Risk Factors and Prevalence Associated With Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A Tertiary Care Hospital Experience in Western Mexico.

Introduction Laparoscopic cholecystectomy (LC) is a common procedure used for the treatment of different pathologies caused by gallstones in the gallbladder, and one of the most common indications is acute cholecystitis. The definitive treatment for acute cholecystitis is surgery, and LC is the gold standard. Nevertheless, transoperative complications (like intraoperative bleeding, anatomical abnormalities of the gallbladder, etc.) of LC and some other preoperative factors (like dilatation of bile duct, increased gallbladder wall thickness, etc.) can cause or be a risk factor for conversion to open cholecystectomy (OC). The objective of this study was to determine the risk factors and prevalence associated with the conversion from LC to OC in patients with gallbladder pathology and the indication for LC. Materials and methods This was a prospective cohort study. We included patients of both sexes over 18 years of age with gallbladder disease. To determine the risk factors associated with conversion, we performed a bivariate analysis and then a multivariate analysis. Results The rate of conversion to OC was 4.54%. The preoperative factors associated with conversion, in the bivariate analysis, were common bile duct dilatation (p=0.008), emergency surgery (p=0.014), and smoking (p=0.001); the associated intraoperative variables were: laparoscopic surgery duration (p <0.0001), Calot triangle edema (p=0.033), incapacity to hold the gallbladder with atraumatic laparoscopic tweezers (p=0.036), and choledocholithiasis (p=0.042). Laparoscopic Surgery duration was the only factor with a significant association in the multivariate analysis (p=0.0036); we performed a receiver operating characteristic (ROC) curve analysis and found a cut-off point of 120 minutes for the duration of laparoscopic surgery with a sensitivity and a specificity of 67 and 88%, respectively. Conclusion The prevalence of conversion from LC to OC is similar to that reported in the international literature. The risk factors associated with conversion to OC, in this study, should be confirmed in future clinical studies, in this same population, with a larger sample size.

Laparoscopic hepaticojejunostomy after bile duct injury.

BACKGROUND: The incidence of bile duct injuries (BDI) after cholecystectomy, which is a life-threatening condition that has several medical and legal implications, currently stands at about 0.6%. The aim of this study is to describe our experience as the first center to use a laparoscopic approach for BDI repair. METHODS: A prospective study between June 2012 and September 2014 was developed. Twenty-nine consecutive patients with BDI secondary to cholecystectomy were included. Demographics, comorbidities, presenting symptoms, details of index surgery, type of lesion, preoperative and postoperative diagnostic work-up, and therapeutic interventions were registered. Videos and details of laparoscopic hepaticojejunostomy (LHJ) were recorded. Injuries were staged using Strasberg classification. A side-to-side anastomosis with Roux-en-Y reconstruction was always used. In patients with E4 and some E3 injuries, a segment 4b or 5 section was done to build a wide anastomosis. In E4 injuries, a neo-confluence was performed. Complications, mortality, and long-term evolution were recorded. RESULTS: Twenty-nine patients with BDI were operated. Women represented 82.7% of the cases. The median age was 42 years (range 21-74). Injuries at or above the confluence occurred in 62%, and primary repair at our institution was performed at 93.1% of the cases. Eight neo-confluences were performed in all E4 injuries (27.5%). The median operative time was 240 min (range 120-585) and bleeding 200 mL (range 50-1100). Oral intake was started in the first 48 h. Bile leak occurred in 5 cases (17.2%). Two patients required re-intervention (6.8%). No mortality was recorded. The maximum follow-up was 36 months (range 2-36). One patient with E4 injury developed a hepaticojejunostomy (HJ) stenosis after 15 months. This was solved with endoscopic dilatation. CONCLUSIONS: The benefits of minimally invasive approaches in BDI seem to be feasible and safe, even when this is a complex and catastrophic scenario.

[Transgastric laparo-endoscopic approach for difficult access lesions. Experimental mode]. / Abordaje laparo-endoscópico transgástrico para lesiones de difícil acceso. Modelo experimental.

BACKGROUND: Gastric neoplasms can be treated by laparoscopy in a safe and efficient way. Some lesions are not accessible to laparoscopic surgery due to their location. A transgastric approach is proposed as an alternative. OBJECTIVE: Show the results with the application of an endoscopic laparotomy in an animal model that maintains functional anatomy, to resect the posterior gastric neoplasms of the stomach wall, close to the cardia and pre-pyloric region. METHODS: The laparo-endoscopic technique for resection of gastric neoplasms located in the posterior wall was developed in twelve pigs at the Hospital General Gea González from May to December 2011. TECHNIQUE: An endoscopy was performed to establish the site of insertion of intragastric trocars. Three gastrotomies were made in the anterior wall; under endoscopic and laparoscopic vision the trocars were inserted. The stomach was insufflated with CO2. The lesion was resected maintaining a 20 mm circumferencial margin. The gastrotomies were sutured. The statistic analysis was made with t Student and exact Fisher tests. RESULTS: One-hundred percent of resections were achieved in an average time of 102.33 minutes (± 4.50). Two complications and no transoperatory deceases occurred. DISCUSSION: The technique we describe allows an appropriate approach to gastric lesions located in the posterior wall, those near to the esophagogastric juntion and the prepiloric region, due to the excellent exposure managed by working inside the stomach with a laparoscopic vision and the two intragastric movile ports. CONCLUSIONS: The laparoscopic transgastric approach is feasible and safe for the resection of gastric neoplasms located in the posterior wall, those close to the esophago-gastric junction, and the pre-pyloric region.

Antecedentes: las neoplasias gástricas pueden tratarse de forma segura y eficaz mediante laparoscopia. Debido a su localización algunas lesiones son inaccesibles mediante cirugía laparoscópica, como alternativa se propone el abordaje transgástrico. Objetivo: exponer los resultados con la aplicación de una técnica laparo-endoscópica en un modelo animal que mantenga funcional la anatomía, para resecar neoplasias gástricas de la pared posterior del estómago, próximas al cardias y a la región pre-pilórica. Material y métodos: el estudio se efectuó entre los meses de mayo a diciembre de 2011en el Hospital General Gea González y consistió en experimentar en 12 cerdos la técnica laparo-endoscópica para resección de neoplasias gástricas de la pared posterior. La inserción de los trócares intragástricos se realizó mediante endoscopia. Se efectuaron tres gastrotomías en la pared anterior y con visión endoscópica los trócares se introdujeron con el auxilio laparoscópico. El estómago se insufló con CO2. La lesión se resecó manteniendo un margen circunferencial de 20 mm, se suturaron las gastrotomías, se utilizaron la prueba de t de Student y la prueba exacta de Fisher para el análisis estadístico. Resultados: todas las resecciones fueron exitosas y se efectuaron en un tiempo promedio de 102.33 minutos (± 4.50), hubo dos complicaciones y ninguna defunción transoperatoria. Conclusiones: el abordaje laparoscópico transgástrico es factible y seguro para resecar neoplasias de la pared posterior del estómago, próximas a la unión esófago-gástrica y área prepilórica.

[Laparoscopic choledochoduodenostomy as an optional treatment choledocholithiasis]. / Coledocoduodenoanastomosis laparoscópica como opción terapéutica en coledocolitiasis compleja.

INTRODUCTION: Choledochoduodenostomy is indicated for unsolved choledocholithiasis and biliary malignant or benign stenosis. This surgical procedure has been feared for its potential complications. This article shows our initial experience with this laparo-endoscopic approach. METHODS: We performed laparoscopic choledochoduodenoastomy in seven elderly patients with recurrent or unsolved choledocholithiasis. Additionally, laparo-endoscopic extraction of gallstones was performed in necessary cases. We gathered and analyzed the demographic data, diagnostic proofs and follow up of the patients. RESULTS: Average age of patients was 71 years, with 57.1% of women in our population. Main omorbidities of our patients included obesity in 71.4%, diabetes mellitus type 2 in 57.4%, and arterial hypertension in 42.85%. Patients had in average 2.7 previous episodes of choledocholithiasis and/or cholangitis and the average diameter of the removed stones was 22.6 mm. Average follow-up was 155 days (range 28 to 420). DISCUSSION: Laparoscopic chooledochoduodenostomy has proved to be safe, effective and be superior to open surgery, as long as an appropriate selection of patients is performed and surgeons with experience on laparoscopic techniques are available. All these factors reduce the long-term complications with which this surgical procedure has been related. CONCLUSIONS: Laparoscopic choledochoduodenostomy is an option for the definitive surgical treatment of "difficult choledocholithiasis" in elderly patients with multiple comorbidities; it also offers the advantages of the minimally invasive approaches.

Mejoría en el score de riesgo cardiovascular por la cirugía bariátrica / Improvement in the cardiovascular risk score due to bariatric surgery

Introducción: La obesidad se ha considerado como un factor de riesgo para desarrollar eventos coronarios agudos. Los principales factores para desarrollar este tipo de enfermedades están presentes en la mayoría de los pacientes sometidos a cirugía bariátrica. Objetivo: Evaluar el riesgo cardiovascular de los pacientes sometidos a cirugía bariátrica en forma preoperatoria y postoperatoria tras un seguimiento a dos años. Sede: Hospital General ''Dr. Manuel Gea González''. Diseño: Estudio retrospectivo, longitudinal, observacional y comparativo. Material y métodos: Pacientes de la clínica de cirugía bariátrica, operados con la técnica de bypass gástrico, calculando el riesgo cardiovascular de forma preoperatoria y posteriormente a dos años de seguimiento. Resultados: Se incluyeron 64 pacientes (13 hombres y 51 mujeres). La edad promedio de los hombres fue 42 años su índice de masa corporal promedio fue 49.44 kg/m², la puntuación del riesgo cardiovascular preoperatoria fue: 5.15 (2-9). Al seguimiento a dos años su índice de masa corporal promedio disminuyó a 36.23 kg/m², la puntuación del riesgo cardiovascular fue: 2.38 (0-5). En las mujeres la edad promedio fue de 36 años, su índice de masa corporal promedio previo a la cirugía fue 45.32 kg/m², la puntuación del riesgo cardiovascular fue: 4.3 (-10 a 13). A un seguimiento de dos años su índice de masa corporal promedio fue 28.64 kg/m² (20.1-42.1), la puntuación del riesgo cardiovascular fue -4.1 (-11 a 8). Conclusión: La cirugía bariátrica no sólo ha demostrado ser un método eficaz y seguro para la disminución del peso corporal en pacientes con obesidad mórbida, también aquí se demuestra que disminuye el riesgo cardiovascular que poseen estos pacientes.

Introduction: Obesity has been considered a risk factor for acute coronary events. The main factors to develop this type of diseases are present in most of the patients subjected to bariatric surgery. Objective: To assess the cardiovascular risk of patients subjected to bariatric surgery preoperatively and at 2-years follow-up. Setting: General Hospital ''Dr. Manuel Gea González''. Design: Retrospective, longitudinal, observational, and comparative study. Patients and methods: Patients from the bariatric surgery clinic, operated with the gastric bypass technique, calculating the cardiovascular risk preoperatively and at 2-year follow-up. Results: The study included 64 patients (13 men and 51 women). Average age of men was 42 years, their average body mass index was 49.44 kg/m², preoperative cardiovascular risk score was 5.15 (2-9). At 2-year follow-up, their BMI diminished to 36.23 kg/m², the cardiovascular risk score was 2.38 (0-5). In women, average age was of 36 years, their body mass index before surgery was of 45.32 kg/m², the cardiovascular risk score was 4.3 (-10 a 13). At 2-year follow-up, their average body mass index reduced to 28.64 kg/m² (20.1-42.1), and the cardiovascular risk score was -4.1 (-11 to 8). Conclusion: Bariatric surgery has not only been demonstrated as an efficacious and safe method to reduce body weight in patients with morbid obesity but also to diminish the cardiovascular risk depicted by these patients.