Eosinophilic cholecystitis: a retrospective study spanning a fourteen-year period

INTRODUCTION AND AIMS

Eosinophilic cholecystitis is a rare entity that was first described in 1949 and is clinically indistinguishable from calculous cholecystitis. Histologically, there is transmural inflammatory infiltration of the gallbladder wall, more than 90% of which is composed of eosinophils. The aim of the present article was to review the prevalence of eosinophilic cholecystitis and analyze the clinical and surgical characteristics of patients diagnosed with the disease that were operated on at our hospital.

MATERIALS AND METHODS

A retrospective study was conducted on patients that underwent cholecystectomy and whose postoperative histopathologic diagnosis was eosinophilic cholecystitis, within the time frame of January 2000 and August 2014. The demographic, clinical, paraclinical, surgical, and histopathologic variables were described.

RESULTS

Over a period of 14 years, a total of 7,494 patients underwent cholecystectomy. Of those patients, 12 had a postoperative histologic diagnosis of eosinophilic cholecystitis. Mean patient age for disease presentation was 39 years (±11 years), and female sex was predominant, with 7 cases. All the patients had concomitant gallstones and 10 patients presented with acute cholecystitis that required urgent cholecystectomy. All the cases were considered idiopathic. We found a prevalence of 0.16%, corresponding to 1 case for every 625 cholecystectomies performed at our hospital.

CONCLUSION

We found a low prevalence of eosinophilic cholecystitis (0.16%) in our study population. The clinical manifestations were similar to those of calculous cholecystitis. Cholecystectomy is adequate treatment in patients with idiopathic disease.

[Skills comparison using a 2D vs. 3D laparoscopic simulator]

BACKGROUND

The development and application of 3D images in laparoscopic surgery has brought the benefit of in-depth perception that traditional laparoscopic surgery lacked. Previous studies in surgical populations have demonstrated the advantages of 3D technology. To limit bias of the previous experiences of participants, this study was performed in a population without any experience in this area.

MATERIAL AND METHODS

An experimental, open, cross-sectional, comparative study between surgical skills achievements using 2D and a 3D laparoscopy equipment, using each subject as their own control. Six skills were evaluated in 2D and 3D modalities.

RESULTS

Of the 40 participants included, 20 began the skills in the 2D modality and then performed them in 3D, and the other 20 began in 3D. Of the 118 skills evaluated there was a time improvement in 72% in the 3D group compared to 37% in the 2D modality (P=.000). The accomplishment percentage using the 3D laparoscopy was greater for both groups. There was a statistically significant difference in the better time for the 3D performed tasks. Just over half (52.5%) of participants preferred 3D laparoscopy, 15% preferred 2D, and 32.5% had no preferences.

DISCUSSION

As other studies have demonstrated, there was improvement in the overall performance using the 3D laparoscope. Bias was limited by using a population without surgical experience.

CONCLUSIONS

3D laparoscopic surgical skills showed superior to 2D, with higher percentages of tasks completion, less time in performing them, and a shorter learning curve.

Laparoscopic management of pancreatic pseudocysts: experience at a general hospital in Mexico City

BACKGROUND

Invasive management of pancreatic pseudocysts (PP) is currently indicated in those patients with symptoms or complications. Treatment options are classified as surgical (open and laparoscopic) and non-surgical (endoscopic and radiologic).

AIM

To describe the morbidity, mortality, and efficacy in terms of technical and clinical success of the laparoscopic surgical approach in the treatment of patients with PP in the last 3 years at our hospital center.

METHODS

We included patients with PP treated with laparoscopic surgery within the time frame of January 2012 and December 2014. The morbidity and mortality associated with the procedure were determined, together with the postoperative results in terms of effectiveness and recurrence.

RESULTS

A total of 38 patients were diagnosed with PP within the last 3 years, but only 20 of them had invasive treatment. Laparoscopic surgery was performed on 17 of those patients (mean pseudocyst diameter of 15.3, primary drainage success rate of 94.1%, complication rate of 5.9%, and a 40-month follow-up).

CONCLUSIONS

The results obtained with the laparoscopic technique used at our hospital center showed that this approach is feasible, efficacious, and safe. Thus, performed by skilled surgeons, it should be considered a treatment option for patients with PP.

[A standard questionnaire to reduce the routine battery of preoperative tests for elective surgery]

BACKGROUND

Preoperative medical testing in the United States is estimated at $3,000,000 USD per year. In an attempt to reduce this cost, some key points have been described with the purpose of promoting appropriate preoperative measurements with an adequate costObjective: To evaluate the utility of a preoperative standardized questionnaire in adult patients prior to elective surgery to detect which patients could be operated without laboratory testing.

METHOD

An observational, prospective and analytic study was carried out. The questionnaire has been applied to 176 patients, all adults scheduled for elective surgery from April 2011 to March 2012.

RESULTS

There were 57.4% females and 42.6% males. Ages varied between 18 and 85 years old, with a median of 46 years; 40.3% of the patients were > 50 years old and 59.7% were < 50 years old. The negative predictive value of the questionnaire is 95.88% (CI 95.34-96.42%).

CONCLUSION

This questionnaire is a useful instrument to determinate the necessity of preoperative laboratory testing in young, clinical healthy and elective surgery patients in a general hospital.

[Intraoperative choledochoscopy usefulness in the treatment of difficult biliary stones]

BACKGROUND

Choledocholithiasis presents in 5-10% of the patients with biliary lithiasis. Numerous treatment algorithms have been considered for this disease, however, up to 10% of these therapeutic procedures may fail. Intraoperative choledochoscopy has become a useful tool in the treatment of patients with difficult-to-manage choledocholithiasis.

OBJECTIVES

To determine the usefulness of intraoperative choledochoscopy in the laparoendoscopic treatment of difficult stones that was carried out in our service.

PATIENTS AND METHODS

A cross-sectional study was conducted. The case records were reviewed of the patients that underwent intraoperative choledochoscopy during biliary tree exploration plus laparoscopic choledochoduodenal anastomosis within the time frame of March 1, 2011 and May 31, 2012, at the Hospital General Dr. Manuel Gea González. Transabdominal choledochoscopies were performed with active stone extraction when necessary, followed by peroral choledochoscopies through the recently formed bilioenteric anastomosis. The data were analyzed with descriptive statistics and measures of central tendency.

RESULTS

The mean age was 71 years, 57% of the patients were women, and the ASA III score predominated. Active extraction of stones with 7 to 35mm diameters was carried out in 4 of the cases and the absence of stones in the biliary tract was corroborated in all the patients. The mean surgery duration was 18 minutes (range: 4 to 45min).

CONCLUSIONS

Choledochoscopy is a safe and effective minimally invasive procedure for the definitive treatment of difficult stones.

[Transgastric laparo-endoscopic approach for difficult access lesions. Experimental mode]

BACKGROUND

Gastric neoplasms can be treated by laparoscopy in a safe and efficient way. Some lesions are not accessible to laparoscopic surgery due to their location. A transgastric approach is proposed as an alternative.

OBJECTIVE

Show the results with the application of an endoscopic laparotomy in an animal model that maintains functional anatomy, to resect the posterior gastric neoplasms of the stomach wall, close to the cardia and pre-pyloric region.

METHODS

The laparo-endoscopic technique for resection of gastric neoplasms located in the posterior wall was developed in twelve pigs at the Hospital General Gea González from May to December 2011.

TECHNIQUE

An endoscopy was performed to establish the site of insertion of intragastric trocars. Three gastrotomies were made in the anterior wall; under endoscopic and laparoscopic vision the trocars were inserted. The stomach was insufflated with CO2. The lesion was resected maintaining a 20 mm circumferencial margin. The gastrotomies were sutured. The statistic analysis was made with t Student and exact Fisher tests.

RESULTS

One-hundred percent of resections were achieved in an average time of 102.33 minutes (± 4.50). Two complications and no transoperatory deceases occurred.

DISCUSSION

The technique we describe allows an appropriate approach to gastric lesions located in the posterior wall, those near to the esophagogastric juntion and the prepiloric region, due to the excellent exposure managed by working inside the stomach with a laparoscopic vision and the two intragastric movile ports.

CONCLUSIONS

The laparoscopic transgastric approach is feasible and safe for the resection of gastric neoplasms located in the posterior wall, those close to the esophago-gastric junction, and the pre-pyloric region.

[Sigmoid diverticulitis in adolescent. Case report]

BACKGROUND

Few cases have been reported in children and adolescents of sigmoid diverticulitis. Most of the case reports in medical literature are associated with true congenital diverticula and genetic diseases of collagen synthesis.

CLINICAL CASE

13 year-old female who was admitted to General and Endoscopic Surgery service with diagnosis of complicated appendicitis. Laparotomy was performed finding complicated sigmoid diverticular disease. Lavage, sigmoidectomy and primary anastomosis were performed. The histopathological findings reported a perforated pseudo-diverticulum of the sigmoid colon with peritonitis. The patient was discharged 72 hours after surgery and no complications were reported.

CONCLUSION

There are only case reports about colonic diverticulitis in children and adolescents, and its etiology has not yet been well established. This patient had sigmoid pseudo-diverticula and did not present genetic concomitant disease. This case is an exception to data reported on literature about diverticular disease in this population.

[Giant abscessed urachal cyst in adult. Case report]

BACKGROUND

during gestation, the urachus represents the connection between the dome of the bladder and the allantoic duct. This infection occurs preferentially in young adults, advocating the haematogenous or lymphatic pathway as possible routes of transmission, while a cord or bladder origin may also occur. Urachal cysts are rare in adult life, and is observed in only about 2% of adults.

CLINIC CASE

A 30-year-old male patient with a history of alcoholic hepatitis, diabetes mellitus type 2, chronic malnutrition, increased volume beginning with generalized abdominal pain, abdominal tumor of 20 by 15 cm, mobile, solid, without signs of peritoneal irritation. CT showed the presence of tumor, probably bladder-dependent, and apparently cystic. Exploratory laparotomy was found infected urachal cyst, draining 3,000 cc purulent material. A partial resection of the anterior face, keeping the back by firm adherence to bowel loops was done and is evolving satisfactorily.

DISCUSSION

urachal abnormalities are rare, with male / female ratio of 2 / 1. Although urachal abscess is an infection confined to an enclosed space, definitive treatment should not be the simple incision and drainage, because of the possibility of malignant transformation of urachal remnants. The definitive treatment should be considered complete excision of urachal cyst, when the infection is limited.

CONCLUSION

the urachus cyst is a rare pathology and is a diferencial diagnosis for acute appendicitis and it is necessary to know this treatment.

[Laparoscopic choledochoduodenostomy as an optional treatment choledocholithiasis]

INTRODUCTION

Choledochoduodenostomy is indicated for unsolved choledocholithiasis and biliary malignant or benign stenosis. This surgical procedure has been feared for its potential complications. This article shows our initial experience with this laparo-endoscopic approach.

METHODS

We performed laparoscopic choledochoduodenoastomy in seven elderly patients with recurrent or unsolved choledocholithiasis. Additionally, laparo-endoscopic extraction of gallstones was performed in necessary cases. We gathered and analyzed the demographic data, diagnostic proofs and follow up of the patients.

RESULTS

Average age of patients was 71 years, with 57.1% of women in our population. Main omorbidities of our patients included obesity in 71.4%, diabetes mellitus type 2 in 57.4%, and arterial hypertension in 42.85%. Patients had in average 2.7 previous episodes of choledocholithiasis and/or cholangitis and the average diameter of the removed stones was 22.6 mm. Average follow-up was 155 days (range 28 to 420).

DISCUSSION

Laparoscopic chooledochoduodenostomy has proved to be safe, effective and be superior to open surgery, as long as an appropriate selection of patients is performed and surgeons with experience on laparoscopic techniques are available. All these factors reduce the long-term complications with which this surgical procedure has been related.

CONCLUSIONS

Laparoscopic choledochoduodenostomy is an option for the definitive surgical treatment of "difficult choledocholithiasis" in elderly patients with multiple comorbidities; it also offers the advantages of the minimally invasive approaches.

[Laparoscopic drainage of a pancreatic pseudocyst: a case report]

Pancreatic pseudocysts are defined as homogeneous pancreatic or peripancreatic collections that are not associated with necrotic tissue and are surrounded by granulated or fibrous tissue with no epithelium. Management has been classified as surgical (conventional and laparoscopic) and nonsurgical (endoscopic and radiologic). The aim of this report is to describe our initial experience in the management of a pancreatic pseudocyst by means of laparoscopic posterior cyst-gastrostomy anastomosis, performed at the Pancreas Clinic of the Hospital General "Dr. Manuel Gea González" in Mexico City. New techniques and instrumentation have contributed to the relatively recent development of laparoscopic pancreatic surgery. Our technique has practical advantages that have been confirmed by other authors, such as simple hemostasis, a wide viewing angle enabling adequate necrosectomy, anastomosis that does not require the use of staples, and the possibility of resolving other associated intra-abdominal pathologies, as in this case.

[Effectiveness of intercostal nerve block with ropivacaine in analgesia of patients undergoing emergency open cholecystectomy under general anesthesia]

INTRODUCTION

Postoperative pain after open cholecystectomy is associated with reduced respiratory function, longer recovery period before deambulation and oral food intake, and prolonged hospital stay. Intercostal nerve block provides satisfactory analgesia and ropivacaine is the most widely used local anesthetic agent in intercostal nerve block due to its excellent effectiveness, lower cardiovascular toxicity, and longer half-life.

AIMS

To evaluate intercostal nerve block effectiveness with ropivacaine in patients undergoing emergency open cholecystectomy under general anesthesia compared with conventional management.

MATERIAL AND METHODS

A controlled clinical trial was carried out on 50 patients undergoing open cholecystectomy, 25 patients without intercostal nerve block versus 25 patients with intercostal nerve block using ropivacaine at 0.5% combined with epinephrine. Intraoperative minimum alveolar concentration and inhalation anesthetic use were evaluated. Tramadol as rescue analgesic agent and pain were evaluated during immediate postoperative period by means of the Visual Analog Scale at 8, 16, and 24 hours.

RESULTS

Mean inhalation anesthetic use was lower in the intercostal nerve block group with 13% vs 37% in the group without intercostal nerve block (p= 0.01). Rescue tramadol requirement was lower in the intercostal nerve block group than in the group without intercostal nerve block at 8 hours (8% vs 67%), 16 hours (0% vs 83%), and 24 hours (12% vs 79%) (p<0.0001). Visual Analog Scale for Pain results were similar in both groups.

CONCLUSIONS

Intercostal nerve block reduces intraoperative inhalation anesthetic use, immediate postoperative pain, and tramadol intake as rescue analgesic agent in patients undergoing open cholecystectomy.

[Anatomic variants of biliary ducts detected by endoscopio colangiography]

INTRODUCTION

The gallbladder and bile ducts originate through a complex process during the 4th gestational week; there is a wide variety in their anatomy.

OBJECTIVE

To identify the type, frequency, and association with certain pathologies of anatomic variations of bile ducts in patients in which endoscopic retrograde colangiography (ERC) was performed.

METHODS

Six hundred and six patients in whom ERCs were performed from 2005 to 2007 in the Endoscopio Unit at the Hospital General Dr. Manuel Gea González in Mexico City were included. Variations in bile duct anatomy seen in the X-ray taken during ERC were identified. Demographic characteristics of the patients, indications of the study, complications, treatments, and type of anatomic variant were registered. Descriptive statistics were used to analyze the information. X2 and Fisher´s exact test were also performed for the comparison between patients with and without anatomic variations.

RESULTS

We identified biliary anatomic variations in 5.1% of patients in the study. Among them, seventy- seven per cent were women, with a mean age of 41 years. The anatomic variation most frequently found was a low union of the cystic duct with the common hepatic duct. The main diagnosis during ERC was choledocholithiasis in 71% of patients. Bile duct injuries were found in only 3.2% of patients with anatomic variations.

CONCLUSIONS

Anatomic variations in bile ducts identified by ERC are frequent in Mexican population; nevertheless they were not associated with the occurrence of bile duct injuries.

[Epidemiology of xanthogranulomatous cholecystitis]

OBJECTIVE

In order to study patients with a diagnosis of xanthogranulomatous cholecystitis (XGC), we analyzed their demographics, epidemiology and clinical data.

MATERIAL AND METHODS

We analyzed the clinical records of XGC during a period of 6 years, obtaining demographic, epidemiologic and clinical data.

RESULTS

Of a total of 1425 cholecystectomies performed between January 1991 and December 1996, we found 35 cases of XGC (2.4%). Twenty six (74%) were women (median age: 44 years), 60% were from a low socioeconomic group, 34% has a history of alcoholism and smoking, and 25 patients (71%) had a blood type of O positive. Thirteen patients (37%) presented obstructive jaundice, 11 had dilatation of the choledocus and were treated with ERCP. Of the 35 cholecystectomies, 15 were urgent and 20 elective. Eight were operated laparoscopically and two were converted because of firm adhesions. We had 5 transoperative complications.

DISCUSSION

Pre-operative XGC diagnosis is difficult, often mistaken for gall bladder cancer. The incidence in our study (2.4%) is higher than reports in industrialized countries (0.7-1.8%), with a female predominance. The most frequent clinical presentation is that of chronic cholecystitis, but we found a high percentage of patients with obstructive jaundice. We had 0% mortality and 26% morbidity, and no association was found between XGC and gallbladder cancer.

[Cost/benefit of preoperative examinations for routine elective surgery]

INTRODUCTION

Preoperative exams are a common practice for surgeons; however, their use is not based on a scientific or medical basis. In the best of scenarios, it is an institutional policy.

MATERIAL AND METHODS

We wanted to determine the utility and cost-effectiveness ratio of of preoperative routine tests (PRT) and we analyzed retrospectively the frequency of complications, hospital stay, and cost-effectiveness of PRT, in subjects with no concomitant disease, who were having elective surgery performed by the general surgery service. We included 141 male and female subjects, ages from 18 to 40 years, during 2002.

RESULTS

There was no increase in complication frequency in patients with PRT abnormalities (6.2% versus 5.1%, OR 0.82, p = 0.78), or hospital stay time (2.37 versus 2.76, p = 0.55). PRT were repeated in 19.1%, expiration being the most frequent reason (46%). Urinalysis was the most frequent abnormal test (21.4%). We found only five clinically relevant abnormalities (3.5%). Only three patients required therapeutic intervention prior to surgery. The detection cost for PRT abnormalities requiring preoperative medical intervention was 22,732 Mexican pesos (approximately USD 2,022).

CONCLUSIONS

The use of PRT in young clinically healthy subjects is an expensive and inefficient practice.