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Choledocholithiasis is the most common cause of obstructive jaundice and occurs in 5-10% of patients with cholelithiasis.To design a preoperative predictive score for choledocholithiasis.A prospective study was carried out in 556 patients admitted to our department for biliary disease. Preoperative clinical, laboratory, and ultrasound variables were compared between patients without choledocholithiasis and 65 patients with this diagnosis. A multivariate logistic analysis was performed to obtain a predictive model of choledocholithiasis, determining sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).Predictors of choledocholithiasis were the presence of a prior history of biliary disease (history of biliary colic, acute cholecystitis, choledocholithiasis or acute biliary pancreatitis) (p=0.021, OR=2.225, 95% CI: 1.130-4.381), total bilirubin values4mg/dl (p=0.046, OR=2.403, 95% CI: 1.106-5.685), alkaline phosphatase values150mg/dl (p=0.022 income, OR=2.631, 95%: 1.386-6.231), gamma-glutamyltransferase (GGT) values100mg/dl (p=0.035, OR=2.10, 95% CI: 1.345-5.850), and an ultrasound finding of biliary duct8mm (p=0.034, OR=3.063 95% CI: 1086-8649). A score superior to 5 had a specificity and PPV of 100% for detecting choledocholithiasis and a score less than 3 had a sensitivity and NPV of 100% for excluding this diagnosis.The preoperative score can exclude or confirm the presence of choledocholithiasis and allows patients to directly benefit from laparoscopic cholecystectomy (LC) or prior endoscopic retrograde cholangiopancreatography (ERCP).

The aim of this study was to assess the influence of age in laparoscopic cholecystectomy (LC) for the treatment of acute cholecystitis by determining the benefits and postoperative complications in patients older than 65 years.Between January 2003 and March 2006, we performed 134 urgent LC for acute cholecystitis: 58 patients older than 65 years (group 1) were compared with 76 patients younger than 65 years (group 2). Preoperative, intraoperative and postoperative variables were compared between groups 1 and 2. ASA score was used in the preoperative anesthetic evaluation.A total of 31.2% of patients in group 1 had high surgical risk (24% ASA III and 9.2% ASA IV). The conversion rate was 24.1% in group 1 versus 11.3% in group 2 (p = 0.04), due to difficulty in surgical dissection and advanced cholecystitis. The mean length of postoperative hospital stay was 4.7 +/- 3.2 days in group 1 versus 3.3 +/- 2.4 days in group 2 (p = 0.001). The overall rate of postoperative complications was 33.1% and 18.7% respectively, with a predominance of infectious complications.Although age should not be an exclusion factor for LC, the conversion rate, postoperative complications and length of hospital stay are increased in the elderly. Higher morbidity due to the underlying disease and longer disease duration with more advanced cholecystitis complicate the laparoscopic approach in these patients.

Acute typhlitis is usually associated with severe immunosuppressive conditions. Initially described as closely associated with infantile myeloid leukaemia, its incidence increased along the last decade.retrospective review.12 immunodepressed patients affected of acute typhilis in our hospital between 1994 and 2001. Suspected diagnosis was established by clinical symptoms and abdominal CT findings, and was confirmed with pathological finding in the surgical specimen. Clinical and radiological diagnosis, treatment, complications and survival of patients are discussed.3 patients with a previous diagnosis af acute myeloid leukemia, 2 patients with non-Hodgkin lymphoma, 2 patients with aplastic anaemia, one patient with AIDS, and 4 patients with kidney transplantation were included in our study. Prednisone, cyclosporine, Ara-C and vincristine were the most frequently involved drugs. Most frequent clinical findings included abdominal pain, fever, nausea-vomiting and abdominal distension. CT diagnosis revealed caecum and colic involvement with rarefaction of pericaecal fat. Medical treatment was successful in only 33% of all patients, the other patients requiring a surgical procedure including right hemicolectomy with or without intestinal anastomosis. Mortality reached 58.3 per cent, representing multiorganic sepsis the main cause of death.although early diagnosis of acute typhlitis bears a better prognosis, mortality rates are up 50 % in spite of an established treatment.

To evaluate the evolution of postoperative pain and convalescence in a group of patients undergoing elective laparoscopic cholecystectomy under a multimodal anesthesia-analgesia treatment protocol.Eighty-four consecutive patients undergoing elective laparoscopic cholecystectomy were given intramuscular ketoprofen during induction, anesthesia, with minimal use of opioids, and intraperitoneal irrigation with bupivacaine. We assessed the rate of conversion to hospitalization, hospital stay in hours, duration of the pain-free interval, oral analgesics per day at home, and intensity of postoperative pain and physical activity daily on a visual analog scale.The procedures were carried out on an outpatient basis in 90.5% of the cases, and the mean postoperative hospital stay was 7.2 +/- 0.9 hours. Eight patients required an overnight stay. No postoperative analgesics were required by 27.3% of the patients. Patients requiring analgesics had pain-free intervals lasting 17.3 +/- 11.8 hours after discharge. On the third day after surgery 80% had used no analgesics and over 75% had no pain or only minor pain. On the fourth postoperative day 50% were able to perform activities of daily living without help, and 50% returned to work on the eleventh day after surgery.The multimodal analgesia-anesthesia treatment proposed allows a high percentage of laparoscopic cholecystectomies to be performed on an outpatients basis. The protocol provides good control of postoperative pain and nausea and rapid return to habitual activity.

The anomalies related to omphalomesenteric duct remnant constitute an uncommon cause of intestinal obstruction, of which Meckel"s diverticulum and its variants represent the most important clinical presentation. In most cases they are asymptomatic and usually affect young patients. When symptomatic, they usually present episodes of gastrointestinal bleeding or acute abdomen syndromes caused by strangulation of intestinal loops as a result of fibrous intraabdominal remnants or inflammation produced by the diverticulum. In most cases, the unexpected presence of these alterations makes intraoperative diagnosis necessary. Treatment is surgical and consists in exeresis of the diverticulum or the fibrous band causing the clinical picture. We report two cases of persistence of the vitelline duct resolved by laparoscopic approach.

Analysis of acceptance and perception of quality in patients undergoing ambulatory laparoscopic cholecystectomy.84 consecutive patients undergoing elective laparoscopic cholecystectomy within SVS (Servei Valencia de Salut) through a special plan for waiting lists.A prospective analysis of related variables with quality perception evaluated by a specialized nurse with no interaction with the surgical team.Ambulatory acceptance, 80 percent; return to work or daily activities at 72 hours after surgery, 40 percent. Extra need of medical attention was as follows: emergency general practitioner 2.7 percent, emergency room attention in 1.3 percent, extra telephone interview with the surgeon 6.0 percent. Global estimation of the procedure was very good or good by 94.7 percent.High acceptance rate, high quality perception. Up to 20 percent of patients would change from ambulatory to traditional surgery, possibly due to cultural factors.

Munchausen syndrome is a subtype included in factitious disorders in which somatic signs and symptoms predominate. The patient self-inflicts damage with the only objective of assuming asick role." This is an underdiagnosed disorder characterized by numerous hospital admissions and history of visits to different medical specialists. Early diagnosis would avoid high health care costs caused by unnecessary explorations, and social, work and familial deterioration of the patient. We report a case with two affected brothers, rare in the literature reviewed, and we analyze suspicion criteria in the daily clinical practice.