El comportamiento del factor de necrosis tumoral alfa e interleucina 6 en lesiones de vías biliares postcolecistectomía / Tumor necrosis factor-alpha and interleukin-6 levels among patients suffering a bile duct injury during cholecystectomy

Background: During cholecystectomy, the bile duct may be injured. When this complication occurs, Kupffer cells are activated and produce tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL6) to phagocyte toxic products Aim: To measure serum levels of TNF-α and IL-6 among patients that suffered a bile duct injury after a cholecystectomy. Patients and Methods: Serum levels of TNF-α and IL-6 were measured prior to the bile-enteric derivation and after one year of follow up, in 31 patients that had a complete bile duct obstruction after open or laparoscopic cholecystectomy and in 5 healthy controls. Results: At baseline TNF-α levels in healthy subjects and patients with bile duct injury were 0 and 43.9 ± 2.9 ng/mL, respectively (p < 0.01). At one year of follow up, TNF-á became undetectable among patients. At baseline, the values for IL-6 among healthy controls and patients were 3.0 ± 2.0 and 72.0 ± 94.7 pg/mL respectively, (p < 0,004). After one year of follow up, IL-6 levels decreased to 6.4 ± 0.3 pg/mL among patients. Conclusions: TNF-α and IL-6 levels were elevated before bile-enteric derivation among patients with bile duct injury and became normal one year later.

Efecto del tamaño de la incisión en la gravedad de la lesin de la vía biliar iatrogénica posterior a colecistectomía abierta / Association between wound size after open cholecystectomy with severity of iatrogenic biliary tract lesions

Antecedentes: La lesión transoperatoria de la vía biliar durante la colecistectomía abierta y laparoscópica es un evento catastrófico que se asocia con morbilidad y mortalidad significativas. El objetivo fue documentar si el tamaño de la incisión en colecistectomía abierta está asociado a lesiones más complejas de la vía biliar. Métodos: Estudio de cohorte prospectivo de marzo de 2006 a febrero de 2007. Se incluyeron 66 pacientes con lesiones de la vía biliar posterior a colecistectomía abierta. Se analizó el tamaño de la incisión. Resultados: Se incluyeron 66 pacientes, 70% del sexo femenino, con un promedio de edad de 44 años. El 70% fue tratado por colecistitis aguda. La mayoría tuvo sobrepeso o sufría diferentes grados de obesidad. En 76% de los casos, la lesión no fue advertida durante el procedimiento quirúrgico primario. Todos los pacientes con lesión de vía biliar grave (Strasberg E-3 y E-4) tuvieron incisiones menores a 10 cm de longitud. El tamaño de la incisión se asoció con lesiones inadvertidas (p=0.000), así como con el grado de lesión (p=0.000). No pudo demostrarse asociación estadísticamente significativa entre lesiones de la vía biliar y colecistectomía electiva o urgente, e incisión quirúrgica media o subcostal para la colecistectomía. Conclusiones: Nuestros hallazgos sugieren que el acceso quirúrgico menor durante la colecistectomía abierta puede ser un factor de riesgo, ya que incisiones pequeñas se asociaron con lesiones de la vía biliar más graves e imposibilidad para reconocer este daño durante el procedimiento. Sugerimos cumplir estrictamente los principios quirúrgicos de una adecuada exposición durante la colecistectomía abierta como medida para prevenir lesiones de la vía biliar.

BACKGROUND: Transoperative biliary tract injury during open or laparoscopic cholecystectomy is a catastrophic event associated with significant morbidity and mortality. Our objective was to determine if wound size during open cholecystectomy is associated with more complex biliary tract injuries. METHODS: Prospective cohort study performed between March 2006 and February 2007. Sixty-six patients with biliary tract injuries after open cholecystectomy were included. Wound size was analyzed. RESULTS: Sixty six patients were included, 70% were female with a median age of 44. Seventy four percent were treated for acute cholecystitis. Most participants were overweight or had various degrees of obesity. Biliary tract injuries were not recognized during the primary surgical procedure in 76% of cases. All patients with severe biliary tract injuries (Strasberg E-3 and E-4) had a wound size less than 10 cm in length. Wound size was associated with unrecognized injuries (p=0.000), as well as with injury severity (p=0.000). We were notable to demonstrate a statistically significant association between biliary tract injuries and elective or emergency surgical procedures and midline or subcostal surgical incision for cholecystectomy. CONCLUSIONS: Our findings suggest that minor surgical access during open cholecystectomy may constitute a risk factor since smaller incisions were associated with more severe biliary tract injuries and an inability to observe this damage during the surgical procedure. We suggest to adhere strictly to the guidelines of an adequate surgical exposure during open cholecystectomy to prevent biliary tract injuries.