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INTRODUÇÃO Cardiomiopatia (CMP) induzida por estresse, como a cardiomiopatia de Takotsubo, pode ter características clínicas semelhantes à isquemia miocárdica, como elevação de troponinas, alterações no Eletrocardiograma (ECG), mas sem obstrução coronariana ou lesões isquêmicas. Semelhante, a CMP induzida por Feocromocitoma possui sintomas também semelhantes a CMP hipertrófica, hipertensão e edema pulmonar devido a fatores cardiogênicos ou não cardiogênicos. Ambas supracitadas podem ter associação com excesso de catecolaminas, mas raramente estão associadas. RELATO DO CASO Paciente masculino, 46 anos, diabético, com história de estresse por situações familiares importantes, recentemente. Chega no serviço de emergência, com queixas de dispnéia, náuseas e êmese, iniciados há 1 dia, associado a retenção urinária e parestesia em mãos e paraparesia de membros inferiores. Refere também tratamento com Amoxicilina + Clavulanato há um mês por Colecistite Aguda. Na chegada, paciente se encontrava taquicárdico, taquipneico e saturando 98% em uso de óculos nasal a 2l/min, além de acidose metabólica. Realizou-se uma tomografia computadorizada de abdome, que evidenciou uma massa em Adrenal, sugestivo de Feocromocitoma, bem como metanefrinas urinárias e catecolaminas positivas. Ainda na emergência, evoluiu com insuficiência respiratória aguda por edema agudo de pulmão, necessitando de manejo com Nitroglicerina e 03 ampolas de Furosemida e uso de máscara não reinalante a 10l/min. Foi encaminhado para Unidade de Terapia Intensiva, onde foi realizado um ECG com alterações primárias da repolarização, seguido de alterações nos valores de Troponina e alterações no Ecocardiograma (ECO) de acinesia apical, hipocinesia de todos os segmentos médios e contratilidade preservada em segmentos basais. Cateterismo cardíaco com achados semelhantes ao ECO e presença de balonamento na ventriculografia, além de ausência de lesões obstrutivas em coronárias. CONCLUSÃO A excepcionalidade desse caso diz respeito ao quadro de síndrome coronariana aguda com dois motivos plausíveis e evidenciados na condução do caso, sendo eles: CMP de Takotsubo e a induzida por Feocromocitoma. Fica evidente, pela evolução do quadro, a gravidade do mesmo e a importância de considerar diagnósticos diferenciais, inclusive os menos comuns.

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BACKGROUND: The laparoscopic cholecystectomy is the treatment of choice for patients with benign biliary disease. It is necessary to evaluate survival after laparoscopic cholecystectomy in patients over 80 years old to determine whether the long-term mortality rate is higher than the reported recurrence rate. If so, this age group could benefit from a more conservative approach, such as antibiotic treatment or cholecystostomy. Therefore, the aim of this study was to evaluate the factors associated with 2 years survival after laparoscopic cholecystectomy in patients over 80 years old. METHODS: We conducted a retrospective observational cohort study. We included all patients over 80 years old who underwent laparoscopic cholecystectomy. Survival analysis was conducted using the Kaplan‒Meier method. Cox regression analysis was implemented to determine potential factors associated with mortality at 24 months. RESULTS: A total of 144 patients were included in the study, of whom 37 (25.69%) died at the two-year follow-up. Survival curves were compared for different ASA groups, showing a higher proportion of survivors at two years among patients classified as ASA 1-2 at 87.50% compared to ASA 3-4 at 63.75% (p = 0.001). An ASA score of 3-4 was identified as a statistically significant factor associated with mortality, indicating a higher risk (HR: 2.71, CI95%:1.20-6.14). CONCLUSIONS: ASA 3-4 patients may benefit from conservative management due to their higher risk of mortality at 2 years and a lower probability of disease recurrence.

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OBJETIVO: determinar la microbiología y la prevalencia de cultivos de bilis positivos en la Colecistitis Aguda (CA). METODOLOGÍA DE LA INVESTIGACIÓN: serie de casos consecutivos anidados en una cohorte RESULTADOS: se han incluido 196 pacientes con un promedio de edad de 46,5 años (DE± 14,735 años) distribuidos por género en 88 pacientes del género femenino (44,9%) y 108 del género masculino (55,1%). El promedio de leucocitosis fue de 10.000 x mm3 con desvío izquierdo (80% de segmentados promedio). La prevalencia de cultivos positivos durante la CA fue de 64 pacientes (32,65%). El germen más cultivado fue la E. Coli en 28 pacientes con (43,75 %). En la sensibilidad del antibiograma, amoxicilina y Acido clavulánico presenta 53,12% de resistencia cuando están asociadas y 25,56% cuando se usa amoxicilina sola. La amikacina, ceftriaxona, cefepime, imipemen, cloranfenicol, ciprofloxacina, cotrimoxazol y gentamicina tienen sensibilidad superior al 50%. En las formas edematosas el cultivo fue de 19,7%, hidrops vesicular 31,25%, en piocolecisto el porcentaje de cultivos positivos fue de 50% y en abscesos retrovesiculares fue de 79,16%. CONCLUSIONES: la prevalencia de cultivo positivo en CA es de 32,65% con la E. Coli como germen más frecuente. La elección del antibiótico debe estar basada en el conocimiento de la microbiología del Hospital y de la sensibilidad determinada por los cultivos y antibiograma

AIM: to determine the microbiology and prevalence of positive bile culture un acute Cholecystitis. RESEARCH METODOLOGY: Consecutive case series nested in a cohort RESULTS: 196 patients with a mean age of 46,5 años (DE± 14,735 años) were included, distributed by gender 88 female patients (44,9%) and 108 male patients (55,1%). The mean leukocytosis was 10.000 x mm3 with 80% of neutrophils. The prevalence of positive bile culture in AC was in 64 patients (32,65%). The most cultivated germ was E. Coli in 28 patients (43,75 %). In the sensitivity of the antibiogram amoxilin with clavulanic acid shows 53,12% of resistence and when is used amoxicillin alone is 25,56%. Amikacin, ceftriaxon, cefepim, imipemen, chloranphenicol, ciprofloxacin, cotrimoxazole and gentamicin have sensitivity greater to 50%. In edematous AC the positive culture was 19,7%, hydrops gallblader 31,25%, in piocolecyst 50% and in retro gallbalder abscess was 79,16%. CONCLUSIONS: the prevalence positive bile culture was 32,65% with E. Coli as the most frequent germ. The choice of antibiotic should be based on the knowledge of the hospital´s microbiology and the sensitivity determinated by cultures and antibiogram

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Acute cholecystitis (AC) is an acute inflammatory process of the gallbladder that may be associated with potentially severe complications, such as empyema, gangrene, perforation of the gallbladder, and sepsis. The gold standard treatment for AC is laparoscopic cholecystectomy. However, for a small group of AC patients, the risk of laparoscopic cholecystectomy can be very high, mainly in the elderly with associated severe diseases. In these critically ill patients, percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option, a bridge to cholecystectomy. The objective of this Brazilian College of Digestive Surgery Position Paper is to present new advances in AC treatment in high-risk surgical patients to help surgeons, endoscopists, and physicians select the best treatment for their patients. The effectiveness, safety, advantages, disadvantages, and outcomes of each procedure are discussed. The main conclusions are: a) AC patients with elevated surgical risk must be preferably treated in tertiary hospitals where surgical, radiological, and endoscopic expertise and resources are available; b) The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise; c) Laparoscopic cholecystectomy remains an excellent option of treatment, mainly in hospitals in which percutaneous or endoscopic gallbladder drainage is not available; d) Percutaneous cholecystostomy and endoscopic gallbladder drainage should be performed only in well-equipped hospitals with experienced interventional radiologist and/or endoscopist; e) Cholecystostomy catheter should be removed after resolution of AC. However, in patients who have no clinical condition to undergo cholecystectomy, the catheter may be maintained for a prolonged period or even definitively; f) If the cholecystostomy catheter is maintained for a long period of time several complications may occur, such as bleeding, bile leakage, obstruction, pain at the insertion site, accidental removal of the catheter, and recurrent AC; g) The ideal waiting time between cholecystostomy and cholecystectomy has not yet been established and ranges from immediately after clinical improvement to months. h) Long waiting periods between cholecystostomy and cholecystectomy may be associated with new episodes of acute cholecystitis, multiple hospital readmissions, and increased costs. Finally, when selecting the best treatment option other aspects should also be considered, such as costs, procedures available at the medical center, and the patient's desire. The patient and his family should be fully informed about all treatment options, so they can help making the final decision.

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Introducción. La colecistectomía laparoscópica es el estándar de oro para el manejo de la patología de la vesícula biliar con indicación quirúrgica. Durante su ejecución existe un grupo de pacientes que podrían requerir conversión a técnica abierta. Este estudio evaluó factores perioperatorios asociados a la conversión en la Clínica Central OHL en Montería, Colombia. Métodos. Estudio observacional analítico de casos y controles anidado a una cohorte retrospectiva entre 2018 y 2021, en una relación de 1:3 casos/controles, nivel de confianza 95 % y una potencia del 90 %. Se caracterizó la población de estudio y se evaluaron las asociaciones según la naturaleza de las variables, luego por análisis bivariado y multivariado se estimaron los OR, con sus IC95%, considerando significativo un valor de p<0,05, controlando variables de confusión. Resultados. El estudio incluyó 332 pacientes, 83 casos y 249 controles, mostrando en el modelo multivariado que las variables más fuertemente asociadas con la conversión fueron: la experiencia del cirujano (p=0,001), la obesidad (p=0,036), engrosamiento de la pared de la vesícula biliar en la ecografía (p=0,011) y un mayor puntaje en la clasificación de Parkland (p<0,001). Conclusión. La identificación temprana y análisis individual de los factores perioperatorios de riesgo a conversión en la planeación de la colecistectomía laparoscópica podría definir qué pacientes se encuentran expuestos y cuáles podrían beneficiarse de un abordaje mínimamente invasivo, en búsqueda de toma de decisiones adecuadas, seguras y costo-efectivas

Introduction. Laparoscopic cholecystectomy is the gold standard for the management of gallbladder pathology with surgical indication. During its execution, there is a group of patients who may require conversion to the open technique. This study evaluated perioperative factors associated with conversion at the OHL Central Clinic in Montería, Colombia. Methods. Observational analytical case-control study nested in a retrospective cohort between 2018 and 2021, in a 1:3 case/control ratio, 95% confidence level and 90% power. The study population was characterized and the associations were evaluated according to the nature of the variables, then the OR were estimated by bivariate and multivariate analysis, with their 95% CI, considering a value of p<0.05 significant, controlling for confounding variables. Results. The study included 332 patients, 83 cases and 249 controls, showing in the multivariate model that the variables most strongly associated with conversion were: the surgeon's experience (p=0.001), obesity (p=0.036), gallbladder wall thickening on ultrasonography (p=0.011), and a higher score in the Parkland classification (p<0.001). Conclusions. Early identification and individual analysis of the perioperative risk factors for conversion in the planning of laparoscopic cholecystectomy could define which patients are exposed, and which could benefit from a minimally invasive approach, in search of making safe, cost-effective, and appropriate decisions

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BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for acute calculous cholecystitis; however, in patients at high risk for surgery, particularly in the elderly, insertion of a percutaneous catheter drainage (PCD) at gallbladder is recommended. Current evidence suggests that PCD may have less favorable outcomes than LC, but also that LC-associated complications increase in direct relation to patient age. There is no recommendation supported by robust evidence to decide between one or the other procedure in super elderly patients. METHODS: A retrospective observational cohort study was designed to analyze the surgical outcomes of super elderly patients with cholecystitis who underwent LC versus PCD for treatment. The surgical outcomes of a subgroup of high-risk patients were also analyzed. RESULTS: A total of 96 patients who met the inclusion criteria between 2014 and 2021 were included. The median age of patients were 92 years (IQR: 4.00) with a female predominance (58.33%). The overall morbidity rate in the series was 36.45% and mortality rate was 7.29%. There was no statistically significant difference when compared to the associated morbidity and mortality among patients who underwent LC versus those who underwent PCD, neither in the analysis of the complete series or in the subgroup of high-risk patients. CONCLUSIONS: The morbidity and mortality associated with the two most frequently recommended therapeutic options for operating super elderly patients with acute cholecystitis are high. We found no evidence of superiority in outcomes for either of the two procedures in this age group.

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INTRODUCTION: cholelithiasis is a highly prevalent disease of the digestive system in the world. In Brazil, it is a routine condition, whose studies suggest a prevalence of around 10% of adults. Colonization of bile and gallstone pathogens can occur when there is bacterial stasis and proliferation. This proliferation is facilitated by the adhesion and biofilm formation capacity of some bacteria. There are also lithogenic processes that involve bacterial participation. Studies have shown changes in the microbiota of the gallbladder of patients undergoing cholecystectomy, which may impact empirical treatment with antibiotics. METHODOLOGY: microbiological analyzes of the sonication fluid of the gallstones and of two samples with bile were performed. Identification and antimicrobial susceptibility testing were performed according to a standard routine. RESULTS: of the 34 patients, 76.4% were female. The age group was 48 years +/- 16.61. Acute cholecystitis occurred in 50% of cases. Bactobilia was evidenced in 32.1% of the cases. Klebisiella pneumoniae was noted as the most prevalent pathogen in acute cholecystitis; and Enterobacter sp, in cases of uncomplicated cholelithiasis. Greater sensitivity was obtained in the search for microorganisms in the sonication fluid samples of the stones in relation to the bile samples (p=0.0058). CONCLUSION: there was a higher prevalence of bactobilia in patients with acute cholecystitis compared to those with uncomplicated cholelithiasis. The use of sonication in bacterial investigation proved to be superior to the conventional method and can be considered.

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Introducción. En pacientes con diagnóstico de colecistitis aguda tratados con colecistostomía, el tiempo óptimo de duración de la terapia antibiótica es desconocido. El objetivo de este trabajo fue comparar los resultados clínicos en pacientes con diagnóstico de colecistitis aguda manejados inicialmente con colecistostomía y que recibieron cursos cortos de antibióticos (7 días o menos) versus cursos largos (más de 7 días). Métodos. Se llevó a cabo un estudio de cohorte observacional, retrospectivo, que incluyó pacientes con diagnóstico de colecistitis aguda manejados con colecistostomía, que recibieron tratamiento antibiótico. Se hizo un análisis univariado y de regresión logística para evaluar la asociación de variables clínicas con la duración del tratamiento antibiótico. El desenlace primario por evaluar fue la mortalidad a 30 días. Resultados. Se incluyeron 72 pacientes. El 25 % (n=18) recibieron terapia antibiótica por 7 días o menos y el 75 % (n=54) recibieron más de 7 días. No hubo diferencias significativas en la mortalidad a 30 días entre los dos grupos ni en las demás variables estudiadas. La duración de la antibioticoterapia no influyó en la mortalidad a 30 días (OR 0,956; IC95% 0,797 - 1,146). Conclusión. No hay diferencias significativas en los desenlaces clínicos de los pacientes con colecistitis aguda que son sometidos a colecistostomía y que reciben cursos cortos de antibióticos en comparación con cursos largos

Introduction.In patients with acute cholecystitis who receive treatment with cholecystostomy, the optimal duration of antibiotic therapy is unknown. The objective of this study is to compare short courses of antibiotics (7 days or less) with long courses (more than 7 days) in this population. Methods. We performed a retrospective observational cohort study which included patients diagnosed with acute cholecystitis, who received antibiotic therapy and were taken to cholecystostomy. Univariate analysis and logistic regression were performed to evaluate the association between clinical variables and the duration. The main outcome evaluated was 30-day mortality. Results. Seventy-two patients were included, 25% (n=18) were given 7 or fewer days of antibiotics while 75% (n=54) were given them for more than 7 days. Demographic data between both groups were similar (age, severity of cholecystitis, comorbidities). There were no significant differences in 30-day mortality between both groups. Antibiotic duration did not influence mortality at 30 days (OR 0.956, 95% CI 0.797 - 1.146). Conclusion. There are no significant differences in the clinical outcomes of patients with acute cholecystitis who undergo cholecystostomy and receive short courses of antibiotics compared to long courses

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BACKGROUND: Nonagenarian patients are an age group in progressive growth. In this age group, indications for surgical procedures, including cholecystectomy, will be increasingly frequent, as biliary pathology and its complications are frequent in this population group. The main objective of this study was to analyze the safety and outcomes of laparoscopic cholecystectomy in patients older than 90 years. METHODS: A retrospective observational cohort study was designed. This study involved 600 patients that were classified in 4 age groups for analysis (under 50 years, 50-69 years, 70-89 years, and over 90 years). Demographic, clinical, paraclinics, surgical, and outcome variables were compared according to age group. A multivariate analysis, which included variables considered clinically relevant, was performed to identify factors associated with mortality and complications classified with the Clavien-Dindo scale. RESULTS: The patients evaluated had a median age of 65.0 (IQR 34.0) years and there was a female predominance (61.8%). A higher complication rate, conversion rate, subtotal cholecystectomy rate, and prolonged hospital stay were found in nonagenarians. The overall mortality rate was 1.6%. Mortality in the age group over 90 years was 6.8%. Regression models showed that age over 90 years (RR 4.6 CI95% 1.07-20.13), presence of cholecystitis (RR 8.2 CI95% 1.29-51.81), and time from admission to cholecystectomy (RR 1.2 CI95% 1.10-1.40) were the variables that presented statistically significant differences as risk factors for mortality. CONCLUSION: Cholecystectomy in nonagenarian patients has a higher rate of complications, conversion rate, subtotal cholecystectomy rate, and mortality. Therefore, an adequate perioperative assessment is necessary to optimize comorbidities and improve outcomes. Also, it is important to know the greatest risk for informed consent and choose the surgical equipment and schedule of the procedure.

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