Factores pronósticos que influyen en el regreso temprano de los pacientes sometidos a colecistectomía laparoscópica ambulatoria / Prognostic factors affecting the early discharge of patients undergoing ambulatory laparoscopic cholecystectomy

Introducción: La colelitiasis sintomática es la indicación más frecuente de colecistectomía. Su abordaje por vía laparoscópica ha demostrado ser seguro y eficiente, siendo considerado actualmente el gold standard. La tendencia actual es realizarla de manera ambulatoria siempre que sea posible. No existe una aceptación generalizada de la cirugía ambulatoria debido al temor del cirujano a las potenciales complicaciones postoperatorias, y preferencia del paciente a la hospitalización. En México hay pocos hospitales que incluyen a la colecistectomía laparoscópica en programas ambulatorios. Los reportes de la literatura internacional que han determinado los factores que influyen en el tiempo de egreso temprano son escasos y de tipo retrospectivo. El objetivo de este estudio es determinar qué variables influyen en el tiempo de egreso de manera significativa. Material y métodos: Se realizó una cohorte prospectiva a los pacientes operados de colecistectomía laparoscópica en la UMAA n.° 55 IMSS, de julio de 2010 a enero de 2011. Se construyó una base de datos para determinar la relación estadística entre las variables y el tiempo de egreso. Se tomaron en consideración edad, tiempo de evo-lución de enfermedad litiásica, tiempo quirúrgico, evidencia histopatológica de agudización, complicaciones intraoperatorias, antecedente de cirugía abdominal y dolor, así como presencia de náuseas o vómitos postquirúrgicos. El investigador no influyó en la decisión de egresar u hospitalizar al paciente por ser un estudio de tipo observacional; dicha decisión corrió por parte del cirujano que realizó la intervención, tal y como se realiza de forma tradicional. Todos los pacientes fueron operados por un solo cirujano. Resultados: En el periodo comprendido entre julio de 2010 y enero de 2011 se operaron un total de 80 pacientes. De esta muestra, 64 fueron mujeres (80 %) y 16 hombres (20 %), con una media de edad de 36,9 años. El 92,5 % de los pacientes se catalogaron con una clase funcional I por la ASA. Con un IMC de 28 y una evolución de la enfermedad litiásica de 220 días, el 50 % tenía antecedentes quirúrgicos positivos. El tiempo quirúrgico fue de 80,5 minutos. Se presentaron complicaciones intraoperatorias tales como perforación (37,5 %) y sangrado 56 ml promedio. No se requirió conversión a procedimiento abierto en ningún caso. Se evaluó tanto el dolor postquirúrgico como la presencia de náuseas y vómitos al momento del egreso, a las 24 horas, ocho días, y un mes, con una media de escala visual análoga de 3,2, 3,3 y 1,1 puntos, respectivamente. Se realizó un análisis univariado por medio de V para variables cualitativas, y prueba t de student para variables cuantitativas. Solamente la variable náuseas al egreso fue significativa (p = 0,01). Conclusiones: La realización de la CL en CMA es factible, segura y eficiente. Creemos que este proceso asistencial debería ofrecerse a un número mayor de pacientes, siempre y cuando exista una correcta selección de los pacientes, un especial interés por parte de los cirujanos que la realicen y recursos hospitalarios que lo permitan (AU)

Introduction: The symptomatic cholelithiasis is the most common indication for cholecystectomy, the laparoscopic approach has proven to be safe and effective being currently considered the gold standard, the current trend is to do on an outpatient basis whenever possible. There is widespread acceptance of ambulatory surgery because of fear of the surgeon to potential postoperative complications, and patient preference to hospitalization. In Mexico there are few hospitals that include laparoscopic cholecystectomy in outpatient programs. The international literature reports have identified the factors that influence early discharge time is scarce and retrospective. The aim of this study is to determine which variables influence the time of discharge significantly . Material and methods: We conducted a prospettive cohort. For the patients undergoing laparocopic cholecystectomy in the UMMA No. 55 IMSS, July 2010 to January 2011, was built a darabase to determine the statistical relationshio between the variables and the time of discharge were considered: age, duration of stone disease, surgical time, histopathological evidence of aggravation, intraoperative complications, history of abdominal surgery, as well as pain, presence of nausea or postoperative vomiting, The investigator did not influence the decision to graduate or hospitalization for being an observational study, the decision was given part of the surgeon who perforemed the procedure, as is done traditionally. All the patients operated on by a single surgeon. Results: In the perios July 2010 to January 2011 were operated a total of 80 patients. From this sample 64 were women (80%) and 16 men (20%), mean age 36.9 years. 92.5 % of patients were classified with a functional class I by the ASA. With a BMI of 28 and an evolution of stone disease of 220 days, 50% had positive surgical history surgical time was 80.5 minutes, intraoperative complications such as bleeding and vomiting at the time od discharge, 24 hours, eight days and one month with a mean visual analog scale of 3.2, 3.3, 1.1. points respectively was carried out Univariate Analysis by X2 for qualities variables and Student t test for quantitative variables. Only variable was significant nausea at discharge (p= 0.001). Conclusions: The performance of LC in day surgery is feasible, safe and efficient. We believe this process care should be offered to a larger number of patients provided there is proper patient selection, a special interest of the surgeons who performed and hospital resources permitted (AU)

[The relationship between the effectiveness and specific features of the early postoperative rehabilitation of the patients presenting with cholelithiasis].

The objective of the early postoperative rehabilitation of the patients presenting with cholelithiasis is to prevent the further progression of the disease and reduce the risk of development of post-cholecystectomy disorders. The combined treatment including the use of low-mineralized mineral waters, magnetic, laser, and EHF-therapy makes it possible to significantly improve the parameters of interest due to the marked improve mentor normalization of the clinical and laboratory characteristics, the increase of adaptive capabilities, and the correction of the psycho-emotional and vegetative status of the patients. Taken together, the peculiarities of the combined rehabilitative treatment of the patients with cholelithiasis during the early postoperative period account for its high clinical effectiveness amounting to 94.7%. The results of the study give reason to recommend the application of the proposed technology for the rehabilitative treatment of the patients presenting with cholelithiasis.

Intervenciones de enfermería en la atención del adulto con colelitiasis y colecistitis crónica agudizada / Interventions Nursing Care Adult Chronic cholecystitis with cholelithiasis erxacerbated

Introducción. Los trastornos de la vía biliar afectan una proporción importante de la población mundial; más del 95% son atribuibles a la colecistitis aguda. La principal manifestación es el dolor agudo abdominal por lo que el 50% de los pacientes han tenido este síntoma al menos 48 horas antes de su ingreso.Método. Se realizaron cuatro búsquedas sistematizadas de información donde arrojo meta análisis, ensayos clínicos aleatorizados y/o estudios de cohorte publicados que dieron respuesta a las preguntas planteadas, de los cuales se seleccionaran las fuentes con mayor puntaje obtenido, en la evaluación de su metodología, las de mayor nivel en cuanto a gradación de evidencias y recomendaciones.Resultado. El signo de Murphy positivo en la colecistitis presenta una sensibilidad del 97%; el 95% de la colecistitis se asocia con la colelitiasis y aumenta riesgo de complicaciones, la Escala Visual Análoga (EVA) permite establecer una base de control y alivio del dolor y del 1 al 3% de las mujeres embarazadas presentan litios vesiculares.Conclusión. La colecistitis aguda ocurre entre los 30 y 80 años, siendo más frecuente en mujeres, es de importancia la valoración de los signos y síntomas, además de identificar complicaciones secundarias con la finalidad que el personal de enfermería elabore un plan de cuidados especifico ante los problemas reales del paciente, contemplando intervenciones en la ministración de medicamentos, preparación quirúrgica garantizando la seguridad del paciente y cuidados postquirúrgicos para minimizar factores de riesgo de infección y las recomendaciones del autocuidado para su egreso.

Introduction. The biliary disorders affect a significant proportion of the world population; more than 95% are attributable to acute cholecystitis. The main manifestation is abdominal pain so sharp 50% of patients have this symptom at least 48 hours before admission.Method. Four systematized information searches were performed which threw meta-analysis, randomized clinical trials and / or studies published cohort that provided answers to the questions, of which the sources were selected with the highest score obtained in the evaluation methodology ,the highest level as to grading evidence and recommendations.Result. The positive sign of cholecystitis Murphy has a sensitivity of 97%; 95% of cholecystitis and cholelithiasis associated with increased risk of complications, the Visual Analogue Scale (VAS) allows us to set a base control and pain relief and 1 to 3% of pregnant women have vesicular lithiums.Conclusion. Acute cholecystitis occurs between 30 and 80 years, being more common in women, it is important the assessment of signs and symptoms, and identify secondary complications in order that nurses develop a specific plan of care to actual problems of the patient, contemplating interventions in the ministration of medicines, surgical preparation ensuring patient safety and postoperative care to minimize infection risk factors and recommendations for self discharge.

Introdução. Os distúrbios biliares afetar uma proporção significativa da população mundial; mais de 95% são atribuíveis a colecistite aguda. A principal manifestação é a dor abdominal tão acentuada de 50% dos pacientes apresentam este síntoma pelo menos 48 horas antes da admissão.Método. quatro informações sistematizadas pesquisas onde eu jogo meta-análise, ensaios clínicos randomizados e / ou estudos publicados coorte que forneceram respostas para as perguntas, das quais as fontes foram selecionados com a maior pontuação obtida na metodologia de avaliação foram feitas, maior nível de evidências e recomendações de classificação.Resultado. O sinal positivo de colecistite Murphy tem uma sensibilidade de 97%; 95% de colecistite e colelitíase associada ao aumento do risco de complicações, a Escala Analógica Visual (VAS) permite que você defina um controle base e alívio da dor e 1 a 3% das mulheres grávidas têm lithiums vesiculares.Conclusão. colecistite aguda ocorre entre 30 e 80 anos, sendo mais comum em mulheres, é importante a avaliação de sinais e sintomas, e identificar complicações secundárias com as enfermeiras objectivo q desenvolver um plano específico de atendimento a problemas paciente real, contemplando intervenções no ministério de medicamentos, preparo cirúrgico, garantindo a segurança do paciente e cuidados pós-operatórios para minimizar os fatores de risco de infecção e recomendações para a auto descarga.

[The early postoperative rehabilitation of the patients presenting with cholelithiasis and experiencing psychoemotional stress].

Early postoperative rehabilitation of the patients presenting with cholelithiasis and experiencing psychoemotional stress is designed to restore the function of bile secretion, enhance their adaptive capabilities, and normalize the psychovegetative status for the purpose of preventing further progress of the disease and reducing the risk of the development of post-cholecystectomy syndrome. The inclusion of drinking mineral water, magnetic laser therapy, and UHF therapy in the combined rehabilitative treatment of such patients results in the appreciable enhancement of all functional abilities of the body manifest as the significant improvement and normalization of clinical and laboratory characteristics (elimination of clinical symptoms of the disease, improvement of general and biochemycal parameters of peripheral blood). Simultaneously, the adaptive capabilities and the psychovegetative status of the patients improved as apparent from the increased lymphocyte count, normalization of the Kerdo and Hildebrandt indices and indices of stress level, decreased psychoemotional stress, enhancement of physical functioning characteristics. Taken together, these changes account for the high effectiveness of the above procedures of early postoperative rehabilitation of the patients presenting with cholelithiasisand experiencing psychoemotional stress (94.7%).

[Results of early rehabilitation after various methods of cholecystectomy at Ust'-Kachka resort]. / Rezul'taty rannei reabilitatsii posle razlichnykh variantov kholetsistéktomii na kurorte Ust'-Kachka.

Early rehabilitation after open cholecystectomy or cholecystectomy from a mini-approach was performed in 101 patients with cholelithiasis treated surgically at Ust-Kachka health resort. Changes in clinico-laboratory indices reflecting the condition of hepatopancreatobiliary system and central hemodynamics before and after rehabilitation were studied depending on the variant of cholecystectomy. Advantages of early rehabilitation of patients after different variants of cholecystectomy at Ust-Kachka health resort in normalization of general condition of the patients and in prevention of functional disorders progression early after operation are demonstrated.

[Experience of the 7th Central Military Clinical Aviation Hospital in early diagnostics, treatment, rehabilitation, and expert evaluation of cholelithiasis in flying personnel]. / Opyt raboty 7 Tsentral'nogo voennogo klinicheskogo aviatsionnogo gospitalia po rannei diagnostike, lecheniiu, reabilitatsii i ékspertnoi otsenke kholelitiaza u letnogo sostava.

The Seventh Central military clinical aviation hospital is experienced in performing laparocholecystectomy (LCE) in pilots afflicted with cholelithiasis (CL). In the period from 1990 to 2001, 92 operations were carried out after which 80 patients (87%) were permitted to fly. Medical discharge of 12 patients (13%) was associated not with CL but with some morphofunctional shifts caused by concomitant diseases. Seven to five-yr. follow-up of the 80 pilots who had returned their flying status after LCE showed their good tolerance for the flight loads.

[Experience gained by the use of mineral water at a health resort on early rehabiliation of patients operated on for cholelithiasis]. / Opyt kurortnoi reabilitatsii bol'nykh, perenesshikh operatsiiu po povodu zhelchnokamennoi bolezni.

Our studies suggest to us expediency of assigning those patients having been operated on for cholelithiasis running an uncomplicated course for rehabilitative treatment in a sanatorium-health resort setting with Mirgorodskaya type low mineralized weak-alkaline sodium-chloride water.

[Laparoscopic cholecystectomy in the treatment, rehabilitation and clinical health certification of the flying personnel with cholelithiasis]. / Laparoskopicheskaia kholetsistéktomiia v lechenii, reabilitatsii i ékspertize letnogo sostava s zhelchnokamennoi bolezn'iu.

Applicability of laparoscopic cholecystectomy (LSCE), a modern approach to the treatment of cholelithiasis, to rehabilitation, and military medical and military aviation certification was evaluated. Since 1994, 303 LSCE operations, including to 97 patients-aviators, have been performed by way of penetrating the abdominal wall with a standard laporoscopic stand (K-Chtorz, Germany). After introduction of LSCE, only 9 operations (2.9%) were fulfilled with the conventional technique. Immediate results of treatment of aviators were satisfactory and characterized by a good cosmetic effect, more rapid recovery of the motor activity, minimal complications (2.2%), absence of severe post-operational pancreatic/biliary dysfunctions, and expedited course of treatment.

[Validation of the early health-resort rehabilitation of patients who have undergone a cholecystectomy]. / Obosnovanie rannei kurortnoi reabilitastsii bol'nykh, perenesshikh kholetsistéktomiiu.

The paper addresses the issue of expediency of early sanatorium treatment of patients with prior cholecystectomy; indications and contraindications are determined as are optimal terms for refferring such patients to specialized departments of gastroenterologic sanatoria in Ukraine. Impact of sanatorium treatment on functional state of the liver and immune system in early periods after cholecystectomy was studied.

[The work experience of the Central Military Aviation Research Hospital in the occupational rehabilitation of flight personnel after lithotripsy]. / Opyt raboty TsVNIAG po professional'noi reabilitatsii letnogo sostava posle litotripsii.

The evolution of the domestic-certified lithotriptors has made a complete professional rehabilitation of all pilots (100%) suffered from urolithiasis without operative intervention possible. Of 156 pilots who have been exposed to remote shock-wave lithotripsy (RSWL) in recent three years 120 individuals (93%) had the urate stones in the renal calyces. Before introducing the RSWL in clinical practice such concrement were recognized as inoperable and the urolithic pilots have no prospects for continuation of their flying activities. After the RSWL application there was a decrease in the secretory-excretory renal function due to the disturbed urodynamics by the migratory fragments of crushed stones in the renal system. The recovery of renal function occurred after complete passage of the crushed stone fragments. Depending on the composition of a crushed concrement, severity of inflammatory process taking place in the kidneys and urinary tracts, the special program of countermeasures to prevent relapsed lithogenesis was recommended for use by the patients. The relapse of renal stone formation after RSWL application was noted in 4 (3.2%) pilots. In these pilots, the concrements were recrushed by the mentioned method and professional qualification of above individuals was retained. Until recently, the treatment of cholelithic disease was recognized as a purely surgical problem--with the introduction of RSWL of renal stone into clinical practice there appeared real possibility to apply the similar approach to crushing the gallstones. To attain these ends, the experimental studies with the use of lithotriptor "URAT-P" have been performed. 140 gallstones of 0.5 to 2.0 cm in size were crushed. The parameters of shock waves are determined.(ABSTRACT TRUNCATED AT 250 WORDS)

[A clinical decision analysis to assess therapeutic modalities for symptomatic gallstones with respect to patient's quality of life and cost-effectiveness].

A clinical decision analysis was performed to assess new therapeutic modalities for symptomatic gallstones with respect to patient's quality of life (QOL) and cost-effectiveness. A decision tree-based state transition model (Markov approach) implemented to simulate a five-year period of follow-up was constructed. Non-surgical treatments were superior to surgery in enhancing patient's QOL. This advantage was dependent upon the efficacy of non-surgical treatments (stone clearance rate) and patient's age. The optimal candidates were patients with a single radiolucent stone less than 2 cm in diameter for extracorporeal shock-wave lithotripsy (ESWL), and patients with multiple floating stones for oral dissolution, respectively, especially in the elderly. ESWL was less cost-effective than laparoscopic cholecystectomy (LC). ESWL was superior to LC in enhancing patient's utility, but more expensive than LC. LC was economically cost-effective and superior to open cholecystectomy in enhancing patient's QOL for all eligible patients. LC appears to be the therapeutic modality of first choice for the majority of patients with symptomatic gallstones. In conclusion, the results of our analysis suggest the followings. Non-surgical treatments have an advantage over surgery in enhancing patient's QOL and are acceptable alternatives to surgery on the basis of their optimal indications and laparoscopic cholecystectomy is the new standard therapeutic modality in the treatment of symptomatic gallbladder stones.

[The management procedure for patients with cholelithiasis and the results of rehabilitative treatment after cholecystectomy based on polyclinic observations]. / Taktika vedeniia bol'nykh s zhelchnokamennoi bolezn'iu i rezul'taty vosstanovitel'nogo lecheniia posle kholetsistéktomii po nabliudeniiam v poliklinike.

Based on an analysis of the dynamic ultrasonic, biochemical and hormonal data on 550 patients operated on for cholelithiasis and comparison of preoperative and pathomorphological diagnoses, indications for surgical treatment of cholelithiasis patients in the stage of so-called "lithocarriership" were developed and a group at risk for cancer was identified as well. A comprehensive analysis of the clinical and instrumental data on 185 patients operated on for cholelithiasis, made in the long-term periods (from 1 to 3 years) after cholecystectomy indicates the efficacy of differentiated rehabilitation treatment, including elderly subjects and the necessity of early surgical treatment of cholelithiasis before there may develop irreversible alterations in the choledochus, liver and pancreas and in the gallbladder itself. Comparison of the dynamic ultrasonic data, liver and pancreas functions and factors such as sex, age, obesity and physical exercise makes it possible to predict the course of cholelithiasis to a certain degree of probability at the asymptomatic stage and to specify the policy of managing such patients under ambulatory conditions.

[The early rehabilitation of patients, operated on for peptic ulcer and cholelithiasis, at Mirgorod health resort]. / Ranniaia reabilitatsiia bol'nykh, operirovannykh po povodu iavennoi i zhelchnokamennoi boleznei, v usloviiakh kurorta Mirgorod.

The authors analyzed the condition of 51 patients in the early period of operation for ulcer and cholelithiasis. It was found that most patients showed asthenic, dyspeptic and pam syndromes, anemia, hypoacidic or achylous gastritis, inflammation at the operative site. As a result of treatment at the Mirgorod health resort (physiotherapy, mineral water) there occurred a significant improvement in the patients' condition. It is concluded that rehabilitation of patients following surgical intervention on the 20th day of operation for ulcer and cholelithiasis at the Mirgorod health resort has good perspectives.