[Choice of therapeutic approach in acute cholecystitis in the elderly]. / Elección de la conducta terapéutica en la colecistitis aguda del anciano.

BACKGROUND: Acute cholecystitis in elderly patients is a common disease characterized by a high mortality rate and serious complications. AIM: To compare conservative vs. surgical therapy for acute cholecystitis in the elderly. METHODS: This is a retrospective study including patients 70 years-old or older with the diagnosis of acute cholecystitis (AC) treated between 2003 and 2009. Epidemiological and clinical data, diagnostic approach, surgical variables and cost-effectiveness were analyzed. According to the first therapeutic intent, the analysis was performed among final treatment groups and among older than 80 years and younger cases. p < 0.05 was considered significant. Statistical analysis was performed with StatView(©) 5.0. RESULTS: During the six-year period 173 episodes of acute cholecystitis were treated on 147 patients (52% females), with a mean age of 80.6 years (range 70-101). In 103 cases medical treatment was taken, with 82 cases of resolution of the clinical picture, 15 unexpected operations and 6 deceases. Other 70 cases were undergone surgery as first option, 78.5% of them through laparoscopy with a conversion rate of 19.7%. CONCLUSIONS: In our study, surgery and medical treatment get similar outcomes, making better progress those who underwent early laparoscopic cholecystectomy. We recommend performing emergency surgery in high-risk elderly patients rather than conservative therapy due to a tendency to increase morbidity with later approach.

[New diagnostic and surgical approach to Mirizzi syndrome]. / Nuevas posibilidades diagnósticas y terapéuticas en el síndrome de Mirizzi.

Mirizzi's syndrome is an unusual complication of gallstone disease, in which a stone impacting in the neck of the gallbladder (Hartmann s pouch) compresses the common bile duct. This mechanical obstruction leads to obstructive jaundice frequently followed by inflammatory changes and several complications. We present two patients affected by Mirizzi's syndrome whose diagnosis was correct in the preoperative period and approached by laparoscopy. A case was converted to open procedure due to adhesions in the Calot's triangle, and therefore, treated with subtotal cholecystectomy and choledochorrhaphy over a T tube. In the other case the laparoscopy access became successful. Both postoperative courses were uneventful. In this article, suitable diagnostic techniques are analyzed. On the other hand, we discuss what is the best therapeutic option, with a special attention to the relevance of endoscopic retrograde cholangiopancreatography and laparoscopic approach in the management of those patients.

[Focal peritonitis as a form of clinical presentation of listeriosis]. / Peritonitis focal como forma de presentación clínica de una listeriosis.

Infections by germs of Listeria genus can occur sporadically or in epidemic outbreaks and have different clinical presentations. Abdominal origin is very unusual among them, especially in no immunocompromised patients or without concurrent liver illness. We present a young healthy man who is lacking in underlying diseases, suffering from focal peritonitis caused by Listeria monocytogenes. The patient had to be operated on, requiring immediate colectomy and evacuation of a retroperitoneal abscess. The postoperative evolution was favorable under antibiotic treatment with amoxicillin and clavulanic acid during 3 weeks. The clinical-epidemiological and therapeutic aspects of listeriosis are analysed in the discussion, giving special attention to abdominal infective episodes.

Spontaneous pneumothorax: consecutive treatment of a series of 45 cases. Preliminary results of using therapeutic videothoracoscopy. / Neumotórax espontáneo: tratamiento consecutivo de una serie de 45 casos. Resultados preliminares del uso de la videotoracoscopia terapéutica.

The appearance of procedures derived from video assisted thoracoscopy (VAT) has fostered new breakthroughs in the treatment of spontaneous pneumothorax. Our early experience with a study protocol using this technique is described. Patients admitted to our hospital in 1995 with a diagnosis of spontaneous pneumothorax were enrolled consecutively. Diagnosis was based on symptoms and pneumothorax was quantified by measuring the interpleural distance observed on the chest film. The initial treatment was pleural drainage; VAT was ordered in cases of recurrence, when lung reexpansion failed or when air leakage was persistent. Forty-five cases (30 men, 15 women) are reported. Mean age was 29 years. Eleven (24%) patients had had earlier pleural drainage but were suffering recurrences. The right side was involved in 14 (54%) cases. Initial treatment was pleural drainage and in 32 cases no other treatment was given. VAT was performed on 11 patients. In 1 (9%) patient the procedure became a minithoracotomy, or video-assisted thoracoscopic surgery. In 2 patients conventional thoracotomy was performed. Mean time the procedure lasted was 80 min. Mean follow-up was 3 months. There were no recurrences among patients treated with VAT and surgery. Our initial experience demonstrates that VAT is the technique of preference for the definitive treatment of spontaneous pneumothorax. There is less postoperative pain, increased comfort, no noteworthy morbidity, shorter postoperative hospital stays and prompt return to normal activity for the patient; these advantages lead us to choose this treatment over open surgery.

[Spontaneous retroperitoneal hemorrhage induced by anticoagulation treatment]. / Hemorragia retroperitoneal espontánea inducida por tratamiento anticoagulante.

Contribution of one case of spontaneous retroperitoneal haemorrhage presented after therapy with anticoagulants. Review of causes of transperitoneal haemorrhage, relative frequency, as well as signs and symptoms, and diagnosis. The sparse number of haemorrhagic complications after anticoagulant therapy with heparin and urokinase-associated adjusted heparin are described. Treatment is instituted based on precipitating condition and, in the present case, with suppression of medication and volume replacement together with an strict evolutive monitoring by means of ultrasound, computerized axial tomography (CT) and magnetic nuclear resonance (MNR).

[Graves' disease with associated thyroid nodules (nodular Graves' disease). Clinical, diagnostic and therapeutic considerations]. / Enfermedad de Graves-Basedow con nódulos tioideos asociados (enfermedad de Graves-Basedow nodular). Consideraciones clínicas, diagnósticas y terapéuticas.

BACKGROUND: Sometimes Graves disease (GD) can appear in association with thyroid nodules, which seems to increase the risk of carcinoma. In this article, we try to establish clinical characteristics, diagnostic means and appropriate treatment for Graves patients with co-existent nodules. METHOD: A retrospective study was made of 153 consecutive patients who underwent operation for GD between 1967 and 2000. Each patient was subject to a regular protocol including physical examination, diagnostic test, total or subtotal thyroidectomy and follow-up in the long term with the purpose of making a valuation of the postsurgical morbidity, evolution and relapses. Data were processed through computing in order to get the statistical information. RESULTS: 28.1% of GD had thyroid nodules and carcinoma was diagnosed in four patients (9.3%), all of them belonging to papillary variety. Surgery consisted of 57 subtotal thyroidectomies (37.3%) and 94 total thyroidectomies. Parathyroid and recurrent morbidity was established in 4.6 and 3.9%, respectively, a year later since the operation, though it had a strong tendency to decrease from 1980. 96% of cases showed no relapse. CONCLUSIONS: Nodular GD is very common in our setting, especially in Graves patients with late beginning who wait for ages until they are undergone surgery. Initial treatment should be by means of braking therapy with antithyroid drugs and clinical, cytologic and ultrasonographic control. Surgery would be advised, from the outset or during the follow-up, in view of either any suspicion about cancer or presence of local growth. The procedure of choice is total thyroidectomy performed with low morbidity.