Percutaneous cholecystostomy as treatment for acute cholecystitis: What has happened over the last five years? A literature review. / Colecistostomía percutánea como tratamiento de colecistitis aguda: ¿qué ha pasado en los últimos 5 años? Revisión de la literatura.

Acute cholecystitis is one of the most frequent diseases faced by the general surgeon. In recent decades, different prognostic factors have been observed, and effective treatments described, to improve the results in patients with said pathology (lower morbidity and mortality, shorter hospital stay, and minimum conversion of laparoscopic to open procedures). In general, laparoscopic cholecystectomy is the standard treatment for acute cholecystitis, but it is not exempt from complications, especially in patients with numerous comorbidities or those that are critically ill. Percutaneous cholecystostomy emerged as a less invasive alternative for the treatment of acute cholecystitis in patients with organ failure or a prohibitive surgical risk. Even though it is an effective procedure, its usefulness and precise indications are subjects of debate. In addition, there is little evidence on cholecystostomy catheter management. We carried out a review of the literature covering the main aspects physicians involved in the management of acute cholecystitis should be familiar with.

Vagal blocking improves glycemic control and elevated blood pressure in obese subjects with type 2 diabetes mellitus.

BACKGROUND: An active device that downregulates abdominal vagal signalling has resulted in significant weight loss in feasibility studies. OBJECTIVE: To prospectively evaluate the effect of intermittent vagal blocking (VBLOC) on weight loss, glycemic control, and blood pressure (BP) in obese subjects with DM2. METHODS: Twenty-eight subjects were implanted with a VBLOC device (Maestro Rechargeable System) at 5 centers in an open-label study. Effects on weight loss, HbA1c, fasting blood glucose, and BP were evaluated at 1 week to 12 months. RESULTS: 26 subjects (17 females/9 males, 51 ± 2 years, BMI 37 ± 1 kg/m(2), mean ± SEM) completed 12 months followup. One serious adverse event (pain at implant site) was easily resolved. At 1 week and 12 months, mean excess weight loss percentages (% EWL) were 9 ± 1% and 25 ± 4% (P < 0.0001), and HbA1c declined by 0.3 ± 0.1% and 1.0 ± 0.2% (P = 0.02, baseline 7.8 ± 0.2%). In DM2 subjects with elevated BP (n = 15), mean arterial pressure reduced by 7 ± 3 mmHg and 8 ± 3 mmHg (P = 0.04, baseline 100 ± 2 mmHg) at 1 week and 12 months. All subjects MAP decreased by 3 ± 2 mmHg (baseline 95 ± 2 mmHg) at 12 months. CONCLUSIONS: VBLOC was safe in obese DM2 subjects and associated with meaningful weight loss, early and sustained improvements in HbA1c, and reductions in BP in hypertensive DM2 subjects. This trial is registered with ClinicalTrials.gov NCT00555958.

Laparoscopic adrenalectomy: lessons learned from an initial series of 100 patients.

BACKGROUND: Laparoscopic adrenalectomy is considered the gold standard for the surgical treatment of adrenal disorders in most centers. This study analyzes the authors' experience using the lateral intraperitoneal approach with the first 100 patients. In addition to analyzing the authors' experience, this article aims to contrast it with some published series as an internal quality control. METHODS: In a 10-year period, 138 laparoscopic adrenalectomies were performed for 100 patients. Demographics, surgical results, complications, and long-term outcomes were analyzed. RESULTS: The participants comprised 69 women and 31 men with a mean age of 37 years. The procedures included 24 right, 38 left, and 38 bilateral adrenalectomies. The indications for surgery were Cushing's disease for 33 patients, pheochromocytoma (4 bilateral) for 23 patients, Cushing's syndrome for 18 patients, Conn's syndrome for 16 patients, and incidentaloma for 10 patients. Five procedures were converted to open surgery. Two patients with pheochromocytoma required intraoperative blood transfusion. The mean operative time was 174 min for unilateral adrenalectomies and 302 min for the bilateral procedures. The mean hospital stay was 5 days. Surgical morbidity included an abdominal wall hematoma, a small pneumothorax, and intraabominal bleeding in one patient that required reexploration. There were three operative mortalities not related to the technique. The long-term results showed control of hypercortisolism in all the patients with Cushing's disease and 82% of the patients with pheochromocytoma. Most of the patients with Conn's syndrome (91.4%) became normotensive after surgery. CONCLUSIONS: Laparoscopic adrenalectomy is safe and effective. The complications are mild, and mortality is related more to the patient's condition than to the surgical technique.

Comparative study of 2 variants of a modified esophageal transection in the Sugiura-Futagawa operation.

OBJECTIVE: To compare 2 techniques of esophageal transection in our modification of the Sugiura-Futagawa procedure for the treatment of bleeding portal hypertension in low-risk patients who cannot undergo surgery to have shunts placed. DESIGN: A prospective controlled trial comparing 2 variants of transection (classic, complete section of the anterior muscularis externa and whole mucosa; modified, placement of a circumferential running suture without opening the mucosa). SETTING: Academic university hospital. PATIENTS: Eighty-three low-risk patients (Child-Pugh score A and B) with a history of bleeding portal hypertension were operated on (35 classic, 48 modified transections) between 1989 and 1996. Both groups were comparable. MAIN OUTCOME MEASURES: Postoperative dehiscence of the transection was evaluated as well as fistulization, postoperative stenosis, rebleeding, postoperative endoscopic findings, survival, and mortality. RESULTS: Fistulization was observed in 1 (2%) of the patients in the modified group, and dehiscence in 1 patient (2%). In the classic group, 3 (8%) of the patients had dehiscence (relative risk, 2.6) and 1 (2%) of the patients, fistulization. No differences were observed regarding rebleeding (6 patients [6%] vs 5 patients [7%]), postoperative stenosis (4 patients [8%] vs 5 patients [10%]), postoperative endoscopic findings, survival, and mortality (early and late). CONCLUSION: The modified variant of the transection has a lower frequency of postoperative dehiscence, with the same long-term results.

Is splenectomy necessary in devascularization procedures for treatment of bleeding portal hypertension?

OBJECTIVE: To investigate whether splenectomy as a part of devascularization procedures is necessary. DESIGN: Prospective, controlled, randomized trial. SETTING: University hospital, referral center. PATIENTS: A total of 55 patients (Child-Pugh class A and B) with a history of bleeding portal hypertension were treated by means of a modified Sugiura-Futagawa procedure. Twenty-three patients underwent splenectomy and 22 did not. METHODS: Postoperative outcome was recorded and comparison of the 2 groups was done with the Fisher exact test. Kaplan-Meier survival curves were constructed. Main outcome and postoperative differences between the patients who underwent splenectomy and those who did not were investigated. RESULTS: Both groups were comparable in the postoperative period. Significant differences were observed in transfusion requirements and postoperative portal vein thrombosis, both favoring the group without splenectomy. No differences in rebleeding, encephalopathy rate, operative time, or postoperative complications were observed. CONCLUSION: Splenectomy is not routinely necessary in devascularization procedures for bleeding portal hypertension.

The first 50 cases of primary hyperparathyroidism treated by an endocrine surgery team.

BACKGROUND: Primary hyperparathyroidism (HPT) is a common endocrine disease treated very effectively by surgery. There have been changes in the management of parathyroid surgery in our hospital: since 1991, all patients have been treated by a service of endocrine surgery. OBJECTIVE: To analyze the outcome of the first 50 patients treated in the endocrine surgery service. METHODS: A prospective analysis of clinical characteristics, laboratory studies, intraoperative findings, surgical complications and outcome of 50 patients with primary HPT seen between July 1991 and March 1994 was performed. RESULTS: Ten patients were male and 40 female with a mean age of 53 years. A parathyroid adenoma was found in 43 patients, a parathyroid hyperplasia in five, a double adenoma in one and an adenoma in a supernumerary gland in one patient. Surgical cure of the disease was achieved in 96% of the patients after one surgical procedure and in 100% during the same hospital stay after repeat cervical exploration. CONCLUSIONS: Our results support the use of surgical cervical exploration in the treatment of primary HPT.

[Prolonged esophageal pH monitoring. Evaluation of 170 tests]. / pHmetria esofagiana prolongada--avaliação de 170 exames.

The authors present the experience from a university service of 170 outpatients submitted to 24-hour esophageal pH recording. Indications were: typical symptoms such as heartburn (67 patients), with and without endoscopic esophagitis, chest pain (65 patients; 40% had normal coronariography), a select group with dysphagia (28), besides eight asthmatics, one chronic intractable hiccups, and one esophageal ulcer. There was abnormal reflux in 47% of the total group. pH recording showed abnormal results in 86% of patients presenting heartburn and esophagitis and in 50% of patients without esophagitis. In the chest pain group, 37% had abnormal reflux, but pain with reflux episode could be observed only in 1/5 of them. Twenty percent of dysphagia patients had pathologic reflux and 50% among asthmactics, but the number of patients is small. Authors emphasize the importance of pHmetry as a diagnostic tool and suggest that it is important the knowledge of reflux pattern in healthy Brazilian people.