[Mirizzi syndrome: experience at Spanish Hospital of Veracruz]. / Síndrome de Mirizzi. Experiencia del Hospital Español de Veracruz.

BACKGROUND: Mirizzi syndrome is a complication of gallbladder stones impacted in Hartmann's pouch or cystic duct with compression of the bile duct. The diagnosis is made by imaging studies, although most of them are found through intraoperative surgical findings. Treatment is cholecystectomy and bile duct restoration when needed. OBJECTIVE: to analyze a series of cases of Mirizzi syndrome and compare the results with those published in the literature. CLINICAL CASE: We report 4 cases with Mirizzi syndrome in a cohort of 1,034 cases studied in the Hospital Español of Veracruz over 21 years. RESULTS: In our series the frequency of Mirizzi syndrome was 0.38%, the average age was 32.1 ± 58.4 years, 50% were male gender and 25% had jaundice with a demonstrable liver profile. In 1 case, ultrasound suggested Mirizzi syndrome and percutaneous cholangiography and computed tomography confirmed the diagnosis. All patients underwent laparoscopic cholecystectomy, and 2 transcystic cholangiographies were performed. One case was classified as Type I-A and three as type I-B. (Beltran and Csendes). The postoperative evolution was satisfactory in all and no mortality was presented. CONCLUSIONS: Mirizzi syndrome should be suspected in patients with gallstones who develop obstructive jaundice and it must be confirmed with imaging studies. The surgeon must take extreme precautions to avoid accidental injury to the bile ducts.

Antecedentes: el síndrome de Mirizzi es una complicación de la litiasis vesicular por cálculos impactados en la bolsa de Hartmann o conducto cístico que comprimen la vía biliar principal; el diagnóstico se establece mediante estudios de imagen, aunque la mayor parte son hallazgos transoperatorios; su tratamiento es la colecistectomía con restauración de la vía biliar. Objetivo: analizar una serie de casos de síndrome de Mirizzi y comparar los resultados con lo publicado en la bibliografía mundial. Casos clínicos: se comunican cuatro casos con síndrome de Mirizzi de una cohorte de 1,034 casos con enfermedad litiásica vesicular del Hospital Español de Veracruz, en 21 años. La frecuencia en esta muestra es de 0.38%, con edad promedio de 32.1 ± 58.4 años; 50% son hombres y 25% tuvo ictericia y coluria con perfil hepático demostrativo. En un caso el ultrasonido sugirió síndrome de Mirizzi; el diagnóstico se corroboró por colangiografía percutánea y tomografía computada. A todos los pacientes se les realizó colecistectomía laparoscópica, y en dos se efectuó colangiografía transcística. Un caso correspondió al tipo I-A y 3 al tipo I-B según la Clasificación de Beltrán y Csendes. La evolución postoperatoria fue satisfactoria y no hubo mortalidad. Conclusiones: el síndrome de Mirizzi debe sospecharse en pacientes con litiasis vesicular con ictericia obstructiva. El cirujano debe extremar las precauciones para evitar lesionar la vía biliar.

Nuevos paradigmas en el manejo de la apendicitis / New paradigms in the management of appendicitis

Objetivo: Analizar y comparar los resultados obtenidos con las diferentes técnicas quirúrgicas que existen y el manejo conservador de la apendicitis. Sede: Instituto de Investigaciones Médico-Biológicas y Facultad de Medicina de la Universidad Veracruzana. Diseño: Revisión de la literatura. Material y métodos: Se procedió a la revisión bibliográfica de los principales artículos científicos publicados en los últimos 6 años, así como las bases de datos en las fuentes electrónicas de las bibliotecas EBSCOhost, Cochrane y UpToDate. Se analiza y presenta toda la literatura crítica sobre el tratamiento de la apendicitis complicada y no complicada por medio de cirugía convencional, cirugía laparoscópica, NOTES®, cirugía a través de un solo puerto, manejo médico y/o manejo conservador, publicadas entre los años 1996 y 2012. Resultados: La apendicetomía convencional ha sido durante muchos años el estándar de oro para su manejo. En 1982, se introdujo el abordaje laparoscópico que ha demostrado ser tan seguro y eficiente como la cirugía convencional; posteriormente, en 2004, se introdujo la cirugía endoscópica a través de orificios naturales (NOTES®), y en 2007, la cirugía a través de un solo puerto. Recientemente, han aparecido publicaciones sobre su manejo conservador con cirugía de intervalo, lo cual evita un gran número de intervenciones innecesarias con morbimortalidad, comparables a los pacientes sometidos a cirugía en forma urgente. Conclusiones: La apendicetomía continúa siendo el estándar de oro del manejo de la apendicitis aguda; sin embargo, han surgido alternativas de manejo diferentes al criterio quirúrgico tradicional, las cuales han demostrado ser útiles y permiten disminuir la cirugía innecesaria, sin incremento de la morbimortalidad.

Objective: To analyze and compare the results obtained with the diverse surgical techniques currently in use and the conservative management of appendicitis. Setting: Institute of Medical Biological Research and School of Medicine of the University of Veracruz, Mexico. Design: Review of the literature. Material and methods: We performed a bibliographical review of the main scientific articles published in the last 6 years, as well as of the databases contained in the EBSCOhost, Cochrane and UpToDate electronic libraries. We analyze and present critical literature on the management of complicated and non-complicated appendicitis by means of conventional surgery, laparoscopic surgery, NOTES® surgery, one-port surgery, medical handling and/or conservative management, published between 1996 and 2012. Results: Conventional appendicectomy has been for many years the gold standard for its management. In 1982, the laparoscopic approach was introduced and has shown to be as safe and efficient as conventional surgery; later on, in 2004, the natural orifice transluminal endoscopic surgery (NOTES®) was introduced, and surgery through only one port was introduced in 2007. Recently, reports on the conservative management with interval surgery have been published, which avoids a large number of unnecessary intervention with morbidity and mortality comparable to that of patients subjected to emergency surgery. Conclusions: Appendicectomy remains the gold standard for the management of acute appendicitis; however, alternatives have arisen for a different management to that of the traditional surgical criterion, which have demonstrated to be useful and have allowed diminishing unnecessary surgeries, without increasing morbidity and mortality.

Heller myotomy and laparoscopic fundoplication in achalasia. A retrospective experience.

BACKGROUND: Laparoscopic myotomy associated with fundoplication is a useful therapeutic resource for the treatment of achalasia. The aim of the study was to analyze the outcomes of the surgical treatment of achalasia in a group of patients treated at the Hospital Naval de la Secretaría de Marina and at the Hospital Español in Veracruz during a 6-year period. METHODS: Eleven patients were submitted to myotomy and fundoplication. Variables analyzed were age, gender, symptom duration, surgical complications, surgical time, day/stay, and postoperative morbidity. RESULTS: Mean age was 41.7 years ± 7.69 years; 63.64% of the patients were male and 36.36% were female. Average time from symptom onset was 2.5 ± 1.38 years. All patients had received previous unsuccessful medical and endoscopic treatment. Diagnosis was confirmed by esophagogram, endoscopy and manometry. All patients underwent Heller myotomy and fundoplication. Operative time was 140.4 ± 26.2 min. Average days/stay was 3.7 ± 1.4 days. Postoperative course was satisfactory in all patients and there was no perioperative mortality. Average follow-up was 3.8 ± 2.3 years. CONCLUSIONS: In our group, laparoscopic myotomy with fundoplication was a safe procedure offering excellent results comparable with those published in the literature. There is controversy about the type of fundoplication; therefore, the choice is at the discretion of the surgeon.

Enfermedad diverticular complicada: Manejo quirúrgico en el Hospital Español de Veracruz / Complicated diverticular disease: Surgical management at the Hospital Español de Veracruz

Objetivo: Evaluar los resultados del tratamiento quirúrgico de pacientes con enfermedad diverticular complicada en un periodo de 9 años. Sede: Hospital Español de Veracruz (tercer nivel de atención). Diseño: Observacional, descriptivo, transversal, retrospectivo. Análisis estadístico: Medidas de frecuencia relativa y tendencia central. Pacientes y métodos: Estudio de 41 pacientes operados por enfermedad diverticular del colon complicada. Variables analizadas: Características sociodemográficas, factores de riesgo, indicaciones quirúrgicas, técnica quirúrgica empleada, complicaciones y evolución postoperatoria. Resultados: La edad promedio fue 66 ± 12.3 años, con predominio del género femenino (51.22%). Las principales indicaciones quirúrgicas fueron: perforación (43.90%), diverticulitis de repetición (21.95%), hemorragia (19.51%), fístula de colon a vejiga y vagina (9.76%) y obstrucción (4.88%). La obesidad fue el factor de riesgo más frecuente (24.39%). En el 56.10% de los casos la cirugía fue electiva. En el 92.69% se efectuó resección primaria con anastomosis y en 7.31% procedimiento de Hartmann. La evolución de los pacientes fue satisfactoria en el 78.05%. La mortalidad del grupo fue de 2.44%. Conclusiones: La experiencia de nuestro grupo en el manejo de la enfermedad diverticular complicada revela una elevada morbilidad, con mortalidad similar a la reportada en la literatura mundial. Es recomendable que el manejo sea realizado por cirujanos expertos y en hospitales de concentración.

Objective: To assess the results of surgical treatment of patients with complicated diverticular disease in a 9-year period. Setting: Hospital Español de Veracruz (third level health care). Design: Observational, descriptive, cross-sectional, retrospective study. Statistical analysis: Relative frequency and central tendency measures. Patients and methods: We studied 41 patients with complicated colonic diverticular disease. Analyzed variables were: sociodemographic characteristics, risk factors, surgical indications, surgical technique used, complications, and postoperative evolution. Results: Average age was of 66 ± 12.3 years, predominating women (51.22%). The main surgical indications were: perforation (43.90%), recurring diverticulitis (21.95%), hemorrhage (19.51%), colon fistula toward the bladder and vagina (9.76%), and obstruction (4.88%). Obesity was the most frequent risk factor (24.39%). Surgery was elective in 56.10% cases. Primary resection with anastomoses was performed in 92.69% of the cases and Hartman's procedure in 7.31%. Evolution of patients was satisfactory in 78.05%, and mortality in the group was of 2.44%. Conclusions: Our experience in the management of complicated diverticular disease reveals a high morbidity, with mortality similar to that reported in the worldwide literature. It is advisable that management be performed by experienced surgeons and at concentration hospitals.