Colangiografía intraoperatoria: curva de aprendizaje en una Residencia de Cirugía General / Intraoperative cholangiography: Learning curve in a General Surgery residency

RESUMEN Antecedentes: el uso de la colangiografía intraoperatoria dinámica (CIOd) durante la colecistectomía laparoscópica (Colelap) sigue siendo un tema en discusión. Objetivos: Este trabajo tiene como objetivo describir y evaluar la curva de aprendizaje y los hallazgos en la CIOd durante las colecistectomías laparoscópicas realizadas por residentes de Cirugía General, incluyéndola como herramienta para una colecistectomía segura, así como entrenamiento para el de sarrollo de habilidades y destrezas. Material y métodos: se incluyeron pacientes con indicación de colecistectomía laparoscópica pro gramada o de urgencia. En las cirugías se realizó tracción según Hunter, visión crítica de seguridad y CIOd sistemática, por un residente mayor y la CIOd por un residente inferior, tutorizado por cirujano de planta. Se evaluaron curva de aprendizaje, tiempos operatorios, relación del tiempo de CIOd con el tiempo de duración de la Colelap (CIO/CX), redisección del cístico y litiasis cística y coledociana. Resultados: se operaron 456 pacientes durante un año (2017-2018). Se observó que, independiente mente de quien realice la CIOd, los residentes pudieron mejorar su curva de aprendizaje, objetiván dose tiempos más cortos para la Colelap, CIOd y la relación CIO/CX. Los coeficientes de aprendizaje fueron mejores en cirugías más complejas en relación con el semestre. El 5,26% presentó litiasis cole dociana (n = 24); de estas, 66,7% tenían litiasis cística (n = 16) y 25% colecistitis (n = 6) asociadas. Todas se resolvieron por vía transcística. No hubo conversiones y se realizó CIOd en el 100%. Conclusión: la CIOd es un procedimiento ideal para ser practicado de manera sistemática durante la Residencia, porque da el entrenamiento necesario para el manejo de la vía transcística, permite evitar una lesión quirúrgica de vía biliar mayor y el diagnóstico de coledocolitiasis.

ABSTRACT Background: The use of dynamic intra-operative cholangiography (dIOC) during laparoscopic cholecystectomy (Lap Chole) remains a topic under discussion. Objectives: This study aims to describe and evaluate the learning curve and findings in the dIOC during laparoscopic cholecystectomies performed by Residents of General Surgery, including it as a tool for a safe cholecystectomy, as well as training for the development of skills and abilities. Material and methods: Patients with indication of scheduled or emergency laparoscopic cholecystectomy were included. In the surgeries, traction was performed according to Hunter, critical safety vision and systematic dIOC, by a senior Resident and the dIOC by a less trained resident, tutored by a staff surgeon. Learning curve, operative times, dIOC time relationship with Lap Chole duration time (IOC/LC), repeated cystic dissection, cystic lithiasis and choledocholithiasis were evaluated. Results: 456 patients were operated for one year (2017-2018). It was observed that regardless of who performs the dIOC, they were able to improve their learning curve, objectifying shorter times for Lap Chole, dIOC and the IOC/LC relationship. The learning coefficients were better in complex surgeries in relation to the semester. 5.26 % had choledocholithiasis (n = 24), of these, 66.7% had cystic lithiasis (n = 16) and 25% associated cholecystitis (n = 6). All were resolved trancystically. There were no conversions and dIOC was performed in 100% of cases. Conclusion: The dIOC is an ideal procedure to be practiced systematically during residency. Because it gives the necessary training for the management of the transcystic pathway, allows avoiding an upper bile duct injury and the diagnosis of choledocholithiasis.

The Usefulness of Magnetic Resonance Cholangio-Pancreatography in the Diagnosis of Choledochal Cyst

PURPOSE: Choledochal cysts are cystic or diffuse dilatation of any portion of the biliary tree. An anomalous pancreaticobiliary ductal union (APBDU) is one of the commonly accepted causes of a cholodochal cyst. The ability of MRCP to demonstrate an APBDU has not been established in children and appears to have limited value in demonstrating an associated APBDU. We investigate the usefulness, and application, of MRCP in delineating the cyst type and an APBDU in patients with choledochal cysts, and compared it with operative cholangiography. METHODS: Ten children with choledochal cyst, who had both MRCP and cholangiography, as preoperative diagnostic modalities, at the Division of Pediatric Surgery, Keimyung University, Dongsan Medical Center, between March 1999 and August 2002, were selected for this study. We analyzed and compared their MRCP images with those of the intraoperative cholangiographies, with regard to the type of cyst, size and association of an APBDU. RESULTS: The types of the choledochal cyst, based on the MRCP, were two Ia, three Ic, and five IVa, whereas those based on the operative cholangiographies were one Ic and nine IVa. A common channel was demonstrated by MRCP and operative cholangiography in four (40%) and six (60%) of the ten patients, respectively. Each diagnostic modality correlated with the size (Pearson correlation, P<0.01) and the length of the cyst, but an APBDU on both modalities did not reach statistical significance, even though the common channel was not identified in a large cyst on MRCP. CONCLUSION: MRCP is a noninvasive and safe diagnostic modality for the delineation an APBDU in children with choledochal cysts. However, it has limited value for demonstrating an APBDU in children with a large cyst due to overlapping with the pancreaticobiliary ductal system. Operative cholangiography seems to be more valuable than MRCP in patients with large choledochal cysts.

Is Routine Operative Cholangiography Necessary

BACKGROUND: Various studies on the prediction of common bile duct (CBD) stones through preoperative or operative cholangiography have been reported. When CBD stones were suspected due to preoperative screening factors, endoscopic retrograde cholangiopancreatography was done as a first choice and operative cholangiography could be omitted. We want to know the indications of selective cholangiography and the significance of routine operative cholangiography during a simple cholecystectomy. METHODS: The cases of 134 patients who received on open cholecystectomy between Jan. 1995 and Sept. 1997 were reviewed. Twenty-even (27) cases of a choledocholithotomy without cholangiography were discarded from this study. Our cases were divided into two groups: group I included 9 patients who had CBD Stones, which was pathologicaly confirmed by operative cholangiography, and group II included 98 patients who had no CBD Stones, which pathologicaly confirme by operative cholangiography. The predictability of pathologic CBD. was calculated by the factors as the total bilirubin, alkaline phosphatase, AST, ALT, GGT, CBD. diameter by sonography. According to the number of positive screening factors, 3 grades of scoring were imposed in each case. Grade I was the case where 0- screening factor was positive, grade II was the case where 2 screening factors were positive, and grade III was the case where 3 or more screening factors were positive. RESULTS: Eighty-ive (85) cases were grade I, 6 cases were grade II, and 16 cases were grade III. In grade I, only one case had asymptomatic CBD stones, and the negative predictability was 98.8%. In grade II, there were no CBD lesions, and the negative predictability was 100%. In grade III, there were 8 cases of pathologic CBD lesions, and the negative predictability was 50%. CONCLUSIONS: Precise prediction of CBD lesions before a cholecystectomy is of value in deciding whether or not to perform an operative cholangiography. In our study, we graded the patients according to 5 non-nvasive screening factors. In grade I cases, the negative predictability of 98.8% was acceptable for omitting the operative cholangiography. In grade II cases, the negative predictability was 100%, but in these cases, there was the possibility of pathologic CBD Stones. Hence, in these cases, an operative cholangiography may be done, depending on the surgeon's decision. In grade III cases, an operative cholangiography or a preoperative ERCP. is mandatory.

Prediction and Management of Choledocholithiasis in Patients Undergoing Laparoscopic Cholecystectomy due to Cholelithiasis / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography(ERCP) or operative cholangiography is the procedure to demonstrate and remove stones of the biliary tree in patients undergoing laparoscopic cholecystectomy(LC) due to cholelithiasis. However, ERCP or operative cholangiography is an invasive procedure. The next question then is when and for what indication should ERCP or operative cholangiography be performed. The aims of this study were to assess whether prediction of common bile duct(CBD) stones by the noninvasive method such as liver function test and/or clinical findings is possible, and to investigate which method is more adequate for removal of CBD stones found on ERCP or operative cholangiography. METHODS: A total 207 patients with symptomatic cholelithiasis scheduled for LC were enrolled from September 1993 to August 1996. Patients who were already found to have either extrahepatic or intrahepatic biliary stones on sonogram were excluded. Patients were classified into risk group and non-risk group. Patients who belong to the risk group were those having CBD dilatation by ultrasonography, history of jaundice or cholangitis, gallstone pancreatitis, or elevated transaminases. RESULTS: 54 cases were confirmed to have CBD stones by preoperative ERCP(49 cases) and operative cholangiography(5 cases). Detection rate of CBD stones in risk group was 26.8%(22.2% in CBD dilatation, 50.0% in jaundice, 42.9% in history of cholangitis, and 0% in history gallstone pancreatitis or elevated transaminase). Detection rate of CBD stones in non-risk group was 7.7%. All of 12 patients who had CBD stones were successfully removed(10 with preoperative endoscopic removal, 1 with postoperative endoscopic removal, and 1 with CBD exploration). CONCLUSIONS: Jaundice or cholangitis need the preoperative ERCP and, if stones are found, they can be revoved endoscopically. CBD dilatation may be an indication for operative cholangiography rather than preoperative ERCP, and, if CBD stones were found, they can be revoved by laparoscopic CBD exploration or postoperative ERCP. But history of gallstone pancreatitis, elevated transaminases, or patients with no risk factors may not need preoperative ERCP or operative cholangiography considering the cost-effectiveness or possible morbidity.