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ABSTRACT BACKGROUND: Gallbladder polyps are becoming a common finding in ultrasound. The management has to consider the potential risk of malignant lesions. AIMS: The aim of this study was to analyze the ultrasound findings in patients undergoing cholecystectomy due to gallbladder polyps and compare them for histopathological findings (HPs). METHODS: Patients with an ultrasonographic diagnosis of gallbladder polyp and who underwent cholecystectomy from 2007 to 2020 were included in the study. RESULTS: A total of 447 patients were included, of whom 58% were women. The mean age was 45±12 years. The mean size of polyps in US was 7.9±3.6 mm. Notably, 9% of polyps were greater than 10 mm, and single polyps were significantly larger than the multiple ones (p=0.003). Histopathological findings confirmed the presence of polyps in 88.4%, with a mean size of 4.8±3.4 mm. In all, 16 cases were neoplastic polyps (4.1%), 4 of them being malignancies, and all were single and larger than 10 mm. We found a significant correlation between ultrasound and histopathological findings polyp size determination (r=0.44; p<0.001). The Bland-Altman analysis obtained an overestimation of the US size of 3.26 mm. The receiver operating characteristic (ROC) curve analysis between both measures obtained an area under the receiver operating characteristic curve (AUC) of 0.77 (95%CI 0.74-0.81). Ultrasound polyps size larger than 10 mm had an odds ratio (OR) of 8.147 (95%CI 2.56-23.40) for the presence of adenoma and malignancy, with a likelihood ratio of 2.78. CONCLUSIONS: There is a positive correlation and appropriate diagnostic accuracy between ultrasound size of gallbladder polyps compared to histopathological records, with a trend to overestimate the size by about 3 mm. Neoplastic polyps are uncommon, and it correlates with size. Polyps larger than 10 mm were associated with adenoma and malignancy.

RESUMO RACIONAL: Os pólipos da vesícula biliar estão se tornando um achado comum na ultrassonografia (US). O manejo deve levar em consideração o risco de lesões malignas. OBJETIVOS: Analisar os achados da ultrassonografia em pacientes submetidos à colecistectomia por pólipos vesicais e compará-los com os achados histopatológicos. MÉTODOS: Foram revisados os prontuários médicos dos pacientes com diagnóstico ultrassonográfico de pólipo vesicular e submetidos à colecistectomia no período de 2007 a 2020. RESULTADOS: Foram incluídos no estudo 447 pacientes. A média de idade foi 45±12anos, sendo 58% mulheres. O tamanho médio dos pólipos na US foide 7,9±3,6mm. Nove por cento foram maiores que 10 mm, e os pólipos únicos encontrados foram maiores do que os múltiplos (p=0,003). A HP confirmou a presença de pólipos em 88,4%, tamanho médio 4,8±3,4mm. Dezesseis eram pólipos neoplásicos (4,1%) e quatro deles malignos, únicos e maiores que 10 mm. Foi encontrado correlação significativa entre a determinação do tamanho do pólipo ao ultrassonografia e histopatológicos (r=0,44; p<0,001). A análise de Bland-Altman obteve uma superestimação do tamanho do pólipo ao US em 3,26 mm. A análise da curva da característica de operação do receptor entre as duas medidas obteve uma área sob a curva curva da característica de operação do receptor (AUC) de 0,77 (IC95% 0,74-0,81). Pólipos ao ultrassonografia maiores que 10 mm apresentaram razão de chance (OR) de 8,147 (IC95% 2,56-23,40) para presença de adenoma e malignidade, com razão de verossimilhança de 2,78. CONCLUSÕES: Há uma correlação positiva e acurácia diagnóstica apropriada entre o tamanho dos pólipos da vesícula biliar por ultrassonografia em comparação com os achados histopatológicos, com uma tendência de superestimar o tamanho em cerca de 3 mm. Pólipos maiores que 10 mm foram associados a adenoma e malignidade.

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Purpose: The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed. Methods: Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal. Results: Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. Conclusions: LC can be performed using different techniques, although the use of EBVS is highly recommended.

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ABSTRACT Objective: to determine the prevalence of incidental gallbladder cancer (IGBC) in cholecystectomies performed in a tertiary public hospital and to describe technical and epidemiological aspects of performing cholecystectomies for presumably benign disease. Method: descriptive, retrospective observational study, based on analysis of medical records of patients undergoing cholecystectomy with preoperative hypothesis of benign disease between January 2018 and January 2022. Results: prevalence of gallbladder adenocarcinoma in our sample was 0.16%, similar to data in the literature. Technical aspects during cholecystectomy were also described with a frequency similar to that found in the literature. Conclusion: despite a rare disease, IGBC is relevant in the routine of the General Surgeon. Its diagnosis, staging and treatment directly affect the prognosis. Technical aspects during cholecystectomy are not always remembered by surgeons and can interfere with the prognosis and subsequent treatment of the patient.

RESUMO Objetivos: determinar a prevalência de câncer incidental de vesícula biliar (CIVB) em colecistectomias realizadas em um hospital público terciário e descrever aspectos técnicos e epidemiológicos na realização de colecistectomias por doença presumidamente benigna. Método: estudo observacional descritivo, retrospectivo, a partir da análise de prontuários de pacientes submetidos à colecistectomia com hipótese pré-operatória de doença benigna entre janeiro de 2018 e janeiro de 2022. Resultados: a prevalência de adenocarcinoma de vesícula biliar na amostra avaliada foi de 0,16%, semelhante aos dados da literatura mundial. Os aspectos técnicos durante a realização da colecistectomia também foram descritos com frequência semelhante ao encontrado na literatura. Conclusão: o CIVB é uma doença rara mas de importância relevante na rotina do Cirurgião Geral. Seu diagnóstico, estadiamento e tratamento implicam diretamente no prognóstico. Aspectos técnicos durante a realização da colecistectomia nem sempre são lembrados pelos cirurgiões e podem interferir no prognóstico e tratamento subsequente do paciente.

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ABSTRACT - BACKGROUND: Gallbladder diseases (GBD) are one of the most common medical conditions requiring surgical intervention, both electively and urgently. It is widely accepted that sex and ethnic characteristics mighty influence both prevalence and outcomes. AIM: This study aimed to evaluate the differences on distributions of gender and ethnicity related to the epidemiology of GBD in the Brazilian public health system. METHODS: DATASUS was used to retrieve patients' data recorded under the International Code of Diseases (ICD-10) - code K80 from January 2008 to December 2019. The number of admissions, modality of care, number of deaths, and in-hospital mortality rate were analyzed by gender and ethnic groups. RESULTS: Between 2008 and 2019, a total of 2,899,712 patients with cholelithiasis/cholecystitis (K80) were admitted to the hospitals of the Brazilian Unified Health System, of whom only 22.7% were males. Yet, the in-hospital mortality rate was significantly higher in males (15.9 per 1,000 male patients) than females (6.3 per 1,000 female patients) (p<0.05). Moreover, men presented a significantly higher risk of death (RR=2.5; p<0.05) and longer hospital stay (4.4 days vs. 3.3 days; p<0.05) than females. Compared to females, men presented a higher risk of death across all self-declared ethnic groups: whites (RR=2.4; p<0.05), blacks (RR=2.7; p<0.05), browns (RR=2.6; p<0.05), and Brazilian Indians (RR=2.13; p<0.05). CONCLUSION: In the years 2008-2019, women presented the highest prevalence of hospital admissions for GBD in Brazil, and men were associated with worse outcomes, including all ethnic groups.

RESUMO - RACIONAL: Doenças da vesícula biliar (DVB) são uma das condições médicas mais comuns que requerem intervenção cirúrgica, tanto eletiva como urgente. É amplamente aceito que o sexo e as características étnicas podem influenciar a prevalência e os desfechos. OBJETIVO: Avaliar as diferenças nas distribuições de gênero e etnia relacionados à epidemiologia da DVB no sistema público de saúde brasileiro. MÉTODOS: O DATASUS foi usado para elencar os dados de pacientes registrados no Código Internacional de Doenças (CID-10) sob o código K80, de janeiro de 2008 a dezembro de 2019. O número de admissões, caráter de atendimento, número de óbitos e taxa de mortalidade hospitalar foram analisados por gênero e por etnia. RESULTADO: Entre 2008 e 2019, 2.899.712 pacientes com colelitíase/colecistite (K80) foram admitidos em hospitais do Sistema Único de Saúde (SUS), dos quais apenas 22,7% eram do sexo masculino. Ainda assim, a taxa de mortalidade intra-hospitalar masculina (15,9:1.000 pacientes homens) foi significativamente maior do que a feminina (6,3:1.000 pacientes mulheres) (p<0,05). Ademais, homens apresentaram risco de morte significativamente maior em comparação às mulheres (RR=2,5; p<0,05) e maior tempo de internação hospitalar (4,4 dias versus 3,3 dias; p<0,05). Em comparação ao sexo feminino, homens apresentaram maior risco de morte em todos os grupos étnicos autodeclarados: brancos (RR=2,4; p<0,05), negros (RR=2,7; p<0,05), pardos (RR=2,6; p<0,05) e indígena (RR=2,13; p<0,05). CONCLUSÃO: Nos anos de 2008-2019, as mulheres apresentaram as maiores prevalências de internações hospitalares por DVB no Brasil, porém, os homens foram associados a piores desfechos, inclusive entre todos os grupos étnicos.

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Introducción: aproximadamente el 10 % de las personas con colelitiasis desarrollará colecistitis Aguda. A nivel mundial se utiliza la Guía de Tokio, fundamental para un diagnóstico y clasificación. La clasificación según severidad predice con precisión la mortalidad, duración de la hospitalización y tasas de conversión de laparotomía. Los criterios utilizados son: signos y síntomas característicos, hallazgo de exámenes físicos, datos laboratoriales y de imágenes. Objetivos: evaluar la aplicación de los criterios de Tokio para el diagnóstico de colecistitis aguda en el del Servicio de Cirugía, Departamento de Urgencias Adultos del Hospital Nacional. Metodología: estudio observacional descriptivo transversal y retrospectivo. Se analizaron las fichas de pacientes que acudieron al del Servicio de Cirugía, Departamento de Urgencias Adultos del Hospital Nacional entre el 1 de enero al 1 de septiembre del 2019. Resultados: de 66 pacientes estudiados, la edad promedio fue de 45 años, con predominio de sexo femenino. El 100 % presentó dolor en hipocondrio derecho; en el 73 % se halló proteína C reactiva elevada, y la pared vesicular engrosada fue el signo imagenológico más frecuente, en 38 casos (58 %). El 74 % cumplió con los criterios para diagnóstico definitivo de colecistitis aguda. Conclusiones: la guía de Tokio fue una herramienta útil, aplicable y necesaria para el diagnóstico oportuno de la colecistitis aguda en los pacientes del Hospital Nacional. Además, es muy valiosa para clasificarla por severidad y así orientar al tratamiento adecuado.

Introduction: approximately 10 % of people with cholelithiasis will develop Acute Cholecystitis. The Tokyo Guide, essential for diagnosis and classification, is used worldwide. Classification according to severity accurately predicts mortality, length of hospitalization, and laparotomy conversion rates. The criteria used are: characteristic signs and symptoms, findings of physical examinations, laboratory data and images. Objectives: to evaluate the application of the Tokyo criteria for the diagnosis of acute cholecystitis in the Surgery Service, Adult Emergency Department of the Hospital Nacional. Methodology: descriptive, cross-sectional and retrospective observational study. The files of patients who attended the Surgery Service, Adult Emergency Department of the Hospital Nacional between January 1 to September 1, 2019 were analyzed. Results: of 66 patients studied, the average age was 45 years, with a predominance of females. 100 % presented pain in the right upper quadrant; In 73 %, elevated CRP was found, and the thickened gallbladder wall was the most frequent imaging sign, in 38 cases (58 %). 74 % met the criteria for a definitive diagnosis of acute cholecystitis. Conclusions: the Tokyo guideline was a useful, applicable and necessary tool for the timely diagnosis of acute cholecystitis in patients at the Hospital Nacional. In addition, it is very valuable to classify it by severity and thus guide the appropriate treatment.

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Fundamento: el SIT resulta un síndrome poco frecuente sin ser una rareza. Su origen causal aún es incierto, se le considera debido a la expresión de un gen autosómico recesivo, con incidencia igual en ambos sexos y sin mostrar predilección racial. Está caracterizado por la posición invertida de los órganos en las cavidades torácica y abdominal con respecto al plano sagital, dando la imagen anatómica de las vísceras en espejo. Objetivo: presentar el caso de una paciente con ambas enfermedades asociadas que resulta poco comunes y de interés médico. Caso clínico: paciente normolínea, de piel blanca, femenina y de 38 años de edad, con buena salud anterior a pesar de padecer de una importante anomalía congénita. Llevaba seis meses con síntomas de dispepsia y cólicos biliares a repetición del abdomen izquierdo que se diagnosticó por el método clínico, ultra sonografía y radiología de padecer litiasis vesicular única, donde se confirmó el situs inversus, asociación que es infrecuente. Se interconsulta con cardiología y anestesia, previo consentimiento informado, se realiza colecistectomía abierta con buena evolución hasta su egreso. Conclusiones: la evolución en el intra operatorio y luego en el posoperatorio inmediato y mediato fue buena, a los seis meses del tratamiento está asintomática y con aumento de peso corporal.

Background: a brief revision about two medical subjects was made: totalis situs inversus and gallstone disease and its clinical characteristics, as well as its regular treatment that includes the video-assisted cholecystectomy and the traditional one. A references has been made about this clinical association found in a woman with this congenital anomaly since her childhood, the totalis situs inversus. Objective: to present this patient with both associated deceases that are uncommon and of medical interest. Clinical case: a regular patient was treated, white skin color, female, 38 years old, with good previous health condition in spite of suffering of a major congenital abnormality. She was six month suffering symptoms of dyspepsia and biliary colic repeated in the left abdomen and diagnosed with only gallstone by clinical method, ultrasonography and radiology, getting confirmed this way the totalis situs inversus, association that is uncommon. An interconsultation with Cardiology and Anesthesiology was made, and getting previously the informed consent, an open cholecystectomy was performed with good evolution until her final discharge. Conclusions: the evolution in the intraoperative and later in the immediate and mediate postoperative was good, and after six month of treatment, the patient is asymptomatic and has gained body weight.

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BACKGROUND: The occurrence of gallstones following Roux-en-Y gastric bypass (RYGB) has been extensively reported. As RYGB promotes improvement in insulin resistance (IR), which is one of the factors enrolled in the pathophysiology of gallstones, this study aims to determine the influence of IR and its post-RYGB course on the development of gallstones. METHODS: This is a prospective cohort study that enrolled 108 morbidly obese subjects free of gallstones which underwent RYGB and were followed up for 24 months, through clinical, laboratory, and ultrasound examinations. IR was assessed through the surrogate marker homeostasis model assessment (HOMA). RESULTS: Of the individuals evaluated, 29 (26.8%) developed gallstones following RYGB. In the univariate analysis, postsurgical gallstones were associated with preoperative HOMA (p < 0.0001), preoperative fasting glucose (p = 0.0019), preoperative fasting insulin (p = 0.0001), and preoperative triglycerides (p = 0.0001). Multivariate analysis revealed that preoperative HOMA was the only factor independently associated with gallstones (p < 0.0001). The incidence of gallstones among individuals with IR was 46.8%; in the non-IR subjects, the incidence was 7.4% (p < 0.0001). Preoperative IR led to a relative risk of 6.02 (95% CI = 2.1-17.3; p = 0.0009) of gallstones. CONCLUSIONS: As gallstones often occur following RYGB, there is controversy regarding their management. Some authors propose systematic cholecystectomy along with RYGB, while others suggest that the aggregate risk of the concomitant approach is significantly higher. As IR was a significant risk factor in this study, an individualized approach for this population may be proposed. Further research is needed to confirm these findings.

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The technique of a single-port laparoscopy was developed over the last years as an attempt to lower surgical aggression and improve the aesthetic results of the minimally invasive surgery. A new robotic platform used with the da Vinci® Robotic System Single-Site System® (Intuitive Surgical, Sunnyvale, California, United States) was recently launched on the global market and is still not documented in Brazil. The authors report on the first four robotic single-port cholecystectomies performed with this da Vinci® Robotic System in Brazil.

A técnica de um único portal laparoscópico foi desenvolvida ao longo dos últimos anos, numa tentativa de diminuir a agressão cirúrgica e melhorar ainda mais os resultados estéticos da cirurgia minimamente invasiva. Uma nova plataforma robótica, usada com o Sistema Robótico da Vinci®Single-Site System® (Intuitive Surgical, Sunnyvale, Califórnia, Estados Unidos), foi recentemente lançada no mercado mundial e é ainda inédita no Brasil. Os autores relatam as primeiras quatro colecistectomias robóticas com portal único realizadas com este Sistema Robótico da Vinci® no Brasil.

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The yellow nail syndrome is scarcely described and is characterized by dystrophic nails, pulmonary disturbances and lymphedema of extremities. A case of this syndrome is reported in an 89-year-old Brazilian woman with well-controlled diabetes mellitus and arterial hypertension. Additionally to the typical syndrome, the patient also presented pincer nails and yellow-brownish chromonychia. She was admitted because of acute abdominal symptoms associated with sigmoid diverticulitis and an adjacent abscess. The imaging studies revealed pulmonary and pleural changes, in addition to pericardial effusion. Incidentally, the features of Phrygian cap gallbladder anomaly were found. Neither diverticular disease nor gallbladder disorders have been related to yellow nail syndrome. In the present case study, the synchronism between some of these conditions could be casual; but diverticular disease, cholelithiasis, and diaphragmatic hernia are associated in the Saint's triad. MÉD UIS. 2015;28(3):387-91.

El síndrome de las uñas amarillas está poco descrito y se caracteriza por uñas distróficas, trastornos pulmonares y linfedema de las extremidades. Se presenta un caso de este síndrome en una mujer brasileña de 89 años de edad con diabetes mellitus bien controlada e hipertensión arterial. Adicionalmente al síndrome típico, la paciente presentó uñas en pinza y cromoniquia amarillo-marrón. La paciente fue admitida debido a síntomas abdominales agudos asociados con diverticulitis del sigmoide y un absceso adyacente. Los estudios de imágenes revelaron cambios pulmonares y pleurales, además de un derrame pericárdico. Incidentalmente, se encontraron anomalías características de vesícula biliar en gorro frigio. Ni la enfermedad diverticular ni los trastornos de la vesícula biliar se han relacionado con el síndrome de las uñas amarillas. En el presente estudio de caso, el sincronismo entre algunas de estas condiciones podría ser casual, pero la enfermedad diverticular, colelitiasis, y hernia hiatal se asocian a esta tríada. MÉD UIS. 2015;28(3):387-91.

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OBJETIVO: Analisar o tempo operatório, a permanência hospitalar, a taxa de conversão, a morbidade e a mortalidade de pacientes idosos submetidos à colecistectomia videolaparoscópica por doença da vesícula biliar. MÉTODOS: Estudo descritivo, retrospectivo, realizado no prontuário de 960 pacientes, de ambos os sexos, com idade entre 60 e 97 anos no período de janeiro de 1993 a agosto de 2009. RESULTADOS: O tempo operatório variou de nove a 180 minutos. O tempo de internação variou de 24 a 120 horas. A conversão ocorreu em 28 pacientes (2,92 por cento), dos quais 67,9 por cento eram mulheres e 28,6 por cento homens tendo sido em 11 casos (39,3 por cento) realizada minilaparotomia e em 17 (60,7 por cento) a via aberta convencional. As intercorrências no transoperatório foram duas rupturas da vesícula biliar, uma falha no pneumoperitônio e uma na clipagem do ducto cístico. No pós-operatório observaram-se cinco hérnias umbilicais incisionais. As complicações sistêmicas foram: nove arritmias cardíacas, uma icterícia pós-operatória, um infarto agudo do miocárdio e um infarto enteromesentérico. Mortalidade ocorreu em três pacientes (0,3 por cento), um por infarto agudo do miocárdio no transoperatório, uma sepse e um infarto enteromesentérico. CONCLUSÃO: Os pacientes idosos submetidos à colecistectomia videolaparoscópica apresentaram baixo tempo de internação hospitalar e baixa morbimortalidade. O tempo operatório e o de internação hospitalar foram curtos, demonstrando que a colecistectomia videolaparoscópica é procedimento seguro e eficaz nos idosos.

OBJECTIVE: to evaluate the operative time, hospital stay, conversion rate, morbidity and mortality in elderly patients undergoing laparoscopic cholecystectomy for gallbladder disease. METHODS: we conducted a descriptive, retrospective study with the chats of 960 patients, aged 60 and 97 years in the period from January 1993 to August 2009. RESULTS: operative time ranged from nine to 180 minutes. The length of stay ranged from 24 to 120 hours. Conversion occurred in 28 patients (2.92 percent), of whom 67.9 percent were women and 28.6 percent men, a minilaparotomy having been performed in 11 cases (39.3 percent) and in 17 (60.7 percent) the conventional open route. The perioperative complications were two ruptures of the gallbladder, one failure in the pneumoperitoneum and one in clipping the cystic duct. Postoperative complications were five umbilical incisional hernias. Systemic complications were: nine arrhythmias, one postoperative jaundice, one acute myocardial infarction and one mesenteric infarction. Mortality occurred in three patients (0.3 percent), one due to perioperative myocardial infarction, one due to sepsis and one because of mesenteric infarction. CONCLUSION: elderly patients undergoing laparoscopic cholecystectomy had low hospital stay and low morbimortality. The operative time and hospital stay were short, demonstrating that laparoscopic cholecystectomy is safe and effective in the elderly.

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La colecistitis calculosa aguda es la causa más importante de colecistectomías en el mundo. En esta revisión de tema se resume la fisiopatología del proceso inflamatorio de la vesícula biliar secundaria a la obstrucción de la vía biliar, así como sus manifestaciones clínicas, estudios diagnósticos y su manejo médico-quirúrgico.

Acute calculous cholecystitis is the most important cause of cholecystectomies worldwide. We review the physiopathology of the inflammatory process in this organ secondary to biliary tract obstruction, as well as its clinical manifestations, workup, and the treatment it requires.

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OBJETIVO: O objetivo do estudo é saber qual a orientação terapêutica para os doentes com pólipos vesiculares (PVs), que tipo de vigilância realizar, saber diferenciar entre um pólipo benigno e um pólipo maligno e proporcionar uma tranquilização em relação à "cancrofobia". Tipo de estudo: Realizou-se um estudo retrospectivo de cinco anos. Local: O estudo foi realizado nos Hospitais da Universidade de Coimbra, num Serviço de Cirurgia. População: Foram estudados todos os doentes operados no Serviço de Cirurgia II com o diagnóstico pré-operatório de PV, entre janeiro de 2003 e dezembro 2007. MÉTODOS: Foi feita correlação clínico-patológica de todos os doentes. Feita avaliação: de dados demográficos, da apresentação clínica, dos principais sintomas, das patologias associadas e exames complementares de diagnóstico realizados. RESULTADOS: Foram estudados 93 doentes, sendo que em 91 doentes tratava-se de pólipos benignos e em dois doentes de pólipos malignos. Dos 91 pólipos benignos, 73 (78,5 por cento) eram pólipos de colesterol, 14 (15 por cento) hiperplasias e dois (2,2 por cento) adenomas. Em dois (2,2 por cento) doentes tratava-se de pólipos malignos, adenocarcinoma da vesícula biliar. O diâmetro médio dos pólipos benignos é de 6 mm, 40 (43 por cento) doentes apresentavam lesões múltiplas. Nos pólipos malignos e pré-malignos (adenomas) o diâmetro médio é de 18,8 mm, são todas lesões solitárias e a idade média destes doentes é de 57,7 anos. CONCLUSÃO: Conclui-se que o tratamento cirúrgico dos PVs é a colecistectomia e só deve ser realizado quando existe: clínica relacionada com o PV; pólipos de diâmetro superior a 10 mm; crescimento do pólipo num curto espaço de tempo; pólipo séssil ou base de inserção larga; pólipo com longo pedículo; idade do doente superior a 50 anos; coexistência de litíase vesicular; pólipos localizados no infundíbulo da vesícula ou alterações ecográficas na parede vesicular.

OBJECTIVE: Appropriate treatment and timing hinge on whether the lesion is benign or malignant. Study: A five years retrospective descriptive analysis was performed. Location : Department of General Surgery in Hospitals of the University of Coimbra. Patients: We present a series of 93 consecutive patients who had elective surgery for known gallbladder polyps, treated from January 2003 to December 2007. METHODS: An analysis was performed using clinical and radiological files of patients electively treated for gallbladder polyp. Ninety-three consecutive patients were evaluated, treated and followed in a Department of General Surgery in a Central Hospital in that period. Biographic, clinical and radiological data were compiled. RESULTS: In 91 patients a benign lesion was found. Two (2.16 percent) patients had adenocarcinoma. Among benign polyps, 73 (78,5 percent) were cholesterol polyps, 14 (15 percent) were hyper-plastic and 2 (2.19 percent) were premalignant adenomas. Mean diameter of benign polyps, excluding adenomas, was 6 mm. In 40 (43 percent) patients, multiple lesions were found. The mean diameter in the subset of malignant and premalignant polyps was 18.8 mm, in all instances these were found to be single lesions; and mean age at presentation was 57,7 years. CONCLUSION: Cholecystectomy is the appropriate surgical treatment for gallbladder polyps, when removal is warranted. Patients benefitting from surgery are those who are symptomatic, whose polyps exceed 10 mm in diameter and , have shown to be enlarging, to be sessile or broad-based, to have long pedicles;and also have . infundibular polyps, coexisting gallstones or changes on the gallbladder wall appearance at ultrasonography.

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RESUMO

BACKGROUND: Emphysematous cholecystitis is life-threatening condition characterized by gas-forming infection of the gallbladder. It is mostly seems in old male patients with systemic, specially diabetes and vascular diseases. CASE REPORT: - A 30-year-old man without previous diseases was admitted because of right upper quadrant pain and nausea. On admission the patient was febrile (38.7o) with normal bilirubin levels. The white blood count was 26700/µl and reactive protein C was 470. Axial sections of single slice computed tomography imaging (section thickness 5 mm), revealed gallbladder wall enhancement after i.v. contrast, as well as dilatation of the gallbladder with intraluminal air. The patient underwent open cholecystectomy. The culture of the bile showed clostridium perfringes. The postoperative course of the patient was uneventful. CONCLUSION: This is a rare form of cholecystitis that carries a high mortality and usually present insidious clinical signs. CT is the most accurate imaging technique. Antibiotic therapy should begin quickly and include coverage of common pathogens, particularly Clostridia. Surgical intervention should take place as early as possible.

INTRODUÇÃO: Colecistite enfisematosa é uma condição de risco de vida caracterizada por infecção da vesícula biliar por agentes produtores de gás. Na sua apresentação mais comum atinge preferencialmente homens idosos portadores de doenças sistêmicas em especial diabetes e vasculopatias. RELATO DO CASO: Paciente do sexo masculino, 30 anos de idade e sem co-morbidades que se apresenta ao pronto-socorro com história de dor abdominal em hipocôndrio direito há cinco dias, febre (38,7o) e náuseas. Os exames laboratoriais mostravam leucocitose (26700/µl) e elevação dos marcadores de inflamação (proteína C reativa, PCR 470). A tomografia computadorizada do abdome revelou realce da parede vesicular após injeção de contraste i.v., bem como dilatação da vesícula com a presença de ar intraluminal. O paciente foi submetido à colecistectomia através de incisão subcostal direita. A cultura da bile foi positiva para Clostridium perfringes. A evolução pós-operatória do paciente foi satisfatória. CONCLUSÃO: Esta é uma rara forma de colecistite com alta mortalidade e usualmente se apresenta com sinais clínicos insidiosos.Tomografia computadorizada é a mais acurada forma de diagnóstico de imagem. Antibioticoterapia de largo espectro deve começar rapidamente incluindo proteção à Clostridia. Procedimento cirúrgico deve ser indicado tão cedo quanto possível.