Agenesia de la vesícula biliar: una serie de casos multicéntrica y revisión de la literatura / Agenesis of the gallbladder: A multicenter case series and review of the bibliography

La agenesia de la vesícula biliar es una entidad rara en pediatría con una evolución normalmente silente, y representa un desafío diagnóstico para el médico que enfrenta estos casos por primera vez. Algunos pacientes pueden, sin embargo, presentar síntomas que simulan otras patologías del árbol biliar, y muchos de ellos son operados ante esta sospecha. Sin embargo, el diagnóstico oportuno de esta entidad permite llevar a cabo un tratamiento médico que muchas veces es suficiente para resolver el problema del paciente. Si bien es una condición benigna, los pacientes suelen presentar otras malformaciones asociadas que son más graves en naturaleza y que deben investigarse activamente para poder derivarlos a los especialistas de manera oportuna. Presentamos nuestra experiencia en el diagnóstico y tratamiento de estos pacientes, así como una breve revisión de la literatura. Esperamos que sea de utilidad para el médico que encuentre un caso similar.

Gallbladder agenesis is a rare condition in pediatrics that is usually asymptomatic and represents a diagnostic challenge for physicians seeing these cases for the first time. Some patients may, however, present with symptoms that mimic other diseases of the bile ducts, and many of them undergo surgery due to such suspicion. Still, a timely diagnosis of gallbladder agenesis allows for medical treatment that is often sufficient to resolve the patient's problem. Although it is a benign condition, patients often present with other associated, more serious malformations and should be actively studied for a timely referral to other specialists. Here we describe our experience with the diagnosis and treatment of these patients and a brief review of the bibliography. We hope it will be helpful for physicians facing similar cases.

Cáncer de vesícula biliar, experiencia del Servicio de Cirugía General del Hospital Nacional de Itauguá del 2010 al 2020 / Gallbladder cancer, experience in the General Surgery Service of the Itauguá National Hospital since 2010 to 2020

Introducción: El cáncer vesicular es una neoplasia infrecuente mundialmente, exceptuando países donde la mortalidad por su causa es alta como Chile, a pesar de ello es el tumor biliar más común, con una incidencia aproximada de 0,8-1,2% y casi exclusivamente en mujeres. Objetivos: Describir la frecuencia, perfil demográfico, clínica, tratamiento y hallazgos anatomopatológicos del cáncer vesicular en pacientes del Hospital Nacional de Itauguá del 2010 al 2020. Materiales y métodos: Se encontraron 19 casos confirmados por biopsia, pero solo 15 fichas estaban completas. El estudio fue retrospectivo, descriptivo y observacional, muestreo no probabilístico de corte transversal. Resultados: De la muestra final (N=15), 13 pacientes fueron mujeres, la edad promedio fue de 60 años. Del total, 4 pacientes ingresaron para cirugía programada con diagnóstico de colecistopatía crónica litiásica y los otros 11 tenían sospecha de tumor vesicular y/o ictericia o colangitis aguda de origen neoplásico probable, todos fueron operados, el motivo de consulta más frecuente fue dolor en hipocondrio derecho, el 99 % fueron adenocarcinomas por anatomía patológica. Conclusión: La etiología principal del cáncer vesicular fue la colelitiasis, es de baja incidencia a nivel nacional, la mayoría de nuestros pacientes se encontraban en estadios terminales, o con poca oportunidad para la resección R0, por lo cual son de mal pronóstico y hasta hoy en día son de difícil detección en etapa inicial. En algunos casos como en 4 de nuestras pacientes el diagnóstico es fortuito mediante el hallazgo histológico en piezas de colecistectomía que fueron intervenidos en principio por patología benigna.

Introduction: Gallbladder cancer is an infrequent neoplasm worldwide, except for countries where mortality from its cause is high, such as Chile. Despite this, it is the most common biliary tumor, with an approximate incidence of 0.8-1.2% and almost exclusively in women. Objectives: To describe the frequency, demographic profile, clinic, treatment and anatomopathological findings of gallbladder cancer in patients of the Itauguá National Hospital from 2010 to 2020. Materials and methods: 19 biopsy-confirmed cases were found, but only 15 files were complete. The study was retrospective, descriptive and observational, non-probabilistic cross-sectional sampling. Results: Of the final sample (N=15), 13 patients are women; the average age was 60 years. Of the total, 4 patients were admitted for scheduled surgery with a diagnosis of chronic gallstone gallbladder disease and the other 11 had suspected gallbladder tumor and/or jaundice or acute cholangitis of probable neoplastic origin, all were operated on, the most frequent reason for consultation was pain in the hypochondrium right, 99% were adenocarcinomas by pathology. Conclusion: The main etiology of gallbladder cancer was cholelithiasis, it has a low incidence nationwide, most of our patients were in terminal stages, or with little opportunity for R0 resection, for which they have a poor prognosis and up to today they are difficult to detect in the initial stage. In some cases, such as in 4 of our patients, the diagnosis is fortuitous through the histological finding in cholecystectomy specimens that were initially operated on for benign pathology.

Prevalencia de cáncer de vesícula en pacientes pos operados de colecistectomía en un Hospital de Tercer Nivel en el 2021 en Paraguay / Prevalence of gallbladder cancer in patients undergoing cholecystectomy in a Third-Level Hospital in 2021 in Paraguay

Introducción: El cáncer de vesícula biliar (CVB) es la neoplasia más frecuente de las vías biliares, su diagnóstico suele hacerse de forma tardía llevando a una reducción en las opciones terapéuticas y alta mortalidad. La importancia de hacer un diagnóstico oportuno es la mejoría en el pronóstico debido a mayores opciones terapéuticas e incluso curación de la enfermedad, lo que hace muy relevante conocer la prevalencia de CVB en pacientes colecistectomizados. Objetivos: Determinar la prevalencia del cáncer de vesícula en la anatomía patológica de pacientes colecistectomizados en el Hospital General de Barrio Obrero en el año de 2021. Materiales y métodos: Estudio observacional, descriptivo, retrospectivo y de corte transversal, con datos colectados de los expedientes clínicos: edad, sexo, motivo de consulta, antecedentes patológicos personales y patologías basales, hallazgo operatorio y resultados de anatomía patológica. Los datos fueron cargados en una planilla Excel y analizados estadísticamente. Resultados: Se diagnosticaron 2 carcinomas mal diferenciados (3,5%) de todas las colecistectomías. El promedio de edad fue de 39a (DS +/- 14;16), sexo femenino (63%). Las comorbilidades más frecuentes fueron obesidad (58,7%), hipertensión arterial (33,8%), diabetes y dislipidemia (12,8% cada). Conclusión: El cáncer de vesícula biliar tiene una alta prevalencia regional, debido a factores de riesgo relacionados al estilo de vida y dieta. El hallazgo más llamativo fue encontrar con una mayor prevalencia en el grupo de edad entre 31-50 años en lugar de mayores a 60 años.

Introduction: Gallbladder cancer (CVB) is the most common neoplasm of the bile ducts; its diagnosis is usually made late, leading to a reduction in therapeutic options and high mortality. The importance of making a timely diagnosis is the improvement in prognosis due to greater therapeutic options and even cure of the disease, which makes it very relevant to know the prevalence of CVB in cholecystectomized patients. Objectives: Determine the prevalence of gallbladder cancer in the pathological anatomy of cholecystectomized patients at the Barrio Obrero General Hospital in the year 2021. Materials and methods: Observational, descriptive, retrospective and cross-sectional study, with data collected from clinical records: age, sex, reason for consultation, personal pathological history and baseline pathologies, operative finding and pathological anatomy results. The data were loaded into an Excel spreadsheet and analyzed statistically. Results: 2 poorly differentiated carcinomas were diagnosed (3.5%) of all cholecystectomies. The average age was 39 years (SD +/- 14;16), female (63%). The most frequent comorbidities were obesity (58.7%), high blood pressure (33.8%), diabetes and dyslipidemia (12.8% each). Conclusion: Gallbladder cancer has a high regional prevalence, due to risk factors related to lifestyle and diet. The most striking finding was a higher prevalence in the age group between 31-50 years rather than those over 60 years of age.

Asociación entre metaplasia, displasia y cáncer de vesícula biliar en una EPS de Bogotá, Colombia / Association between metaplasia, dysplasia and gallbladder cancer in an EPS in Bogotá, Colombia

Introducción. El cáncer de vesícula biliar es el más común en el tracto biliopancreático y una importante causa de mortalidad. La metaplasia y la displasia han sido mencionados como probables precursores relacionados con la secuencia metaplasia-displasia-cáncer. El objetivo de este estudio fue establecer las posibles asociaciones entre estas alteraciones histopatológicas y su relación con la edad y el sexo de los pacientes. Métodos. Estudio observacional retrospectivo descriptivo, con un componente analítico de corte transversal. Se incluyeron los informes de patología de pacientes llevados a colecistectomía laparoscópica electiva y ambulatoria, entre enero de 2015 y diciembre de 2020, con colecistitis crónica, colelitiasis o pólipos vesiculares, mayores de 18 años. Se describieron las características demográficas por sexo y edad utilizando medias, desviaciones estándar y porcentajes. Se emplearon la prueba de chi cuadrado y la prueba exacta de Fisher para evaluar la asociación entre las variables cualitativas. Resultados. Se incluyeron 4871 informes de patología. En esta cohorte se encontró asociación estadísticamente significativa entre metaplasia, displasia y cáncer de vesícula (p<0,05), al igual que con el sexo y la edad de los pacientes. Conclusiones. Los resultados sugieren una asociación entre metaplasia, displasia y cáncer de vesícula biliar en la población estudiada. Se recomienda la realización de investigaciones complementarias para definir la posible causalidad entre metaplasia, displasia y cáncer de vesícula biliar en una población más heterogénea.

Introduction. Gallbladder cancer is the most common cancer in the biliopancreatic tract and an important cause of mortality. Metaplasia and dysplasia have been mentioned as probable precursors related to the metaplasia-dysplasia-cancer sequence. The objective of this study was to establish the possible associations between these histopathological alterations and their relationship with the age and sex of the patients. Methods. Descriptive retrospective observational study, with a cross-sectional analytical component. Pathology reports of patients undergoing elective and outpatient laparoscopic cholecystectomy were included between January 2015 and December 2020, with chronic cholecystitis, cholelithiasis, or gallbladder polyps, over 18 years of age. Demographic characteristics by sex and age was performed using means, standard deviations, and percentages. The chi2 test and Fisher's exact test were used to evaluate the association between the qualitative variables. Results. 4871 pathology reports were included. In this cohort, a statistically significant association was found between metaplasia, dysplasia, and gallbladder cancer (p<0.05), as well as with the sex and age of the patients. Conclusions. The results suggest an association between metaplasia, dysplasia and gallbladder cancer in the study population. Additional research is recommended to define the possible causality between metaplasia, dysplasia, and gallbladder cancer in a more heterogeneous population.

Gallbladder Adenomyomatosis in Pediatrics: A Case Report / Adenomiomatosis vesicular en pediatría: a propósito de un caso

Abstract Objective: Gallbladder adenomyomatosis (ADM) is a rare disease in pediatrics, characterized by epithelial proliferation and muscle hypertrophy, associated with the formation of fistulous tracts, classically called Rokitansky-Aschoff sinuses. It is an anatomical and clinical entity that is difficult to diagnose. Ultrasound is the primary diagnostic tool, but ADM is confirmed by its characteristic histological findings. Clinical case: A 15-year-old adolescent with a previous diagnosis of congenital scoliosis and hemivertebra at T11-12 with secondary spinal cord compression and butterfly vertebrae at T5-L3 was admitted for surgical management of this entity. In the immediate postoperative period, band-like abdominal pain and elevated pancreatic enzymes were present, considering the initial diagnosis of acute pancreatitis. Imaging studies revealed a thickened gallbladder with increased size and findings compatible with gallbladder ADM. The patient showed improvement in symptoms after undergoing laparoscopic cholecystectomy. The diagnosis of gallbladder ADM was later confirmed by histology. Conclusion: Gallbladder ADM is extremely rare in children; little is known about its pathogenesis and pathology. It is diagnosed mainly by ultrasound, which identifies hypertrophy of the muscular layer and the formation of fistulous tracts, known as Rokitansky-Aschoff sinuses.

Resumen Objetivo: La adenomiomatosis vesicular es una enfermedad poco frecuente en pediatría, caracterizada por la proliferación epitelial e hipertrofia muscular, asociada a la formación de trayectos fistulosos, clásicamente denominados senos de Rokitansky-Aschoff. Corresponde a una entidad anatomoclínica de muy difícil diagnóstico; la ecografía es la principal herramienta diagnóstica, y se realiza su confirmación por los hallazgos histológicos característicos. Caso clínico: Se trata de un adolescente de 15 años con diagnóstico previo de escoliosis congénita y hemivértebra en T11-12 con compresión medular secundaria y vértebras en mariposa en T5-L3, quien ingresa para el manejo quirúrgico de dicha entidad; en el posoperatorio inmediato presenta dolor abdominal en banda y elevación de enzimas pancreáticas, y se considera el diagnóstico inicial de pancreatitis aguda. En los estudios de imagen se evidencia una vesícula con engrosamiento aumentada de tamaño y con hallazgos compatibles de adenomiomatosis vesicular. La paciente presenta mejoría de sus síntomas después de la realización de colecistectomía laparoscópica. El diagnóstico de adenomiomatosis vesicular fue confirmado posteriormente por histología. Conclusión: La adenomiomatosis de la vesícula biliar es sumamente rara en niños, poco se conoce de su patogenia y patología; se diagnostica principalmente por ecografía, en la que se identifica la hipertrofia de la capa muscular y la formación de trayectos fistulosos, conocidos como senos de Rokitansky-Aschoff.

Cáncer incidental de vesícula: incidencia y factores asociados en pacientes de una institución de la ciudad de Medellín / Incidental gallbladder cancer: Incidence and associated factors in patients from an institution in the city of Medellín

Introducción. El cáncer de vesícula biliar es una de las neoplasias más frecuentes de la vía biliar y la mayoría de los casos se diagnostican de forma incidental o en estadios avanzados. En Colombia existen pocas publicaciones acerca de la prevalencia y características clínicas de pacientes con cáncer insospechado de vesícula biliar. El objetivo de este trabajo fue actualizar la información existente. Métodos. Estudio de tipo transversal basado en registros médicos. Como variable de resultado se definió el hallazgo incidental de patología maligna reportado por un patólogo y el subtipo histológico. Se midieron variables demográficas, clínicas y quirúrgicas. Se calcularon OR con sus respectivos intervalos de confianza (IC95%). Resultados. De los 2630 casos analizados, en cuatro se hizo diagnóstico de cáncer incidental de vesícula, con una prevalencia del 0,15 %. Se encontraron como características asociadas al cáncer incidental de vesícula, la edad, el antecedente de cáncer y la presencia de pólipos. Conclusiones. Esta es una patología poco frecuente en la población evaluada, lo que permite afirmar que no es necesario realizar estudios prequirúrgicos más amplios de forma rutinaria, a menos que el paciente presente alguno de los factores asociados.

Introduction. Gallbladder cancer is one of the most common neoplasms of the bile duct and most cases are diagnosed incidentally or in advanced stages. In Colombia, there are few publications about the prevalence and clinical characteristics of patients with unsuspected gallbladder cancer. The objective of this work was to update the existing information. Methods. Cross-sectional study based on medical records. The incidental finding of malignant pathology reported and the histological subtype were defined as the outcome variable. Demographic, clinical and surgical variables were measured. ORs were calculated with their respective 95% CI. Results. Of the 2630 cases analyzed, four were diagnosed with incidental gallbladder cancer, with a prevalence of 0.15%. Characteristics associated with incidental gallbladder cancer were age, history of cancer and the presence of polyps. Conclusions. This is a rare pathology in the population evaluated, which allows us to recommend that it is not necessary to routinely perform more extensive presurgical studies, unless the patient presents any of the associated factors.

Metástasis de carcinoma renal de células claras en la vesícula biliar / Gallbladder metastasis of clear cell renal carcinoma

Resumen El carcinoma renal de células claras (CRCC) es una neoplasia maligna poco común que representa el 3% de todos los tumores malignos en adultos. Este tumor presenta una alta tendencia a desarrollar metástasis sincrónicas o metacrónicas en diferentes sitios anató micos. Aunque la metástasis en la vesícula biliar por CRCC es extremadamente rara, se han reportado casos esporádicos en la literatura médica. Presentamos el caso de una mujer de 78 años con antecedentes de carcinoma indiferenciado de cavum, carcinoma basocelular y CRCC en riñón derecho. Se sometió a nefrectomía radical. El análisis histopatológico confirmó el diagnóstico de CRCC sin invasión vascular ni ureteral. Dos años después, du rante el seguimiento, se detectó una lesión nodular en la vesícula biliar mediante tomografía computarizada. A pesar de la ausencia de síntomas, se decidió la resección quirúrgica. Se realizó colecistectomía laparoscópica sin complicaciones. El examen histopatológico confirmó la presencia de metástasis de CRCC en la vesícula biliar. La paciente evolucionó favorablemente encontrándose en seguimiento sin recurrencia. La metástasis vesicular por CRCC es extremadamente rara, pero los cirujanos deben considerarla en pacientes con antecedentes de CRCC. El diagnóstico diferencial prequirúrgico entre el carcinoma primario de vesícula biliar y la metástasis de CRCC puede ser desafiante y, a menudo, se confirma mediante el examen histopatológi co. La resección quirúrgica completa parece ser la mejor opción de tratamiento para lograr una supervivencia libre de enfermedad.

Abstract Clear cell renal cell carcinoma (ccRCC) is an uncom mon malignant neoplasm that accounts for 3% of all malignant tumors in adults. This tumor exhibits a high tendency to develop synchronous or metachronous me tastases in different anatomical sites. Although gallblad der metastasis from ccRCC is extremely rare, sporadic cases have been reported in the medical literature. We present the case of a 78-year-old woman with a history of undifferentiated nasopharyngeal carcinoma, basal cell carcinoma, and ccRCC in the right kidney. She un derwent radical nephrectomy. Histopathological analysis confirmed the diagnosis of ccRCC without vascular or ureteral invasion. Two years later, during follow-up, a nodular lesion was detected in the gallbladder through computed tomography. Despite the absence of symp toms, surgical resection was decided. Laparoscopic cho lecystectomy was performed without complications. Histopathological examination confirmed the presence of ccRCC metastasis in the gallbladder. The patient had a favorable outcome and is currently under follow-up without recurrence. Gallbladder metastasis from ccRCC is extremely rare, but surgeons should consider this possibility in patients with a history of ccRCC. Preoperative differential diagno sis between primary gallbladder carcinoma and ccRCC metastasis can be challenging and is often confirmed through histopathological examination. Complete sur gical resection is the best treatment option to achieve disease-free survival.

Cáncer incidental de vesícula biliar tras Colecistectomía Laparoscópica / Incidental gallbladder cancer after Laparoscopy Cholecystectomy

El carcinoma de vesícula biliar es una entidad poco frecuente. El diagnóstico precoz de esta neoplasia es difícil, ya que sus síntomas son muy inespecíficos y muchas veces estes se realiza de manera tardía cuando el enfermo posee una enfermedad avanzada y solo para mitigar los síntomas. Con el crecimiento exponencial en el número de colecistectomías laparoscópicas en las últimas décadas, se ha generado un aumento en la detección de neoplasias incidentales, permitiendo ofrecer tratamiento curativo en un gran grupo de pacientes. Se evaluaron todas las colecistectomías realizadas durante julio de 2019 a diciembre de 2022 en el Hospital Nacional de Clínicas, Córdoba, Argentina. La evaluación patológica de todas las muestras quirúrgicas reveló una incidencia de 0,83% de adenocarcinoma insospechado en colecistectomías realizadas. 66% de los pacientes con neoplasias insospechadas pertenecían al sexo femenino

Gallbladder carcinoma is a rare entity. Early diagnosis of this neoplasia is difficult, since its symptoms are very unspecific and often this is done late when the patient has an advanced disease and only to mitigate symptoms. With the exponential growth in the number of laparoscopic cholecystectomies in recent decades, there has been an increase in the detection of incidental neoplasms, allowing offering curative treatment in a large group of patients. All cholecystectomies performed during July 2019 to December 2022 were evaluated at the National Hospital of Clinics, Córdoba, Argentina. Pathological evaluation of all surgical samples revealed an incidence of 0.83% of unsuspected adenocarcinoma in cholecystectomies performed. 66% of patients with unsuspected neoplasms were female

Duración de la antibioticoterapia en pacientes con colecistitis aguda manejados con colecistostomía. ¿Afecta los desenlaces clínicos? / Duration of antibiotic therapy in patients with acute cholecystitis managed with cholecystostomy. Does it affect clinical outcomes?

Introducción. En pacientes con diagnóstico de colecistitis aguda tratados con colecistostomía, el tiempo óptimo de duración de la terapia antibiótica es desconocido. El objetivo de este trabajo fue comparar los resultados clínicos en pacientes con diagnóstico de colecistitis aguda manejados inicialmente con colecistostomía y que recibieron cursos cortos de antibióticos (7 días o menos) versus cursos largos (más de 7 días). Métodos. Se llevó a cabo un estudio de cohorte observacional, retrospectivo, que incluyó pacientes con diagnóstico de colecistitis aguda manejados con colecistostomía, que recibieron tratamiento antibiótico. Se hizo un análisis univariado y de regresión logística para evaluar la asociación de variables clínicas con la duración del tratamiento antibiótico. El desenlace primario por evaluar fue la mortalidad a 30 días. Resultados. Se incluyeron 72 pacientes. El 25 % (n=18) recibieron terapia antibiótica por 7 días o menos y el 75 % (n=54) recibieron más de 7 días. No hubo diferencias significativas en la mortalidad a 30 días entre los dos grupos ni en las demás variables estudiadas. La duración de la antibioticoterapia no influyó en la mortalidad a 30 días (OR 0,956; IC95% 0,797 - 1,146). Conclusión. No hay diferencias significativas en los desenlaces clínicos de los pacientes con colecistitis aguda que son sometidos a colecistostomía y que reciben cursos cortos de antibióticos en comparación con cursos largos

Introduction.In patients with acute cholecystitis who receive treatment with cholecystostomy, the optimal duration of antibiotic therapy is unknown. The objective of this study is to compare short courses of antibiotics (7 days or less) with long courses (more than 7 days) in this population. Methods. We performed a retrospective observational cohort study which included patients diagnosed with acute cholecystitis, who received antibiotic therapy and were taken to cholecystostomy. Univariate analysis and logistic regression were performed to evaluate the association between clinical variables and the duration. The main outcome evaluated was 30-day mortality. Results. Seventy-two patients were included, 25% (n=18) were given 7 or fewer days of antibiotics while 75% (n=54) were given them for more than 7 days. Demographic data between both groups were similar (age, severity of cholecystitis, comorbidities). There were no significant differences in 30-day mortality between both groups. Antibiotic duration did not influence mortality at 30 days (OR 0.956, 95% CI 0.797 - 1.146). Conclusion. There are no significant differences in the clinical outcomes of patients with acute cholecystitis who undergo cholecystostomy and receive short courses of antibiotics compared to long courses

Adenocarcinoma de vesícula biliar: un caso de presentación temprana / Gallbladder adenocarcinoma: an early-stage case

El cáncer de la vesícula biliar es una enfermedad rara, con una incidencia mundial de 2 casos por cada 100 000 individuos con un pronóstico desfavorable. Con el aumento de colecistectomías por causas benignas, se ha incrementado la detección incidental de neoplasias vesiculares en las piezas quirúrgicas, siendo este el método diagnóstico más frecuente, generando retrasos en el manejo y requiriendo reintervenciones extensas. Debido a lo anterior, se resalta la importancia de un diagnóstico temprano preoperatorio, con el objetivo de ofrecer un tratamiento quirúrgico potencialmente curativo. Se presenta el caso de un paciente masculino de 72 años con un cuadro intermitente de dolor abdominal y pérdida de peso de un año de evolución, el cual fue diagnosticado con cáncer vesicular en etapa temprana y sometido a una colecistectomía laparoscópica extendida con linfadenectomía y hepatectomía parcial con una evolución a 6 meses sin complicaciones y bajo un protocolo de vigilancia periódica.

Gallbladder cancer is a rare disease, accounting a global incidence of 2 cases per 100 000 individuals with an unfavorable prognosis. The rise in cholecystectomies for benign causes has increased an incidental detection of vesicular neoplasms in the surgical specimens, being the main diagnostic method, therefore it generated delay in the management, requiring extensive re-interventions. It is important to improve early preoperative diagnosis, with the aim of offering a potentially curative surgical treatment. We present a case of a 72-year-old male with intermittent abdominal pain and weight loss of one year of evolution, who was diagnosed with early stage gallbladder cancer and underwent an extended laparoscopic cholecystectomy with lymphadenectomy and partial hepatectomy with a 6 months evolution without complications and under a periodic surveillance protocol.

Gallbladder polyps: correlation and agreement between ultrasonographic and histopathological findings in a population with high incidence of gallbladder cancer / Pólipos da vesícula biliar: correlação e concordância entre achados ultrassonográficos e histopatológicos em uma população com alta incidência de câncer de vesícula biliar

ABSTRACT BACKGROUND: Gallbladder polyps are becoming a common finding in ultrasound. The management has to consider the potential risk of malignant lesions. AIMS: The aim of this study was to analyze the ultrasound findings in patients undergoing cholecystectomy due to gallbladder polyps and compare them for histopathological findings (HPs). METHODS: Patients with an ultrasonographic diagnosis of gallbladder polyp and who underwent cholecystectomy from 2007 to 2020 were included in the study. RESULTS: A total of 447 patients were included, of whom 58% were women. The mean age was 45±12 years. The mean size of polyps in US was 7.9±3.6 mm. Notably, 9% of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p=0.003). Histopathological findings confirmed the presence of polyps in 88.4%, with a mean size of 4.8±3.4 mm. In all, 16 cases were neoplastic polyps (4.1%), 4 of them being malignancies, and all were single and larger than 10 mm. We found a significant correlation between ultrasound and histopathological findings polyp size determination (r=0.44; p<0.001). The Bland-Altman analysis obtained an overestimation of the US size of 3.26 mm. The receiver operating characteristic (ROC) curve analysis between both measures obtained an area under the receiver operating characteristic curve (AUC) of 0.77 (95%CI 0.74-0.81). Ultrasound polyps size larger than 10 mm had an odds ratio (OR) of 8.147 (95%CI 2.56-23.40) for the presence of adenoma and malignancy, with a likelihood ratio of 2.78. CONCLUSIONS: There is a positive correlation and appropriate diagnostic accuracy between ultrasound size of gallbladder polyps compared to histopathological records, with a trend to overestimate the size by about 3 mm. Neoplastic polyps are uncommon, and it correlates with size. Polyps larger than 10 mm were associated with adenoma and malignancy.

RESUMO RACIONAL: Os pólipos da vesícula biliar estão se tornando um achado comum na ultrassonografia (US). O manejo deve levar em consideração o risco de lesões malignas. OBJETIVOS: Analisar os achados da ultrassonografia em pacientes submetidos à colecistectomia por pólipos vesicais e compará-los com os achados histopatológicos. MÉTODOS: Foram revisados os prontuários médicos dos pacientes com diagnóstico ultrassonográfico de pólipo vesicular e submetidos à colecistectomia no período de 2007 a 2020. RESULTADOS: Foram incluídos no estudo 447 pacientes. A média de idade foi 45±12anos, sendo 58% mulheres. O tamanho médio dos pólipos na US foide 7,9±3,6mm. Nove por cento foram maiores que 10 mm, e os pólipos únicos encontrados foram maiores do que os múltiplos (p=0,003). A HP confirmou a presença de pólipos em 88,4%, tamanho médio 4,8±3,4mm. Dezesseis eram pólipos neoplásicos (4,1%) e quatro deles malignos, únicos e maiores que 10 mm. Foi encontrado correlação significativa entre a determinação do tamanho do pólipo ao ultrassonografia e histopatológicos (r=0,44; p<0,001). A análise de Bland-Altman obteve uma superestimação do tamanho do pólipo ao US em 3,26 mm. A análise da curva da característica de operação do receptor entre as duas medidas obteve uma área sob a curva curva da característica de operação do receptor (AUC) de 0,77 (IC95% 0,74-0,81). Pólipos ao ultrassonografia maiores que 10 mm apresentaram razão de chance (OR) de 8,147 (IC95% 2,56-23,40) para presença de adenoma e malignidade, com razão de verossimilhança de 2,78. CONCLUSÕES: Há uma correlação positiva e acurácia diagnóstica apropriada entre o tamanho dos pólipos da vesícula biliar por ultrassonografia em comparação com os achados histopatológicos, com uma tendência de superestimar o tamanho em cerca de 3 mm. Pólipos maiores que 10 mm foram associados a adenoma e malignidade.

Acute cholecystitis in high-risk patients. surgical, radiological, or endoscopic treatment? brazilian college of digestive surgery position paper / Colecistite aguda em pacientes de alto risco. tratamento cirúrgico, radiológico ou endoscópico? posicionamento do colégio brasileiro de cirurgia digestiva

ABSTRACT Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

RESUMO A colecistite aguda (CA) é um processo inflamatório agudo da vesícula biliar que pode estar associado a complicações potencialmente graves, como empiema, gangrena, perfuração da vesícula biliar e sepse. O tratamento padrão para a CA é a colecistectomia laparoscópica. No entanto, para um pequeno grupo de pacientes com CA, o risco de colecistectomia laparoscópica pode ser muito alto, principalmente em idosos com doenças graves associadas. Nestes pacientes críticos, a colecistectomia percutânea ou a drenagem endoscópica da vesícula biliar guiada por ultrassom podem ser uma opção terapêutica temporária, como ponte para a colecistectomia. O objetivo deste artigo de posicionamento do Colégio Brasileiro de Cirurgia Digestiva é apresentar novos avanços no tratamento da CA em pacientes cirúrgicos de alto risco, para auxiliar cirurgiões, endoscopistas e clínicos a selecionar o melhor tratamento para os seus pacientes. A eficácia, segurança, vantagens, desvantagens e resultados de cada procedimento são discutidos. As principais conclusões são: a) Pacientes com CA e risco cirúrgico elevado devem ser tratados preferencialmente em hospitais terciários onde a experiência e os recursos cirúrgicos, radiológicos e endoscópicos estão disponíveis. b) A modalidade de tratamento ideal para pacientes com elevado risco cirúrgico, deve ser individualizada, com base nas condições clínicas e na experiência disponível. c) A colecistectomia laparoscópica continua sendo uma excelente opção de tratamento, principalmente em hospitais em que a drenagem da vesícula biliar percutânea ou endoscópica não está disponível. d) A colecistostomia percutânea e a drenagem endoscópica da vesícula biliar devem ser realizadas apenas em hospitais bem equipados e com radiologista intervencionista e/ou endoscopista experientes. e) O cateter de colecistostomia deve ser removido após a resolução da CA. No entanto, em pacientes que não têm condição clínica para realizar colecistectomia, o cateter pode ser mantido por um período prolongado ou mesmo definitivamente. f) Se o cateter de colecistostomia for mantido por longo período de tempo podem ocorrer várias complicações, como sangramento, fístula biliar, obstrução, dor no local de inserção, remoção acidental do cateter e CA recorrente. g) O tempo de espera ideal entre a colecistostomia e a colecistectomia ainda não foi estabelecido, e vai desde imediatamente após a melhoria clínica, até meses após. h) Longos períodos de espera entre colecistostomia e colecistectomia podem estar associados a novos episódios de CA, múltiplas readmissões hospitalares e aumento dos custos. Finalmente, ao selecionar a melhor opção de tratamento, outros aspectos também devem ser considerados, como custos, disponibilidade dos procedimentos no centro médico e o desejo do paciente. O paciente e sua família devem ser completamente informados sobre todas as opções de tratamento, para que possam ajudar a tomar a decisão final.

Asymptomatic cholelithiasis: expectant or cholecystectomy. a systematic review / Colelitíase assintomática: expectante ou colecistectomia. revisão sistemática

ABSTRACT BACKGROUND: Asymptomatic cholelithiasis is a highly prevalent disease, and became more evident after the currently greater access to imaging tests. Therefore, it is increasingly necessary to analyse the risks and benefits of performing a prophylactic cholecystectomy. AIMS: To seek the best evidence in order to indicate prophylactic cholecystectomy or conservative treatment (clinical follow-up) in patients with asymptomatic cholelithiasis. METHODS: A systematic review was performed using the PubMed/Medline database, according to PRISMA protocol guidelines. The review was based on studies published between April 26, 2001 and January 07, 2022, related to individuals older than 18 years., The following terms/operators were used for search standardization: (asymptomatic OR silent) AND (gallstones OR cholelithiasis). RESULTS: We selected 18 studies eligible for inference production after applying the inclusion and exclusion criteria. Also, the Tokyo Guideline (2018) was included for better clarification of some topics less or not addressed in these studies. CONCLUSIONS: Most evidence point to the safety and feasibility of conservative treatment (clinical follow-up) of asymptomatic cholelithiasis. However, in post-cardiac transplant patients and those with biliary microlithiasis with low preoperative surgical risk, a prophylactic cholecystectomy is recommended. To establish these recommendations, more studies with better levels of evidence must be conducted.

RESUMO RACIONAL: A colelitíase assintomática é uma doença altamente prevalente, e atualmente tornou-se mais evidente, após o maior acesso a exames de imagem. Portanto, é cada vez mais necessário analisar os riscos e benefícios de realizar uma colecistectomia profilática. OBJETIVOS: Buscar as melhores evidências para indicar colecistectomia profilática ou tratamento conservador (acompanhamento clínico) em pacientes com colelitíase assintomática. MÉTODOS: Foi realizada revisão sistemática, no PubMed/Medline, de acordo com as diretrizes do protocolo PRISMA, selecionando estudos publicados entre 26/04/2001 e 01/07/2022, relacionados a indivíduos maiores de 18 anos, com padronização de busca usando os seguintes termos/operadores: (Assintomático OU Silencioso) E (Cálculos biliares OU colelitíase). RESULTADOS: Foram selecionados 18 estudos elegíveis após a aplicação dos critérios de inclusão e exclusão. Além disso, a Tokyo Guideline (2018) foi incluída para melhor esclarecimento de alguns tópicos menos ou não abordados nestes estudos. CONCLUSÕES: A maioria das evidências aponta para a segurança e viabilidade do tratamento conservador (acompanhamento clínico) da colelitíase assintomática. Entretanto, em pacientes com transplante pós-cardíaco e aqueles com microlitíase biliar com baixo risco cirúrgico pré-operatório, a colecistectomia profilática é recomendada. Para estabelecer completamente estas recomendações, mais estudos com melhores níveis de evidência devem ser conduzidos.

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.

Ultrasonographic aspects of the gallbladder mucocele in 30 dogs: retrospective study / Aspectos ultrassonográficos da mucocele biliar em 30 cães: estudo retrospectivo

Gallbladder mucocele is characterized by hyperplasia of the gallbladder epithelium, increased mucus production, accumulation, and densification of the bile content, which can lead to biliary obstruction, necrosis, and rupture of the gallbladder wall. Its finding may be accidental or related to symptoms. A retrospective study (2016-2019) was carried out based on abdominal ultrasound examinations in dogs, correlating aspects of the gallbladder and biliary system in the mucocele with existing comorbidities. Thirty dogs diagnosed with biliary mucocele were evaluated, of which 46.66% had the disease at an early stage, and 53.33% showed a more advanced stage. Of these, 66.66% were related to endocrinopathies and hyperadrenocorticism. Signs of extrahepatic bile duct obstruction and biliary peritonitis were observed in two animals. Due to their potential risk of complications, follow-up ultrasound assessments are indicated in cases that opt for clinical treatment, not excluding the need for surgical intervention.(AU)

A mucocele biliar caracteriza-se pela hiperplasia do epitélio da vesícula biliar, aumento da produção de muco, acúmulo e densificação do conteúdo biliar, podendo levar à obstrução, necrose e ruptura da parede da vesícula biliar. Seu achado pode ser acidental ou estar relacionado à sintomatologia. Foi realizado um estudo retrospectivo (2016-2019) a partir de exames ultrassonográficos abdominais em cães, correlacionando os aspectos da vesícula biliar na mucocele, com comorbidades existentes. Foram avaliados 30 cães com diagnóstico de mucocele biliar, dos quais 46,66% apresentaram a doença em estágio inicial e 53,33% demonstraram estágio mais avançado. Destes, 66,66% tinham endocrinopatias, principalmente hiperadrenocorticismo. Sinais de obstrução de vias biliares extra-hepáticas e peritonite biliar foram observados em dois animais. Por seu potencial risco de complicação, avaliações ultrassonográficas de seguimento são indicadas nos casos de tratamento clínico, não se descartando a necessidade de intervenção cirúrgica.(AU)

Adenocarcinoma de vesícula biliar: una entidad poco frecuente y mortal. A propósito de un caso / Gallbladder adenocarcinoma: a rare and fatal entity. A case report

Introducción: El adenocarcinoma de vesícula biliar es de las neoplasias digestivas con peor pronóstico; es poco común, y está asociado a una alta mortalidad. La mayoría de los diagnósticos son incidentales cuando se realiza exploración quirúrgica por sospecha de colelitiasis; encontrando malignidad en el 1 a 2% de estos casos. Produce síntomas inespecíficos, llevando a diagnósticos tardíos, empeorando así el pronóstico. Las características de esta neoplasia y el diagnóstico tardío hacen que muchas veces la resección curativa no sea posible. Caso Clínico : Paciente femenino de 45 años, quien refiere inicio de enfermedad actual (IEA) en diciembre de 2021 cuando posterior a ingesta de comida presenta dolor de aparición súbita, opresivo, de fuerte intensidad en epigastrio, intermitente. Ultrasonido abdominal (USA) reporta LOE vesicular. Se decide resolución mediante colecistectomía abierta extendida, donde se encuentra vesícula biliar (VB), con tumor en su interior que ocupa 30% de la luz, se realiza biopsia intraoperatoria, diagnosticándose ADC de vesícula. La paciente evolucionó satisfactoriamente y es egresada. En controles periódicos no hay evidencia de recidiva de la enfermedad. Conclusión : El cáncer de vesícula biliar (CVB) es una patología poco común, de difícil diagnóstico y asociado a una alta tasa de mortalidad, que produce síntomas inespecíficos por lo que es necesario un alto índice de sospecha para su diagnóstico. El manejo y conducta terapéutica depende de la extensión y el estadiaje del tumor. Es necesaria la realización de más estudios para determinar y estandarizar el manejo de esta infrecuente neoplasia(AU)

Introduction: Gallbladder adenocarcinoma is one of the digestive neoplasms with the worst prognosis; it is uncommon and is associated with high mortality. Most diagnoses are incidental when surgical exploration is performed due to suspected cholelithiasis, with malignancy found in 1 to 2% of these cases. It produces nonspecific symptoms, leading to late diagnoses, thereby worsening the prognosis. The characteristics of this neoplasm and the late diagnosis often make curative resection impossible.Clinical Case : A 45-year-old female patient who reported the onset of the current illness in December 2021. After a meal, she experienced sudden, intense, and intermittent epigastric pain. Abdominal ultrasound (US) reported gallbladder wall thickening. It was decided to perform an extended open cholecystectomy, and a tumor was found inside the gallbladder, occupying 30% of its lumen. An intraoperative biopsy was performed, diagnosing gallbladder adenocarcinoma. The patient recovered satisfactorily and was discharged. Subsequent follow-up visits have shown no evidence of disease recurrence.Conclusion : Gallbladder cancer (GBC) is a rare condition with a challenging diagnosis and a high mortality rate. It produces nonspecific symptoms, so a high index of suspicion is necessary for its diagnosis. The management and therapeutic approach depend on the tumor's extent and staging. Further studies are needed to determine and standardize the management of this uncommon neoplasm(AU)

Colecistectomia robótica por incisão única na doença da vesícula biliar: revisão sistemática e metanálise / Robotic single-incision cholecystectomy in gallbladder disease: systematic review and meta-analysis

Introdução: A colecistectomia por incisão única assistida por robótica é técnica cirúrgica emergente para o tratamento da doença da vesícula biliar. Objetivo: Analisar os resultados clínicos e o custo efetividade dela, com foco no tempo de permanência hospitalar, tempo de operação, custo total e taxa de conversão entre robótica e outros procedimentos. Métodos: Revisão sistemática e metanálise foram realizadas de acordo com o Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Os bancos de dados PubMed, Embase e Cochrane foram pesquisados desde o início até março de 2023. Análise estatística foi feita usando o R versão 6.2.1. Metanálise de efeitos aleatórios com razão de risco, diferença média e intervalo de confiança de 95% foi estimada usando a variância inversa e o método de Mantel-Haenszel para resultados binários e o estimador DerSimonian-Laird para resultados contínuos. Resultados: Um total de 452 pacientes foram envolvidos, incluindo 4 estudos randomizados. Os desfechos escolhidos para metanálise foram: permanência hospitalar (MD −0.03 dias, CI 95% −0.12 a 0.18, p=0.708), tempo de operação (MD 12.93 min, CI 95% −21.40 a 47.25, p=0.460) e taxa de conversão (RR 0.90, CI 95% 0.44 a 1.83, p=0.771). Conclusão: Não houve diferença estatisticamente significativa em relação à duração da permanência hospitalar, tempo de operação e taxa de conversão entre a colecistectomia robótica por incisão única e outras técnicas cirúrgicas para a doença da vesícula biliar.

Introduction: Robotic-assisted single-incision cholecystectomy is an emerging surgical technique for the treatment of gallbladder disease. Objective: To analyze the clinical results and its cost effectiveness, focusing on length of hospital stay, operating time, total cost and conversion rate between robotics and other procedures. Methods: Systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Embase, and Cochrane databases were searched from inception through March 2023. Statistical analysis was performed using R version 6.2.1. Random effects meta-analysis with hazard ratio, mean difference and 95% confidence interval was estimated using inverse variance and the Mantel-Haenszel method for binary outcomes and the DerSimonian-Laird estimator for continuous results. Results: A total of 452 patients were enrolled, including 4 randomized trials. The outcomes chosen for meta-analysis were: hospital stay (MD −0.03 days, CI 95% −0.12 to 0.18, p=0.708), operating time (MD 12.93 min, CI 95% −21.40 to 47.25, p=0.460) and of conversion (RR 0.90, CI 95% 0.44 to 1.83, p=0.771). Conclusion: There was no statistically significant difference regarding length of hospital stay, operating time and conversion rate between single-incision robotic cholecystectomy and other surgical techniques for gallbladder disease.

Tomografía computada y resonancia magnética en la patología de la vesícula biliar: más allá de la litiasis / Computed tomography and magnetic resonance in gallbladder patology: beyond lithiasis

Resumen La enfermedad de la vesícula biliar es una causa común de dolor abdominal. Si bien por lo general el dolor es secundario a la presencia de litiasis y colecistitis aguda, el espectro de la enfermedad es amplio e incluye anomalías congénitas, otros procesos inflamatorios y neoplasias. La tomografía computada (TC) y la resonancia magnética (RM) tienen un papel relevante en aquellos casos en los que la ecografía no es concluyente y en la planificación del tratamiento. Dentro de las anomalías congénitas, la forma en “gorro frigio” es la más frecuente. Los pólipos son en su mayoría lesiones benignas, siendo las características de malignidad un tamaño superior a 10 mm, solitario y sésil. La adenomiomatosis es reconocible por el engrosamiento de la pared vesicular y los componentes quísticos intramurales. Es importante reconocer el gas intramural e intraluminal en la colecistitis enfisematosa y los microabscesos y hemorragias intraluminales en la colecistitis gangrenosa debido a su alta morbilidad y mortalidad. La colecistitis xantogranulomatosa presenta nódulos intramurales que ocupan más del 60% del área de la pared engrosada y la conservación lineal del realce de la mucosa sin interrupción. El carcinoma vesicular se presenta como una lesión infiltrante que se extiende al hígado, un engrosamiento mural o una masa polipoide intraluminal.

Abstract Gallbladder disease is a common cause of abdominal pain. Although the pain is usually secondary to the presence of lithiasis and acute cholecystitis, the spectrum of the disease is broad and includes congenital anomalies, other inflammatory processes and neoplasms. Computed tomography (CT) and magnetic resonance (MRI) have a relevant role in those cases in which ultrasound is not conclusive and in treatment planning. Among the congenital anomalies, the “phrygian cap” shape is the most frequent. Polyps are mostly benign lesions, with the characteristics of malignancy being larger than 10 mm, solitary and sessile. Adenomyomatosis is recognizable by gallbladder wall thickening and intramural cystic components. It is important to recognize intramural and intraluminal gas in emphysematous cholecystitis and intraluminal microabscesses and hemorrhages in gangrenous cholecystitis because of its high morbidity and mortality. Xanthogranulomatous cholecystitis presents with intramural nodules occupying more than 60% of the thickened wall area and linear preservation of mucosal enhancement without interruption. Gallbladder carcinoma presents as an infiltrative lesion extending to the liver, a mural thickening or an intraluminal polypoid mass.

Gangrena vesicular por colecistitis hemorrágica en paciente sin factores de riesgo: reporte de un caso

La colecistitis hemorrágica es una complicación rara de la colecistitis aguda, pero con alta mortalidad. Clínicamente es idéntica a la colecistitis aguda, y no suele presentarse con hemorragia gastrointestinal. Presentamos el caso de un varón 57 años, sin antecedentes, ni uso de anticoagulantes, referido a nuestro hospital por una "tumoración vesicular", tras los estudios tomográficos y de colangioresonancia, asociado a la caída de hemoglobina sérica, se define su sospecha. Ingresa a sala de operaciones y se evidencia una vesícula gangrenada, conteniendo coágulos y cálculos. Confirmando su diagnóstico con el estudio histopatológico. Debido a su similitud clínica, debe considerarse en pacientes con antecedentes de terapia anticoagulante, trauma, malignidad, o hallazgos compatibles con colecistitis alitiásica. Pero puede presentarse en pacientes sin antecedentes y estar asociado a colelitiasis. El diagnóstico temprano de esta complicación potencialmente fatal es importante para facilitar el manejo quirúrgico urgente, siendo el apoyo imagenológico, necesario para su sospecha.

Hemorrhagic cholecystitis is a rare complication of acute cholecystitis, but with high mortality. Clinically it is identical to acute cholecystitis, and it does not usually present with gastrointestinal bleeding. We present the case of a 57-year-old man, with no history or use of anticoagulants, referred to our hospital for a "gallbladder tumor", after tomographic and cholangioresonance studies, associated with a drop in serum hemoglobin, suspicion of him is defined. He enters the operating room and a gangrenous gallbladder is evident, containing clots and stones. Confirming his diagnosis with histopathological study. Due to its clinical similarity, it should be considered in patients with a history of anticoagulant therapy, trauma, malignancy, or findings consistent with acalculous cholecystitis. But it can occur in patients with no history and be associated with cholelithiasis. Early diagnosis of this potentially fatal complication is important to facilitate urgent surgical management, imaging support being necessary for its suspicion.

Proteína C reactiva y su relación con las complicaciones posoperatorias en cirugía colorrectal electiva / Association between C-reactive protein and postoperative complications in elective colorectal surgery

RESUMEN Antecedentes: el uso de la proteína C reactiva (PCR) ha adquirido relevancia como identificador de complicaciones posoperatorias La morbilidad en cirugía colorrectal se estima en un 30% de los pacientes operados, lo que demanda medidas para su temprana identificación y terapéutica. Objetivo: describir las curvas de mediciones sucesivas de PCR y su relación con el desarrollo de complicaciones posoperatorias y niveles de glóbulos blancos en una serie de pacientes operados de cirugía colorrectal. Materiales y métodos: se realizó una revisión retrospectiva sobre un registro prospectivo de 2205 pacientes operados por la División de Cirugía Gastroenterológica del Hospital de Clínicas, entre enero de 2019 y julio de 2020. Se incluyeron 69 pacientes que cumplieron con los criterios de selección. Se consignaron datos del seguimiento clínico y dosaje de PCR, recuento de glóbulos blancos, vía de abordaje y desarrollo de complicaciones. Resultados: el promedio de edad fue de 59 años (DS 13,6; rango 33-85), 31 fueron hombres (43%). La tasa de complicaciones fue del 13,04%; más frecuente fue la fístula anastomótica (fístula, colección), seguida por complicaciones de la herida (hematoma, evisceración). Todos los pacientes mostraron un ascenso inicial del valor de PCR entre el 2° y 3er día, en relación con la lesión quirúrgica, los no complicados presentaron una cinética de descenso y los complicados. curvas de segundo ascenso o no descenso en las mediciones seriadas de PCR, y exhibían valores superiores de PCR cada día Se advirtieron diferencias estadísticamente significativas entre los valores de proteína C reactiva al 5° día posoperatorio en el subgrupo de pacientes complicados con respecto a aquellos con un curso indolente (28 mg/dL vs. 6,1 mg/dL, p < 0,001; IC: 11,24-39,61). hubo diferencia significativa al 5o día entre complicados y no complicados, independientemente de la vía de abordaje. con un valor de corte de PCR de 10,92 mg/dL obtuvimos una sensibilidad del 87,50% y una especificidad del 100% para excluir complicaciones. Conclusiones: la medición de la proteína C reactiva de forma seriada en los posoperatorios de cirugía colorrectal mostró un correlato con la identificación temprana de las complicaciones en nuestra serie, tanto en sus valores absolutos diarios como en la cinética de su comportamiento. se formula el uso de valores de corte para el alta segura.

ABSTRACT Background: The use of C-reactive protein (CRP) has gained relevance as a marker of marker of postoperative complications. As the incidence of complications of colorectal surgery is estimated to be of 30%, measures should for their early identification and treatment. Objective: To describe the performance of consecutive CRP determinations and their relationship with the development of postoperative complications and with white blood cell count in a series of patients undergoing colorectal surgery. Materials and methods: A retrospective review was performed using a prospective registry of 2205 patients operated on at the Department of Digestive Surgery of Hospital de Clínicas, between January 2019 and July 2020. A total of 69 patients fulfilling the selection criteria were included. Clinical follow-up data, CRP levels, white blood cell count, type of approach and development of complications were recorded. Results: Mean age was 59 years (SD 13.6; range 33-85) and 31 were men (43%). The complication rate was 13.04%. Anastomotic leak (fistula, fluid collection) was the most common complication, followed by surgical site complications (hematoma, evisceration). All patients showed an initial increase in CRP values between days 2 and 3, in relation with the surgical lesion, and then decreased in those without complications. Patients with complications had second rise or lack of decrease in serial CRP measurements, and higher CRP values each day. There were statistically significant differences between the CRP levels on postoperative day 5 in the subgroup of patients with complications compared with those with an indolent course (28 mg/dL vs. 6.1 mg/dL, p < 0.001; CI: 11.24-39.61). There was a significant difference on day 5 between patients with and without complications, irrespective of the approach. With a cut-off value of CRP of 10.92 mg/dL on postoperative day 5 we obtained a sensitivity of 87.50% and specificity of 100% to rule out complications. Conclusions: Serial determination of CRP in the postoperative period after colorectal surgery was associated with early identification of complications in our series, both in daily absolute values and in the kinetics of its performance. The use of cut-off values for safe discharge is proposed.