A “window” in the duodenal bulb: an atypical presentation of chronic cholecystitis

A 74-year-old male presented with melena and fatigue, without fever or abdominal pain. Laboratory examination revealed anemia, leukocytosis, elevated C-reactive protein levels and conjugated hyperbilirubinemia with elevated liver enzymes. Upper endoscopy identified blood in the stomach and duodenum and a 6 mm hole in the anterosuperior surface of the duodenal bulb with spontaneous drainage of a bloody brownish content. The mucosa surrounding the hole was normal and there was a discrete mucosal flap that throbbed with air insufflation. Abdominal computed tomography identified a fistulous tract between the duodenal bulb and the gallbladder with a 2 mm caliber, suggesting a cholecystoduodenal fistula. Diagnosis is often difficult because symptoms are nonspecific and variable but gastrointestinal bleeding is a rare clinical presentation. (AU)

Síndrome de absceso hepático asociado a colecistitis por Klebsiella pneumoniae hipervirulenta K1 ST23 / Liver abscess syndrome associated with cholecystitis caused by K1 ST 23 hypervirulent Klebsiella pneumoniae

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¿Pueden los biomarcadores inflamatorios ayudar al diagnóstico y predecir el pronóstico de la colecistitis aguda gangrenosa? Un estudio prospectivo / No disponible

INTRODUCCIÓN: el diagnóstico de la colecistitis aguda gangrenosa constituye un reto diagnóstico para el médico y en pocas ocasiones se realiza de manera preoperatoria. MATERIAL Y MÉTODOS: presentamos un estudio longitudinal prospectivo de 180 pacientes a los que se les realiza colecistectomía secundaria a colecistitis aguda. Se realiza curva ROC para determinar el punto de corte preoperatorio de diferentes biomarcadores (ratio neutrófilo-linfocito [RNL], proteína C reactiva [PCR], ratio plaqueta-linfocito [RPL], lactato y procalcitonina) y asociación con hallazgos perioperatorios y postoperatorios. RESULTADOS: el área bajo la curva para RNL, PCR, RPL, lactato y procalcitonina fue de 0,75, 0,8, 0,65 y 0,6, respectivamente. CONCLUSIÓN: RNL > 5 y PCR > 100 permanecen como factores independientes de gangrena (odds ratio [OR] ajustada de 2 y 2,1, respectivamente)

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Eficacia de una estrategia analgésica preincisional con ibuprofeno, paracetamol y dexametasona en colecistectomía laparoscópica. Estudio observacional prospectivo / Efficacy of a preincisional analgesic strategy with ibuprofen, paracetamol and dexamethasone in laparoscopic cholecystectomy. Prospective observational study

OBJETIVOS: Evaluar la eficacia y seguridad de una técnica analgésica preventiva multimodal utilizando dexametasona, ibuprofeno y paracetamol preincisionales como estrategia analgésica perioperatoria tras colecistectomía laparoscópica. METODOLOGÍA: Estudio observacional prospectivo en pacientes sometidos a colecistectomía laparoscópica bajo un protocolo anestésico común y analgesia preincisional multimodal con ibuprofeno (800 mg), paracetamol (1 g) y dexametasona (0,1 mg/kg) intravenosos e infiltración de portales de inserción de trócares con bupivacaína 0,5 %; medicación analgésica intravenosa de rescate con metamizol (2 g) y cloruro mórfico (bolus de 1 mg). Se registraron intensidades de dolor mediante escala verbal numérica y escala categórica en reposo y movimiento, necesidad y dosis de analgesia de rescate, complicaciones anestésico-quirúrgicas y grado de satisfacción en Unidad de Recuperación Postanestésica (a los 20 min, 2 h de su ingreso y al alta) y a las 24 h de la intervención. RESULTADOS: Se analizaron datos de 112 pacientes: 71 mujeres y 41 hombres, con una media de edad de 61,15 ± 16,23 años; un peso medio de 76,20 ± 12,68 kg; duración del tiempo quirúrgico (entre incisión cutánea y cierre de portales de inserción de trócares fue de 92,11 ± 30,64 min); se utilizaron dosis intraoperatorias de 1,91 ± 15,78 mcgs/kg/h de fentanilo; el estado físico se calificó como de ASA I (34,8 %), II (40,2 %), III (22,3 %) y IV (2,7 %). Se objetivaron 2 picos máximos de dolor: a los 20 min y a las 24 h de intervención, más intenso en movimiento (inspiración forzada). En 23 casos se registró la presencia de dolor agudo intenso que requirió analgesia adicional (necesidad de cloruro mórfico en 6 casos). Se documentaron 30 casos de complicaciones perioperatorias: 17 (15,18 %) pacientes refirieron náuseas y/o vómitos, 10 (8,93 %) irritabilidad venosa y 3 (2,68 %) inestabilidad hemodinámica. CONCLUSIONES: La estrategia analgésica multimodal utilizada en este estudio proporcionó una analgesia eficaz con recuperación anestésico-quirúrgica rápida y de alta calidad en la mayoría de los pacientes, con bajos requerimientos de opioides perioperatorios, en los casos en los que se precisó. Baja incidencia y gravedad de complicaciones perioperatorias, lo que facilitó tasas elevadas de cirugía ambulatoria

AIMS: To evaluate efficacy and security with a multimodal preventive analgesic technique (intravenous paracetamol, ibuprofen, dexametasone and local anesthetic infiltration incision) in postoperative pain management after laparoscopic cholecystectomy. METHODOLOGY: Observational prospective study in laparoscopic cholecystectomy under common anesthetic protocol and multimodal pre-incisional analgesia using intravenous ibuprofen (800 mg), paracetamol (1 g), dexamethasone (0.1 mg/kg) and 0.5 % bupivacaine portals infiltration. Analgesic rescue with metamizole (2 g) and morphine clorure (1 mg boluses). We noted pain grade, rescue analgesia, anesthetic-chirurgic complications and satisfaction level at five moments: in UCPA stay (20 min and 2 h after surgery and before discharge) and 24 h after surgery. RESULTS: 112 patients: 71 women and 41 men, 61.15 ± 16.23 aged; 76.20 ± 12.68 kg weight, surgery time of 92.11 ± 30.64 minutes; 1.91 ± 15,78 microgrames/kg/h fentanyl doses; ASA I (34,8 %), II (40,2 %), III (22,3 %) y IV (2,7 %). Two maximum pain peaks: at 20 min and at 24 h after the intervention and during movement. Severe pain and additional analgesia in 23 cases, and need for morphine chloride boluses in 6. Thirty cases complications were documented: emesis in 17 people (15.18 %), venous irritability in 10 cases (8.93 %) and hemodynamic instability in 3 cases (2.68 %). CONCLUSIONS: The multimodal analgesic strategy used in this study provided effective analgesia with fast, highquality anesthetic-surgical recovery in most patients. In case it was need, low perioperative opioid requirements. Low rate and severity of perioperative complications, which facilitated high outpatient surgery rates

Implementação de uma bundle para redução do risco de infeção no local cirúrgico em doentes submetidosa colecistectomia / Implementation of a bundle to reduce the risk of local infection in patients undergoing cholecystectomy

Surgical site infection (SSI) is an actual reality that has consequences, both economically and on the patient's wellbeing. An exploratory descriptive survey design was used in this research. The aim of the study is to evaluate and analyse the effectiveness of bundle implementation in the patient's undergoing laparoscopic cholecystectomy. This work emerged under a project "Stop Hospital Infection", created with the intent of implementing best practices and improve measures, to achieve a decrease in incidence and thus morbidity and mortality associated with acquired infections in patients at some Portuguese hospitals. A total of 333 patients who underwent laparoscopic cholecystectomy were studied from February 1, 2016 to May 31, 2018. The data was collected during June 2018, through consultation of the clinical file and respective clinical audit with a checklist. The checklist was prepared in accordance with the evidence-based guidelines for the prevention of SSIs by the Department of Public Health in Portugal and included the patient demographic data. Of the total participants, 63% were female, aged between 20 and 87 years and with an average age of 60 years. We recorded an overall rate of SSI of 2% (n = 5), and the rate at start stage for this type of surgery was 13%. Given these results and accordingly to scientific evidence, holds that the implementation of a bundle with adherence rates that are greater than 95% reduces the SSI, we suggest that the surgical bundles should be performed and we should further study with a larger sample including comorbidities

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Colecistitis xantogranulomatosa: diagnóstico diferencial con colecistitis aguda y cáncer de vesícula / No disponible

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Colecistitis necrohemorrágica tras terapia renal sustitutiva / Necrohaemorrhagic cholecystitis after renal replacement therapy

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Microbiota biliar en pacientes colecistectomizados: revisión de la antibioterapia empírica / Biliary microbiote in cholecystectomized PATIENTS: review of empirical antibiotherapy

INTRODUCCIÓN: La colecistitis constituye una importante causa de ingreso hospitalario. En colecistitis moderada o severa, el retraso en el tratamiento puede acarrear complicaciones graves. Nuestro objetivo es analizar los microorganismos aislados en bilis de pacientes colecistectomizados y su patrón de sensibilidad para evaluar el tratamiento empírico en aquellos casos en que la extirpación quirúrgica de la vesícula deba demorarse. PACIENTES Y MÉTODOS: Estudio descriptivo prospectivo de los cultivos biliares de pacientes sometidos a colecistectomía desde mayo de 2013 hasta febrero de 2015, en el Servicio de Cirugía del Hospital General Universitario de Castellón. RESULTADOS: Se estudiaron 196 pacientes, 83 mujeres (42,3%) y 113 hombres (57,7%), con una media de edad de 61,5 años. Los antibióticos más utilizados como tratamiento empírico fueron piperacilina/tazobactam (77,8%) y amoxicilina/clavulánico (14,8%). En el 46,4% de los pacientes (91/196) los cultivos de bilis fueron positivos. Se aislaron un total de 165 microorganismos. La mayoría eran bacilos gramnegativos (60,5%), principalmente Enterobacterales (91/54,5%), siendo Escherichia coli el microorganismo más frecuente (24%) seguido de Klebsiella spp. (12,5%). Se aislaron 3 E. coli productoras de betalactamasa de espectro extendido (BLEE) y 1 Klebsiella pneumoniae BLEE. No se aislaron microorganismos productores de carbapenemasa ni Staphylococcus aureus resistente a meticilina. CONCLUSIÓN: La microbiota biliar, con predominio de Enterobacterales, es similar a la encontrada en estudios europeos

INTRODUCTION: Cholecystitis is an important cause of hospital admission. In moderate or severe cholecystitis, the delay in treatment can lead to serious complications. Our objective is to analyze the microorganisms isolated in bile from cholecystectomized patients and their sensitivity pattern, to evaluate the empirical treatment in those cases in which the surgical removal of the gallbladder should be delayed. PATIENTS AND METHODS: Prospective descriptive study of biliary cultures of patients undergoing cholecystectomy from May 2013 to February 2015, in the Surgery Department of the Hospital General Universitari de Castelló. RESULTS: We studied 196 patients, 83 women (42.3%) and 113 men (57.7%), with an average age of 61.5 years. The most used antibiotics as empiric treatment were piperacillin/tazobactam (77.8%) and amoxicillin/clavulanic (14.8%). In 46.4% of patients (91/196) bile cultures were positive.165 microorganisms were isolated. The majority were Gram-negative bacilli (60.5%), mainly of the Enterobacterales order (91/54.5%), with Escherichia coli being the most frequent microorganism (24%) followed by Klebsiella spp. (12.5%).3 E. coli with extended-spectrum beta-lactamase (ESBL) and 1 K. pneumoniae with ESBL were isolated. Microorganisms producing carbapenemase and methicillin-resistant Staphylococcus aureus were not isolated. CONCLUSION: The bile microbiota, with a predominance of Enterobacterales is similar to that found in european studies

Acute calculous cholecystitis: a real-life management study in a tertiary teaching hospital

Aim: to describe the management of acute calculous cholecystitis in a tertiary teaching hospital and the outcomes obtained. Material and methods: a retrospective single tertiary center cohort study. Results: medical records of 487 patients were analyzed. The mean follow-up was 44.5 +/- 17.0 months. Treatment alternatives were cholecystectomy (64.3%), conservative treatment (23.0%), endoscopic retrograde cholangiopancreatography (17.4%), percutaneous cholecystostomy (10.7%) and endoscopic ultrasound-guided gallbladder drainage (0.8%). Most cholecystectomies were delayed (88.8%). Recurrences occurred in 38.2% of patients. Although cholecystectomy was the therapeutic approach with the lowest recurrence rate once performed, 44.6% of patients that underwent delayed surgery had pre-surgical recurrences. Conclusions: delayed cholecystectomy is still commonly performed, even though it is related with a high frequency of preoperative recurrences

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Parálisis diafragmática unilateral tras colecistectomía laparoscópica / Unilateral diaphragmatic paralysis after laparoscopic cholecystectomy

La colecistectomía laparoscópica supone hoy en día el tratamiento gold estándar de la patología aguda de la vía biliar. A pesar de las numerosas ventajas que presenta respecto a la cirugía abierta clásica, no está exenta de complicaciones. Presentamos el caso de un paciente varón de 82 años que tras el diagnóstico de colecistitis gangrenosa es intervenido de urgencia de colecistectomía laparoscópica, presentando en las primeras 24h del postoperatorio un episodio de insuficiencia respiratoria aguda, motivo por el cual ingresa en reanimación. Los estudios realizados a posteriori mostraron una parálisis del hemidiafragma derecho, probablemente relacionada con la cirugía

Laparoscopic cholecystectomy is currently the gold standard treatment for acute biliary tract pathology. Despite its many advantages compared to open surgery, it is not without complications. We present the case of an 82-year-old man who, after a diagnosis of gangrenous cholecystitis, underwent urgent laparoscopic cholecystectomy. During the first 24hours after the surgery, he had an episode of acute respiratory failure, for which he was admitted to the critical care unit. Studies performed later showed paralysis of the right diaphragm that was probably related to the surgery

Subtotal cholecystectomy versus cholecystostomy

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Two neonatal cases of food protein-induced enterocolitis syndrome with pale stool and transient biliary dilatation

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Un nuevo caso de pseudoaneurisma de la arteria hepática derecha secundario a colecistectomía laparoscópica / Laparoscopic cholecystectomy complications: a new case report of a right hepatic artery pseudoaneurysm that caused jaundice

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The impact of a percutaneous cholecystostomy catheter in situ until the time of cholecystectomy on the development of recurrent acute cholecystitis: a historical cohort study

Background: the optimal duration of percutaneous cholecystostomy in patients with acute cholecystitis is unknown. Methods: this study was a retrospective analysis of patients (age ≥ 18 years) who underwent percutaneous cholecystostomy due to acute calculous cholecystitis. Patients were grouped according to treatment modality: percutaneous cholecystostomy as a definitive treatment (group 1), subsequent surgical treatment after the removal of the catheter (group 2) and those remaining in situ (group 3). The development of gallstone-related complications was the main outcome. Results: there were 24 females (43.6%) and 31 males (56.4%) included in the study with a mean age of 64.8 ± 15.9 years. There were 16 (29.1%), 19 (34.5%) and 20 (36.4%) patients in groups 1, 2, and 3, respectively. The catheter withdrawal time for group 1 and group 2 was 18.2 ± 6.9 and 20.7 ± 13.4 days, respectively. Surgical treatment was performed after a mean of 85.4 ± 93.5 days following catheter removal in group 2 and a mean of 64 ± 32.5 days while the PC tube was in place in group 3. There were one (6.3%) and two cases of a recurrence (10.5%) in groups 1 and 2, respectively. Two patients developed choledocholithiasis (10%) in group 3. Conclusion: maintaining percutaneous cholecystostomy tubes in place until the time of surgery in surgically fit patients may help to prevent a recurrence after acute calculous cholecystitis

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Hemoperitoneo tras estallido vesicular diferido como consecuencia de traumatismo abdominal / Hemoperitoneum due to delayed gallbladder rupture after abdominal trauma

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Técnica anestésica y calidad de la recuperación tras colecistectomía laparoscópica: ¿un caso cerrado? / Anesthesia technique and quality of recovery after laparoscopic cholecystectomy: Case closed?

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