicCholecystectomy

Objetivo: Caracterizar el tratamiento laparoscópico de pacientes con colecistitis difícil en el Servicio de Cirugía I del Hospital Universitario de Caracas durante el quinquenio2017-2021. Métodos: Estudio retrospectivo, observacional, descriptivo y de corte transversal. Muestra de tipo no probabilístico por conveniencia, seleccionada de la base de datos del Departamento de Historias Médicas del Hospital Universitario de Caracas. El análisis estadístico se realizó con el programa SPSS en su versión 26. Resultados: se recolectaron61 Historias Clínicas con características de colecistectomías laparoscópicas difíciles, el grupo etario más numeroso con67,19%, fue entre 30-59 años; sexo predominante: el femenino con 85,2%; el 42,62% de los pacientes presentaron a su ingreso: litiasis vesicular simple, el cólico vesicular persistente fue la complicación más frecuente con 31,23%. El 65,57% se ubicó en Grado I según Nassar como hallazgo intraoperatorio más frecuente, y según Parkland el 75,40% en grado I, sin individuos afectados con Grado V. Todos los casos fueron tratados quirúrgicamente (colecistectomía laparoscópica total).Conclusión: el total de los pacientes sometidos a tratamiento quirúrgico con hallazgos de colecistectomía laparoscópica difícil, se completó mediante colecistectomía laparoscópica total(AU)

Objective: To characterize the surgical treatment of difficult cholecystectomy in the Chair of Clinical and Surgical therapeutics "A" / Surgery Service I of the University Hospital of Caracas during the five-year period 2017 -2021.Methods: A retrospective, observational, descriptive and cross-sectional study will be carried out. The sample will be of anon-probabilistic type for convenience, selecting from the listof patients in the database of the Department of Medical Records of the Hospital Universitario de Caracas. The statistical analyzes will be carried out with the SPSS program in its version 26. Results: 61 difficult laparoscopic cholecystectomies were observed, the most frequent age group with 67.19%, was between 30-59 years, the female sex with 85.2% was the predominantone. 42.62% of the admission diagnoses were simple gallstones, followed by persistent gallbladder colic as the most frequent complication with 31.23%. 65.57% represent Grade I accordingto Nassar as the most frequent intraoperative finding and according to Parkland 75.40% represented by grade I, leaving Grade V without affected individuals. 100% of the sample were surgically treated by total laparoscopic cholecystectomy. Conclusion: the total number of patients undergoing surgical treatment with difficult laparoscopic cholecystectomy findingswas completed by total laparoscopic cholecystectomy(AU)

HISTOPATHOLOGY OF GALLBLADDER SPECIMENS AFTER CHOLECYSTECTOMY: A RETROSPECTIVE STUDY

Background Current approach to detect the presence of gallbladder carcinoma involves a routine histopathological examination of all gallbladder specimens, regardless of the clinical characteristics of the patient or macroscopic aspect of the gallbladder. Available pathological reports were interpreted for the following parameters: age, gender, and pathological diagnosis. In addition, the demographic information and clinicopathologic characteristics of the patients with histopathologic findings were assessed in detail, and re-examination of the available specimens was done. Inpatient records of the Methods patients who had been operated for elective and emergency cholecystectomies in the hospital associated with Khaja Bandanawaz University – Faculty of medical Sciences; from January 2018 to November 2022, were retrospectively evaluated. Results A total of 661 gallbladder specimens submitted for histopathological examination during the study period were included in the study. The results of histopathological examination of these gallbladder specimens showed that chronic cholecystitis was found in 535 (81%), acute cholecystitis in 46 (6.99%), cholesterolosis in 44 (6.5%) patients, Dysplasia was found in 34 (5.14%) patients, and gallbladder carcinoma was detected in 2 (0.30%) patients. Conclusion A strategy of selective approach for histopathological examination of gallbladder specimens may be safe in areas with very low incidence of gallbladder carcinoma. Such selective strategy is more cost-effective, reduces the workload of pathologists, and does not appear to compromise patient outcome.

Expression of estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2/neu in gallbladder carcinoma in North Indian population

Background: Gallbladder carcinoma (GBC) although rare is most frequent malignant neoplasm of biliary tract system and sixth most common malignancy of digestive tract. GBC is more common in females and there are studies which show expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 neu (HER2/neu) in GBC suggesting possible molecules for targeted therapy, but results are inconsistent. Aims and Objectives: The aim of this study was to find out expression of ER, PR, and HER2/neu in GBC in North Indian population and their possible association with clinicopathological features. Materials and Methods: A total 59 resected cases of GBC diagnosed by histopathological examination were included in the study. Expression of ER, PR, and HER2/neu was accessed by immunohistochemistry method and correlated with various clinicopathological features. Results: ER expression was absent in all GBC cases. PR expression was present in only one case. Positive expression of HER2/neu was present in 13 (22%) cases, in which 12 cases were of conventional adenocarcinoma and one case was of papillary adenocarcinoma. Well and moderately differentiated tumor had significantly higher HER2/neu expression as compared to poorly differentiated tumors (P = 0.001). Pre-obese patients had significantly higher HER2/neu expression as compared to non-obese patients (P = 0.008). Conclusion: In our study, there was no expression of estrogen and PR in GBC in North Indian population. Although small in number, there is a subset of patients who overexpress HER2/neu receptor that may benefit from targeted therapy.

The effect of polyene phosphatidylcholine combined with Shudan decoction on the recovery of gallbladder function after fallbladder-preserving cholecystolithotomy / 中国医师进修杂志

Objective:To investigate the effect of polyene phosphatidylcholine combined with Shudan decoction on the recovery of gallbladder function after gallbladder-preserving cholecystolithotomy.Methods:Sixty patients with gallbladder stone admitted to Shenzhen Hospital (Longgang), Beijing University of Chinese Medicine from June 2018 to July 2021 were selected. All patients were received gallbladder-preserving cholecystolithotomy, and they were divided in two groups by random number table, each group with 30 patients. The control group was treated with polyene phosphatidylcholine capsule after the operation, while the observation group was treated with Shudan decoction on the basis of the control group. After 30 d of continuous treatment, the traditional Chinese medicine symptoms score, gallbladder contraction function and the levels of serum alkaline phosphatase (ALP), gamma-glutamine transferase (GGT), incidence of adverse reactions, clinical efficacy were compared between the two groups.Results:After treatment, the scores of abdominal distension, abdominal pain and anorexia in the observation group were lower than those in the control group ( P<0.05). After treatment, the thickness of the gallbladder wall in the observation group was lower than that in the control group and the the gallbladder contraction rate was higher than that in the control group: (2.62 ± 0.29) mm vs. (3.21 ± 0.32) mm, (74.17 ± 6.49)% vs. (62.03 ± 6.05)%, there were statistical differences ( P<0.05). After treatment, the levels of GGT and ALP in the observation group were lower than those in the control group: (132.32 ± 30.09) U/L vs. (150.27 ± 30.33)U/L, (56.12 ± 14.89) U/L vs. (75.07 ± 16.22) U/L, there were statistical differences ( P<0.05). The total effective rate in the observation group was higher than that in the control group: 96.67%(29/30) vs. 80.00%(24/30), there was statistical difference ( χ2 = 4.04, P<0.05). The adverse reactions in the two groups had no significant differences ( P>0.05). Conclusions:Polyene phosphatidylcholine combined with Shudan decoction has a definite efficacy for patients with cholecystolithiasis after gallbladder-preserving cholecystolithotomy, and can effectively promote the recovery of their gallbladder function and with good safety.

Effects of orlistat on the viability of human gallbladder cancer cells / 中华消化外科杂志

Objective:To investigate the effects of orlistat on the viability of human gall-bladder cancer (GBC) cells.Methods:The experimental study was conducted. The human GBC NOZ cells with high expression of FSAN was screened out through in vitro cultivating human GBC-SD, SGC-996 and NOZ cells. The cell proliferation assay, clone formation assay and protein detection experiment were used to analysis of the effects of orlistat on the viability of human GBC cells. Cell grouping: NOZ cells cultured with medium were set as the control group, cultured with medium + 10 μmol/L orlistat were set as the low-dose orlistat group, cultured with medium + 100 μmol/L orlistat were set as the high-dose orlistat group, respectively. Observation indicators: (1) expression of FASN protein in human GBC cells; (2) effects of orlistat on the proliferation of human GBC NOZ cells; (3) effects of orlistat on apoptosis of human GBC NOZ cells. Measurement data with normal distribution were represented as Mean± SD, the ANOVA test was used for comparison between groups and the least significant difference method was used for pairwise comparison. Results:(1) Expression of FASN protein in human GBC cells. Results of western blot showed that the relative expression of FASN protein in human GBC NOZ, GBC-SD and SGC-996 cells was 0.57±0.06, 0.12±0.04 and 0.10±0.02, respectively, showing a significant difference among them ( F=115.67, P<0.05). There were significant differences between the NOZ cells and the GBC-SD or the SGC-996 cells ( P<0.05), and there was no significant difference between the GBC-SD cells and the SGC-996 cells ( P>0.05). (2) Effects of orlistat on the proliferation of human GBC NOZ cells. ① Results of cell proliferation assay showed that the absorbance value of NOZ cells was 2.34±0.12, 1.57±0.08 and 1.07±0.13 in the control group, low-dose orlistat group and high-dose orlistat group, respectively, showing a significant difference among them ( F=205.88, P<0.05). ② Results of clone formation assay showed that the number of NOZ cells clones was 257±23, 153±11 and 83±11 in the control group, low-dose orlistat group and high-dose orlistat group, respectively, showing a significant difference among them ( F=92.64, P<0.05). ③Results of western blot showed that the relative expression of Cyclin-D1 protein of NOZ cells was 2.31±0.10, 1.52±0.05 and 1.23±0.11 in the control group, low-dose orlistat group and high-dose orlistat group, respectively, showing a significant difference among them ( F=120.73, P<0.05). The relative expression of CDK-4 protein of NOZ cells was 1.58±0.04, 1.21±0.02 and 1.19±0.04 in the control group, low-dose orlistat group and high-dose orlistat group, respectively, showing a signifi-cant difference among them ( F=110.45, P<0.05). (3) Effects of orlistat on apoptosis of human GBC NOZ cells. Results of western blot showed that the relative expression of Bcl-2 protein of NOZ cells was 1.07±0.03, 0.36±0.03 and 0.15±0.02 in the control group, low-dose orlistat group and high-dose orlistat group, respectively, showing a significant difference among them ( F=1 242.93, P<0.05). The relative expression of Bax protein of NOZ cells was 0.51±0.03, 0.38±0.05 and 1.38±0.04 in the control group, low-dose orlistat group and high-dose orlistat group, respectively, showing a signifi-cant difference among them ( F=583.51, P<0.05). Conclusion:Orlistat can inhibit the growth of human GBC NOZ cells and promote their apoptosis.

Current situation and prospect in the clinical treatment of gallbladder cancer / 中华消化外科杂志

Gallbladder carcinoma is a tumor with poor prognosis and lack of effective comprehensive treatment. At present, surgical resection is still the main treatment for gallbladder carcinoma. Precise evaluation and adequate preparation before surgery, and safe, effective, standar-dized resection are the key points to successful treatment of gallbladder carcinoma. In clinic, there has been a growing appreciation of the prevention and reasonable treatment of incidental gallbladder carcinoma. Neoadjuvant and conversion therapy give full play to the effects of chemotherapy, targeted therapy, and immunotherapy agents on tumor cells, which can achieve the goal of downstage or conversion of tumors before surgery, increasing the radical resection rate, and improving the prognosis of patients.

Application of percutaneous transhepatic gallbladder drainage with delayed laparoscopic cholecystectomy in the treatment of acute cholecystitis / 国际外科学杂志

Objective:To compare the clinical efficacy of percutaneous transhepatic gallbladder drainage (PTGBD) combined with delayed laparoscopic cholecystectomy (LC) with direct LC in the treatment of acute cholecystitis.Methods:A single-center case-control retrospective study was used. Sixty-three patients with acute cholecystitis with onset time ≥ 72 hours during the period from August 1, 2021 to December 10, 2022 in the Department of Hepatobiliary Surgery of the 900TH Hospital of Joint Logistics Support Force were selected. There were 38 males and 25 females, aged (57.3±15.4) years, with an age range of 28-87 years. According to whether PTGBD treatment was performed before LC, they were divided into experimental group ( n=29) and control group ( n=34). Experimental group was treated with PTGBD combined with delayed LC and control group was treated with LC only.The differences in operative time, intra-operative bleeding, intra-operative transit open rate, post-operative hospital days, total hospital days, hospital costs, short-term post-operative complications of LC and post-operative time to exhaustion were compared and analysed between the two groups. Measurement data with normal distribution were expressed as mean±standard deviation ( ± s), and independent sample t-test was used for comparison between groups.Measurement data with skewed distribution were expressed as M( Q1, Q3), and rank sum test was used for comparison between groups; Chi-square test was used to compare the counting data groups. Results:Intraoperative bleeding, total hospital days, hospital costs and postoperative time to exhaustion were 0(0, 50) mL, 13(11, 18) d, 29 015.0 (22 791.6, 39 000.8) yuan and 1(1, 2) d in the experimental group and 50(0, 88) mL, 7(6, 11) d, 16 015.0 (15 832.1, 22 185.1) yuan, 2(1, 3) d, the difference was statistically significant between the two groups( P<0.05). In the experimental group, the operative time, the intraoperative transit open rate, the number of postoperative hospital days, and the incidence of short-term postoperative complications of LC were 80 (55, 115) min, 13.8%, 5 (3, 7) days, 34.5%, respectively, compared with 98(70, 125) min, 20.6%, 5(3, 6) days, 38.2% in the control group, the difference between the two groups was not statistically significant ( P>0.05). Conclusion:The clinical efficacy of PTGBD combined with delayed LC is better than direct line LC, and it is feasible and effective for patients with cholecystitis whose inflammatory indexes have returned to normal and who have high gallbladder tone.

XU Jingshi's Experience in Using Zhuru （Caulis Bambusae in Taenia） in Clinical Practice / 中医杂志

This paper summarized professor XU Jingshi's understanding and clinical experience of using Zhuru （Caulis Bambusae in Taenia）. It is suggested that suitable processed products should be flexibly selected according to the pathogenesis. Ginger-fried Zhuru is good at clearing the gallbladder and harmonizing the stomach， and balancing the ascending and descending， and self-made Xiaohua Funing Decoction （消化复宁汤）， modified Huanglian Wendan Decoction （黄连温胆汤）， and Danqi Heluo Beverage （丹七和络饮） can be used to treat palpitations， restlessness， upset， insomnia， and others. Dried Zhuru can resolve phlegm and clear heat， harmonize the center and calm spirit， and self-made Qingdan Cuimian Formula （清胆催眠方） is often used to treat palpitations， restlessness， insomnia， etc. Raw Zhuru is good at clearing the lung and dispelling phlegm， relieving cough and calming panting， which is commonly used in treating phlegm-heat cough and asthma caused by phlegm heat accumulating in the lung and ascending counterflow of lung qi. In addition， as Zhuru can clear heart and remove vexation， direct counterflow downward and relieve constraint， self-made Shugan Liyu Formula （疏肝理郁方） is often used to treat all diseases caused by constraints. Considering Zhuru has the function of harmonizing the actions of all medicinals in a formula， guiding the medicinals into the stomach， and regulating the ascending and descending of qi movement in central spleen and stomach， self-made Fuzheng Anzhong Decoction （扶正安中汤） can be used for postoperative treatment of various malignant tumors.

Effect of LncRNA GHET1 on Proliferation, Apoptosis, and Metastasis of Gallbladder Cancer Cells by Targeting miR-27b / 肿瘤防治研究

Objective To investigate the effect of GHET1 on the biological behavior of gallbladder cancer cells and the regulatory mechanism of GHET1 on miR-27b. Methods The expression of GHET1 and miR-27b in 50 samples of gallbladder cancer was detected by real-time quantitative PCR. The si-NC vector, si-GHET1 vector, miR-27b inhibitor, and si-GHET1 vector+miR-27b inhibitor were transfected into SGC-996 cells and set as the control group, GHET1 interference group, miR-27b interference group, and GHET1+miR-27b interference group. Cell proliferation, apoptosis, and metastasis in each group were detected by MTT, flow cytometry, and Transwell assays. The regulatory effect of GHET1 on miR-27b was validated by luciferase reporter gene assay. Results GHET1 expression was higher in cancer tissues than that in paracancerous ones. miR-27b expression was lower in cancer tissues than that in paracancerous tissues. GHET1 was negatively correlated with miR-27b expression (P<0.05), and GHET1 expression was associated with TNM staging and lymph node metastasis (P<0.05). High GHET1 expression was associated with poor prognosis of patients with gallbladder cancer (P<0.05). Compared with the control group, the GHET1 interference group showed decreased cell-proliferation ability, increased apoptosis rate, and reduced number of cell metastasis. The miR-27b interference group showed increased cell-proliferation ability, decreased apoptosis rate, and increased number of cell metastasis (P<0.05). Compared with the GHET1 interference group, the GHET1+miR-27b interference group showed increased cell-proliferation ability, decreased apoptosis rate, and increased number of cell metastasis (P<0.05). GHET1 inhibited miR-27b expression by acting as a sponge of miR-27b. Conclusion GHET1 promotes the proliferation and metastasis and inhibits the apoptosis of gallbladder cancer cells by targeting miR-27b, suggesting that GHET1/miR-27b axis plays a role in gallbladder cancer progression.

Acute cholecystitis in high-risk patients. surgical, radiological, or endoscopic treatment? brazilian college of digestive surgery position paper / Colecistite aguda em pacientes de alto risco. tratamento cirúrgico, radiológico ou endoscópico? posicionamento do colégio brasileiro de cirurgia digestiva

ABSTRACT Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

RESUMO A colecistite aguda (CA) é um processo inflamatório agudo da vesícula biliar que pode estar associado a complicações potencialmente graves, como empiema, gangrena, perfuração da vesícula biliar e sepse. O tratamento padrão para a CA é a colecistectomia laparoscópica. No entanto, para um pequeno grupo de pacientes com CA, o risco de colecistectomia laparoscópica pode ser muito alto, principalmente em idosos com doenças graves associadas. Nestes pacientes críticos, a colecistectomia percutânea ou a drenagem endoscópica da vesícula biliar guiada por ultrassom podem ser uma opção terapêutica temporária, como ponte para a colecistectomia. O objetivo deste artigo de posicionamento do Colégio Brasileiro de Cirurgia Digestiva é apresentar novos avanços no tratamento da CA em pacientes cirúrgicos de alto risco, para auxiliar cirurgiões, endoscopistas e clínicos a selecionar o melhor tratamento para os seus pacientes. A eficácia, segurança, vantagens, desvantagens e resultados de cada procedimento são discutidos. As principais conclusões são: a) Pacientes com CA e risco cirúrgico elevado devem ser tratados preferencialmente em hospitais terciários onde a experiência e os recursos cirúrgicos, radiológicos e endoscópicos estão disponíveis. b) A modalidade de tratamento ideal para pacientes com elevado risco cirúrgico, deve ser individualizada, com base nas condições clínicas e na experiência disponível. c) A colecistectomia laparoscópica continua sendo uma excelente opção de tratamento, principalmente em hospitais em que a drenagem da vesícula biliar percutânea ou endoscópica não está disponível. d) A colecistostomia percutânea e a drenagem endoscópica da vesícula biliar devem ser realizadas apenas em hospitais bem equipados e com radiologista intervencionista e/ou endoscopista experientes. e) O cateter de colecistostomia deve ser removido após a resolução da CA. No entanto, em pacientes que não têm condição clínica para realizar colecistectomia, o cateter pode ser mantido por um período prolongado ou mesmo definitivamente. f) Se o cateter de colecistostomia for mantido por longo período de tempo podem ocorrer várias complicações, como sangramento, fístula biliar, obstrução, dor no local de inserção, remoção acidental do cateter e CA recorrente. g) O tempo de espera ideal entre a colecistostomia e a colecistectomia ainda não foi estabelecido, e vai desde imediatamente após a melhoria clínica, até meses após. h) Longos períodos de espera entre colecistostomia e colecistectomia podem estar associados a novos episódios de CA, múltiplas readmissões hospitalares e aumento dos custos. Finalmente, ao selecionar a melhor opção de tratamento, outros aspectos também devem ser considerados, como custos, disponibilidade dos procedimentos no centro médico e o desejo do paciente. O paciente e sua família devem ser completamente informados sobre todas as opções de tratamento, para que possam ajudar a tomar a decisão final.

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.

Ultrasonographic aspects of the gallbladder mucocele in 30 dogs: retrospective study / Aspectos ultrassonográficos da mucocele biliar em 30 cães: estudo retrospectivo

Gallbladder mucocele is characterized by hyperplasia of the gallbladder epithelium, increased mucus production, accumulation, and densification of the bile content, which can lead to biliary obstruction, necrosis, and rupture of the gallbladder wall. Its finding may be accidental or related to symptoms. A retrospective study (2016-2019) was carried out based on abdominal ultrasound examinations in dogs, correlating aspects of the gallbladder and biliary system in the mucocele with existing comorbidities. Thirty dogs diagnosed with biliary mucocele were evaluated, of which 46.66% had the disease at an early stage, and 53.33% showed a more advanced stage. Of these, 66.66% were related to endocrinopathies and hyperadrenocorticism. Signs of extrahepatic bile duct obstruction and biliary peritonitis were observed in two animals. Due to their potential risk of complications, follow-up ultrasound assessments are indicated in cases that opt for clinical treatment, not excluding the need for surgical intervention.(AU)

A mucocele biliar caracteriza-se pela hiperplasia do epitélio da vesícula biliar, aumento da produção de muco, acúmulo e densificação do conteúdo biliar, podendo levar à obstrução, necrose e ruptura da parede da vesícula biliar. Seu achado pode ser acidental ou estar relacionado à sintomatologia. Foi realizado um estudo retrospectivo (2016-2019) a partir de exames ultrassonográficos abdominais em cães, correlacionando os aspectos da vesícula biliar na mucocele, com comorbidades existentes. Foram avaliados 30 cães com diagnóstico de mucocele biliar, dos quais 46,66% apresentaram a doença em estágio inicial e 53,33% demonstraram estágio mais avançado. Destes, 66,66% tinham endocrinopatias, principalmente hiperadrenocorticismo. Sinais de obstrução de vias biliares extra-hepáticas e peritonite biliar foram observados em dois animais. Por seu potencial risco de complicação, avaliações ultrassonográficas de seguimento são indicadas nos casos de tratamento clínico, não se descartando a necessidade de intervenção cirúrgica.(AU)

Comparative evaluation of three laparoscopic cholecystectomy techniques in rabbit's model

Purpose: The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed. Methods: Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal. Results: Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. Conclusions: LC can be performed using different techniques, although the use of EBVS is highly recommended.

Colecistectomia robótica por incisão única na doença da vesícula biliar: revisão sistemática e metanálise / Robotic single-incision cholecystectomy in gallbladder disease: systematic review and meta-analysis

Introdução: A colecistectomia por incisão única assistida por robótica é técnica cirúrgica emergente para o tratamento da doença da vesícula biliar. Objetivo: Analisar os resultados clínicos e o custo efetividade dela, com foco no tempo de permanência hospitalar, tempo de operação, custo total e taxa de conversão entre robótica e outros procedimentos. Métodos: Revisão sistemática e metanálise foram realizadas de acordo com o Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Os bancos de dados PubMed, Embase e Cochrane foram pesquisados desde o início até março de 2023. Análise estatística foi feita usando o R versão 6.2.1. Metanálise de efeitos aleatórios com razão de risco, diferença média e intervalo de confiança de 95% foi estimada usando a variância inversa e o método de Mantel-Haenszel para resultados binários e o estimador DerSimonian-Laird para resultados contínuos. Resultados: Um total de 452 pacientes foram envolvidos, incluindo 4 estudos randomizados. Os desfechos escolhidos para metanálise foram: permanência hospitalar (MD −0.03 dias, CI 95% −0.12 a 0.18, p=0.708), tempo de operação (MD 12.93 min, CI 95% −21.40 a 47.25, p=0.460) e taxa de conversão (RR 0.90, CI 95% 0.44 a 1.83, p=0.771). Conclusão: Não houve diferença estatisticamente significativa em relação à duração da permanência hospitalar, tempo de operação e taxa de conversão entre a colecistectomia robótica por incisão única e outras técnicas cirúrgicas para a doença da vesícula biliar.

Introduction: Robotic-assisted single-incision cholecystectomy is an emerging surgical technique for the treatment of gallbladder disease. Objective: To analyze the clinical results and its cost effectiveness, focusing on length of hospital stay, operating time, total cost and conversion rate between robotics and other procedures. Methods: Systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, and Cochrane databases were searched from inception through March 2023. Statistical analysis was performed using R version 6.2.1. Random effects meta-analysis with hazard ratio, mean difference and 95% confidence interval was estimated using inverse variance and the Mantel-Haenszel method for binary outcomes and the DerSimonian-Laird estimator for continuous results. Results: A total of 452 patients were enrolled, including 4 randomized trials. The outcomes chosen for meta-analysis were: hospital stay (MD −0.03 days, CI 95% −0.12 to 0.18, p=0.708), operating time (MD 12.93 min, CI 95% −21.40 to 47.25, p=0.460) and of conversion (RR 0.90, CI 95% 0.44 to 1.83, p=0.771). Conclusion: There was no statistically significant difference regarding length of hospital stay, operating time and conversion rate between single-incision robotic cholecystectomy and other surgical techniques for gallbladder disease.

Gallbladder polyps: correlation and agreement between ultrasonographic and histopathological findings in a population with high incidence of gallbladder cancer / Pólipos da vesícula biliar: correlação e concordância entre achados ultrassonográficos e histopatológicos em uma população com alta incidência de câncer de vesícula biliar

ABSTRACT BACKGROUND: Gallbladder polyps are becoming a common finding in ultrasound. The management has to consider the potential risk of malignant lesions. AIMS: The aim of this study was to analyze the ultrasound findings in patients undergoing cholecystectomy due to gallbladder polyps and compare them for histopathological findings (HPs). METHODS: Patients with an ultrasonographic diagnosis of gallbladder polyp and who underwent cholecystectomy from 2007 to 2020 were included in the study. RESULTS: A total of 447 patients were included, of whom 58% were women. The mean age was 45±12 years. The mean size of polyps in US was 7.9±3.6 mm. Notably, 9% of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p=0.003). Histopathological findings confirmed the presence of polyps in 88.4%, with a mean size of 4.8±3.4 mm. In all, 16 cases were neoplastic polyps (4.1%), 4 of them being malignancies, and all were single and larger than 10 mm. We found a significant correlation between ultrasound and histopathological findings polyp size determination (r=0.44; p<0.001). The Bland-Altman analysis obtained an overestimation of the US size of 3.26 mm. The receiver operating characteristic (ROC) curve analysis between both measures obtained an area under the receiver operating characteristic curve (AUC) of 0.77 (95%CI 0.74-0.81). Ultrasound polyps size larger than 10 mm had an odds ratio (OR) of 8.147 (95%CI 2.56-23.40) for the presence of adenoma and malignancy, with a likelihood ratio of 2.78. CONCLUSIONS: There is a positive correlation and appropriate diagnostic accuracy between ultrasound size of gallbladder polyps compared to histopathological records, with a trend to overestimate the size by about 3 mm. Neoplastic polyps are uncommon, and it correlates with size. Polyps larger than 10 mm were associated with adenoma and malignancy.

RESUMO RACIONAL: Os pólipos da vesícula biliar estão se tornando um achado comum na ultrassonografia (US). O manejo deve levar em consideração o risco de lesões malignas. OBJETIVOS: Analisar os achados da ultrassonografia em pacientes submetidos à colecistectomia por pólipos vesicais e compará-los com os achados histopatológicos. MÉTODOS: Foram revisados os prontuários médicos dos pacientes com diagnóstico ultrassonográfico de pólipo vesicular e submetidos à colecistectomia no período de 2007 a 2020. RESULTADOS: Foram incluídos no estudo 447 pacientes. A média de idade foi 45±12anos, sendo 58% mulheres. O tamanho médio dos pólipos na US foide 7,9±3,6mm. Nove por cento foram maiores que 10 mm, e os pólipos únicos encontrados foram maiores do que os múltiplos (p=0,003). A HP confirmou a presença de pólipos em 88,4%, tamanho médio 4,8±3,4mm. Dezesseis eram pólipos neoplásicos (4,1%) e quatro deles malignos, únicos e maiores que 10 mm. Foi encontrado correlação significativa entre a determinação do tamanho do pólipo ao ultrassonografia e histopatológicos (r=0,44; p<0,001). A análise de Bland-Altman obteve uma superestimação do tamanho do pólipo ao US em 3,26 mm. A análise da curva da característica de operação do receptor entre as duas medidas obteve uma área sob a curva curva da característica de operação do receptor (AUC) de 0,77 (IC95% 0,74-0,81). Pólipos ao ultrassonografia maiores que 10 mm apresentaram razão de chance (OR) de 8,147 (IC95% 2,56-23,40) para presença de adenoma e malignidade, com razão de verossimilhança de 2,78. CONCLUSÕES: Há uma correlação positiva e acurácia diagnóstica apropriada entre o tamanho dos pólipos da vesícula biliar por ultrassonografia em comparação com os achados histopatológicos, com uma tendência de superestimar o tamanho em cerca de 3 mm. Pólipos maiores que 10 mm foram associados a adenoma e malignidade.

Effect of acupuncture combined with low frequency rTMS on comorbid mild-to-moderate depressive disorder and insomnia: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the impacts of acupuncture on depressive mood and sleep quality in patients with comorbid mild-to-moderate depressive disorder and insomnia, and explore its effect mechanism.@*METHODS@#A total of 60 patients with comorbid mild-to-moderate depressive disorder and insomnia were randomly divided into an observation group (30 cases, 1 case dropped off) and a control group (30 cases, 2 cases dropped off). In the observation group, acupuncture and low frequency repeated transcranial magnetic stimulation (rTMS) were combined for the intervention. Acupuncture was applied to Baihui (GV 20), Yintang (GV 24+), Neiguan (PC 6) and Yanglingquan (GB 34), etc., the needles were retained for 30 min; and the intradermal needles were embedded at Xinshu (BL 15) and Danshu (BL 19) for 2 days. After acupuncture, the rTMS was delivered at the right dorsolateral prefrontal cortex (R-DLPFC), with 1 Hz and 80% of movement threshold, lasting 30 min in each treatment. In the control group, the sham-acupuncture was adopted, combined with low frequency rTMS. The acupoint selection and manipulation were the same as the observation group. In the two groups, acupuncture was given once every two days, 3 times weekly; while, rTMS was operated once daily, for consecutive 5 days a week. The duration of treatment consisted of 4 weeks. Hamilton depression scale-17 (HAMD-17) and Pittsburgh sleep quality index (PSQI) scores were observed before and after treatment, as well as 1 month after the treatment completion (follow-up period) separately. Besides, the levels of nerve growth factor (BDNF) and γ-aminobutyric acid (GABA) in the serum were detected before and after treatment in the two groups.@*RESULTS@#After treatment and in follow-up, the HAMD-17 scores were lower than those before treatment in the two groups (P<0.05), and the scores in the observation group were lower than the control group (P<0.05). After treatment, the total scores and the scores of each factor of PSQI were reduced in the two groups in comparison with those before treatment except for the score of sleep efficiency in the control group (P<0.05); the total PSQI score and the scores for sleep quality, sleep latency, sleep efficiency and daytime dysfunction in the observation group were all lower than those in the control group (P<0.05). In the follow-up, except for the scores of sleep duration and sleep efficiency in the control group, the total PSQI score and the scores of all the other factors were reduced compared with those before treatment in the two groups (P<0.05); the total PSQI score and the scores of sleep quality, sleep latency, sleep duration, sleep efficiency and daytime dysfunction in the observation group were lower than the control group (P<0.05). After treatment, the levels of serum BDNF and GABA were increased in comparison with those before treatment in the observation group (P<0.05), and the level of serum BDNF was higher than that in the control group (P<0.05).@*CONCLUSION@#Acupuncture relieves depressive mood and improves sleep quality in patients with comorbid mild-to-moderate depressive disorder and insomnia. The effect mechanism may be related to the regulation of BDNF and GABA levels and the promotion of brain neurological function recovery.