Experience of a reference center on ventriculo-gallbladder shunt as an alternative treatment for peritoneal failure in children.

PURPOSE: Ventriculo-peritoneal shunt is the gold standard for non-obstructive hydrocephalus. Despite advances in material, infection prevention, and valve technologies, failure can still occur. The aim of this article is to present a comprehensive study based on the experience of a reference center in pediatric neurosurgery in Rio de Janeiro with the use of the ventriculo-gallbladder shunt as an alternative to peritoneal failure. METHODS: A retrospective study was conducted from January 2018 to December 2023 of patients diagnosed with cerebrospinal fluid shunt dysfunction due to peritoneal failure and submitted to ventriculo-gallbladder shunt as an alternative in a reference center of Rio de Janeiro. RESULTS: From 2018 to 2023, 18 peritoneal failures were diagnosed. Among them, 10 patients (55.5%) were selected for ventriculo-gallbladder shunt (VGS). Different causes were responsible for the hydrocephalus in these patients. VGS was placed at a mean age of 35.4 months. Four patients had temporary complications: 2 self-limited diarrheas in the first month and 2 shunt infections. After the resolution of the infection, a new VGS was placed successfully. The average follow-up was 18.8 months (follow-up 9-68 months) without further issues. CONCLUSION: VGS is a viable option for patients facing peritoneal failure. This paper provides valuable insights into the surgical technique and outcomes associated with this alternative.

Ventriculo-gallbladder shunt: case series and literature review.

BACKGROUND: The ventriculoperitoneal shunt (VPS) is the gold-standard surgical technique to treat hypertensive hydrocephalus; however, it may fail in 20 to 70% of cases. The present study shows an alternative for patients with contraindications to VPS. METHODS: A case series of nine patients. The medical records of all patients under 17 years of age who underwent ventriculo-gallbladder (VGB) shunt at a pediatric hospital from January 2014 to October 2022 were reviewed. RESULTS: There were 6 (66.7%) males and 3 (33.3%) females. The average age of 73.6 months or 6.1 years at the time of surgery. They had undergone, on average, 5.1 VPS reviews before the VGB shunt. Five (55.5%) had complications of VGB shunt: infection (11.1%), atony (11.1%), hypodrainage (11.1%), and ventriculoenteric fistula (22.2%); all these patients got better at surgical reapproach, and in two of them, the VGB shunt was re-implanted. CONCLUSION: This case series shows a lower risk of death and a similar risk of complications compared to other alternative shunts. This article spotlighted VGB as a viable alternative when VPS fails or has contraindications.

Suturing with or without surgical glue is superior to surgical glue alone for sealing ex vivo swine gallbladders.

OBJECTIVE: To assess the effectiveness of various sealing techniques in cholecystotomies under maximum intraluminal pressure stress using an ex vivo swine model. SAMPLE: 30 gallbladders from different animals were used. METHODS: The experiment was conducted ex vivo, with the formation of 3 groups, each comprising 10 samples. Group 1 utilized a traditional single-layer Cushing suture made from polydioxanone material. Group 2 employed a single layer of Cushing suture, also made from polydioxanone material, but in conjunction with surgical glue (n-butyl cyanoacrylate). Group 3 relied solely on the use of surgical glue (n-butyl cyanoacrylate) for sealing the edges of the surgical wound. The intraluminal pressure was gauged with a pressure transducer. RESULTS: The maximum intraluminal pressures (mean ± SD) sustained in G1, G2, and G3 were, respectively, 48.70 ± 21.32 mm Hg, 110.90 ± 37.52 mm Hg, and 10.9 ± 4.07 mm Hg. Comparisons between groups showed that G2 supported significantly higher pressures (56.1% higher) than G1 (P < .001) and G3 (90.2% higher; P < .001). When G1 was compared with G3, a significantly higher pressure (77.6%) was also observed (P < .01). CLINICAL RELEVANCE: The study's conclusions demonstrated the safest suture techniques for the gallbladder and provided advice regarding the use of surgical glue.

EUS-Guided gallbladder drainage vs percutaneous transhepatic drainage in patients with acute cholecystitis: a systematic review and meta-analysis.

Occasionally, cholecystectomy is not possible because the patient is not suitable for surgery, and non-operative management should be performed. In these patients, the non-operative management can be through the percutaneous transhepatic gallbladder drainage (PTGBD) or the endoscopic gallbladder drainage. We decided to compare the efficacy and safety of PTGBD and EUS-GBD in the non-operative management of patients with acute cholecystitis. We conducted a systematic review in different databases, such as PubMed, OVID, Medline, and Cochrane Databases. This meta-analysis considers studies published until September 2021. Six studies were selected (2 RCTs). These studies included 749 patients. The mean age was 72.81 ±7.41 years, and males represented 57.4%. EUS-GBD technical success was lower than PTGBD (RR, 0.97; 95% CI, 0.95-0.99), whereas clinical success and adverse events rates were similar in both groups. Twenty-one deaths were reported in all six studies. The global mortality rate was 2.80%, without differences in both groups (2.84% and 2.77% in the EUS-GBD group and the PTGBD groups, respectively). EUS-GBD and PTGBD were successful techniques for gallbladder drainage in patients with acute cholecystitis who are non-tributary for surgery. EUS-GBD has a similar clinical success rate and a similar adverse events rate in comparison to PTGBD. The high technical success and the low adverse events rate of the EUS approach to gallbladder make this technique an excellent alternative for patients with acute cholecystitis who cannot be undergoing surgery.

Colecistite xantogranulomatosa simulando câncer de vesícula biliar: relato de caso / Xanthogranulomatous cholecystitis mimicking gallbladder cancer: case report

Introdução: A Colecistite Xantogranulomatosa (CX) é uma doença idiopática rara, caracterizada pela fibrose severa decorrente de depósitos de histiócitos lipídicos na parede da vesícula biliar (VB). Possui como principal característica um espessamento volumoso da parede da VB, com grande propensão a infiltrar-se em órgãos adjacentes, levando até mesmo à formação de fístulas. Por esse motivo, a realização de sua colecistectomia costuma ser causa de grande dificuldade, seja por via aberta ou laparoscópica, devido à fibrose excessiva. Embora seja uma condição benigna, a CX muitas vezes se estende para os órgãos vizinhos e sua aparência macroscópica pode ser confundida com câncer de VB. Objetivo: Relatar um caso raro envolvendo CX simulando um Câncer de VB e sua correlação com a literatura médica. Metodologia: Trata-se do relato de um caso atendido no Pronto Socorro da Cirurgia e Retaguarda da Enfermaria do Hospital do Servidor Público Municipal (HSPM), na cidade de São Paulo - SP. Ainda, foram revisados artigos publicados nos últimos 10 anos sobre o tema. Conclusão: Embora a CX muitas vezes possa ser confundida com câncer de VB, principalmente por conta de seus achados no diagnóstico por imagem (em termos de espessamento da parede da VB e o envolvimento de outros órgãos), a presença de cálculos biliares é muito alta nos casos de CX em comparação à neoplasia, tornando tal achado um diferencial importantíssimo na distinção das duas doenças. Já para o câncer de VB, um diagnóstico diferencial pode ser a presença de nódulos intramurais no próprio órgão. Além disso, a CX deve ser gerenciada considerando cuidadosamente os achados e contribuições de uma equipe multidisciplinar. Ainda, análises anatomopatológicas intraoperatórias podem fazer diferença, evitando que sejam realizados procedimentos que são típicos no manejo de neoplasias. Palavras-Chave: Colecistite Xantogranulomatosa, Câncer de Vesícula Biliar, Relato de Caso, Manejo, Diferenciação.

Vesicular agenesis and cholangitis, an infrequent association. Case report.

BACKGROUND: Vesicular agenesis is a rare congenital malformation. CLINICAL CASE: Male, 65 years old, preoperative diagnosis of gallbladder agenesis, presenting with cholangitis, unsatisfactory ERCP, resolution by laparotomy, drainage and biliary exploration. DISCUSSION: The association between cholangitis and gallbladder agenesis presents few reports in the universal literature, a preoperative diagnosis reduces surgical risk, anatomical alteration represents an increased risk of iatrogenic injury during surgical exploration. CONCLUSIONS: Vesicular agenesis, a rare and even more infrequent entity, its association with cholangitis, its preoperative diagnosis, facilitates a surgical plan avoiding iatrogenic injuries.

ANTECEDENTES: La agenesia vesicular es una malformación congénita poco frecuente. CASO CLÍNICO: Varón de 65 años con diagnóstico preoperatorio de agenesia vesicular, cursando con colangitis, colangiopancreatografía retrógrada endoscópica insatisfactoria, resolución por laparotomía, exploración y drenaje biliar. DISCUSIÓN: La asociación de colangitis y agenesia vesicular ha sido poco reportada en la literatura. Un diagnóstico preoperatorio disminuye el riesgo quirúrgico. La alteración anatómica representa un riesgo de lesión iatrogénica durante la exploración quirúrgica. CONCLUSIONES: La agenesia vesicular es una afección rara, y aún más infrecuente es su asociación con colangitis. Su diagnóstico preoperatorio facilita un plan quirúrgico y evita lesiones iatrogénicas.

A contemporary analysis of xanthogranulomatous cholecystitis in a Western cohort.

BACKGROUND: Xanthogranulomatous cholecystitis is a particularly destructive variant of cholecystitis marked by unique inflammatory changes evident in pathologic specimens. Multiple case series have evaluated this process. However, these often focus on differentiating it from malignancy and have largely been conducted in Asia, where the disease may differ from that seen in the Western hemisphere. This study evaluated surgical outcomes after cholecystectomy for xanthogranulomatous cholecystitis at a high-volume tertiary care institution in the United States. The goal was to determine whether the process can be identified preoperatively and whether modifications should be made to the operative approach in this setting. METHODS: Patients with histopathological confirmation of xanthogranulomatous cholecystitis who underwent cholecystectomy between 2002 and 2019 were identified from an updated institutional database. Data regarding demographics, imaging findings, surgical procedures, and perioperative complications were reviewed retrospectively. A cohort of patients undergoing cholecystectomy for more typical diagnoses was also identified for comparison. RESULTS: Twenty-seven patients with a histopathologic diagnosis of xanthogranulomatous cholecystitis were identified. The median age was 64, and 17/27 (63.0%) were male. The majority of cases were done electively on patients admitted that day (17/27). Seventeen patients were evaluated with diagnostic ultrasonography, 21 with computed tomography scan, and 8 with magnetic resonance imaging; 21/27 patients had multiple modality studies. The most common singular finding was gallbladder wall thickening, but the radiographic findings were otherwise inconsistent. Twenty-five patients had planned laparoscopic cholecystectomies, but only 10 were completed. Only 8 of the 15 converted procedures were completed as simple cholecystectomies. Five patients required subtotal cholecystectomy. Median estimated blood loss was 250 cm3, and the median time of procedure was nearly 3 hours. Eight patients had complications, including 6 severe complications such as intraoperative bile duct injury. CONCLUSION: Xanthogranulomatous cholecystitis unfortunately has a nonspecific presentation, which can make it difficult to recognize preoperatively. It is to be suspected in cases featuring a distended, severely inflamed gallbladder that does not match the benign appearance of the patient. When the diagnosis is suspected, an open approach is justified and patients should be counseled as to the increased likelihood of atypical approaches and elevated risk of complication. Referral to a hepatobiliary specialist is to be considered.

Vólvulo vesicular: un hallazgo quirúrgico / Vesicular volvulus: a surgical finding

Se describe el caso clínico de una paciente de 95 años de edad, quien acudió al Cuerpo de Guardia del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba por presentar dolor abdominal difuso, de comienzo súbito con 48 horas de evolución, acompañado de náuseas y vómitos de escasa cuantía y de coloración oscura, así como ligera distención abdominal, sin expulsión de heces ni gases. Se decidió su ingreso para tratamiento quirúrgico urgente, con el diagnóstico presuntivo de oclusión intestinal. Durante la cirugía se encontró la vesícula distendida con su pedículo torcido. Se realizó colecistectomía típica. La paciente evolucionó satisfactoriamente y no presentó complicaciones posoperatorias.

The case report of a 95 years patient is described, she went to the emergency department of Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba due to a diffuse abdominal pain, of sudden beginning with 48 hours of clinical course, accompanied by nauseas and vomits of scarce quantity and dark color, as well as slight abdominal distention, without expulsion of stools neither gases. Her admission was decided for emergency surgical treatment, with the presumptive diagnosis of intestinal occlusion. During the surgery the distended gallbladder with bent pedicle was found. A typical cholecystectomy was carried out. The patient had a favorable clinical course and she didn't present postoperative complications.

Gender Differences in Postoperative Pain, Nausea and Vomiting After Elective Laparoscopic Cholecystectomy.

BACKGROUND: Although reports suggest that pain and postoperative nausea and vomiting (PONV) may be more frequent in women, the evidence is inconsistent. The objective of this study was to investigate whether women are more sensitive to pain and PONV after laparoscopic cholecystectomy (LC). METHODS: A total of 370 women and 275 men were included in a retrospective cohort study. All underwent LC under standardized general anesthesia. The variables analyzed included clinical and anthropometric parameters. End points were the incidence of nausea, vomiting, pain, and the requirement for additional pain relievers and antiemetics to control these. RESULTS: The women were younger and had lower body weight than the men (p < 0.001). Body mass index was within the normal range for 50% of women and 30% of men (p < 0.001). Pain was more common in women at 1, 6, 12 and 24 h after surgery (p < 0.02). Narcotics in addition to the doses used to lessen pain intensity (p = 0.01) were required in 60 women and 19 men (p < 0.001). PONV was more frequent in women at 1 and 6 h after surgery (p < 0.01). Rescue antiemetics were required in 35 women and 11 men (p = 0.008). Hospital stay was shorter for men (p < 0.001). Four patients in each group developed postoperative complications (p = 0.14). There was no mortality. CONCLUSIONS: Early postoperative pain, nausea and vomiting after LC were more common in women, who more frequently required analgesic and antiemetic rescue medication.

Cholecystectomy - a potential selection bias in studies assessing the metabolic effects of bariatric surgeries.

Bile acids (BAs) are key mediators of the glycemic control after bariatric surgeries. Cholecystectomy modifies the kinetics of BAs, and whether this procedure influences the BAs pool and its metabolic response to bariatric surgeries is not known. We used targeted and untargeted metabolomics to assess whether cholecystectomy influenced plasma and fecal BAs fluctuations and the systemic metabolomic profile after Roux-en-Y gastric bypass (RYGB). Women with obesity and type 2 diabetes were included. Sample collections and clinical evaluations were performed before and 3 months after RYGB. RYGB influenced 9 fecal and 3 plasma BAs in patients with cholecystectomy (p ≤ 0.05). Comparisons between patients with and without cholecystectomy revealed different concentrations of 4 fecal and 5 plasma BAs (p ≤ 0.05). Cholecystectomy impacted the global metabolomics responses to RYGB, and patients who underwent the gallbladder removal also lacked some significant improvements in clinical markers, primarily the lipid profile. By affecting the BAs concentrations, cholecystectomy seems to alter the systemic metabolic response to RYGB. Therefore, cholecystectomy may act as a bias in assessments of the metabolic effects of bariatric surgeries and their relationships with clinical outcomes.

Técnica de linfadenectomía y resección del lecho vesicular laparoscópica por cáncer vesícula biliar incidental / Lymphadenectomy technique and laparoscopic vesicular bed resection for incidental gallbladder cancer

Resumen El cáncer de vesícula es infrecuente a nivel mundial, a diferencia de su alta incidencia en Chile. Su pronóstico es malo en general, y dependerá de su forma de presentación, siendo mejor en los casos diagnosticados después de una colecistectomía laparoscópica por patología benigna. La reintervención, que incluye la resección hepática y linfadenectomía, es el pilar de la terapia curativa en esta neoplasia. Presentamos la descripción de la técnica quirúrgica realizada en los pacientes con cáncer de vesícula de diagnóstico incidental, en el Servicio de Cirugía de Clínica Alemana de Santiago y en el Hospital de la Fuerza Aérea de Chile. El abordaje laparoscópico representa una alternativa quirúrgica válida en el tratamiento de pacientes con cáncer de vesícula biliar diagnosticados después de la colecistectomía. La estandarización de la técnica debiera contribuir a su mayor empleo y a la obtención de buenos resultados desde un punto de vista oncológico.

Gallbladder cancer is considered an infrequent disease but in Chile has a higher incidence. Prognostic is considered dismal except in those patients in whom the diagnosis is performed after the cholecystectomy specimen study. Reoperation with gallbladder bed resection and lymphadenectomy is considered the treatment in patients with incidental cases. We show the way this operation is performed in Clinica Alemana of Santiago and in the Air Force Hospital. The laparoscopic approach is an alternative to those patients in whom the diagnosis was done after the cholecystectomy. Laparoscopy allows to accomplish same objectives and to obtain identical results that the open approach. The technical standardization should contribute to spread its employment and to improve the results.

Perforación traumática aislada de la vesícula biliar: revisión de la literatura actual con reporte de un caso / Isolated gallbladder perforation following blunt abdominal trauma: literature review and case report

Resumen Introducción La lesión de la vesícula biliar secundaria a trauma abdominal cerrado constituye un evento infrecuente de perforación traumática de ella, de presentación tardía. Objetivo Revisar la literatura científica actualmente disponible y además describimos un caso. Materiales y Método Utilizando la plataforma PubMed se buscan las siguientes palabras clave: " Blunt abdominal trauma ". Se seleccionan las series con lesiones de la vesícula biliar: " Traumatic gallbladder rupture". Se seleccionan los reportes de lesiones aisladas de la vesícula biliar: " Isolated gallbladder rupture ". Se seleccionan los reportes de presentación tardía de lesiones aisladas de la vesícula biliar: " Delayed presentation of isolated gallbladder rupture ". Resultados De todas estas publicaciones se seleccionan las que a criterio de los autores son relevantes para el presente caso. Discusión La mayoría de las perforaciones de la vesícula biliar se producen en vesículas sanas de paredes delgadas distendidas por el ayuno o el consumo de alcohol. No existe una presentación clínica clásica. Los estudios imagenológicos son inespecíficos y se llega al diagnóstico definitivo durante la exploración quirúrgica. El tratamiento de esta lesión es la colecistectomía. Conclusiones El diagnóstico no es fácil, pero la resolución es relativamente simple y el pronóstico es bueno. El presente caso ilustra este tipo de lesiones en pacientes con trauma abdominal cerrado.

Introduction Gallbladder injury secondary to blunt abdominal trauma is a rare event. Aim Review the current available scientific literature and describe a case. Materials and Method Using the PubMed platform, the following keywords were searched: "Blunt abdominal trauma". Series with gallbladder lesions were selected: "Traumatic gallbladder rupture". Reports of isolated lesions of the gallbladder were selected: "Isolated gallbladder rupture". Reports of late presentation of isolated lesions of the gallbladder were selected: "Delayed presentation of isolated gallbladder rupture". Of all these publications, those that were relevant to the present case were selected according to the criteria of the authors. Case report A 20 years-old male patient suffered an abdominal trauma two weeks before presentation at our Institution. He underwent an exploratory laparotomy showing bilious content and a gallbladder perforation over the peritoneal wall as an isolated injury. Discussion Most isolated gallbladder perforations occur in healthy gallbladders with thin walls and distended because fasting or alcohol consumption. There are no classical clinical features to diagnose this specific injury and radiologic studies are nonspecific. Definitive diagnosis is often reached during surgery as it was with our patient. Recommended treatment is cholecystectomy. Conclusions This case illustrates this unique kind of gallbladder injury in patients with blunt abdominal trauma. A clear diagnosis is not easy however, the treatment is simple and prognosis is good.

Adenomyomatosis of the gallbladder in an adolescent, a very rare condition. / Adenomiomatosis vesicular en un adolescente, una afección muy rara.

Adenomyomatosis of the gallbladder is an acquired, degenerative disease characterized by epithelial proliferation with hypertrophy of the muscularis layer with forming of sinus tracts, termed Rokitansky-Aschoff sinuses. Adenomyomatosis is diagnosed mainly by ultrasonography. The pathogenesis, pathology, and indications for surgery in this condition are not well understood. It is an extremely rare condition in children. We present a case of a 17-year boy with adenomyomatosis of the gallbladder successfully managed with laparoscopic cholecystectomy.

La adenomiomatosis vesicular es una enfermedad degenerativa adquirida que se caracteriza por proliferación epitelial con hipertrofia de la capa muscular y formación de trayectos fistulosos, conocidos como senos de Rokitansky-Aschoff. La adenomiomatosis se diagnostica principalmente mediante ecografía. No se conocen cabalmente la patogenia, la patología ni las indicaciones para cirugía de esta afección. Es sumamente rara en niños. En este artículo, presentamos el caso de un varón de 17 años con adenomiomatosis vesicular tratado adecuadamente con una colecistectomía laparoscópica.

Gallbladder histological alterations in patients undergoing cholecystectomy for cholelithiasis. / Alterações histológicas da vesícula biliar de doentes submetidos à colecistectomia por colelitíase.

OBJECTIVE: to describe the histological findings of the gallbladders of patients undergoing cholecystectomy and to evaluate the presence of factors associated with gallbladder incidental cancer. METHODS: we conducted a descriptive, cross-sectional, observational study with 1,278 histopathological exams of gallbladders coming from cholecystectomy for cholelithiasis and of their reports, held from January 2008 to December 2017. RESULTS: the most common pathological finding was chronic cholecystitis, present in 1,251 patients (97.8%), followed by gallbladder cholesterolosis, in 131 (10.2%). Gallbladder cancer was identified in six patients, with a prevalence of 0.5% in this sample. There was a significant association between the presence of cancer and age ≥60 years and wall thickness ≥0.3cm. CONCLUSION: there was low prevalence of gallbladder cancer in this population, higher occurrence in the elderly and association of the tumor with gallbladder wall thickness.

OBJETIVO: descrever os achados histológicos das vesículas biliares de pacientes submetidos à colecistectomia e avaliar a presença de fatores associados ao câncer incidental da vesícula. MÉTODOS: estudo descritivo, transversal e observacional de 1.278 exames anatomopatológicos de vesículas biliares oriundas de colecistectomias por colelitíase e de seus respectivos laudos, realizadas no período de janeiro de 2008 a dezembro de 2017. RESULTADOS: o achado anatomopatológico mais frequente foi a colecistite crônica, presente em 1.251 pacientes (97,8%), seguido pela colesterolose em 131 (10,2%). O câncer de vesícula foi identificado em seis pacientes, com prevalência de 0,5% nesta amostra. Houve associação significativa entre a presença de câncer e idade ≥60 anos e com a espessura da parede ≥0,3cm. CONCLUSÃO: houve baixa prevalência de câncer de vesícula na população avaliada, maior ocorrência na população idosa e associação de tumor com espessamento da parede vesicular.

Cirugía de Rescate, Una Opción Eficaz Para Colecistectomía Laparoscópica Difícil / Cohort Study: Rescue surgery, an effective option for difficult laparoscopic cholecystectomy

INTRODUCCIÓN: El tratamiento estándar de la colecistitis aguda es la colecistectomía laparos-cópica (CL). La colecistectomía laparoscópica estándar (CLE) requiere la disección del triángu-lo de Calot y la exposición del conducto cístico; este procedimiento está asociado a lesión del conducto biliar y sangrado del lecho hepático. La colecistectomía subtotal laparoscópica (CSL) podría ser una alternativa en estas situaciones, puesto que se considera como un procedimiento asociado a escasas complicaciones. MATERIALES Y MÉTODOS: Se realizó un estudio de cohortes prospectivo. El universo incluyó a 180 pacientes en quienes se realizó una colecistectomía difícil; la misma que fue definida como: empiema, gangrena, perforación, inflamación severa con fibrosis, síndrome de Mirizzi, plastrón vesicular, cirrosis hepática y variantes anatómicas. Se clasificó en dos grupos; Grupo 1 (colecis-tectomía tradicional, 90 pacientes), y Grupo 2 (colecistectomía de rescate, 90 pacientes), en el grupo 2 se emplearon técnicas de rescate como: Pribram, subtotal reconstructiva, fenestrativa y disección retrograda. Se consideró como evento resultante la presencia de complicaciones (le-sión de vía biliar, sangrado, colecciones y coledocolitiasis residual, infección del sitio quirúrgico). Para el análisis estadístico se usó el programa SPSS 22.0 y Epidat 3.1. RESULTADOS: Se observó que la incidencia general de complicaciones en los pacientes con co-lecistectomía difícil fue de 9.44%, la incidencia de complicaciones en expuestos (colecistectomía tradicional) fue del 14.44%, versus una incidencia en no expuestos (colecistectomía de rescate) del 4.44%; RR 3.25 (IC 95%: 1.02 ­ 9.58), p= 0.04. Entre las técnicas de rescate se empleó: cole-cistectomía retrógrada 63.33% (n=57), colecistectomía tipo Pribram modificada 21.1% (n=19), subtotal reconstructiva 14.44% (n=13), y subtotal fenestrativa 0.9% (n=1). CONCLUSIÓN: La colecistectomía de rescate en colecistectomía difícil es eficaz para disminuir el riesgo de complicaciones como sangrado y lesión de vía biliar, no existió diferencia entre la frecuencia de coledocolitiasis residual entre los dos grupos.(AU)

BACKGROUND: The standard treatment for acute cholecystitis is laparoscopic cholecystectomy. Standard laparoscopic cholecystectomy requires the dissection of Calot's triangle and exposure of the cystic duct; this procedure is associated with bile duct injury and bleeding from the liver vascular bed. Laparoscopic subtotal cholecystectomy could be an alternative in these situations, since it is considered as a procedure associated with few complications. METHODS: A prospective cohort study was conducted. The universe included 180 patients in whom a difficult cholecystectomy was performed; the same was defined as: empyema, gangrene, perfo-ration, severe inflammation with fibrosis, Mirizzi syndrome, vesicular plastron, liver cirrhosis and anatomical variants. It was classified into two groups; Group 1 (traditional cholecystectomy, 90 patients), and Group 2 (rescue cholecystectomy, 90 patients), group 2 used rescue techniques such as: Pribram, subtotal reconstructive, fenestrative and retrograde dissection. The presence of com-plications (bile duct injury, bleeding, collections and residual choledocholithiasis, infection of the surgical site) was considered as an event. The softwares SPSS 22.0 and Epidat 3.1 were used for the statistical analysis. RESULTS: It was observed that the general incidence of complications in patients with difficult cholecystectomy was 9.44%, the incidence of complications in exposed patients (traditional cho-lecystectomy) was 14.44%, versus an incidence in unexposed patients (salvage cholecystectomy). 4.44%; RR 3.25 (95% CI: 1.02 - 9.58), p= 0.04. The following techniques were used: retrograde chole-cystectomy 63.33% (n=57), modified Pribram cholecystectomy 21.1% (n=19), reconstructive subto-tal 14.44% (n=13), and fenestrative subtotal 0.9 % (n=1). CONCLUSION: Rescue cholecystectomy in difficult cholecystectomy is effective to reduce the risk of complications such as bleeding and bile duct injury; there was no difference between the frequen-cies of residual choledocholithiasis between the two groups.(AU)

A Duplicated Gallbladder in a Patient Presenting with Acute Cholangitis. A Case Study and a Literature Review.

Gallbladder duplication can present a clinical challenge primarily due to difficulties with diagnosis and identification. Recognition of this anomaly and its various types is important since it can complicate a gallbladder disease or a simple hepatobiliary surgical procedure. The case report of a 63-year-old woman who presented with cholangitis and underwent a successful laparoscopic management of symptomatic gallbladder duplication is described, emphasizing several important considerations. Using ERCP, MRCP and 3D reconstructions the two cystic ducts with one common bile duct were identified. A review of the literature in referral of this variant, its anatomical classifications and significance to clinical and surgical practice is included. In conclusion, gallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder when evaluating radiologic studies. In case of surgery, preoperative diagnosis is essential to prevent possible biliary injuries or reoperation if accessory gallbladder has been overlooked during initial surgery. Laparoscopic cholecystectomy remains feasible for intervention can be safely done and awareness is necessary to avoid complications or multiple procedures.

Alterações histológicas da vesícula biliar de doentes submetidos à colecistectomia por colelitíase / Gallbladder histological alterations in patients undergoing cholecystectomy for cholelithiasis

RESUMO Objetivo: descrever os achados histológicos das vesículas biliares de pacientes submetidos à colecistectomia e avaliar a presença de fatores associados ao câncer incidental da vesícula. Métodos: estudo descritivo, transversal e observacional de 1.278 exames anatomopatológicos de vesículas biliares oriundas de colecistectomias por colelitíase e de seus respectivos laudos, realizadas no período de janeiro de 2008 a dezembro de 2017. Resultados: o achado anatomopatológico mais frequente foi a colecistite crônica, presente em 1.251 pacientes (97,8%), seguido pela colesterolose em 131 (10,2%). O câncer de vesícula foi identificado em seis pacientes, com prevalência de 0,5% nesta amostra. Houve associação significativa entre a presença de câncer e idade ≥60 anos e com a espessura da parede ≥0,3cm. Conclusão: houve baixa prevalência de câncer de vesícula na população avaliada, maior ocorrência na população idosa e associação de tumor com espessamento da parede vesicular.

ABSTRACT Objective: to describe the histological findings of the gallbladders of patients undergoing cholecystectomy and to evaluate the presence of factors associated with gallbladder incidental cancer. Methods: we conducted a descriptive, cross-sectional, observational study with 1,278 histopathological exams of gallbladders coming from cholecystectomy for cholelithiasis and of their reports, held from January 2008 to December 2017. Results: the most common pathological finding was chronic cholecystitis, present in 1,251 patients (97.8%), followed by gallbladder cholesterolosis, in 131 (10.2%). Gallbladder cancer was identified in six patients, with a prevalence of 0.5% in this sample. There was a significant association between the presence of cancer and age ≥60 years and wall thickness ≥0.3cm. Conclusion: there was low prevalence of gallbladder cancer in this population, higher occurrence in the elderly and association of the tumor with gallbladder wall thickness.