Biliary peritonitis in a dog after perforation of the gallbladder during laparoscopic cholecystectomy

Background: Iatrogenic gallbladder perforation during laparoscopic cholecystectomy (LC) is a common complication and occurs in at least one third of human patients undergoing LC. This is attributed to the fragility of the gallbladder wall associated with mucocele and cholecystitis, in addition to the need for repetitive gripping and traction of the gallbladder during its manipulation with laparoscopic instruments. As complications from this event are rare in human patients, conversion to laparotomy is not routinely indicated and the adverse consequences of bile spillage are minimized by abundant irrigation of the peritoneal cavity and adequate antimicrobial therapy. On the other hand, there is little information regarding the outcome of laparoscopic management of this complication in laparoscopic cholecystectomies in dogs, particularly since most surgeons indicate conversion in these cases. Thus, we describe a case of biliary peritonitis that developed in a dog after laparoscopic management of iatrogenic perforation of the gallbladder during a laparoscopic cholecystectomy, in a case of gallbladder mucocele. To the best of our knowledge, there are no reports of biliary peritonitis following laparoscopic management of iatrogenic gallbladder perforation during LC in dogs. Case: A 14-year-old Poodle was referred for clinical evaluation with selective appetite, recurrent episodes of hyporexia, and abdominal discomfort. Ultrasound findings characterized chronic liver disease and gallbladder mucocele. The patient was referred for laparoscopic cholecystectomy, during which the gallbladder was iatrogenically perforated, with extravasation of a large volume of bile content. This complication was managed by copious abdominal irrigation via laparoscopic access and antimicrobial therapy. On the second postoperative day, the patient started to present apathy, hyporexia, emesis, and jaundice. The patient remained hospitalized in the intensive care unit for stabilization and monitoring through hematological examinations and serial abdominal ultrasound. Due to progressive worsening of the clinical picture, an exploratory laparotomy was performed ten days after the initial surgical procedure. This examination showed multiple adhesions and the presence of bile residues adhered to numerous points on the peritoneal surface and pancreas. Despite the intensive treatment instituted, death occurred 10 h after the second surgical procedure. Discussion: The high risk of gallbladder perforation during laparoscopic cholecystectomies correlates with the dissection step or repetitive grasping and traction of the gallbladder with laparoscopic instruments. Conversion is not routinely indicated and laparoscopic management is considered effective in humans. However, in this case, the presence of a large volume of extravasated semisolid bile content and its adherence to the mesothelial surface made it impossible to remove it in its entirety despite the abundant irrigation of the abdominal cavity, resulting in a picture of biliary peritonitis in the postoperative period. In view of the reported negative outcome, the authors encourage the adoption of measures that minimize the risk of gallbladder perforation when performing LC in dogs. These include the use of atraumatic instruments or aspiration of bile content before surgical manipulation. Cases in which such a complication is recorded should be carefully monitored to enable early diagnosis and treatment of biliary peritonitis. Furthermore, conversion should be considered when there is extravasation of large volumes of bile, particularly in the presence of gallbladder mucocele, until future studies establish the safety and effectiveness of laparoscopic management of this complication.

A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases

Purpose; Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the “critical view of safety”, the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury.; Methods; A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-oclock position as cranial, 6-oclock as dorsal, 9-oclock as caudal, and 12-oclock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images.; Results; All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-oclock position, 6-oclock position, 9-oclock position, 12-oclock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-oclock and 12-oclock position were pitfalls that might cause biliary injury.; Conclusion; The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.(AU)

A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases

Purpose Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the critical view of safety, the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury. Methods A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-oclock position as cranial, 6-oclock as dorsal, 9-oclock as caudal, and 12-oclock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images. Results All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-oclock position, 6-oclock position, 9-oclock position, 12-oclock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-oclock and 12-oclock position were pitfalls that might cause biliary injury. Conclusion The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.(AU)

Diagnóstico e tratamento de mucocele da vesícula biliar em cão / Diagnosis and treatment of gall bladder mucocele in dog

A mucocele de vesícula biliar se caracteriza pelo acúmulo anormal de bile semissólida na vesícula biliar. O presente trabalho relata o caso de uma cadela idosa, da raça yorkshire atendida em um Hospital Veterinário particular (Serviço Médico Veterinário – SEMEVE), com quadro de vômitos, anorexia, prostração e tremores, iniciados no dia do atendimento. Durante a anamnese, a tutora relatou que a paciente tinha sido diagnosticada há três anos com dislipidemia, sendo descartadas afecções endócrinas como causa do quadro. Ao exame físico, o animal apresentava sensibilidade à palpação abdominal e discreta icterícia em esclera. Durante o ultrassom de abdômen foi diagnosticada a mucocele de vesícula biliar, através da ecogenicidade, padrão apresentado pela bile e histórico clínico do animal. O tratamento inicial foi com antibioticoterapia, fluidoterapia suplementada com vitamina b e potássio, analgésico, antiemético e protetor gástrico. Devido a piora do quadro apresentada nos exames, 48 horas após o internamento, foi realizada colecistectomia. No transcirúrgico identificou-se aderência do omento à vesícula biliar e líquido ao redor dela. Foi realizada cultura com antibiograma da bile e mantida a terapia alopática. O histopatológico da vesícula biliar apontou colecistite aguda supurada. A cultura isolou a bactéria Sthapylococcus intermedius. Após 60 dias de realizada a cirurgia, o animal encontrava-se clinicamente saudável e como os exames para controle apontaram resolução completa das alterações, foi dada alta médica.

The gallbladder mucocele (GBM) is characterized by abnormal accumulation of semisolid bile in the gallbladder. This case repor is about a female dog, Yorkshire, attended on a private Veterinary Hospital (Serviço Médico Veterinário – SEMEVE). The dog had vomiting, anorexia, prostration and tremors that started on the day of the appointment. During the anamnesis, the tutor reported that the patient had been diagnosed with dyslipidemia three years before, however, endocrine disorders were ruled out as the cause of the condition. At the physical examination, the animal presented sensitivity to abdominal palpation and mild sclera jaundice. During the abdominal ultrasound it was diagnosed gallbladder mucocele, through echogenicity and the pattern presented by the bile associated with the clinical history of the animal. The initial treatment was with antibiotic therapy, fluid therapy supplemented with vitamin B and potassium, analgesic, antiemetic and gastric protector. Due to the worsening of the dog seen in the exams, 48 hours after admission, cholecystectomy was performed. In the transurgical procedure, omentum adherence to the gallbladder and fluid around it was identified. Culture with bile antibiogram was performed and allopathic therapy was maintained. The histopathology of the gallbladder showed acute suppurated cholecystitis. The culture isolated the bacterium Sthapylococcus intermedius. After 60 days of the surgery, the animal was clinically healthy and the tests for control showed complete resolution of the changes, so it was given medical discharge.

Diagnóstico e tratamento de mucocele da vesícula biliar em cão / Diagnosis and treatment of gall bladder mucocele in dog

A mucocele de vesícula biliar se caracteriza pelo acúmulo anormal de bile semissólida na vesícula biliar. O presente trabalho relata o caso de uma cadela idosa, da raça yorkshire atendida em um Hospital Veterinário particular (Serviço Médico Veterinário SEMEVE), com quadro de vômitos, anorexia, prostração e tremores, iniciados no dia do atendimento. Durante a anamnese, a tutora relatou que a paciente tinha sido diagnosticada há três anos com dislipidemia, sendo descartadas afecções endócrinas como causa do quadro. Ao exame físico, o animal apresentava sensibilidade à palpação abdominal e discreta icterícia em esclera. Durante o ultrassom de abdômen foi diagnosticada a mucocele de vesícula biliar, através da ecogenicidade, padrão apresentado pela bile e histórico clínico do animal. O tratamento inicial foi com antibioticoterapia, fluidoterapia suplementada com vitamina b e potássio, analgésico, antiemético e protetor gástrico. Devido a piora do quadro apresentada nos exames, 48 horas após o internamento, foi realizada colecistectomia. No transcirúrgico identificou-se aderência do omento à vesícula biliar e líquido ao redor dela. Foi realizada cultura com antibiograma da bile e mantida a terapia alopática. O histopatológico da vesícula biliar apontou colecistite aguda supurada. A cultura isolou a bactéria Sthapylococcus intermedius. Após 60 dias de realizada a cirurgia, o animal encontrava-se clinicamente saudável e como os exames para controle apontaram resolução completa das alterações, foi dada alta médica.(AU)

The gallbladder mucocele (GBM) is characterized by abnormal accumulation of semisolid bile in the gallbladder. This case repor is about a female dog, Yorkshire, attended on a private Veterinary Hospital (Serviço Médico Veterinário SEMEVE). The dog had vomiting, anorexia, prostration and tremors that started on the day of the appointment. During the anamnesis, the tutor reported that the patient had been diagnosed with dyslipidemia three years before, however, endocrine disorders were ruled out as the cause of the condition. At the physical examination, the animal presented sensitivity to abdominal palpation and mild sclera jaundice. During the abdominal ultrasound it was diagnosed gallbladder mucocele, through echogenicity and the pattern presented by the bile associated with the clinical history of the animal. The initial treatment was with antibiotic therapy, fluid therapy supplemented with vitamin B and potassium, analgesic, antiemetic and gastric protector. Due to the worsening of the dog seen in the exams, 48 hours after admission, cholecystectomy was performed. In the transurgical procedure, omentum adherence to the gallbladder and fluid around it was identified. Culture with bile antibiogram was performed and allopathic therapy was maintained. The histopathology of the gallbladder showed acute suppurated cholecystitis. The culture isolated the bacterium Sthapylococcus intermedius. After 60 days of the surgery, the animal was clinically healthy and the tests for control showed complete resolution of the changes, so it was given medical discharge.(AU)

Carcinoid of the gallbladder in two dogs / Carcinoide de vesícula biliar em dois cães

A carcinoid is a rare neoplasm derived from neuroendocrine cells that may arise in the hepatobiliary system. This report described two cases of carcinoid of the gallbladder in dogs, with emphasis on the clinical, pathological and immunohistochemical aspects. Case 1 was a 10-year-old female Shih Tzu, with a history of prostration and occasional episodes of diarrhea and vomiting. Case 2 was a 10-year-old male Cocker Spaniel, with a history of diarrhea and abdominal pain. Abdominal ultrasonography suggested a neoplasm of the gallbladder in both cases. The dogs underwent cholecystectomy, and 10% formalin-fixed samples were sent for pathological examination. Histologically, a neoplastic proliferation of neuroendocrine cells was observed in the gallbladder submucosa of both cases. Immunohistochemical labeling for neuroendocrine antibodies, such as synaptophysin, neuron-specific enolase and chromogranin A, confirmed the diagnoses. Carcinoid of the gallbladder is a rare neoplasm in dogs, without specific clinical signs, but should be included in the differential diagnosis of lesions that affect this organ.(AU)

Carcinoide é um neoplasma raro derivado de células neuroendócrinas, que pode surgir no sistema hepatobiliar. Este relato descreve dois casos de carcinoide da vesícula biliar em cães, com ênfase nos aspectos clínicos, patológicos e imuno-histoquímicos. O caso 1 era uma fêmea, Shih Tzu de 10 anos de idade, com histórico de letargia e ocasionais episódios de diarreia e vômito. O caso 2 era um macho, Cocker Spaniel de 10 anos, que apresentava diarreia e dor abdominal. Através da ultrassonografia abdominal foi sugerida neoplasia na vesícula biliar em ambos os casos. Os caninos foram submetidos à colecistectomia e amostras em formol a 10%, seguidamente, foram enviadas para o laboratório de patologia. Histologicamente, observou-se proliferação neoplásica de células neuroendócrinas na submucosa da vesícula biliar nos dois casos. A marcação imuno-histoquímica para os anticorpos neuroendócrinos, como sinaptofisina, enolase específica de neurônios e cromogranina A confirmou o diagnóstico. Carcinoide de vesícula biliar é uma neoplasia rara em cães, sem sinais clínicos específicos, mas deve ser incluída no diagnóstico diferencial das lesões que afetam esse órgão.(AU)

Protective efficacy of combined use of parecoxib and dexmedetomidine on postoperative hyperalgesia and early cognitive dysfunction after laparoscopic cholecystectomy for elderly patients

Purpose:To investigate efficacy of combined use of parecoxib and dexmedetomidine on postoperative pain and early cognitive dysfunction after laparoscopic cholecystectomy for elderly patients.Methods:The present prospective randomized controlled study included a total of 80 patients who underwent laparoscopic cholecystectomy surgery during January 2016 to November 2017 in our hospital. All patients were randomly divided into 4 groups, the parecoxib group, the dexmedetomidine group, the parecoxib and dexmedetomidine combined group, and the control group. Demographic data and clinical data were collected. Indexes of heart rate (HR), mean arterial pressure (MAP), levels of jugular venous oxygen saturation (SjvO2) and jugular venous oxygen pressure (PjvO2) were recorded at different time points before and during the surgery. The mini-mental state examination (MMSE) score, Ramsay score and Visual Analogue Score (VAS) were measured.Results:Levels of both SjvO2 and PjvO2 were significantly higher in parecoxib group, dexmedetomidine group and the combined group than the control group. Meanwhile, levels of both SjvO2 and PjvO2 in the combined group were the highest. VAS scores were significantly lower in the combined group than all other groups, and total patient controlled intravenous analgesia (PCIA) pressing times within 48 h after surgery were the lowest in the combined group. Both Ramsay and MMSE scores were the highest in the combined group compared with other groups, while were the lowest in the control group.Conclusion:The combined use of parecoxib and dexmedetomidine could reduce the postoperative pain and improve the postoperative sedation and cognitive conditions of patients after laparoscopic cholecystectomy.(AU)

Colecistectomía asociada a enterotomia duodenal en una infestación por Platynosomum sp. en un gato doméstico / Cholecystectomy associated to duodenal enterotomy in the infestation by Platynosomum sp. in a domestic cat / Colecistectomia associada à enterotomia duodenal na infestação por Platynosomum sp. em um gato doméstico

Platynosomum sp. es el más grande parásito hepatobiliar de la familia Felidae, causador de una lesión obstructiva extrahepática que puede ser tratada por cirugía. Un felino, sin raza definida, dos años de edad, semidomiciliado, fue atendido con un cuadro clínico de apatía, ictericia, deshidratación y elevación de enzimas hepáticas. En la ecografía abdominal se observó el hígado aumentado, vasos hepáticos y la vena porta con un mayor diámetro, la vesícula llena de contenido anecoico, sedimentación, espesamiento y hiperrefringencia de la pared de el conducto biliar principal dilatado con pared gruesa. Fue realizada colecistectomía con enterotomia duodenal. La inspección de los contenidos de la vesícula biliar reveló parásitos con una apariencia aplanada y la evaluación microscópica fue consistente con Platynosomum sp. El tratamiento con niclosamida y oxibendazol fue efectivo. Colecistectomía asociada con enterotomia duodenal es eficaz en tales casos.(AU)

Platynosomum sp. is the major hepatobiliary parasite of felids, causing an extra-hepatic obstructive lesion which may be treated by surgery. A two-year old cross-bred feline, semi-domiciled, was attended with a clinical picture of apathy, jaundice, dehydration and increase in hepatic enzymes. In the abdominal ultrasonography the liver was observed enlarged, hepatic and portal veins with increased diameter, gall bladder filled by anechoic content, with sediment, thickening and hyperechogenicity of the wall and a dilated main bile duct with a thickened wall. The cholecystectomy with a duodenal enterotomy was performed. The inspection of the gall bladders content revealed parasites with a flattened aspect and the microscopic evaluation was compatible with Platynosomum sp. A treatment with niclosamide and oxibendazole was efficient. Cholecystectomy associated to a duodenal enterotomy is efficient in these cases.(AU)

Platynosomum sp. é o maior parasito hepatobiliar de felídeos, causando uma lesão obstrutiva extra-hepática a qual pode ser tratada por cirurgia. Um felino, de dois anos de idade, sem raça definida, semidomiciliado, foi atendido apresentando um quadro clínico de apatia, icterícia, desidratação e aumento de enzimas hepáticas. Na ultrassonografia abdominal o fígado estava aumentado, vasos hepáticos e veia porta com aumento de diâmetro, vesícula biliar preenchida por conteúdo anecoico, com sedimentação, espessamento e hiperecogenicidade da parede e ducto biliar principal dilatado com parede espessada. Realizou-se a colecistectomia com enterotomia duodenal. A inspeção do conteúdo da vesicular biliar revelou parasitos com um aspecto achatado e a avaliação microscópica foi compatível com Platynosomum sp. O tratamento com niclosamida e oxibendazole foi eficiente. Colecistectomia associada à enterotomia duodenal é eficiente nesses casos.(AU)

Colecistectomía asociada a enterotomia duodenal en una infestación por Platynosomum sp. en un gato doméstico / Cholecystectomy associated to duodenal enterotomy in the infestation by Platynosomum sp. in a domestic cat / Colecistectomia associada à enterotomia duodenal na infestação por Platynosomum sp. em um gato doméstico

Platynosomum sp. es el más grande parásito hepatobiliar de la familia Felidae, causador de una lesión obstructiva extrahepática que puede ser tratada por cirugía. Un felino, sin raza definida, dos años de edad, semidomiciliado, fue atendido con un cuadro clínico de apatía, ictericia, deshidratación y elevación de enzimas hepáticas. En la ecografía abdominal se observó el hígado aumentado, vasos hepáticos y la vena porta con un mayor diámetro, la vesícula llena de contenido anecoico, sedimentación, espesamiento y hiperrefringencia de la pared de el conducto biliar principal dilatado con pared gruesa. Fue realizada colecistectomía con enterotomia duodenal. La inspección de los contenidos de la vesícula biliar reveló parásitos con una apariencia aplanada y la evaluación microscópica fue consistente con Platynosomum sp. El tratamiento con niclosamida y oxibendazol fue efectivo. Colecistectomía asociada con enterotomia duodenal es eficaz en tales casos.

Platynosomum sp. is the major hepatobiliary parasite of felids, causing an extra-hepatic obstructive lesion which may be treated by surgery. A two-year old cross-bred feline, semi-domiciled, was attended with a clinical picture of apathy, jaundice, dehydration and increase in hepatic enzymes. In the abdominal ultrasonography the liver was observed enlarged, hepatic and portal veins with increased diameter, gall bladder filled by anechoic content, with sediment, thickening and hyperechogenicity of the wall and a dilated main bile duct with a thickened wall. The cholecystectomy with a duodenal enterotomy was performed. The inspection of the gall bladder’s content revealed parasites with a flattened aspect and the microscopic evaluation was compatible with Platynosomum sp. A treatment with niclosamide and oxibendazole was efficient. Cholecystectomy associated to a duodenal enterotomy is efficient in these cases.

Platynosomum sp. é o maior parasito hepatobiliar de felídeos, causando uma lesão obstrutiva extra-hepática a qual pode ser tratada por cirurgia. Um felino, de dois anos de idade, sem raça definida, semidomiciliado, foi atendido apresentando um quadro clínico de apatia, icterícia, desidratação e aumento de enzimas hepáticas. Na ultrassonografia abdominal o fígado estava aumentado, vasos hepáticos e veia porta com aumento de diâmetro, vesícula biliar preenchida por conteúdo anecoico, com sedimentação, espessamento e hiperecogenicidade da parede e ducto biliar principal dilatado com parede espessada. Realizou-se a colecistectomia com enterotomia duodenal. A inspeção do conteúdo da vesicular biliar revelou parasitos com um aspecto achatado e a avaliação microscópica foi compatível com Platynosomum sp. O tratamento com niclosamida e oxibendazole foi eficiente. Colecistectomia associada à enterotomia duodenal é eficiente nesses casos.

Development of a model for laparoscopic cholecystectomy video assisted training. A randomized study

Purpose: To identify the surgical trainee benefits through the use of video assisted training (VAT). Methods: Twelve cases of uncomplicated laparoscopic cholecystectomy (LC) were selected. Edited video segments focused on essential intra-operative anatomical structure identification and critical surgical steps. Evaluation of these videos was constructed on a scoring system based on pre and post-teach tests. Results: The mean value of the pre-teach score was 33.2 ± 18.0 points and in the post-teach test the mean value was 66.7 ± 9.7 points. A statistically significant difference was seen when comparing pre and post-teach results (p .00001). Conclusion: The widespread and the systematic use of video assisted learning may be a useful and economic tool in adjunct to the surgical training techniques practiced until now throughout the surgical community.(AU)

Assessment of a new kind of surgical simulator. The physical surgical simulator

Purpose: To evaluate whether the use of the physical surgical simulator may benefit the development of laparoscopic skills.Methods: Ten medical students were divided into two groups: the first one performed ten weekly training sessions with a physical surgical simulator - ETX A2 LAP and, afterwards, one laparoscopic cholecystectomy in a porcine model, while the second group performed only a laparoscopic cholecystectomy. Both groups were compared regarding bleeding, total surgical time, time to perform each surgical step and qualitative parameters, based on a previously validated tool.Results: There was no difference in any of the evaluated parameters.Conclusion: We did not find any evidence of benefit in the use of the physical simulator for surgical performance in medical students.(AU)

Colecistite necrosante em um cão: relato de caso / Necrosant cholecystitis in a dog: report Case

Objetiva-se com esse relato, descrever um caso de colecistite necrosante em um cão, fêmea, da raça Yorkshire Terrier. O paciente deu entrada no Hospital Veterinário da UNIJUÍ, apresentando vômito e diarreia escura. Através do exame de ultrassonografia, evidenciou vesícula biliar com parede em dupla camada e com formato irregular, sugerindo-se uma colecistite necrosante. Diante disso, o canino foi encaminhado para uma colecistectomia, como forma de tratamento. Esse relato salienta a importância do diagnóstico rápido e correto dea doença, sendo que isso foi determinante para o estabelecimento do tratamento adequado e recuperação do animal em questão.

The objective of this paper is to describe a necrosant cholecystitiscase in a female dog, York Shire Terrier breed. The patient was admitted to the Veterinary Hospitalof UNIJUÍ, presenting vomiting and dark diarrhea. Ultrasonography showed a biliary vesicle with an irregularly shaped double-layer wall, suggesting a necrosant cholecystitis. Therefore, the canine was referred to a cholecystectomy as a form of treatment, where the gallbladder was excised. This paper emphasizes the importance of the rapid and correct diagnosis of this disease, and this was determinant for the establishment of appropriate treatment and recovery of the animal in question.

Colecistite necrosante em um cão: relato de caso / Necrosant cholecystitis in a dog: report Case

Objetiva-se com esse relato, descrever um caso de colecistite necrosante em um cão, fêmea, da raça Yorkshire Terrier. O paciente deu entrada no Hospital Veterinário da UNIJUÍ, apresentando vômito e diarreia escura. Através do exame de ultrassonografia, evidenciou vesícula biliar com parede em dupla camada e com formato irregular, sugerindo-se uma colecistite necrosante. Diante disso, o canino foi encaminhado para uma colecistectomia, como forma de tratamento. Esse relato salienta a importância do diagnóstico rápido e correto dea doença, sendo que isso foi determinante para o estabelecimento do tratamento adequado e recuperação do animal em questão.(AU)

The objective of this paper is to describe a necrosant cholecystitiscase in a female dog, York Shire Terrier breed. The patient was admitted to the Veterinary Hospitalof UNIJUÍ, presenting vomiting and dark diarrhea. Ultrasonography showed a biliary vesicle with an irregularly shaped double-layer wall, suggesting a necrosant cholecystitis. Therefore, the canine was referred to a cholecystectomy as a form of treatment, where the gallbladder was excised. This paper emphasizes the importance of the rapid and correct diagnosis of this disease, and this was determinant for the establishment of appropriate treatment and recovery of the animal in question.(AU)

Comparative study of respiratory muscle strength in women undergoing conventional and single-port laparoscopic cholecystectomy

Purpose: To evaluate respiratory muscle strength (PImax and PEmax) before and 24 and 48 h after conventional and single-port laparoscopic cholecystectomy. Methods: Forty women with symptomatic cholelithiasis (18 to 70 years) participated in the study. The patients were divided into two groups: 21 patients undergoing conventional laparoscopic cholecystectomy and 19 patients undergoing single-port laparoscopic cholecystectomy. Differences were considered to be significant when p 0.05. Results: The results showed a greater decline in PImax after 24 h in the group submitted to conventional laparoscopic cholecystectomy, with a significant difference between groups (p=0.0308). Conclusion: Recovery of the parameters studied was more satisfactory and respiratory muscle strength was less compromised in the group submitted to single-port laparoscopic cholecystectomy.(AU)

Comparative study of pain in women submitted to conventional laparoscopic cholecystectomy versus single-port laparoscopic cholecystectomy

Purpose: To evaluate postoperative pain in patients submitted to conventional laparoscopic cholecystectomy with four ports versus single-port laparoscopic cholecystectomy with only one port. Methods: Twenty-one patients were included in the conventional laparoscopic cholecystectomy group and 19 other patients in the single-port laparoscopic cholecystectomy group. A VAS was used for the assessment of postoperative pain at three time points. Differences were considered statistically significant when p 0.05. Results: Intergroup analysis showed no significant difference in VAS scores between the conventional laparoscopic cholecystectomy and single-port laparoscopic cholecystectomy groups at any of the time points studied. Conclusion: This study found no significant difference in postoperative pain between the two groups.(AU)

Colecistectomia laparoscópica com três portais em cães via gasless ou pneumoperitônio com CO2.

Os objetivos desta tese foram, em uma primeira etapa, avaliar os resultados da colecistectomia laparoscópica (CL) via três portais de acesso em cães com doenças benignas da vesícula biliar em um estudo retrospectivo. A segunda etapa consistiu na proposição e avaliação da exeqüibilidade de uma técnica correspondente na modalidade gaslessem cadáveres caninos, utilizando um dispositivo personalizado de elevação mecânica da parede abdominal, e compará-la à técnica com pneumoperitônio em determinadas variáveis cirúrgicas. No artigo 1, foram revisados os registros médicos de 14 casos de CL operados por dois cirurgiões com diferentes proeficiências. O tempo cirúrgico médio foi de 69,21 ± 21.7 min (variação 45-104), não houve conversão em nenhum dos pacientes e 85,7% dos cães receberam alta hospitalar no dia do procedimento. As complicações transoperatórias em sua maioria foram classificadas como menores. Dois pacientes apresentaram complicações pós-operatórias que exigiram reintervenção, sendo um dos casos não relacionado à CL, e vieram a óbito após o segundo procedimento cirúrgico. No estudo prospectivo do artigo 2, 16 cadáveres foram distribuídos em dois grupos, os do GCG (n=8) foram submetidos à CL com o uso da plataforma de tração multidirecional e os do GCP (n=8) submetidos à CL com pneumoperitônio (10 mmHg). O tempo operatório total, os tempos de cada etapa do procedimento e as complicações transoperatórias foram registrados. O grau de dificuldade das abordagens cirúrgicas foi avaliado pelo cirurgião e auxiliar a partir de duas escalas adaptadas, uma escala visual analógica e uma escala Likert. A técnica proposta de CL gasless foi exeqüível em todos os animais. O tempo cirúrgico total foi maior para o grupo GCG (p=0,02), assim como o tempo para a etapa de dissecção da vesícula biliar do leito hepático (p=0,03). Para ambas as escalas, o grau de dificuldade para execução do procedimento foi maior para o GCG nas etapas de exposição e dissecção do ducto cístico, hemostasia e transecção do ducto cístico, visualização de estruturas anatômicas e para o somatório de todas as etapas (p<0,05). Não houve diferença na incidência de complicações transoperatórias entre as duas técnicas. Diante dos resultados apresentados, concluímos que a CL com três portais de acesso é uma abordagem viável e segura para o tratamento de doenças benignas da vesícula biliar em cães, possibilitando a redução da lesão de acesso cirúrgico por dispensar um trocarte adicional, sem ampliar a complexidade do procedimento considerando o acesso de quatro portais. A CL utilizando a plataforma de tração multidirecional foi viável em cadáveres caninos e similar à técnica correspondente utilizando pneumoperitônio quanto à incidência de complicações transoperatórias. Ainda que o tempo cirúrgico e o grau de dificuldade para a execução da técnica proposta sejam superiores, viabilizar uma técnica de CL que dispense o uso de pneumoperitônio representa uma valiosa alternativa para pacientes incapazes de compensar as alterações promovidas pela insuflação abdominal.

The aims of this thesis were, in a first step, to evaluate the results of laparoscopic cholecystectomy (CL) via three-port access in dogs with benign gallbladder diseases in a retrospective study. The second step consisted of proposing and evaluating the feasibility of a gasless three-port access CL in canine cadavers, using a personalized device for mechanical elevation of the abdominal wall, and comparing it to the corresponding technique with pneumoperitoneum in certain surgical variables. In article 1, the medical records of 14 cases of CL performed by two surgeons with different proficiencies were reviewed. The average surgical time was 69.21± 21.7 min (range 45-104), there was no conversion in any of the patients and 85.7% of the dogs were discharged on the day of the procedure. Most intraoperative complications were classified as minor. Two patients had postoperative complications that required reintervention, one of which was unrelated to CL, anddied after the second surgical procedure. In the prospective study of article 2, 16 cadavers were divided into two groups, those from the GCG (n = 8) were submitted to CL using the multidirectional traction platform and those from the GCP (n = 8) underwent CL with pneumoperitoneum (10 mmHg). The total surgical time, the times of each stage of the procedure, and the intraoperative complications were recorded. The degree of difficulty of surgical approaches was assessed by the surgeon and auxiliary fromtwo types of adapted scales, a visual analog scale and a Likert scale. The proposed gasless CL technique was feasible in all animals. The total surgical time was longer for the GCG group (p=0.02), as well as the time for the stage of gallbladder dissection of the liver bed (p=0.03).For both scales, the degree of difficulty in performing the procedure was greater for the GCG in the stages of exposure and dissection of the cystic duct, hemostasis, and transection of the cystic duct, visualization of anatomical structures, and for the sum ofall steps (p<0.05). There was no difference in the incidence of intraoperative complications between the two techniques. Given the results presented, we conclude that CL with three-port access is a viable and safe approach for the treatment of benign gallbladder diseases in dogs, making it possible to reduce the surgical access injury by avoiding the use of an additional trocar, without increasing the complexity of the procedure considering the access of four-port. CL using the multidirectional traction platform was viable in canine cadavers and similar to the corresponding technique using pneumoperitoneum for the incidence of intraoperative complications. Even though the surgical time and the degree of difficulty for the execution of the proposed technique are higher, to enable a CL technique that does not require the use ofpneumoperitoneum represents a valuable alternative for patients unable to compensate for changes caused by abdominal insufflation.

COLECISTECTOMIA LAPAROSCÓPICA UTILIZANDO DISPOSITIVO SELANTE DE VASOS E MODIFICAÇÃO DA TÉCNICA UTILIZANDO NÓ EXTRACORPÓREO EM COELHOS: ESTUDO EXPERIMENTAL

As cirurgias laparoscópicas possuem vantagens conhecidas sendo amplamente utilizada na medicina humana, havendo tendência muito grande de redução dos procedimentos cirúrgicos abertos. Contudo, na medicina veterinária, esse avanço nas videocirurgias não ocorre da mesma maneira. As cirurgias minimamente invasivas ainda estão restritas a alguns centros, havendo poucas pesquisas que buscam o avanço das técnicas em pequenos animais. A colecistectomia laparoscópica (CL) é técnica cirúrgica minimamente invasiva recente na medicina veterinária. Estudos randomizados in vivo que avaliam diferentes métodos de divulsão e ligadura do trato biliar extra-hepático por laparoscopia comprovam benefícios aos pacientes. Sendo assim, o objetivo deste estudo randomizado foi relatar as complicações e os resultados perioperatórios de coelhos submetidos a três técnicas diferentes de CL. 30 coelhos foram divididos em 3 grupos. Grupo A (n = 10): técnica de CL iniciando-se pelo fundo da vesícula biliar (VB) em direção ao ducto cístico (Retrógada) pelo instrumento de dissecção Hook e aplicação de nó extracorpóreo para ligadura de ducto cístico. Grupo B (n = 10): técnica de CL convencional por pinça Maryland bipolar para dissecção da VB e Dispositivo Selante de Vasos (DSV- LigaSure ) para selagem do ducto cístico. Grupo C (n = 10): técnica de CL convencional com utilização de DSV para dissecção da VB e DSV para selagem de ducto cístico. Os dados dos procedimentos cirúrgicos foram coletados e analisados (taxa de perfuração da VB, sangramento dos tecidos adjacentes à iv VB, tempo para dissecção da VB e tempo total de cirurgia). A função hepática: AST, ALT, FA, BT, BD, GGT e fibrinogênio foi avaliada no pré-operatório e nos dias 3,7 15 após a cirurgia. Avaliações ultrassonográficas seriadas foram realizadas no período pós-operatório a fim de se verificar ausência de extravasamento de bile e peritonite biliar. Alterações abdominais macroscópicas foram verificadas aos quinze dias de pós-operatório por meio da necropsia e o grau de aderências pós-operatórias foi classificado de 0 a 4. Amostras de fígado para avaliação histopatológica foram coletadas de todos os animais. Foi avaliada a presença de siderófagos e utilizada uma escala de 1 a 4 para o grau de fibrose, necrose e células gigantes. O grupo A apresentou um tempo de dissecção da VB maior do que os grupos B e C. A perfuração do VB e sangramento dos tecidos adjacentes ao VB foram semelhantes entre os grupos testados. Os níveis de GGT e ALP aumentaram (p0,05) no dia 3 pós-operatório no grupo A. No 15º dia pós-operatório, as enzimas voltaram aos valores pré-operatórios. A mediana de células gigantes, necrose, fibrose e proporção de siderofagos não foram influenciadas pelas técnicas de CL. Conclui-se que elevações transitórias em enzimas hepatocelulares de coelhos após CL podem ser uma observação benigna e podem não ter quaisquer características clínicas. O grupo A teve um escore de adesão maior do que os grupos B e C e foi associado à técnica menos previsível. A CL pode ser realizada por meio de diferentes técnicas, embora o uso de DSV seja altamente recomendado.

Laparoscopic cholecystectomy (LC) has become the gold standard management option for benign gallbladder (GB) disease and cholelithiasis. The aim of this randomized study was to evaluate the intraoperative complications and perioperative outcome of rabbits undergoing 3 different techniques of LC. In this study, we compared the effect of different LC techniques on changes in liver function tests (LFTs). And finally, we investigated and compared the degree of postoperative adhesions and histopathological changes of the liver bed after LC techniques. Methods:30 white male New Zealand rabbits were divided into 3 groups. Group A (n=10) Fundus-first dome-down technique by Hook dissecting instrument and Roeder Slipknot applied for Cystic Duct Ligation. The GB was dissected free from the liver bed starting at the fundus toward the GB neck using Hook electrocautery (KarlStorz 36 cm length). The cystic duct and cystic artery were ligated using extracorporeally Roeder slipknot - extracorporeal slipknot (Roeder knot). Group B (n=10) Conventional technique by Maryland dissecting forceps for GB dissection and Electrothermal Bipolar Vessel Sealing (EVBS) for Cystic duct seal. Rabbits underwent conventional technique using Bipolar Maryland dissecting forceps (maryland36 cm length) and the EVBS LigaSure Maryland Jaw 5mm-23cm (Medtronic, Dublin, Ireland) for Cystic duct seal. Group C conventional technique by Electrothermal Bipolar Vessel Sealing (EBVS) for GB dissection and EVBS for cystic duct seal. Rabbits who underwent conventional technique dissection of the gallbladder by the LigaSure Maryland Jaw 5mm-23cm (Medtronic, Dublin, Ireland) and LigaSure for cystic duct seal. The surgical procedure data were collected and analyzed (GB perforation rate, time to GB bed dissection and length of surgery, bleeding from tissues adjacent to gallbladder)Blood samples were obtained pre-operatively and on day 3, 7 and day 15 after surgery to compare liver enzyme alterations (aspartate transaminase [AST], alanine transaminase [ALT], alkaline phosphatase [ALP], bilirubin, direct bilirubin, total protein, albumin; gamma-glutamyl transferase (GGT), fibrinogen.The necropsy analysis was performed 15 days after surgery, and the degree of postoperative adhesions was classified from 0 to 4. Liver samples for histological examination were taken from all groups. The presence of vi siderophages was evaluated and a scale from 1 to 4 was used for the degree of fibrosis, necrosis and giant cells. Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. GGT and ALP levels increased (p0.05) on day 3 post-operatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. The median of giant cells, Necrosis, Fibrosis and proportion of Siderophags were not influenced by the CL techniques. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. LC can be performed using different techniques, although the use of EBVS is highly recommended.

Evaluation of systemic inflammatory responses in cholecystectomy by means of access. Single-port umbilical incision, transvaginal NOTES, laparoscopy and laparotomy

To evaluate and compare clinical and inflammatory responses to the surgical trauma caused by cholecystectomy via several access approaches: single-port umbilical incision (SILS), transvaginal natural orifice transluminal endoscopic surgery (NOTES), laparoscopy, and Laparotomy. METHODS : Twenty-eight female pigs were equally divided into four groups and submitted to cholecystectomy by single-port umbilical incision, transvaginal NOTES, laparoscopy, or Laparotomy. An additional five animals served as controls (sham group). Animals were monitored perioperatively regarding anesthesia and surgical procedure times, as well as for the presence of complications. Postoperatively, they were evaluated regarding time to ambulation and feeding, and the presence of clinical events. Procalcitonin, C-reactive protein (CRP), and AQUI feron-gamma (IFN-) measurements were performed before surgery and immediately, two days, and seven days after surgery. Animals were sacrificed and necropsied at seven days after surgery. RESULTS : All procedures were successfully performed as proposed in each group. Only minor complications, such as gallbladder perforation and bleeding from the liver bed, were observed during surgery in all groups. The vaginal NOTES group showed higher anesthesia and surgical procedure times compared to the other groups (p 0.001). No other between-group differences in perioperative or postoperative times, clinical evolution, or serum inflammatory markers were observed. Only adhesions were found on necropsy, with no differences between groups. CONCLUSION: The single-port umbilical and transvaginal NOTES access approaches were feasible and safe compared to laparoscopic and laparotomy for cholecystectomy.(AU)

Colecistectomia videolaparoscópica em felino com colelitíase / Videolaparoscopic cholecystectomy in feline with cholethiasis

A colelitíase, ou litíase biliar, é rara em felinos. O presente relato descreve o caso de um felino, macho, sem raça definida, com seis anos de idade que apresentava anorexia, dor abdominal, vômito e hipertermia. Ao exame ultrassonográfico de abdômen, a vesícula biliar apresentava formato irregular, paredes espessas e estruturas hiperecogênicas na região do seu colo e saída do ducto cístico, sugerindo presença de cálculos biliares. O paciente foi submetido à videolaparoscopia seguida de colecistectomia. Após sete dias, o animal obteve alta hospitalar e, aos 60 dias de pós-operatório, não demonstrou recidiva dos sinais clínicos.

Cholelithiasis, or gallstones, is rare in cats. This report describes the case of a six years-old mongrel cat male that had anorexia, abdominal pain, vomiting and hyperthermia. The abdominal ultrasound revealed a gallbladder with irregular shape andhyperechogenic structures, in the gallbladder's neck and in the output of the cystic duct, suggesting gallstones. The patient was undergone to a laparoscopic cholecystectomy. The animal was hospitalized for a week and after sixty days the owner no longer report clinical signs previously presented.

Colecistectomia videolaparoscópica em felino com colelitíase / Videolaparoscopic cholecystectomy in feline with cholethiasis

A colelitíase, ou litíase biliar, é rara em felinos. O presente relato descreve o caso de um felino, macho, sem raça definida, com seis anos de idade que apresentava anorexia, dor abdominal, vômito e hipertermia. Ao exame ultrassonográfico de abdômen, a vesícula biliar apresentava formato irregular, paredes espessas e estruturas hiperecogênicas na região do seu colo e saída do ducto cístico, sugerindo presença de cálculos biliares. O paciente foi submetido à videolaparoscopia seguida de colecistectomia. Após sete dias, o animal obteve alta hospitalar e, aos 60 dias de pós-operatório, não demonstrou recidiva dos sinais clínicos.(AU)

Cholelithiasis, or gallstones, is rare in cats. This report describes the case of a six years-old mongrel cat male that had anorexia, abdominal pain, vomiting and hyperthermia. The abdominal ultrasound revealed a gallbladder with irregular shape andhyperechogenic structures, in the gallbladder's neck and in the output of the cystic duct, suggesting gallstones. The patient was undergone to a laparoscopic cholecystectomy. The animal was hospitalized for a week and after sixty days the owner no longer report clinical signs previously presented.(AU)