Quantitative study of metals in bile from patients with cholelithiasis.

OBJECTIVE: Biliary lithiasis is a multifactorial phenomenon that is decisively influenced by the composition of bile. We analyzed the presence of eight metals in bile and compared their concentrations in healthy persons and patients with cholelithiasis. METHODS: We studied bile from 119 patients who underwent cholecystectomy because of symptomatic cholelithiasis, and from 25 control subjects in whom the gallbladder was removed for reasons other than cholelithiasis. Metal concentrations were analyzed by atomic absorption spectrophotometry. The subjects were divided into subgroups according to age, sex and type of stone. RESULTS: Bile from patients with cholelithiasis contained significantly less of the essential element magnesium (Mg) and the toxic element lead (Pb) than bile from control subjects. Calcium (Ca) and strontium (Sr) concentrations were also lower in patients with gallstones than in the control group, although the differences were not significant. CONCLUSIONS: Biliary concentrations of Mg and Pb were significantly lower in patients with cholelithiasis than in the control group. The biliary excretion of Ca and Sr was lower in patients than in controls, although the differences were not statistically significant.

Open biliary tract surgery: multivariate analysis of factors affecting mortality.

BACKGROUND/AIM: The overall mortality rate in patients undergoing supraduodenal choledochotomy for benign biliary tract disease is around 3%. The aim of this study is to identify and quantify factors affecting the mortality in a group of patients undergoing open common bile duct exploration for benign biliary disease. METHODS: Patients (n = 158) who underwent common bile duct exploration during a 5-year period in a teaching hospital were retrospectively reviewed. RESULTS: Univariate and multivariate statistical analyses were performed. The former identified four statistically significant variables: age (p < 0.001), acute cholangitis on admission (p < 0. 001), heart disease (p < 0.05), and a dilated common bile duct on preoperative ultrasound scan (p < 0.05). Multivariate analysis identified three variables which independently increased operative mortality: age (p = 0.05), heart disease (p = 0.03), and cholangitis (p = 0.008). The latter was associated with the greatest operative mortality, since it increased almost eight times the risk to die after surgical intervention. CONCLUSION: We conclude that an adequate perioperative cardiovascular management may be important in order to improve surgical outcome. Appropriate antibiotic prophylaxis and subsequent treatment after routine operative bile cultures may reduce septic complications and mortality. Finally, an alternative procedure, such as endoscopic sphincterotomy, may be indicated in high-risk patients in order to drain the common bile duct preoperatively and to decrease the risk of unresponsive biliary sepsis.

Value of tonometry in postoperative high risk patients with digestive surgery.

Intramucosal pH (pHi) in splanchnic organs is a reliable index of local tissular perfusion, and can be measured by tonometry. At the Surgical Intensive Care Unit we used tonometry to determine tissular perfusion in patients who underwent major digestive surgery. We report a prospective study of 20 patients with elective and emergency surgery. All of them underwent gastric tonometry and 10 of them, who had colonic disease, also underwent sigmoid tonometry. The values below pHi = 7.30 were associated with increased morbidity and mortality.

[Study of the secretion of P substance, neurotensin and somatostatin in healthy adults]. / Estudio de la secreción de sustancia P, neurotensina y somatostatina en adultos sanos.

OBJECTIVE: A study in humans of the profile of physiologic secretion, basal and postprandial of three gastrointestinal peptides has been carried out. METHOD: 20 healthy subjects were studied (9 women and 11 men); any previous digestive pathology has not been included. The study was carried out by determining P substance, neurotensin and somatostatin in plasma by means of RIA I125. The subjects were studied in basal conditions of fasting and the samples were taken at 30, 60 and 90 minutes intervals after the oral intake of a semi-liquid preparation made up of the three immediate principles. RESULTS: It shows the secretion curve of the three gastrointestinal peptides, in a global way and also in relation to sex, age and body weight.

[Intestinal pneumatosis]. / Neumatosis intestinal.

Intestinal pneumatosis is an infrequent disease of difficult clinical and radiologic diagnosis. It may be accompanied by pneumoperitoneum in up to 30% of the cases leading to differential diagnosis with pictures of visceral perforation. We herein present 4 cases of intestinal pneumatosis in whom pneumoperitoneum was associated in 3 patients. Diagnosis was intraoperative in 2 patients submitted to emergency surgery because of an associated acute gastrointestinal event (intestinal volvulus and acute cholecystitis). The other 2 cases were diagnosed by computerized tomography and colonoscopy, respectively, and given their satisfactory clinical evolution they received conservative treatment. The course of the disease was favorable in all the patients with the radiologic signs of pneumatosis disappearing.

Study of the secretion of substance P, neurotensin and somatostatin in patients with cholelithiasis.

A comparative, case-control study on the pre- and postprandial release of three gastrointestinal peptides implicated in gallbladder motility has been carried out in humans in the attempt to determine their possible role in the pathogenesis of cholelithiasis. Fifty-seven adult patients (40 females and 17 males) with an ultrasound diagnosis of gallstones and 20 healthy subjects (9 females and 11 males) without cholelithiasis or other digestive pathology were studied. Plasma substance P, neurotensin and somatostatin were measured by means of RIA-I125 in basal fasting conditions and 30, 60 and 90 minutes after the oral intake of a semiliquid mixed meal. The levels of secretion of each hormone were compared in patients and healthy controls on an overall basis and in terms of sex, age and body weight. We found a basal and postprandial hypersecretion of substance P in patients with gallstones when compared with controls. Individuals with cholelithiasis showed a moderate decrease in neurotensin secretion after the oral meal. Somatostatin release was unchanged. In conclusion, patients with gallstones may present a functional disorder in the secretion of gastrointestinal hormones involved in gallbladder motility.

Complications of laparoscopic cholecystectomy in the ageing patient.

AIM: to determine the safety of simple laparoscopic cholecystectomy in ageing patients. METHOD: the outcome of patients between 60 and 70 years of age and patients over 70 who underwent laparoscopic cholecystectomy for symptomatic non-malignant gallbladder disease was comparatively analysed. All patients over 60 years of age with symptomatic gallbladder disease and without cholecholithiasis, septic shock, diffuse peritonitis, gallbladder malignancy, portal hypertension or contraindication for general anaesthesia were selected for simple laparoscopic cholecystectomy (n = 158). This group represents over 80% of all elderly patients undergoing biliary surgery at our department over this period. Group A (n = 97) included patients from 60 to 69 years of age. Group B (n = 61) comprised patients over 70 years. RESULTS: there was no difference in sex distribution between groups. Operative time and conversion rates were similar in both groups. The overall morbidity rate was 14.5%, with no statistically significant increase in group B (11% for group A vs 20% for group B). No perioperative mortality occurred. Recurrent biliary surgery was required in two patients from group B (3%). Postoperative endoscopic retrograde cholangiography and sphincterotomy was done in four patients from group A (4%). The mean postoperative stay was longer for older patients (group A, 3.1 (2.5) days; group B, 4.2 (4.3) days; P = 0.05). CONCLUSION: simple laparoscopic cholecystectomy is safe in the aged, even for patients over 70. This procedure is associated with a short hospital stay and low rates of re-admission and recurrent biliary surgery.

[Acute cholecystitis and laparoscopic cholecystectomy. Comparison with non-complicated cholelithiasis]. / Colecistitis aguda y colecistectomia laparoscópica. Comparación con la colelitiasis no complicada.

Laparoscopic cholecystectomy has become the treatment of choice for symptomatic cholelithiasis. However, the indication of the laparoscopic approach for acute inflammation of the gallbladder in unclear and further analysis of the results is required. The aim of our study was to compare the results of laparoscopic cholecystectomy after uncomplicated cholelithiasis and after acute cholecystitis. Data from 201 patients who underwent laparoscopic cholecystectomy were collected prospectively. Uncomplicated cholelithiasis was present in 149 patients and 52 individuals had acute cholecystitis. No differences in age, sex distribution or associated diseases were observed between groups. The mean operative time was significantly higher in patients with acute cholecystitis. However, no difference was observed regarding conversion rate (7.3%-7.6%) and morbidity rate (8.7%-9.6%). No mortality has occurred in any group. The average hospital stay after laparoscopic cholecystectomy was greater when acute cholecystitis was present (2.6 days-4.9 days; p < 0.01). But in this case hospitalization was shorter than after elective conversion (8 days; p < 0.001 and p < 0.05). We conclude that patients with acute cholecystitis can undergo laparoscopic cholecystectomy safely, with low morbidity and mortality rates and reduced hospital stay.

[Laparoscopic cholecystectomy: 3 years of experience at a university hospital]. / Colecistectomía laparoscópica: tres años de experiencia en un Hospital Universitario.

We analyse the first 174 patients treated with laparoscopic cholecystectomy (LC) and their follow-up results. Average age was 57 years. Intraoperative cholangiography was not done in anyone. Conversion rate into other forms of intervention was 6.3%. The rate of common bile duct injury has been null. Total morbidity was 6.3%. Two cases of pulmonary embolism and two biliary leakages stand out in the postoperative morbidity. There was no death. After a follow-up period of up to 36 months, only 1 case of residual choledocholithiasis was registered, and it was cured with endoscopy. In this series morbid-mortality figures are low. LC is a safe procedure in the treatment of cholelithiasis, even in older patients.