Factores de riesgo prequirúrgicos para una colecistectomía laparoscópica difícil / Preoperative risk factors for difficult laparoscopic cholecystectomy

RESUMEN Antecedentes: varios estudios observacionales han identificado factores de riesgo (FR) para una colecistectomía laparoscópica difícil (CLD). Objetivo: identificar los FR preoperatorios para CLD en un hospital público de mediana complejidad. Material y métodos: estudio prospectivo de cohorte transversal. Se analizaron 80 pacientes mayores de 18 años sometidos a colecistectomía laparoscópica, entre enero y diciembre de 2019. Se analizaron las variables: edad, sexo, IMC (índice de masa corporal), litiasis vesicular, pancreatitis aguda, colecistitis aguda o crónica, síndrome de Mirizzi, CPRE dentro del mes, numero de cólicos en el último mes, si presentó al menos un cólico en la última semana, leucocitos, enzimas hepáticas mayores, bilirrubina total, hallazgos de ecografía prequirúrgicos, antecedentes de cirugías abdominales previas. Resultados: la incidencia de CLD fue de 47,5%. La tasa de conversión a cirugía convencional fue del 11,25%, el 100% fueron CLD. Los FR para CLD incluyeron sexo masculino (OR: 4,50, IC 95%:1,60-12,62, p: 0,004), cólico en la semana previa a la cirugía (OR:7,17, IC 95%:1,89-27,23, p: 0,004), paredes engrosadas de la vesícula (OR: 4.90, IC 95%:1,90-12,70, p: 0,001), edema perivesicular (OR: 7,14 IC 95%:1,45-35,13 p: 0,016), la vesícula hidrópica (OR: 4,94, IC 95%:1,44-16,88, p: 0,011) y las cirugías previas (OR: 4.38 IC 95%:1,27-15,10 p: 0,001). En el análisis multivariado vemos que los pacientes de sexo masculino y pacientes con cirugías previas presentaban un riesgo elevado para CLD (OR: 6,63 IC 95%:1,75-25,08 p: 0.005; OR: 11.70 IC 95%:1,48-92,37 p: 0,020). Conclusión: se deben centrar los esfuerzos en identificar los pacientes con sospecha de CLD, pudiendo planificar la cirugía y un equipo quirúrgico experimentado.

ABSTRACT Background: The risk factors (RF) for difficult laparoscopic cholecystectomy (DLC) have been identified in many observational studies. Objective: The aim of this study is to identify the preoperative RF for DLC in a secondary care public hospital. Material and methods: We conducted a prospective cross-sectional cohort study of patients > 18 years undergoing laparoscopic cholecystectomy between January and December 2019. The following variables were analyzed: age, sex, body mass index (BMI), cholelithiasis, acute pancreatitis, acute or chronic cholecystitis, Mirizzi syndrome, ERCP within the previous month, episodes of biliary colic in the last month, presence of at least one colic within one week before surgery, white blood cell count, liver enzymes, total bilirubin, preoperative ultrasound and history of upper abdomen surgery. Results: The rate of DLC was 47.5%. Conversion rate to conventional surgery was 11.25% and 100% were categorized as DLC. The RF for DLC included male sex (OR, 4.50; 95% CI,1.60-12.62; p = 0.004), colic within 1 week before surgery (OR, 7.17; 95% CI,1.89-27.23; p = 0.004), gallbladder wall thickening (OR, 4.90; 95% CI,1.90-12.70; p = 0.001), edema around the gallbladder (OR, 7.14; 95% CI, 1.45-35.13; p = 0.016), hidrops gallbladder (OR, 4.94; 95% CI,1.44-16.88; p = 0.011) and previous surgeries (OR, 4.38; 95% CI, 1.27-15.10; p = 0.001). On multivariate analysis, male sex and previous surgery were associated with higher risk of DLC (OR, 6.63; 95% CI,1.75-25.08; p = 0.005; and OR, 11.70, 95% CI,1.48-92.37; p = 0.020, respectively). Conclusion: Efforts should focus on identifying patients with suspicion of DLC to plan surgery with an experienced surgical team.

Esophageal Atresia with Tracheoesophageal Fistula and Gastroesophageal Reflux in Children: Dental Considerations and Case Report.

BACKGROUND: Esophageal Atresia (EA) is defined as the congenital interruption of the continuity of the esophagus. Pediatric patients also have other congenital conditions, such as Tracheo-Esophageal Fistula (TEF). CASE REPORT: A 7-year-old male with TEF referred by a Pediatric Cardiologist, with the principal complaint of "severe and generalized tooth wearing". Considering that the patient was systemically stable, it was decided to perform the oral procedures under local anesthesia and rubber-dam isolation with an antimicrobial prophylaxis regimen. The treatment consisted of the extraction of all maxillary primary incisors and canines and both first molars; in the mandibular arch, only the lower second right molar was extracted, and a distal shoe was placed. Pulpotomies were performed and preformed metallic crowns were placed on the remaining second primary molars, on both lower first molars, and on lower canines and lateral incisors. Finally, a fixed prosthesis was positioned in the upper arch, and cemented through orthodontic bands adapted to both crowned second molars. The patient has been maintained under close medical and dental control. The child showed satisfactory oral conditions, and the vomiting episodes had decreased significantly. CONCLUSIONS: Dentists can learn and then participate in the integral health management of infants and young children affected with EA/TEF, particularly those with dental erosion.

Bioactive Tricalcium Silicate-based Dentin Substitute as an Indirect Pulp Capping Material for Primary Teeth: A 12-month Follow-up.

PURPOSE: The purpose of this study was to evaluate the clinical and radiographic outcomes of a bioactive tricalcium silicate [Ca3SiO5]-based dentin substitute and a light-activated calcium hydroxide [Ca(OH)2]-based liner as indirect pulp treatment (IPT) interventions for vital primary molars with carious lesions approaching the pulp. METHODS: Eighty children, aged four to eight years old, with 160 bilateral primary teeth without signs or symptoms of irreversibly inflamed or degenerative pulp tissue were treated in a split-mouth design trial comparing IPT using Ca3SiO5 or Ca(OH)2. The teeth were treated and restored with a preformed crown in a single session and assessed clinically and radiographically for one, three, six, and 12 months. RESULTS: Sixty patients with 120 treated molars completed the 12-month evaluations. The combined clinical and radiographic success rates were 98.3 percent (59 out of 60) for Ca3SiO5 and 95 percent for Ca(OH)2 (57 out of 60). No significant differences were found for success rates between the two study groups (P>0.05). The combined success rates for both groups was 96.7 percent. CONCLUSIONS: These results suggest that the indirect pulp treatment procedure with either a bioactive Ca3SiO5-based dentin substitute or a Ca(OH)2-based material may be considered a suitable treatment to achieve acceptable therapeutic results when applied on deeply carious primary teeth without degenerative symptoms.

A preliminary report on pelvic floor reconstruction through colpocleisis from 2001 to 2007 at the University Hospital of the Puerto Rico Medical Center.

OBJECTIVE: Describe the pre-, intra-, and postoperative experience of colpocleisis in a group of patients at the University Hospital of the Puerto Rico Medical Center. METHODS: A chart review was done on a subgroup of patients, 70 years or older, on which colpocleisis was performed between January 2001 and December 2007. The evaluation included demographics, comorbidities, and previous pelvic surgeries. The Pelvic Organ Prolapse Quantification (POP-Q) System was used to evaluate pelvic organ prolapse. Surgical procedures, outcomes, and related data were tabulated. RESULTS: Nineteen patients with a mean age of 77 years underwent the procedure, 57.8% presenting more than one comorbidity. Seventy-three percent of the patients had a BMI over 25. Sixty-three percent reported prior pelvic surgeries, 94.7% had stage IV pelvic prolapse, and 73.6% underwent concomitant procedures. Spinal anesthesia was most often used (68%), and the mean hospital stay was 2.1 days. Thirty-one percent of interviewed patients reported preoperative impairment in their daily activities that resolved completely after surgery. Incontinence symptoms resolved in 69% of patients. Ninety-two percent of the patients reported full satisfaction with the surgery. CONCLUSION: Colpocleisis is a safe pelvic reconstructive procedure for high-risk patients with multiple comorbidities. Regional anesthesia can be offered with minimal blood loss, short operative time, and early ambulation.