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

Abdominal ultrasound in amazonian manatee (Trichechus inunguis) (Natterer, 1883) / Ultrassonografia abdominal em peixe boi amazônico (Trichechus inunguis (Natterer, 1883)

Morphophysiological species researches are fundamental, and diagnostic imaging is an excellent technique, already used in wild animals, with great application, not invasive and provide real-time information of each body. Amazonian manatees are on the list of endangered animals classified in the vulnerable category and knowledge of the normal pattern of ultrasound anatomy of organs and tissues is important for the maintenance and well-being of captive specimens contributing to reintroduction actions. The objective of the study was to standardize the examination technique and describe the ultrasound findings of the liver, gallbladder, stomach, urinary bladder and the subcutaneous tissue of the abdominal region in Trichechus inunguis, in order to contribute with the anatomical and sonographic knowledge and assist in the diagnosis and prognosis diseases. The study used 18 animals to describe the normal sonographic anatomy in the abdominal cavity of the Amazonian manatee. During abdominal scan, it was possible to visualize the features of the liver, gallbladder, stomach, urinary bladder obtained satisfactory results in this study. Therefore, other structures were not primarily identified by the reduced time, lots of fat and gases in intestines of animals.

Pesquisas morfofisiológicas em espécies selvagens são fundamentais, e o diagnóstico por imagem é uma excelente técnica, já usada e com grande aplicação, não invasiva e que fornece informações em tempo real de cada órgão. Peixes-boi-amazônico encontram-se na lista de animais ameaçados de extinção classificados na categoria vulnerável e o conhecimento do padrão normal da anatomia ultrassonográfica de órgãos e tecidos é importante para a manutenção e bem-estar de espécimes em cativeiro contribuindo para ações de reintrodução. O objetivo deste estudo foi padronizar a técnica de exame e descrever os achados ultrassonográficos do fígado, vesícula biliar, estômago, vesícula urinária e o tecido subcutâneo da região abdominal em Trichechus inunguis, de modo a contribuir com o conhecimento anátomo-sonográfico e auxiliar no diagnóstico e prognóstico de doenças. O estudo utilizou 18 animais para descrever a anatomia ultrassonográfica normal na cavidade abdominal de peixe-boi amazônico. Durante a varredura abdominal foi possível visualizar as características dos órgãos obtendo resultados satisfatórios neste estudo, concluindo ser uma técnica eficiente para avaliação de determinados órgãos abdominais em peixe-boi amazônico. Entretanto, outras estruturas não foram identificadas principalmente pelo tempo reduzido, muita gordura e gases nos intestinos dos animais.

Colecistectomía Laparoscópica: comparación de Técnica Americana vs Técnica Modificada en relación a elementos de confort del cirujano / Laparoscopic Cholecystectomy: Comparison of the American Technique vs the modified Technique in relation to Surgeon comfort

Introducción: Los cirujanos informaron esfuerzo y dolor musculoesquelético durante o después de un procedimiento. Modificando que la inserción del trócar localizado en línea media clavicular se coloque en línea media, puede mejorar la postura del cirujano. En el Hospital Universitario de Caracas, la técnica de colecistectomía laparoscópica modificada se realiza con frecuencia por disminuir la sensación de esfuerzo y dolor durante el acto quirúrgico. Se plantea el estudio de los elementos de confort para el cirujano con esta técnica modificada. Métodos: Se realizó un estudio prospectivo, descriptivo, comparativo y de corte transversal en cirujanos de pacientes con litiasis vesicular que se resolvieron con colecistectomía laparoscópica, en el Hospital Universitario de Caracas, período enero-agosto 2022. Resultados: Se realizaron 77 colecistectomías laparoscópicas, conformadas por: técnica americana 32 (41,6%) y la técnica modificada 45 (58,4%). La técnica americana evidenció como zona dolorosa la muñeca izquierda (62,5%), y en la técnica modificada reportan en 91,1% sin zona dolorosa. El 43,8% de los cirujanos no se sienten cómodos con la técnica americana, mientras que en la modificada el 97,8% reportaron la técnica cómoda. Los cirujanos refirieron un esfuerzo difícil en el 56,3% con la técnica americana y con la modificada el 82,2% refieren un esfuerzo leve. El grado de dolor en las extremidades fue mayor en los que realizaron la técnica americana en comparación con la modificada, siendo todos los resultados estadísticamente significativos. Conclusión: La técnica modificada tiene ventajas en cuanto a la comodidad del cirujano y su equipo de trabajo y puede emplearse desde el inicio de la formación de cirujanos(AU)

Surgeons reported exertion and musculoskeletal pain during or after a procedure. Modifying the insertion of the trocar located in the clavicular midline to be placed in the midline, to improve the surgeon's posture. At the Hospital Universitario de Caracas, the modified laparoscopic cholecystectomy technique is frequently performed to reduce the sensation of effort and pain during the surgical act. the study of comfort elements for the surgeon with this modified technique is proposed. Methods: A prospective, descriptive, comparative and cross-sectional study was carried out in patients with gallbladder lithiasis at the Hospital Universitario de Caracas, from January to August 2022. Results: 77 laparoscopic cholecystectomies were performed, consisting of: American technique 32 (41, 6%) and the modified technique 45 (58.4%). The American technique showed the left wrist as a painful area (62.5%), and in the modified technique they reported no painful area in 91.1%. 43.8% of the surgeons did not feel comfortable with the American technique, while in the modified one 97.8% reported the comfortable technique. the surgeons reported a difficult effort in 56.3% with the American technique and with the modified one, 82.2% reported a light effort. the degree of pain in the extremities was greater in those who performed the American technique compared to the modified one, all of the results being statistically significant. Conclusion: the modified technique has advantages in terms of comfort for the surgeon and his team and can be used from the beginning of surgeon training

Pancreatitis aguda asociada a infección por SARS-CoV-2. Apropósito de un caso / Acute pancreatitis associated with SARS-CoV-2 infection. Acase report

El nuevo virus del SARS-CoV-2 y su enfermedadCOVID-19 ha representado un desafío para los clínicos,afectando distintos órganos y sistemas. Aunque la gravedadde la infección viene determinada sobre todo por la apariciónde neumonía grave y dificultad respiratoria aguda, se handescrito otras afectaciones en distintos aparatos y sistemas,como la sintomatología gastrointestinal, pancreática y biliar. Elcompromiso pancreático está poco descrito, con escasos reportesen la literatura a nivel mundial, siendo registrado actualmenteen más de 20 países. En este documento, se presenta un casode pancreatitis aguda donde se destaca la nueva posibilidad deasociación al COVID-19. Se trata de paciente de 17 años, desexo femenino, con antecedente de un puerperio tardío, sinhaber tenido contacto con personas confirmadas o sospechosasde COVID-19, ni viajes al extranjero. En vista de la evolucióntórpida de la paciente, se realiza tomografía axial computarizadade abdomen y pelvis donde se reportan los siguientes hallazgos:liquido peri pancreática, vesícula distendida con liquido perivesicular, liquido libre en fondo de saco e interesas. Al realizarlaparotomía exploradora se evidencia necrosis pancreática conlicuefacción en toda su extensión con esteato necrosis en epiplónmayor. Posterior al tratamiento, la paciente evolucionó afebril,con mejoría de la tolerancia oral, sin dolor abdominal, consintomatología respiratoria leve, sin requerir oxígeno en ningúnmomento, completando un total de 21 días de antibioticoterapiaempírica biasociada(AU)

e new SARS-CoV-2 virus and its diseaseCOVID-19 have posed a challenge to clinicians, affectingdifferent organs and systems. Although the severity of theinfection is mainly determined by the occurrence of severepneumonia and acute respiratory distress, other involvementin different organs and systems has been described, suchas gastrointestinal, pancreatic and biliary symptomatology.Pancreatic involvement is poorly described, with few reportsin the literature worldwide, being currently registered in morethan 20 countries. In this paper, a case of acute pancreatitisis presented, highlighting the new possibility of associationto COVID-19. e patient is 17 years old, female, with ahistory of a late puerperium, without having had contact withpeople confirmed or suspected of having COVID-19, or travel abroad. In view of the patient's torpid evolution, a computedaxial tomography of the abdomen and pelvis was performed,where the following findings were reported: peri pancreaticfluid, distended gallbladder with peri vesicular fluid, free fluid inthe cul-de-sac and interstitium. On performing an exploratorylaparotomy, pancreatic necrosis with liquefaction in all itsextension with steato necrosis in the greater omentum wasevidenced. Aer treatment, the patient evolved afebrile, withimproved oral tolerance, without abdominal pain, with mildrespiratory symptoms, without requiring oxygen at any time,completing a total of 21 days of empirical antibiotic therapy(AU)

Hidrops vesicular secundario a vólvulo: reporte de un caso / Gallbladder hydrops due to vesicular volvulus: a case report

Resumen Introducción: El vólvulo de vesícula biliar (VVB) es una causa extremadamente rara de colecistitis aguda. Aproximadamente 500 casos han sido reportados en la literatura mundial. Puede generar una obstrucción total del drenaje vesicular e isquemia con alto riesgo de progresar a perforación y peritonitis biliar. Caso clínico: Mujer de 90 años consultó por dolor hipogástrico de inicio súbito, asociado a masa abdominal palpable y dolorosa en flanco y fosa ilíaca derecha. Tomografía axial computada de abdomen y pelvis demostró una acentuada distensión de la vesícula biliar, ubicada por fuera de la fosa vesicular y con un punto sugerente de torsión. Fue sometida a laparotomía exploradora, desvolvulación seguida de colecistectomía, con evolución posoperatoria favorable. Discusión: Para el desarrollo de un VVB se requiere una "vesícula flotante", su cuadro clínico es inespecífico y muchas veces es confundido con una colecistitis aguda litiásica, su diagnóstico preoperatorio es difícil pese al estudio con imágenes. La intervención quirúrgica oportuna es el único tratamiento resolutivo, con excelentes resultados. Conclusión: La VVB es una patología rara, representa un desafío diagnóstico tanto para cirujanos como radiólogos.

Introduction: Gallbladder volvulus (GV) is an extremely rare cause of acute cholecystitis. Approximately 500 cases have been reported in world literature. It can lead to total obstruction of the gallbladder drainage and ischemia with a high risk of progressing to perforation and biliary peritonitis. Case report: 90-year-old woman consulted due to hypogastric pain of sudden onset, associated with painful palpable abdominal mass in the flank and right iliac fossa. Computed axial tomography of the abdomen and pelvis demonstrated an accentuated distention of the gallbladder, located outside the gallbladder fossa and with a point suggestive of torsion. She underwent exploratory laparotomy, devulvulation followed by cholecystectomy, with favorable postoperative evolution. Discussion: The development of GV requires a "floating gallbladder", its clinical picture is non-specific and is often confused with acute lithiasic cholecystitis. Its preoperative diagnosis is difficult despite the imaging study. Timely surgical intervention is the only resolutive treatment, with excellent results. Conclusion: GV is a rare pathology, it represents a diagnostic challenge for both surgeons and radiologists.

Consensus on the surgical management of benign gallbladder diseases(2021 edition) / 中华外科杂志

Benign gallbladder diseases are common in surgery department,and the incidence rate is increasing in recent years.Currently,nonstandard treatment existed in the surgical management of benign gallbladder diseases in China.Based on relevant domestic and foreign literature,guidelines,and expert consensus,this consensus expounds on the diagnosis and surgical treatment of common benign gallbladder diseases such as gallstone,cholecystitis,gallbladder polypoid,gallbladder adenomyosis,gallbladder variation and deformity,complications after cholecystectomy.Further,recommendations related to diagnosis and treatment were presented to improve the standardization of surgical diagnosis and treatment of benign gallbladder diseases in China,so as to eliminate the clinical harm of gallbladder diseases and reduce the incidence rate of gallbladder cancer and prevent the occurrence.

FU Wen-bin's experience in treatment of depression complicated with obsessive-compulsive disorder from perspective of heart and gallbladder / 中国针灸

Based on the thinking of integrative and holistic acupuncture and moxibustion, FU Wen -bin proposes to treat depression complicated with obsessive-compulsive disorder from perspective of heart and gallbladder. In clinical practice, the treatment pattern of "acupuncture at the top priority, followed by moxibustion, and consolidation at the end" is applied, acupuncture, refined moxibustion, intradermal needle and other therapies are comprehensively adopted, acupoints on the heart meridian, pericardium meridian and gallbladder meridian are selected or back-shu points and front-mu points of the heart, gallbladder and pericardium are matched, and the acupoints on the conception vessel and governor vessel and with the functions of tonifying kidney and regulating qi are added to calm the heart and tranquilize the mind, so as the symptoms of depression and obsessive-compulsive can be effectively relieved.

Factores asociados a retraso en la alimentación enteral en pacientes post colecistectomía en Hospital Militar Central / Factors associated with delayed enteral feeding in post-cholecystectomy patients at Hospital Militar Central

Introducción. Las patologías de la vesícula biliar mayormente encontradas son la colelitiasis y colecistitis, las cuales se presentan con más frecuencia en el sexo femenino y son la sexta causa nacional de egreso hospitalario. El tratamiento quirúrgico es el más indicado. Representando un problema de salud y económico relevante para el país. Objetivo. Determinar los factores asociados al retraso en la nutrición enteral en pacientes posterior a colecistectomía en el Hospital Militar Central. Metodología. Estudio observacional y retrospectivo. Con una muestra de 193 expedientes clínicos de pacientes a quienes se les realizó la colecistectomía en el Hospital Militar Central de enero del año 2021 a junio del año 2022, (18 meses). Resultados. Se puede comprobar que no hay significancia estadística de asociación entre las variables de sexo, edad, comorbilidades del paciente y derrame del contenido biliar con respecto al inicio de la nutrición enteral. No así con la duración de cirugía, apremio quirúrgico, tipo de abordaje, estado de la vesícula biliar, presencia de dreno, que si se ve relacionado con respecto al inicio de la nutrición enteral. Pacientes con una vía oral temprana poseen un egreso hospitalario más rápido, con respecto a la nutrición enteral tardía. Conclusión. Los factores asociados al retraso de la alimentación enteral temprana se clasifican en tres grupos: variables prequirúrgicas, transquirurgicas y postquirúrgicas. El iniciar con una dieta enteral temprana reduce la cantidad de complicaciones que pudiesen presentarse. La estancia hospitalaria en pacientes con un inicio de la vía oral temprana se ve reducida con respecto pacientes con dieta enteral tardía.

Introduction. The most commonly found pathologies of the gallbladder are cholelithiasis and cholecystitis, which occur more frequently in females and are the sixth national cause of hospital discharge. Surgical treatment is the most indicated. Representing a relevant health and economic problem for the country. Aim. To determine the factors associated with the delay in enteral nutrition in patients after cholecystectomy at the Central Military Hospital. Methodology. Observational and retrospective study. With a sample of 193 clinical records of patients who underwent cholecystectomy at the Central Military Hospital from January 2021 to June 2022, (18 months). Results. It can be verified that there is no statistical significance of association between the variables of sex, age, patient comorbidities and spillage of bile content with respect to the start of enteral nutrition. Not so with the duration of surgery, surgical urgency, type of approach, state of the gallbladder, presence of drainage, which is related to the start of enteral nutrition. Patients with an early oral route have a faster hospital discharge, with respect to late enteral nutrition. Conclution. The factors associated with the delay of early enteral feeding are classified into three groups: pre-surgical, trans-surgical and post-surgical variables. Starting an enteral diet early reduces the number of complications that could occur. The hospital stay in patients with an early initiation of the oral route is reduced compared to patients with a late enteral diet.

Cáncer de vesícula biliar, una visión actual / Gallbladder cancer, a current view

Introducción. El diagnóstico de cáncer de vesícula biliar se realiza generalmente de forma incidental durante el estudio de las piezas quirúrgicas o cuando la enfermedad está avanzada y se expresa por su diseminación. Muy pocas veces se diagnostica de forma preoperatoria. Corresponde a la neoplasia más común de las vías biliares y su incidencia varía de acuerdo a la región geográfica. La región andina en Latinoamérica presenta una de las mayores incidencias a nivel mundial. Métodos. Se realizó una revisión narrativa de la literatura, para presentar una información actualizada en lo referente a los factores de riesgo (incluyendo las alteraciones genéticas y moleculares), al diagnóstico y al tratamiento de esta patología. Basados en los datos actuales, presentamos algunas recomendaciones dirigidas al diagnóstico temprano, que permita un manejo más adecuado de nuestros pacientes. Resultados. Se han implicado nuevos factores de riesgo relacionados con la etiología del cáncer de vesícula biliar, como la obesidad, factores genéticos y moleculares. A pesar de la disponibilidad de los métodos diagnósticos imagenológicos, no ha ocurrido una importante variación porcentual en cuanto al estadio al momento del diagnóstico. Conclusiones. El manejo quirúrgico del cáncer de vesícula biliar está indicado en los estadios más tempranos de la enfermedad y es importante evaluar las opciones terapéuticas en pacientes con enfermedad avanzada. Se considera de suma importancia el estudio anatomopatológico de la pieza quirúrgica y la revisión del informe por parte del cirujano.

Introduction. The diagnosis of gallbladder cancer is generally made incidentally during the study of the surgical pieces or when the disease is advanced and is expressed by its dissemination. It is rarely diagnosed preoperatively. It corresponds to the most common neoplasm of the bile ducts and its incidence varies according to the geographical region. The Andean region in Latin America presents one of the highest incidents worldwide. Methods. A narrative review of the literature was carried out to present updated information regarding risk factors (including genetic and molecular alterations), diagnosis and treatment of this pathology. Based on current data, we present some recommendations aimed at early diagnosis, which allows a more adequate management of our patients. Results. New risk factors related to the etiology of gallbladder cancer have been implicated, such as obesity, genetic and molecular factors. Despite the availability of diagnostic imaging methods, there has not been a significant percentage variation in terms of stage at diagnosis. Conclusions. Surgical management of gallbladder cancer is indicated in the earliest stages of the disease and it is important to evaluate therapeutic options in patients with advanced disease. The pathological study of the surgical piece and the review of the report by the surgeon are considered of utmost importance.

Variación anatómica de la vía biliar tipo F de Blumgart / Anatomical variation of Blumgart´s F type bile duct / Variacão anatômica do ducto biliar do tipo F de Blumgart

Se presenta el caso de una paciente de 40 años portadora de litiasis biliar sintomática que se operó de coordinación por abordaje laparoscópico

Adenocarcinoma mucinoso de vesícula biliar originado en neoplasia papilar intracolecística / Mucinous adenocarcinoma of the gallbladder originated from intracholecystic papillary neoplasm

RESUMEN La neoplasia papilar intracolecística con carcinoma mucinoso invasor y células en anillo de sello es una variedad de cáncer de vesícula, una patología agresiva y con mal pronóstico, la cual puede presentarse en forma similar a una colecistitis y, a pesar del tratamiento operatorio y quimioterapia posterior, la supervivencia y pronóstico son peores en relación con los otros cánceres de vesícula. Este artículo tie ne por objetivo describir un tipo histológico muy específico, de baja frecuencia, de cáncer de vesícula y el tratamiento realizado.

ABSTRACT Intracholecystic papillary neoplasm with invasive mucinous adenocarcinoma and signet ring cells is a rare, aggressive variety of gallbladder cancer, with symptoms mimicking cholecystitis. Survival and prognosis are worse that other types of gallbladder cancer despite surgery and chemotherapy. The aim of this article is to describe a case of a rare gallbladder cancer with specific histology and the treatment performed

Colecistitis aguda en vesícula biliar izquierda. Presentación de un caso resuelto en forma segura por vía laparoscópica / Acute cholecystitis in a left sided gallbladder safely managed by laparoscopic surgery

RESUMEN La vesícula izquierda (VI) es una rara anomalía de la vía biliar que, cuando enferma, no suele dar sín tomas diferentes de aquella normoposicionada, haciendo infrecuente su diagnóstico preoperatorio. Presentamos el caso de una colecistitis aguda en un paciente con VI, resuelto en forma segura por vía laparoscópica. Un paciente ingresa por un cuadro típico de colecistitis aguda. Como hallazgo in traoperatorio se constata una vesícula biliar inflamada, ubicada en posición siniestra. Se modificó la ubicación de los puertos de trabajo y se realizó colangiografía transvesicular por punción, antes de iniciar la disección del hilio vesicular. Luego de identificar el conducto cístico, se realizó colangiografía transcística que confirmó la anatomía de la vía biliar completa y expedita. Se completó la colecistec tomía laparoscópica en forma segura. El hallazgo de una VI obliga al cirujano a cambiar la técnica de una colecistectomía laparoscópica. Esta anomalía incrementa el riesgo de lesiones de la vía biliar. La disección cuidadosa del hilio vesicular logrando una visión crítica de seguridad y el uso de colangiogra fía intraoperatoria son de extrema importancia para una colecistectomía segura.

ABSTRACT Left-sided gallbladder (LSGB) is a rare bile duct abnormality, usually found during a cholecystectomy. Symptoms usually do not differ from those of a normally positioned gallbladder, making the preoperative diagnosis extremely uncommon. We report the case of an acute cholecystitis in a patient whit LSGB, safely managed with laparoscopic surgery. A 24-year-old male patient was admitted to our institution with clinical and radiological signs of acute cholecystitis. The intraoperative finding of an acute cholecystitis in a LSGB made us modify ports positioning and a cholangiograhy was done by direct puncture of the gallbladder before hilum dissection. After the cystic duct was identified, a transcystic cholangiography was performed which confirmed a complete and clear bile duct anatomy and laparoscopic cholecystectomy was safely completed. The intraoperative finding of a LSGB makes the surgeon change some aspects of the usual technique to perform a safe cholecystectomy as LSGB significantly increases the risk of common bile duct injuries. Meticulous dissection of the gallbladder hilum to achieve a critical view of safety and the systematic use of intraoperative cholangiography are extremely important to perform a safe laparoscopic cholecystectomy.

Importancia de la vena cística en la colecistectomía laparoscópica / Importance of the cystic vein in laparoscopic cholecystectomy

Resumen Objetivo: Existen diferencias en la descripción de la vena cística en la literatura, en muchas ocasiones sin considerarla un elemento importante. Consideramos que es de vital importancia describir la presencia de la vena cística como elemento significativo que puede alterar la vista crítica de seguridad (VCS) durante las colecistectomías y asimismo, originar errores. Materiales y Método: Entre el 1° de enero de 2014 hasta el 31 de diciembre de 2018, se evaluó la presencia de la vena cística durante la disección del triángulo hepatocístico en las colecistectomías. Resultados: 397 colecistectomías laparoscópicas fueron realizadas, en 30 casos se evidenciaron elementos adicionales en el triángulo hepatocístico que requirieron una disección prolija, la cual después de seguir su trayecto y al evaluar otros reparos anatómicos como el surco de Rouvière y la visualización de la vía biliar, se consideró debido a sus características que se trataba de una vena cística en 8 casos (2%). Discusión: La vena cística es una estructura anatómica cuya existencia se debe tener en mente por parte del cirujano que realiza la colecistectomía laparoscópica, porque puede aparecer como un elemento significativo alterando la vista crítica de seguridad. Aunque en nuestra serie como elemento significativo es del 2%, otras series la describen con una frecuencia mucho mayor. Conclusión: Es necesario realizar más estudios sobre la presencia e importancia como reparo anatómico debido a su valor para prevenir lesiones de la vía biliar y como factor de confusión en la vista crítica de seguridad.

Aim: There are differences in the description of the cystic vein in the literature, often without considering it an important element. We consider it vital to describe the presence of the cystic vein as a significant element that can disturb the critical view of safety during cholecystectomies, and also cause mistakes. Materials and Method: Between January 1, 2014 and December 31, 2018, the presence of the cystic vein during the dissection of the cystohepatic triangle in cholecystectomies was evaluated. Results: 397 laparoscopic cholecystectomies were performed, in 30 cases additional elements were evidenced in the cystohepatic triangle, which required a careful dissection, which after following its path and when evaluating other anatomical repairs such as the Rouvière sulcus and the visualization of the biliary tract, it was considered due to its characteristics that it was a cystic vein in 8 cases (2%). Discussion: The cystic vein is an anatomical structure whose existence must be kept in mind by the surgeon who performs laparoscopic cholecystectomy, because it can appear as a significant element altering the critical view of safety. Although in our series as a significant element it is 2%, other series describe it with a much higher frequency. Conclusion: It is necessary to carry out more studies on the presence and importance as an anatomical repair due to its value to prevent bile duct injuries and as a factor of confusion in the critical safety view.

Aspectos biomoleculares de la prevención de la litogénesis biliar de colesterol / Biomolecular aspects of biliary cholesterol lithogenesis prevention

Introducción: La litogénesis biliar, proceso de sobresaturación de colesterol en la bilis vesicular, es prevenible. Objetivo: Describir las nuevas evidencias biomoleculares de la litogénesis biliar de colesterol como base de la futura terapia preventiva de la litiasis vesicular. Método: Se realizó una revisión sistemática y crítica de las evidencias de impacto sobre la litogénesis biliar. Se consultaron artículos publicados entre 2015-2020 en las bases de datos PubMed, Medline, SciELO, LILACS y Elsevier. Resultados: Se recuperaron evidencias actuales de los mecanismos biomoleculares relacionados con las futuras terapias preventivas de la litiasis vesicular, propuestos como fundamentos teóricos. Conclusiones: La descripción actualizada de la litogénesis biliar de colesterol, con los nuevos conceptos biomoleculares incorporados, aporta a su comprensión el papel de los genes de receptores nucleares, la intervención de estos últimos y de los transportadores de la secreción biliar. Dirigida a médicos generales, cirujanos, gastroenterólogos y fisiólogos, la descripción actualizada de La litogénesis biliar impacta como nuevo paradigma con los conceptos biomoleculares que intervienen en pro de su prevención(AU)

Introduction: Biliary lithogenesis is a preventable process of cholesterol supersaturation in gallbladder bile. Objective: Describe the new biomolecular evidence of biliary cholesterol lithogenesis serving as a basis for future preventive therapy for gallbladder lithiasis. Methods: A systematic critical review was conducted of impact evidence about biliary lithogenesis. The papers consulted were published in the databases PubMed, Medline, SciELO, LILACS and Elsevier from 2015 to 2020. Results: Current evidence was retrieved of biomolecular mechanisms proposed as theoretical foundations for future preventive therapies for gallbladder lithiasis. Conclusions: Intended for general practitioners, surgeons, gastroenterologists and physiologists, the updated description of biliary lithogenesis including the role of nuclear receptors, biliary lipid transporters and the biological value of enterohepatic circulation in the integrity and functioning of the hepatobiliary system as regulators of the cholesterol mechanism, makes an impact as a new paradigm with the biomolecular concepts involved in biliary lithogenesis prevention(AU)

Tratamento colonoscópico de íleo biliar: relato de um caso / Colonoscopic treatment of gallstone ileus: a case report

O íleo biliar representa de 1 a 4% das causas de obstrução mecânica do trato gastrointestinal, causado por um cálculo de origem biliar quando atinge a luz intestinal através de uma fístula bilioentérica. O seu tratamento normalmente é cirúrgico através da enterolitotomia, com ou sem realização de colecistectomia e correção da fístula bilioentérica no mesmo tempo cirúrgico. Relata-se o caso de um paciente de 78 anos com obstrução intestinal ao nível do íleo terminal. Devido ao risco cirúrgico elevado optou-se pela realização de colonoscopia de urgência, que extraiu um cálculo de 2,1cm, impactado na válvula ileocecal. O paciente evoluiu bem após o procedimento, sendo optado pelo tratamento conservador da vesícula biliar e fístula durante o internamento. Conclui-se que pacientes de alto risco se beneficiam com procedimentos menos invasivos, como os endoscópicos, que além de diagnósticos podem ser terapêuticos

The gallstone ileus represents 1 to 4% of the causes of mechanical obstruction from gastrointestinal tract, caused by a gallstone when it reaches the intestinal lumen through a bilioenteric fistula. The treatment is usually the enterolithotomy, with or without cholecystectomy and correction of the bilioenteric fistula at the same surgical time. We report a case of a patient, 78 years old, with intestinal obstruction at the level of the ileocecal valve. The examination showed abdominal distension and pain, with no signs of peritonitis. Due to the surgical risk, a emergency colonoscopy was performed, which removed a 2.1 cm gallstone impacted into the ileocecal valve. The patient evolved well after the procedure and it was chosen the conservative approach to the gallbladder and fistula during the same hospital stay. We conclude that the high-risk patients could benefit from less invasive treatments, such as endoscopy, which can be diagnoses and therapeutic

Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhage

Acute hemorrhagic cholecystitis is a rare, life-threatening condition that can be further complicated by perforation of the gallbladder. We describe a patient with clinical and radiologic findings of acute cholecystitis with a gallbladder rupture and massive intra-abdominal bleeding. Our patient is a 67-year-old male who presented with an ischemic stroke and was treated with early tissue plasminogen activator. His hospital course was complicated by a fall requiring posterior spinal fusion surgery. He recovered well, but several days later developed subxiphoid and right upper quadrant pain and an episode of hemobilia and melena. A computed tomography scan revealed an inflamed, distended gallbladder with indistinct margins and a large hematoma in the gallbladder fossa extending to the right paracolic gutter. The patient also developed hemodynamic instability concerning for hemorrhagic shock. He underwent an emergent laparoscopic converted to open subtotal fenestrating cholecystectomy with abdominal washout for management of his acute hemorrhagic cholecystitis with massive intra-abdominal hemorrhage. Prompt recognition of this lethal condition in high-risk patients is crucial for optimizing patient care.

Metastatic gallbladder carcinoma presenting as an ovarian mass

Metastatic gallbladder carcinoma to the ovaries is occasional but a recognized entity. It can mimic, clinical and morphologically, a primary ovarian tumor, challenging the diagnosis. We present the case of a patient with a lump in the hypogastrium extending into the right iliac fossa and was found to have abdominopelvic cystic lesion with enhancing solid components and multiple sub-centimetric and ill-defined abdominal lymph nodes. Also, subpleural and parenchymal nodules in the lungs were present. She subsequently underwent a laparotomy. Cholecystectomy was also done due to pre-existing symptomatic biliary lithiasis. The histologic report described the ovarian involvement as metastases from a gallbladder carcinoma. The presentation of ovarian metastases can challenge the diagnosis. Hence, careful evaluation of the digestive tract and judicious use of immunohistochemistry should be considered in patients presenting with ovarian masses.