Colecistectomias: análise de um hospital escola / Cholecystectomies - analysis in a school hospital

Introdução: A colecistopatia calculosa atinge cerca de 20% da população ocidental adulta, e dela 15% tornam-se sintomáticos. No Brasil foram realizadas, entre 12/2019 e 11/2020, 138.154 colecistectomias pelo Sistema Único de Saúde Objetivo: Levantar dados das colecistectomias realizadas em 2 anos em um hospital escola, analisando o perfil epidemiológico dos pacientes e resultados operatórios. Método: Foram analizadas 942 colecistectomias. Compararam-se os procedimentos eletivos com os de urgência quanto à necessidade de drenagem, reoperação, complicações pós-operatórias e da ferida operatória. Resultados: Do total, 75,9% eram mulheres com média de 48,2 anos de idade. Procedimentos urgentes foram realizadas em 34,9%. Houve mais complicações nas urgências e nos que necessitaram de drenagem. Houve mais complicações na ferida operatória nos pacientes submetidos à reoperação. Conclusão: A análise dos dados mostrou independência de 5 variáveis na evolução pós-operatória das colecistectomias e elas interferiram negativamente quer por si só, quer em associação. Foram elas: drenagem vs. porta de entrada; drenagem vs. reoperação; porta de entrada vs. complicações pós-operatórias; reoperação vs. complicações no pós-operatório; e reoperação vs. complicações na ferida operatória.

Introduction: Calculous cholecystopathy affects about 20% of the Western adult population, and 15% of them become symptomatic. About 138.154 cholecystectomies were performed between 12/2019 and 11/2020 at Brazil, by the public health system. Objective: To collect data from cholecystectomies performed during 2 years in a teaching hospital, analyzing the epidemiological profile of patients and operative results. Method: 942 cholecystectomies were analyzed. Elective and emergency procedures were compared regarding the need for drainage, reoperation, postoperative and wound complications. Results: Of the total, 75.9% were women with a mean age of 48.2 years. Urgent procedures were performed in 34.9%. There were more complications in emergencies and in those requiring drainage. There were more complications in the surgical wound in patients undergoing reoperation. Conclusion: Data analysis showed independence of 5 variables in the postoperative evolution of cholecystectomies and they negatively interfered either by themselves or in combination. They were: drainage vs. hospital entrance; drainage vs. reoperation; hospital entrance vs. postoperative complications; reoperation vs. postoperative complications; and reoperation vs. complications in the surgical wound.

Fístula colecistoduodenal sin migración de cálculo: reporte de caso / Cholecystoduodenal fistula without gallstones migration: case report / Fístula colecistoduodenal sem migração de cálculos: relatório de caso

El síndrome de Bouveret es una causa infrecuente de íleo biliar, posee una elevada morbimortalidad. Se produce por la migración de un cálculo, generalmente de gran tamaño, hacia el tracto gastrointestinal a través de una fistula colecistoduodenal. El objetivo de esta carta científica es presentar un paciente con un estadio previo de la enfermedad donde la fistula se encuentra constituida, pero sin migración del cálculo, por lo que el diagnóstico oportuno tendría un impacto favorable en el tratamiento y pronóstico debido a que no se encuentra instaurado el cuadro obstructivo intestinal.

Bouveret's syndrome is a rare cause of biliary ileus, with a high morbimortality. It is caused by the migration of a stone, usually large, into the gastrointestinal tract through a cholecystoduodenal fistula. The objective of this scientific letter is to present a patient with a previous stage of the disease where the fistula is constituted, but without migration of the calculus, so that the timely diagnosis would have a favorable impact on the treatment and prognosis because the obstructive intestinal condition is not established.

A síndrome de Bouveret é uma causa rara de íleo biliar com uma morbilidade e mortalidade elevadas. É causada pela migração de uma pedra, geralmente grande, para o tracto gastrointestinal através de uma fístula colecystoduodenal. O objectivo desta carta científica é apresentar um doente com uma fase anterior da doença em que a fístula está presente, mas sem migração da pedra, para que o diagnóstico atempado tenha um impacto favorável no tratamento e prognóstico, uma vez que a condição obstrutiva instestinal não está estabelecida.

Caracterización de la flora bacteriana en los pacientes con colelitiasis y colecistitis atendidos en un centro hospitalario de alta complejidad / Characterization of the bacterial flora in patients with cholelithiasis and cholecystitis treated in a high complexity hospital

Introducción. Las infecciones del árbol biliar surgen principalmente por estasis asociada a colecistitis aguda, coledocolitiasis y colecistitis alitiásica, siendo pilar del tratamiento un drenaje apropiado y un régimen antibiótico eficaz. El objetivo de esta investigación fue caracterizar la flora bacteriana de los cultivos de bilis. Métodos. Se realizó un estudio observacional, descriptivo, de corte transversal y retrospectivo de pacientes llevados a colecistectomía, colangiopancreatografía retrograda endoscópica y colecistostomía en nuestra institución, a quienes se les tomó cultivo de líquido biliar entre 2017 - 2021. Resultados. Se incluyeron 119 pacientes intervenidos, de los cuales 55,4 % fueron mujeres y el promedio de edad fue de 63,1 (± 16). La clasificación Tokio 2 fue la más frecuente (55,4 %). El germen aislado con mayor frecuencia fue E. coli (51,2 %). El antibiótico más usado fue ampicilina más sulbactam (44,6 %) seguido de piperacilina tazobactam (40,3 %). Conclusión. La Escherichia coli es el germen aislado con mayor frecuencia en infecciones del árbol biliar. No hay claridad con respecto al uso de antimicrobianos de manera profiláctica en esta patología, por esto es conveniente generar protocolos para la toma de muestras y cultivos de bilis en esta población, con el fin de establecer la necesidad del uso de antibióticos y conocer los perfiles de resistencia bacteriana.

Introduction. Infections of the biliary tree arise mainly from stasis associated with acute cholecystitis, choledocholithiasis, and acalculous cholecystitis, with appropriate drainage and an effective antibiotic regimen being the mainstay of treatment. This research is proposed with the aim aim to characterize the bacterial flora of bile cultures.Methods. An observational, descriptive, cross-sectional and retrospective study of patients who underwent cholecystectomy, endoscopic retrograde cholangiopancreatography and cholecystostomy in our institution, whom bile fluid culture was taken between 2017 and 2021, was performed. Results. 119 operated patients were included, of which 55.4% were women, the average age was 63.1 (± 16). The TOKIO 2 classification was the most frequent with 55.4% of the patients. The most frequently isolated germ was E. coli with 51.2%. The most used antibiotic was ampicillin plus sulbactam with 44.6% prescription followed by piperacillin tazobactam with a prescription frequency of 40.3%.Conclusion. Escherichia coli is the most frequently isolated germ in infections of the biliary tree. There is no clarity regarding the use of antimicrobials prophylactically in this pathology. For this reason it is convenient to generate protocols for taking samples and bile cultures in this population, in order to establish the need for the use of antibiotics and to know the profiles of bacterial resistance.

Dilataciones quísticas congénitas de las vías biliares (segunda parte). Vías biliares extrahepáticas / Congenital bile duct cystic dilatations (part 2). Extrahepatic bile ducts

RESUMEN Las dilataciones quísticas congénitas de la vía biliar extrahepática son infrecuentes, principalmente en Occidente, y afectan sobre todo a niños pero son poco comunes en adultos. El diagnóstico requiere un alto índice de sospecha y suele llevarse a cabo con estudios colangiográficos de los cuales la CRMN es, en la actualidad, el de mayor utilidad. Es conocido el aumento de malignización de estas dilataciones, por lo que el tratamiento completo de la bolsa quística es obligatorio.

ABSTRACT Congenital dilatation of extrahepatic bile ducts is rare in the Western countries and is more common in children than in adults. The diagnosis requires high level of suspicion and is made by cholangiography tests, among which MRCP is the most useful nowadays. Malignant transformation of these cystic dilatations is well-known; therefore, complete resection of the cystic pouch is mandatory.

Progress in diagnosis and treatment of gangrenous cholecystitis / 中华外科杂志

Gangrenous cholecystitis is a kind of acute cholecystitis, whose course of disease progresses rapidly, early diagnosis is difficult and mortality is high, and clinicians are prone to misdiagnosis and missed diagnosis in clinical work.However, gangrenous cholecystitis has been ignored in various guidelines.This paper systematically summarized the pathogenesis, pathological manifestations, epidemiology, clinical diagnosis and treatment of gangrenous cholecystitis, hoping to provide a complete and clear diagnosis and treatment process for clinicians.

Colelitiasis en Remanente vesicular: reporte de caso / Cholelithiasis in gallbladder remnant: case report / Colelitíase em remanescente de vesícula biliar: relato de caso

Los cálculos biliares se encuentran dentro de los motivos de consulta más frecuentes a nivel mundial, la entidad quirúrgica emergente es la colecistitis en el 90-95 % de los casos, la colecistectomía laparoscópica es la opción ideal de tratamiento, la persistencia de sintomatología postoperatoria, inclusive en el transcurrir de los años es frecuente, en este contexto, es preciso mencionar al síndrome post-colecistectomía que es poco reportado en la localidad. Se presenta el caso de paciente masculino de 71 años de edad con antecedente de colecistectomía abierta hace 13 años, que consulta por meteorismo abdominal, dispepsia, leve dolor en hipocondrio derecho. En los exámenes complementarios de imagen, por ecografía de abdomen, se evidencia colelitiasis en muñón vesicular remanente, diagnóstico certificado por resonancia magnética, indicada previamente por facultativo para control de sus comorbilidades, en el cual se da el hallazgo incidental de litiasis vesicular. Se realiza manejo quirúrgico, colecistectomía laparoscópica, sin ninguna complicación. El paciente mostró adecuada evolución postquirúrgica, siendo dado de alta con analgesia y antibioticoterapia.

Gallstones are among the most frequent reasons for consultation worldwide, the emerging surgical entity is cholecystitis in 90-95% of cases, laparoscopic cholecystectomy is the ideal treatment option, the persistence of postoperative symptoms, even in the passing of the years it is frequent, in this context, it is necessary to mention the post-cholecystectomy syndrome that is little reported in the locality. We present the case of a 71-year-old male patient with a history of open cholecystectomy 13 years ago, who consulted for abdominal bloating, dyspepsia, and mild pain in the right hypochondrium. In the complementary imaging tests, by abdominal ultrasound, cholelithiasis is evidenced in the remaining gallbladder stump, a diagnosis certified by magnetic resonance, previously indicated by the physician to control his comorbidities, in which the incidental finding of gallbladder lithiasis occurs. Surgical management is performed, laparoscopic cholecystectomy, without any complications. The patient showed adequate postoperative evolution, being discharged with analgesia and antibiotic therapy.

Os cálculos biliares estão entre os motivos de consulta mais frequentes em todo o mundo, a entidade cirúrgica emergente é a colecistite em 90-95% dos casos, a colecistectomia laparoscópica é a opção de tratamento ideal, a persistência dos sintomas pós-operatórios, mesmo com o passar dos anos é frequente, nesse contexto, é necessário citar a síndrome pós-colecistectomia que é pouco relatada na localidade. Apresentamos o caso de um paciente do sexo masculino de 71 anos com história de colecistectomia aberta há 13 anos, que consultou por dispepsia, dispepsia e dor leve no hipocôndrio direito. Nos exames complementares de imagem, por ultrassonografia abdominal, evidencia-se colelitíase no coto vesicular remanescente, diagnóstico certificado por ressonância magnética, previamente indicado pelo médico para controle de suas comorbidades, em que ocorre o achado incidental de litíase vesicular. O manejo cirúrgico é realizado, colecistectomia laparoscópica, sem complicações. A paciente apresentou evolução pós-operatória adequada, recebendo alta com analgesia e antibioticoterapia.

Resultados asociados con la realización de colecistectomía subtotal en un hospital de tercer nivel de Bogotá / Results of partial cholecystectomy in a tertiary level hospital in Bogotá

Resumen Introducción: La colecistectomía laparoscópica es actualmente el gold standard en patología vesicular litiásica. Hay un grupo de pacientes que tiene un gran proceso inflamatorio que impide la identificación adecuada del triángulo de seguridad. Dado lo anterior, una alternativa es la realización de colecistectomía subtotal por laparoscopia, para reducir el riesgo de lesión de vía biliar. Objetivo: Describir los resultados clínicos y quirúrgicos en pacientes que se sometieron a la realización de colecistectomía subtotal laparoscópica en el Hospital Universitario Clínica San Rafael en el periodo comprendido entre febrero de 2015 y febrero de 2017. Materiales y Método: Serie de casos, donde se realizó un análisis descriptivo para determinar la distribución de las variables, se utilizaron tablas de contingencia, pruebas Fischer según el caso y su distribución en número y normalidad. Resultados: Se obtuvo información de 28 pacientes, con un promedio de edad de 56,1 años, mayor proporción de hombres. En cuanto a las características clínicas se observaron los antecedentes de diabetes e hipertensión arterial. No hubo complicaciones ni sangrado intraoperatorio importantes. En resultados posoperatorios no se presentó lesión de vía biliar en ninguno, hubo 3 reingresos (10,7%) y hubo una reintervención relacionada con colección intraabdominal. Se reportó una mortalidad secundaria a neumonía. Conclusión: La colecistectomía subtotal es un procedimiento seguro en cuanto a la prevención de lesión de vía biliar.

Introduction: Laparoscopic cholecystectomy is actually the gold standard surgical approach to the gallbladder disease. Some patients with severe cholecystitis and inflammatory changes that makes impossible to dissect the hepatocystic triangle. Is in this case, where the laparoscopic subtotal cholecystectomy is an option, to reduce the risk of biliary injury. Aim: To describe the clinical and surgical results in patients that underwent in laparoscopic subtotal cholecystectomy at Hospital Universitario Clínica San Rafael since February 2015 to February 2017. Materials and Method: A case series study was carried out, with a descriptive analysis to determine the distribution of them. We used contingency tables and fischer tests. Results: 28 laparoscopic subtotal cholecystectomy. The average age of 56.1 years, fifty percent was men. At the clinical characteristics, the history of diabetes and arterial hypertension was observed. There was no bile duct lesion in any and there was a reintervention due to intra-abdominal collection and only one mortality. 50% had biliary leakage and 25% of cases required endoscopic intervention. Conclusion: Laparoscopic subtotal cholecystectomy is a safe procedure.

Asociación entre los factores socioeconómicos y las complicaciones postoperatorias de la colecistectomía / Association between socioeconomic factors and postoperative complications of cholecystectomy

El objetivo de este artículo es determinar si los factores socioeconómicos inciden en las complicaciones posoperatorias de la colecistectomía. Para ello, se definió realizar un estudio de tipo observacional, analítico y enfoque cuantitativo, en 100 pacientes en los que se les realizó colecistectomía. Se aplicó un modelo de regresión logística en el que se incorporaron como variables, factores de riesgo, características socioeconómicas, junto con una variable de control. Se aplicaron tres modelos con variables dependientes alternativas que están delimitadas por el tipo de complicación posoperatoria registrado. Los resultados encontrados mostraron que las mujeres manifiestan un mayor riesgo de presentar complicaciones posteriores a la colecistectomía, igual ocurre en los pacientes de mayor edad. Asimismo el riesgo es mucho menor en las personas con niveles de educación superior y en los pacientes en los que se realizó colecistectomía laparoscópica, alcanzando solo un 5% de riesgo de presentar complicaciones. Las complicaciones posoperatorias luego de la colecistectomía se minimizan al emplear la técnica laparoscópica y los factores socioeconómicos incidirían en el riesgo de padecer complicaciones posoperatorias luego de dicha cirugía, lo que la convierte a la colecistectomía laparoscópica en una operación segura y con muchos otros beneficios y ventajas sobre la cirugía tradicional o convencional.

The article ́s goal isto determine if socioeconomic factors influence the postoperative complications of cholecystectomy. For this, the observational study was defined, analytical and quantitative study was conducted in 100 patients who underwent cholecystectomy. A logistic regression model was applied in which risk factors, socioeconomic characteristics, along with a control variable, were incorporated as variables. Three models were run with alternative dependent variables that are delimited by the type of postoperative complication recorded. The results found showed that women show a higher risk of presenting complications after cholecystectomy, the same occurs in older patients. Likewise, the risk is much lower in people with higher education levels and in patients who underwent laparoscopic cholecystectomy, they only have a 5% risk of presenting complications. Postoperative complications after cholecystectomy are minimized by using the laparoscopic technique and socioeconomic factors would influence the risk of suffering postoperative complications after said surgery, which makes laparoscopic cholecystectomy a safe operation with many other benefits and advantages over traditional or conventional surgery.

Síndrome de bouveret, una forma infrecuente de íleo biliar: a propósito de un caso y revisión de la literatura / Bouveret syndrome, a rare presentation of biliary ileus: case report and literature review

El íleo biliar es una complicación poco frecuente de la colelitiasis o colecistitis litiásica, aparece en menos del 1-3% de los pacientes con estas enfermedades, se define como una obstrucción intestinal mecánica debido a la impactación de uno o más cálculos biliares dentro del tracto gastrointestinal. Ubicaciones menos comunes incluyen estómago y duodeno (síndrome de Bouveret) y el colon. El diagnóstico del síndrome de Bouveret (SB) suele iniciar con una radiografía simple de abdomen; la ecografía abdominal confirma el síndrome de Bouveret si revela neumobilia y ubicación ectópica del cálculo biliar, sin embargo, en la mayoría de los casos se necesita una tomografía computarizada que permite una evaluación completa.Caso Clínico : Se presenta caso de masculino de 57 años de edad quien 8 días previo a su ingreso presenta dolor abdominal en epigastrio de moderada intensidad acompañado de pirosis, halitosis, náuseas, vómitos, intolerancia a la vía oral y ausencia de evacuaciones; acude inicialmente a gastroenterólogo que realiza endoscopia digestiva superior encontrando una imagen de obstrucción a nivel de primera porción de duodeno, motivo por el cual refiere a servicio de cirugía general donde es intervenido quirúrgicamente, se diagnostica el SB realizando gastrotomía, extracción del lito y piloroplastia, presentando adecuada evolución postoperatoria.Conclusión : El SB es un diagnóstico raro que afecta a <0,5% de los pacientes con cálculos biliares por lo que requiere un grado extremadamente alto de sospecha para el diagnóstico y puede observarse de manera incidental en estudios de imágenes en pacientes que presentan síntomas de obstrucción del vaciamiento gástrico(AU)

Biliary ileus is a rare complication of cholelithiasis or lithiasic cholecystitis, appearing in less than 1 to 3% of patients with these diseases, it is a mechanical intestinal obstruction due to the impaction of one or more gallstones within the gastrointestinal tract. Less common locations include the stomach and duodenum (Bouveret syndrome) and the colon. For the diagnosis of Bouveret's syndrome (BS) the initial step is usually a simple abdominal X-ray, while an abdominal ultrasound confirms Bouveret's syndrome if it reveals pneumobilia and ectopic location of the gallstone, in most cases a computed tomography (CT) scan is needed for diagnosis and full evaluation.Clinical Case: We present the clinical case of a 57-year-old male who 8 days prior to his admission presented with moderate intensity abdominal pain in the epigastrium accompanied by heartburn, halitosis, nausea, vomiting, intolerance to oral intake, and absence of evacuations; initially went to a gastroenterologist who performed upper digestive endoscopy, finding an image of obstruction at the level of the first portion of the duodenum, which is why he refers to the general surgery department where he underwent surgery, diagnosing BS by performing gastrotomy, stone extraction, and pyloroplasty, presenting adequate postoperative evolution.Conclusion : BS is a rare diagnosis that affects <0.5% of patients with gallstones and therefore requires an extremely high degree of suspicion for the diagnosis and can be seen incidentally on imaging studies in patients with symptoms of obstruction of gastric emptying(AU)

Prevalencia de colecistolitiasis y cáncer de vesícula en una población rural aymara de Chile

Background: The prevalence of cholelithiasis and gallbladder cancer may be different across ethnic groups. Aim: To study the prevalence of cholelithiasis and gallbladder cancer among Aymara individuals. Material and Methods: An abdominal ultrasound was carried out in a sample of 182 Aymara women aged 46 ± 16 years and 76 Aymara men aged 55 ± 16 years. In addition, the histopathological reports of both patients with a history of previous cholecystectomy and those operated after the study were reviewed. Results: Ultrasound was normal in 150 participants (58%), 76 had cholelithiasis (30%) and 32 (12%) had a history of cholecystectomy. Pathological reports of the excised gallbladder were available for 106 cases and showed a chronic cholecystitis in 98% of cases. Gallbladder cancer was not reported. Conclusions: There is a 42% prevalence of cholelithiasis and no gallbladder cancer in this sample of Aymara population.

Síndrome de Bouveret: Presentación de Caso Clínico / Bouveret Syndrome: Clinical Case Presentation

RESUMEN Introducción: El íleo biliar es una patología poco frecuente caracterizada por obstrucción mecánica intestinal debido a la impactación de un cálculo biliar dentro del tracto gastrointestinal, caracterizado por la tríada de Rigler, se observa en pacientes de edad avanzada con antecedentes de colelitiasis o colecistitis, por la existencia de una fístula bilioentérica. Se asocia a alta morbilidad y mortalidad. Sus síntomas y signos en su mayoría son inespecíficos y su diagnóstico se basa en un enfoque radiológico. Si bien la cirugía abierta ha sido el pilar del tratamiento, recientemente se han empleado otros enfoques, incluyendo cirugía laparoscópica y litotripsia. Caso clínico:Paciente femenino de 100 años de edad con cuadro de dolor abdominal, náusea y vómito de varios días de evolución. El diagnóstico fue realizado por tomografía computarizada. Conclusión: El íleo biliar es una entidad clínica de difícil diagnóstico. El uso de técnicas de imagen puede mejorar la precisión diagnóstica y la toma de recursos terapéuticos. Palabras claves: Obstrucción Intestinal; Cálculos Biliares; Condiciones Patológicas, Signos y Síntomas; Tomografía Computarizada por Rayos X; Litotricia; Laparoscopía

ABSTRACT Introduction: Gallstone ileus is a rare pathology characterized by mechanical intestinal obstruction due to the impaction of a gallstone inside the gastrointestinal tract, characterized by the Rigler triad, it is observed in elderly patients with a history of cholelithiasis or chole-cystitis, due to the existence of a bilioenteric fistula. It is associated with high morbidity and mortality. Its symptoms and signs are mostly nonspecific and its diagnosis is based on a radiological approach. Although open surgery has been the mainstay of treatment, other approaches have recently been used, including laparoscopic surgery and lithotripsy. Clinical case: 100 year-old female patient, with ab-dominal pain, nausea and vomiting that lasted several days of evolution. The diagnosis was made by computed tomography. Conclusion: Gallstone ileus is a clinical entity difficult to diagnose. The use of imaging techniques can improve the diagnostic accuracy and the taking of therapeutic resources. Keywords: Obstrucción Intestinal; Cálculos Biliares; Condiciones Patológicas, Signos y Síntomas; Tomografía Computarizada por Rayos X; Litotricia; Laparoscopía

Adherencia a las guías de práctica clínica en los pacientes con colecistitis aguda / Adherence to clinical practice guidelines in patients with acute cholecystitis

La colecistitis aguda es una enfermedad que se diagnostica a diario en la práctica médica diaria, presentando como síntoma principal dolor en hipocondrio derecho, realizando colecistectomías como una de las primeras diez causas de intervenciones o procedimientos quirúrgicos realizados de forma emergente como ambulatorio, y es por lo cual importante resaltar el interés en el uso de protocolos o algoritmos para la mejor toma de decisiones y resultados en el manejo de dicha entidad. Mediante el siguiente trabajo queremos evaluar y plantear la importancia de la aplicación de las guías de manejo en la práctica clínica en pacientes con colecistitis aguda calculosa, Por medio de la revisión bibliográfica, actualización y análisis de guías utilizadas a nivel internacional para el diagnóstico, clasificación y tratamiento de los pacientes con colecistitis aguda calculosa, con el objetivo de mejorar la atención de los pacientes y realizar promoción, prevención y tratamiento oportuno, de esa forma disminuir el costo de intervención médico y quirúrgico, disminuir los días de estancia intrahospitalaria y evitar las complicaciones graves en los pacientes, sin embargo queremos conocer la variabilidad terapéutica que existe en esta patología. Ante tal situación gracias a la evidencia e investigación científica la terapéutica médica ha ido evolucionando gradualmente, con el fin de mejorar la costo-efectividad de los tratamientos, y por ello que los profesionales en la práctica médica especialmente los cirujanos más allá de la técnica quirúrgica les es importante estar constantemente actualizados con todos los hallazgos y resultados que se reportan en el contexto de esta enfermedad

Palliative Measures with Ethanol Gallbladder Ablation and Endobiliary Radiofrequency Ablation Followed by Endoscopic Biliary Stent Placement in an Advanced Case of Common Bile Duct Cancer: A Case Report / 대한소화기학회지

Endobiliary radiofrequency ablation (RFA) is a procedure performed widely to induce locoregional tumor control by the transfer of thermal energy to the lesion and subsequent tumor necrosis. A 72-year-old male with a prior history of acute calculous cholangitis and perforated cholecystitis was admitted to the Kyungpook National University Hospital complaining of fever and nausea. He had an indwelling percutaneous transhepatic gallbladder drainage (PTGBD) catheter from the previous episode of perforated cholecystitis. An abdominal CT scan showed marked dilation of both the intrahepatic and extrahepatic bile ducts. Common bile duct cancer was confirmed histologically after an endobiliary biopsy. A surgical resection was considered to be the initial treatment option. During open surgery, multiple metastatic nodules were present in the small bowel mesentery and anterior abdominal wall. Resection of the tumor was not feasible, so endobiliary RFA was performed prior to biliary stenting. Cholecystectomy was required for the removal of the PTGBD catheter, but the surgical procedure could not be performed due to a cystic ductal invasion of the tumor. Instead, chemical ablation of the gallbladder (GB) with pure ethanol was performed to breakdown the GB mucosa. Palliative treatment for a biliary obstruction was achieved successfully using these procedures. In addition, a PTGBD catheter was removed successfully without significant side effects. As a result, an improvement in the patient's quality of life was accomplished.

Management of non traumatic surgical emergencies during the COVID-19 pandemia / Conduta nas urgências e emergências cirúrgicas não traumáticas durante a pandemia COVID-19

ABSTRACT In December 2019, in Wuhan, China, the first cases of what would be known as COVID-19, a disease caused by an RNA virus called SARS-CoV-2, were described. Its spread was rapid and wide, leading the World Health Organization to declare a pandemic in March 2020. The disease has distinct clinical presentations, from asymptomatic to critical cases, with high lethality. Parallel to this, patients with non-traumatic surgical emergencies, such as acute appendicitis and cholecystitis, continue to be treated at the emergency services. In this regard, there were several doubts on how to approach these cases, among them: how to quickly identify the patient with COVID-19, what is the impact of the abdominal surgical disease and its treatment on the evolution of patients with COVID-19, in addition to the discussion about the role of the non-operative treatment for abdominal disease under these circumstances. In this review, we discuss these problems based on the available evidence.

RESUMO Em dezembro de 2019, em Wuhan na China, foram descritos os primeiros casos do que seria conhecida como a COVID-19, doença causado por um RNA vírus denominado SARS-CoV-2. A disseminação foi rápida e ampla, levando a Organização Mundial de Saúde a decretar pandemia em março de 2020. A doença tem apresentação clínica variada, desde portadores assintomáticos até casos críticos, com alta letalidade. Paralelamente a isto, pacientes com urgências cirúrgicas não traumáticos, como apendicites agudas e colecistites agudas, continuam a ser atendidos nos serviços de emergências. Neste contexto, surgiram várias dúvidas sobre a conduta nestes casos, entre essas: como identificar rapidamente o paciente com COVID-19, qual o impacto da doença cirúrgica abdominal e o tratamento na evolução dos pacientes com COVID-19, além da discussão sobre o emprego de tratamento não operatório para a doença abdominal nestas circunstâncias. Nesta revisão, trazemos a discussão destes problemas sob a luz das evidências disponíveis.

Biliary tract infections and their Microbiological Spectrum- A study from coastal region of Southern India / Infecciones de vías biliares y su espectro microbiologico- Un estudio en región de la costa del sur de la India

Objective: Biliary tract infections include cholangitis and cholecystitis. They are associated with high morbidity and mortality in elderly patients with co-morbid disease. The present study was undertaken to determine the microbial aetiology causing biliary tract infections and also to study their antimicrobial resistance profile. Materials & methods: A retrospective study was conducted from January 2011 to December 2016 at the Enteric Diseases Division, Kasturba Medical College Hospital, Manipal. Patients with biliary tract infections admitted in tertiary referral health care hospital, Manipal were included for the study. Aerobic and anaerobic bacteriological and fungal aetiology of biliary tract infections were recorded along with their antimicrobial resistance profile. Results: Out of 307 bile samples sent for aerobic culture and susceptibly testing 187 (60.91%) were positive for culture, of which Escherichia coli (44.4%) was the predominant aetiology followed by Klebsiella pneumoniae (27.3%). Among the 14 samples sent for anaerobic culture, 5 (35.75%) specimens showed growth, of which Bacteroides fragilis group was found to be the predominant anaerobe. Among the 201 bacterial pathogens tested for their antimicrobial susceptibility, 108 (53.73%) isolates were resistant, out of which 9 were PDR Enterobacteriaceae with 12 ESBL strains. All the Candida species were susceptible to fluconazole with the exception of C. glabrata and C. krusei. All the anaerobic isolates were found to be susceptible to Metronidazole. Conclusions: The high rate of bacterial infection particularly gram-negative bacteria was recorded. It is necessary that antimicrobial therapy be initiated when culture or the clinical conditions reports caution. Routine aerobic and anaerobic culturing of bile samples with biliary tract infections are imperatively necessary. With the emergence of multidrug resistant pathogens and change in the microbiological spectrum of biliary tract infections, there is a need for the empirical antimicrobial therapy in every clinical setting.

Objectivo: Las infecciones del tracto biliar incluyen colangitis y colecistitis. Se asocian a gran mortalidad y morbildiad en pacientes ancianos y con comorbilidad. El presente studio se hizo para detemrianr la etiologia microbiana que produce infecciones biliares y para estudiar su perfil de resistencia antimicrobiana. Materiales & metodos: Se hizo un studio retrospectivo entre los meses de Enero 2011 a Diciembre de 2016 en la "Enteric Diseases Division, Kasturba Medical College Hospital, Manipal" en India. Los pacientes con infección de vías biliares admitidos al centro de atención de tercer nivel se incluyeron en el estudio. Se buscaron bacterias aerobicas y anaerobicas y etiologia fungica y se analizó su perfil de resistencia antibiotica. Resultados: De 307 muestras de bilis enviadas para cultivo aerobico y antibiograma, 187 (60.91%) crecieron en el medio de cultivo, predominando Escherichia coli (44.4%) seguida por Klebsiella pneumoniae (27.3%). Entre las 14 muestras analizadas en medio anaerobio, 5 (35.75%) mostraron crecimiento de Bacteroides fragilis. Entre 201 bacterias probadas por antibiograma, 108 (53.73%) tuvieron perfil de resistencia, de los cuales 9 fueron PDR Enterobacteriaceae con 12 cepas ESBL. Todas las especies de Candida fueron susceptibles al fluconazol con la excepción de C. glabrata y C. krusei. Todos los aislados anaerobios fueron susceptibles al Metronidazol. Conclusiones: Se encontró una alta tasa de infección bacteriana con predominio de gram-negativos. Se hace necesario iniciar terapia antimicrobiana cuando lo sugieren las condiciones clínicas o el resultado del cultivo. El cultivo rutinario de bilis es imperioso. Dado el aumento de patógenos multirresistentes se requiere inicio empírico inmediato

Quiste de conducto cístico / Cystic duct cyst

Los quistes congénitos de la vía biliar son infrecuentes y se definen por la dilatación quística del árbol biliar en cualquiera de sus porciones. Los quistes del conducto cístico son aún menos frecuentes. Su etiología permanece incierta y el tratamiento consiste en la resección debido a su potencial desarrollo de malignidad. Presentamos el caso de una paciente en la que se diagnosticó dilatación del conducto cístico y fue tratada por vía laparoscópica.

Congenital biliary duct cysts are rare and are defined as cystic dilatations of the biliary tree in any of its portions. Cystic duct cysts are more uncommon. Their etiology remains uncertain and they should be resected due to the possible development of malignancy. We report the case of a female patient with a diagnosis of dilation of the cystic duct that was treated with laparoscopic surgery.

Colecistitis hemorrágica: reporte de caso y revisión de la literatura / Hemorrhagic cholecystitis: case report and literature review

Resumen Introducción: La colecistitis hemorrágica es una complicación poco frecuente de la colecistitis aguda con una alta mortalidad. Materiales y Método: Paciente con dolor abdominal en hipocondrio derecho e ictericia. Los exámenes de laboratorio y ultrasonido hepatobiliar mostraron datos sugestivos de colecistitis aguda; durante su estancia hospitalaria presenta deterioro de su estado general, realizándose tomografía computarizada mostrando imágenes sugestivas de colecistitis hemorrágica y hemoperitoneo. Resultados: Laparotomía de urgencia, corroborando los hallazgos tomográficos y resolviéndose satisfactoriamente con la colecistectomía. Discusión: El diagnóstico de colecistitis hemorrágica es difícil ya que sus manifestaciones clínicas de inicio no difieren de la colecistitis aguda, por lo que la sospecha clínica y el adecuado estudio de imagen son importantes para su detección. Conclusión: A pesar que la colecistitis hemorrágica con perforación y hemoperitoneo es una patología muy poco común, de diagnóstico confuso, es importante establecer la realización de una tomografía computarizada abdominal con contraste endovenoso en pacientes con sospecha de colecistitis aguda grave.

Introduction: Hemorrhagic cholecystitis is a rare complication of acute cholecystitis with a high mortality. Materials and Method: Patient with abdominal pain in right hypochondrium and jaundice. Laboratory analyses and hepatobiliary ultrasound suggested acute cholecystitis, however, general worsening during hospital stay was observed and a computed tomography was performed, revealing hemorrhagic cholecystitis and hemoperitoneum. Results: Urgent laparotomy which confirmed tomographic results, successfully solved with cholecystectomy. Discussion: Hemorrhagic cholecystitis diagnosis is difficult as symptoms at the beginning do not differ from acute cholecystitis, then, clinical suspicion and a correct image analysis is crucial for its detection. Conclusion: Although, perforated hemorrhagic cholecystitis with hemoperitoneum is a very rare entity with confused diagnosis, an abdominal computed tomography with intravenous contrast is very important in any patient with severe acute cholecystitis suspicion.

Does male gender increase the risk of laparoscopic cholecystectomy? / O gênero masculino aumenta o risco de colecistectomia laparoscópica?

ABSTRACT Background: Laparoscopic cholecystectomy is the preferable treatment for chronic or acute cholecystitis. Some factors may increase the rate of laparoscopic conversion to open cholecystectomy and perioperative complications. The role of gender as a risk factor for laparoscopic cholecystectomy is controversial. Aim: To evaluate the role of the gender on the operative findings and outcome of laparoscopic cholecystectomy. Method: All patients who underwent laparoscopic cholecystectomy for chronic or acute cholecystitis were included. Demographic, clinical, laboratory, imaging exams, intraoperative and postoperative data were obtained and analyzed. The data was obtained retrospectively from electronic medical records and study protocols. Results: Of a total 1,645 patients who were subjected to laparoscopic cholecystectomy, 540 (32.8%) were men and 1,105 (67.2%) were women. Mean age was similar in both genders (p=0.817). Operative time has longer in the male (72.48±28.50) than in the female group (65.46±24.83, p<0.001). The rate of acute cholecystitis was higher in the male (14.3%) than in the female group (5.1%, p<0.001). There was no difference between the genders in regard to the rate of conversion (p=1.0), intraoperative complication (p=1.0), postoperative complication (p=0.571), and operative mortality (p=1.0). Conclusion: Male gender is not an independent risk factor for laparoscopic conversion and perioperative complications.

RESUMO Racional: A colecistectomia laparoscópica é o tratamento de escolha para colecistite crônica ou aguda. Alguns fatores podem aumentar a taxa de conversão para colecistectomia laparotômica e de complicações perioperatórias. O papel do gênero, como um fator de risco para colecistectomia laparoscópica, é controverso. Objetivo: Avaliar o papel do gênero nos achados operatórios e no desfecho da colecistectomia laparoscópica. Métodos: Todos os pacientes que foram submetidos à colecistectomia laparoscópica por colecistite crônica ou aguda foram incluídos. Dados demográficos, clínicos, laboratoriais, de imagem, intraoperatórios e pós-operatórios foram obtidos e analisados. Os dados foram obtidos retrospectivamente a partir de prontuários eletrônicos e protocolos de estudo. Resultados: De um total de 1.645 pacientes que foram submetidos à colecistectomia laparoscópica, 540 (32,8%) eram homens e 1.105 (67,2%) mulheres. A idade média foi semelhante em ambos os gêneros (p=0,817). O tempo operatório foi maior nos homens (72,48±28,50) do que nas mulheres (65,46±24,83) (p<0,001). A taxa de colecistite aguda foi maior no grupo masculino (14,3%) do que no feminino (5,1%, p<0,001). Não houve diferença entre os gêneros quanto à taxa de conversão (p=1,0), complicação intraoperatória (p=1,0), complicação pós-operatória (p=0,571) e mortalidade operatória (p=1,0). Conclusão: O gênero masculino não é fator de risco independente para a conversão laparoscópica e complicações perioperatórias.

Alterações histológicas da vesícula biliar de doentes submetidos à colecistectomia por colelitíase / Gallbladder histological alterations in patients undergoing cholecystectomy for cholelithiasis

RESUMO Objetivo: descrever os achados histológicos das vesículas biliares de pacientes submetidos à colecistectomia e avaliar a presença de fatores associados ao câncer incidental da vesícula. Métodos: estudo descritivo, transversal e observacional de 1.278 exames anatomopatológicos de vesículas biliares oriundas de colecistectomias por colelitíase e de seus respectivos laudos, realizadas no período de janeiro de 2008 a dezembro de 2017. Resultados: o achado anatomopatológico mais frequente foi a colecistite crônica, presente em 1.251 pacientes (97,8%), seguido pela colesterolose em 131 (10,2%). O câncer de vesícula foi identificado em seis pacientes, com prevalência de 0,5% nesta amostra. Houve associação significativa entre a presença de câncer e idade ≥60 anos e com a espessura da parede ≥0,3cm. Conclusão: houve baixa prevalência de câncer de vesícula na população avaliada, maior ocorrência na população idosa e associação de tumor com espessamento da parede vesicular.

ABSTRACT Objective: to describe the histological findings of the gallbladders of patients undergoing cholecystectomy and to evaluate the presence of factors associated with gallbladder incidental cancer. Methods: we conducted a descriptive, cross-sectional, observational study with 1,278 histopathological exams of gallbladders coming from cholecystectomy for cholelithiasis and of their reports, held from January 2008 to December 2017. Results: the most common pathological finding was chronic cholecystitis, present in 1,251 patients (97.8%), followed by gallbladder cholesterolosis, in 131 (10.2%). Gallbladder cancer was identified in six patients, with a prevalence of 0.5% in this sample. There was a significant association between the presence of cancer and age ≥60 years and wall thickness ≥0.3cm. Conclusion: there was low prevalence of gallbladder cancer in this population, higher occurrence in the elderly and association of the tumor with gallbladder wall thickness.