RESUMO
A 78-year-old male with high-risk surgical presented severe acute cholecystitis and required cholecystostomy. The patient was referred later for assessment of the surgical treatment. A cholangio-MRI revealed a lesion on the gallbladder fundus with hepatic lesions suggestive of metastatic gallbladder carcinoma, which was confirmed in the histological analysis. The tumor progressed despite the chemotherapy through the cholecystostomy tract and developed peritoneal carcinomatosis. The patient did not respond to chemotherapy and he died 12 months later.
Assuntos
Colecistite , Colecistostomia , Neoplasias da Vesícula Biliar , Masculino , Humanos , Idoso , Neoplasias da Vesícula Biliar/diagnóstico por imagem , Neoplasias da Vesícula Biliar/cirurgia , Doença Aguda , Vesícula Biliar/diagnóstico por imagem , Vesícula Biliar/cirurgia , Resultado do TratamentoRESUMO
The epithelioid angiosarcoma is a type of sarcoma is very rare (<1 % of all sarcomas). The most frequent location is in extremities, therefore is the axial region less common.Differential diagnosis with other histologic variants of intra-abdominal hepatic and splenic angiosarcomas is essential. Surgery is the treatment of choice, and there is no current evidence on the management of cases with locoregional or distant involvement.
Assuntos
Hemangioendotelioma Epitelioide , Hemangiossarcoma , Sarcoma , Humanos , Hemangiossarcoma/diagnóstico , Hemangiossarcoma/patologia , Diagnóstico Diferencial , Fígado/patologiaRESUMO
BACKGROUND: The transcystic approach to laparoscopic common bile duct exploration has gained popularity for the single-stage management of choledocholithiasis with concomitant gallstones. Our team previously described the use of a porcine aorta segment to simulate the common bile duct during laparoscopic skill training. METHODS: With the advent of the transcystic approach as a contender for the first-line technique of accessing the common bile duct, we present an evolution of the laparoscopic training model using a Porcine Aorta-Renal Artery (PARA) specimen to simulate the structural integrity, dimensions and spatial distribution of both the human cystic and common bile ducts. RESULTS: This training model allows the use of a choledochoscope for transcystic exploration of the biliary tree. It combines fidelity and reproducibility required for a simulated training model to offer experience in laparoscopic transcystic common bile duct exploration. Validation of the model was demonstrated by 21 surgeons who completed a questionnaire after performing the simulated procedure. In all sections assessing reliability, face validity and content validity of the model, mean rating scores were between 4 and 5 out of five (good or excellent). CONCLUSIONS: We present the evolution of an established training model for laparoscopic common bile duct exploration which focusses the attention on the transcystic approach to the common bile duct and the use of lithotripsy techniques. The need for such a model reflects the shift in the current practice of the laparoendoscopic management of choledocholithiasis with concomitant gallstones from transductal to transcystic approach.
Assuntos
Colecistectomia Laparoscópica , Coledocolitíase , Laparoscopia , Animais , Coledocolitíase/cirurgia , Ducto Colédoco/cirurgia , Humanos , Artéria Renal , Reprodutibilidade dos Testes , SuínosRESUMO
A 58-year-old male underwent an aortic valve replacement due to an acute aortic regurgitation for aortic valve endocarditis. The patient maintained febrile syndrome during the postoperative period, in spite of broad-spectrum antibiotics. The CT scan showed an aneurysmal dilatation (45 mm in diameter) on the right hepatic artery. The appearance of a rapidly growing aneurysmal lesion, which was observed in previous radiologic examinations, suggested a diagnosis of a mycotic aneurysm secondary to infective endocarditis. A selected angiography of the celiac trunk was performed, which confirmed the diagnosis. An endovascular approach was applied and an aneurysm coil embolization was performed. Targeted antibiotic therapy was applied during 6 weeks and the patient showed an improvement and was discharged. He is currently asymptomatic. Discussion Mycotic hepatic artery aneurysms (MHAAs) are uncommon (less than 0.1%) and mainly affect the extrahepatic region (1). In most cases, MHAAs are asymptomatic and a high clinical suspicion is needed. Arteriography is the gold standard and it can be used as a diagnostic and therapeutic tool (2). MHAAs are associated with a high risk of rupture, even in patients without symptoms suggestive of MHAA or previous endocarditis (3). Thus, an early diagnosis and treatment is necessary. Surgery or endovascular techniques may be performed. The endovascular approach is accepted in intrahepatic MHAAs or in high risk patients (1,3). In our patient, a radiological exam was needed due to the persistent febrile syndrome. An endovascular approach was performed after a multidisciplinary team decision.
Assuntos
Aneurisma Infectado , Endocardite Bacteriana , Endocardite , Aneurisma Infectado/diagnóstico por imagem , Aneurisma Infectado/etiologia , Aneurisma Infectado/terapia , Valva Aórtica , Endocardite Bacteriana/complicações , Endocardite Bacteriana/diagnóstico por imagem , Artéria Hepática/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND AND AIM: Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal types of cancer; most patients die during the first 6 months after diagnosis. With a 5% 5-year survival rate, is the fourth leading cause of cancer death in developed countries. In this regard, several clinical, histopathologic and biological characteristics of the disease favoring long-term survival after pancreaticoduodenectomy have been reported to be significant prognostic factors. Despite the availability of this information, there is no consensus about the different prognostic factors reported in the literature, probably due to variations in patient selection, methods, and sample size studied. The aim of this study was to identify the clinical and pathologic features associated to prognosis of the disease after pancreaticoduodenectomy. MATERIALS AND METHODS: The clinical and pathologic data from 78 patients who underwent a potentially curative resection for PDAC at our institution between 2003 and 2014 were analyzed retrospectively. RESULTS: Overall, high-grade PDAC cases showed larger tumor size (P=0.009) and a higher frequency of deaths in association with a nonsignificantly shortened patient overall survival (median of 12.5 vs. 21.7 mo; P=0.065) as compared with low-grade PDAC patients. High histologic grade (P=0.013), preoperative drainage on the main bile duct (P=0.014) and absence of adjuvant therapy (P=0.035) were associated with a significantly poorer outcome. Overall survival multivariate analysis showed histologic grade (P=0.019) and bile duct preoperative drainage (P=0.016) as the sole independent variables predicting an adverse outcome. CONCLUSIONS: Our results indicate that histologic tumor grade and preoperative biliary drainage are the only significant independent prognostic factors in PDAC patients after pancreatectomy.
Assuntos
Carcinoma Ductal Pancreático/patologia , Drenagem/métodos , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Ductal Pancreático/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Gradação de Tumores , Neoplasias Pancreáticas/cirurgia , Cuidados Pré-Operatórios/métodos , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
The role of early laparoscopic cholecystectomy (ELC) in "oldest-old" patients with acute calculous cholecystitis (ACC) is still controversial. The aim of this study is to assess the safety of ELC for ACC in ≥ 85-year-old patients. Multicentric retrospective study that analysed data of patients who underwent ELC for ACC between 2013 and 2018. Patients ≥ 85-year-old (oldest-old patients) were compared with younger patients, before and after propensity score matching (PSM). The main outcomes were mortality, post-operative complications, length of stay (LOS), and readmissions. The study included 1670 patients. The unmatched comparison revealed a selection bias towards the oldest-old group, which was associated with higher Charlson Comorbidity Index (5 vs 1, p < 0.001), more ASA III/IV subjects (54.2% vs 19.3%, p < 0.001), class II/III ACC (80.1% vs 69.1%, p = 0.016) and higher Chole-Risk Score (p > 0.001). The oldest-old also required more conversion to open surgery (20% vs 10.3%, p = 0.005). Postoperatively, they had a higher 90-day mortality rate (7.6% vs 1%, p < 0.001), more total complications (40.6% vs 17.7%, p < 0.001), complications ≥ IIIa Clavien-Dindo (14.4% vs 5.8%, p = 0.002), longer LOS (6 vs 5 days, p < 0.001), and more readmissions (6.6% vs 2.6%, p < 0.001). After PSM (n = 206), the two groups were comparable in terms of baseline characteristics and intraoperative outcomes. No differences were observed in post-operative complications; bile leak; incisional, intrabdominal, urinary or respiratory tract infections; LOS or readmissions. In the oldest-old, ELC for ACC is still associated with significant morbidity and mortality. However, it seems to be safe in selected patients. Therefore, age itself should not be regarded as a contraindication to ELC for ACC.
Assuntos
Colecistectomia Laparoscópica , Colecistite Aguda , Idoso de 80 Anos ou mais , Colecistectomia Laparoscópica/efeitos adversos , Colecistite Aguda/cirurgia , Humanos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Pontuação de Propensão , Sistema de Registros , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Timing for early laparoscopic cholecystectomy (ELC) in patients with acute calculous cholecystitis (ACC) is still controversial. This study assesses ELC for ACC with delayed presentation, according to hospital volume. Multicentric retrospective analysis of 1868 ELC. Patients were classified into two groups according to the timing of surgery from clinical onset and centre volume. Group 1 (G1) within the first 7 days, group 2 (G2) beyond that. Then centres were classified in low volume centres (LVC) and higher volume centres (HVC) according to the number of ELC performed per year. Overall, G2 showed increased conversion rate (17.7% vs 10.7%; p = 0.004), intraoperative complications (7.3% vs 2.9%; p = 0.001); postoperative haemorrhage (3.6% vs 0.8%; p < 0.001), infections (16.6% vs 9.3%; p = 0.003) and global complications (27.6% vs 19.8%; p = 0.011). HVC in comparison with LVC presented decreased conversion rate (17.1% vs 7.6%; p < 0.001), intraoperative bleeding (2.1% vs 1%; p = 0.047), postoperative bile leakage (4.1% vs 2.1%; p = 0.011), infectious (13.7% vs 7.5%; p < 0.001) and global complications (25.7% vs 17.1%; p < 0.001). HVC did not show an increase in any of the above-mentioned outcomes when G1 and G2 were compared. ELC must be indicated cautiously in patients with ACC and more than 1 week of symptom duration. It should be performed in centres with sufficient experience in the management of this disease.
Assuntos
Colecistectomia Laparoscópica , Colecistite Aguda/cirurgia , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/estatística & dados numéricos , Colecistite Aguda/etiologia , Conversão para Cirurgia Aberta/estatística & dados numéricos , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Hospitais/estatística & dados numéricos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Retrospectivos , Segurança , Fatores de TempoRESUMO
The Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Tropical Medicine and International Health (SEMTSI), the Spanish Association of Surgeons (AEC), the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), the Spanish Society of Thoracic Surgery (SECT), the Spanish Society of Vascular and Interventional Radiology (SERVEI), and the Spanish Society of Paediatric Infectious Diseases (SEIP) considered it pertinent to issue a consensus statement on the management of cystic echinococcosis (CE) to guide healthcare professionals in the care of patients with CE. Specialists from several fields (clinicians, surgeons, radiologists, microbiologists, and parasitologists) identified the most clinically relevant questions and developed this Consensus Statement, evaluating the available evidence-based data to propose a series of recommendations on the management of this disease. This Consensus Statement is accompanied by the corresponding references on which these recommendations are based. Prior to publication, the manuscript was open for comments and suggestions from the members of the SEIMC and the scientific committees and boards of the various societies involved.
Assuntos
Equinococose , Doenças Transmissíveis , Consenso , Equinococose/diagnóstico , Equinococose/terapia , Saúde Global , Humanos , Pneumologia , Radiologia Intervencionista , Sociedades Médicas , Espanha , Cirurgia Torácica , Medicina TropicalAssuntos
Hemangioma , Neoplasias Hepáticas , Neoplasias Primárias Múltiplas , Neoplasias Esplênicas , Feminino , Hemangioma/diagnóstico , Hemangioma/terapia , Humanos , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/terapia , Pessoa de Meia-Idade , Neoplasias Primárias Múltiplas/diagnóstico , Neoplasias Primárias Múltiplas/terapia , Neoplasias Esplênicas/diagnóstico , Neoplasias Esplênicas/terapiaRESUMO
INTRODUCTION: Gastric outlet obstruction is a complication of advanced tumors. It causes upper gastrointestinal obstruction, with progressive malnutrition and reduced survival. Currently, gastrojejunostomy or stent placement (SP) are feasible alternatives for the treatment of malignant gastric outlet obstruction. The aim of this study is to compare the efficacy and survival of both techniques. METHODS: Single-center observational and prospective study of 58 patients with gastric outlet obstruction who underwent surgical treatment with stomach-partitioning gastrojejunostomy (SPGJ) or SP with self-expanding intraluminal prostheses between 2007 and 2018. RESULTS: Thirty patients underwent SPGJ and 28 SP. The mean age of the first group was significantly lower (69 vs. 78 years, respectively; P=.001). There were no statistically significant differences in terms of sex, perioperative risk or tumor etiology. Postoperative complications were non-significantly higher in the SPGJ group (P=.156). SP was associated with a shorter hospital stay (P=.02) and faster oral intake (P<.0001). However, SP had significantly higher rates of persistent and recurrent obstruction (P=.048 and .01, respectively), poorer energy targets (P=.009) and shorter survival (9.61 vs. 4.47 months; P=.008). CONCLUSIONS: SPGJ presents greater luminal permeability, better oral intake and greater survival than SP. SP is preferable for non-surgical patients with a limited short-term prognosis.
Assuntos
Derivação Gástrica/métodos , Obstrução da Saída Gástrica/cirurgia , Stents , Estômago/cirurgia , Idoso , Feminino , Derivação Gástrica/efeitos adversos , Obstrução da Saída Gástrica/etiologia , Neoplasias Gastrointestinais/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos ProspectivosAssuntos
Equinococose Hepática/cirurgia , Laparoscópios , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeAssuntos
Cistos/congênito , Gastropatias/congênito , Estômago/anormalidades , Adulto , Cistos/epidemiologia , Cistos/patologia , Cistos/cirurgia , Mucosa Gástrica/patologia , Humanos , Masculino , Gastropatias/epidemiologia , Gastropatias/patologia , Gastropatias/cirurgia , Tomografia Computadorizada por Raios XAssuntos
Fístula Cutânea/parasitologia , Equinococose Hepática/complicações , Idoso , Humanos , MasculinoAssuntos
Adesivo Tecidual de Fibrina , Laparoscopia , Ductos Biliares , Colágeno , Ducto Colédoco , IncidênciaRESUMO
La tuberculosis es una de las enfermedades infecciosas más frecuentes de distribución mundial, con una amplia presentación clínica. La afectación hepática de la tuberculosis es poco frecuente, pero más infrecuente aún lo es el tuberculoma hepático. Se presenta el caso de una paciente con tuberculoma hepático solitario que simula metástasis hepática secundaria a tumor neuroendocrino
Tuberculosis is one of the most common infectious diseases, with worldwide distribution and ample clinical manifestations. Hepatic tuberculosis is rare but hepatic tuberculoma is even rarer. We report an unusual case of a solitary hepatic tuberculoma simulating hepatic metastasis of a neuroendocrine tumor