Laparoscopic hepaticojejunostomy and gastrojejunostomy for palliative treatment of pancreatic head cancer in 48 patients.

INTRODUCTION: Approximately 80% of patients with pancreatic cancer are not candidates for curative resection at the time of diagnosis. The objective of this study is to show that although endoscopic treatment is the standard palliation, surgical laparoscopic treatment is both feasible and effective for these patients. MATERIALS AND METHODS: Preoperative resectability was evaluated by dynamic contrast-enhanced computed tomography scans. Endoscopic palliation was the first choice for patients with metastatic disease and for patients with locally advanced pancreatic cancer with bad performance status. Laparoscopic surgical palliation was indicated for patients with jaundice and locally advanced pancreatic cancer (elective palliation) and for patients with jaundice with metastatic disease and failure in the endoscopic/percutaneous treatment (necessary palliation). Elective palliation consisted of Roux-en-Y hepaticojejunostomy and gastrojejunostomy and necessary palliation consisted of laparoscopic hepaticojejunostomy alone. RESULTS: A total of 48 patients received laparoscopic surgical palliation. Morbidity rate was 33.3% and mortality was 2.08%. There was no need for late surgeries in any of the patients. CONCLUSION: Surgical laparoscopic palliation is a feasible treatment option for locally advanced pancreatic cancer. Even though metallic stents are still the best palliation method for patients with systemic disease, if stents fail, the laparoscopic approach is a viable treatment.

Use of artificial intelligence in the detection of the critical view of safety during laparoscopic cholecystectomy.

BACKGROUND: This study aimed to evaluate the use of artificial intelligence (AI) to detect the critical view of safety during elective laparoscopic cholecystectomy. METHODS: This was a prospective, observational study evaluating the detection of the critical view of safety with an AI software in a consecutive series of elective laparoscopic cholecystectomies compared with the blinded evaluation of 3 surgeons. The program was created using the digital tools PyCharm (JetBrains), Google Colab Pro (https://colab.google/), and YOLOv8 (Ultralytics). RESULTS: A total of 40 consecutive elective laparoscopic cholecystectomies were included in the study. The program was able to detect the critical view of safety in all cases following the experts' blinded opinion. CONCLUSION: In this preliminary experience, an AI software was able to detect the critical view of safety in elective laparoscopic cholecystectomies. Its application during nonelective cases, in which the critical view of safety is harder to achieve, might warrant further studies.

An infrequent cause of cholestasis: morphine-induced cholestasis / [Una causa infrecuente de colestasis extrahepática: colestasis inducida por morfina.]

Introduction: Extrahepatic cholestasis by opiates is a very rare entity of which only case reports are recorded in the literature. Methods: We present the case of a patient who developed abdominal pain and cholestasis after consumption of high doses of morphine for pain management of her underlying disease, treated by laparoscopic surgery. Results: The patient evolved favorably in the postoperative period without bilirrhage and was discharged on the fifth day with bilirubin values ​​within normal parameters. Conclusion: Sphincter of Oddi dysfunction syndrome secondary to long-term use of opioids is a very rare entity. However, it should be suspected in cases of extrahepatic cholestasis in which no stones or tumors are observed and in patients with long-term use of high-dose opiates either due to addiction or chronic pain treatment.

Introducción: La colestasis extrahepática producida por opiáceos es una entidad sumamente infrecuente de la cual solo se registran reportes de casos en la literatura. Métodos: Se presenta el caso clínico de una paciente que desarrolló dolor abdominal y colestasis luego del consumo prolongado de morfina a altas dosis, tratada por cirugía laparoscópica. Resultados: La paciente evoluciona favorablemente en el postoperatorio sin bilirragia y es dada de alta al quinto día con valores de bilirrubina dentro de los parámetros normales. Conclusión: El síndrome de disfunción del esfínter de Oddi secundario a consumo por tiempo prolongado de opioides es una entidad muy infrecuente. Sin embargo, debe sospecharse ante cuadros de colestasis extrahepáticas en los que no se observe litiasis ni tumores y en pacientes con consumo de opiáceos a altas dosis por tiempo prolongado ya sea por adicción o por tratamiento del dolor crónico.

Ten strategies to improve the efficacy of laparoscopic biliary surgery. / Diez estrategias para mejorar la eficacia de la cirugía biliar laparoscópica.

Laparoscopic surgery is the gold standard treatment of symptomatic gallstones. For some, it is also the treatment of choice for choledocholithiasis. Certain special and rare circumstances regarding the number, size and location of bile duct stones or altered bile duct anatomy (embryonic or acquired), can be challenging to resolve with usual laparoscopic techniques. For these situations, we describe 10 surgical strategies that are relatively simple and inexpensive to apply, making them appropriate to be used in most surgical centers.

A Multimodal Approach for the First-Line Treatment of Infected Pancreatic Necrosis.

OBJECTIVES: Because infected pancreatic necrosis (IPN) has multiple presentations, not all patients are likely to benefit from the same first-line treatment. Our objective was to evaluate morbidity and mortality in a series of patients treated with a multimodal therapeutic approach. METHODS: Between May 2012 and May 2019, 51 patients diagnosed with IPN were treated. The 5 initial treatment alternatives were as follows: percutaneous drainage, minimally invasive necrosectomy, antibiotics alone, transgastric necrosectomy, and temporizing percutaneous/endoscopic drainage. Initial treatment selection depended on evolution, clinical condition, and extension of pancreatic necrosis. Success, morbidity, and mortality rates were determined. RESULTS: In terms of determinant-based classification, 37 were classified as severe, and 14 as critical. Percutaneous, temporizing drainage, minimally invasive necrosectomy, antibiotics alone and transgastric necrosectomy approaches were used in 21, 10, 11, 4, and 5 patients, respectively. Necrosectomy was not required in 18 patients (35%). There were no significant differences in mortality among the different treatment approaches (P < 0.45). Overall success, morbidity, and mortality rates were 68.6%, 52.9%, and 7.8%, respectively. CONCLUSIONS: The multimodal approach seems to be a rational and efficient strategy for the initial treatment of IPN.

Persistent villi hypoperfusion explains intramucosal acidosis in sheep endotoxemia.

OBJECTIVE: To test the hypothesis that persistent villi hypoperfusion explains intramucosal acidosis after endotoxemic shock resuscitation. DESIGN: Controlled experimental study. SETTING: University-based research laboratory. SUBJECTS: A total of 14 anesthetized, mechanically ventilated sheep. INTERVENTIONS: Sheep were randomly assigned to endotoxin (n = 7) or control groups (n = 7). The endotoxin group received 5 microg/kg endotoxin, followed by 4 microg x kg(-1) x hr(-1) for 150 mins. After 60 mins of shock, hydroxyethylstarch resuscitation was given to normalize oxygen transport for an additional 90 mins. MEASUREMENTS AND MAIN RESULTS: Endotoxin infusion decreased mean arterial blood pressure, cardiac output, and superior mesenteric artery blood flow (96 +/- 10 vs. 51 +/- 20 mm Hg, 145 +/- 30 vs. 90 +/- 30 mL x min(-1) x kg(-1), and 643 +/- 203 vs. 317 +/- 93 mL x min(-1) x kg(-1), respectively; p < .05 vs. basal), whereas it increased intramucosal-arterial PCO2 (deltaPCO2) and arterial lactate (3 +/- 3 vs. 14 +/- 8 mm Hg, and 1.5 +/- 0.5 vs. 3.7 +/- 1.3 mmol/L; p < .05). Sublingual, and serosal and mucosal intestinal microvascular flow indexes, and the percentage of perfused ileal villi were reduced (3.0 +/- 0.1 vs. 2.3 +/- 0.4, 3.2 +/- 0.2 vs. 2.4 +/- 0.6, 3.0 +/- 0.0 vs. 2.0 +/- 0.2, and 98% +/- 3% vs. 76% +/- 10%; p < .05). Resuscitation normalized mean arterial blood pressure (92 +/- 13 mm Hg), cardiac output (165 +/- 32 mL x min(-1) x kg(-1)), superior mesenteric artery blood flow (683 +/- 192 mL x min(-1) x kg(-1)), and sublingual and serosal intestinal microvascular flow indexes (2.8 +/- 0.5 and 3.5 +/- 0.7). Nevertheless, deltaPCO2, lactate, mucosal intestinal microvascular flow indexes, and percentage of perfused ileal villi remained altered (10 +/- 6 mm Hg, 3.7 +/- 0.9 mmol/L, 2.3 +/- 0.4, and 78% +/- 11%; p < .05). CONCLUSIONS: In this model of endotoxemia, fluid resuscitation corrected both serosal intestinal and sublingual microcirculation but was unable to restore intestinal mucosal perfusion. Intramucosal acidosis might be due to persistent villi hypoperfusion.

Fístula colecistoduodenal sin migración de cálculo: reporte de caso / Cholecystoduodenal fistula without gallstones migration: case report / Fístula colecistoduodenal sem migração de cálculos: relatório de caso

El síndrome de Bouveret es una causa infrecuente de íleo biliar, posee una elevada morbimortalidad. Se produce por la migración de un cálculo, generalmente de gran tamaño, hacia el tracto gastrointestinal a través de una fistula colecistoduodenal. El objetivo de esta carta científica es presentar un paciente con un estadio previo de la enfermedad donde la fistula se encuentra constituida, pero sin migración del cálculo, por lo que el diagnóstico oportuno tendría un impacto favorable en el tratamiento y pronóstico debido a que no se encuentra instaurado el cuadro obstructivo intestinal.

Bouveret's syndrome is a rare cause of biliary ileus, with a high morbimortality. It is caused by the migration of a stone, usually large, into the gastrointestinal tract through a cholecystoduodenal fistula. The objective of this scientific letter is to present a patient with a previous stage of the disease where the fistula is constituted, but without migration of the calculus, so that the timely diagnosis would have a favorable impact on the treatment and prognosis because the obstructive intestinal condition is not established.

A síndrome de Bouveret é uma causa rara de íleo biliar com uma morbilidade e mortalidade elevadas. É causada pela migração de uma pedra, geralmente grande, para o tracto gastrointestinal através de uma fístula colecystoduodenal. O objectivo desta carta científica é apresentar um doente com uma fase anterior da doença em que a fístula está presente, mas sem migração da pedra, para que o diagnóstico atempado tenha um impacto favorável no tratamento e prognóstico, uma vez que a condição obstrutiva instestinal não está estabelecida.

Íleo biliar: análisis de 21 casos / Gallstone ileus: analysis of 21 cases

RESUMEN Antecedentes : el íleo biliar es una complicación infrecuente de la litiasis vesicular, observada más comúnmente en mujeres añosas. Es causada por la migración, a través de una fístula bilioentérica, de un cálculo que produce la obstrucción del tránsito intestinal, que requiere tratamiento quirúrgico. Objetivo : describir las variables preoperatorias, intraoperatorias y posoperatorias de una serie de casos de íleo biliar y la incidencia de íleo biliar recurrente. Material y métodos: se realizó un estudio retrospectivo observacional de pacientes operados con abdomen agudo obstructivo por íleo biliar entre enero de 2009 y diciembre de 2021. Las variables estudiadas fueron: estudios por imágenes, comorbilidades, vías de abordaje quirúrgico, tipo de cirugía, morbimortalidad y recurrencia del íleo. Resultados : sobre 667 pacientes que ingresaron con obstrucción intestinal, 21 tenían íleo biliar (3,1%). El diagnóstico se realizó por tomografía en el 80% de los casos. El abordaje quirúrgico fue por laparotomía en 20 casos y 1 por laparoscopia convertida. La cirugía más utilizada fue la enterotomía con enterorrafia en 18 casos. El tratamiento de la obstrucción fue la cirugía inmediata, mientras que el de la fístula biliar fue diferido en la mayoría de las oportunidades, debido a que el riesgo de tratarla en el momento era muy elevado. La morbilidad fue del 38% y la recurrencia del íleo biliar 4,7%. No se registró mortalidad. Conclusión : el íleo biliar fue una patología infrecuente, que pudo ser correcta y oportunamente diagnosticada y tratada con cirugía, con una baja incidencia de íleo biliar recurrente.

ABSTRACT Background : Gallstone ileus is a rare complication of cholelithiasis and mainly affects elder women. It is caused by gallstone migration through a cholecystoenteric fistula producing bowel obstruction, with the need for surgical treatment. Objective : The aim of this work was to describe the preoperative, intraoperative and postoperative variables of a case series of gallstone ileus and the incidence of recurrent gallstone ileus. Material and methods : We conducted an observational and retrospective study of patients undergoing surgery due to acute bowel obstruction caused by gallstone ileus between January 2009 and December 2021. The variables analyzed were imaging tests, comorbidities, surgical approach, type of surgery, morbidity and mortality and recurrent ileus. Results : Of 667 patients admitted with bowel obstruction, 21 had gallstone ileus (3.1%). The diagnosis was made by computed tomography scan in 80% of the cases. The surgical approach was laparotomy in 20 cases and 1 patient undergoing laparoscopy required conversion. Enterotomy with enterorrhaphy was the most common procedure used in 18 cases. The obstruction was treated by immediate surgery, while the biliary fistula was deferred in most cases because the risk of immediate treatment was very high. Morbidity was 38% and recurrence of gallstone ileus 4.7%. No deaths were reported. Conclusion : Gallstone ileus was a rare condition that was correctly diagnosed and timely treated with surgery, with a low incidence of recurrent gallstone ileus.

Retroperitonitis apendicular: factores asociados y manejo de una complicación seria

Antecedentes: La retroperitonitis es una rara y severa complicación de la apendicitis. Hasta el presente solo unos pocos reportes de casos han sido publicados en la literatura inglesa. Objetivo: El objetivo de este trabajo es analizar una serie consecutiva de 11 casos tratados en nuestra institución. Materiales y Método: Análisis retrospectivo de una base de datos recolectada en forma prospectiva de todos los pacientes admitidos por retroperitonitis de origen apendicular durante el período marzo 2017-septiembre 2020. Se analizarán las variables asociadas con esta complicación y su manejo. Resultados: 11 pacientes de un total de 601 con diagnóstico de apendicitis presentaron una retroperitonitis durante el período analizado (1,83%). El retardo en el diagnóstico fue en promedio de 8 días (rango 3 - 14 días). Todos los pacientes tuvieron un apéndice retrocecal y 81% presentaron un coprolito asociado. 45% fueron manejados inicialmente con abdomen abierto y contenido, y 55% con cierre fascial primario (50% de fracaso). La morbilidad y mortalidad fueron del 81% y 18%, respectivamente Discusión: La localización retrocecal del apéndice, la presencia de un coprolito y la presentación atípica, con demora en el diagnóstico, fueron factores comunes presentes en nuestra experiencia. El manejo con cierre fascial primario fracasó en la mitad de los casos. La morbimortalidad fue elevada. Conclusión: La retroperitonitis es una infrecuente pero severa complicación de la apendicitis, con elevada morbimortalidad.

Background: Retroperitonitis is a rare and life-threatening complication of appendicitis. So far, only a few cases have been described so far in the English literature. Aim: The objetive of this paper is to analyze a consecutive series of 11 patients treated at our institution. Materials and Method: Retrospective analysis of a prospectively collected database of all patients admitted for appendicular retroperitonitis during the period March 2017-September 2020. The variables associated with this complication and its management are analyzed. Results: 11 patients from 601 with a diagnosis of appendicitis presented with retroperitonitis during the study period (1.83%). Mean delay in diagnosis was 8 days (range 3-14 days). The location of the appendix was retrocecal in all cases and 81% had an appendicolith associated. 45% were initially managed with open abdomen. A 50% failure rate occurred after primary fascial closure. Morbidity and mortality rates were 81% and 18%, respectively. Discussion: Retrocecal location of the appendix, the presence of an appendicolith and atypical presentation with delayed diagnosis were common factors present in our experience. Primary fascial closure was associated with a 50% failure rate. Morbidity and mortality were high. Conclusion: Retroperitonitis is a rare but severe complication of appendicitis, with high morbidity and mortality rates.

Innovación en técnica quirúrgica: Dos técnicas no convencionales para el tratamiento de la coledocolitiasis / Innovative surgical techniques. Two non-conventional techniques for the treatment of choledocholithiasis

RESUMEN La litiasis vesicular asociada a coledocolitiasis puede tener distintos tratamientos, endoscópicos o quirúrgicos, dependiendo del paciente, el entrenamiento del personal médico y de la disponibilidad de instrumental. Ninguno ha demostrado estar exento de complicaciones. Presentamos dos técnicas tendientes a mejorar los resultados del tratamiento quirúrgico de la coledocolitiasis. Una es la extracción transcística de coledocolitiasis y stent, en pacientes que fueron tratados endoscópicamente por colangitis, tendiente a resolver el problema (la litiasis vesicular, la coledocolitiasis y el stent) en un solo tiempo por cirugía laparoscópica. La segunda es una nueva indicación de una técnica ya descripta, la dilatación papilar anterógrada con balón, utilizada en este caso para disminuir las fugas biliares tras un cierre primario de colédoco.

ABSTRACT Cholelithiasis associated with choledocholithiasis may have different treatments, either by endoscopy or surgery, depending on the patient, level of training of the medical staff and availability of instruments. None of them is free of complications. We report two non-conventional techniques aimed at improving the results of the management of choledocholithiasis. Transcystic removal of common bile duct stones and stent in patients who underwent endoscopic treatment for cholangitis is one of these new techniques to manage cholelithiasis, choledocholithiasis and stent removal in a single procedure through laparoscopy. The second technique is a new indication of a previously described procedure, antegrade balloon papillary dilation to reduce biliary leaks after primary closure of the common bile duct.

Venoarterial PCO2-to-arteriovenous oxygen content difference ratio is a poor surrogate for anaerobic metabolism in hemodilution: an experimental study.

BACKGROUND: The identification of anaerobic metabolism in critically ill patients is a challenging task. Observational studies have suggested that the ratio of venoarterial PCO2 (Pv-aCO2) to arteriovenous oxygen content difference (Ca-vO2) might be a good surrogate for respiratory quotient (RQ). Yet Pv-aCO2/Ca-vO2 might be increased by other factors, regardless of anaerobic metabolism. At present, comparisons between Pv-aCO2/Ca-vO2 and RQ have not been performed. We sought to compare these variables during stepwise hemorrhage and hemodilution. Since anemia predictably produces augmented Pv-aCO2 and decreased Ca-vO2, our hypothesis was that Pv-aCO2/Ca-vO2 might be an inadequate surrogate for RQ. METHODS: This is a subanalysis of a previously published study. In anesthetized and mechanically ventilated sheep (n = 16), we compared the effects of progressive hemodilution and hemorrhage by means of expired gases analysis. RESULTS: There were comparable reductions in oxygen consumption and increases in RQ in the last step of hemodilution and hemorrhage. The increase in Pv-aCO2/Ca-vO2 was higher in hemodilution than in hemorrhage (1.9 ± 0.2 to 10.0 ± 0.9 vs. 1.7 ± 0.2 to 2.5 ± 0.1, P < 0.0001). The increase in Pv-aCO2 was lower in hemodilution (6 ± 0 to 10 ± 1 vs. 6 ± 0 to 17 ± 1 mmHg, P < 0.0001). Venoarterial CO2 content difference and Ca-vO2 decreased in hemodilution and increased in hemorrhage (2.6 ± 0.3 to 1.2 ± 0.1 vs. 2.8 ± 0.2 to 6.9 ± 0.5, and 3.4 ± 0.3 to 1.0 ± 0.3 vs. 3.6 ± 0.3 to 6.8 ± 0.3 mL/dL, P < 0.0001 for both). In hemodilution, Pv-aCO2/Ca-vO2 increased before the fall in oxygen consumption and the increase in RQ. Pv-aCO2/Ca-vO2 was strongly correlated with Hb (R 2 = 0.79, P < 0.00001) and moderately with RQ (R 2 = 0.41, P < 0.0001). A multiple linear regression model found Hb, RQ, base excess, and mixed venous oxygen saturation and PCO2 as Pv-aCO2/Ca-vO2 determinants (adjusted R 2 = 0.86, P < 0.000001). CONCLUSIONS: In hemodilution, Pv-aCO2/Ca-vO2 was considerably increased, irrespective of the presence of anaerobic metabolism. Pv-aCO2/Ca-vO2 is a complex variable, which depends on several factors. As such, it was a misleading indicator of anaerobic metabolism in hemodilution.

Systemic and microcirculatory effects of blood transfusion in experimental hemorrhagic shock.

BACKGROUND: The microvascular reperfusion injury after retransfusion has not been completely characterized. Specifically, the question of heterogeneity among different microvascular beds needs to be addressed. In addition, the identification of anaerobic metabolism is elusive. The venoarterial PCO2 to arteriovenous oxygen content difference ratio (Pv-aCO2/Ca-vO2) might be a surrogate for respiratory quotient, but this has not been validated. Therefore, our goal was to characterize sublingual and intestinal (mucosal and serosal) microvascular injury after blood resuscitation in hemorrhagic shock and its relation with O2 and CO2 metabolism. METHODS: Anesthetized and mechanically ventilated sheep were assigned to stepwise bleeding and blood retransfusion (n = 10) and sham (n = 7) groups. We performed analysis of expired gases, arterial and mixed venous blood gases, and intestinal and sublingual videomicroscopy. RESULTS: In the bleeding group during the last step of hemorrhage, and compared to the sham group, there were decreases in oxygen consumption (3.7 [2.8-4.6] vs. 6.8 [5.8-8.0] mL min-1 kg-1, P < 0.001) and increases in respiratory quotient (0.96 [0.91-1.06] vs. 0.72 [0.69-0.77], P < 0.001). Retransfusion normalized these variables. The Pv-aCO2/Ca-vO2 increased in the last step of bleeding (2.4 [2.0-2.8] vs. 1.1 [1.0-1.3], P < 0.001) and remained elevated after retransfusion, compared to the sham group (1.8 [1.5-2.0] vs. 1.1 [0.9-1.3], P < 0.001). Pv-aCO2/Ca-vO2 had a weak correlation with respiratory quotient (Spearman R = 0.42, P < 0.001). All the intestinal and sublingual microcirculatory variables were affected during hemorrhage and improved after retransfusion. The recovery was only complete for intestinal red blood cell velocity and sublingual total and perfused vascular densities. CONCLUSIONS: Although there were some minor differences, intestinal and sublingual microcirculation behaved similarly. Therefore, sublingual mucosa might be an adequate window to track intestinal microvascular reperfusion injury. Additionally, Pv-aCO2/Ca-vO2 was poorly correlated with respiratory quotient, and its physiologic behavior was different. Thus, it might be a misleading surrogate for anaerobic metabolism.

Uso del pódcast como herramienta educativa en una residencia de Cirugía General en tiempos de COVID-19 / Use of podcasts as educational tool in a residency program in general surgery in the time of COVID-19 pandemic

RESUMEN Antecedentes: la pandemia de COVID-19 alteró la formación de los residentes de cirugía, disminuyendo sus oportunidades de aprendizaje. La lectura y análisis de trabajos científicos a través de pódcast podrían ser una opción para atenuar ese problema. Objetivo: evaluar la aceptación por parte de los residentes de Cirugía del uso de pódcast como una nueva herramienta educativa. Material y métodos: estudio exploratorio, analítico y longitudinal, realizado desde mayo hasta diciembre de 2020. Cada semana, un residente fue el encargado de leer, analizar y confeccionar una presentación grabada en forma de pódcast sobre un artículo seleccionado por médicos de planta. Se evaluó la experiencia de los residentes mediante un cuestionario tipo Likert diseñado por los investigadores. Resultados: se realizaron 37 pódcast, que se reprodujeron 2091 veces. El 100% de los residentes informó que esta herramienta fomentó la discusión académica entre pares, el 88% que le generó preguntas de investigación y el 43% que lo inspiró a una revisión bibliográfica. Conclusión: la lectura y análisis de trabajos a través de pódcast es bien aceptada y puede ser una herramienta adicional para el aprendizaje en épocas atípicas.

ABSTRACT Background: COVID-19 pandemic altered the training of residents in surgery, reducing their opportunities to learn. Reading and analyzing scientific paper via podcasts could be an option to mitigate such problem. Objective: The aim of this study is to evaluate residents in surgery acceptance of the use of podcasts as a new educational tool. Material and methods: We conducted a longitudinal, analytical and exploratory study between May and December 2020. Each week, a resident was in charge of reading, analyzing and preparing a recorded presentation in the format of a podcast of an article selected by a staff physician. The residents' experience was assessed by means of a Likert-type questionnaire designed by the investigators. Results: A total of 37 podcasts were recorded with a total number of plays of 2091. All the residents reported that this tool encouraged the academic peer discussion, 88% responded that it generated research questions and 43% agreed that listening to the podcasts served as inspiration to perform a bibliographic search. Conclusion: Reading and analyzing scientific papers via podcasts is well accepted and could be an additional tool for learning in atypical times.

Reporte de Caso Clínico: Migración de cálculo dificultoso / Case Report: Migration of Large Gallstone

INTRODUCCIÓN: La coledocolitiasis es una patología con alta tasa de migración al duodeno de cálculos pequeños. No obstante, la migración asintomática de cálculos mayores a 1 cm (macrolitiasis) es atípica. A continuación, presentamos un caso de migración de un macrocálculo ubicado en colédoco medio. CASO CLÍNICO: Presentamos el caso de un hombre de 27 años que consulta por epigastralgia postprandial de 4 meses de evolución. La ecografía abdominal mostró barro biliar y un macro-cálculo en colédoco, con Colangio-RM se confirmó diagnóstico. Se decidió realizar una colecistectomía laparoscópica, con colangiografía intraoperatoria (CIO). EVOLUCIÓN: Durante la colecistectomía laparoscópica, no se evidenció cálculos en la colangiografía intraoperatoria, ante la discordancia entre las imágenes preoperatorias la CIO, se realizó instrumentación transcística con canastilla de Dormia, sin extracción de cálculos. El paciente evolucionó favorablemente, sin complicaciones dadas por la migración del macro-cálculo. Se realizó CRM posquirúrgica, sin evidencia de imágenes endoluminales en la vía biliar. CONCLUSIÓN: La patología biliar es dinámica, pudiendo presentar migración litiásica, aún en macro cálculos o cálculos de difícil manejo. Si bien la ecografÍa y la CRM tienen alta sensibilidad para su diagnóstico; la CIO es fundamental para hacer diagnóstico y tratamiento de la patología litiásica resolviéndola en un solo tiempo operatorio evitando procedimientos múltiples.(au)

BACKGROUND: Common bile duct lithiasis is a pathology with a high rate of migration of small stones to the duodenum. However, asymptomatic migration of stones larger than 1cm (macrolithiasis) is atypical. We present a case of migration of a macrocalculus located in the middle of the common bile duct. CASE REPORTS: We present the case of a 27-years-old man, who consulted for postprandial epigastric pain, that started 4 months ago. Abdominal ultrasound showed biliary sludge and common bile duct macrocalculus, with Cholangio-MRI the diagnosis was confirmed. A laparoscopic cholecystectomy with intraoperative cholangiography was performed. EVOLUTION: During the laparoscopic cholecystectomy, no stones were evidenced in the intraoperative cholangiograpy. Due to the disagreement between the preoperative IOC images, transcystic instrumentation with a Dormia basket was performed, without stone extraction. The patient had a favorably evolution, without complications due to the stone migration. Postoperative MRC was performed, without evidence of endoluminal images in the bile duct. CONCLUSIONS: Biliary pathology is dynamic, with the possibility of gallstone migration, even for large gallstones and complicated cases. Although ultrasound and MRI have high sensitivy for diagnosis; IOC is essential to diagnose and treat lithiasic pathology, resolving it in a single operating time, avoiding multiple procedures.

Adenocarcinoma mucinoso de vesícula biliar originado en neoplasia papilar intracolecística / Mucinous adenocarcinoma of the gallbladder originated from intracholecystic papillary neoplasm

RESUMEN La neoplasia papilar intracolecística con carcinoma mucinoso invasor y células en anillo de sello es una variedad de cáncer de vesícula, una patología agresiva y con mal pronóstico, la cual puede presentarse en forma similar a una colecistitis y, a pesar del tratamiento operatorio y quimioterapia posterior, la supervivencia y pronóstico son peores en relación con los otros cánceres de vesícula. Este artículo tie ne por objetivo describir un tipo histológico muy específico, de baja frecuencia, de cáncer de vesícula y el tratamiento realizado.

ABSTRACT Intracholecystic papillary neoplasm with invasive mucinous adenocarcinoma and signet ring cells is a rare, aggressive variety of gallbladder cancer, with symptoms mimicking cholecystitis. Survival and prognosis are worse that other types of gallbladder cancer despite surgery and chemotherapy. The aim of this article is to describe a case of a rare gallbladder cancer with specific histology and the treatment performed

Pancreatectomía posneoadyuvancia en cáncer resecable "borderline" / Pancreatectomy after neoadjuvant therapy in borderline resectable pancreatic cancer

RESUMEN Antecedentes: la pancreatectomía posneoadyuvancia en paciente sin progresión de la enfermedad es el tratamiento estándar en el cáncer pancreático "borderline"; sin embargo, no existe hasta ahora ninguna serie nacional publicada. Objetivo: evaluar la morbilidad y mortalidad de la pancreatectomía en pacientes con cáncer de páncreas resecable "borderline" tratados previamente con neoadyuvancia. Material y métodos: se analizaron 15 pacientes tratados en el período 2011-2018. Se evaluaron los datos epidemiológicos, el tipo de neoadyuvancia, la respuesta radiológica posneoadyuvancia, la morbilidad, mortalidad y supervivencia. Se compararon los 15 pacientes pancretectomizados posneoadyuvancia con 15 pacientes pancreatectomizados sin neoadyuvancia previa. Resultados: de los 15 pacientes, 8 eran del sexo masculino y el promedio de edad fue de 66,5 años. El tipo de neoadyuvancia más frecuente fue folforinox (n = 6) y gemcitabina/placitaxel (n = 5); se adicionó radioterapia en 8 pacientes. La evaluación radiológica posneoadyuvancia mostró enfermedad estable en 10 pacientes y respuesta parcial en 4. Se realizaron 11 duodenopancreatectomías y 4 esplenopancreatectomías. En 10 pacientes fue necesario algún tipo de resección vascular. La morbilidad fue del 60% (9/6), no se registró mortalidad y la supervivencia media fue de 23,4 meses. No hubo diferencias significativas en la morbilidad, mortalidad y supervivencia cuando se comparó con los 15 pacientes pancreatectomizados sin neaodyuvancia. Conclusión: el tratamiento con neoadyuvancia en cáncer de páncreas avanzado permite ampliar su resecabilidad. La pancreatectomía posneoadyuvancia, en centros de alto volumen, tiene morbilidad, mortalidad y supervivencia similares a las de las pancreatectomías que no requieren neaoadyuvancia.

ABSTRACT Background: Pancreatectomy after neoadjuvant therapy in patients without disease progression is the standard treatment for borderline pancreatic cancer; however, no national series have been published to date. Objective: The aim of this study is to evaluate morbidity and mortality of patients with borderline resectable pancreatic cancer undergoing pancreatectomy after neoadjuvant therapy. Material and methods: A total of 15 patients treated between 2011 and 2018 were analyzed. The epidemiologic data, type of neodajuvant therapy, radiological evaluation of the response to neoadjuvant therapy, morbidity, mortality and survival were evaluated. These 15 patients who underwent pancreatectomy after neoadjuvant therapy were compared with 15 pancreatectomized patients without previous neoadjuvant therapy. Results: Mean age was 66.5 years and 8 patients were men. The most common neoadjuvant therapy regimens were FOLFIRINOX (n = 6) and gemcitabine/paclitaxel (n = 5); 8 patients required additional radiation therapy. The radiological evaluation of the response to neoadjuvant therapy showed stable disease in 10 patients and partial response in 4. Eleven patients underwent pancreaticoduodenectomy and 4 underwent splenectomy and pancreatectomy. Ten patients required some type of vascular resection. Morbidity was 60% (9/15), there were no deaths and mean survival was 23.4 months. There were no significant differences in morbidity, mortality and survival with the 15 pancreatectomized patients without previous neoadjuvant therapy. Conclusion: Neoadjuvant therapy has extended resectability of advanced pancreatic cancer. In high volume centers, pancreatectomy after neoadjuvant therapy has similar morbidity, and survival to those of pancreatic resections without previous neoadjuvant therapy.

Intestinal and sublingual microcirculation are more severely compromised in hemodilution than in hemorrhage.

The alterations in O2 extraction in hemodilution have been linked to fast red blood cell (RBC) velocity, which might affect the complete release of O2 from Hb. Fast RBC velocity might also explain the normal mucosal-arterial Pco2 (ΔPco2). Yet sublingual and intestinal microcirculation have not been completely characterized in extreme hemodilution. Our hypothesis was that the unchanged ΔPco2 in hemodilution depends on the preservation of villi microcirculation. For this purpose, pentobarbital-anesthetized and mechanically ventilated sheep were submitted to stepwise hemodilution (n = 8), hemorrhage (n = 8), or no intervention (sham, n = 8). In both hypoxic groups, equivalent reductions in O2 consumption (V̇o2) were targeted. Microcirculation was assessed by videomicroscopy, intestinal ΔPco2 by air tonometry, and V̇o2 by expired gases analysis. Although cardiac output and superior mesenteric flow increased in hemodilution, from the very first step (Hb = 5.0 g/dl), villi functional vascular density and RBC velocity decreased (21.7 ± 0.9 vs. 15.9 ± 1.0 mm/mm(2) and 1,033 ± 75 vs. 850 ± 79 µm/s, P < 0.01). In the last stage (Hb = 1.2 g/dl), these variables were lower in hemodiution than in hemorrhage (11.1 ± 0.5 vs. 15.4 ± 0.9 mm/mm(2) and 544 ± 26 vs. 686 ± 70 µm/s, P < 0.01), and were associated with lower intestinal fractional O2 extraction (0.61 ± 0.04 vs. 0.79 ± 0.02, P < 0.01) but preserved ΔPco2 (5 ± 2 vs. 25 ± 4 mmHg, P < 0.01). Therefore, alterations in O2 extraction in hemodilution seemed related to microvascular shunting, not to fast RBC velocity. The severe microvascular abnormalities suggest that normal ΔPco2 was not dependent on CO2 washout by the villi microcirculation. Increased perfusion in deeper intestinal layers might be an alternative explanation.

Abordaje laparoscópico sistemático de la coledocolitiasis / Routine laparoscopic management of common bile duct stones

RESUMEN Antecedentes: la prevalencia conjunta de litiasis vesicular y coledociana aumenta con la edad y llega al 15% en la octava década de la vida. Su manejo continúa siendo controvertido: algunos profesionales prefieren el abordaje en un tiempo por videolaparoscopia, y otros, el abordaje en dos tiempos con endoscopia (CPRE preoperatoria) seguida de colecistectomía laparoscópica. Objetivo: evaluar la eficacia y seguridad del manejo en un tiempo por videolaparoscopia en pacientes consecutivos con diagnóstico de litiasis vesicular y coledociana. Material y métodos: estudio retrospectivo con datos de una base de datos prospectiva, entre julio de 2008 y julio de 2018. Resultados: sobre un total de 2447 colecistectomías laparoscópicas realizadas en el citado período, 416 (17%) presentaron litiasis coledociana. El éxito global de la vía transcística en la extracción de litiasis coledociana fue del 81,2%: del 70,4% en los casos con diagnóstico prequirúrgico de colestasis extrahepática litiásica y del 92,9% en los otros diagnósticos. La morbilidad fue del 4%, sin mortalidad ni lesiones quirúrgicas de la vía biliar. Conclusión : el manejo en un tiempo por videolaparoscopia es eficaz y seguro debido al elevado éxito global de la instrumentación transcística (ITC). El diagnóstico preoperatorio de coledocolitiasis condi ciona una disminución de esa eficacia, por mayor indicación de coledocotomía, con un aumento de la morbilidad y del tiempo de internación.

ABSTRACT Background: The prevalence of common bile duct stones associated with cholelithiasis increases with age and is about 15 % in the 8th decade of life but its management is still controversial. Some surgeons prefer the single-stage approach with laparoscopy while others suggest the two-stage management with preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. Objective: The aim of the present study was to evaluate the efficacy of feasibility of single-stage laparoscopic surgery in patients with cholelithiasis and choledocholithiasis. Material and methods: We conducted a retrospective study with prospectively collected data between July 2008 and July 2018. Results: Of 2447 laparoscopic cholecystectomies performed during the study period, 416 presented common bile duct stones. The global success of the transcystic approach to clear common bile duct stones was 81.2%, 70.4% in the cases with preoperative diagnosis of choledocholithiasis and 92.9% for other diagnoses. The rate of complications was 4% without deaths or bile duct injuries. Conclusion: Single-stage laparoscopic surgery is an efficient and safe approach based on the high global success of transcystic exploration. The preoperative diagnosis of choledocholithiasis reduces the efficacy of the procedure due to greater indication of choledocotomy, with complications and longer length of hospital stay.

Litiasis coledociana de difícil resolución / Difficult common bile duct stones

RESUMEN Antecedentes: el manejo laparoscópico en un tiempo de la coledocolitiasis se acompaña de una tasa de éxito elevada en la mayoría de los casos. Una excepción a esto son los cálculos coledocianos difi cultosos. Objetivo: describir los resultados del manejo de cálculos coledocianos dificultosos. Material y métodos: revisión retrospectiva de una serie consecutiva de casos de cálculos coledocianos dificultosos tratados durante el período 2018-2020. Resultados: 8 pacientes cumplieron con el criterio de inclusión. El manejo en un tiempo por videola paroscopia (5 casos) tuvo un 60% de conversión a cirugía abierta. Los otros pacientes (3 casos) fueron manejados inicialmente con endoscopia biliar por colangitis grave y fueron resueltos luego en forma electiva por instrumentación transcística. Conclusión: esta experiencia inicial sugiere que el abordaje en dos tiempos podría favorecer la resolu ción mininvasiva de los cálculos coledocianos dificultosos.

ABSTRACT Background: Single-stage procedure for the treatment of choledocholithiasis by laparoscopy is associated with high success rate in most cases. Difficult common bile duct stones are an exception to this rule. Objective: The aim of this study is to describe the results obtained with the management of difficult common bile duct stones. Material and methods: We conducted a retrospective review of a consecutive series of cases of difficult common bile duct stones treated between 2018-2020. Results: Eight patients fulfilled the inclusion criteria. Of the 5 patients managed with single-stage approach through video-assisted laparoscopy, 60% required conversion to open surgery. The other 3 cases were initially managed with endoscopic cholangiography due to severe cholangitis and were solved with elective transcystic instrumentation. Conclusion: This initial experience suggests that the two-stage approach could be better to treat difficult common bile duct stones with a minimally invasive approach.

Colecistectomía y trasplante cardíaco / Cholecystectomy and heart transplantation

RESUMEN Antecedentes: los avances en cuidados perioperatorios e inmunosupresión permitieron que la su pervivencia de los pacientes trasplantados aumente significativamente, así observamos que la litiasis vesicular es más frecuente en este grupo de pacientes. Objetivo: el objetivo de este trabajo es analizar y describir los resultados obtenidos en colecistecto mías en pacientes trasplantados cardíacos. Material y métodos: seleccionamos los pacientes mediante una búsqueda cruzada entre las bases de datos de Trasplante Cardíaco y Cirugía Biliar. Recopilamos información sobre sus antecedentes médi cos, parámetros clínicos y de laboratorio, entre otros. Resultados: entre enero 1994-diciembre 2017 se realizaron 154 trasplantes cardíacos con una edad media de 40 años; 16 pacientes fueron incluidos en este estudio y en los cuales fue realizada la cole cistectomía laparoscópica posterior al trasplante. No se registraron morbilidad, readmisiones ni mor talidad. Conclusión: la colecistectomía laparoscópica es segura y es el método de elección en pacientes tras plantados cardíacos. Se debe realizar colangiografía intraoperatoria, ya que los predictores de litiasis coledociana suelen estar alterados.

ABSTRACT Background: The advances in perioperative care and immunosuppressive treatment resulted in a significant increase in survival of transplant patients; as a result, cholelithiasis is more common in transplant patients. Objective: The aim of this study is to analyze and describe the results obtained in cholecystectomies in heart transplant patients. Material and methods: We selected patients by cross-referencing the databases of heart transplantation and scheduled biliary surgeries, and collected information on their medical history, clinical parameters and laboratory tests, among other data. Results: Between January 1994 and December 2017, 154 heart transplant procedures were performed; mean age was 40 years; 16 underwent laparoscopic cholecystectomy after heart transplantation and were included in this study. There were no complications, readmissions or deaths. Conclusion: Laparoscopic cholecystectomy is safe and is the method of choice for heart transplant patients with cholelithiasis. Intraoperative cholangiography should be performed as the predictors of choledocholithiasis are usually abnormal.