Risk Factors and Prevalence Associated With Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A Tertiary Care Hospital Experience in Western Mexico.

Introduction Laparoscopic cholecystectomy (LC) is a common procedure used for the treatment of different pathologies caused by gallstones in the gallbladder, and one of the most common indications is acute cholecystitis. The definitive treatment for acute cholecystitis is surgery, and LC is the gold standard. Nevertheless, transoperative complications (like intraoperative bleeding, anatomical abnormalities of the gallbladder, etc.) of LC and some other preoperative factors (like dilatation of bile duct, increased gallbladder wall thickness, etc.) can cause or be a risk factor for conversion to open cholecystectomy (OC). The objective of this study was to determine the risk factors and prevalence associated with the conversion from LC to OC in patients with gallbladder pathology and the indication for LC. Materials and methods This was a prospective cohort study. We included patients of both sexes over 18 years of age with gallbladder disease. To determine the risk factors associated with conversion, we performed a bivariate analysis and then a multivariate analysis. Results The rate of conversion to OC was 4.54%. The preoperative factors associated with conversion, in the bivariate analysis, were common bile duct dilatation (p=0.008), emergency surgery (p=0.014), and smoking (p=0.001); the associated intraoperative variables were: laparoscopic surgery duration (p <0.0001), Calot triangle edema (p=0.033), incapacity to hold the gallbladder with atraumatic laparoscopic tweezers (p=0.036), and choledocholithiasis (p=0.042). Laparoscopic Surgery duration was the only factor with a significant association in the multivariate analysis (p=0.0036); we performed a receiver operating characteristic (ROC) curve analysis and found a cut-off point of 120 minutes for the duration of laparoscopic surgery with a sensitivity and a specificity of 67 and 88%, respectively. Conclusion The prevalence of conversion from LC to OC is similar to that reported in the international literature. The risk factors associated with conversion to OC, in this study, should be confirmed in future clinical studies, in this same population, with a larger sample size.

Association of the PNPLA2, SCD1 and Leptin Expression with Fat Distribution in Liver and Adipose Tissue From Obese Subjects.

The expansion of adipose tissue is regulated by insulin and leptin through sterol regulatory element-binding protein-1c (SREBP-1c), up-regulating lipogenesis in tissues by Stearoylcoenzyme A desaturase 1 (SCD1) enzyme, while adipose triglyceride lipase (ATGL) enzyme is key in lipolysis. The research objective was to evaluate the expression of Sterol Regulatory Element Binding Transcription Factor 1 (SREBF1), SCD1, Patatin Like Phospholipase Domain Containing 2 (PNPLA2), and leptin (LEP) genes in hepatic-adipose tissue, and related them with the increment and distribution of fat depots of individuals without insulin resistance. Thirty-eight subjects undergoing elective cholecystectomy with liver and adipose tissue biopsies (subcutaneous-omental) are included. Tissue gene expression was assessed by qPCR and biochemical parameters determined. Individuals are classified according to the body mass index, classified as lean (control group, n=12), overweight (n=11) and obesity (n=15). Abdominal adiposity was determined by anthropometric and histopathological study of the liver. Increased SCD1 expression in omental adipose tissue (p=0.005) and PNPLA2 in liver (p=0.01) were found in the obesity group. PNPLA2 decreased expression in subcutaneous adipose tissue was significant in individuals with abdominal adiposity (p=0.017). Anthropometric parameters positively correlated with liver PNPLA2 and the expression of liver PNPLA2 with serum leptin. SCD1 increased levels may represent lipid storage activity in omental adipose tissue. Liver PNPLA2 increased expression could function as a primary compensatory event of visceral fat deposits associated to the leptin hormone related to the increase of adipose tissue.

Intraoperative cholangiography versus magnetic resonance cholangiography in patients with mild acute biliary pancreatitis: A prospective study in a second-level hospital.

Cholecystectomy is the only definitive management of pancreatitis secondary to gallstone disease. Approximately 20% to 30% of patients with acute biliary pancreatitis (ABP) will have persistent common bile duct (CBD) stones. Therefore, choosing a method for the early diagnosis of choledocholithiasis is essential to reduce waiting days for surgery and hospital stay in these patients.The aim of this study was to compare the use of magnetic resonance cholangiography (MRC) and intraoperative cholangiography (IOC), and its impact on the length of the hospital stay in patients with mild ABP and an intermediate probability of choledocholithiasis.We prospectively evaluated all patients diagnosed with mild ABP and an intermediate probability of choledocholithiasis at admission and 48 hours after, from June, 2017 to December, 2017. Study subjects were identified upon admission and were classified into 2 groups of patients according to their choledocholithiasis predictors; a MRC was performed in the group 1, and an IOC was done in group 2.In all, 47 patients were enrolled in the final analysis of this study. Hospital stay in group 1 (CMR) patients was 8.29 (±2.69) days compared with 6.43 (±2.57) days in the group 2 (IOC) (P = .007). Mean waiting days for cholecystectomy was 17.14 (±26.04) days for group 1 and 5 (±2.69) days for group 2.We suggest an IOC as the election method for the diagnosis of CBD stones in patients with mild ABP in medical centers similar to ours because it reduces waiting days for surgery and hospital stay compared to the MRC.

Karewsky syndrome: A case report and review of the literature.

INTRODUCTION: Gallstone ileus can be a lethal disease, rarely suspected in the clinical scenario. It represents about 25% of all bowel obstruction cases in patients older than 65. There is a classification of gallstone ileus based on the onset time: acute, subacute and chronic (Karewsky syndrome). We describe the first reported case of chronic gallstone ileus. CASE PRESENTATION: A 78-year-old female was admitted to the ER with a 15-day case of consistent bowel obstruction. The subject reported a five-year history of recurrent hospital admissions that resolved spontaneously after non-surgical management. Karewsky syndrome was diagnosed and managed with enterolithotomy. After five days of postoperative evolution the patient was discharged, and at six months follow up, no other hospital admission or relapse has been registered. DISCUSSION: The gallstone ileus diagnosis demands a higher clinical suspicion, there is no biochemical marker, and an abdominal CT is ideal for imaging-based diagnosis. There is no consensus on the optimal surgical approach. CONCLUSION: We describe the first case of Karewsky syndrome and a gastro-jejune and gastric-choledochus double fistula. We emphasize the importance of higher clinical suspicion for patients with bowel obstruction older than 65 years old and make evident that although there are not evidence-based guidelines for this treatment, enterolithotomy is a recommended approach.

Amyand hernia: Case report and review of the literature.

INTRODUCTION: Amyand Hernia is a rare disease seen in approximately 1% of all hernias, complications of it, like acute appendicitis, or perforated appendicitis are even more rare, about 0.1%. Its diagnosis is very difficult in the pre-operative period; it is usually an incidental finding. PRESENTATION OF CASE: This paper describes the case of a forty-year-old male patient, which was presented to the outpatient clinic of surgery with an incarcerated right side inguinal hernia without any signs of ischemic complications. He was admitted, and an hernioplasty was performed, as an incidental finding we encountered an Amyand hernia treated without appendectomy and placement of a prosthetic mesh without any complications. DISCUSSION: This disease represents a very challenging diagnosis, seven years ago the standardization of management had already been established; in this case we encountered a type 1 Amyand's Hernia so we performed a standard tension free hernioplasty without complications. CONCLUSION: Amyand hernia is a rare condition, which represents two of the most common diseases a general surgeon has to face. Standardization of treatment is still ongoing and more prospective studies need to be done. This case demonstrates that this pathology must remain in the mind of the surgeons especially in the event of a strangulated hernia and offer a comprehensive review.

Nuevo esquema perioperatorio para disminuir la morbilidad de la cirugía de visícule biliar / A new peri-operatory scheme for decreaning morbidity of gallbladder surgery

Con el objeto de valorar los efectos del esquema propuesto contra la terapéutica usual en la morbimortalidad del posoperatorio de vesícula biliar, se realizó un estudio prospectivo no aleatorio en el que participaron tres cirujanos en el grupo de estudio y dos en el de control. Se incluyó a 30 pacientes mayores de 12 años de edad, de uno u otro sexo, con diagnóstico confirmado de colelitiasis, en cualquier etapa evolutiva y sin patología sistêmica agregada. En relación al grupo control se observó disminución de náusea y vómito, del inicio de dolor y su intensidad, y de la necesidad de analgésicos en el posoperatorio, con valores de p = 0.001, así como ausencia de complicaciones pulmonares y de peristaltismo gastroduodenal, sin succión nasogástrica