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

When to remove the drainage catheter in patients with percutaneous cholecystostomy?

SUMMARY OBJECTIVE: The treatment for patients with acute calculous cholecystitis who have high surgical risk with percutaneous cholecystostomy instead of surgery is an appropriate alternative choice. The aim of this study was to examine the promising percutaneous cholecystostomy intervention to share our experiences about the duration of catheter that has yet to be determined. METHODS: A total of 163 patients diagnosed with acute calculous cholecystitis and treated with percutaneous cholecystostomy between January 2011 and July 2020 were reviewed retrospectively. The Tokyo Guidelines 2018 were used to diagnose and grade patients with acute cholecystitis. RESULTS: The mean age was 71.81±12.81 years. According to the Tokyo grading, 143 patients had grade 2 and 20 patients had grade 3 disease. The mean duration of catheter was 39.12±37 (1-270) days. Minimal bile leakage into the peritoneum was noted in 3 (1.8%) patients during the procedure. The rate of complications during follow-up of the patients who underwent percutaneous cholecystostomy was 6.9% (n=11), and the most common complication was catheter dislocation. Cholecystectomy was performed in 33.1% (n=54) of the patients at follow-up. Post-cholecystectomy complication rate was 12.9%. At the follow-up, the rate of recurrent acute cholecystitis episodes was 5.5%, while the mortality rate was 1.8%. The length of follow-up was five years. CONCLUSIONS: The rate of recurrence was significantly higher among the patients with catheter for <21 days. We recommend that the duration of catheter should be minimum 21 days in patients undergoing percutaneous cholecystostomy.

Colecistitis enfisematosa: presentación de tres casos / Emphysematous cholecystitis: a report of three cases

Antecedentes: la colecistitis enfisematosa (CE) es una forma de presentación infrecuente de la colecistitis aguda. Material y métodos: presentecedentes patológicos, mientras que los otros eran diabéticos. A todos se les realizó tomografía computarizada (TC). Dos pacientes fueron sometidos a colecistectomía videolaparoscópica (CL) con buena evolución, mientras que en un caso se realizó colecistostomía percutánea (CP). Discusión: la CE se refiere a la presencia de gas en la luz o en la pared de la vesícula biliar. La tasa de morbilidad es del 50%. Los pacientes suelen padecer diabetes, pero puede presentarse en pacientes más jóvenes sin factores de riesgo. La TC es el método de elección para el diagnóstico. El tratamiento definitivo es la CL, aunque la CP es otra opción válida. Conclusión: la CL se considera un enfoque eficaz y seguro para el tratamiento de la CE.

Background: Emphysematous cholecystitis (EC) is a rare presentation of acute cholecystitis. Material and methods: We report three cases of EC in two men and one woman between 55 and 79 years. One of the patients was otherwise healthy while the other two were diabetics. A computed tomography (CT) scan was performed in all the cases. Two patients underwent video-assisted laparoscopic cholecystectomy with favorable outcome and one patient underwent percutaneous cholecystostomy. Discussion: Emphysematous cholecystitis is characterized by the presence of gas in the gallbladder lumen or wall. Mortality rate is 50%. Most patients are diabetics, but EC may present in younger patients without risk factors. Computed tomography scan is the method of choice for the diagnosis. Cholecystectomy is indicated as definite treatment, but percutaneous cholecystostomy may be a valid option. Conclusions: Laparoscopic cholecystectomy and antibiotics are effective and safe to treat.

Acute Acalculous Cholecystitis Associated with Sunitinib Treatment for Renal Cell Carcinoma / 대한소화기학회지

A 64-year-old man was treated with sunitinib as a first-line therapy for metastatic renal cell carcinoma. He was given oral sunitinib in cycles of 50 mg once daily for 2 weeks followed by a week off. During the 5th week of treatment right upper quadrant pain developed, but this resolved spontaneously during the 6th week (off treatment). However, on the 8th week of treatment, he was admitted to hospital because the acute right upper quadrant pain recurred with nausea, vomiting, and fever. Acute acalculous cholecystitis was then diagnosed by ultrasonography and CT. In addition, his laboratory findings indicated disseminated intravascular coagulation. Accordingly, sunitinib therapy was discontinued and broad-spectrum antibiotics initiated. He subsequently recovered after emergent percutaneous cholecystostomy. His Naranjo Adverse Drug Reaction Probability Scale score was 7, indicaing a probable association of the event with sunitinib. Suspicion of sunitinib-related acute cholecystitis is required, because, although uncommon, it can be life-threatening.

Controversias en el manejo de la colecistitis aguda tardía / Controversies in the management of late acute cholecystitis

La colecistitis aguda es la inflamación de la vesícula biliar, en la mayoría de los casos, explicada por la presencia de cálculos mixtos o de colesterol que producen obstrucción y desencadenan factores inflamatorios diversos. La colecistectomía por vía laparoscópica se ha convertido en su tratamiento estándar y definitivo. El procedimiento quirúrgico debe realizarse idealmente en las primeras 72 horas después de iniciados los síntomas, lo que habitualmente se denomina como cuadro agudo. Existe controversia sobre cuál es el manejo más adecuado cuando han pasado más de 72 horas del inicio de los síntomas, condición denominada 'colecistitis aguda tardía', cuando se considera que el proceso inflamatorio es mayor y, el procedimiento, técnicamente más complejo y peligroso.Para esta condición, se han establecido dos estrategias iniciales de manejo: la cirugía temprana ­durante la hospitalización inicial­ o el tratamiento conservador con antibióticos para la supuesta resolución completa de la inflamación, es decir, 'enfriar el proceso'; varias semanas después, se practica una colecistectomía laparoscópica tardía ­diferida o electiva­. Existen muchas publicaciones sobre ambas estrategias, en las que se exponen los beneficios y probables complicaciones de cada una; en la actualidad, se sigue debatiendo sobre el momento óptimo para practicar la intervención quirúrgica. Los trabajos más recientes y con mayor peso epidemiológico, resaltan los beneficios de la cirugía temprana pues, aunque las complicaciones intraoperatorias ocurren en las mismas proporciones, la cirugía en la hospitalización inicial reduce los costos, los reingresos y los tiempos hospitalarios.Después de revisar la literatura disponible a favor y en contra, este artículo pretende recomendar el procedi-miento temprano, inclusive cuando hayan pasado más de tres días de iniciados los síntomas y, solo en casos muy seleccionados, diferir la cirugía (AU)

Acute cholecystitis is the inflammation of the gallbladder, in most cases explained by the presence of mixed or cholesterol stones that produce obstruction by triggering various inflammatory factors; for its definitive management, laparoscopic cholecystectomy became the gold standard, the surgical procedure should ideally be performed within the first 72 hours after the onset of symptoms, which is usually referred to as acute condition; There are controversies in what is the most appropriate management when more than 72 hours have elapsed from the onset of symptoms, a condition called late acute cholecystitis, at which time the inflammatory process is commonly believed to be greater and the procedure more technically complex and dangerous.For this condition, two management strategies have been defined, which consist of early surgery (during index hospitalization) versus initial conservative antibiotic treatment for the supposed complete resolution of the inflammation "cooling the process", followed by a late laparoscopic cholecystectomy several weeks later (deferred, elective); For both strategies, there is abundant literature exposing the benefits and probable complications that concern each one, but at the present time the optimal moment to practice the surgical intervention is still being debated. The most recent works show some benefits in favor of early surgery, since although intraoperative complications occur in the same proportions, surgery in the index hospitalization reduces costs, readmissions, and hospital times. The present article, reviewing the wide literature available for and against, has as main objective to recommend this procedure early, even when more than three days of symptoms have passed, and only in very selected cases, defer surgery (AU)

Current Status of Endoscopic Gallbladder Drainage

The gold standard for treatment of acute cholecystitis is laparoscopic cholecystectomy. However, cholecystectomy is often not suitable for surgically unfit patients who are too frail due to various co-morbidities. As such, several less invasive endoscopic treatment modalities have been developed to control sepsis, either as a definitive treatment or as a temporizing modality until the patient is stable enough to undergo cholecystectomy at a later stage. Recent developments in endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with endoscopic ultrasound EUS-specific stents having lumen-apposing properties have demonstrated potential as a definitive treatment modality. Furthermore, advanced gallbladder procedures can be performed using the stents as a portal. With similar effectiveness as percutaneous transhepatic cholecystostomy and lower rates of adverse events reported in some studies, EUS-GBD has opened exciting possibilities in becoming the next best alternative in treating acute cholecystitis in surgically unfit patients. The aim of this review article is to provide a summary of the various methods of gallbladder drainage GBD with particular focus on EUS-GBD and the many new prospects it allows.

Efficacy of preoperative percutaneous cholecystostomy in the management of acute cholecystitis according to severity grades

BACKGROUND/AIMS: The aim of this retrospective study was to assess the efficacy of percutaneous cholecystostomy (PC) for patients with acute cholecystitis (AC) according to severity. METHODS: A total of 325 patients who underwent cholecystectomy between January 2008 and October 2010 were enrolled. Patients were classified into three groups based on severity grade according to the Tokyo guidelines for AC: grade I (mild), grade II (moderate), and grade III (severe). These groups were further classified into two subgroups based on whether or not they underwent preoperative PC. RESULTS: A total of 184 patients were classified into the grade I group (57%), 135 patients were classified into the grade II group (42%), and five patients were classified into the grade III group (1%). In the grade I and II groups, the mean length of hospital stay was significantly shorter in the patients who did not undergo PC than in those who received PC (10.7 ± 4.4 vs. 13.7 ± 5.8, p < 0.001; 11.8 ± 6.5 vs. 16.9 ± 12.5, p = 0.003, respectively). The mean length of preoperative hospital stay was significantly shorter in the patients without PC than in those with PC in the grade I and II groups (5.8 ± 3.3 vs. 8.2 ± 4.6, p = 0.001; 6.0 ± 4.4 vs. 8.8 ± 5.2, p = 0.002). In addition, the operative time was shorter in patients without PC, especially in the grade I group (94.6 ± 36.4 vs. 107.3 ± 33.5, p = 0.034). CONCLUSIONS: Preoperative PC should be reserved for only selected patients with mild or moderate AC. No significant benefit of preoperative PC was identified with respect to clinical outcome or complications.

Percutaneous Transhepatic Biliary Drainage in a Two-Month-Old Infant with Inspissated Bile Syndrome

Inspissated bile syndrome (IBS) is a relatively rare condition. Many treatment options are available, including medication, surgery, and surgical interventions, such as insertion of cholecystostomy drain, endoscopic retrograde cholangiopancreatography, internal biliary drainage, and percutaneous transhepatic biliary drainage (PTBD). We herein report the first case of IBS that was successfully treated with PTBD in a two-month-old infant in Korea. PTBD was initiated on postnatal day 72. On postnatal day 105, we confirmed complete improvement and successfully removed the catheters. This report suggests that PTBD is a viable and safe treatment option for obstructive jaundice in very young infants.

Conversion of Percutaneous Cholecystostomy to Endoscopic Gallbladder Stenting by Using the Rendezvous Technique

We report the successful conversion of percutaneous cholecystostomy (PC) to endoscopic transpapillary gallbladder stenting (ETGS) with insertion of an antegrade guidewire into the duodenum. An 84-year-old man presented with severe acute cholecystitis and septic shock. He had significant comorbidities, and emergent PC was successfully performed. Subsequent ETGS was attempted but unsuccessful owing to difficulties with cystic duct cannulation. However, via the PC tract, the guidewire was passed antegradely into the duodenum, and ETGS with a double-pigtail plastic stent was successfully performed with the rendezvous technique. The PC tube was removed, and no recurrence was reported during the 17-month follow-up period. Conversion of PC to ETGS is a viable option in patients with acute cholecystitis who are not candidates for surgery. Antegrade guidewire insertion via the PC tract may increase the success rate of conversion and decrease the risk of procedure-related complications.

Endoscopic Transpapillary Gallstone Removal with Recurrent Acute Cholecystitis / 대한췌담도학회지

We report a case of successfully removed gallstone by endoscopic transpapillary approach with recurrent acute cholecystitis. An 84-year-old man presented with acute calculous cholecystitis. He is concurrently diagnosed with colon cancer at the time of admission. After percutaneous transhepatic gallbladder drainage (PTGBD), He was discharged. After a total of seven PTGBD exchanges for three years, we successfully removed gallstone via an endoscopic transpapillary approach, and no recurrence was reported during the 27-month follow-up period. This procedure may be performed in patients who can access to the gallbladder through the cystic duct.

Inmunoexpresión p53, sangre oculta en heces de pacientes colecistectomizados y colelitiasis con adenomas colónicos / P53 Immunoexpression, Faecal Occult Blood from Cholecystectomized Patients and Cholelithiasis with Colonic Adenomas

Introducción: la secuencia adenoma- adenocarcinoma, es resultado de fallos genéticos en las células intestinales heredados o adquiridos. Objetivo: determinar la posible relación entre la inmunoexpresión de la p53 y la positividad de la sangre oculta en heces en los adenomas de colon con alto grado de displasia diagnosticados en pacientes colecistectomizados o con colelitiasis. Métodos: se realizó un estudio descriptivo, de corte transversal, en el Instituto de Gastroenterología, en el período de mayo de 2013 hasta junio de 2015. Se realizaron pruebas estadísticas descriptiva y de chi Cuadrado y probabilidad exacta de Fisher. Resultados: la proporción de adenomas con alto grado de displasia fue similar en pacientes colecistectomizados y con colelitiasis (50 por ciento) respectivamente. Una alta proporción se diagnosticó en colecistectomizados femeninas (35 por ciento), con 60 y más años de edad (53 por ciento) y 11 y más años de colecistectomizados (60 por ciento), mientras que en las colelitiasis fueron masculinos (30 por ciento). Conclusiones: una alta proporción de adenomas con alto grado de displasia presentan inmunoexpresión de la p53 y sangre en heces positiva en pacientes colecistectomizados y con colelitiasis, que se reporta por vez primera(AU)

Introduction: The adenoma - adenocarcinoma sequence is a result of inherited or acquired genetic failures in the intestinal cells. Objective: To determine the immunohistochemical expression of p53 and the positivity of the fecal occult blood test in colon adenomas with high degree of diagnosed dysplasia in cholecystectomized patients or with cholelithiasis. Methods: Descriptive, cross-sectional study conducted in the Institute of Gastroenterology in the period of May, 2013 to June, 2015. Statistical tests were statistics testing, exact Chi Square and Fisher's probability tests. Results: The proportion of adenomas with high degree of dysplasia was similar in cholecystectomized patientsand with cholelithiasis (50 percent) respectively. A high proportion diagnosed in colecistectomizados women (35 percent), 60 and more years of age (53 percent) and 11 and more years of performed cholecystectomy (60 percent), whereas cholelithiasis prevailed in males (30 percent). Conclusions: High proportion of adenomas with high degree of dysplasia present p 53 immunoexpression and positive fecal occult blood test in cholecystectomized patients and patients with cholelithiasis that is reported for the first time(AU)

Colecistectomía laparoscópica con manejo ambulatorio ultracorto / Laparoscopic cholecystectomy with ultra short hospital stay

Introducción. La colecistectomía laparoscópica es la técnica de elección para el tratamiento de la enfermedad biliar benigna. El manejo ambulatorio en este tipo de procedimientos podría ofrecer ahorros económicos y una mayor disponibilidad de camas. Objetivo. El propósito del presente estudio es mostrar nuestra experiencia al practicar colecistectomías laparoscópicas con manejo ambulatorio menor de seis horas. Materiales y métodos. Se llevó a cabo un estudio de cohortes en pacientes sometidos a colecistectomía laparoscópica en la Clínica Gestión Salud de Cartagena de Indias, Colombia, entre el 1° de octubre de 2009 y el 31 de agosto de 2013. Resultados. Se practicaron 1.260 colecistectomías laparoscópicas. Se cumplieron los criterios para manejo ambulatorio en 1.207 (95,8 %) casos. El tiempo promedio de hospitalización hasta el alta hospitalaria, fue de 4,18 horas (rango: 3 a 10). De los 1.207 pacientes que cumplieron criterios para manejo ambulatorio, 23 (1,9 %) requirieron ser hospitalizados y la primera causa de hospitalización fue el diagnóstico intraoperatorio de enfermedad biliar aguda. El porcentaje de reingreso de pacientes dados de alta, fue del 0,6 %. Conclusiones. En esta serie, la colecistectomía laparoscópica se pudo practicar con manejo ambulatorio ultracorto para el tratamiento de la enfermedad biliar benigna en pacientes seleccionados, sin que esto atentara contra la seguridad del paciente ni se tradujera en altos índices de reingreso o consulta.

Background: At the introduction of laparoscopic cholecystectomy it was usual to have a one-day hospital stay (overnight) after surgery. Refinement of the surgical and anesthetic techniques has resulted in the discharge of patients on the same day of the operation. The aim of this study was to present our experience with laparoscopic cholecystectomy as an ambulatory procedure, with a hospital stay of less than six hours. Methods: A cohort study was carried out including all patients submitted to laparoscopic cholecystectomy. Inclusion criteria were: ages between 17 and 75 years, benign gallbladder disease (polyps and cholelithiasis), elective surgery, 1 and 2 ASA classification, residence at less than 20 kilometer distance, available telephone contact and the ambulatory regime informed consent. The same two surgeons operated on all patients. All patients were given general anesthesia with local anesthetic infiltration at the port sites. Results: A total of 1260 laparoscopic cholecystectomies were performed. 1207 (95,8%) had criteria to be included in the ambulatory regime. Only 23 (1.9%) out of the 1207 patients required hospitalization. Average time for hospital discharge was 4.18 hours (r: 3-10) and readmission percentage was 0.6%. Conclusions: In our series an ultra-short ambulatory laparoscopic cholecystectomy regime was implemented for the treatment of the benign biliary disease in selected patients with no negative incidence on the patients safety, and very low readmission rate and postoperative consultations.

Timing of Cholecystectomy after Percutaneous Cholecystostomy for Acute Cholecystitis / 대한소화기학회지

BACKGROUND/AIMS: Laparoscopic cholecystectomy is the standard treatment for acute cholecystitis. Percutaneous cholecystostomy is an alternative treatment to resolve acute inflammation in patients with severe comorbidities. The purpose of this study is to determine the optimal timing of laparoscopic cholecystectomy after percutaneous cholecystostomy for the patients with acute cholecystitis. METHODS: This retrospective study was conducted in patients who underwent cholecystectomy after percutaneous cholecystostomy from January 2010 through November 2014. Seventy-four patients were included in this study. The patients were divided into two groups by the operation timing. Group I patients underwent cholecystectomy within 10 days after percutaneous cholecystostomy (n=30) and group II patients underwent cholecystectomy at more than 10 days after percutaneous cholecystostomy (n=44). RESULTS: There was no significant difference between groups in conversion rate to open surgery, operation time, perioperative complications rate, and days of hospital stay after operation. However, complications related to cholecystostomy such as catheter dislodgement occurred significantly more often in group II than group I (group I:group II=0%:18.2%; p=0.013). CONCLUSIONS: Timing of laparoscopic cholecystectomy after percutaneous cholecystostomy did not influence postoperative outcomes. However, late surgery caused more complications related to cholecystostomy than early surgery. Therefore, early laparoscopic cholecystectomy should be considered over late surgery after percutaneous cholecystostomy insertion.

Percutaneous Cholecystostomy Is Appropriate as Definitive Treatment for Acute Cholecystitis in Critically Ill Patients: A Single Center, Cross-sectional Study / 대한소화기학회지

BACKGROUND/AIMS: Percutaneous cholecystostomy (PC) is an effective treatment for cholecystitis in high-risk surgical patients. However, there is no definitive agreement on the need for additional cholecystectomy in these patients. METHODS: All patients who were admitted to Cheju Halla General Hospital (Jeju, Korea) for acute cholecystitis and who underwent ultrasonography-guided PC between 2007 and 2012 were consecutively enrolled in this study. Among 82 total patients enrolled, 35 underwent laparoscopic cholecystectomy after recovery and 47 received the best supportive care (BSC) without additional surgery. RESULTS: The technical and clinical success rates for PC were 100% and 97.5%, respectively. The overall mean survival was 12.8 months. In the BSC group, mean survival was 5.4 months, and in the cholecystectomy group, mean survival was 22.4 months (p<0.01). However, there was no significant difference between these groups in multivariate analysis (relative risk [RR]=1.92; 95% CI, 0.77-4.77; p=0.16). However, advanced age (RR=1.05; 95% CI, 1.02-1.08; p=0.001) and higher class in the American Society of Anesthesiologists' physical status (RR=3.06; 95% CI, 1.37-6.83, p=0.006) were significantly associated with survival in the multivariate analysis. Among the 47 patients in the BSC group, the cholecystostomy tube was removed in 31 patients per protocol. Recurrent cholecystitis was not observed in either group of patients during the follow-up period. CONCLUSIONS: In high-risk surgical patients, PC without additional cholecystectomy might be the best definitive management. Furthermore, the cholecystostomy drainage catheter can be safely removed in certain patients.

Acute Acalculous Cholecystitis without Cholangitis As a Complication of Endoscopic Snare Papillectomy for Ampullary Adenoma / 대한췌담도학회지

Endoscopic snare papillectomy (ESP) for ampulla of Vater tumor (AVT) has been performed successfully instead of surgical ampullectomy (SA) because ESP is a less invasive procedure than SA. Hemorrhage, perforation and pancreatitis are relatively common complications of ESP and other rare complications such as cholangitis, liver abscess has been reported. Recently we encountered a case of acute acalculous cholecystitis after ESP for AVT, which was treated successfully with percutaneous cholecystostomy with intravenous antibiotics. We therefore report this case with a brief review of the literature.

Colecistostomía. Una técnica quirúrgica con indicación actual en pacientes de alto riesgo / Cholecystostomy. A surgical technique with current indication in high-risk patients

Objetivo: Demostrar que la colecistostomía es un procedimiento quirúrgico seguro y aplicable actualmente. Método: Descripción de dos casos con diagnóstico de colecistitis aguda y alto riesgo quirúrgico, a quienes se les realizó la colecistostomía. Una fue realizada con anestesia local en el área de la emergencia y la otra tuvo que realizarse en quirófano, en vista de fallas técnicas de las máquinas anestésicas, ambos casos tratados en el Hospital General del Oeste "Dr. José Gregorio Hernández" los Magallanes de Catia. Servicio de Cirugía I. Resultados: Ambos pacientes eran mayores de 60 años. Entre los resultados paraclínicos destaca la leucocitosis con desviación a la izquierda. Los pacientes fueron catalogados como ASA IV y ASA III. Ambos recibieron antibióticos endovenosos desde su ingreso, sin mejoría clínica ni paraclínica. Se realizó la colecistostomía quirúrgica, logrando conseguir la estabilidad hemodinámica. Posteriormente, fueron llevados a trata-miento quirúrgico definitivo de manera electiva, lográndose una evolución satisfactoria. Conclusión: En pacientes de edad avanzada con comorbilidades que condicionen un alto riesgo anestésico y quirúrgico en el contexto de un cuadro de colecistitis aguda sin respuesta al tratamiento médico, la colecistostomía proporciona una excelente alternativa quirúrgica temporal, para lograr la estabilidad hemodinámica y así disminuir la morbimortalidad(AU)

Objective: To demonstrate that cholecystostomy is a safe surgical procedure and applicable today. Method: Description of two cases with a diagnosis of acute cholecystitis and high surgical risk, who held the cholecystostomy. One was carried out under local anaesthesia in the area of the emergency and the other had to be done at operating room, in view of technical failures of the anaesthetic equipment, study done at Hospital General del Oeste "Dr. Jose Gregorio Hernandez" Magallanes de Catia, Caracas, Surgery service I. Results: Both patients were over the age of 60, the paraclinical findings include leukocytosis with left shift. The patients were classified as ASA III and IV. Both received intravenous antibiotics from your income, without clinical or paraclinical improvement. He was the surgical cholecystostomy, managing to achieve hemodynamic stability. Subsequently, were taken to definitive surgical treatment of elective way, with a satisfactory evolution. Conclusion: In older patients with comorbidities that determine high risk surgical and anesthetic in the context of acute cholecystitis with no response to medical treatment, the cholecystostomy provides an excellent temporary surgical alternative, to achieve hemodynamic stability and thus reduce morbidity and mortality(AU)

Fístula de alto gasto / High output fistula

Se presenta a un paciente de 37 años de edad que acude a nuestro Cuerpo de Guardia politraumatizado, con lesiones torácicas y abdominales, con síntomas y signos sugestivos de fracturas costales múltiples, con hemotórax derecho y hemoperitoneo, corroborado imaginológicamente y en la punción abdominal. Se realiza pleurostomía mínima intermedia y laparotomía exploratoria. Se le encuentran lesiones hepáticas de los segmentos VI, V, VIII y IV, con una profundidad mayor de 3 cm, además, deserosamientos en las asas delgadas intestinales y colon. Se realiza hepatorrafia y empaquetamiento hepático. Posteriormente van apareciendo complicaciones, por lo que tiene que ser reintervenido en máqs de 60 ocasiones. Entre ellas, la aparición de una fístula de alto gasto, que lo llevó a la desnutrición y a la permanencia con el abdomen expuesto durante 7 meses hasta el egreso. Se revisa la literatura correspondiente a estas entidades(AU)

A 37 years-old multi-traumatized male patient went to our emergency service. He had many injures in the thorax and the abdomen, together with symptoms and signs suggestive of multiple costal fractures, with right hemothorax and hemoperitoneum, all of which was confirmed by imaging techniques and by abdominal puncture. Minimal intermediate pleurostomy and exploratory laparoscopy were performed. We found hepatic lesions in the 6th, 5th, 8th and 4th segments, over 3 cm deep; additionally, the loss of serosa from the intestinal ansae and from the colon. Hepatorrhaphy and hepatic packing were also performed. Later on, more complications appeared, so he had to be re-operated more than 60 times. The occurrence of a high output fistula led him to malnutrition and his abdomen remained exposed for 7 months until he was finally discharged from hospital. This paper also presented a literature review on this topic(AU)

A Case of Gallbladder Perforation Complicated by Acalculous Cholecystitis due to Non-Typhoidal Salmonella / 대한내과학회지

Salmonella infections can cause a variety of diseases, but acute acalculous cholecystitis complicated by gallbladder perforation occurs very rarely in adults. Here, we report a case of acute acalculous cholecystitis with gallbladder perforation after non-typhoidal group D Salmonella infection. A 71-year-old man was admitted with fever, chills, and watery diarrhea. Blood cultures taken on admission were positive for non-typhoidal group D Salmonella. The patient subsequently developed acute acalculous cholecystitis, and abdominal ultrasound and computed tomography revealed gallbladder perforation. Because of other medical problems, cholecystectomy could not be performed. The patient's symptoms and signs were not resolved, even after parenteral antibiotic injection and percutaneous cholecystostomy. Despite meticulous supportive care, the patient died after progression to multiple organ dysfunction.

Fluoroscopy-Guided Percutaneous Gallstone Removal Using a 12-Fr Sheath in High-Risk Surgical Patients with Acute Cholecystitis

OBJECTIVE: To evaluate the technical feasibility and clinical efficacy of percutaneous transhepatic cholecystolithotomy under fluoroscopic guidance in high-risk surgical patients with acute cholecystitis. MATERIALS AND METHODS: Sixty-three consecutive patients of high surgical risk with acute calculous cholecystitis underwent percutaneous transhepatic gallstone removal under conscious sedation. The stones were extracted through the 12-Fr sheath using a Wittich nitinol stone basket under fluoroscopic guidance on three days after performing a percutaneous cholecystostomy. Large or hard stones were fragmented using either the snare guide wire technique or the metallic cannula technique. RESULTS: Gallstones were successfully removed from 59 of the 63 patients (94%). Reasons for stone removal failure included the inability to grasp a large stone in two patients, and the loss of tract during the procedure in two patients with a contracted gallbladder. The mean hospitalization duration was 7.3 days for acute cholecystitis patients and 9.4 days for gallbladder empyema patients. Bile peritonitis requiring percutaneous drainage developed in two patients. No symptomatic recurrence occurred during follow-up (mean, 608.3 days). CONCLUSION: Fluoroscopy-guided percutaneous gallstone removal using a 12-Fr sheath is technically feasible and clinically effective in high-risk surgical patients with acute cholecystitis.

Hepaticocholecystoduodenostomy compared with Roux-en-y choledochojejunostomy for decompression of the biliary tract

The nature of palliative decompressive surgery for unresectable periampullary tumor is usually determined by the experience of the surgeon. We compared hepaticocholecystoduodenostomy [HCD], a new palliative decompressive anastomotic technique, to Roux-en-y choledochojejunostomy [CDJ] in this prospective, randomized study. Twenty patients who were to undergo surgery for palliative bypass were randomized into two groups: group I was subjected to HCD [10 patients] and group II to CDJ [10 patients]. Pre- and postoperative liver function tests, operative time, operative blood loss, onset of postoperative enteral feeding, length of hospital stay and survival rates were compared into the two groups. Effective surgical decompression was observed clinically as well as on analysis of pre- and postoperative liver function tests in both the groups. The results were statistically significant in favor of patients in group I when compared to those of group II with respect to operative time 84.7 [10.3] min vs 133.6 [8.9] min; P=<.0001], operative blood loss 137.8 [37.2] mL vs 201.6 [23.4] mL; P=/001], postoperative enteral feeding 3.3 [0.5] days vs 5.0 [0.7] days; P=<.0001] and length of hospital stay 7.5 [0.7] days vs 9.7 [1.2] days; P=<.0001]. During follow-up, recurrent jaundice was observed in one patient in group I and two patients in group II, while duodenal obstruction developed in one patient in the group I series. Gastrointestinal hemorrhage occurred in one patient belonging to group II. The difference in mean survival time was not statistically significant. Based on this small series, HCD seems to be a better palliative surgical procedure than the routinely performed CDJ