Complicações da cirurgia videolaparoscópica no tratamento de doenças da vesícula e vias biliares

During which period should we avoid cholecystectomy in patients who underwent endoscopic retrograde cholangiopancreatography?

OBJECTIVE

To determine the period during which we should avoid cholecystectomy after endoscopic retrograde cholangiopancreatography.

METHODS

A retrospective analysis of electronic medical charts of 532 patients undergoing endoscopic retrograde cholangiopancreatography, between March 2013 and December 2017.

RESULTS

Approximately one-third of patients underwent the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography. The conversion rate was 3.8%. The need for abdominal drainage and the finding of biliary tract injury after surgery were observed in 15.1% and 1.9% of patients, respectively. The length of stay was significantly shorter among patients undergoing surgery more than 30 days after endoscopic retrograde cholangiopancreatography. These patients had a median length of stay of one day, whereas the median length of stay in the group undergoing the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography was 2 days.

CONCLUSION

The period during which we should avoid cholecystectomy is between 4 and 30 days after endoscopic retrograde cholangiopancreatography.

Risk stratification for complications of laparoscopic cholecystectomy based on associations with sociodemographic and clinical variables in a public hospital

BACKGROUND

Cholelithiasis is the most common disease of the biliary tract. We aimed to associate complications resulting from laparoscopic cholecystectomy with patients' sociodemographic and clinical data, stratifying risk based on this association.

METHODS

We retrospectively reviewed the medical records of 2520 patients undergoing laparoscopic cholecystectomy from January 2013 to March 2017 at our institution. Sociodemographic, clinical, and surgical complication data were collected. Unadjusted and adjusted logistic regression models were used to determine independent factors associated with the outcomes of interest. Based on the results, we proposed a risk stratification model, a treatment flowchart, and a severity score.

RESULTS

Mean age was 48.9 years; 83.53% were female. Intraoperative complications occurred in 206 (8.17%) patients, and postoperative complications in 54 (2.14%). Male sex, older age, diabetes, multiple previous operations, and urgent surgery (odds ratio = 23.77) were significantly associated with surgical complications in both unadjusted and adjusted models.

CONCLUSIONS

We could propose a flowchart based on our risk stratification model and develop a severity score based on the association between complications of laparoscopic cholecystectomy and sociodemographic/clinical data.

SINGLE PORT LAPAROSCOPIC CHOLECYSTECTOMY: TECHNICAL ASPECTS AND RESULTS

Background:

The search for less traumatic surgical procedures without compromising efficacy and safety, together with the technological advances and greater experience of the teams, led to the development of operative techniques with increasingly smaller incisions, the so-called “minimally invasive surgeries”.

Aim:

To evaluate the technical aspects and results of single port cholecystectomy.

Method:

Were analyzed 170 patients between 18-74 years submitted to videolaparoscopic cholecystectomies by single port, regardless of elective or urgent indication, without restriction of patient selection.

Results:

Among the 170 operations, 158 were exclusively performed by single port, and the conversion rate was 7% (inclusion of other accessory trocars or conversion to multiportal). Conversion to open surgery occurred in three cases (1.76%). The mean surgical time was 67.97 min, showing a marked decrease when was reached close to 50 cases and a stabilization after 100 surgeries. The overall complication rate was 10%, with minor complications such as: incisional pain, hematomas, granulomas, port access hernias (9.41%).

Conclusion:

Single port cholecystectomy can, after standardization and surgical team training, be a safe surgical procedure associated with a recognized aesthetic advantage.

FATORES DE RISCO PARA INFECÇÃO DO SÍTIO CIRÚRGICO EM CIRURGIAS POTENCIALMENTE CONTAMINADAS

RESUMO Objetivo: associar os fatores de risco do período pós-operatório de cirurgias potencialmente contaminadas, com a ocorrência da infecção do sítio cirúrgico no período pós-operatório hospitalar e domiciliar. Método: período de coleta de dados foi de fevereiro a junho de 2015, com 84 pacientes acompanhados nos três primeiros dias de pós-operatório e sete dias após a alta hospitalar, através de questionários elaborados para avaliação do sítio cirúrgico, das condições clínicas do paciente e da análise de prontuário. Para verificação dos fatores de risco influenciáveis e classificação das infecções do sítio cirúrgico, utilizou-se um questionário com variáveis que foram analisadas de forma descritiva através da frequência simples, porcentagem e medidas de posição e dispersão. Para a associação e nível de significância dos fatores de risco foram realizados testes estatísticos. Resultados: nenhum dos pacientes entrevistados desenvolveu infecção profunda do sítio cirúrgico ou de órgão/espaço, sendo que sete desenvolveram infecção do sítio cirúrgico superficial no pós-operatório hospitalar e 41 em domicílio. Os fatores de risco analisados não foram significativos para o desenvolvimento das infecções. Conclusões: recomenda-se que as instituições implantem um serviço de vigilância e acompanhamento pós-alta, a fim de que se melhore a confiabilidade das taxas de incidência das infecções do sítio cirúrgico; melhorar a qualidade dos cuidados com os pacientes; compreensão epidemiológica e identificação dos fatores de risco. Além disso, propõe-se facilitar o processo de referência e contra referência através de capacitações da Estratégia de Saúde da Família para identificação destes fatores de risco, atuando em rede.

Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

OBJECTIVE

to evaluate the pulmonary function of women submitted to conventional and single-port laparoscopic cholecystectomy.

METHODS

forty women with symptomatic cholelithiasis, aged 18 to 70 years, participated in the study. We divided the patients into two groups: 21 patients underwent conventional laparoscopic cholecystectomy, and 19, single-port laparoscopic cholecystectomy. We assessed pulmonary function through forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and the FEV1/FVC ratio, measured before and 24 hours after the procedure.

RESULTS

in both groups, FVC and FEV1 were lower in the postoperative period than those obtained in the preoperative period, with a greater reduction in the group undergoing conventional laparoscopic cholecystectomy. Regarding the FEV1/FVC (%) values, there was no statistically significant difference in any of the groups or times analyzed.

CONCLUSION

there was a greater decline in FVC and FEV1 in the postoperative group of patients submitted to conventional laparoscopic cholecystectomy.

PREVALENCE AND PREDICTORS OF CHANGES IN BOWEL HABITS AFTER LAPAROSCOPIC CHOLECYSTECTOMY

BACKGROUND:

The incidence of cholecystolithiasis is approximately 15% of the population. It is believed that between 30-40% of cholecystectomy patients have symptoms after surgery, being changes in bowel habits the most common among them.

AIM:

1) Defining the prevalence, and 2) identifying predictors of changes in bowel habits after laparoscopic cholecystectomy.

METHODS:

This is a retrospective cross-sectional study with an initial sample of 150 patients diagnosed with cholecystolithiasis operated between July and September 2014. Patients were submitted to a questionnaire about the presence of gastrointestinal symptoms and changes in stools consistency before and after the surgical procedure. They were divided into two groups (with or without changes in bowel habits) being combined with the following variables: high blood pressure, body mass index, hypothyroidism, adherence to postoperative dietary orientations, previous abdominal and bariatric surgery.

RESULTS:

The prevalence of changes in bowel habits in the study population was 35.1%. The association between it and gastrointestinal symptoms was demonstrated to be statistically significant (‰2=7.981; p=0.005), and people who did not have gastrointestinal symptoms had 2.34 times the odds of not presenting changes in bowel habits. None of the other investigated factors had shown to be a predictor of risk for post-cholecystectomy changes in bowel habits.

CONCLUSION:

1) There was a high prevalence of changes in bowel habits, and 2) there was association between changes in bowel habits and the presence of gastrointestinal symptoms.

RACIONAL:

A incidência da colecistopatia calculosa é de aproximadamente 15% da população brasileira. Acredita-se que entre 30-40% dos pacientes colecistectomizados apresentem sintomas pós-operatório, sendo a alteração do hábito intestinal o mais comum.

OBJETIVO:

1) Determinar a prevalência, e 2) identificar preditores de mudanças do hábito intestinal pós-colecistectomia videolaparoscópica.

MÉTODOS:

Estudo transversal retrospectivo com amostra inicial de 150 pacientes diagnosticados com colecistopatia calculosa, operados entre julho e setembro de 2014. Os pacientes foram submetidos a um questionário sobre a presença de sintomas gastrointestinais após a operação, e a alterações do aspecto das fezes antes e depois do procedimento. A amostra foi dividida em dois grupos (com ou sem mudanças do hábito intestinal) sendo realizadas associações com as seguintes variáveis: hipertensão arterial, IMC, hipotireoidismo, seguimento de dieta no pós-operatório, operação abdominal prévia e operação bariátrica.

RESULTADOS:

A prevalência de mudanças do hábito intestinal na população estudada foi de 35,1%. A associação entre elas e sintomas gastrointestinais demonstrou-se estatisticamente significativa (‰2=7,981; p=0,005), sendo que as pessoas que não apresentavam os sintomas tinham 2,34 vezes mais chances de não apresentarem mudanças do hábito intestinal. Nenhum dos demais fatores investigados demonstrou ser preditor de risco para mudanças do hábito intestinal pós-colecistectomia.

CONCLUSÕES:

1) Observou-se alta prevalência de mudanças do hábito intestinal, e 2) houve associação entre mudança do hábito intestinal e a presença de sintomas gastrointestinais.

Randomized study for assessment of hypolipidic diet in digestive symptoms immediately following laparoscopic cholecystectomy

OBJECTIVE

To validate the need for prescribing low-fat diet in the prevention or reduction of dyspeptic symptoms in the postoperative period in patients undergoing laparoscopic cholecystectomy.

METHODS

We selected 40 patients, free of liver or pancreatic disease, biliary gallstones, gastritis, ulcer, diabetes and dyslipidemia, who were divided into two groups. We conducted dietary anamnesis, identification of dyspepsia before the onset of cholelithiasis and guidance on appropriate postoperatively feeding (normal or low-fat). We used the chi-square test and Pearson correlation for statistical assessment, considering p d" 0.05 as significant.

RESULTS

When comparing the two groups of patients without preoperative dyspepsia, it was observed that in group I seven patients (63.6%) were asymptomatic and in group II, four (66.7%). In group I, four (36.4%) had onset of symptoms and in group II, two (33.3%), p = 0.684. When correlating the two groups with preoperative dyspeptic symptoms, it was observed that there was permanence, appearance or disappearance of symptoms postoperatively, p = 0.114.

CONCLUSION

There was no significant effect of low-fat diet in the prevention of gastrointestinal symptoms, especially in preoperatively asymptomatic patients. Thus, there is no need of a low-fat diet. So, it is up to the surgeon to evaluate each patient individually and adjust the diet to his/her needs and clinical conditions.

Comparative study between ligature with thread or metallic clamping by means of laparoscopy with the purpose of experimental biliary obstruction in swines

PURPOSE

To induce a total extra-hepatic obstructive jaundice in swines, by ligation of the common bile duct by laparoscopic surgery.

METHODS

Eight swines of the Landrace race, 36-day-old, originated from the same matrix, distributed in two groups. Group A: was used titanium metal clip to the common bile duct ligation in three animals; group B: were ligated with 2-0 cotton thread in five animals.

RESULTS

The ligation of the biliary ducts was performed successfully in all animals, with easy identification of the common bile duct by laparoscopy. There weren't difficulties in the procedures, mainly due to the increased surgical field provided by the excellent quality of light and image of the appliance. The clinical signs of jaundice were evident in the animals in seven days. In group A, two animals showed bile duct perforation near the clip, probably due to ischemic necrosis, progressing to peritonitis and death. In group B, five animals showed obstructive jaundice without any amendment.

CONCLUSION

Under the conditions of this study, we therefore recommend the use of unabsorbed wires to experimental biliary obstruction, in order to avoid complications, such as ischemia and necrosis, followed by perforation of the wall of the bile ducts.