Colecistectomía: resultados de una década de experiencia / Cholecystectomy: results. a decade of experience

Introducción: La colecistectomía, sea a través de una incisión subcostal o videolaparoscópica es la intervención quirúrgica por excelencia para remover la vesícula biliar. El objetivo del estudio es presentar la experiencia acumulada en este tipo de cirugía a través de diez años, sus indicaciones, sus modalidades quirúrgicas, la relación con otras patologías así como las complicaciones de las técnicas empleadas. Metodología: Se incluyen todos los casos quirúrgicos de pacientes con enfermedad de la vesícula y vías biliares ingresados del 01 de enero del 2006 al 31 de diciembre del 2016 en el Departamento de Cirugía del Hospital San Vicente. Resultados: Del 2006 al 2016 se intervinieron 985 pacientes de los cuales, 888 (90.15%) corresponden al sexo femenino. La edad promedio fue de 41 años para ambos sexos, no mostrando diferencias 40.78 vs. 40.95. La colecistitis crónica fue la indicación pre operatoria en el 98.7% y su relación con hernia umbilical fue del 2.23%. La técnica quirúrgica abierta se realizó en 702 (70.27%) y la vía laparoscópica en 260 (26.40%). La tasa global de complicaciones fue del 2.33% (23 / 985 pacientes) siendo el sangrado el más observado en 12 pacientes (1.21%) y la lesión de la vía biliar en 5 (0.50%). Conclusiones: La afección de la vesícula sigue afectando principalmente al sexo femenino, su resolución es esencialmente quirúrgica y en la actualidad la colecistectomía video laparoscópica se considera la cirugía por excelencia, sin que ésta anule la vía abierta por múltiples factores. Es un procedimiento de baja morbilidad y en nuestra serie no se acompañó de mortalidad.

Background: Cholecystectomy, performed with open incision or laparoscopically, by excellence it is the surgery to remove the pathological gallbladder. The aim of this study is to present the experience gained in this type of surgery within ten years, showing indicatons, surgical modalites, and the relaton with other pathologies as well as complicatons of the techniques employed. Methods: All surgical cases of patents with diseased gallbladder and bile ducts are admited from January 01, 2006 to December 31, 2016 in the Department of Surgery of San Vicente Hospital. Results: 985 patents were included, 888 (90.15%) are female. Average age was 41 years old for both sexes, showing no diferences 40.78 vs. 40.95. Chronic Cholecystts was the main preoperatve diagnosis in 98.7%, and its relaton with an umbilical hernia was 2.23%. The open technique was performed on 702 patents (70.27%) and laparoscopic approach on 260 patents (26.40%). The overall complicaton rate was 2.33%. Hemorrhage was the most common in 12 patents (1.21%), and bile duct injury in 5 patents (0.50%). Conclusion: Gallbladder disease is stll more common in women. Treatment is essentally surgical and currently laparoscopic cholecystectomy is considered the standard of care. Cholecystectomy has a low incidence of morbidity and in this study there was no mortality

Effectiveness of laparoscopic surgery for gallstones and common bile duct lithiasis: a systematic overview / Efectividad de la cirugía laparoscópica para colecistolitiasis y coledocolitiasis: revisión global de la evidencia

The aim of the present study was to evaluate the available evidence on the effectiveness of laparoscopic surgery for treating gallstones and common bile duct lithiasis (CBDL). A systematic overview was performed. Medline, EMBASE and The Cochrane Library were searched (1998-2008). Systematic reviews (SR), clinical practice guidelines (CPG), randomised clinical trials (RCT) and observational studies were included. Internal validity and overall quality of the evidence were assessed. The available evidence was classified according to the Oxford Centre for Evidence Based Medicine proposal. 87 studies were included in this review (12 SR, 23 RCT, 3 CPG, 13 cohort studies, 3 cross-sectional studies, 2 case and control studies and 31 case series). Compared with open cholecystectomy, laparoscopic cholecystectomy (LC) is associated with shorter operating time, shorter hospital stay and better quality of life (high quality evidence). The use of antibiotic prophylaxis does not appear to reduce the infection rate in low-risk patients (high quality evidence). Although many techniques have been advocated to perform LC their effectiveness is as yet inconclusive (low-quality evidence). Two-stage surgery is the most appropriate strategy for high-risk patients with CBDL (high-quality evidence). Mortality is similar to open surgery, as the effectiveness is similar to that of endoscopic treatment (high-quality evidence). As a conclusion we can state that the evidence concerning the effectiveness of laparoscopic surgery for gallstones and CBDL is scarce and of low methodological quality and that better quality studies are warranted to assess these techniques more adequately.

El objetivo del presente estudio fue evaluar la evidencia disponible respecto de la efectividad de la cirugía laparoscópica en el tratamiento de la colelitiasis y la litiasis de la vía biliar (LVBP). Para ello, se realizó una revisión global de la evidencia disponible. Se realizaron búsquedas en las bases de datos MEDLINE, EMBASE y The Cochrane Library (1998-2008). Se incluyeron guías de práctica clínica (GPC), revisiones sistemáticas (RS), ensayos clínicos con asignación aleatoria (EC) y estudios observacionales. Se valoró la validez interna y la calidad global de los estudios. Los datos disponibles y la evidencia generada se clasificaron en base a la propuesta del Centro de Oxford de Medicina Basada en la Evidencia. 87 estudios fueron incluidos en esta revisión (3 GPC, 12 RS, 23 EC, 13 estudios de cohortes, 3 estudios transversales, 2 estudios de casos y de controles y 31 series de casos). En comparación con la colecistectomía abierta, la colecistectomía laparoscópica (CL) se asocia con menor tiempo operatorio y estancia hospitalaria y mejor calidad de vida (evidencia de alta calidad). El uso de profilaxis antibiótica no parece reducir la tasa de infección en pacientes de bajo riesgo (evidencia de alta calidad). Aunque se han descrito numerosas técnicas para realizar una CL, su eficacia no es aún concluyente (evidencia de baja calidad). La cirugía en dos etapas es la estrategia más adecuada para los pacientes de alto riesgo con LVBP (evidencia de alta calidad). La mortalidad del tratamiento laparoscópico de la LVBP es similar a la de la cirugía abierta; y como su eficacia es similar a la del tratamiento endoscópico (evidencia de alta calidad). Se puede concluir señalando que la evidencia disponible respecto de la efectividad de la cirugía laparoscópica para el tratamiento de la colelitiasis y la LVBP es escasa y de baja calidad metodológica; y que se requieren estudios de mejor calidad para valorar de forma más apropiada estas técnicas.

Colecistectomía laparoscópica con trócar umbilical único de 12 mm y óptica con canal operatorio: asistido con agujas percutaneas y dispositivos magneticos: reporte de 80 casos / Laparoscopic cholecystectomy with single umbilical trocar of 12mm and an optical device with a working cannel: assisted with percutaneous needles and magnetic devices: report of 80 cases

Presentar nuestra experiencia en la técnica de colecistectomia laparoscópica con trócar umbilical único. Sede: Departamento de Cirugía General de dos hospitales privados. Diseño: estudio prospectivo, observacional. 80 pacientes intervenidos quirúrgicamente con la técnica de colecistectomía laparoscópica con trócar umbilical único de 12mm y óptica con canal operatorio, 74 asistidos con agujas, percutáneas y 6 añadiendo dispositivos magnéticos, desde octubre 2008 al 31 de agosto del 2010. Se excluyeron casos de coledocolitiasis, cáncer y pacientes con cirugías abdominales previas. Se analizó edad, sexo, índice de masa corporal (IMC), tiempo quirúrgico, estancia hospitalaria, complicaciones, índice de conversión y resultado estético. Predomino el sexo femenino (5 a 1). La edad promedio fue de 41 años. El tiempo quirúrgico promedio fue de 63 minutos. IMC promedio 29. Adición de trócar en 7 pacientes (9%), no hubo conversiones a técnicas abiertas. El tiempo de hospitalización fue de 24 horas. Sin cicatriz abdominal visible en 73 pacientes en los que se completó el procedimiento por un trócar (91%). Morbilidad=3,75%, mortalidad=0%. La colecistectomía con trócar umbilical único y óptica con canal de trabajo asistida con agujas percutaneas es aplicable en el 91% de los pacientes con enfermedad vasicular. Con los imanes se logró tracción satisfactoria de la vesícula, siendo de mucha utilidad al realizar la técnica "cirugía sin huella".

To present our experience in the technique of laparoscopic cholecystectomy with single umbilical trocar. Headquarters: Departament of General Surgery of two private hospitals Design: Prospective, observational study. 80 patients operated with the techniqué of laparoscopic cholecystectomy with single umbilical trocar of 12mm and an optical device with a working channel: 74 attended with percutaneous needles and 6 adding magnetic devices, from Octuber 2008 to August 31, 2010. Cases of choledocholithiasis, cancer and patients with previous abdominal surgery were excluded. Age, sex, body mass index (BMI), surgical time, hospital stay, complications, index of conversión and cosmetic result were analyzed. Feminine sex predominated (5 to 1). The average age was 41 years. The surgical time average was 70 minutes. IMC average 29. Addition of trocars was need in 7 patients (9%), there were no conversion to open surgery. The hospitalization time was 24 hours. Abdominal scar was not visible in 73 patients in whom the precedure with one trocar was completed (91%). Morbidity=3.75%, mortality=0%. The laparoscopic cholecystectomy with single umbilical trocar of 12mm and an optical device with a working cannel attended with percutaneous needles is applicable in 91% of patients with gallbladder disease. With magnets satisfactory traction of the gallbladder was obtained, being very useful to per-form the technique "surgery without trace".

Abdominal wall abscess following laparoscopic cholecystectomy: an unusual late complication of lost Gallstones

Laparoscopic Cholecystectomy [LC] is associated with a significant risk of gallbladder perforation with spillage of bile and stones into the peritoneal cavity. The retrieval of the spilled stones is not always possible by laparoscopic technique. Majority of these cases do not have any problem in future but sometimes the lost stones lead to serious complications. The authors present a case of lost gallstones, which resulted into an abdominal wall abscess and discharging sinus 9 years after LC. This late presentation is among the very few reports after LC. Risk factors for gallbladder perforation, various techniques to avoid spillage of stones, possible complications and their management is discussed

Consideraciones técnicas durante la colecistectomía laparoscópica en paciente con situs inversus totalis / Technical considerations during laparoscopic cholecystectomy in a patient with situs inversus totalis

Introducción: La colecistectomía laparoscópica es uno de los procedimientos quirúrgicos más efectuados por el cirujano general. Esto ha permitido establecer una estrategia quirúrgica bien definida para su ejecución; sin embargo, ciertos factores pueden llevar a modificar la técnica. Los objetivos de este informe son describir y analizar las variaciones de la técnica quirúrgica y los resultados obtenidos con la colecistectomía laparoscópica en una paciente con situs inversus totalis. Caso clínico: Mujer de 70 años de edad con diagnósticos de colecistopatía crónica litiásica y situs inversus totalis. Detallamos los cambios en la técnica quirúrgica y describimos la variación en la distribución anatómica de los órganos intraabdominales observada durante el procedimiento quirúrgico. La paciente evolucionó satisfactoriamente y refirió alto grado de satisfacción con el resultado quirúrgico. Conclusiones: La variación en la distribución anatómica de los órganos intraabdominales, así como la alteración en la localización de la arteria cística y los cambios en la ubicación de los puertos de trabajo, nos indujeron a modificar la técnica de la colecistectomía laparoscópica, lo cual no alteró el resultado quirúrgico ni la evolución posoperatoria.

BACKGROUND: Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures by the general surgeon. This situation allows determining a defined surgical strategy in most patients. However, some factors may induce modification by the surgical team. Our objectives were to describe and analyze the variation of the surgical technique used during laparoscopic cholecystectomy in a female patient with situs inversus totalis. CLINICAL CASE: We report the case of a 70-year-old female with a diagnosis of chronic gallstone cholecystitis and situs inversus totalis. Modifications in the surgical technique are detailed, and anatomic variations of the intraabdominal organs are described. Postoperative evolution was satisfactory and the patient was highly satisfied with the surgical outcome. There was no associated morbidity. CONCLUSIONS: Variations in intraabdominal anatomy, alteration of cystic artery location and changes in position of the abdominal ports prompted us to modify the standard surgical technique for laparoscopic cholecystectomy. However, these factors did not alter results or the patient's postoperative evolution.

Life style and outcome following open cholecystectomy

Gallstone disease remains one of the most common medical problems leading to surgical intervention. The Increasing number of cholecystectomy has increased the need to assess the effects of the surgery on presenting symptoms. Cholecystectomy is intended to relieve symptoms of gallstones, but unfortunately some patients will experience post-cholecystectomy symptoms, including pain. There is limited information in the literature on gallstone-related pain and its influence on quality of life. The aim of this study is to investigate whether preoperative variables could predict the symptomatic outcome after cholecystectomy. This study examined symptomatology and quality of life following elective cholecystectomy for symptomatic gallstone disease with defined indications for surgery. Eighty three patients had open cholecystectomy in charity teaching hospital during the period between March 2007 and March 2008. Preoperative data on pain, symptoms, and history was recorded, and the questionnaire on pain and symptoms was filled 1 year postoperatively. Preoperative sonography evaluated gallbladder motility, gallstones, and gallbladder volume. Preoperative variables in patients with or without post-cholecystectomy pain were compared statistically, and significant variables were combined in a logistic regression model to predict the postoperative outcome. The results show that sixty eight patients completed all questionnaires. 54 of patients [80%] had documented gallstones preoperatively, 44 [64.7%] had biliary pain and 49 [72%] had both biliary pain and documented gallstones prior to surgery. Twenty three patients had some pain postoperatively. Of these thirteen patients continued to have abdominal pain after the operation. Patients with pain 1 year after cholecystectomy were characterized by the preoperative presence of a high dyspepsia score, 'irritating' abdominal pain, and an Introverted personality and by the absence of 'agonizing' pain and of symptoms coinciding with pain [P < 0.003]. In a constructed logistic regression model 8 of 11 predicted patients had postoperative pain [PV pos = 0.73]. Of 57 patients predicted as having no pain postoperatively, 52 were pain-free [PV neg = 0.91]. The cure rate for biliary colic was 85% if stones were documented preoperatively, and 49% when they were not [P< 0.05]. It was concluded that most patients [81%] with biliary colic and gallstones have complete relief of upper abdominal pain after cholecystectomy. Pain relief in patients felt to have acalculus cholecystitis was only 52%. Non-pain symptoms were common preoperatively [82%] and were relieved in 44% of patients

Intestinal metaplasia in gallbladders: prevalence study / Metaplasia intestinal na vesícula biliar: estudo da prevalência

CONTEXT AND OBJECTIVE: Gallbladder cancer is usually diagnosed at a late stage and generally results in death. Discovery of predisposing factors for this neoplasia could prevent this outcome. In this study, we assess the presence of one of these factors: intestinal metaplasia in gallbladders with stones and inflammatory processes. DESIGN AND SETTING: Cross-sectional study in Hospital do Servidor Público Estadual de São Paulo. METHOD: The first 80 gallbladders from patients who underwent elective cholecystectomy between April and August 2002, presenting stones and chronic inflammation, were studied. The patients were divided into groups according to their age: CC1, from 15 to 40 years; CC2, from 41 to 60 years; and CC3, from 61 to 85 years. RESULTS: Twenty-one patients (26 percent) were male, while 59 (74 percent) were female. In the group CC1, intestinal metaplasia was present in 85.71 percent of the 21 patients studied; in CC2, in 79.41 percent of 34 patients; and in CC3, in 56.00 percent of 25 patients. These differences presented statistical significance (p = 0.04542). CONCLUSION: Intestinal metaplasia is extremely frequent in gallbladders with inflammation and lithiasis, especially in younger patients.

CONTEXTO E OBJETIVO: O câncer da vesicular biliar é diagnosticado tardiamente na maioria das vezes, levando invariavelmente a morte rápida. A detecção de fatores predisponentes ao aparecimento dessa neoplasia pode evitar esse desfecho. Avaliamos, neste estudo, a presença de um desses fatores, a metaplasia intestinal em vesículas biliares com cálculos e inflamação. TIPO DE ESTUDO E LOCAL: Estudo transversal, realizado Hospital do Servidor Público Estadual de São Paulo. MÉTODOS: Foram estudadas as primeiras 80 vesículas biliares de pacientes submetidos a colecistectomias eletivas entre abril e outubro de 2002, que apresentavam cálculos e inflamações crônicas. Os pacientes foram divididos em grupos segundo a faixa etária: CC1 de 15 a 40 anos, CC2 de 41 a 60 anos e CC3 de 61 a 85 anos. RESULTADOS: 21 pacientes (26 por cento) eram do sexo masculino, enquanto 59 (74 por cento) do sexo feminino. No grupo CC1, foram estudados 21 pacientes e encontrou-se metaplasia intestinal em 85,17 por cento. Já no grupo CC2 a presença de metaplasia intestinal foi de 79,41 por cento em 34 pacientes, e no grupo CC3, de 56,00 por cento em 25 pacientes avaliados. As diferenças tiveram significância estatística (p = 0,04542). CONCLUSÃO: A prevalência de metaplasia intestinal é extremamente alta em vesículas biliares com colecistite crônica e litíase, particularmente em pacientes jovens.

Efectividad del tratamiento laparoscópico de la colelitiasis y la coledocolitiasis: revisión global de la evidencia / Efficacy of Laparoscopy for treatment of cholecystolithiasis and common bile duct lithiasis

Introducción: La laparoscopia es el estándar de referencia en el tratamiento de la colecistolitiasis. No obstante su efectividad es todavía poco conocida. El objetivo de este estudio es evaluar la evidencia disponible sobre la efectividad de la cirugía laparoscópica en el tratamiento de la colecistolitiasis y de la litiasis de la vía principal (LVBP). Material y Métodos: Se realizó una búsqueda en las bases de datos MEDLINE, EMBASE y la biblioteca Cochrane. Se consideraron todo tipo de estudios publicados entre 1988 y 2006. Se llevó a cabo la evaluación de la validez interna de la evidencia así como su calidad global. Resultados: Se seleccionaron 80 estudios (9 revisiones sistemáticas, 19 ensayos clínicos, 4 guías de práctica clínica, 15 estudios de cohortes, 1 de casos y controles y 32 series de casos). La colecistectomía laparoscópica (CL), respecto de la colecistectomía, se asocia a mayor tiempo operatorio, menor estancia hospitalaria y mejor calidad de vida, siendo un procedimiento relativamente seguro (calidad alta). El uso de profilaxis antibiótica no ofrece ningún beneficio en términos de disminución de la tasa de infecciones en pacientes de bajo riesgo [calidad alta]. Se han descrito multiplicidad de variantes tecnológicas para la realización de una CL, no obstante, la efectividad de las mismas es escasa y no concluyente. En el tratamiento de la LVBP, la cirugía en dos etapas es la estrategia más apropiada en pacientes de alto riesgo (calidad alta). La mortalidad es similar a la de la cirugía abierta y la efectividad es similar al tratamiento endoscópico (calidad alta). Conclusiones: La evidencia disponible es escasa y de baja calidad metodológica, situación que dificulta la formulación de recomendaciones. Son necesarios estudios de mejor calidad que evalúen de manera adecuada éstas técnicas.

Minilaprotomy cholecystectomy with mini clip applicator a useful alternative to laparoscopic cholcystectomy

To analyze outcome of after LC [Laparoscopic Cholecystectomy] and MC [Minilaparotomy Cholecystectomy] for symptomatic Gall Stones. Randomised prospective study. Lahore General hospital Lahore from January 2003 to December 2004. Study comprised of two groups [A and B] of 320 people with 160 patient in each group. Group A was offered LC and Group BMC outcome data looked at operative time, rate of conversion to conventional cholecystectomy, operative complication, post of stay, wound infection and patient satisfaction. A total number of 320 patients underwent cholecystectomy with 160 in each LC and MC group. There were 280 [77%] females and 40[33%] males. Median operating time was 60 and 40 minutes for LC and MC, while conversion to conventional cholecystectomy was 12.5% in LC group and 6% in MC group. There was 3% minor bile duct injury in LC and 0% in LC group. There was 6% of wound infection in LC group and 9.3% in MC group while median hospital stay was 1 day for LC and 2 days for MC group while patient satisfaction was 90% for LC and 80% for MC group. MC [Minilaparotomy Cholecystectomy] is a safe and feasible technique in which minimal invasiveness of LC [laparoscopic cholecystectomy] is preserved, so advocating MC for those patients who do not need to return to work early and who are also concerned with cosmetic result

Metabolic and stress responses of the body to trauma: produced by the laparoscopic and open cholecystectomy.

Laparoscopic cholecystectomy is regarded as gold standard therapy for symptomatic gall stone disease. This study was done to compare the metabolic and stress responses between open and lapraroscopic cholecystectomy and to evaluate their significance in postoperative recovery. Thirty patients with symptomatic gall stone disease were treated with open and laparoscopic cholecystectomy on elective basis (14 versus 16). Three samples of blood were collected from each patient to investigate serum cortisol, adrenaline, nor-adrenaline, C-reactive protein and blood glucose level. The mean age of patients was 41.86+/-10.13 blood glucose and stress hormones (cortisol, adrenaline, nor adrenaline) and C-reactive protein all were found significantly raised in the postoperative period in open cholecystectomy than laparoscopic cholecystectomy group. The postoperative recovery was also prolonged in the open group. The obvious clinical advantages of laparoscopic cholecystectomy over open cholecystectomy is mainly because of less metabolic and stress response.