Abstract Background: In a cesarean section, epidural analgesia with 0.125% bupivacaine and 1.5% lidocaine or 0.25% bupivacaine with 1.0% lidocaine concentrations can be used. A higher concentration of bupivacaine reaches better analgesia but with a higher rate of drug-related adverse events. Aim: The aim of the study was to assess analgesia and safety of 0.125% bupivacaine and 1.5% lidocaine or 0.25% bupivacaine with 1.0% lidocaine during cesarean. Materials and methods: Prospective cohort stratified following both bupivacaine concentrations. Results: One hundred women with full-term pregnancies were selected (fifty per cohort). At 20 and 30 min after epidural administration, there was a higher proportion of motor blockade cases from the 0.125% bupivacaine and 1.5% lidocaine cohort (p = 0.0229 and p = 0.0006, respectively). There was no significant difference among sensitive blockage. A 0.25% bupivacaine and 1.0% lidocaine concentration showed a tendency to hypotension (p < 0.001) and bradycardia (p = 0.4100). From 0.125% bupivacaine and 1.5% lidocaine cohort, 25 cases (50%) presented at least one adverse event; in contrast with 44/50 (88%) from 0.25% bupivacaine and 1.0% lidocaine cohort (p < 0.001). Conclusion: In epidural analgesia during cesarean, using 0.125% bupivacaine and 1.5% lidocaine presented similar analgesia than 0.25% bupivacaine and 1.0% lidocaine. However, a higher bupivacaine concentration is significantly related to more frequent drug-related adverse events (especially hypotension).

Resumen Antecedentes: En una cesárea se puede emplear analgesia epidural con bupivacaína 0.125% and lidocaína 1.5% ó bupivacaína 0.25% and lidocaína 1.0%. Una concentración mayor de bupivacaína alcanza mayor analgesia con más eventos adversos. Objetivo: evaluar la analgesia y seguridad de bupivacaína 0.125% and lidocaína 1.5% ó bupivacaína 0.25% and lidocaína 1.0%. Materiales y métodos: Cohorte prospectivo estratificado según ambas concentraciones de bupivacaína. Resultados: Se recuperó cien gestantes a término (cincuenta por cohorte). A los 20 y 30 minutos tras la administración epidural hubo más casos con mayor bloqueo motor en quienes se empleó bupivacaína 0.125% and lidocaína 1.5% (p = 0.0229 y p = 0.0006, respectivamente). No hubo diferencia significativa respecto al bloqueo sensitivo. Bupivacaína 0.25% and lidocaína 1.5% mostró una tencencia a la hipotensión (p < 0.001) y a la bradicardia (p = 0.4100). De la cohorte de bupivacaína 0.125% and lidocaína 1.5%, 25 casos (50%) presentaron cuando menos un evento adverso, en contraste con 44/50 (88%) de la cohorte de bupivacaína 0.25% and lidocaína 1.0% (p < 0.001). Conclusión: En la analgesia epidural durante cesárea, bupivacaína 0.125% and lidocaína 1.5% está asociado con un efecto analgésico similar a bupivacaína 0.25% and lidocaína 1.0%. Sin embargo, mayores concentraciones están significativamente relacionadas con mayor tasa de eventos adversos (especialmente hipotensión).

Abstract Aim: The aim of the study was to determine the usefulness of known biomarkers as pre-operative predictors of complicated acute appendicitis (CAA) and perforated appendicitis (PA). Materials and methods: This was an observational, analytic, cross-sectional, and prospective study at Hospital Teodoro Maldonado Carbo (August 2016-December 2017). Evaluated biomarkers: white blood cells count, neutrophil percentage (N%), neutrophil-to-lymphocyte ratio, glucose, total bilirubin, C-reactive protein, and procalcitonin (PCT). The statistical analysis was performed by means of the area under the receiver operating characteristics (AUROC) curve estimation. Biomarkers' cutoff point was identified using Youden's index. Sensitivity, specificity, positive, and negative predictive value (NPV) (positive predictive value [PPV] and NPV) were estimated. Results: One hundred and twenty-eight cases were included (median age 30 years, 44% female), 70 cases (54%) corresponded to CAA (PA 38/70). N% and PCT obtained an AUROC of 78% and 80% for CAA (PA 76% and 81%), respectively. A N% > 78.1% predicted CAA with a sensitivity, specificity, PPV, and NPV of 82%, 62%, 72%, and 72% (> 74.9%, PA: 94%, 53%, 46%, and 96%), respectively. PCT > 0.14 ng/dL predicted CAA with sensitivity, specificity, PPV, and NPV of 69%, 79%, 80%, and 68% (PA: 84%, 69%, 53%, and 91%). Conclusion: The N% and PCT represent useful pre-operative biomarkers for discarding PA when an acute appendicitis is suspected.

Resumen Objetivo: Determinar la utilidad de conocidos biomarcadores como predictores de apendicitis aguda complicada (AAC) y perforada (AP). Método: Estudio observacional, analítico, transversal, de recuperación prospectiva, realizado en el Hospital Teodoro Maldonado Carbo (agosto de 2016 a diciembre de 2017). Biomarcadores evaluados: glóbulos blancos, porcentaje de neutrófilos (%N), índice neutrófilo/linfocito, glucosa, bilirrubina total, proteína C reactiva y procalcitonina (PCT). El análisis estadístico se realizó mediante estimación del área bajo la curva ROC (Receiver Operating Characteristics). Se individualizó el valor de corte mediante el índice de Youden. Se estimaron la sensibilidad, la especificidad, el valor predictivo positivo (VPP) y el valor predictivo negativo (VPN). Resultados: Se incluyeron 128 casos (mediana de edad 30 años, 44% mujeres), de los que 70 (54%) correspondieron a AAC (AP 38/70). El %N y la PCT obtuvieron un área ROC del 78% y el 80% para AAC (AP 76% y 81%), respectivamente. Un %N > 78.1% predijo AAC con una sensibilidad, una especificidad, un VPP y un VPN del 82%, 62%, 72% y 72% (> 74.9%, AP: 94%, 53%, 46% y 96%). Una PCT > 0.14 ng/dl predijo AAC con una sensibilidad, una especificidad, un VPP y un VPN del 69%, 79%, 80% y 68% (AP: 84%, 69%, 53% y 91%). Conclusión: El %N y la PCT constituyen biomarcadores útiles en el descarte de AP cuando se sospecha una apendicitis aguda.

Abstract Background: After appendectomy due to complicated acute appendicitis (CAA), there are some alternatives as antibiotic scheme: ciprofloxacin/metronidazole; as well as monoscheme based on carbapenems: ertapenem, meropenem, and imipenem. Aim: This study aims to prove the efficacy of carbapenems versus ciprofloxacin/metronidazole in CAA post-operative management in terms of preventing complications during post-operative period and decreasing hospital stay. Materials and methods: This was an observational, analytical, longitudinal, and prospective cohort study (March 2014-November 2016). Patients were classified into two groups, according to the prescribed antibiotic scheme: some carbapenems or ciprofloxacin/metronidazole. Results: Ninety-eight patients were enrolled. There was an requirement for antibiotic therapy rotation only in the ciprofloxacin/metronidazole (7/49, 14.3%; p = 0.004). Carbapenems reached a mean hospital stay of 4.45 days, in contrast with ciprofloxacin/metronidazole, 8.29 days (p = 0.020). In post-surgical follow-up, there were more cases of curative resolution in the group in the carbapenems group (35/49 vs. 15/49 p < 0.001) as well as a greater number of cases with some late infection in the ciprofloxacin/metronidazole group (1/49 vs. 10/49, p = 0.010). Conclusion: In the post-operative management of CAA, carbapenems represent an important indication to be considered as first-line antibiotic therapy.

Resumen Antecedentes: Tras la cirugía por apendicitis aguda complicada existen varias alternativas de esquema antibiótico, entre las que destacan ciprofloxacino/metronidazol, o bien monoterapia con algún carbapenémico, como ertapenem, meropenem e imipenem. Objetivo: Determinar la eficacia de los carbapenémicos en comparación con ciprofloxacino/metronidazol en el manejo posquirúrgico de la apendicitis aguda complicada, en términos de prevención de complicaciones durante el posoperatorio y de reducción de la estancia hospitalaria. Método: Estudio observacional, analítico, longitudinal, prospectivo y de cohorte, de marzo de 2014 a noviembre de 2016. Los pacientes fueron clasificados en dos grupos según el esquema antibiótico prescrito: un carbapenémico o ciprofloxacino/metronidazol. Resultados: Se seleccionaron 98 pacientes. Solo hubo necesidad de rotación de antibiótico en el grupo de ciprofloxacino/metronidazol (7 de 49, 14.3%; p = 0.004). En el grupo de carbapenémico, la media de estancia hospitalaria fue de 4.45 días, y en el grupo de ciprofloxacino/metronidazol fue de 8.29 días (p = 0.020). En el seguimiento posquirúrgico hubo más casos de resolución curativa en el grupo de carbapenémico (35 de 49 vs. 15 de 49; p < 0.001), así como un mayor número de casos con alguna infección tardía en el grupo de ciprofloxacino/metronidazol (1 de 49 vs. 10 de 49; p < 0.001). Conclusión: En el manejo posquirúrgico de la apendicitis aguda complicada, los carbapenémicos representan una importante indicación que debe considerarse como antibioticoterapia de primera línea.

RESUMO CONTEXTO: A dilatação por velas é considerada uma técnica eficaz para o tratamento de estenoses esofágicas benignas simples. A “regra de três” tem sido defendida para prevenir eventos adversos relatados, como sangramento e perfuração. No entanto, a adesão a esta regra aumentou o custo e a duração do tratamento. OBJETIVO: Demonstrar a segurança e os benefícios de longo prazo das dilatações progressivas por velas até chegar a 15 mm (45Fr) em uma única sessão de endoscopia com não adesão à regra de três. MÉTODOS: Uma análise retrospectiva de dados coletados prospectivamente de pacientes com estenoses esofágicas benignas simples tratadas com múltiplos dilatadores de velas progressivas até atingir 15 mm (45Fr) em uma única sessão. RESULTADOS: A mediana de idade foi de 58 anos (variação de 28-89) e 83,3% dos pacientes eram do sexo feminino. O principal sintoma de apresentação foi a disfagia para sólidos em 11/12 casos (91,6%). A causa da estenose esofágica benigna simples foi distribuída como segue: 7/12 membranas esofágicas, 2/12 estenose péptica, 2/12 anéis de Schatzki e um ferimento cáustico. 75% necessitaram apenas de uma sessão para o sucesso clínico. Não foram descritos eventos adversos graves. Nenhum retorno dos sintomas foi anotado em uma continuação mediana de 20 meses. CONCLUSÃO: A regra de três em pacientes com as estenoses esofágicas benignas simples secundárias às membranas esofágicas, os anéis de Schatzki e as estenoses péptica tratadas com os dilatadores de Savary-Gilliard não é necessária, mostrando bons resultados clínicos. Estudos prospectivos com mais pacientes são necessários.

ABSTRACT BACKGROUND: Bougies dilation is considered an effective technique for the treatment of simple benign esophageal strictures. The “rule of three” has been advocated to prevent reported adverse events such as bleeding and perforation. However, adherence to this rule has increased the cost and duration of treatment. OBJECTIVE: To demonstrate the safety and long-term benefits of progressive bougie dilations until reaching 15 mm (45Fr) in one single session endoscopy with non-adherence to the rule of three. METHODS: A retrospective analysis of a prospectively collected data of patients with simple benign esophageal strictures treated with multiple progressive bougie dilators until reaching 15 mm (45Fr) in one single session. RESULTS: The median age was 58 years (range 28-89), and 83.3% of patients were female. The main presenting symptom was dysphagia for solids in 11/12 cases (91.6%). The cause of their simple benign esophageal stricture was distributed as follows: 7/12 esophageal webs, 2/12 peptic stenosis, 2/12 Schatzki rings and one caustic injury. 75% required only one session for clinical success. No serious adverse events were described. No recurrence of symptoms was noted in a median follow-up of 20 months. CONCLUSION: The rule of three in patients with simple benign esophageal strictures secondary to esophageal webs, Schatzki rings and peptic strictures treated with Savary-Gilliard dilators is not necessary, showing good clinical results. Prospective studies with more patients are necessary.

Gallbladder agenesis is a rare disease, which its symptomatology emulates biliary pathology. It is presented between 0.007 to 0.027% of those patients in whom a cholecystectomy is performed. After it, its evolution is asymptomatic. We present the case of a 19 years old female patient with clinical presentationof cholelithiasis. Ultrasound reveals scleroatrophic vesicle. Elective cholecystectomy was performed,but the gallbladder was not found. The patient presented an asymptomatic evolution in the postoperative period and in the annual follow-up. In addition, we performed a case review from clinical case reports obtained from Medline. Fourteen patients were included in the review of cases, compared to another five studied in a series of cases. There was no significant difference between the two groups. Gallbladder agenesis usually happens between 40 and 64 years, with pain in the upper right quadrant and ultrasound diagnosis of cholelithiasis. It is unlikely to reach a preoperative diagnosis. If it is intervened, it is preferable to limit to laparoscopic examination. The following evolution will be asymptomatic, althoughthe cause of it is not known yet.

La agenesia de vesícula biliar es una enfermedad rara cuya sintomatología emula patología biliar. Está presente entre el 0,007 al 0,027% de aquellos en quienes se practica una colecistectomía. Luego de la misma, su evolución es asintomática. Se presenta el caso de una paciente femenina de 19 años con cuadro clínico compatible con colelitiasis. La ecografía revela vesícula escleroatrófica. Se realizó colecistectomía electiva, sin hallarse vesícula biliar. Tanto en el posoperatorio, como en el seguimiento anual, el curso fue asintomático. Además, se realizó una revisión de casos a partir de publicaciones de casos clínicos obtenidos de Medline. Catorce pacientes fueron incluidos en la revisión de casos, comparándose con otros cinco estudiados en una serie de casos. No existió diferencia significativa entre ambos grupos. La agenesia de vesícula biliar se presenta comúnmente entre los 40 y 64 años, con dolor en cuadrante superior derecho y diagnóstico ecográfico de colelitiasis. Es poco probable llegar a un diagnóstico preoperatorio. De intervenirse, es preferible limitarse a la exploración laparoscópica. La evolución ulterior será asintomática, sin estar claro aún el por qué.