Cardiomiopatia de Takotsubo associada a feocromocitoma: um caso atípico e complexo / Takotsubo cardiomyopathy associated with pheochromocytoma: an atypical and complex case

INTRODUÇÃO Cardiomiopatia (CMP) induzida por estresse, como a cardiomiopatia de Takotsubo, pode ter características clínicas semelhantes à isquemia miocárdica, como elevação de troponinas, alterações no Eletrocardiograma (ECG), mas sem obstrução coronariana ou lesões isquêmicas. Semelhante, a CMP induzida por Feocromocitoma possui sintomas também semelhantes a CMP hipertrófica, hipertensão e edema pulmonar devido a fatores cardiogênicos ou não cardiogênicos. Ambas supracitadas podem ter associação com excesso de catecolaminas, mas raramente estão associadas. RELATO DO CASO Paciente masculino, 46 anos, diabético, com história de estresse por situações familiares importantes, recentemente. Chega no serviço de emergência, com queixas de dispnéia, náuseas e êmese, iniciados há 1 dia, associado a retenção urinária e parestesia em mãos e paraparesia de membros inferiores. Refere também tratamento com Amoxicilina + Clavulanato há um mês por Colecistite Aguda. Na chegada, paciente se encontrava taquicárdico, taquipneico e saturando 98% em uso de óculos nasal a 2l/min, além de acidose metabólica. Realizou-se uma tomografia computadorizada de abdome, que evidenciou uma massa em Adrenal, sugestivo de Feocromocitoma, bem como metanefrinas urinárias e catecolaminas positivas. Ainda na emergência, evoluiu com insuficiência respiratória aguda por edema agudo de pulmão, necessitando de manejo com Nitroglicerina e 03 ampolas de Furosemida e uso de máscara não reinalante a 10l/min. Foi encaminhado para Unidade de Terapia Intensiva, onde foi realizado um ECG com alterações primárias da repolarização, seguido de alterações nos valores de Troponina e alterações no Ecocardiograma (ECO) de acinesia apical, hipocinesia de todos os segmentos médios e contratilidade preservada em segmentos basais. Cateterismo cardíaco com achados semelhantes ao ECO e presença de balonamento na ventriculografia, além de ausência de lesões obstrutivas em coronárias. CONCLUSÃO A excepcionalidade desse caso diz respeito ao quadro de síndrome coronariana aguda com dois motivos plausíveis e evidenciados na condução do caso, sendo eles: CMP de Takotsubo e a induzida por Feocromocitoma. Fica evidente, pela evolução do quadro, a gravidade do mesmo e a importância de considerar diagnósticos diferenciais, inclusive os menos comuns.

Computed tomography versus ultrasound for the diagnosis of acute cholecystitis: a systematic review and meta-analysis.

OBJECTIVES: Some patients undergo both computed tomography (CT) and ultrasound (US) sequentially as part of the same evaluation for acute cholecystitis (AC). Our goal was to perform a systematic review and meta-analysis comparing the diagnostic performance of US and CT in the diagnosis of AC. MATERIALS AND METHODS: Databases were searched for relevant published studies through November 2023. The primary objective was to compare the head-to-head performance of US and CT using surgical intervention or clinical follow-up as the reference standard. For the secondary analysis, all individual US and CT studies were analyzed. The pooled sensitivities, specificities, and areas under the curve (AUCs) were determined along with 95% confidence intervals (CIs). The prevalence of imaging findings was also evaluated. RESULTS: Sixty-four studies met the inclusion criteria. In the primary analysis of head-to-head studies (n = 5), CT had a pooled sensitivity of 83.9% (95% CI, 78.4-88.2%) versus 79.0% (95% CI, 68.8-86.6%) of US (p = 0.44). The pooled specificity of CT was 94% (95% CI, 82.0-98.0%) versus 93.6% (95% CI, 79.4-98.2%) of US (p = 0.85). The concordance of positive or negative test between both modalities was 82.3% (95% CI, 72.1-89.4%). US and CT led to a positive change in management in only 4 to 8% of cases, respectively, when ordered sequentially after the other test. CONCLUSION: The diagnostic performance of CT is comparable to US for the diagnosis of acute cholecystitis, with a high rate of concordance between the two modalities. CLINICAL RELEVANCE STATEMENT: A subsequent US after a positive or negative CT for suspected acute cholecystitis may be unnecessary in most cases. KEY POINTS: When there is clinical suspicion of acute cholecystitis, patients will often undergo both CT and US. CT has similar sensitivity and specificity compared to US for the diagnosis of acute cholecystitis. The concordance rate between CT and US for the diagnosis of acute cholecystitis is 82.3%.

Outcomes after laparoscopic cholecystectomy in patients older than 80 years: two-years follow-up.

BACKGROUND: The laparoscopic cholecystectomy is the treatment of choice for patients with benign biliary disease. It is necessary to evaluate survival after laparoscopic cholecystectomy in patients over 80 years old to determine whether the long-term mortality rate is higher than the reported recurrence rate. If so, this age group could benefit from a more conservative approach, such as antibiotic treatment or cholecystostomy. Therefore, the aim of this study was to evaluate the factors associated with 2 years survival after laparoscopic cholecystectomy in patients over 80 years old. METHODS: We conducted a retrospective observational cohort study. We included all patients over 80 years old who underwent laparoscopic cholecystectomy. Survival analysis was conducted using the Kaplan‒Meier method. Cox regression analysis was implemented to determine potential factors associated with mortality at 24 months. RESULTS: A total of 144 patients were included in the study, of whom 37 (25.69%) died at the two-year follow-up. Survival curves were compared for different ASA groups, showing a higher proportion of survivors at two years among patients classified as ASA 1-2 at 87.50% compared to ASA 3-4 at 63.75% (p = 0.001). An ASA score of 3-4 was identified as a statistically significant factor associated with mortality, indicating a higher risk (HR: 2.71, CI95%:1.20-6.14). CONCLUSIONS: ASA 3-4 patients may benefit from conservative management due to their higher risk of mortality at 2 years and a lower probability of disease recurrence.

Microbiología de la colecistitis aguda y selección de antibióticos basado en el perfil de sensibilidad / Microbiology of acute cholecystitis and antibiotic selection based on sensitivity profile

OBJETIVO: determinar la microbiología y la prevalencia de cultivos de bilis positivos en la Colecistitis Aguda (CA). METODOLOGÍA DE LA INVESTIGACIÓN: serie de casos consecutivos anidados en una cohorte RESULTADOS: se han incluido 196 pacientes con un promedio de edad de 46,5 años (DE± 14,735 años) distribuidos por género en 88 pacientes del género femenino (44,9%) y 108 del género masculino (55,1%). El promedio de leucocitosis fue de 10.000 x mm3 con desvío izquierdo (80% de segmentados promedio). La prevalencia de cultivos positivos durante la CA fue de 64 pacientes (32,65%). El germen más cultivado fue la E. Coli en 28 pacientes con (43,75 %). En la sensibilidad del antibiograma, amoxicilina y Acido clavulánico presenta 53,12% de resistencia cuando están asociadas y 25,56% cuando se usa amoxicilina sola. La amikacina, ceftriaxona, cefepime, imipemen, cloranfenicol, ciprofloxacina, cotrimoxazol y gentamicina tienen sensibilidad superior al 50%. En las formas edematosas el cultivo fue de 19,7%, hidrops vesicular 31,25%, en piocolecisto el porcentaje de cultivos positivos fue de 50% y en abscesos retrovesiculares fue de 79,16%. CONCLUSIONES: la prevalencia de cultivo positivo en CA es de 32,65% con la E. Coli como germen más frecuente. La elección del antibiótico debe estar basada en el conocimiento de la microbiología del Hospital y de la sensibilidad determinada por los cultivos y antibiograma

AIM: to determine the microbiology and prevalence of positive bile culture un acute Cholecystitis. RESEARCH METODOLOGY: Consecutive case series nested in a cohort RESULTS: 196 patients with a mean age of 46,5 años (DE± 14,735 años) were included, distributed by gender 88 female patients (44,9%) and 108 male patients (55,1%). The mean leukocytosis was 10.000 x mm3 with 80% of neutrophils. The prevalence of positive bile culture in AC was in 64 patients (32,65%). The most cultivated germ was E. Coli in 28 patients (43,75 %). In the sensitivity of the antibiogram amoxilin with clavulanic acid shows 53,12% of resistence and when is used amoxicillin alone is 25,56%. Amikacin, ceftriaxon, cefepim, imipemen, chloranphenicol, ciprofloxacin, cotrimoxazole and gentamicin have sensitivity greater to 50%. In edematous AC the positive culture was 19,7%, hydrops gallblader 31,25%, in piocolecyst 50% and in retro gallbalder abscess was 79,16%. CONCLUSIONS: the prevalence positive bile culture was 32,65% with E. Coli as the most frequent germ. The choice of antibiotic should be based on the knowledge of the hospital´s microbiology and the sensitivity determinated by cultures and antibiogram

ACUTE CHOLECYSTITIS IN HIGH-RISK PATIENTS. SURGICAL, RADIOLOGICAL, OR ENDOSCOPIC TREATMENT? BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER.

Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

Factores asociados con la conversión a técnica abierta en la colecistectomía laparoscópica / Factors associated with conversion to open technique in laparoscopic cholecystectomy

Introducción. La colecistectomía laparoscópica es el estándar de oro para el manejo de la patología de la vesícula biliar con indicación quirúrgica. Durante su ejecución existe un grupo de pacientes que podrían requerir conversión a técnica abierta. Este estudio evaluó factores perioperatorios asociados a la conversión en la Clínica Central OHL en Montería, Colombia. Métodos. Estudio observacional analítico de casos y controles anidado a una cohorte retrospectiva entre 2018 y 2021, en una relación de 1:3 casos/controles, nivel de confianza 95 % y una potencia del 90 %. Se caracterizó la población de estudio y se evaluaron las asociaciones según la naturaleza de las variables, luego por análisis bivariado y multivariado se estimaron los OR, con sus IC95%, considerando significativo un valor de p<0,05, controlando variables de confusión. Resultados. El estudio incluyó 332 pacientes, 83 casos y 249 controles, mostrando en el modelo multivariado que las variables más fuertemente asociadas con la conversión fueron: la experiencia del cirujano (p=0,001), la obesidad (p=0,036), engrosamiento de la pared de la vesícula biliar en la ecografía (p=0,011) y un mayor puntaje en la clasificación de Parkland (p<0,001). Conclusión. La identificación temprana y análisis individual de los factores perioperatorios de riesgo a conversión en la planeación de la colecistectomía laparoscópica podría definir qué pacientes se encuentran expuestos y cuáles podrían beneficiarse de un abordaje mínimamente invasivo, en búsqueda de toma de decisiones adecuadas, seguras y costo-efectivas

Introduction. Laparoscopic cholecystectomy is the gold standard for the management of gallbladder pathology with surgical indication. During its execution, there is a group of patients who may require conversion to the open technique. This study evaluated perioperative factors associated with conversion at the OHL Central Clinic in Montería, Colombia. Methods. Observational analytical case-control study nested in a retrospective cohort between 2018 and 2021, in a 1:3 case/control ratio, 95% confidence level and 90% power. The study population was characterized and the associations were evaluated according to the nature of the variables, then the OR were estimated by bivariate and multivariate analysis, with their 95% CI, considering a value of p<0.05 significant, controlling for confounding variables. Results. The study included 332 patients, 83 cases and 249 controls, showing in the multivariate model that the variables most strongly associated with conversion were: the surgeon's experience (p=0.001), obesity (p=0.036), gallbladder wall thickening on ultrasonography (p=0.011), and a higher score in the Parkland classification (p<0.001). Conclusions. Early identification and individual analysis of the perioperative risk factors for conversion in the planning of laparoscopic cholecystectomy could define which patients are exposed, and which could benefit from a minimally invasive approach, in search of making safe, cost-effective, and appropriate decisions

Comparison of bacterial profile of gallbladder with gallstones from patients undergoing cholecystectomy due to complicated and uncomplicated cholelithiasis: changes in the epidemiological scenario.

INTRODUCTION: cholelithiasis is a highly prevalent disease of the digestive system in the world. In Brazil, it is a routine condition, whose studies suggest a prevalence of around 10% of adults. Colonization of bile and gallstone pathogens can occur when there is bacterial stasis and proliferation. This proliferation is facilitated by the adhesion and biofilm formation capacity of some bacteria. There are also lithogenic processes that involve bacterial participation. Studies have shown changes in the microbiota of the gallbladder of patients undergoing cholecystectomy, which may impact empirical treatment with antibiotics. METHODOLOGY: microbiological analyzes of the sonication fluid of the gallstones and of two samples with bile were performed. Identification and antimicrobial susceptibility testing were performed according to a standard routine. RESULTS: of the 34 patients, 76.4% were female. The age group was 48 years +/- 16.61. Acute cholecystitis occurred in 50% of cases. Bactobilia was evidenced in 32.1% of the cases. Klebisiella pneumoniae was noted as the most prevalent pathogen in acute cholecystitis; and Enterobacter sp, in cases of uncomplicated cholelithiasis. Greater sensitivity was obtained in the search for microorganisms in the sonication fluid samples of the stones in relation to the bile samples (p=0.0058). CONCLUSION: there was a higher prevalence of bactobilia in patients with acute cholecystitis compared to those with uncomplicated cholelithiasis. The use of sonication in bacterial investigation proved to be superior to the conventional method and can be considered.

Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute calculous cholecystitis in patients over 90 years of age.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for acute calculous cholecystitis; however, in patients at high risk for surgery, particularly in the elderly, insertion of a percutaneous catheter drainage (PCD) at gallbladder is recommended. Current evidence suggests that PCD may have less favorable outcomes than LC, but also that LC-associated complications increase in direct relation to patient age. There is no recommendation supported by robust evidence to decide between one or the other procedure in super elderly patients. METHODS: A retrospective observational cohort study was designed to analyze the surgical outcomes of super elderly patients with cholecystitis who underwent LC versus PCD for treatment. The surgical outcomes of a subgroup of high-risk patients were also analyzed. RESULTS: A total of 96 patients who met the inclusion criteria between 2014 and 2021 were included. The median age of patients were 92 years (IQR: 4.00) with a female predominance (58.33%). The overall morbidity rate in the series was 36.45% and mortality rate was 7.29%. There was no statistically significant difference when compared to the associated morbidity and mortality among patients who underwent LC versus those who underwent PCD, neither in the analysis of the complete series or in the subgroup of high-risk patients. CONCLUSIONS: The morbidity and mortality associated with the two most frequently recommended therapeutic options for operating super elderly patients with acute cholecystitis are high. We found no evidence of superiority in outcomes for either of the two procedures in this age group.

Duración de la antibioticoterapia en pacientes con colecistitis aguda manejados con colecistostomía. ¿Afecta los desenlaces clínicos? / Duration of antibiotic therapy in patients with acute cholecystitis managed with cholecystostomy. Does it affect clinical outcomes?

Introducción. En pacientes con diagnóstico de colecistitis aguda tratados con colecistostomía, el tiempo óptimo de duración de la terapia antibiótica es desconocido. El objetivo de este trabajo fue comparar los resultados clínicos en pacientes con diagnóstico de colecistitis aguda manejados inicialmente con colecistostomía y que recibieron cursos cortos de antibióticos (7 días o menos) versus cursos largos (más de 7 días). Métodos. Se llevó a cabo un estudio de cohorte observacional, retrospectivo, que incluyó pacientes con diagnóstico de colecistitis aguda manejados con colecistostomía, que recibieron tratamiento antibiótico. Se hizo un análisis univariado y de regresión logística para evaluar la asociación de variables clínicas con la duración del tratamiento antibiótico. El desenlace primario por evaluar fue la mortalidad a 30 días. Resultados. Se incluyeron 72 pacientes. El 25 % (n=18) recibieron terapia antibiótica por 7 días o menos y el 75 % (n=54) recibieron más de 7 días. No hubo diferencias significativas en la mortalidad a 30 días entre los dos grupos ni en las demás variables estudiadas. La duración de la antibioticoterapia no influyó en la mortalidad a 30 días (OR 0,956; IC95% 0,797 - 1,146). Conclusión. No hay diferencias significativas en los desenlaces clínicos de los pacientes con colecistitis aguda que son sometidos a colecistostomía y que reciben cursos cortos de antibióticos en comparación con cursos largos

Introduction.In patients with acute cholecystitis who receive treatment with cholecystostomy, the optimal duration of antibiotic therapy is unknown. The objective of this study is to compare short courses of antibiotics (7 days or less) with long courses (more than 7 days) in this population. Methods. We performed a retrospective observational cohort study which included patients diagnosed with acute cholecystitis, who received antibiotic therapy and were taken to cholecystostomy. Univariate analysis and logistic regression were performed to evaluate the association between clinical variables and the duration. The main outcome evaluated was 30-day mortality. Results. Seventy-two patients were included, 25% (n=18) were given 7 or fewer days of antibiotics while 75% (n=54) were given them for more than 7 days. Demographic data between both groups were similar (age, severity of cholecystitis, comorbidities). There were no significant differences in 30-day mortality between both groups. Antibiotic duration did not influence mortality at 30 days (OR 0.956, 95% CI 0.797 - 1.146). Conclusion. There are no significant differences in the clinical outcomes of patients with acute cholecystitis who undergo cholecystostomy and receive short courses of antibiotics compared to long courses

Laparoscopic cholecystectomy in super elderly (> 90 years of age): safety and outcomes.

BACKGROUND: Nonagenarian patients are an age group in progressive growth. In this age group, indications for surgical procedures, including cholecystectomy, will be increasingly frequent, as biliary pathology and its complications are frequent in this population group. The main objective of this study was to analyze the safety and outcomes of laparoscopic cholecystectomy in patients older than 90 years. METHODS: A retrospective observational cohort study was designed. This study involved 600 patients that were classified in 4 age groups for analysis (under 50 years, 50-69 years, 70-89 years, and over 90 years). Demographic, clinical, paraclinics, surgical, and outcome variables were compared according to age group. A multivariate analysis, which included variables considered clinically relevant, was performed to identify factors associated with mortality and complications classified with the Clavien-Dindo scale. RESULTS: The patients evaluated had a median age of 65.0 (IQR 34.0) years and there was a female predominance (61.8%). A higher complication rate, conversion rate, subtotal cholecystectomy rate, and prolonged hospital stay were found in nonagenarians. The overall mortality rate was 1.6%. Mortality in the age group over 90 years was 6.8%. Regression models showed that age over 90 years (RR 4.6 CI95% 1.07-20.13), presence of cholecystitis (RR 8.2 CI95% 1.29-51.81), and time from admission to cholecystectomy (RR 1.2 CI95% 1.10-1.40) were the variables that presented statistically significant differences as risk factors for mortality. CONCLUSION: Cholecystectomy in nonagenarian patients has a higher rate of complications, conversion rate, subtotal cholecystectomy rate, and mortality. Therefore, an adequate perioperative assessment is necessary to optimize comorbidities and improve outcomes. Also, it is important to know the greatest risk for informed consent and choose the surgical equipment and schedule of the procedure.

Retrospective validation of parkland grading scale in a Latin-American high-volume center.

BACKGROUND: Increased complication rates following laparoscopic cholecystectomies have been described, likely related to surgical difficulty, anatomical variations, and gallbladder inflammation severity. Parkland Grading Scale (PGS) stratifies the severity of intraoperative findings to predict operative difficulty and complications. This study aims to validate PGS as a postoperative-outcome predictive tool, comparing its performance with Tokyo Guidelines Grading System (TGGS). METHODS: This is a single-center retrospective cohort study where PGS and TGGS performances were evaluated regarding intraoperative and postoperative outcomes. Both univariate and bivariate analyses were performed on each severity grading scale using STATA-SE 16.0 software. Additionally, we proposed a Logistic Regression Model for each scale. Their association with outcomes was compared between both scales by their Receiver Operating Characteristic Curve. RESULTS: 400 Patients were included. Grade 1 predominance was observed for both PGS and TGGS (47.36% and 25.3%, respectively). A positive association was observed between higher PGS grades and inpatient postoperative care, length of stay, ICU care, and antibiotic requirement. Based on the area under the ROC curve, better performance was observed for PGS over TGGS in the evaluated outcomes. CONCLUSION: PGS performed better than TGGS as a predictive tool for inpatient postoperative care, length of stay, ICU, and antibiotic requirement, especially in severe cases.

Endoscopic ultrasound (EUS)-guided cholecystostomy versus percutaneous cholecystostomy (PTC) in the management of acute cholecystitis in patients unfit for surgery: a systematic review and meta-analysis.

BACKGROUND AND AIM: Surgical cholecystectomy is the gold standard strategy for the management of acute cholecystitis (AC). However, some patients are considered unfit for surgery due to certain comorbid conditions. As such, we aimed to compare less invasive treatment strategies such as endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and percutaneous gallbladder drainage (PT-GBD) for the management of patients with AC who are suboptimal candidates for surgical cholecystectomy. METHODS: A comprehensive search of multiple electronic databases was performed to identify all the studies comparing EUS-GBD versus PT-GBD for patients with AC who were unfit for surgery. A subgroup analysis was also performed for comparison of the group undergoing drainage via cautery-enhanced lumen-apposing metal stents (LAMS) versus PT-GBD. The outcomes included technical and clinical success, adverse events (AEs), recurrent cholecystitis, reintervention, and hospital readmission. RESULTS: Eleven studies including 1155 patients were included in the statistical analysis. There was no difference between PT-GBD and EUS-GBD in all the evaluated outcomes. On the subgroup analysis, the endoscopic approach with cautery-enhanced LAMS was associated with lower rates of adverse events (RD = - 0.33 (95% CI - 0.52 to - 0.14; p = 0.0006), recurrent cholecystitis (- 0.05 RD (95% CI - 0.09 to - 0.02; p = 0.02), and hospital readmission (- 0.36 RD (95% CI-0.70 to - 0.03; p = 0.03) when compared to PT-GBD. All other outcomes were similar in the subgroup analyses. CONCLUSIONS: EUS-GBD using cautery-enhanced LAMS is superior to PT-GBD in terms of safety profile, recurrent cholecystitis, and hospital readmission rates in the management of patients with acute cholecystitis who are suboptimal candidates for cholecystectomy. However, when cautery-enhanced LAMS are not used, the outcomes of EUS-GBD and PT-GBD are similar. Thus, EUS-GBD with cautery-enhanced LAMS should be considered the preferable approach for gallbladder drainage for this challenging population.

Colecistostomía en tiempos de COVID-19 / Cholecystostomy in COVID-19 Times

Introducción: Con el advenimiento de la pandemia por la enfermedad de la COVID-19 ha sido necesario reorganizar los servicios de salud y modificar en cierta medida la indicación quirúrgica en la colecistitis aguda. Objetivo: Caracterizar la colecistostomía como una alternativa segura y eficaz para la resolución de la colecistitis aguda litiásica en pacientes en los que no está indicada la cirugía, portador o no de la COVID-19. Métodos: Se realizó una revisión descriptiva narrativa desde el 2019 hasta el 2021 de las fuentes primarias y secundarias que abordan este tema; fue este período de tiempo en el que se desarrolló la pandemia provocada por SARS-Cov 2. Se usaron el Google Chrome y las bases de datos electrónicas MEDLINE/PubMed, INDEXMEDICUS y fuentes de información en revistas basadas en evidencias como ACP Journal Best Evidence y Cochrane. Desarrollo: El impacto de la crisis sanitaria sobre los servicios quirúrgicos se traduce en la cancelación de las colecistectomías electivas en el 97,6 por ciento de los centros. Esta decisión no es inocua, puesto que se ha estimado un riesgo anual de desarrollar complicaciones del 1-3 por ciento en la colelitiasis sintomática. Conclusiones: La colecistostomía es el método más acertado a utilizar para la resolución de la colecistitis aguda litiásica en pacientes en los que no está indicada la cirugía, con mala respuesta al tratamiento médico y sin tener la completa seguridad de que el paciente es o no portador de la COVID-19(AU)

Introduction: With the arrival of the COVID-19 pandemic, to reorganize health services has been necessary, as well as to modify, to a certain extent, the surgical indication for acute cholecystitis. Objective: To characterize cholecystostomy as a safe and effective alternative for the resolution of acute lithiasic cholecystitis in patients with no surgical indication, whether or not they have COVID-19. Methods: A narrative-descriptive review was carried out from 2019 to 2021 of primary and secondary sources addressing this topic; this time period marked the development of the pandemic caused by SARS-CoV-2. Google Chrome was used, together with the electronic databases MEDLINE/PubMed and INDEXMEDICUS, as well as sources of information in evidence-based journals, such as ACP Journal Best Evidence and Cochrane. Development: The impact of the health crisis over surgical services is translated into the cancellation of elective cholecystectomies in 97.6 percent of the centers. This decision is not innocuous, since an annual risk of developing complications has been estimated at 1-3 percent for symptomatic cholelithiasis. Conclusions: Cholecystostomy is the most successful method to be used for the resolution of acute lithiasic cholecystitis in patients with no surgical indication or poor response to medical treatment, without complete certainty as to whether or not the patient has COVID-19(AU)

Cholecystectomy before, simultaneously, or after ERCP in patients with acute cholecystitis: A protocol for systematic review and/or meta analysis.

INTRODUCTION: Cholecystectomy is the intervention of choice for treating acute cholecystitis; when conservative management does not work, it operates on the patient outside the critical condition. It can be performed together with or after endoscopic papillotomy through endoscopic retrograde cholangiopancreatography (ERCP) when it is concurrent with a situation of cholechodocolithiasis or when there is compression and consequent increase in pressure in the bile duct caused by a calculus jammed in the vesicular infundibulum (Mirizzi's syndrome), with or without jaundice, fever, and pain in the right hypochondrium (Charcot's Triad), which can progress to sepsis of biliary origin. This review aims to assess whether the timing of cholecystectomy (before or after ERCP) interferes with the postoperative period and clinical outcome in patients with acute cholecystitis. METHODS AND ANALYSIS: By searching the MEDLINE/PubMed, Embase, Web of Science, ScienceDirect, ClinicalTrials.gov, CINAHAL, Latin American and Caribbean Literature in Health Sciences, Scopus and Cochrane Central databases, Controlled Trials Registry Randomized clinical trials will be searched to analyze whether ERCP performed before or after open or laparoscopic cholecystectomy (LC) in patients with acute cholecystitis is beneficial or not, through the analysis of postoperative complications. No language or publication period restrictions will be imposed. The primary outcome will be postoperative complications (postoperative morbidity and mortality). Four independent reviewers will select the studies and extract data from the original publications, with a fifth reviewer in case of disagreement regarding the inclusion or not of particular research in the present review. The risk of bias will be assessed using The Risk of Bias 2 (RoB 2.0) tool, and the certainty of evidence will be evaluated using the grading of recommendations assessment, development, and evaluation. Data synthesis will be performed using the Review Manager software (RevMan V.5.2.3). To assess heterogeneity, we will calculate the I2 statistics. Additionally, a quantitative synthesis will be performed if the included studies are sufficiently homogeneous. ETHICS AND DISCLOSURE: Since the present study will review secondary data, previously published and scientifically validated, it will not be necessary to obtain ethical approval. The results of this systematic review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: International Prospective Registry of Systematic Reviews (PROSPERO) CRD42021290726.

Opciones terapéuticas para la colecistitis aguda: de las guías de Tokio 2018 a la práctica clínica / Therapeutic options for acute cholecystitis: from the Tokyo guidelines 2018 to clinical practice / Opções terapêuticas para colecistite aguda: das diretrizes de Tóquio 2018 à prática clínica

Resumen: Introducción: el tratamiento "gold standard" de la colecistitis aguda es la colecistectomía laparoscópica temprana. En pacientes añosos de alto riesgo anestésico-quirúrgico, con cuadros de evolución subaguda y/o con repercusión sistémica, es alternativa el tratamiento médico exclusivo o asociado al drenaje vesicular percutáneo. Objetivo: analizar y comparar las recomendaciones internacionales con las conductas terapéuticas en dos centros asistenciales de tercer nivel para pacientes con colecistitis aguda. Método: trabajo descriptivo, prospectivo de 161 pacientes con colecistitis aguda litiásica asistidos en los departamentos de emergencia del Hospital de Clínicas y el Hospital Español entre mayo de 2018 y mayo de 2019. Resultados: la colecistectomía laparoscópica temprana fue indicada en el 88% de los pacientes, con 3% de conversión y 9% de morbilidad. 12% recibieron manejo no operatorio, asociándose en el 65% colecistostomía percutánea. La edad avanzada, comorbilidades, discrasias y la severidad del cuadro presentaron asociación significativa con la modalidad terapéutica (p <0,05). El 40% de los pacientes en los que se realizó manejo no operatorio presentó recurrencias sintomáticas. A todos se les realizó la colecistectomía en diferido. Conclusiones: la colecistectomía laparoscópica temprana es la conducta terapéutica más frecuente. Las principales indicaciones de manejo no operatorio en nuestro medio son las características sistémicas desfavorables. El mismo presenta altas tasas de éxito y escasa morbilidad con una recurrencia sintomática del 40%.

Abstract: Introduction: early laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis. However, exclusive medical treatment (EMC) or medical treatment associated with percutaneous gallbladder drainage is the treatment of choice in elderly patients given their high surgical and anesthetic risk and upon the subacute course of the condition and/or its systemic repercussions. Objective: to analyze and compare international guidelines to the therapeutic behavior for patients with acute cholecystectomy in two third-level hospitals. Methodology: descriptive, prospective study of 161 patients with litiasic acute cholecystitis treated in the ER of Hospital de Clínicas and Hospital Español between May 2018 and May 2019. Results: early laparoscopic cholecystectomy was indicated in 88% of patients, conversion being 3% and morbidity 9%. Twelve percent of patients received non-surgical treatment, 65% of which evidenced percutaneous cholecystostomy. Old age, comorbidities, dyscrasias, and severity of the condition were closely related to the therapeutic modality (p < 0.05). Forty percent of patients who received non-surgical treatment presented symptomatic repercussions. They all underwent delayed cholecystectomy. Conclusions: early laparoscopic cholecystectomy is the most frequent treatment of choice. Unfavorable systemic characteristics are the main indications for non-surgical management in our country. This surgical treatment evidences high success rates and scarce morbidity with 40% of systemic repercussions.

Resumo: Introdução: o tratamento padrão ouro da colecistite aguda é a colecistectomia laparoscópica precoce. Em pacientes idosos com alto risco anestésico-cirúrgico, com evolução subaguda e/ou repercussão sistêmica, o tratamento clínico isolado ou associado à drenagem percutânea da vesícula biliar é uma alternativa. Objetivo: analisar e comparar recomendações internacionais com condutas terapêuticas em dois centros terciários para pacientes com colecistite aguda. Método: estudo descritivo e prospectivo de 161 pacientes com colecistite aguda de cálculos atendidos nos serviços de emergência do Hospital de Clínicas e Hospital Español no período maio de 2018 - maio de 2019. Resultados: a colecistectomia laparoscópica precoce foi indicada em 88% dos pacientes, com 3% de conversão e 9% de morbidade. 12% receberam tratamento não operatório, associado a 65% colecistostomia percutânea. Idade avançada, comorbidades, discrasias e gravidade do quadro apresentaram associação significativa com a modalidade terapêutica (p < 0,05). 40% dos pacientes nos quais o manejo não operatório foi realizado apresentaram recidivas sintomáticas. Todos foram submetidos à colecistectomia diferida. Conclusões: a colecistectomia laparoscópica precoce é a abordagem terapêutica mais frequente. As principais indicações para o manejo não operatório em nosso meio são as características sistêmicas desfavoráveis. Apresentando altas taxas de sucesso e baixa morbidade com recorrência sintomática de 40%.

Gravedad de colecistitis aguda en paciente lúpica con COVID-19 / Severity of acute cholecystitis in a lupus patient with COVID-19

Las enfermedades reumáticas constituyen un grupo de afecciones cuyo mecanismo patogénico se enfoca en la persistencia de un proceso inflamatorio que origina manifestaciones articulares y sistémicas. Aunque no es frecuente, en ocasiones el proceso inflamatorio genera complicaciones graves que requieren intervención quirúrgica como es el caso de la colecistitis aguda. Se presenta el caso de una paciente femenina de 36 años de edad, con diagnóstico de lupus eritematoso sistémico de 5 años de evolución que ingresa con COVID-19 y a los 6 días de hospitalización comienza con un cuadro franco de abdomen agudo que requirió intervención quirúrgica de urgencia. Se presenta el cuadro por la coexistencia de la enfermedad reumática, la infección por COVID-19 y el evento agudo secundario al proceso inflamatorio que causan ambas afecciones(AU)

Rheumatic diseases constitute a group of conditions whose etiopathogenic mechanism focuses on the persistence of an inflammatory process that generates joint and systemic manifestations. Although it is not frequent, sometimes the inflammatory process generates serious complications that require surgical intervention, as is the case with acute cholecystitis. The case of a 36-year-old female patient is presented, with a diagnosis of systemic lupus erythematosus of 5 years of evolution who was admitted due to symptoms compatible with COVID-19 and after 6 days of hospitalization she began with a clear picture of acute abdomen that required emergency surgical intervention. The picture is presented due to the coexistence of rheumatic disease, COVID-19 infection and the acute event secondary to the inflammatory process that both conditions generate(AU)

[Clinical practice guideline for Diagnosis and management of cholelithiasis, cholecystitis and choledocholithiasis for the Peruvian Social Security (EsSalud)]. / Guía de práctica clínica para el diagnóstico y manejo de la colelitiasis, colecistitis aguda y coledocolitiasis en el Seguro Social del Perú (EsSalud).

INTRODUCTION: This article summarizes the clinical practice guide (CPG) for the diagnosis and management of cholelithiasis, acute cholecystitis and choledocholithiasis in the Peruvian Social Security (EsSalud). OBJECTIVE: To provide clinical recommendations based on evidence for the management of patients with cholelithiasis, acute cholecystitis and choledocholithiasis in EsSalud. METHODS: a guideline task force (GTF) was formed with internists, general surgeons, gastroenterologists, and methodologists. The group proposed 10 clinical questions to be answered in this Clinical practice guideline (CPG). Systematic searches of preview reviews were performed and when it was necessary, primary studies from PubMed and CENTRAL during 2017 were reviewed. The evidence was selected aiming to answer each proposed question. Certainty of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodical work sessions, the group used GRADE methodology for reviewing the evidence and formulating recommendations, good clinical practice items and three flowcharts for diagnosis and treatment. Finally, the CPG was approved by Resolution Nº 046-IETSI-ESSALUD-2017. RESULTS: This CPG approached 10 clinical questions divided into two topics: diagnosis and management. Based on these questions; one strong recommendation, five weak recommendations, and 17 good clinical practice items and three flowcharts were formulated. CONCLUSION: This paper abstracts the methodology and evidence-based conclusions of the CPG for diagnosis and management of cholelithiasis, acute cholecystitis and choledocholithiasis in EsSalud.

Incidencia de litiasis vesicular asintomática en pacientes con complicaciones biliares / Incidence of asymptomatic gallstones in patients with biliary complications / Incidência de cálculos biliares asintomáticos em pacientes com complicações biliares

Introducción: Las complicaciones de la litiasis biliar (LB) son una causa importante de morbilidad en nuestro país y en el mundo entero y generan elevados costos en salud. Objetivo: El objetivo de este trabajo fue determinar, que pacientes con una complicación de su patología litiásica de la vía biliar (colecistitis, colangitis aguda, pancreatitis aguda), fueron previamente asintomáticos, resultando dicha complicación el debut de la enfermedad. Lugar: Sanatorio Asociación Española de Socorros Mutuos, Montevideo Uruguay. Diseño: Estudio observacional descriptivo, retrospectivo, análisis de historias clínicas. Materiales y Métodos: Se analizaron 234 casos clínicos. Se constató en este grupo de pacientes, características epidemiológicas, metodología diagnóstica, tratamientos recibidos y complicaciones. Resultados: Del total de pacientes (n=234), 109 (46.6%) tenían una litiasis vesicular asintomática (LVA) y la complicación biliar, fue el debut de su enfermedad. La colecistitis aguda fue la complicación más frecuente (68%), en segundo lugar, la colangitis aguda (22%) y en tercer lugar la pancreatitis aguda (10%). La edad promedio de presentación de la enfermedad fue los 59 años. Conclusiones: Casi la mitad de los pacientes (46.6%) que presentaron una complicación de su litiasis biliar eran asintomáticos. Este sería un argumento importante para indicar la colecistectomía laparoscópica con un criterio profiláctico en pacientes con una LVA.

Introduction : Complications of gallstones are an important cause of morbidity in our country and throughout the world and generate high health costs. Objective: The objective of this study was to determine which patients with a complication of their bile duct stone pathology (cholecystitis, acute cholangitis, acute pancreatitis) were previously asymptomatic, and this complication resulted in the onset of the disease. Place: Sanatorium Asociación Española de Socorros Mutuos, Montevideo Uruguay. Design: Descriptive and retrospective observational study with an analysis of medical records. Materials and Methods: 234 clinical cases were analyzed. Epidemiological characteristics, diagnostic methodology, treatments received, and complications were assessed in this group of patients. Results: Of the total number of patients (n=234), 109 (46.6%) had an asymptomatic gallbladder lithiasis and the biliary complication was the debut of their disease. Acute cholecystitis was the most frequent complication (68%), followed by acute cholangitis (22%) and third by acute pancreatitis (10%). The average age of presentation of the disease was 59 years. Conclusions: Almost half of the patients (46.6%) who presented a complication of their gallstones were asymptomatic. This would be an important argument to indicate laparoscopic cholecystectomy with a prophylactic criterion in patients with asymptomatic gallbladder lithiasis.

Introdução: As complicações dos cálculos biliares são uma importante causa de morbidade em nosso país e em todo o mundo e geram altos custos de saúde. Objetivo: O objetivo deste estudo foi determinar quais pacientes com uma complicação de sua patologia de cálculo do ducto biliar (colecistite, colangite aguda, pancreatite aguda) eram previamente assintomáticos, e essa complicação resultou no aparecimento da doença. Local: Sanatório Asociación Española de Socorros Mutuos, Montevidéu - Uruguai. Desenho: Estudo observacional descritivo, retrospectivo, análise de histórias clínicas. Materiais e Métodos: Foram analisados ​​234 casos clínicos. Características epidemiológicas, metodologia diagnóstica, tratamentos recebidos e complicações foram avaliadas neste grupo de pacientes. Resultados: Do total de pacientes (n=234), 109 (46,6%) apresentavam litíase vesicular assintomática e a complicação biliar foi o início da doença. A colecistite aguda foi a complicação mais frequente (68%), seguida da colangite aguda (22%) e a terceira da pancreatite aguda (10%). A idade média de apresentação da doença foi de 59 anos. Conclusões: Quase metade dos pacientes (46,6%) que apresentaram complicação de seus cálculos biliares eram assintomáticos. Esse seria um argumento importante para indicar a colecistectomia laparoscópica com critério profilático em pacientes com litíase vesicular assintomática.

Variante anatómica de la vía biliar durante la colecistectomía laparoscópica / Anatomical variant of the bile duct during laparoscopic cholecystectomy / Variante anatômica do ducto biliar durante colecistectomia laparoscópica

Se presenta la colangiografía intraoperatoria obtenida durante la colecistectomía laparoscópica de una paciente de 58 años con el diagnóstico de colecistitis aguda.