Vólvulo vesicular: un hallazgo quirúrgico / Vesicular volvulus: a surgical finding

Se describe el caso clínico de una paciente de 95 años de edad, quien acudió al Cuerpo de Guardia del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba por presentar dolor abdominal difuso, de comienzo súbito con 48 horas de evolución, acompañado de náuseas y vómitos de escasa cuantía y de coloración oscura, así como ligera distención abdominal, sin expulsión de heces ni gases. Se decidió su ingreso para tratamiento quirúrgico urgente, con el diagnóstico presuntivo de oclusión intestinal. Durante la cirugía se encontró la vesícula distendida con su pedículo torcido. Se realizó colecistectomía típica. La paciente evolucionó satisfactoriamente y no presentó complicaciones posoperatorias.

The case report of a 95 years patient is described, she went to the emergency department of Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba due to a diffuse abdominal pain, of sudden beginning with 48 hours of clinical course, accompanied by nauseas and vomits of scarce quantity and dark color, as well as slight abdominal distention, without expulsion of stools neither gases. Her admission was decided for emergency surgical treatment, with the presumptive diagnosis of intestinal occlusion. During the surgery the distended gallbladder with bent pedicle was found. A typical cholecystectomy was carried out. The patient had a favorable clinical course and she didn't present postoperative complications.

Técnica de linfadenectomía y resección del lecho vesicular laparoscópica por cáncer vesícula biliar incidental / Lymphadenectomy technique and laparoscopic vesicular bed resection for incidental gallbladder cancer

Resumen El cáncer de vesícula es infrecuente a nivel mundial, a diferencia de su alta incidencia en Chile. Su pronóstico es malo en general, y dependerá de su forma de presentación, siendo mejor en los casos diagnosticados después de una colecistectomía laparoscópica por patología benigna. La reintervención, que incluye la resección hepática y linfadenectomía, es el pilar de la terapia curativa en esta neoplasia. Presentamos la descripción de la técnica quirúrgica realizada en los pacientes con cáncer de vesícula de diagnóstico incidental, en el Servicio de Cirugía de Clínica Alemana de Santiago y en el Hospital de la Fuerza Aérea de Chile. El abordaje laparoscópico representa una alternativa quirúrgica válida en el tratamiento de pacientes con cáncer de vesícula biliar diagnosticados después de la colecistectomía. La estandarización de la técnica debiera contribuir a su mayor empleo y a la obtención de buenos resultados desde un punto de vista oncológico.

Gallbladder cancer is considered an infrequent disease but in Chile has a higher incidence. Prognostic is considered dismal except in those patients in whom the diagnosis is performed after the cholecystectomy specimen study. Reoperation with gallbladder bed resection and lymphadenectomy is considered the treatment in patients with incidental cases. We show the way this operation is performed in Clinica Alemana of Santiago and in the Air Force Hospital. The laparoscopic approach is an alternative to those patients in whom the diagnosis was done after the cholecystectomy. Laparoscopy allows to accomplish same objectives and to obtain identical results that the open approach. The technical standardization should contribute to spread its employment and to improve the results.

Perforación traumática aislada de la vesícula biliar: revisión de la literatura actual con reporte de un caso / Isolated gallbladder perforation following blunt abdominal trauma: literature review and case report

Resumen Introducción La lesión de la vesícula biliar secundaria a trauma abdominal cerrado constituye un evento infrecuente de perforación traumática de ella, de presentación tardía. Objetivo Revisar la literatura científica actualmente disponible y además describimos un caso. Materiales y Método Utilizando la plataforma PubMed se buscan las siguientes palabras clave: " Blunt abdominal trauma ". Se seleccionan las series con lesiones de la vesícula biliar: " Traumatic gallbladder rupture". Se seleccionan los reportes de lesiones aisladas de la vesícula biliar: " Isolated gallbladder rupture ". Se seleccionan los reportes de presentación tardía de lesiones aisladas de la vesícula biliar: " Delayed presentation of isolated gallbladder rupture ". Resultados De todas estas publicaciones se seleccionan las que a criterio de los autores son relevantes para el presente caso. Discusión La mayoría de las perforaciones de la vesícula biliar se producen en vesículas sanas de paredes delgadas distendidas por el ayuno o el consumo de alcohol. No existe una presentación clínica clásica. Los estudios imagenológicos son inespecíficos y se llega al diagnóstico definitivo durante la exploración quirúrgica. El tratamiento de esta lesión es la colecistectomía. Conclusiones El diagnóstico no es fácil, pero la resolución es relativamente simple y el pronóstico es bueno. El presente caso ilustra este tipo de lesiones en pacientes con trauma abdominal cerrado.

Introduction Gallbladder injury secondary to blunt abdominal trauma is a rare event. Aim Review the current available scientific literature and describe a case. Materials and Method Using the PubMed platform, the following keywords were searched: "Blunt abdominal trauma". Series with gallbladder lesions were selected: "Traumatic gallbladder rupture". Reports of isolated lesions of the gallbladder were selected: "Isolated gallbladder rupture". Reports of late presentation of isolated lesions of the gallbladder were selected: "Delayed presentation of isolated gallbladder rupture". Of all these publications, those that were relevant to the present case were selected according to the criteria of the authors. Case report A 20 years-old male patient suffered an abdominal trauma two weeks before presentation at our Institution. He underwent an exploratory laparotomy showing bilious content and a gallbladder perforation over the peritoneal wall as an isolated injury. Discussion Most isolated gallbladder perforations occur in healthy gallbladders with thin walls and distended because fasting or alcohol consumption. There are no classical clinical features to diagnose this specific injury and radiologic studies are nonspecific. Definitive diagnosis is often reached during surgery as it was with our patient. Recommended treatment is cholecystectomy. Conclusions This case illustrates this unique kind of gallbladder injury in patients with blunt abdominal trauma. A clear diagnosis is not easy however, the treatment is simple and prognosis is good.

Cirugía de Rescate, Una Opción Eficaz Para Colecistectomía Laparoscópica Difícil / Cohort Study: Rescue surgery, an effective option for difficult laparoscopic cholecystectomy

INTRODUCCIÓN: El tratamiento estándar de la colecistitis aguda es la colecistectomía laparos-cópica (CL). La colecistectomía laparoscópica estándar (CLE) requiere la disección del triángu-lo de Calot y la exposición del conducto cístico; este procedimiento está asociado a lesión del conducto biliar y sangrado del lecho hepático. La colecistectomía subtotal laparoscópica (CSL) podría ser una alternativa en estas situaciones, puesto que se considera como un procedimiento asociado a escasas complicaciones. MATERIALES Y MÉTODOS: Se realizó un estudio de cohortes prospectivo. El universo incluyó a 180 pacientes en quienes se realizó una colecistectomía difícil; la misma que fue definida como: empiema, gangrena, perforación, inflamación severa con fibrosis, síndrome de Mirizzi, plastrón vesicular, cirrosis hepática y variantes anatómicas. Se clasificó en dos grupos; Grupo 1 (colecis-tectomía tradicional, 90 pacientes), y Grupo 2 (colecistectomía de rescate, 90 pacientes), en el grupo 2 se emplearon técnicas de rescate como: Pribram, subtotal reconstructiva, fenestrativa y disección retrograda. Se consideró como evento resultante la presencia de complicaciones (le-sión de vía biliar, sangrado, colecciones y coledocolitiasis residual, infección del sitio quirúrgico). Para el análisis estadístico se usó el programa SPSS 22.0 y Epidat 3.1. RESULTADOS: Se observó que la incidencia general de complicaciones en los pacientes con co-lecistectomía difícil fue de 9.44%, la incidencia de complicaciones en expuestos (colecistectomía tradicional) fue del 14.44%, versus una incidencia en no expuestos (colecistectomía de rescate) del 4.44%; RR 3.25 (IC 95%: 1.02 ­ 9.58), p= 0.04. Entre las técnicas de rescate se empleó: cole-cistectomía retrógrada 63.33% (n=57), colecistectomía tipo Pribram modificada 21.1% (n=19), subtotal reconstructiva 14.44% (n=13), y subtotal fenestrativa 0.9% (n=1). CONCLUSIÓN: La colecistectomía de rescate en colecistectomía difícil es eficaz para disminuir el riesgo de complicaciones como sangrado y lesión de vía biliar, no existió diferencia entre la frecuencia de coledocolitiasis residual entre los dos grupos.(AU)

BACKGROUND: The standard treatment for acute cholecystitis is laparoscopic cholecystectomy. Standard laparoscopic cholecystectomy requires the dissection of Calot's triangle and exposure of the cystic duct; this procedure is associated with bile duct injury and bleeding from the liver vascular bed. Laparoscopic subtotal cholecystectomy could be an alternative in these situations, since it is considered as a procedure associated with few complications. METHODS: A prospective cohort study was conducted. The universe included 180 patients in whom a difficult cholecystectomy was performed; the same was defined as: empyema, gangrene, perfo-ration, severe inflammation with fibrosis, Mirizzi syndrome, vesicular plastron, liver cirrhosis and anatomical variants. It was classified into two groups; Group 1 (traditional cholecystectomy, 90 patients), and Group 2 (rescue cholecystectomy, 90 patients), group 2 used rescue techniques such as: Pribram, subtotal reconstructive, fenestrative and retrograde dissection. The presence of com-plications (bile duct injury, bleeding, collections and residual choledocholithiasis, infection of the surgical site) was considered as an event. The softwares SPSS 22.0 and Epidat 3.1 were used for the statistical analysis. RESULTS: It was observed that the general incidence of complications in patients with difficult cholecystectomy was 9.44%, the incidence of complications in exposed patients (traditional cho-lecystectomy) was 14.44%, versus an incidence in unexposed patients (salvage cholecystectomy). 4.44%; RR 3.25 (95% CI: 1.02 - 9.58), p= 0.04. The following techniques were used: retrograde chole-cystectomy 63.33% (n=57), modified Pribram cholecystectomy 21.1% (n=19), reconstructive subto-tal 14.44% (n=13), and fenestrative subtotal 0.9 % (n=1). CONCLUSION: Rescue cholecystectomy in difficult cholecystectomy is effective to reduce the risk of complications such as bleeding and bile duct injury; there was no difference between the frequen-cies of residual choledocholithiasis between the two groups.(AU)

Alterações histológicas da vesícula biliar de doentes submetidos à colecistectomia por colelitíase / Gallbladder histological alterations in patients undergoing cholecystectomy for cholelithiasis

RESUMO Objetivo: descrever os achados histológicos das vesículas biliares de pacientes submetidos à colecistectomia e avaliar a presença de fatores associados ao câncer incidental da vesícula. Métodos: estudo descritivo, transversal e observacional de 1.278 exames anatomopatológicos de vesículas biliares oriundas de colecistectomias por colelitíase e de seus respectivos laudos, realizadas no período de janeiro de 2008 a dezembro de 2017. Resultados: o achado anatomopatológico mais frequente foi a colecistite crônica, presente em 1.251 pacientes (97,8%), seguido pela colesterolose em 131 (10,2%). O câncer de vesícula foi identificado em seis pacientes, com prevalência de 0,5% nesta amostra. Houve associação significativa entre a presença de câncer e idade ≥60 anos e com a espessura da parede ≥0,3cm. Conclusão: houve baixa prevalência de câncer de vesícula na população avaliada, maior ocorrência na população idosa e associação de tumor com espessamento da parede vesicular.

ABSTRACT Objective: to describe the histological findings of the gallbladders of patients undergoing cholecystectomy and to evaluate the presence of factors associated with gallbladder incidental cancer. Methods: we conducted a descriptive, cross-sectional, observational study with 1,278 histopathological exams of gallbladders coming from cholecystectomy for cholelithiasis and of their reports, held from January 2008 to December 2017. Results: the most common pathological finding was chronic cholecystitis, present in 1,251 patients (97.8%), followed by gallbladder cholesterolosis, in 131 (10.2%). Gallbladder cancer was identified in six patients, with a prevalence of 0.5% in this sample. There was a significant association between the presence of cancer and age ≥60 years and wall thickness ≥0.3cm. Conclusion: there was low prevalence of gallbladder cancer in this population, higher occurrence in the elderly and association of the tumor with gallbladder wall thickness.

Comparison of surgical site infections between laparoscopic and open cholecystectomy

Background: This study assessed the causes of infection in cholecystectomy and compared the infection rates between the open and laparoscopic cholecystectomy

Materials and Methods: This was a retrospective cohort study, performed on all patients admitted to Shariati Hospital since February 2017 for cholecystectomy. Initially, the patients were evaluated for infection risk factors, and then surgical site infection rates in these individuals were measured. Infection was assessed at the time of patients discharge [in the first few days after surgery] and again a month later, either in clinic or by phone. Information from 81 patients was collected, and SPSS software version 24 was used to analyse the data using appropriate statistical tests. Statistical significance was defined as p value < 0.05

Results: The mean age of the participants was 45.89 +/- 13.38. The relationship between surgical site infections [SSI] and age, sex, comorbidities [diabetes, hypertension, ischemic heart disease, malignancy, chronic lung disease, and chronic kidney disease], taking corticosteroids, smoking, and the emergency or elective nature of the surgery was not significant. The mean age of the patients who underwent open cholecystectomy was higher than the laparoscopic group [p = 0.005]. Similarly, the average hospitalization period for those underwent open cholecystectomy was higher [p = 0.03]. Finally, the infection rates for open cholecystectomy were 6 times higher than laparoscopic surgeries [RR: 6.11]

Conclusion: There was no significant relationship between SSIs and the risk factors assessed in this study. However, infection rates were higher in the open cholecystectomy group. More studies on the various risk factors of infection and the differences between the laparoscopic and open surgical methods are required

Colecistectomía: resultados de una década de experiencia / Cholecystectomy: results. a decade of experience

Introducción: La colecistectomía, sea a través de una incisión subcostal o videolaparoscópica es la intervención quirúrgica por excelencia para remover la vesícula biliar. El objetivo del estudio es presentar la experiencia acumulada en este tipo de cirugía a través de diez años, sus indicaciones, sus modalidades quirúrgicas, la relación con otras patologías así como las complicaciones de las técnicas empleadas. Metodología: Se incluyen todos los casos quirúrgicos de pacientes con enfermedad de la vesícula y vías biliares ingresados del 01 de enero del 2006 al 31 de diciembre del 2016 en el Departamento de Cirugía del Hospital San Vicente. Resultados: Del 2006 al 2016 se intervinieron 985 pacientes de los cuales, 888 (90.15%) corresponden al sexo femenino. La edad promedio fue de 41 años para ambos sexos, no mostrando diferencias 40.78 vs. 40.95. La colecistitis crónica fue la indicación pre operatoria en el 98.7% y su relación con hernia umbilical fue del 2.23%. La técnica quirúrgica abierta se realizó en 702 (70.27%) y la vía laparoscópica en 260 (26.40%). La tasa global de complicaciones fue del 2.33% (23 / 985 pacientes) siendo el sangrado el más observado en 12 pacientes (1.21%) y la lesión de la vía biliar en 5 (0.50%). Conclusiones: La afección de la vesícula sigue afectando principalmente al sexo femenino, su resolución es esencialmente quirúrgica y en la actualidad la colecistectomía video laparoscópica se considera la cirugía por excelencia, sin que ésta anule la vía abierta por múltiples factores. Es un procedimiento de baja morbilidad y en nuestra serie no se acompañó de mortalidad.

Background: Cholecystectomy, performed with open incision or laparoscopically, by excellence it is the surgery to remove the pathological gallbladder. The aim of this study is to present the experience gained in this type of surgery within ten years, showing indicatons, surgical modalites, and the relaton with other pathologies as well as complicatons of the techniques employed. Methods: All surgical cases of patents with diseased gallbladder and bile ducts are admited from January 01, 2006 to December 31, 2016 in the Department of Surgery of San Vicente Hospital. Results: 985 patents were included, 888 (90.15%) are female. Average age was 41 years old for both sexes, showing no diferences 40.78 vs. 40.95. Chronic Cholecystts was the main preoperatve diagnosis in 98.7%, and its relaton with an umbilical hernia was 2.23%. The open technique was performed on 702 patents (70.27%) and laparoscopic approach on 260 patents (26.40%). The overall complicaton rate was 2.33%. Hemorrhage was the most common in 12 patents (1.21%), and bile duct injury in 5 patents (0.50%). Conclusion: Gallbladder disease is stll more common in women. Treatment is essentally surgical and currently laparoscopic cholecystectomy is considered the standard of care. Cholecystectomy has a low incidence of morbidity and in this study there was no mortality

Twelve years of experience using cholecystojejunal by-pass for palliative treatment of advanced pancreatic cancer / Derivação colecistojejunal para o tratamento paliativo do câncer de pâncreas avançado

ABSTRACT Background: The cholecistojejunal bypass is an important resource to treat obstructive jaundice due to advanced pancreatic cancer. Aim: To assess the early morbidity and mortality of patients with pancreatic cancer who underwent cholecystojejunal derivation, and to assess the success of this procedure in relieving jaundice. Method: This retrospective study examined the medical records of patients who underwent surgery. They were categorized into early death and non-early death groups according to case outcome. Results: 51.8% of the patients were male and 48.2% were female. The mean age was 62.3 years. Early mortality was 14.5%, and 10.9% of them experienced surgical complications. The cholecystojejunostomy procedure was effective in 97% of cases. There was a tendency of increased survival in women and patients with preoperative serum total bilirubin levels below 15 mg/dl. Conclusion: Cholecystojejunal derivation is a good therapeutic option for relieving jaundice in patients with advanced pancreatic cancer, with acceptable rates of morbidity and mortality.

RESUMO Racional: A derivação colecistojejunal é um importante recurso para o tratamento de pacientes com icterícia obstrutiva secundária ao câncer de pâncreas avançado. Objetivo: Avaliar a morbimortalidade precoce dos doentes com câncer de pâncreas submetidos à derivação colecistojejunal, assim como avaliar o alivio da icterícia. Método: Estudo retrospectivo de prontuários de pacientes que foram operados. Eles foram categorizados de acordo com a resolução dos casos em: morte precoce e sem morte precoce. Resultados: 51,8% dos pacientes eram homens e 48,2% mulheres. A média etária foi de 62,3 anos. A mortalidade precoce foi de 14,5%. 10,9% evoluíram com complicações cirúrgicas. A colecistojejunostomia foi efetiva em 97% dos casos. Houve tendência à maior sobrevida em mulheres e pacientes com níveis séricos de bilirrubina total pré-operatório menor do que 15mg/dl. Conclusão: A derivação colecistojejunal constitui boa opção terapêutica para alívio da icterícia em pacientes com câncer de pâncreas avançado, apresentando morbimortalidade aceitável.

Torsión vesicular a propósito de un caso / On a case report of gallbladder torsion

La torsión vesicular es una entidad muy poco frecuente en la que se produce un giro de la vesícula biliar a lo largo de su eje con afectación de la irrigación vascular de forma completa o incompleta. En este artículo presentamos una paciente de 98 años, que fue hospitalizada para tratamiento quirúrgico urgente con diagnóstico de colecistitis aguda; durante el acto quirúrgico se detectó torsión vesicular. Esta enfermedad es frecuente en personas ancianas del sexo femenino. Su diagnóstico preoperatorio es muy difícil y generalmente se realiza en el acto operatorio. El tratamiento es siempre quirúrgico (detorsión de la vesícula y colecistectomía). Por las dificultades diagnósticas que presenta esta enfermedad es importante conocerla para evitar las complicaciones derivadas de una actuación médica tardía(AU)

Gallbladder torsion is an uncommon clinical entity. It is known to occur when of the gallbladder rotation occurs along the axis of the cystic duct and vascular pedicle, with affectation of vascular irrigation in a complete or incomplete form. This article presents a 98-year-old woman, who was hospitalized for emergency surgical treatment with a diagnosis of acute cholecystitis; gallbladder torsion was diagnosed in the operative act. This disease is more frequently found in females and aged patients. The positive preoperative diagnosis of gallbladder torsion is much difficult and is frequently carried out in the operative act. The chosen treatment is to distortion of the gallbladder and cholecystectomy. Knowing gallbladder torsion will permit avoiding the complications derived from an overdue medical intervention(AU)

Agenesia del lóbulo hepático derecho asociado a agenesia vesicular / Agenesis of the right hepatic lobe associated with gallbladder agenesis

Background: Anatomical abnormalities of the liver are rare and their association with gallbladder agenesis are even more uncommon. Case report: We report a 63 years old man complaining of jaundice, without pain or fever. A magnetic resonance imaging showed a right hepatic lobe agenesis associated with gallbladder agenesis. Jaundice subsided spontaneously.

Introducción: Las anomalías anatómicas del hígado son raras, la asociación a una agenesia vesicular es más infrecuente aún, siendo su diagnóstico generalmente un hallazgo. Caso clínico: Presentamos el caso de un paciente masculino de 63 años que consulta por ictericia, sin dolor ni fiebre, al cual se le realiza diagnóstico por imagen con resonancia magnética de agenesia de lóbulo hepático derecho asociado a agenesia vesicular. Dado que el paciente no tiene litiasis biliar, se decide tratamiento médico.

Endoscopic Nasogallbladder Drainage in Patients with Acute Cholecystitis: What's Predictive Factor for Technical Success?

No abstract available.

Endoscopic Nasogallbladder Drainage in Patients with Acute Cholecystitis: What's Predictive Factor for Technical Success?

No abstract available.

Trígono cistohepático: área crítica anatómica para la seguridad quirúrgica / Trigonum cystohepaticum: critical anatomical area for surgical safety

El conocimiento de la anatomía de la vía biliar y sus variantes para la realización de una cirugía segura, resulta fundamental. La extirpación de la vesícula requiere cuidadosa atención, conocer muy bien la anatomía de la región, teniendo en cuenta la posibilidad de variaciones anatómicas. La mala interpretación de la anatomía percibida más que una falta en la destreza técnica es la causa de la lesión de la vía biliar durante la colecistectomía. Diferenciar el límite y el contenido del trígono cistohepático. Diseñar las áreas de Visión Crítica y de Seguridad como medida de seguridad en el paciente quirúrgico. Revisión de 458 partes quirúrgicos de colecistectomías de enero/2010 a octubre/2012, en el Servicio de Cirugía General del Hospital Aeronáutico Central, y disección de 12 cadáveres adultos formolizados al 10% en la III Cátedra de Anatomía - Facultad de Medicina - Universidad de Buenos Aires. De 458 colecistectomías, se clasificaron los partes quirúrgicos, dividiéndose según menciona: triángulo de Calot en 247 (53,93%); triángulo hepatocístico en 59 (12,88%); área de visión crítica en 152 (33,18%); ninguno mencionó al triángulo de Budde o trígono cistohepático. Se disecaron 12 cadáveres adultos donde se identificó: arteria cística originándose de arteria hepática derecha en 9 (75%); originándose de arteria hepática izquierda en 2 (16,66%) y originándose de arteria hepática en 1 (8,34%). En 7 (58,35%) se la visualiza en trígono cistohepático. El conocimiento de la anatomía de la vía biliar y sus variantes para la realización de una cirugía segura, resulta fundamental. El triángulo descrito por Calot corresponde a la mitad inferior del triángulo descrito por Buddé. El sector lateral (Triangulo de Seguridad) es el verdadero área de visión critica a disecar por la menor probabilidad de lesionar estructuras nobles.

Knowing the anatomy of the bile duct and its anatomical variations becomes essential to safely perform any surgery. Gallbladder resection requires careful attention: knowing the region's anatomy by heart and taking into account the possibility of anatomical variations. Misunderstanding the anatomy is not only a failure in technical ability but also a cause of injury to the bile duct during a cholescystectomy. The objectives of this study were, to distinguish the boundaries and content of the trigonum cystohepaticum. Furthermore, to design the areas of Safety and Critical Vision as a safety measure for the patient undergoing surgery. Analysis of 458 surgical reports on cholecystectomies performed from January 2010 to October 2012 by the Hospital Aeronáutico's General Surgery Department, and dissection of 12 adult cadavers preserved in a 10% formalin solution at the IIIrd Chair of Anatomy, School of Medicine, University of Buenos Aires. From 458 cholecystectomies, surgical reports were classified as mentioning: Calot triangle, 247 (53.93%); cystohepatic triangle, 59 (12.88%); critical vision area, 152 (33.18%). None of them mentioned Buddé triangle or trigonum cystohepaticum. Twelve adult cadavers were dissected in which we identified the cystic artery: originating from right hepatic artery, 9 (75%); originating from left hepatic artery, 2 (16.66%); and originating from hepatic artery, 1 (8.34%). Trigonum cystohepaticum is observed in 7 cadavers (58.35%). Knowing the anatomy of the bile duct and its anatomical variations becomes essential to safely perform any surgery. The triangle described by Calot is the lower half of the triangle described by Buddé. The lateral portion (Safety Triangle) is the area of critical vision to be dissected due to the lower probability of injuring noble structures.

Lesiones de la vía biliar en colecistectomías laparoscópicas / Bile duct injures from laparoscopic cholecystectomy

Introducción: en febrero de 1991, se realizó la primera colecistectomía laparoscópica en Cuba. No obstante sus beneficios, las lesiones de la vía biliar parecen ser más frecuentes. Objetivo: describir el comportamiento de las lesiones de la vía biliar en 6 centros de 5 provincias del país, a fin de detectar deficiencias al ser corregidas. Métodos: se realizó un estudio multicentros, descriptivo y retrospectivo de 27 lesiones de la vía biliar ocurridas en 17 288 colecistectomías laparoscópicas realizadas en 6 hospitales universitarios. Se colectó el dato primario a través de un cuestionario de 13 puntos, aplicado a cada paciente lesionado, y común para todos los centros. Resultados: el porcentaje de lesiones de la vía biliar en esta serie fue bajo (0,15 por ciento). En 59,2 por ciento, el diagnóstico fue posoperatorio y casi el 63 por ciento fueron graves lesiones tipo E de Strasberg. Las técnicas de reparación más empleadas fueron las derivaciones biliodigestivas, pero las lesiones diagnosticadas durante el transoperatorio fueron en la mayoría de los casos tratados con reparación sobre sonda. Se presentaron complicaciones mayores en 25,9 por ciento. Conclusiones: el porcentaje de lesiones en nuestro estudio es bajo, pero predominan las de caracter grave. Las estenosis posquirúrgicas, estuvieron predominantemente relacionadas con la elección errónea de la técnica primaria de reparación(AU)

Introduction: On February 1991 the first laparoscopic cholecistectomy (LC) was performed in Cuba. Despite the benefits of this approach, bile ducts injuries (BDI) seem to be more frequent. Objective: To describe the behavior of the bile duct injuries in six hospitals located in 5 provinces throughout the country so as to detect deficiencies to be corrected. Methods: A retrospective, multicenter and descriptive study of 27 bile duct injuries on 17288 LC performed in 6 university hospitals throughout the country. The primary data was collected through a 13 point-questionnaire applied to every injured patient, and equal for all the centers. Results: The percentage of BDI in this series was low (0.15 percent). In 59.2 percent of cases, the diagnosis was made postoperatively and almost 63 percent were severe Strasberg's type E lesions. The most used repair techniques were bile digestive derivations, but lesions identified transoperatively were in most of the cases treated with T tube repairs. Major complications occurred in 25.9 percent of patients. Conclusions: The percentage of lesions in our study is low, but they were mostly severe. The postsurgical stenosis was mainly related with the wrong selection of the primary repair technique(AU)

Vesícula biliar aberrante / Aberrant gall bladder

Se presenta el caso de una paciente de 65 años de edad, que ingresó en el Centro Nacional de Cirugía Endoscópica a causa de un dolor mantenido y sensación de pesadez debajo de la costilla derecha, además de trastornos dispépticos. Después de los estudios de laboratorio e imaginológicos, se diagnosticó la vesícula biliar ocupada por cálculos y con poco volumen. Durante la intervención quirúrgica se encontró un piocolecisto y otra vesícula de características normales en cara anterior del hígado. Por resultar una localización infrecuente y aberrante de la vesícula biliar, además de aparecer doble, se decide exponer las características clínicas y los resultados quirúrgicos de este caso a la comunidad científica nacional e internacional(AU)

This is the case of a patient aged 65 admitted in the National Center of Endoscopic Center due to a sustained pain and heaviness sensation under the right rib and also dyspeptic disorders. After the laboratory and imaging studies, authors diagnosed a gall bladder occupied by calculi and with a low volume. During surgical intervention there was noted a gall bladder and other gall bladder of normal features in the lower face of liver. Because it is a infrequent and aberrant location of the gall bladder, authors decide to show international and national scientific community the clinical features and the surgical results of this case(AU)

Mucoclasia y esclerosis de la vesícula biliar: estudio experimental de la factibilidad / Mucoclasia and sclerosis of the gallbladder: an experimental study of the feasibility

Introducción: Antes de la aparición y auge de la colecistectomía videolaparoscópica, existieron intentos para eliminar la visícula biliar de la manera no quirúrgica, aplicando químicos, calor o láser con finalidad de necrosar su mucosa y reducir la vesícula a una cicatriz inocua. El objetivo de este trabajo es determinar si la aplicación de sustencias mucoclásicas y esclerosantes no estudiadas previamente (hipoclorito de sodio, GRF (gelatina-resorcinol-formol)) o el láser de diodo pueden lograr una cucoclasia completa y esclerosis de la vesícula biliar del modelo animal usado. Material y métodos: se dividieron 50 conejos en 5 grupos de 10 animales. Se accedio quirúrgicamente a la vesícula biliar. En el grupo A se aplicó hipoclorito de sodio y para la oclusión del conducto cístico y de la luz vesicular, un adhesivo: cola de fibrina. En el grupo B, se usó formol al 5% y posteriormente, como adhesivo, una mezcla de gelatina con fenol. Estos 3 son los componentes de un adehsivo llamado GRF, usado principalmente en cirugía vascular. En el grupo C se aplicó láser de diodo de 980 nm endoluminalmente a travéz de una fibra óptica. Es el tipo de láser utilizado en flebología. En el grupo D se usó etanol como esclerosante más cola de fibrina, sirviendo de control debido a su uso probado en varios trabajos de escleroterapia vesicular. El grupo E fue en control donde solo se inyectó solución salina isotónica. A los 65 días se sacrificaron los animales y se observó el resultado del procedimiento macroscópica e histológicamente, evaluando la presencia de luz vesicular remanente, de áreas con mucosa viable y la fibrosis producida. Análisis estadístico: test de Fisher.

Introduction: Cholecystectomy is the current treatment for the biliary lithiaisis. Nevertheless, attempts have been made to eliminate the gallbladder's epithelium and to generate sclerosis of the organ using chemical sbstances, heat and laser. The purpose of this investigation is to determine if the application of sodium hypochlorite, GRF (gelatin-resorcinol-formaline) or diode laser can produce mucoclasis and fibrosis of the gallbladder, leading to the functional exclusion of the organ. Material and methods: Fifty rabbits were divided into 5 groups of 10 animals. The gallbladder was accessed surgically. In group A, sodium hypochlorite was injected into the gallbladder cavity as a sclerosing agent, after which fibrin glue was applied to occlude the cystic duct and collapse the residual organ humen, thus avoiding bile reflex. In group B: 5% formaldehide was used, and the adhesive was a mix of gelatin and fenol (GRF, a product used principally in vascular surgery). In group C, a 980 nm In Ga As P diode laser (currently used in phlebology), was applied intraluminally theough an 600 micrometres optic fiber in order to shrink the gallbladder. In group D, the sclerosing agent was ethanol and fibrin glue was used to seal the lumen. In group E, the control group, only saline solution was injected into the gallbladder cavity. After 65 days the animals were sacrificed and the result of the procedure was observed macroscopically and histologically. The presence of remanant gallbladder lumen, fibrosis and areas of viable mucosa were assessed. Fisher's test was used for statistical analysis.

Agenesis of Gall Bladder: Its Emryological Basis and Clinical Significance.

Congenital absence of the gall bladder is a rare anomaly which may occur alone or with other malformations with incidence ranging from 0.01-0.05%. Awareness of this entity by clinicians and radiologists is essential because many of these patients present with biliary symptoms and have unnecessary operations. This presentation, coupled with the inability of standard abdominal ultrasonography to convincingly diagnose agenesis of the gallbladder, can put the surgeon in a diagnostic and intraoperative dilemma. Here we report a suspected case of chronic cholecystitis who underwent a laparoscopic cholecystectomy and was found to have a congenital absence of gall bladder and cystic duct. Standard pre-operative investigative modalities which were fallacious and misleading. The embryological basis and clinical significance have been discussed.

Carcinoma de vesícula biliar mascarado por Síndrome de Mirizzi: relato de caso e revisão da literatura / Carcinoma of the gallbladder masked by Mirizzi Syndrome: case report andliterature review

Objetivos: este relato de caso visa descrever uma forma pouco comum de apresentação de câncer de vesícula biliar, mascarado pela Síndrome de Mirizzi.Descrição do caso: uma mulher consultou por náuseas, acolia e colúria, que haviam iniciado dois meses antes, e icterícia, de início recente. A ecografia abdominal evidenciou dilatação da via biliar com coledocolitíase e colelitíase. Uma colangiopancreatografia endoscópica retrógrada mostrou obstrução no terço médio do ducto hepático comum, não sendo visualizado cálculo. A suspeita diagnóstica inicial foi de Síndrome de Mirizzi. Foi inserida uma endoprótese na via biliar principal, com plano de cirurgia. Durante o procedimento cirúrgico foram encontradas lesões macroscópicas em peritônio e vesícula biliar, que indicaram interrupção da cirurgia e coleta de material para biópsia. O exame anatomopatológico evidenciou adenocarcinoma. A paciente teve alta hospitalar com acompanhamento oncológico e plano de quimioterapia.Conclusões: a concomitância da Síndrome de Mirizzi com carcinoma de vesícula é extremante rara, pois são doenças pouco frequentes. Para o diagnóstico definitivo do tumor de vesícula biliar é sempre imperativo o estudo anatomopatológico de todas as peças cirúrgicas.

Aims: This case report aims to describe an unusual presentation of gallbladder cancer, masked by Mirizzi Syndrome.Case description: a woman complained of nausea, dark urine and acholic stools started two months earlier, and jaundice started later. An abdominal ultrasound showed dilatation of the bile duct with choledocholithiasis and cholelithiasis. A cholangiopancreatography showed obstruction in the middle third of the common bile duct, without visualization of gallstones. The initial diagnosis was Mirizzi Syndrome. A stent was inserted in the main bile duct, to plan surgery. During surgery macroscopic lesions were found in gallbladder and peritoneum, which indicated interruption of the surgery and sample collection for biopsy. Pathological examination revealed adenocarcinoma. The patient was discharged with oncological follow-up plan and chemotherapy.Conclusions: The coexistence of Mirizzi Syndrome with carcinoma of the gallbladder is extremely rare, because both diseases are uncommon. Anatomopathological examination of all surgical specimens is always imperative for the definitive diagnosis of gallbladder tumor.