Fístula colecistoduodenal sin migración de cálculo: reporte de caso / Cholecystoduodenal fistula without gallstones migration: case report / Fístula colecistoduodenal sem migração de cálculos: relatório de caso

El síndrome de Bouveret es una causa infrecuente de íleo biliar, posee una elevada morbimortalidad. Se produce por la migración de un cálculo, generalmente de gran tamaño, hacia el tracto gastrointestinal a través de una fistula colecistoduodenal. El objetivo de esta carta científica es presentar un paciente con un estadio previo de la enfermedad donde la fistula se encuentra constituida, pero sin migración del cálculo, por lo que el diagnóstico oportuno tendría un impacto favorable en el tratamiento y pronóstico debido a que no se encuentra instaurado el cuadro obstructivo intestinal.

Bouveret's syndrome is a rare cause of biliary ileus, with a high morbimortality. It is caused by the migration of a stone, usually large, into the gastrointestinal tract through a cholecystoduodenal fistula. The objective of this scientific letter is to present a patient with a previous stage of the disease where the fistula is constituted, but without migration of the calculus, so that the timely diagnosis would have a favorable impact on the treatment and prognosis because the obstructive intestinal condition is not established.

A síndrome de Bouveret é uma causa rara de íleo biliar com uma morbilidade e mortalidade elevadas. É causada pela migração de uma pedra, geralmente grande, para o tracto gastrointestinal através de uma fístula colecystoduodenal. O objectivo desta carta científica é apresentar um doente com uma fase anterior da doença em que a fístula está presente, mas sem migração da pedra, para que o diagnóstico atempado tenha um impacto favorável no tratamento e prognóstico, uma vez que a condição obstrutiva instestinal não está estabelecida.

Cáncer de vesícula biliar ¿la contaminación por bilis afecta el pronóstico? / Gallbladder Cancer: does bile contamination affect the prognosis?

Resumen Introducción: En algunas áreas el cáncer de la vesícula biliar se detecta en hasta el 3,5% de los pacientes intervenidos por colelitiasis. Con el objetivo de evaluar el rol de la ruptura de la vesícula y la consiguiente contaminación por bilis, se evaluó una serie de pacientes portadores de cáncer de vesícula diagnosticado posterior a la colecistectomía. Materiales y Método: El estudio se efectuó en 109 pacientes en quienes se diagnosticó un cáncer de vesícula posterior a la colecistectomía. El grupo a estudiar se dividió de acuerdo a la ocurrencia o no de contaminación por bilis al momento de la colecistectomía, como también de acuerdo a la magnitud de ésta. Resultados: De los pacientes estudiados, en 32 se documentó la ocurrencia de contaminación por bilis al momento de la colecistectomía. De estos, en 13 la contaminación fue considerada mayor. El tiempo promedio de seguimiento fue de 33 meses, 35 pacientes (32,1%) fallecieron durante el seguimiento. La sobrevida media de la totalidad de la serie que tuvo contaminación por bilis no se diferenció de los pacientes sin contaminación. Sin embargo, el grupo que tuvo una contaminación catalogada como mayor, presentó una sobrevida estadísticamente inferior al resto de los pacientes. Finalmente, se realizó un análisis mediante el modelo de regresión de COX que incluyó edad, género, nivel de invasión y tipo de contaminación, resultando la existencia de contaminación mayor por bilis un factor independientemente asociado al pronóstico. Conclusión: La presencia de ruptura vesicular y contaminación mayor por bilis debiera considerarse un factor pronóstico.

Background: Incidental gallbladder cancer is observed in up to 3.5% of patients undergoing laparoscopic cholecystectomy. To study the role of wall perforation on the prognosis, we evaluated a series of patients in whom perforation occurred during the cholecystectomy. Materials and Method: 109 patients who underwent a laparoscopic cholecystectomy in whom final diagnosis was gallbladder cancer were the focus of the study. We divided the patients according the occurrence of spillage. Furthermore, patients with spillage were divided into two categories according the spillage magnitude. Results: Of the patients, spillage was documented in 32 (29.3%). In 13 patients spillage was considered major. The median follow-up of patients was 36 months, while 35 (32.1%) patients died during the follow-up. Five-year survival of all patients with spillage was not statistically different from the group without spillage. However, the group with major spillage had a statistically worse survival than the rest. A Cox regression analysis including age, gender, level of invasion and spillage category showed that major spillage was independently associated with a worse prognosis.

Análisis epidemiológico de cáncer de vesícula / Epidemiologic analysis of gallbladder cancer

Antecedentes: El cáncer de vesícula biliar se caracteriza por ser un tumor de mal pronóstico y diagnóstico tardío. Objetivo: Describir variables epidemiológicas del cáncer de vesícula en nuestro centro y compararlos con la bibliografía internacional. Material y métodos: En pacientes sometidos a colecistectomía entre el 1º de enero de 2006 y el 31 de diciembre de 2015, se estudiaron las siguientes variables: sexo, edad, relación mujer/varón, causa de colecistectomía, clasificación en urgencias y programadas; en los casos de cáncer de vesícula: sexo, edad, histopatología, diferenciación celular, invasión (de pared vesicular, angiolinfática, del ganglio cístico, tejidos vecinos y del hígado), estadificación (clasificaciones de Nevin y de Unión Internacional Contra el Cáncer-UICC). Resultados: Se diagnosticaron 92 neoplasias vesiculares (1,26% de todas las colecistectomías). El promedio de edad para cáncer de vesícula fue 57,9 años (rango 22-88); sexo femenino 64 (69,5%, con relación mujer/varón 2:1. La histopatología mostró 86 (93,4%) adenocarcinomas, 4 (4,4%) carcinomas escamosos y 2 (2,2%) indiferenciados con elementos de origen mesenquimático y epitelial de vesícula. Las lesiones asociadas fueron adenocarcinoma con metaplasia escamosa, 2 casos; mucosecretante, 2 casos; papilar, 1 caso; metaplasia intestinal y antral, 1 caso. En 60 (65,4%) casos fueron moderadamente diferenciados; bien diferenciados, 12 (13%); pobremente diferenciados, 11 (11,9%) e indiferenciados, 4 (4,3%). En 5 casos (5,4%), no se especificaba la diferenciación celular. Conclusión: El cáncer de vesícula diagnosticado luego de una colecistectomía es más frecuente en mujeres, con tipo histológico adenocarcinoma, llamando la atención la cantidad de pacientes jóvenes diagnosticados.

Background: Gallbladder cancer is characterized by poor prognosis and late diagnosis. Objective: The aim of our study is to describe the epidemiological variables of gallbladder cancer at our centre and to compare them with data from the worldwide literature. Material and methods: Patients undergoing cholecystectomy between January 1, 2006, and December 31, 2015. The following variables were analyzed: sex, age, male to female ratio, reason for cholecystectomy, urgent or scheduled. In case of gallbladder cancer, sex, age, histopathology, cell differentiation, gallbladder layer invasion, lymphovascular, cystic lymph node, adjacent tissues and liver invasion; and cancer staging according to Nevin staging system and the Union for International Cancer Control (UICC). Results: Ninety-two gallbladder neoplasms were found, representing 1.26% of all cholecystectomies. Mean age of patients with gallbladder cancer was 57.9 years (range, 22-88 years) of whom 69.5% (n=64) were women, with the same female to men ratio of 2:1 described for cholecystectomy. The histopathology of the 92 gallbladder cancers corresponded to adenocarcinoma, 93.4% (n= 86); squamous cell carcinoma, 4.4% (n= 4); and undifferentiated malignancy with elements of epithelial and mesenchymal origin, 2.2% (n= 2). There were two cases of adenocarcinoma with squamous metaplasia, two mucinous carcinomas, one papillary adenocarcinoma and one case of antral-type and intestinal metaplasia. Sixty tumors (65.4%) were moderately differentiated; 12 (13%) well differentiated; 11 (11.9%) poorly differentiated; and 4 (4.3%) were undifferentiated. In 5 cases (5.4%) the type of differentiation was not described. Conclusion: In gallbladder cancer diagnosed after a cholecystectomy, it is more frequent in the female sex, with adenocarcinoma being the most common histological type. Interestingly, the number of young patients with gallbladder cancer is noteworthy.

Uncommon site of metastasis from renal cell carcinoma: Case report.

BACKGROUND: Renal cell carcinomas (CCR) account for 90% of renal tumors. Presence of latent distant metastasis is characteristic of RCC and may manifest more than a decade after nephrectomy. Gallbladder (GB) is a rare site of metastasis, with few reports in the literature. A case of metastasis from RCC to GB nine years after initial diagnosis is reported herein. CASE REPORT: Male patient, 74 years, nine years post right radical nephrectomy for grade 2 clear-cell adenocarcinoma, T3BN0M0. During onset, Magnetic Resonance Imaging (MRI) evidenced T2-weighted hypointense and T1-weighted hyperintense lesion, with early and persistente contrast enhancement and exophytic bulging of the underlying outer vesicular margin. T1-weighted hypointense and T2-weighted slightly hyperintense nodular formation was also evidenced in the body portion of the pancreas, with 1.5 × 1.2 cm. The patient was subjected to videolaparoscopic cholecystectomy associated to endoscopic ultrasound (EUS) intraoperatively for investigation of the pancreatic nodule. The anatomopathological examination of the gallbladder was compatible with infiltrating metastasis from clear-cell carcinoma of primary renal site. A solid, hypoechoic, oval nodule with 14 mm was found at EUS, which cytology was suggestive of clear-cell Carcinoma. Because this is an indolent disease with oligometastasis, local ablative treatment with fractionated stereotactic radiation therapy with a dose of 40 Gy was selected. The patient is found with stable disease one year after radiation therapy. CONCLUSION: Gallbladder is an unusual site of RCC metastasis. In patients with history of this disease, all vesicular lesions should be given attention, even where the primary tumor has been treated many years before.

Colecistectomía convencional abierta en el tratamiento quirúrgico de la litiasis vesicular / Open Cholecystectomy for Surgical Treatment of Gallstones

Fundamento: la colecistectomía es uno de los procedimientos de tratamiento quirúrgico que ha resistido el embate centenario de los años. Sigue siendo la vía adecuada cuando no se cuenta con tecnología avanzada. Objetivo: describir los resultados obtenidos con la colecistectomía convencional abierta, en el tratamiento de la litiasis vesicular. Métodos: estudio descriptivo de los pacientes operados de litiasis vesicular, durante el año 2012, en el Centro Médico Diagnóstico Integral María G. Guerrero Ramos, Distrito Capital, en la República Bolivariana de Venezuela. La información se obtuvo del expediente clínico y un modelo recolector de datos. Se analizaron las variables: edad, sexo, enfermedades asociadas, síntomas y signos, resultados del tratamiento quirúrgico, evolución y complicaciones. Resultados: fueron operados 147 pacientes; predominó el grupo de 41 a 60 años y el sexo femenino; el dolor en hipocondrio derecho y la intolerancia a los alimentos grasos y granos, fueron los síntomas y signos que prevalecieron. La cefazolina fue el antibiótico más utilizado. Los pacientes evolucionaron de forma satisfactoria, las complicaciones fueron mínimas. Conclusiones: la colecistectomía convencional abierta sigue siendo una opción favorable para el tratamiento de la litiasis vesicular, ante la ausencia de tecnología de avanzada.

Background: cholecystectomy is one of the surgical procedures that are still practiced despite the passing of time. It remains the appropriate method to perform in the absence of advanced technology. Objective: to describe the results of the open cholecystectomy in the treatment of gallstones. Methods: a descriptive study was conducted in patients operated on for gallstones in 2012 in the María G. Guerrero Ramos Comprehensive Diagnostic Center in the Capital District, Bolivarian Republic of Venezuela. The information was obtained from medical records and a data collection model. The variables analyzed were: age, sex, associated diseases, signs and symptoms, results of the surgical treatment, outcome and complications. Results: a total of 147 patients underwent surgery; the 41-60 year age group and female patients predominated; right hypochondrial pain and intolerance to fatty foods and grains were the major signs and symptoms. Cefazolin was the most widely used antibiotic. Patients recovered satisfactorily, complications were minimal. Conclusions: open cholecystectomy remains useful for the treatment of gallstones in the absence of advanced technology.

Imagen calcificada y dolor en hipocondrito derecho / Calcified image and pain in the right hypochondrium

Introducción: El cáncer de vesícula ocupa el 5° lugar de aparición de todos cánceres digestivos. En nuestro país es dos veces más frecuente que los tumores ubicados en la vía biliar principal intra o extrahepática. Objetivos: Reporte de caso y revisión bibliográfica. Reporte de Caso: Mujer de 52 años, sin antecedentes clínicos de relevancia, que consulta por dolor abdominal, náuseas y vómitos de 14 días de evolución. Se realiza una ecografía que evidencia engrosamiento parietal y litiasis vesicular. En el intraoperatorio se evidencia Vesícula en Porcelana con infiltración hepática a nivel del fondo.Discusión: Destacar la importancia de una correcta interpretación de las imágenes, a los fines de tomar la conducta que mayor beneficio representa para el paciente. (AU)

Introduction: Gallbladder cancer occupies the 5th place of occurrence among all digestive system cancers. In our country, it is twice more frequent than tumors of the intra or extrahepatic principal biliary tract. Objectives: Case report and literature review. Case Report: 52-year-old woman, with no relevant clinical history, with 14 days of abdominal pain, nausea and vomit. The ultrasound scan reveals parietal thickening and gallstones. During intrasurgical exploration, porcelain gallbladder is found, with hepatic infiltration at fundus. Discussion: To highlight the importance of a correct image interpretation, in order to choose the most beneficial treatment for the patient. (AU)

Imagen calcificada y dolor en hipocondrito derecho / Calcified image and pain in the right hypochondrium

Introducción: El cáncer de vesícula ocupa el 5° lugar de aparición de todos cánceres digestivos. En nuestro país es dos veces más frecuente que los tumores ubicados en la vía biliar principal intra o extrahepática. Objetivos: Reporte de caso y revisión bibliográfica. Reporte de Caso: Mujer de 52 años, sin antecedentes clínicos de relevancia, que consulta por dolor abdominal, náuseas y vómitos de 14 días de evolución. Se realiza una ecografía que evidencia engrosamiento parietal y litiasis vesicular. En el intraoperatorio se evidencia Vesícula en Porcelana con infiltración hepática a nivel del fondo.Discusión: Destacar la importancia de una correcta interpretación de las imágenes, a los fines de tomar la conducta que mayor beneficio representa para el paciente.

Introduction: Gallbladder cancer occupies the 5th place of occurrence among all digestive system cancers. In our country, it is twice more frequent than tumors of the intra or extrahepatic principal biliary tract. Objectives: Case report and literature review. Case Report: 52-year-old woman, with no relevant clinical history, with 14 days of abdominal pain, nausea and vomit. The ultrasound scan reveals parietal thickening and gallstones. During intrasurgical exploration, porcelain gallbladder is found, with hepatic infiltration at fundus. Discussion: To highlight the importance of a correct image interpretation, in order to choose the most beneficial treatment for the patient.

Câncer de vesícula biliar: experiência de 10 anos em um hospital de referência da Amazônia / Gallbllader cancer: 10 years of experience at an Amazon reference hospital

OBJETIVO: Analisar os aspectos epidemiológicos-cirúrgicos dos pacientes com câncer de vesícula biliar (CAVB) atendidos em um Hospital Universitário de Belém/PA, no período de 1999-2009. MÉTODOS: estudo observacional, retrospectivo, descritivo-analítico de fonte secundária dos pacientes com diagnóstico de CAVB, no período de 1999-2009. Foram analisados 75 prontuários, sendo 34 pacientes estudados. As informações coletadas foram utilizadas para o estadiamento tumoral TNM do CAVB e para a caracterização clínico-cirúrgica da população estudada. RESULTADOS: 79 por cento eram do sexo feminino, com média de idade de 66,2±11 anos e tempo de sintomatologia de 10,8±17,2 meses, não obtendo relação estatística com o estadio da doença. Dor no hipocôndrio direito, náuseas e icterícia predominaram como sinais/sintomas. A litíase biliar esteve presente em 91 por cento dos casos, sendo positiva em 100 por cento dos pacientes com estadios I/II. A sensibilidade ultrassonográfica para sugestionar o CAVB no pré-operatório foi 14,28 por cento. A operação mais executada foi a colecistectomia simples, tendo como achado intra-operatório predominante, invasão hepática. O adenocarcinoma foi o tipo histológico preponderante, com destaque para os estadios III e IV. CONCLUSÃO: A série estudada apresentou alta incidência de litíase biliar, o adenocarcinoma com estadio avançado foi o mais prevalente. acarretando um pequeno índice de operações com intenção curativa, 30 por cento dos pacientes operados, e uma taxa de mortalidade de 21 por cento. A valorização dos sintomas e a investigação precoce por exames de imagem poderiam favorecer o tratamento, em fases iniciais do CAVB, proporcionando um melhor prognóstico para os pacientes operados.

OBJECTIVE: To evaluate the epidemiological aspects of surgical patients with gallbladder cancer (GC) enrolled in a University Hospital in Bethlehem (State of Pará - PA), in the period 1999-2009. METHODS: observational, retrospective, descriptive and analytical study of secondary sources of patients with GC in the period 1999-2009. We analyzed 75 medical records, with 34 patients studied. The information collected was used for the TNM tumor staging of GC and to characterize the clinical and surgical population. RESULTS: 79 percent were female, mean age 66.2 ± 11 years and duration of symptoms was 10.8 ± 17.2 months, with no statistical relationship with the stage of disease. Pain in right upper quadrant, nausea and jaundice prevailed as signs / symptoms. Gallstones were present in 91 percent of cases and were positive in 100 percent of patients with stage I / II. The sensitivity of ultrasound to preoperatively suggest GC was 14.28 percent. The simplest operation performed was cholecystectomy, with the predominant intraoperative finding being hepatic invasion. Adenocarcinoma was the predominant histologic type, especially for stages III and IV. CONCLUSION: The present study showed high incidence of gallstone disease. Advanced stage adenocarcinoma was the most prevalent. This resulted in a low rate of operations with curative intent, in 30 percent of the patients, and a mortality rate of 21 percent. The appreciation of symptoms and early investigation by imaging could facilitate treatment in early stages of GC, providing a better prognosis for patients.

Complicações da cirurgia videolaparoscópica no tratamento de doenças da vesícula e vias biliares / Videolaparoscopy complications in the management of biliary diseases

RACIONAL: O tratamento de escolha para as doenças da vesícula biliar é a colecistectomia, cujo objetivo é o alívio de sintomas e o tratamento e/ou prevenção das complicações. OBJETIVO: Identificar as principais complicações da cirurgia videolaparoscópica no tratamento das doenças da vesícula biliar e vias biliares. MÉTODO: Realizou-se busca eletrônica na base de dados LILACS e Medline desde o ano de 1981 a agosto de 2007; foram encontrados 57 artigos, sendo utilizados para o estudo 31 e três capítulos de livros. RESULTADOS: A produção científica submetida à análise de conteúdo evidenciou os seguintes núcleos temáticos: variações anatômicas (3 artigos), iatrogenias (5 artigos), síndrome pós-colecistectomia (1 artigo), complicações raras (3 artigos), síndrome de Mirizzi (1 artigo), complicações pulmonares (2 artigos) e tratamento (1 capítulo de livro e três artigos). CONCLUSÕES: As complicações que podem ocorrer na cirurgia videolaparoscópica da vesícula biliar e das vias biliares têm basicamente duas vertentes: uma é a inexperiência dos cirurgiões com o método laparoscópico (curva de aprendizado) e outra, as variações anatômicas com as quais os cirurgiões, mesmo os mais experientes, podem se deparar.

BACKGROUND: The treatment of choice for diseases affecting the gallbladder is the cholecystectomy, whose aim is improvement of symptoms, treatment and/or prevention of complications. AIM: Identify the main complications with laparoscopic surgery used to treat diseases affecting the gallbladder and the bile ducts. METHODS: An internet search in the LILACS and Medline database covering the period from 1981 up to August 2007 was carried out and 57 studies were found relevant. The present work draws on 31 of these studies and one textbook chapter. RESULTS: The analysis of the content of the studies selected yielded the following thematic issues: anatomic variations (3 studies), iatrogenies (5 studies), post-cholecystectomy syndrome (1 study), rare complications (3 studies), Mirizzi's syndrome (1 study), pulmonary complications (5 studies) and treatment (1 chapter of a medicine textbook and 3 studies). CONCLUSIONS: The complications arising from the videolaparoscopic surgery of the gallbladder and bile ducts are fundamentally due to two factors: the surgeon's lack of training in the laparoscopic technique (learning curve), and the unexpected anatomic variations, which even experienced surgeons may face.

Colecistite aguda decorrente de hemorragia intraluminar da vesícula biliar após trauma abdominal fechado / Posttraumatic acute cholecystitis caused by intra-gallbladder hemorrhage

Isolated gallbladder injury following abdominal blunt trauma is rare and early diagnosis is difficult to make, particularly when no other organ is injured. However, ultrasonography is valuable for investigating gallbladder injuries. We report a case of isolated gallbladder blunt trauma presented as acute cholecystitis with hemobilia. In isolated blunt traumatic injury to the gallbladder, treatment options vary depending on the specific injury. The characteristics of blunt trauma injuries to the gallbladder and their appropriate management are discussed.