Opciones terapéuticas para la colecistitis aguda: de las guías de Tokio 2018 a la práctica clínica / Therapeutic options for acute cholecystitis: from the Tokyo guidelines 2018 to clinical practice / Opções terapêuticas para colecistite aguda: das diretrizes de Tóquio 2018 à prática clínica

Resumen: Introducción: el tratamiento "gold standard" de la colecistitis aguda es la colecistectomía laparoscópica temprana. En pacientes añosos de alto riesgo anestésico-quirúrgico, con cuadros de evolución subaguda y/o con repercusión sistémica, es alternativa el tratamiento médico exclusivo o asociado al drenaje vesicular percutáneo. Objetivo: analizar y comparar las recomendaciones internacionales con las conductas terapéuticas en dos centros asistenciales de tercer nivel para pacientes con colecistitis aguda. Método: trabajo descriptivo, prospectivo de 161 pacientes con colecistitis aguda litiásica asistidos en los departamentos de emergencia del Hospital de Clínicas y el Hospital Español entre mayo de 2018 y mayo de 2019. Resultados: la colecistectomía laparoscópica temprana fue indicada en el 88% de los pacientes, con 3% de conversión y 9% de morbilidad. 12% recibieron manejo no operatorio, asociándose en el 65% colecistostomía percutánea. La edad avanzada, comorbilidades, discrasias y la severidad del cuadro presentaron asociación significativa con la modalidad terapéutica (p <0,05). El 40% de los pacientes en los que se realizó manejo no operatorio presentó recurrencias sintomáticas. A todos se les realizó la colecistectomía en diferido. Conclusiones: la colecistectomía laparoscópica temprana es la conducta terapéutica más frecuente. Las principales indicaciones de manejo no operatorio en nuestro medio son las características sistémicas desfavorables. El mismo presenta altas tasas de éxito y escasa morbilidad con una recurrencia sintomática del 40%.

Abstract: Introduction: early laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis. However, exclusive medical treatment (EMC) or medical treatment associated with percutaneous gallbladder drainage is the treatment of choice in elderly patients given their high surgical and anesthetic risk and upon the subacute course of the condition and/or its systemic repercussions. Objective: to analyze and compare international guidelines to the therapeutic behavior for patients with acute cholecystectomy in two third-level hospitals. Methodology: descriptive, prospective study of 161 patients with litiasic acute cholecystitis treated in the ER of Hospital de Clínicas and Hospital Español between May 2018 and May 2019. Results: early laparoscopic cholecystectomy was indicated in 88% of patients, conversion being 3% and morbidity 9%. Twelve percent of patients received non-surgical treatment, 65% of which evidenced percutaneous cholecystostomy. Old age, comorbidities, dyscrasias, and severity of the condition were closely related to the therapeutic modality (p < 0.05). Forty percent of patients who received non-surgical treatment presented symptomatic repercussions. They all underwent delayed cholecystectomy. Conclusions: early laparoscopic cholecystectomy is the most frequent treatment of choice. Unfavorable systemic characteristics are the main indications for non-surgical management in our country. This surgical treatment evidences high success rates and scarce morbidity with 40% of systemic repercussions.

Resumo: Introdução: o tratamento padrão ouro da colecistite aguda é a colecistectomia laparoscópica precoce. Em pacientes idosos com alto risco anestésico-cirúrgico, com evolução subaguda e/ou repercussão sistêmica, o tratamento clínico isolado ou associado à drenagem percutânea da vesícula biliar é uma alternativa. Objetivo: analisar e comparar recomendações internacionais com condutas terapêuticas em dois centros terciários para pacientes com colecistite aguda. Método: estudo descritivo e prospectivo de 161 pacientes com colecistite aguda de cálculos atendidos nos serviços de emergência do Hospital de Clínicas e Hospital Español no período maio de 2018 - maio de 2019. Resultados: a colecistectomia laparoscópica precoce foi indicada em 88% dos pacientes, com 3% de conversão e 9% de morbidade. 12% receberam tratamento não operatório, associado a 65% colecistostomia percutânea. Idade avançada, comorbidades, discrasias e gravidade do quadro apresentaram associação significativa com a modalidade terapêutica (p < 0,05). 40% dos pacientes nos quais o manejo não operatório foi realizado apresentaram recidivas sintomáticas. Todos foram submetidos à colecistectomia diferida. Conclusões: a colecistectomia laparoscópica precoce é a abordagem terapêutica mais frequente. As principais indicações para o manejo não operatório em nosso meio são as características sistêmicas desfavoráveis. Apresentando altas taxas de sucesso e baixa morbidade com recorrência sintomática de 40%.

Factores de riesgo prequirúrgicos para una colecistectomía laparoscópica difícil / Preoperative risk factors for difficult laparoscopic cholecystectomy

RESUMEN Antecedentes: varios estudios observacionales han identificado factores de riesgo (FR) para una colecistectomía laparoscópica difícil (CLD). Objetivo: identificar los FR preoperatorios para CLD en un hospital público de mediana complejidad. Material y métodos: estudio prospectivo de cohorte transversal. Se analizaron 80 pacientes mayores de 18 años sometidos a colecistectomía laparoscópica, entre enero y diciembre de 2019. Se analizaron las variables: edad, sexo, IMC (índice de masa corporal), litiasis vesicular, pancreatitis aguda, colecistitis aguda o crónica, síndrome de Mirizzi, CPRE dentro del mes, numero de cólicos en el último mes, si presentó al menos un cólico en la última semana, leucocitos, enzimas hepáticas mayores, bilirrubina total, hallazgos de ecografía prequirúrgicos, antecedentes de cirugías abdominales previas. Resultados: la incidencia de CLD fue de 47,5%. La tasa de conversión a cirugía convencional fue del 11,25%, el 100% fueron CLD. Los FR para CLD incluyeron sexo masculino (OR: 4,50, IC 95%:1,60-12,62, p: 0,004), cólico en la semana previa a la cirugía (OR:7,17, IC 95%:1,89-27,23, p: 0,004), paredes engrosadas de la vesícula (OR: 4.90, IC 95%:1,90-12,70, p: 0,001), edema perivesicular (OR: 7,14 IC 95%:1,45-35,13 p: 0,016), la vesícula hidrópica (OR: 4,94, IC 95%:1,44-16,88, p: 0,011) y las cirugías previas (OR: 4.38 IC 95%:1,27-15,10 p: 0,001). En el análisis multivariado vemos que los pacientes de sexo masculino y pacientes con cirugías previas presentaban un riesgo elevado para CLD (OR: 6,63 IC 95%:1,75-25,08 p: 0.005; OR: 11.70 IC 95%:1,48-92,37 p: 0,020). Conclusión: se deben centrar los esfuerzos en identificar los pacientes con sospecha de CLD, pudiendo planificar la cirugía y un equipo quirúrgico experimentado.

ABSTRACT Background: The risk factors (RF) for difficult laparoscopic cholecystectomy (DLC) have been identified in many observational studies. Objective: The aim of this study is to identify the preoperative RF for DLC in a secondary care public hospital. Material and methods: We conducted a prospective cross-sectional cohort study of patients > 18 years undergoing laparoscopic cholecystectomy between January and December 2019. The following variables were analyzed: age, sex, body mass index (BMI), cholelithiasis, acute pancreatitis, acute or chronic cholecystitis, Mirizzi syndrome, ERCP within the previous month, episodes of biliary colic in the last month, presence of at least one colic within one week before surgery, white blood cell count, liver enzymes, total bilirubin, preoperative ultrasound and history of upper abdomen surgery. Results: The rate of DLC was 47.5%. Conversion rate to conventional surgery was 11.25% and 100% were categorized as DLC. The RF for DLC included male sex (OR, 4.50; 95% CI,1.60-12.62; p = 0.004), colic within 1 week before surgery (OR, 7.17; 95% CI,1.89-27.23; p = 0.004), gallbladder wall thickening (OR, 4.90; 95% CI,1.90-12.70; p = 0.001), edema around the gallbladder (OR, 7.14; 95% CI, 1.45-35.13; p = 0.016), hidrops gallbladder (OR, 4.94; 95% CI,1.44-16.88; p = 0.011) and previous surgeries (OR, 4.38; 95% CI, 1.27-15.10; p = 0.001). On multivariate analysis, male sex and previous surgery were associated with higher risk of DLC (OR, 6.63; 95% CI,1.75-25.08; p = 0.005; and OR, 11.70, 95% CI,1.48-92.37; p = 0.020, respectively). Conclusion: Efforts should focus on identifying patients with suspicion of DLC to plan surgery with an experienced surgical team.

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

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

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

Primeras 2000 colecistectomías laparoscópicas ambulatorias en modalidad free-standing en un hospital público de la Argentina / Outcome of the first 2000 ambulatory, laparoscopic cholecystectomies with free-standing modality in a public hospital of Argentina

Antecedentes: la cirugía ambulatoria surge debido al aumento de la demanda y del gasto sanitario. Permite reducir el costo por procedimiento y la mayor eficacia se obtiene con la adopción de una unidad independiente pero que forma parte de un sistema de salud. Objetivo: Comunicar los primeros 2000 casos de colecistectomía laparoscópica ambulatoria en forma sistemática, en el primer hospital público independiente (free-standing) de la Argentina. Material y métodos: en 36 meses se realizaron las primeras 2000 colecistectomías laparoscópicas ambulatorias en régimen independiente (free-standing). Todos los casos fueron pacientes con patología no aguda, con IMC <35 kg/m², edad entre 13 y 65 años, categorizados ASA I o II. Resultados: se realizaron 1766 colecistectomías laparoscópicas convencionales y 234 colecistectomías mínimamente invasivas transumbilicales. Fueron trasladados a otras instituciones 12 pacientes, 3 de ellos por retardo en la recuperación y 9 por hallazgos intraoperatorios. Se diagnosticaron 3 litiasis coledocianas, 1 litiasis única y 2 múltiples durante la cirugía. Cuatro pacientes requirieron cirugía en otras instituciones por complicaciones asociadas con el procedimiento inicial. Conclusión: la colecistectomía laparoscópica en un hospital público free-standing es un proceso seguro, con tasas de complicaciones bajas si se usan los criterios de selección adecuados. La experiencia ganada con esta numerosa serie permitió afinar el sistema de selección y tratamiento.

Background: ambulatory surgery arose due to the increased demand and health expenses, allowing to reduce the cost per procedure. Efficiency may be maximized by adoption of an independent unit, but as part of a health system. Objective: to report the first 2000 cases of systematic, ambulatory laparoscopic cholecystectomies in the first public independent hospital (free-standing) of Argentina. Material and methods: in a free-standing institution, the first 2000 ambulatory laparoscopic cholecystectomies were performed in period of 36 months. All cases were non-acute, with BMI<35kg/m², aged between 13 and 65 years, categorized as ASA I or II. Results: conventional laparoscopic cholecystectomy was carried out in 1766 cases, while a minimally invasive transumbilical technique was done in 234. Twelve patients required transference to another institution, 3 of them due to delay in recovery and 9 due to intraoperative findings. Three cases of choledochalstones were diagnosed intraoperativelly (1 with a single stone and 2 with multiple). Four patients required surgery at a different institution in the immediate postoperative period due to complications associated with the initial surgery. Conclusions: laparoscopic cholecystectomy in an ambulatory free-standing public hospitalis safe, with low complication rates,if the appropriate selection criteria isused. The experience in this large series of cases allowed refining the selection and treatment criteria.

Fatores de risco para morbimortalidade em colecistectomia videolaparoscópica eletiva em idosos / Risk factors for elective laparoscopic cholecystectomy morbimortality in elderly

RESUMO Objetivo: identificar fatores de risco para a ocorrência de complicações pós-operatórias em colecistectomias videolaparoscópicas (CVL) em pacientes idosos. Métodos: estudo observacional com análise de prontuários médicos de pacientes com idade igual ou superior a 60 anos, submetidos à colecistectomia videolaparoscópica eletiva no Hospital Universitário Gaffrée e Guinle, entre os anos de 2006 e 2018. Cirurgias realizadas em regime de emergência ou convertidas para a técnica convencional foram excluídas do estudo. Resultados: foram incluídos no estudo 345 pacientes, sendo 80% do sexo feminino e 62% com idade entre 60 e 69 anos. Houve 39 casos de complicações pós-operatórias (11,3%), em sua maioria (87%) classificadas como tipo I ou II da escala de complicações cirúrgicas de Clavien-Dindo. Houve somente um caso de óbito. Presença e quantidade de doenças coexistentes e classificação de estado físico ASA II ou III conferiram risco maior para o desenvolvimento de complicações e mortalidade pós-operatórias. Conclusão: o estudo identificou a presença de doenças coexistentes e a gravidade das mesmas, segundo a classificação ASA, como fatores de risco para o desenvolvimento de complicações no pós-operatório de colecistectomias videolaparoscópicas em pacientes idosos. Entretanto, a CVL se mostrou uma técnica segura quando empregada nestes pacientes com taxas de morbimortalidade baixas.

ABSTRACT Objective: to identify risk factors for the occurrence of postoperative complications in laparoscopic cholecystectomies (LC) in elderly patients. Methods: an observational study with analysis of medical records of patients aged 60 years and older, submitted to elective LC at Gaffree e Guinle Universitary Hospital, from 2006 to 2018. Surgeries performed on an emergency basis or converted to the conventional technique were excluded from our study. Results: a total of 345 patients were included in our study, being 80% females and 62% aged 60-69 years. There were 39 cases of postoperative complications (11.3%), mostly (87%) classified as grades I or II of Clavien-Dindo surgical complication scale. There was only one death. The presence and the number of coexisting diseases and ASA II or III physical status classification of preoperative patients conferred a greater risk for the development of postoperative complications and mortality. Conclusion: our study identified the presence of coexisting diseases, as well as their severity, according to ASA classification, as risk factors for the development of postoperative complications of LC in elderly patients. However, LC proved to be a safe technique when used in these patients with low morbidity and mortality rates.

Vólvulo de vesícula biliar / Gallbladder volvulus

Paciente femenina de 84 años de edad, raza blanca, con antecedentes de hipertensión arterial, cardiopatía isquémica y de litiasis vesicular de alrededor 40 años de evolución. Acude al cuerpo de guardia del hospital por presentar dolor abdominal en hipocondrio derecho tipo cólico de 3 días de evolución que comienza después de la ingestión de una comida abundante; refiere además náuseas y escalofríos. Se encontró vesícula biliar muy distendida de color oscuro con líquido serohemático abundante perivesicular, por lo que se le diagnosticó vólvulo vesicular biliar. Se le realizó colecistectomía laparoscópica satisfactoria y tuvo una evolución favorable.

Female patient aged 84 years, Caucasian, with a history of blood hypertension, ischemic cardiopathy and vesicular lithiasis for 40 years. She went to the emergency room of the hospital because she felt abdominal pain in right hypochondrium and cholic for 3 days after having had an abundant meal. She also felt nauseas and shrivelling. The diagnosis was dark coloured, much distended gallbladder with abundant serohematic fluid around the bladder, leading to gallbladder volvulus. She underwent laparoscopic cholecistectomy and recovered satisfactorily.

Pre-operative Prediction of Difficult Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy is the gold standard for the symptomatic gall stone disease. Sometime conversion to an open procedure may be necessary due to some difficulties encounter during laparoscopic cholecystectomy. The aim of this study is to determine whether variability of some of pre-defined pre-operative factors may have some bearing of the degree of difficulties that may be encounter during laparoscopic cholecystectomy. Seven parameters Age, Sex, BMI, ASA class, Hypertension, Diabetes and Previous Abdominal Surgery were studied in 112 patients in our department of Surgery, I.P.G.M.E&R and S.S.K.M. Hospital, Kolkata. Univariate analysis was performed using the chi-squared test to determine the factors that were associated with difficult LC, and odds ratios and their 95% confidence intervals were calculated. In 25(22.32%) patients pre-operative difficulties were encountered and out of these 6(5.35%) required conversion to open procedure. ASA class (OR 6.81, 95%CI 2.386-19.438, p <0.001), Hypertension (OR 7.76, 95%CI 2.651-22.706, p <0.001) and Diabetes mellitus (OR 4.26, 95%CI 1.2371-14.692, p 0.025) were found to be statistically significant predictor of difficult laparoscopic cholecystectomy .However, age (p 0.247), male sex (p 1.00), BMI (p 0.161) and past abdominal surgery (p 0.115) were not found to be statistically significant variables. Difficult laparoscopic cholecystectomy can be predicted pre-operatively and that may help in proper pre-operative planning and counseling to reduce overall complications and morbidity.

Colecistectomia videolaparoscópica em 960 pacientes idosos / Laparoscopic cholecystectomy in 960 elderly patients

OBJETIVO: Analisar o tempo operatório, a permanência hospitalar, a taxa de conversão, a morbidade e a mortalidade de pacientes idosos submetidos à colecistectomia videolaparoscópica por doença da vesícula biliar. MÉTODOS: Estudo descritivo, retrospectivo, realizado no prontuário de 960 pacientes, de ambos os sexos, com idade entre 60 e 97 anos no período de janeiro de 1993 a agosto de 2009. RESULTADOS: O tempo operatório variou de nove a 180 minutos. O tempo de internação variou de 24 a 120 horas. A conversão ocorreu em 28 pacientes (2,92 por cento), dos quais 67,9 por cento eram mulheres e 28,6 por cento homens tendo sido em 11 casos (39,3 por cento) realizada minilaparotomia e em 17 (60,7 por cento) a via aberta convencional. As intercorrências no transoperatório foram duas rupturas da vesícula biliar, uma falha no pneumoperitônio e uma na clipagem do ducto cístico. No pós-operatório observaram-se cinco hérnias umbilicais incisionais. As complicações sistêmicas foram: nove arritmias cardíacas, uma icterícia pós-operatória, um infarto agudo do miocárdio e um infarto enteromesentérico. Mortalidade ocorreu em três pacientes (0,3 por cento), um por infarto agudo do miocárdio no transoperatório, uma sepse e um infarto enteromesentérico. CONCLUSÃO: Os pacientes idosos submetidos à colecistectomia videolaparoscópica apresentaram baixo tempo de internação hospitalar e baixa morbimortalidade. O tempo operatório e o de internação hospitalar foram curtos, demonstrando que a colecistectomia videolaparoscópica é procedimento seguro e eficaz nos idosos.

OBJECTIVE: to evaluate the operative time, hospital stay, conversion rate, morbidity and mortality in elderly patients undergoing laparoscopic cholecystectomy for gallbladder disease. METHODS: we conducted a descriptive, retrospective study with the chats of 960 patients, aged 60 and 97 years in the period from January 1993 to August 2009. RESULTS: operative time ranged from nine to 180 minutes. The length of stay ranged from 24 to 120 hours. Conversion occurred in 28 patients (2.92 percent), of whom 67.9 percent were women and 28.6 percent men, a minilaparotomy having been performed in 11 cases (39.3 percent) and in 17 (60.7 percent) the conventional open route. The perioperative complications were two ruptures of the gallbladder, one failure in the pneumoperitoneum and one in clipping the cystic duct. Postoperative complications were five umbilical incisional hernias. Systemic complications were: nine arrhythmias, one postoperative jaundice, one acute myocardial infarction and one mesenteric infarction. Mortality occurred in three patients (0.3 percent), one due to perioperative myocardial infarction, one due to sepsis and one because of mesenteric infarction. CONCLUSION: elderly patients undergoing laparoscopic cholecystectomy had low hospital stay and low morbimortality. The operative time and hospital stay were short, demonstrating that laparoscopic cholecystectomy is safe and effective in the elderly.

What necessitates the conversion to open cholecystectomy? A retrospective analysis of 5164 consecutive laparoscopic operations

OBJECTIVE: Laparoscopic cholecystectomy (LC) has become the gold standard for the surgical treatment of gallbladder disease, but conversion to open cholecystectomy is still inevitable in certain cases. Knowledge of the rate and impact of the underlying reasons for conversion could help surgeons during preoperative assessment and improve the informed consent of patients. We decided to review the rate and causes of conversion from laparoscopic to open cholecystectomy. METHOD: This study included all laparoscopic cholecystectomies due to gallstone disease undertaken from May 1999 to June 2010. The exclusion criteria were malignancy and/or existence of gallbladder polyps detected pathologically. Patient demographics, indications for cholecystectomy, concomitant diseases, and histories of previous abdominal surgery were collected. The rate of conversion to open cholecystectomy, the underlying reasons for conversion, and postoperative complications were also analyzed. RESULTS: Of 5382 patients for whom LC was attempted, 5164 were included this study. The overall rate of conversion to open cholecystectomy was 3.16 percent (163 patients). There were 84 male and 79 female patients; the mean age was 52.04 years (range: 26-85). The conversion rates in male and female patients were 5.6 percent and 2.2 percent, respectively (p<0.001). The most common reasons for conversion were severe adhesions caused by tissue inflammation (97 patients) and fibrosis of Calot's triangle (12 patients). The overall postoperative morbidity rate was found to be 16.3 percent in patients who were converted to open surgery. CONCLUSION: Male gender was found to be the only statistically significant risk factor for conversion in our series. LC can be safely performed with a conversion rate of less than 5 percent in all patient groups.

Encuesta nacional sobre tratamiento quirúrgico de patología del hígado, vía biliar y páncreas / An enquiry about liver, biliary and pancreatic surgery in Chile

Background: Chile has a high incidence of cholelithiasis and associated complications, that usually require surgical treatment. Aim: Lo carry out an enquiry about biliary diseases and their surgical treatment in public and prívate surgical services in Chile. Material and Methods: An enquiry about liver and biliary diseases and their treatment was designed and sent by electronic mail to 35 surgical services. Results: Lhe enquiry was answeredby 17 services. A total of 9.505 cholecystectomies were reported. Between21 and 98 percent of the procedures were laparoscopic. Iatrogenic lesions of the biliary tree were reported in 0.3 percent of the procedures. Choledocolithiasis was found associated to cholelithiasis in 0 to 21 percent of procedures. However, the use of intraoperative cholangiography was incidental. Lhe incidence of gallbladder cancer in cholecystectomies for cholelithiasis fluctuated between 0.2 and 8.9 percent. Liver metastases derived from colorectal cancer were the most common liver tumor operated. Hydatidosis was more common in southern Chile. Pancreatic excision was almost exclusively performed in Metropolitan Santiago. Conclusions: This information will allow the establishment of information and collaboration channels among the surgical services throughout Chile.

Se trata de una encuesta realizada con el objeto de conocer la frecuencia e incidencia de las principales patologías y técnicas quirúrgicas de la esfera hepato-bilio-pancreática atendida en centros de salud públicos y privados del país durante el año 2007. La encuesta fue respondida por 17 instituciones nacionales. Entre los resultados resaltan el total de colecistectomías reportadas de 9.505, de las cuales entre un 21 y 98 por ciento son realizadas por vía laparoscópica. Lesiones iatrogénicas de vía biliar ocurrieron dentro de un rango de 0 a 1,5 por ciento, con una mediana de 0,3 por ciento. La frecuencia de coledocolitiasis asociada a la colelitiasis ocurrió entre un 0 a 21 por ciento, aunque el empleo de colangiografía intraoperatoria es en general de ocurrencia incidental. La incidencia de cáncer vesicular en colecistectomías por colelitiasis es claramente distinta según se trate de instituciones de centro-norte y sur del país, con incidencias que varían entre 0,2 y 8,9 por ciento. Las metástasis hepáticas operadas son principalmente de origen colorrectal, y son los tumores hepáticos más frecuentemente tratados. La hidatidosis hepática manifiesta en esta encuesta su conocida distribución geográfica, siendo más frecuentemente tratada en los centros del sur del país. La cirugía pancreática resectiva tiende a estar concentrada en las instituciones de la región metropolitana.

Rate of conversion and complications of laparoscopic cholecystectomy in a tertiary care center in Saudi Arabia

Problems during laparoscopic cholecystectomy include bile duct injury, conversion to open operation, and other postoperative complications. We retrospectively evaluated the causes for conversion and the rate of conversion from laparoscopic to open cholecystectomy and assessed the postoperative complications. Of 340 patients who presented with symptomatic gall bladder disease over a 2-year period, 290 [85%] patients were evaluated on an elective basis and scheduled for surgery, while the remaining 50 [14.7%] patients were admitted emergently with a diagnosis of acute cholecystitis. The mean age of the patients was 41.9 [12.6] years. Conversion to laparotomy occurred in 17 patients [5%]. The incidence of complications was 3.2%. The most common complication was postoperative transient pyrexia, which was seen in four patients [1.2%] followed by postoperative wound infection in three patients [0.9%], postoperative fluid collection and bile duct injury in two patients each [0.6%].Laparoscopic cholecystectomy remains the 'gold standard' by which all other treatment modalities are judged. Conversion from laparoscopic to open cholecystectomy should be based on the sound clinical judgment of the surgeon and not be due to a lack of individual expertise

Resultados de la colecistectomía videolaparoscópica en el adulto mayor / Analysis of laparoscopic cholecystectomy in the elderly

Se presenta la experiencia en el tratamiento quirúrgico de la patología vesicular litiásica, mediante videolaparoscopia, en una serie prospectiva de 119 pacientes de 60 o más años de edad, de ambos sexos, operados entre Marzo de 2003 y Marzo de 2004, en el Departamento y Servicio de Cirugía del Hospital Barros Luco Trudeau analizando la patología médica asociada, presente en el 70 por ciento, los hallazgos relevantes del estudio ecotomográfico preoperatorio (99,1 por ciento), las cifras de conversión a cirugía laparotómica (19 por ciento), la morbilidad (8,4 por ciento) y la mortalidad (0 por ciento).

We report our surgical experience in videolaparoscopic cholecystectomy in 119 patients with 60 or more years old, operated between March 2003 and March 2004, at the Barros Luco's Surgical Department and Service. We analized the medical pathology (70 percent of patients); the relevant finding at the preoperative ultrasonic study (99,2 percent of patients); the conversion rate (19 percent) and postoperatory results.

Complicación por fuga de cálculos en colecistectomía laparoscópica / Escape of stones as complication of laparoscopic cholecistectomy

Se presenta el caso de una paciente de 72 años que concurrió al servicio de ecografía del Hospital J. F. Muñiz, de la Ciudad de Buenos Aires, para evaluar una tumoración en la pared abdominal y descartar un derrame pleural. Presentaba como antecedente una cirugía laparoscópica, realizada 15 meses antes, y los resultados ecográficos presentaron colecciones originadas por el derrame de cálculos en la cavidad abdominal.

Colecistectomía laparoscópica: experiencia de 10 años en la Pontificia Universidad Católica de Chile / Laparoscopic cholecystectomy: 10 years at the Hospital Clínico Pontificia Universidad Católica de Chile

La colecistectomía laparoscópica es actualmente el tratamiento de elección de la colelitiasis. Nuestro hospital es un centro docente donde cirujanos en formación junto a sus docentes han participado activamente en el desarrollo de esta técnica desde su inicio en mayo de 1991. El objetivo de este estudio es comunicar la experiencia de 10 años con esta técnica en el Hospital Clínico de la Pontificia Universidad Católica de Chile. Se revisaron las fichas clínicas de los pacientes sometidos a colecistectomía laparoscópica desde mayo de 1991 a mayo de 2001. Se registraron los datos demográficos de cada paciente, presentación clínica, exámenes de laboratorio y radiológicos. Se analizó la información técnica del procedimiento a estudiar y la evolución postoperatoria precoz. La serie se compone de 5063 pacientes. La edad promedio fue de 46 años (7 a 88 años), 3392 de ellos mujeres (67 por ciento). El 75 por ciento de los pacientes ingresó en forma electiva y el 25 por ciento de urgencia. El tiempo operatorio promedio fue de 73 min. Se realizó conversión a cirugía abierta en 7 por ciento de los pacientes siendo los factores de conversión más importantes la edad avanzada y la presencia de colecistitis aguda. La estadía postoperatoria promedio fue de 2,9 días. Complicaciones post operatorias se observaron en el 2 por ciento. 0,2 por ciento de los pacientes de esta serie necesitaron ser reintervenidos. La mortalidad operatoria fue de 0,02 por ciento. La colecistectomía laparoscópica demuestra en este estudio ser una forma de tratamiento seguro y efectivo en pacientes con colelitiasis.

Laparoscopic cholecystectomy is at present the gold standard for the treatment of gallstones disease. Since May 1991 this technique has been developed at the Hospital Clínico Pontificia Universidad Católica de Chile in patients under the care of staff surgeons of the Digestive Surgery Department who have been actively involved in post graduate surgical training. The purpose of this study is to communicate the experience in 10 years with this technique in our institution. Clinical charts were reviewed of those patients who underwent laparoscopic cholecystectomy since May 1991 until May 2001. Patient's demographic data were included in the analysis, together with their clinical presentation, laboratory exams and radiological information. The technical information of this procedure and the early course of these patients was also analyzed. Our study includes 5063 patients. The age average was 46 years (7 to 88 years old), 3392 of them female (67 percent). 75 percent of these patients underwent elective surgery, while the other 25 percent emergency surgery. The average operative time was of 73 min. Laparoscopic surgery was converted to open laparotomy in 7 percent of these cases. Advanced age and the presence of acute cholecystitis were the main significant associated conversion factors. The average postoperative recovery time in hospital was 2,9 days. Post operative complications were observed in 2 percent. 0,2 percent of patients of this serie had to be reoperated. The mortality rate was 0,02 percent. Laparoscopic cholecystectomy proves to be a safe and effective treatment in patients with gallstones disease.

Colecistectomía laparoscopica en el Hospital Antonio Lenin Fonseca en el período enero 2001 a diciembre 2005 / Colecistectomía laparoscopica in the Hospital Antonio Lenin Fonseca in the period January 2001 to December 2005

Se realizó un estudio de serie de casos a todos los pacientes ingresados en el servicio de cirugía, en el Hospital Escuela Antonio Lenin Fonseca, durante el periodo de enero 2001 a diciembre 2005, para colecistectomia laparoscópica tanto asistencial como diferenciado. La muestra y el Universo la constituyeron 413 pacientes que se les realizó colecistectomía laparoscópica de los cuales 346 (83.8 por ciento) son del sexo femenino y 67 (16.2 por ciento) del sexo masculino. El grupo de edad con mayor número de casos es de 41 a 60 años (34.8 por ciento) 144 pacientes y 21 a 40 años (34.1 por ciento) 141 pacientes. En relación a los diagnósticos post- quirúrgicos encontrados 303 pacientes /73.3 por ciento) fue colelitiasis, 52 pacientes (12.6 por ciento) con colelitiasis, 52 pacientes (12.6 por ciento) con clecistitis aguda, 18 pacientes (4.3 por ciento) con Hidrops vesicular, 133.1 por ciento) con diagnóstico de colesisto-pancreatitis y 9 (2.2 por ciento) piocolecisto. Solo en 17 pacientes para un 4.2 por ciento) se convirtio el procedimiento de cirugía laparoscópica a cirugía abierta. Con respecto a las causas por las que se decidió convertir a cirugía abierta se encontró el 35.2 por ciento) con 6 pacientes ante. La dificultad para visualizar la vía biliar, 3 pacientes con un (17.6 por ciento) por sangrado y 2 pacientes por falla técnicas del equipo, así como lesión de la vía biliar principal y fistulas colecisto - entérica. En cuanto al tiempo quirúrgico 223 pacientes (54 por ciento) con una duración de 30 minutos a 1 hora, 145 pacientes (35 por ciento) de 1 a 2 horas y un mínimo porcentaje de (3.1 por ciento) para 13 pacientes de 2 a 3 horas.

Role of laparoscopic cholecystectomy in the management of acute cholecystitis

To evaluate the safe technique of surgery in patients with acute cholecystitis and to highlight the better method in which patient can be prevented from complications. A descriptive study. This study was conducted at Larkana, Sindh from February 2002 to August 2004. A total of 504 patients underwent laparoscopic cholecystectomy. Out of these, 398 patients were treated by elective laparoscopic cholecystectomy and 106 patients underwent emergency laparoscopic cholecystectomy for acute cholecystectitis. Among 106 patients, females were double [73.1%] than males and most of these patients were received within 24 hours of the onset of symptoms. In 56 [52.83%] patients, ultrasound revealed odematous gall bladder, mucocele, empyma, contracted, perforated and gangrenous gall bladder. Per-operative complication was encountered in 71 [66.98%] patients including bleeding, minor injury to common bile duct [CBD] and liver, adhesions of gall bladder with omentum, stomach, colon, CBD, and distorted anatomy of Calot's triangle. The minimum time taken during the procedure was 50 minutes. In 5 [4.72%] patients, the laparoscopic procedure was converted to open and reasons for conversion were bleeding, tight, dense adhesions and perforated gallbladder leading to biliary peritonitis. Emergency cholecystectomy is reliable and safe modality in the management of acute cholecystitis. Certain factors are responsible for the conversion, which include delayed arrival of patient, patients with perforated gall bladder, bleeding and adhesions. Hence, emergency laparoscopic cholecystectomy seems to be safe, cost effective, and timely surgery with modern conception. This timely surgery prevents the complications associated with acute cholecystitis

Colecistectomía laparoscópica: experiencia del Hospital Clínico Regional Valdivia / Laparoscopic cholecystectomy: experience of the Hospital Clínico Regional Valdivia

La colecistectomía laparoscópica (CL) se ha convertido en esta última década en la técnica de elección para la resolución de la patología litiásica vesicular en nuestro país. En Valdivia se inicia en octubre de 1992. Se presenta una serie prospectiva de 1256 pacientes seleccionados de acuerdo a protocolo predefinido para ser sometido a una CL electiva. Utilizamos casi exclusivamente la técnica francesa y sólo en un 0,6 por ciento la técnica americana. La complicación intraoperatoria más frecuente fue la rotura vesicular con un 15,8 por ciento. Hubo un 0,4 por ciento de lesión de la vía biliar. La conversión debió efectuarse en un 5,3 por ciento de los casos siendo la causa más frecuente la coledocolitiasis. Tenemos un 2,7 por ciento de complicaciones postoperatorias inmediatas y sólo un 0,79 por ciento corresponde a complicaciones quirúrgicas propiamente tal. No hay mortalidad en la serie. La mayoría de los pacientes (85,8 por ciento) fue dado de alta al día siguiente de la cirugía. El 95 por ciento no presenta complicaciones al control ambulatorio. Se concluye que la CL es una técnica segura y eficaz, con mínima morbilidad y debería ser la técnica de eleccción para tratar la colelitiasis en equipos que cuenten con la experiencia para realizarla

Colecistectomía laparoscópica en pacientes mayores de 60 años: experiencia de un hospital de tercer nivel / laparoscopic cholecystectomy in patients age 60 years or older: report of a tertiary level hospital

Introducción: se presenta la experiencia en colecistectomía laparoscópica en 61 pacientes mayores de 60 años en un periodo de cinco años.Material y método: los pacientes femeninos fueron 41 (67.2 por ciento) y 20 masculinos (32.7 por ciento), los márgenes de edad fueron 37 pacientes de 60 a 70 años y 24 pacientes mayores de 71 años, la cirugía fue electiva en 57 pacientes (93.4 por ciento) y de urgencia en cuatro pacientes (6.5 por ciento).Dentro de los antecedentes hubo 15 pacientes con Diabetes mellitus 2, 14 con hipertensión arterial y 20 con otras enfermedades. Resultados: a cuatro pacientes se les diagnosticó coledocolitiasis por colangiografía y un caso presentó ictericia a los seis meses del postoperatorio.Se presentaron en tres casos conversión a cirugía abierta (4.9 por ciento), dos por hemorragia de lecho hepático y uno por fuga biliar del cístico por mala colocación de grapa.Las complicaciones en siete pacientes (11.4 por ciento) fueron bradicardia postoperatoria, hemorragia de lecho hepático, alteración metabólica y dolor precordial.La estancia intrahospitalaria fue en promedio de 48 hrs, el regreso a las actividades cotidianas fue en promedio de siete días. Los reportes de patología fueron 45 con colesterolosis y colecistitis crónica litiásica, 10 con colecistitis aguda litiásica, tres con colecistitis purulenta, y tres con otros como pólipo vesicular e hidrocolecisto.Discusión: los pacientes mayores de 60 años presentaron mayor riesgo de complicación por la posibilidad de descompensación metabólica, sin embargo, la cirugía laparoscópica disminuyó este riesgo, por lo que se debe considerar como la vía quirúrgica de elección para patología vesicular.

Errores diagnóstico vinculados a colecistectomía laparoscópica / Diagnosis errors related a laparoscopic cholecystectomy

Antecedentes: Entre las desventajas de la cirugía laparoscópica se cuenta la dificultad para palpar las estructuras, lo que conlleva el riesgo de no detectar patologías coexistentes. Objetivo: Analizar, en 1824 pacientes sometidos a colecistectomía laparoscópica (CL), la patología adicional no detectada. Proponer medidas preventivas para reducir esta incidencia. Diseño: Retrospectivo. Análisis de casuística. Población: Entre el 22-10-90 y el 29-04-2000 se realizó CL a 1824 pacientes con diagnóstico de litiasis vesicular. De éstos, en 11 casos (0,6 por ciento), se detectó patología tumoral en el postoperatorio, maligna en 9 casos, benigna en 2, en lapsos variables de 0 a 18 meses, que no fue sospechada en pre, intra o postoperatorio inmediato. En el mismo período fueron operados 8 pacientes portadores de diferentes neoplasias digestivas que previamente habían recibido CL en otros centros, entre 4 y 26 meses antes. Método: En los pacientes propios fueron analizados, tanto la ficha prospectiva cuanto la grabación de la intervención, -que siempre se practican, en la búsqueda de más datos. Se investigaron síntomas o signos y exámenes previos vinculados a la patología que no se detectól...