Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.

Laparoscopy showed good to excellent accuracy for diagnosis and grading of acute appendicitis. The better grading system allowed the evaluation of patients with acute appendicitis in the same clinical stage.

BackgroundClosure of appendicular stump has been performed in different ways; however, the use of the metal endoclip in complicated grades of acute appendicitis, has not been evaluated yet in a prospective way.ObjectiveTo establish the effectiveness of appendiceal stump closure by metal endoclip for complicated appendicitis.MethodFrom January 2009 to January 2011 were evaluated 131 consecutive patients who underwent a laparoscopic appendectomy for complicated acute appendicitis. From those, 118 underwent appendiceal stump closure by metal endoclip. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 52.7% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix, which may lead to abscess formation and degrees of peritonitis. The outcomes viability, operative time, infection complication, operative complications, and conversion rate were chosen to evaluate the procedure.ResultsThe appendiceal stump closure by metal endoclip was used in 90% of cases. The presence of appendix base necrosis was the most important factor involved in failure of the procedure. Laparoscopic knot (1.5%), laparoscopic endo-suture (3.8%) and video assisted laparotomy (4.7%) were the alternatives used in difficult cases. The mean operative time was (67.54 ± 28.13 minutes). The wound and intra-abdominal infection rates were 2.54% and 5.08%, respectively. There were no operative complications and the conversion rate was 0.85%.ConclusionThe appendiceal stump closure by metal endoclip, in complicated grades of acute appendicitis, is a safe and effective procedure. In patients with appendix base necrosis it should be avoided in favor of other alternatives.

Abstract. Dengue fever has been a major problem in hospital settings in Brazil for the past 15 years. The main concern has been the severe forms, i.e., dengue hemorrhagic fever and dengue shock syndrome. Hemorrhagic events of different degrees have also been a major concern. We report five cases of large vein thrombotic events associated with the acute phase of dengue fever, including a previously non-reported case of mesenteric vein thrombosis. Complications such as these could have been overlooked in the diagnosis of dengue fever, given that the major concern is the hemorrhagic event.Dengue fever frequently affects Brazil, where thousands of cases have been diagnosed annually and all four dengue virus serotypes (DENV-1 through DENV-4) have been reported, sometimes concurrently in the same region.

Background and Objectives:The mobile cecum is an embryologic abnormality and has been associated with functional colon disease (chronic constipation and irritable bowel syndrome). However, unlike functional disease, the primary treatment is operative, using laparoscopic cecopexy. We compare the epidemiology and pathophysiology of mobile cecum syndrome and functional colon disease and propose diagnostic and treatment guidelines.Method:This study was a case–control series of 15 patients who underwent laparoscopic cecopexy. Age, gender, recurrent abdominal pain, and constipation based on Rome III criteria were assessed. Ileocecal–appendiceal unit displacement was graded as follows: I (cecum retroperitoneal or with little mobility); II (wide mobility, crossing the midline); and III (maximum mobility, reaching the left abdomen). Patients with Grades II and III underwent laparoscopic cecopexy. The clinical outcomes were evaluated according to modified Visick's criteria, and postoperative complications were assessed according to the Clavien-Dindo classification.Results:The mean age was 31.86 ± 12.02 years, and 13 patients (86.7%) were women. Symptoms of constipation and abdominal pain were present in 14 (93.3%) and 11 (73.3%), respectively. Computed tomography was performed in 8 (53.3%) patients. The mean operative time was 41 ± 6.66 min. There were no postoperative infections. One (7.8%) patient was classified as Clavien Dindo IIIb and all patients were classified as Visick 1 or 2.Conclusion:Many patients with clinical and epidemiological features of functional colon disease in common in fact have an anatomic anomaly, for which the treatment of choice is laparoscopic cecopexy. New protocols should be developed to support this recommendation.

CONTEXT: Squamous cell carcinoma arising from chronic lymphedema has only been reported in the literature 11 times (12 cases). Some aspects of its pathogenesis remain unclear and, for the first time, attention has been drawn to epidemiological data. CASE REPORT:A 90-year-old white female with chronic unilateral lower-limb lymphedema, secondary to trauma 20 years earlier, presented with a three-month history of a vegetating cutaneous lesion. There had not been any previous local ulceration. The tumor was completely excised and the histopathological analysis showed that it was an infiltrating squamous cell carcinoma. A literature review in the Medline (Medical Literature Analysis and Retrieval System Online) and Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde) databases using the MeSH (Medical Subject Heading) terms "Carcinoma, Squamous Cell" AND "Lymphedema" identified 112 references and found 12 similar case reports. RESUMOCONTEXTO: O crescimento de carcinoma de células escamosas a partir de linfedema crônico foi relatado apenas 11 vezes na literatura (12 casos).Aspectos sobre sua patogênese ainda não foram completamente elucidados e pela primeira vez chama-se atenção para os dados epidemiológicos.

BackgroundLaparoscopy has not been consolidated as the approach of first choice in the management of complicated appendicitis. Methodological flaws and absence of disease stratification criteria have been implicated in that less evidence. The objective is to study the safe and effectiveness of laparoscopy in the management of complicated appendicitis according to laparoscopic grading system.MethodFrom January 2008 to January 2011, 154 consecutive patients who underwent a laparoscopic appendectomy for complicated appendicitis were evaluated in the prospective way. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 58.3% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix and were graded as 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis) and 5 (diffuse peritonitis). The outcomes including operative time, infection complication, operative complications and conversion rate were chosen to evaluate the procedure.ResultsThe grade 3A was the most frequent with 50 (32.4%) patients. The mean operative time was 69.4 ± 26.3 minutes. The grade 4A showed the highest mean operative time (80.1 ± 26.7 minutes). The wound and intra-abdominal infection rates were 2.6 and 4.6%, respectively. The base necrosis was the most important factor associated with the conversion (5.2%). The grades 4A and 5 were associated with greater possibility of intra-abdominal collection. There were no operative complications.ConclusionThe laparoscopic management of all complicated grades of acute appendicitis is safe and effective and should be the procedure of first choice. The laparoscopic grading system allows us to assess patients in the same disease stage.

During a laparoscopic appendectomy, the closure of the appendiceal stump is an important step because of postoperative complications from its inappropriate management. The development of life-threatening events such as stercoral fistulas, postoperative peritonitis, and sepsis is feared and unwanted. The tactical modification of the appendiceal stump closure with a single endoligature, replacing the invaginating suture, adjusted very well to laparoscopic appendectomy, and nowadays is the procedure of choice, whenever possible. Among the alternatives that do not make use of an invaginating suture, studies advocate the use of an endostapler, endoligature (endo-loop), metal clips, bipolar endocoagulation, and polymeric clips. All alternatives have advantages and disadvantages against the different clinical stages of acute appendicitis, and it should be noted that the different forms of appendiceal stump closure have never been assessed in prospective randomized studies. Knowledge about and appropriate use of all of them are important for a safe and more cost-effective procedure.