Tratamiento de la colecistitis aguda en el anciano: cirugía urgente frente a terapia médica y cirugía diferida / Treatment of acute Cholecystitis in the elderly: urgent surgery versus medical therapy and surgery delay

INTRODUCCIÓN. La colecistitis aguda (CA) en el anciano es una entidad clínica frecuente, caracterizada por la elevada tasa de complicaciones y mortalidad. La elección entre cirugía urgente o tratamiento conservador más cirugía diferida es un motivo de controversia. MATERIAL Y MÉTODOS. Estudio de una cohorte retrospectiva sobre pacientes con edad igual o superior a 70 años tratados de colecistitis aguda entre 2003 y 2009. Se analizaron parámetros epidemiológicos, clínicos, diagnósticos, quirúrgicos y de coste-efectividad. Método estadístico: utilizamos los test Chi-2, ôtõ de Student y ANOVA. El nivel de significación se estableció paravalores p < 0.05. RESULTADOS. Durante los 6 años estudiados fueron tratados 173 episodios de CA en 147pacientes (52 por ciento mujeres), con una edad media de 80.6 años (máximo 101). En 103 episodios (77 pacientes) se adoptó tratamiento médico de los que 31 se operaron de forma electiva conun 100 por ciento de abordajes laparoscópicos, baja tasa de conversión (6.4 por ciento) y morbilidad (9.6 por ciento) sin registrarse mortalidad. Otros 85 pacientes fueron intervenidos de urgencia con un 78.5 por ciento de abordajes laparoscópicos, tasa de conversión del 19.7 por ciento, morbilidad 53 por ciento y mortalidad 3.5 por ciento. CONCLUSIONES. Considerando todas las variables la cirugía urgente y el tratamiento médico seguido de colecistectomía electiva obtienen resultados similares, aunque los enfermos sometidos a colecistectomía laparoscópica precoz fueron los que mejor evolucionaron.

INTRODUCTION. Acute cholecystitis in elderly patients is a frequent disease characterized by a high mortality rate and serious complications. The choice between emergency surgery or conservative therapy in addition to delayed surgery is a controversial issue. PATIENTS AND METHODS. Retrospective cohort study over patients aged 70 years or older undergoing acute cholecystitis treatment between 2003 and 2009. Epidemiological, clinical, diagnostic, surgical and cost effectiveness parameters were analysed. Statistical method: Weuse Chi squared test, Student´s t test and ANOVA. A level of p < 0.05 was accepted as significant. RESULTS. During the six-year period studied 173 episodes of acute cholecystitis were treated on 147 patients (52 percent females), with an average age of 80.6 years (maximum 101). In 103 episodes(77 patients) medical treatment was taken, 31 of them undergone elective surgery by means of 100 percent laparoscopic approach, 6,4 percent conversion rate, 9,6 percent morbidity in absence of mortality. In other 85 patients emergency surgery was performed, 78.5 percent of them through laparoscopy approach with a conversion rate of 19.7 percent , 53 percent morbidity and 3,5 percent mortality. Conclusions. Taking into account all variables, emergency surgery and medical treatment followed by elective cholecistectomy get similar outcomes, making better progress those who underwent early laparoscopic cholecystectomy.

[Puerperal peritonitis due to vernix caseosa]. / Peritonitis puerperal por vernix caseosa.

Vernix caseosa peritonitis (VCP) is a complication caused by inflammatory response to amniotic fluid spilled into the maternal peritoneal cavity during a cesarean section.The physiopathology mechanisms are still incompletely understood. However, keratina granulomas could be induced by the squamous cells inside the vernix.In spite of its infrequent condition this entity should be included in the differential diagnosis of abdominal pain and acute abdomen in the post-partum after cesarean section.In this article, we present a case of VCP, and we discuss the clinical and histopathologic findings that allow its prompt recognition as well as to guide us towards the correct surgical and therapeutic technique.

[Treatment of acute cholecystitis in the elderly: urgent surgery versus medical therapy and surgery delay]. / Tratamiento de la Colecistitis Aguda en en el Anciano: Cirugía Urgente frente a Terapia Médica y Cirugía Diferida.

INTRODUCTION: Acute cholecystitis in elderly patients is a frequent disease characterized by a high mortality rate and serious complications. The choice between emergency surgery or conservative therapy in addition to delayed surgery is a controversial issue. PATIENTS AND METHODS: Retrospective cohort study over patients aged 70 years or older undergoing acute cholecystitis treatment between 2003 and 2009. Epidemiological, clinical,diagnostic, surgical and cost-effectiveness parameters were analysed. STATISTICAL METHOD: We use Chi squared test, Student's t test and ANOVA. A level of p < 0.05 was accepted as significant. RESULTS: During the six-year period studied 173 episodes of acute cholecystitis were treated on 147 patients (52% females), with an average age of 80.6 years (maximum 101). In 103 episodes (77 patients) medical treatment was taken, 31 of them undergone elective surgery by means of 100% laparoscopic approach, 6,4% conversion rate, 9,6% morbidity in absence of mortality. In other 85 patients emergency surgery was performed, 78.5% of them through laparoscopy approach with a conversion rate of 19.7%, 53% morbidity and 3,5% mortality. CONCLUSIONS: Taking into account all variables, emergency surgery and medical treatment followed by elective cholecistectomy get similar outcomes, making better progress those who underwent early laparoscopic cholecystectomy.

Colecistectomía laparoscópica en octogenarios / Laparoscopic cholecystectomy in octogenarians

Introducción. En el presente artículo analizamos los resultados y complicaciones de la colecistectomía laparoscópica en pacientes octogenarios. El objetivo es establecer si la cirugía endoscópica, programada o urgente, es el tratamiento electivo de la colelitiasis en edades extremas.Materiales y métodos. Realizamos un estudio retrospectivo sobre pacientes con edad igual o superior a 80 años, sometidos a una colecistectomía laparoscópica entre enero de 2002 y junio de 2008. Los principales parámetros analizados fueron: epidemiología, forma de presentación, valoración del estado general y del riesgo anestésico, tasa de conversión, morbilidad y estancia hospitalaria.Resultados. En el periodo estudiado se intervinieron 75 pacientes, 46 mujeres (61 porciento) y 29 hombres con una edad media de 84,1 años (máxima, 94). La cirugía fue programada en 48 casos (64 porciento) y urgente en 27. La tasa de conversión a colecistectomía abierta fue de 9,3 porciento y, la estancia hospitalaria media, de 3,8 días. Dos enfermos precisaron de una reintervención y se contabilizaron dos decesos.Conclusiones. La colecistectomía laparoscópica es la técnica de elección para el tratamiento de la colelitiasis sintomática en octogenarios. La colecistitis aguda del anciano debe ser tratada mediante abordaje laparoscópico, salvo contraindicación, preferentemente antes de aparezcan complicaciones.

[Mirizzi syndrome associated with complicated cholelitiasis in the elderly patient. Diagnosis and laparoscopic treatment]. / Síndrome de Mirizzi asociado a la Colelitiasis complicada del anciano: diagnóstico y tratamiento laparoscopio.

INTRODUCTION: The Mirizzi Syndrome (MS) is a rare variation of cholelitiasis, in which a calculus impacted in the Hartmann Pouch compresses the biliary pathway triggering an obstructive jaundice, frequently followed by inflammatory phenomenon and a number of complications. OBJECTIVE: To establish the frequency of the Mirizzi Syndrome in complicated cholelitiasis in the elderly patient and analyze the most suitable diagnosis and treatment options. PATIENTS AND METHOD: Cases of Mirizzi Syndromes in symptomatic inflammatory biliary lithiasis were selected in a five-year period among patients older than 70, who had undergone urgent operation. Epidemiology, private hospital, diagnosis, operating variables, morbility and hospitalization were analyzed. RESULTS: Twelve (12) patients with Mirizzi Syndrome were detected, with an average age of 77.2 in 197 cases of complicated cholelitiasis. A laparoscopic examination was made in 67% of the cases, with a conversion rate of 50%. The most frequent finding was the biliary extrinsic compression without Csendes-I fistula (58%). The postsurgical morbility was of 58%, including two deaths (17%) and the medium-term postoperative hospital stay was of 9.5 days. CONCLUSIONS: This research emphasizes the importance of the Mirizzi Syndrome (MS) in the symptomatic cholelitiasis in geriatric patients. This syndrome usually acts like a biliar surgical emergency and the early diagnosis of an elderly patient with jaundice is the key that enables immediate biliary decompression through a cholecystectomy. Management choices are in debate; however, due to its advantages in cases of elderly patients, a laparoscopic treatment is proposed, unless strictly contraindicated.

La valva adaptable o la necesidad que aguza el ingenio / The adaptable valve or the need to rack one´s brains

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