Complicación de colecistectomía laparoscópica no publicada / Complication of laparoscopic cholecystectomy unpublished

Introducción: Las complicaciones de la cirugía laparoscópica son una nueva entidad nosológica de fines del siglo XX, desde el inicio de la misma se han publicado múltiples complicaciones desde leves hasta graves, incluso con muerte de los pacientes. Objetivo: Presentación de un caso clínico. Caso Clínico: Paciente femenino de 48 años, se realizó colecistectomía laparoscópica en sanatorio privado con técnica americana sin complicaciones. 14 meses después consulta a nuestro hospital por dolores abdominales de tipo punzante, sin otro tipo de sintomatología, antecedente de 4 cesáreas y eventración media infraumbilical. Se solicita radiografía de abdomen y TAC. Se evidencia oblito quirúrgico, se decide la intervención quirúrgica, laparotomía media infraumbilical. Hallazgo: mandril de aguja de Verres. Buena evolución con alta a las 72 hs. Discusión: No se halló reporte sobre la posibilidad que el mandril de una aguja descartable se desprenda y quede dentro de la cavidad abdominal. Numerosos trabajos avalan la no utilización de la aguja de Verres para el neumoperitoneo, y aconsejan la utilización de la técnica de Hasson o mini-laparotomía, o los sistemas tipo optic-view para el ingreso de la cavidad.

Introduction: Complications of laparoscopic surgery are a new entity of the late twentieth century, from the beginning of the century have been published multiple complications, from mild to severe, even death of the patients. Objective: Presentation of a clinical case. Case report: Female aged 48, with a history of laparoscopic cholecystectomy in a private hospital 14 months ago with no complications, consulted our hospital with sharp abdominal pain, no other symptoms, with history of two caesarean sections and a infraumbilical eventration. CT and radiography is requested. Evidenced surgical oblito, deciding surgical intervention, infraumbilical laparotomy. Finding: Verres needle mandrel. Patient is discharged 72 hs later. Discusion: We found no report on the possibility that verres needle mandrel discards and remain in the abdominal cavity. Numerous studies support the non use of the Verres needle for the pneumoperitoneum and advise the use of Hasson technique or mini-laparoscopy, as well as the optic-view systems.

Hernioplasty with and without mesh: analysis of the immediate complications in a randomized controlled clinical trial.

BACKGROUND: Inguinal hernia repair is the most common procedure in general surgery and 80,000 operations are performed annually in Great Britain, 100,000 in France and 700,000 in the US. Given its high frequency has a major impact, both in the medical and economic aspects. AIM: Analyze the immediate postoperative complications comparing mesh versus non mesh hernioplasty. METHOD: Randomized control trial, with the enrollment of 263 patients underwent surgery for inguinal hernia randomized by randomization table. Treatment (mesh, Lichtenstein or without mesh, Bassini technique) was assigned using sequentially numbered opaque envelopes having fulfilled the inclusion criteria. The variables analyzed were: postoperative pain, seroma, hematoma, infection, return to normal activities and recurrence. RESULTS: The mean age was 55.5 years, 88% patients were male and 12% female. The pain was higher in patients operated with mesh. CONCLUSIONS: The inguinal hernia repair mesh group had less immediate postoperative complications and significantly earlier return to work than hernioplasty without mesh, this being one of the most important conclusions.

HERNIOPLASTY WITH AND WITHOUT MESH: ANALYSIS OF THE IMMEDIATE COMPLICATIONS IN A RANDOMIZED CONTROLLED CLINICAL TRIAL / HERNIOPLASTIA COM E SEM TELA: ANÁLISE DAS COMPLICAÇÕES IMEDIATAS EM UM ENSAIO CLÍNICO RANDOMIZADO CONTROLADO

Background:Inguinal hernia repair is the most common procedure in general surgery and 80,000 operations are performed annually in Great Britain, 100,000 in France and 700,000 in the US. Given its high frequency has a major impact, both in the medical and economic aspects.Aim:Analyze the immediate postoperative complications comparing mesh versus non mesh hernioplasty.Method:Randomized control trial, with the enrollment of 263 patients underwent surgery for inguinal hernia randomized by randomization table. Treatment (mesh, Lichtenstein or without mesh, Bassini technique) was assigned using sequentially numbered opaque envelopes having fulfilled the inclusion criteria. The variables analyzed were: postoperative pain, seroma, hematoma, infection, return to normal activities and recurrence.Results:The mean age was 55.5 years, 88% patients were male and 12% female. The pain was higher in patients operated with mesh.Conclusions:The inguinal hernia repair mesh group had less immediate postoperative complications and significantly earlier return to work than hernioplasty without mesh, this being one of the most important conclusions.

Racional:Correção de hérnia inguinal é o procedimento mais comum em cirurgia geral, sendo que 80.000 operações são realizadas anualmente na Grã-Bretanha, 100.000 na França e 700.000 nos EUA. Dada à sua alta frequência tem grande impacto, tanto nos aspectos médicos como nos econômicos.Objetivo:Analisar as complicações pós-operatórias imediatas comparando hernioplastia com e sem tela.Método:Ensaio clínico randomizado, com a inclusão de 263 pacientes que foram submetidos à operação de hérnia inguinal, randomizados por tabela de randomização. Os tratamentos foram para o grupo com tela Lichtenstein e ao sem malha técnica de Bassini. Usaram-se envelopes sequencialmente numeradas opacos após terem sido cumpridos os critérios de inclusão. As variáveis ​​analisadas foram: dor pós-operatória, seroma, hematoma, infecção, retorno às atividades normais e recorrência.Resultados:A idade média foi de 55,5 anos; 88% dos pacientes eram mulheres e 12% homens. A dor foi maior nos pacientes operados com tela.Conclusões:O grupo com tela teve menos complicações pós-operatórias imediatas e significativamente mais rápido retorno ao trabalho do que hernioplastia sem tela, sendo esta uma das conclusões mais importantes.

[Mirizzi Syndrome: Prevalence, diagnosis and treatment]. / Síndrome de Mirizzi: Prevalencia, diagnóstico y tratamiento.

BACKGROUND: The Mirizzi syndrome was described by Pablo Luis Mirizzi in 1948, who emphasized this syndrome was characterized by the obstruction of the common hepatic duct due to mechanical compression caused by an impacted stone in the gallbladder neck or in the cystic duct. The incidence ranges from 0.05% to 4%. MATERIAL AND METHODS: We performed a retrospective cross-sectional study. Based on the database of the General Surgery Division of the Prof Alejandro Posadas National Hospital, between July 2007and June 2013, charts of all patients with biliary lithiasis disease operated in this period were analyzed. We analyzed the clinical features, the various diagnostic techniques and the treatment carried out in each of them. RESULTS: Surgery due to biliary lithiasis was performed in 2,160 patients. Fourteen patients, 8 females and 6 males, had Mirizzi syndrome (0.65%). The mean age was 55.3 years old (range 34-70 years old). Four patients were scheduled for elective surgery and 10 were operated during emergency. Preoperative differential diagnosis was: extrahepatic cholestasis 10, cholecystitis 3 and biliary duct stenosis vs gallbladder cancer 1. The treatments performed were: 3 conventional cholecystectomies with intraoperative dynamic cholangiography, 2 conventional cholecystectomies plus choledochoplasty with Kehr tube, 2 laparoscopic cholecystectomies plus choledochoplasty with Kehr tube, 1 partial cholecystectomy with Pezzer catheterization, 3 choledochoduodenostomy, 1 choledochoplasty with gallbladder remnant, 1 hepaticojejunostomy and 1 treatment in two steps (percutaneous biliary drainage and cholecystectomy). Regarding complications, we observed 1 autolimited leak from the choledocoduodenostomy, 1 death in an ederly patient, and 1 hepatic abscess treated by a minimaly invasive approach. CONCLUSIONS: Mirizzi syndrome is a disease with low prevalence, which must be taken into account in biliary surgery, because the treatment varies according to the intraoperative findings and the experience of the surgical team.

Primary gastric rhabdomyosarcoma. Case report.

Rhabdomyosarcomas are rare and malignant tumors. There have been reported two histological types of gastric rhabdomyosarcomas, the pleomorphic and embryonal cell types. We report the case of a 53-year-old male with endoscopic diagnosis of a Bormann type III ulcer which revealed a gastric primary rhabdomyosarcoma. Ultrasound showed two liver lesions, two hepatic pedicle lymph nodes and a huge primary gastric tumor. CT scan revealed a primary gastric tumor. The patient is submitted to a distal gastrectomy with a Billroth II reconstruction and a resection of the distal liver metastases at segment IV The patient was discharged uneventfully on the eighth postoperative day. The gold standard for a final diagnoses is the immuno-histochemical staining of the endoscopic biopsy. There is very little information on the results of chemotherapy and the surgical treatment is the best choice.

Vesícula de porcelana. Caso clínico y revisión de la literatura / Porcelain gallbladder: a clinical case and a review of the literature

Vesícula en porcelana se define como la calcificación de la pared de la vesícula biliar. Es una rara entidad que se observa en el 0,06 a 0,8% de las colecistectomías. Su etiología sigue siendo desconocida. Reportamos dos casos de pacientes con vesícula en porcelana. Un caso es un paciente masculino de 60 años que consulta por sintomatología biliar, se realiza el diagnóstico mediante ecografía y tomografía computada y es intervenido quirúrgicamente realizándose colecistectomía parcial con anatomía patológica que informa: pared vesicular con esclerohialinosis y focos de calcificación distrófica. El otro caso es una paciente femenina de 98 años, cuya forma de presentación fue incidental dado que cursaba con cuadro de oclusión intestinal, se realizó colecistectomía con buena evolución postoperatoria. Series publicadas entre los años 1950 y 1960 avalan que la vesícula en porcelana puede observarse con frecuencia en pacientes con cáncer de vesícula, aunque recientemente se ha desestimando este tipo de relación. El motivo por el cual se presentan estos casos es su baja frecuencia y su controversia en lo que al tratamiento se refiere por su relación con el cáncer de vesícula (AU)

Porcelain bladder is defined as calcification of the gallbladder wall. It is a rare condition and is seen in 0.06% to 0.8% of cholecystectomies. It origin is still unknown. We report two cases of patients with a porcelain gallbladder. One case is a 60 year-old male patient who was seen due to having biliary symptoms. The diagnosis was made by ultrasound and computed tomography, and he was surgically intervened by performing apartial cholecystectomy. The histopathology reported a gallbladder wall with sclerohyalinosis and dystrophic calcification foci. The other case is a 98 year-old female patient, whose form of presentation was incidental given that she suffered from symptoms of an intestinal obstruction. A cholecystectomy was performed with a good post-surgical outcome. A series published in between 1950 and 1960 show that the porcelain bladder can be frequently observed in patients with cancer of the gallbladder, although this relationship is currently being rejected. The reason why these cases are being presented is because of their (AU)

[Porcelain gallbladder: a clinical case and a review of the literature]. / Vesícula de porcelana. Caso clínico y revisión de la literatura.

Porcelain bladder is defined as calcification of the gallbladder wall. It is a rare condition and is seen in 0.06% to 0.8% of cholecystectomies. It origin is still unknown. We report two cases of patients with a porcelain gallbladder. One case is a 60 year-old male patient who was seen due to having biliary symptoms. The diagnosis was made by ultrasound and computed tomography, and he was surgically intervened by performing a partial cholecystectomy. The histopathology reported a gallbladder wall with sclerohyalinosis and dystrophic calcification foci. The other case is a 98 year-old female patient, whose form of presentation was incidental given that she suffered from symptoms of an intestinal obstruction. A cholecystectomy was performed with a good post-surgical outcome. A series published in between 1950 and 1960 show that the porcelain bladder can be frequently observed in patients with cancer of the gallbladder, although this relationship is currently being rejected. The reason why these cases are being presented is because of their low incidence and the controversy over what treatment to use, due to its association with gallbladder cancer.

[Transfistular approach for the treatment of retained biliary stones]. / Abordaje transfistular para el tratamiento de la litiasis residual de la vía biliar.

INTRODUCTION: Residual stones are those persisting in the biliary duct after a surgical intervention. They are found in approximately 2% of cases after a simple cholecistectomy and in 4% to 15% after an exploration of the common duct. MATERIAL AND METHODS: Between January 2009 and June 2008, 81 patients were treated because of residual stones. Age, sex, number of stones, days in the hospital, laboratory, complications and diagnosis were analyzed. RESULTS: Forty-eight patients were male and 33 female. The mean age was 42.5 years. Mean stay at hospital was 1.3 days. The mean number of procedures was 1.19. Fifty-two patients came from another institution and 28 belonged to our institution. The total of complications was 6.5%. CONCLUSIONS: The percutaneous treatment for the residual stones is the goal standard in patients with "T" tube drainage and elevated risk for surgery. The advantage of this procedure is that it is economic, effective and with low risks for the patient. For the treatment of this disease, the collaboration of surgeons, endoscopists, and interventional radiologists is needed.

Malrotación intestinal en adultos: causa infrecuente de abdomen agudo oclusivo / Intestinal malrotation in adults: infrecuent cause of acute oclusive syndrome

El 90 % de los casos de obstrucción por malrotación intestinal ocurre en niños menores de 1 año de edad, siendo altamente infrecuente en adultos. Un paciente de sexo masculino, de 31 años de edad, con antecedente de episodios de dolor abdominal, vómitos y constipación que alternaban con períodos de normalidad desde la niñez es admitido en el hospital por sintomatología similar, la que no cede. Luego de estudios radiológicos y de laboratorio se decide su intervención quirúrgica con el diagnóstico de obstrucción intestinal. El diagnóstico intraoperatorio realizado fue de malrotación intestinal tipo I, practicándose la operación de Ladd. La evolución del paciente es favorable. La infrecuente presentación de esta patología en adultos es lo que motiva la presentación del caso.

The 90 % of the bowel obstruction caused by intestinal malrotation occurred in children younger than 1 year, this type of obstruction is very uncommon in adults. This is a male of 31 years old, with history of abdominal pain, vomits and constipation since he was a child. These symptoms were sporadical, he didn't need any surgical treatment. Recently he was admitted in our institution presenting similar symptoms, without remission of them. After imaging and laboratory studies, was performed a surgery, and the intraoperatoty diagnosis was intestinal malrotation type I. The surgical treatment was the Ladd Operation. The postsurgery evolution was good. Discharged 4 days after the surgery. The aim of this article is to present a rare case of intestinal obstruction in adults caused for an intestinal malrotation.

Tumores estromales (GISTs) del tubo digestivo / Estromales tumors (GISTs) of the alimentary canal

Antecedentes: Los tumores estromales del tubo digestivo son tumores mesenquimáticos distintos a los tumores musculares o nerviosos. Objetivo: Estudiar su incidencia, cuadro clínica, método de diagnóstico, localización, tratamiento, malignidad y evolución. Lugar: Hospital Nacional "Profesor Alejandro Posadas" y práctica privada. Diseño: Estudio retrospectivo, observacional. Población: 16 pacientes. período 2000-2005. Método: Fueron analizadas las historias clínicas y documentación diagnóstica. Se dividio a los pacientes de acuerdo con la localización de su patología. Resultados: Fueron tratados 16 pacientes . 11 con tumores gástricos, 3 de intestino delgado y 2 de colon. La hemorragia digestiva se presentó en 7 de los gástricos y 1 de intestino delgado. La endoscopia fue útil en las hemorragias digestivas. La ecografía y tomografía computarizada sirvieron para el diagnóstico. La certificación se hizo en todos los casos con CD 117. La malignidad se demostró en 6 por tener más de 5 cm y 3 de éstos tenían más de 5 mitosis por 50 campos de gran aumento. Conclusiones: Los tumores estromales se originan en las células de Cajal. Se diagnostican por inmunohistoquímica (CD 117). Son más frecuentes en estómago. La endoscopia, la TAC y la ecoendoscopia son los métodos auxiliares de diagnóstico de mayor utilidad. El número de mitosis y el tamaño son los marcadores más importantes para establecer la malignidad.

[Gastro-duodenal trichobezoars: a rare cause of obstruction of the gastrointestinal tract]. / Tricobezoares gastroduodenales: una causa poco frecuente de obstrucción del tracto de salida.

BACKGROUND: Trichobezoars represent 55% of human bezoars. Patients are women in 90% of cases and have some psychiatric disorder in 40%. OBJECTIVE: To study the clinical features, diagnostic methodology and treatment in patients with trichobezoars. DESIGN: Retrospective analysis of clinical records and case report. METHOD: Four patients were included between January 2000 and March 2004, 3 women and 1 man, with a mean age of 32.3 years (range 22 to 73 years). RESULTS: All patients had an epigastric mass, dyspepsia, vomiting, and weight loss of 5 to 25 kg, without pain. Three patients underwent barium studies, and all of them ultrasonography, computerized tomography and upper gastrointestinal endoscopy. All of them received endoscopic procedures without treatment success. Any patient referred trichophagy and all of them had psychiatric disorders. The surgical treatment was gastrotomy and removal of the bezoar. The average weight was 1,100 g (range 700 to 1,500 g). CONCLUSIONS: The trichobezoar is a rare cause of obstruction of the gastrointestinal tract. The diagnosis should be suspected with the clinical and barium study findings, and confirmed by computerized tomography and endoscopy. Surgery is the treatment of choice. However, other treatments have been described, such as endoscopic fragmentation, extracorporeal lithotripsy and laparoscopic extraction.