Análisis integral de la colecistectomía en una unidad de cirugía ambulatoria y corta estancia. Experiencia de los últimos 7 años / Integral analysis of cholecystectomy in an outpatient surgery and short-stay unit. Experience of the last 7 years

Introducción: La colecistectomía laparoscópica ambulatoria (CLA) se considera en la actualidad un trazador representativo de la calidad de un servicio de cirugía general. La gran diversidad de unidades de cirugía ambulatoria dificulta la comparativa de los diferentes indicadores de calidad. Objetivo: Conocer los resultados del manejo de la CLA en un centro integrado y como afecta a sus indicadores de calidad. Pacientes y método: Estudio observacional prospectivo entre 2015 y 2021 de las colecistectomías programadas en unidad integrada. Resultados: Se intervinieron 887 pacientes, el 76,5 % (n = 679) programados en régimen ambulatorio. La pernocta no planificada (PNP) media fue del 25,2 % (n = 171), siendo el índice de sustitución del 57,8 %. Las principales causas de PNP fueron: intolerancia digestiva (48,5 %), cirugía compleja (29,2 %) y el dolor (12,8 %). Los tiempos quirúrgicos fueron superiores en los pacientes en régimen de ingreso (p < 0,001) y en aquellos que causaron PNP (p < 0,001). Un tiempo quirúrgico superior a los 45 minutos fue causa de PNP de forma significativa (p = 0,007). La tasa global de infección de sitio quirúrgico fue del 3,1 %,siendo la infección profunda del 0,59 %. Ningún paciente reingresó en las primeras 24 horas, siendo la asistencia a urgencias a 30 días del 8,2 % (n = 73),reingresando el 1,91 % (n = 17) de los pacientes, con una tasa de reintervención del 0,35 % (n = 3). La tasa de fístula biliar fue del 0,67 %. Conclusión: La CLA es una técnica segura y expansiva, aunque la obtención de parámetros de calidad estandarizados es complejo por la diversidad de unidades.(AU)

Introduction: Ambulatory laparoscopic cholecystectomy (ALC) is currently considered a representative tracer of the quality of a general surgery service. The great diversity of day surgery units makes it difficult to compare the different quality index. Objective: To know the results of the management of the CLA in an integrated center and how it affects its quality index. Patients and method: Prospective observational study between 2015 and 2021 of scheduled cholecystectomies in an integrated unit. Results: 887 patients were operated on, 76.5 % (n = 679) programmed on an outpatient basis. The average unplanned overnight stay (PNP) was 25.2 % (n = 171), with the replacement rate being 57.8 %. The main causes of PNP were: digestive intolerance (48.5 %), complex surgery (29.2 %) and pain (12.8 %). Surgical times were higher in patients on admission (p < 0.001) and in those who caused PNP (p < 0.001). Surgical time greater than 45 minutes was a significant cause of PNP (p = 0.007). The overall rate of surgical site infection was 3.1 %, with deep infection being 0.59 %. No patient was readmitted in the first 24 hours, with 30-day emergency care being 8.2 % (n = 73), readmission rate of 1.91 % (n = 17), with a reoperation rate of 0.35 % (n = 3). The biliary fistula rate was 0.67 %. Conclusion: CLA is a safe and expansive technique, although obtaining quality standard parameters is complex due to the diversity of units.(AU)

A Novel Technique for the Management of Persistent Biliary Fistulas Developing After Liver Hydatid Cyst Surgeries: Drain Clamping Technique.

BACKGROUND: External biliary fistula, where the residual cyst is associated with the biliary tree, is one of the most common complications after liver hydatid cyst surgery. Surgical procedures become a consideration for patients in whom the biliary fistula persists despite all endoscopic procedures. However, reoperation for biliary fistula after hydatid cyst surgery leads to additional complications and increases morbidity and mortality. AIM: This study aims to treat persistent biliary fistulas that develop after liver hydatid cyst surgery using a simple noninvasive technique. MATERIALS AND METHODS: External drainage surgery was performed on 295 patients with liver hydatid cysts. Endoscopic treatment methods were used in patients who developed biliary fistula after surgery. Despite all endoscopic treatment methods, 14 patients developed persistent biliary fistulas. These patients were subsequently treated using the drain clamping technique. FINDINGS: All persistent fistulas occluded in 11.86 days (with a range of 8-20 days). No complications were observed in the one-year follow-up visits. CONCLUSION: Drain clamping, a novel approach to the treatment of persistent biliary fistulas developed despite all available endoscopic methods, can be safely used. This technique resulted in a complete recovery in patients without the need for surgical procedures.

Fístula colecistogástrica diagnosticada mediante ultrasonografía endoscópica / Cholecystogastric fistula diagnosed by endoscopic ultrasonography

A case of a patient with symptoms of gastric obstruction secondary to cholecystogastric fistula is presented and a brief review of the literature is done.(AU)

[Spontaneous cholecysto-cutaneous fistula: about two cases]. / Fístula colecisto-cutánea espontánea: a propósito de dos casos.

Cholecysto-cutaneous fistula (CCF) is a rare complication of untreated biliary pathology, with fewer than 100 cases documented in the literature. Most are secondary to bacterial infection, although it has also been described in gallbladder adenocarcinoma and post trauma. Its clinical presentation is variable, being able to present systemic affection, and its most frequent external drainage site is in the right hypochondrium. Due to the low incidence of this pathology, and the variety of forms of presentation, its management does not have, to date, standardized bases. We present two cases of patients who consulted in the emergency room at the Hospital Nacional de Clínicas for presenting cholecysto-cutaneous fistula. The treatment of both was surgical.

La fístula colecisto-cutáneas (FCC) es una rara complicación de la patología biliar no tratada, habiendo menos de 100 casos documentados en la literatura. La mayoría son secundarias a infección bacteriana, aunque también fue descripta en el adenocarcinoma de vesícula y posterior a traumatismo. Su presentación clínica es variable, pudiendo presentar afección sistémica, y su sitio más frecuente de drenaje externo es en hipocondrio derecho. Debido a la baja incidencia de esta afección, y a la variedad de formas de presentación, su manejo no tiene hasta el momento bases estandarizadas. Presentamos dos casos de pacientes que consultaron por guardia de urgencias en el Hospital Nacional de Clínicas por presentar fistula colecisto-cutánea. El tratamiento de ambos fue quirúrgico.

Bronchobiliary fistula caused after percutaneous transhepatic biliary drainage treatment: A case report.

RATIONALE: Percutaneous transhepatic biliary drainage (PTBD) plays a significant role especially in the diagnosis and decompression of bile duct obstruction. However, it is associated with complications such as hemobilia, occlusion of drainage, bile leakage, and even bronchobiliary fistula (BBF). PATIENT CONCERNS AND DIAGNOSES: We herein describe a patient with a complication of BBF caused by long-term indwelling PTBD catheters. She underwent multiple operations including bilioenteric anastomosis, hepatic left lateral lobectomy, and long-term PTBD treatment. Her symptoms were mainly cough, fever, and yellow sputum and her diagnosis was confirmed by sputum culture (bilirubin detection was positive). INTERVENTIONS AND OUTCOMES: The patient recovered uneventfully by minimally invasive treatment, was discharged after 1 week of hospitalization, and the drainage tube was removed 2 weeks later. During 2 years of follow-up, no recurrence of BBF was observed. LESSONS: Patients with long-term indwelling PTBD catheters for biliary tract obstruction may lead to BBF. The treatment plan of BBF is tailored to the patient's individualized characteristics. And minimally invasive treatments might be an effective alternate way for the treatment of BBF. The accurate diagnosis, precision treatment, and multidisciplinary team play important roles in the treatment of BBF.

[Hemobilia as a sign of arterio-biliary fistula]. / Gemobiliya kak proyavlenie arteriobiliarnoi fistuly.

Hepatic artery aneurysms (HAA) are rare (20% of all visceral arteries). Most often, HAAs are asymptomatic and detected at autopsy. However, their ruptures and/or bleeding following pressure ulcers in visceral gastrointestinal organs are a significant clinical and diagnostic problem. We present 2 patients with obstructive jaundice and hemobilia. Diagnostics revealed aneurysm of the right hepatic artery with arterio-biliary fistula. Life-threatening hemobilia is a consequence of HAA rupture into biliary system. Endovascular approach is preferable for HAA without clinical manifestations. Awareness of this disease is important for early detection and active surgical intervention before possible complications.

The Presence of an Aberrant Right Hepatic Artery Did Not Influence Surgical and Oncological Outcomes After Pancreaticoduodenectomy: A Comprehensive Systematic Review and Meta-Analysis.

BACKGROUND: The presence of an aberrant right hepatic artery (a-RHA) could influence the oncological and postoperative results after pancreaticoduodenectomy (PD). METHODS: A systematic review and metanalysis were conducted, including all comparative studies having patients who underwent PD without (na-RHA) or with a-RHA. The results were reported as risk ratios (RRs), mean differences (MDs), or hazard ratios (HRs) with 95% confidence intervals (95 CI). The random effects model was used to calculate the effect sizes. The endpoints were distinguished as critical and important. Critical endpoints were: R1 resection, overall survival (OS), morbidity, mortality, and biliary fistula (BL). Important endpoints were: postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT). RESULTS: Considering the R1 rate no significant differences were observed between the two groups (RR 1.06; 0.89 to 1.27). The two groups have a similar OS (HR 0.95; 0.85 to 1.06). Postoperative morbidity and mortality were similar between the two groups, with a RR of 0.97 (0.88 to 1.06) and 0.81 (0.54 to 1.20), respectively. The biliary fistula rate was similar between the two groups (RR of 1.09; 0.72 to 1.66). No differences were observed for non-critical endpoints. CONCLUSION: The presence of a-RHA does not affect negatively the short-term and long-term clinical outcomes of PD.

Risk factors and management of biliary leakage after Endocystectomy for hepatic cystic echinococcosis.

BACKGROUND: Endocystectomy is a conservative surgical approach to managing cystic echinococcosis. Bile leakage is the main complication of this technique. The aim of this study was to evaluate the factors associated with bile leakage and to assess the outcomes and cost efficiency of strategies used to treat bile leakage. METHODOLOGY/PRINCIPAL FINDINGS: Patients who underwent endocystectomy between 2005 and 2020 were included. The preoperative characteristics, intra- and postoperative outcomes, hospital costs, and cost efficiency (the Diagnosis-Related Group reimbursement minus the overall cost) were evaluated prospectively. A total of eighty patients with 142 cysts were included. Postoperative complications occurred in 17 patients (21%), including 11 patients with bile leakage (type A: 1, type B: 6 and type C: 4 patients, total 13%). Bile leakage was more frequent in patients with preoperative MRI signs of cysto-biliary fistulas or intraoperative visible cysto-biliary fistulas (p = 0.03 and p = 0.04, respectively) and in patients with cysts larger than 8 cm (p = 0.03). Patients with bile leakage who underwent reoperation (type C) had significantly shorter hospital stays (9 vs. 16 days, p<0.01) and better cost efficiency than those who received radiologic or endocscopic interventions (€2,072 vs. -€2,097 p = 0.01). No mortality was observed, and recurrence was seen in two patients. CONCLUSIONS/SIGNIFICANCE: Endocystectomy is a safe and efficient technique. Preoperative and intraoperative cysto-biliary fistulas and a cyst diameter larger than 8 cm are correlated to postoperative bile leakage. Early operative management of bile leakage reduces hospital stay and improves cost efficiency compared with radiologic or endoscopic treatments.

Cholecystogastric fistula diagnosed by endoscopic ultrasonography.

A case of a patient with symptoms of gastric obstruction secondary to cholecystogastric fistula is presented and a brief review of the literature is done.

Íleo biliar: descripción de dos casos / Gallstone ileus: Description of two cases

Introducción. El íleo biliar es una complicación rara de la colelitiasis y su incidencia varía del 1 al 4 %. Consiste en la migración de un cálculo de la vesicular biliar al tracto gastrointestinal, generando obstrucción intestinal. Presenta síntomas inespecíficos dependiendo del nivel de la obstrucción, lo que hace que su diagnóstico no suela ser precoz, repercutiendo en el deterioro clínico del paciente. Es especialmente grave en pacientes de edad avanzada y con comorbilidades. Casos clínicos. Se reportan los casos de dos pacientes con dolor abdominal difuso, en quienes se diagnosticó íleo biliar por tomografía. Se realizó manejo quirúrgico, el primero mediante técnica abierta y estrategia de dos pasos, y el otro mediante técnica laparoscópica. Discusión. El íleo biliar es una etiología rara de obstrucción intestinal. El cálculo migra debido a una fistula colecisto-entérica y el nivel de obstrucción es con mayor frecuencia la válvula ileocecal. Los síntomas son inespecíficos y dependen del nivel de obstrucción: dolor abdominal difuso mal caracterizado, náuseas, vómito, ausencia de flatos. El diagnóstico se hace mediante tomografía abdominal, en la cual se evidencia la tríada de Rigler. El manejo es quirúrgico, con enterotomía para extraer el cálculo y resolver la obstrucción. Conclusión. El íleo biliar es una patología que debe ser considerada en el abordaje de la obstrucción intestinal, aunque sea poco frecuente. El manejo quirúrgico es clave para resolver el cuadro de obstrucción intestinal; aún así genera importante morbimortalidad en especial en pacientes de avanzada edad.

Introduction. Gallstone ileus is a rare complication of cholelithiasis, its incidence varies from 1% to 4%. It consists of the migration of a stone from the gallbladder to the gastrointestinal tract, causing intestinal obstruction. It presents with non-specific symptoms depending on the level of the obstruction, which means that its diagnosis is not usually early, with repercussions on the clinical deterioration of the patient, being serious especially in elderly patients and with comorbidities. Clinical cases. Two patients with diffuse abdominal pain are reported. A tomographic diagnosis was made showing gallstone ileus. Surgeries were performed, in the first case using an open technique and a 2-step strategy, and on the second one using a laparoscopic technique. Discussion. Gallstone ileus is a rare etiology of intestinal obstruction. Symptoms are usually poorly characterized: diffuse abdominal pain, nausea, vomiting, absence of flatus. The diagnosis is made by abdominal tomography in which Rigler's triad is evident. Management is surgical through enterotomy to remove the stone and resolve the obstruction. Conclusion. Gallstone ileus is a rare pathology that should be considered in the approach to intestinal obstruction. Surgical management is key to resolving intestinal obstruction. Even so, it generates significant morbidity and mortality, especially in elderly patients.

[Pneumobilia, pneumoperitoneum and pneumowirsung of traumatic etiology: Case report and review of the literature]. / Neumobilia, neumoperitoneo y neumowirsung de etiología traum ática: Reporte de caso y revisión de la literatura.

Pneumobilia is a phenomenon associated with the presence of a biliary-enteric fistula or manipulation of the bile duct during procedures or surgical interventions that cause dysfunction of the sphincter of Oddi. A known, but infrequently reported event, is the increase in intraabdominal pressure after closed abdominal trauma, which causes pneumobilia due to a mechanism of retrograde air leakage towards the bile duct. Depending on the general compromise of each patient, the prognosis can vary from a benign condition that only requires conservative management, to being life threatening. We present the case of a 75-year-old male patient who, after suffering a closed thoraco-abdominal trauma, presented with rib fracture and, in addition, gallbladder wall rupture, pneumoperitoneum, pneumobilia, and pneumowirsung, having a favorable clinical course after receiving conservative management.

Reduced port laparoscopic subtotal cholecystectomy for Mirizzi syndrome with a bilio-biliary fistula: A case report.

A 65-year-old male diagnosed with Mirizzi syndrome with a bilio-biliary fistula was referred to our department and underwent single-incision laparoscopic surgery with an assistant trocar. As typical laparoscopic cholecystectomy could not be performed due to the coexistence of a bilio-biliary fistula, we performed laparoscopic subtotal cholecystectomy as a bail-out procedure according to the recommendation of the recent Tokyo Guidelines (TG18). The neck of the remnant gallbladder could be easily sutured with the effective use of an assistant trocar, and the surgery was completed without any complications. The patient was discharged 5 days after surgery without any complications. While little has been reported on the efficacy of reduced port surgery for Mirizzi syndrome, our surgical approach, i.e. reduced port surgery with an assistant trocar, enabled secure and easy suturing as a bail-out procedure and seemed to be an efficient method that is both less-invasive and safe.

The management of thoracobiliary fistulas in children: a systematic review.

Thoracobiliary fistula (TBF) is a rare condition, in which an atypical communication between the bronchial tree and the biliary tree is present. A comprehensive literature search was conducted on Medline, Embase and Web of Science databases for studies reporting TBF in children. Data regarding patient demographics, site of fistula presentation, preoperative diagnostic procedures needed, and treatment modalities employed were extracted for further analysis. The study pool consisted of 43 studies incorporating 48 cases of TBF. The most frequent symptom was bilioptysis (67%), followed by dyspnea (62.5%), cough (37.5%) and respiratory failure (33%). Regarding the origin of fistula, the left hepatic duct was involved in 29 cases (60.4%), the right hepatic duct in 4 cases (8.3%), and the hepatic junction in 1 case (2%). Surgical management was employed in 46 patients (95.8%). Fistulectomy was performed in 40 patients (86.9%), lung lobectomy or pneumonectomy in 6 (13%), Roux en Y hepaticojejunostomy in 3 (6.5%), and decortication or drainage in 3 cases (6.5%). Three patients died (overall mortality 6.3%), while 17 patients suffered from postoperative complications (overall morbidity 35.4%). TBF in children is a rare but morbid entity which evolves as a result of congenital malformation in the majority of cases. Preoperative imaging of the biliothoracic communication and proper surgical treatment are the components of current management.