Lesión quirúrgica de la vía biliar en residentes. Experiencia de un Centro Formador Universitario / Surgical injury of the biliary tract in residents. Experience of a University Training Center

La lesión quirúrgica de la vía biliar es una complicación peligrosa de la colecistectomía, con importantes secuelas postoperatorias para el paciente en términos de morbilidad, mortalidad y calidad de vida. Tienen una incidencia laparoscópica estimada del 0,4% al 1,5% y del 0,2% al 0,3% en la colecistectomía convencional. El objetivo de este estudio fue evaluar la incidencia de LQVB durante la formación del cirujano y la importancia de realizar colangiografía intraoperatoria (COI) durante esta etapa

Bile duct surgical injury is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality and quality of life. These have an estimated laparoscopic incidence of 0.4% to 1.5% and 0.2% to 0.3% in conventional cholecystectomy. The aim of this study was to evaluate the incidence of LQVB during surgeon training and the importance of performing intraoperative cholangiography (IOC) during this stage

Neoplasia quística mucinosa en la vía biliar intrahepática. Presentación de dos casos / Mucinous cystic neoplasm in the intrahepatic bile duct. Presentation of two cases

Introducción. Las neoplasias quísticas mucinosas del hígado son tumores poco frecuentes, equivalen a menos del 5 % de todas las lesiones quísticas hepáticas y se originan generalmente en la vía biliar intrahepática, con poco compromiso extrahepático. En la mayoría de los casos su diagnóstico es incidental dado que es una entidad generalmente asintomática con un curso benigno; sin embargo, hasta en el 30 % pueden ser malignas. En todos los casos se debe hacer una resección quirúrgica completa de la lesión. Caso clínico. Se presentan dos pacientes con diagnóstico de neoplasia quística mucinosa en la vía biliar intrahepática, así como sus manifestaciones clínicas, hallazgos imagenológicos y tratamiento. Discusión. Debido a su baja incidencia, esta patología constituye un reto diagnóstico, que se puede confundir con otro tipo de entidades más comunes. El diagnóstico definitivo se hace de forma histopatológica, pero en todos los casos, ante la sospecha clínica, se recomienda la resección completa. Conclusión. Se presentan dos pacientes con diagnóstico de neoplasias quísticas mucinosas del hígado, una entidad poco frecuente y de difícil diagnóstico

Introduction. Mucinous cystic neoplasms of the liver are rare tumors, accounting for less than 5% of all liver cystic lesions, and generally originate from the intrahepatic bile duct with little extrahepatic involvement. In most cases its diagnosis is incidental since it is a generally asymptomatic entity with a benign course; however, up to 30% can have a malignant course. In all cases, complete surgical resection of the lesion must be performed. Clinical case. Two patients with a diagnosis of mucinous cystic neoplasm in the intrahepatic bile duct are presented, as well as their clinical manifestations, imaging findings, and treatment. Discussion. Due to its low incidence, this pathology constitutes a diagnostic challenge, which can be confused with other types of more common entities. The definitive diagnosis is made histopathologically, but in all cases, given clinical suspicion, complete resection is recommended. Conclusion. Two patients with a diagnosis of mucinous cystic neoplasms of the liver are presented, a rare entity that is difficult to diagnose

Colecistectomía Laparoscópica difícil: tratamiento quirúrgico / The surgical management of difficult LaparoscopicCholecystectomy

Objetivo: Caracterizar el tratamiento laparoscópico de pacientes con colecistitis difícil en el Servicio de Cirugía I del Hospital Universitario de Caracas durante el quinquenio2017-2021. Métodos: Estudio retrospectivo, observacional, descriptivo y de corte transversal. Muestra de tipo no probabilístico por conveniencia, seleccionada de la base de datos del Departamento de Historias Médicas del Hospital Universitario de Caracas. El análisis estadístico se realizó con el programa SPSS en su versión 26. Resultados: se recolectaron61 Historias Clínicas con características de colecistectomías laparoscópicas difíciles, el grupo etario más numeroso con67,19%, fue entre 30-59 años; sexo predominante: el femenino con 85,2%; el 42,62% de los pacientes presentaron a su ingreso: litiasis vesicular simple, el cólico vesicular persistente fue la complicación más frecuente con 31,23%. El 65,57% se ubicó en Grado I según Nassar como hallazgo intraoperatorio más frecuente, y según Parkland el 75,40% en grado I, sin individuos afectados con Grado V. Todos los casos fueron tratados quirúrgicamente (colecistectomía laparoscópica total).Conclusión: el total de los pacientes sometidos a tratamiento quirúrgico con hallazgos de colecistectomía laparoscópica difícil, se completó mediante colecistectomía laparoscópica total(AU)

Objective: To characterize the surgical treatment of difficult cholecystectomy in the Chair of Clinical and Surgical therapeutics "A" / Surgery Service I of the University Hospital of Caracas during the five-year period 2017 -2021.Methods: A retrospective, observational, descriptive and cross-sectional study will be carried out. The sample will be of anon-probabilistic type for convenience, selecting from the listof patients in the database of the Department of Medical Records of the Hospital Universitario de Caracas. The statistical analyzes will be carried out with the SPSS program in its version 26. Results: 61 difficult laparoscopic cholecystectomies were observed, the most frequent age group with 67.19%, was between 30-59 years, the female sex with 85.2% was the predominantone. 42.62% of the admission diagnoses were simple gallstones, followed by persistent gallbladder colic as the most frequent complication with 31.23%. 65.57% represent Grade I accordingto Nassar as the most frequent intraoperative finding and according to Parkland 75.40% represented by grade I, leaving Grade V without affected individuals. 100% of the sample were surgically treated by total laparoscopic cholecystectomy. Conclusion: the total number of patients undergoing surgical treatment with difficult laparoscopic cholecystectomy findingswas completed by total laparoscopic cholecystectomy(AU)

Ultrasonographic aspects of the gallbladder mucocele in 30 dogs: retrospective study / Aspectos ultrassonográficos da mucocele biliar em 30 cães: estudo retrospectivo

Gallbladder mucocele is characterized by hyperplasia of the gallbladder epithelium, increased mucus production, accumulation, and densification of the bile content, which can lead to biliary obstruction, necrosis, and rupture of the gallbladder wall. Its finding may be accidental or related to symptoms. A retrospective study (2016-2019) was carried out based on abdominal ultrasound examinations in dogs, correlating aspects of the gallbladder and biliary system in the mucocele with existing comorbidities. Thirty dogs diagnosed with biliary mucocele were evaluated, of which 46.66% had the disease at an early stage, and 53.33% showed a more advanced stage. Of these, 66.66% were related to endocrinopathies and hyperadrenocorticism. Signs of extrahepatic bile duct obstruction and biliary peritonitis were observed in two animals. Due to their potential risk of complications, follow-up ultrasound assessments are indicated in cases that opt for clinical treatment, not excluding the need for surgical intervention.(AU)

A mucocele biliar caracteriza-se pela hiperplasia do epitélio da vesícula biliar, aumento da produção de muco, acúmulo e densificação do conteúdo biliar, podendo levar à obstrução, necrose e ruptura da parede da vesícula biliar. Seu achado pode ser acidental ou estar relacionado à sintomatologia. Foi realizado um estudo retrospectivo (2016-2019) a partir de exames ultrassonográficos abdominais em cães, correlacionando os aspectos da vesícula biliar na mucocele, com comorbidades existentes. Foram avaliados 30 cães com diagnóstico de mucocele biliar, dos quais 46,66% apresentaram a doença em estágio inicial e 53,33% demonstraram estágio mais avançado. Destes, 66,66% tinham endocrinopatias, principalmente hiperadrenocorticismo. Sinais de obstrução de vias biliares extra-hepáticas e peritonite biliar foram observados em dois animais. Por seu potencial risco de complicação, avaliações ultrassonográficas de seguimento são indicadas nos casos de tratamento clínico, não se descartando a necessidade de intervenção cirúrgica.(AU)

Excepcional variación anatómica del confluente biliar superior / Exceptional anatomical variation of the upper biliary confluence / Variação anatômica excepcional da confluência biliar superior

Las variaciones de la formación del confluente biliar superior y su frecuencia deben ser conocidas para asegurar óptimos resultados en la cirugía hepática y evitar lesiones quirúrgicas biliares.

Research progress in lineage tracing to explore hepatic parenchymal cell regeneration and repair mechanisms / 中华肝脏病杂志

Hepatic parenchymal cells are a type of liver cells that performs important functions such as metabolism and detoxification. The contribution of hepatic parenchymal cells, bile duct cells, and hepatic stem/progenitor cells to new hepatic parenchymal cells in the process of liver injury repair has become a controversial issue due to their strong proliferation ability. Lineage tracing technology, which has emerged in the past decade as a new method for exploring the origin of cells, can trace specific type of cells and their daughter cells by labeling cells that express the specific gene and their progeny. The article reviews the current literature on the origin and contribution of hepatic parenchymal cells by this technique. About 98% of new hepatic parenchymal cells originate from the existing hepatic parenchymal cells during liver homeostasis and after acute injury. However, under conditions of severe liver injury, such as inhibition of hepatic parenchymal cell proliferation, bile duct cells (mainly liver stem/progenitor cells) become the predominant source of hepatic parenchymal cells, contributing a steady increased hepatocyte regeneration with the extension of time.

Clinical study on early predictors of concurrent bile duct injury following TACE in patients with liver cancer / 中华肝脏病杂志

Objective: To explore the predictive factors of concurrent bile duct injury following transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). Methods: A retrospective study was conducted on 483 HCC patients in relation to TACE postoperative complications. A total of 21 cases of bile duct injury were observed following the TACE procedure. Laboratory data, imaging data, and clinically relevant medical histories were recorded before and after one week following the TACE procedure and follow-up. The χ (2) test, or Fisher's exact probability method, was used for categorical variables. The mean of the two samples was compared using a paired t-test or Wilcoxon rank sum test. The comparison of multiple mean values was conducted using an analysis of variance. Results: Twenty-one cases with bile duct injury had intrahepatic bile duct dilatation, bile tumors, hilar biliary duct stenoses, and other manifestations. 14.3% (3/21) of patients showed linear high-density shadows along the bile duct on a plain CT scan, while 76.2% (16/21) of patients had ALP > 200 U/L one week following TACE procedure, and bile duct injury occurred in later follow-up. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and γ-glutamyl transferase (GGT) were significantly increased in all patients following TACE procedure (t = -2.721, P = 0.014; t = -2.674, P = 0.015; t = -3.079, P = 0.006; t = -3.377, P = 0.003, respectively). Conclusion: The deposition of iodized oil around the bile duct on plain CT scan presentation or the continuous increase of ALP (> 200 U/L) one week following TACE procedure has a certain predictive value for the later bile duct injury.

Drug-induced bile duct injury: progress and challenges / 中华肝脏病杂志

Drug-induced bile duct injury is a specific kind of drug-induced liver injury that has two main pathological types, namely ductopenia, or vanishing bile duct syndrome, and secondary sclerosing cholangitis. However, in recent years, the reports of new drugs that cause bile duct injury have been constantly increasing, and these drugs have different clinicopathological features and a novel pathogenesis. Therefore, this paper summarizes and analyzes the progress and challenges in the etiology, pathogenesis, diagnosis and treatment, and other aspects of drug-induced bile duct injury.

Papel del ácido ursodesoxicólico en 40 años de tratamiento para la colangitis biliar primaria / Role of ursodeoxycholic acid in 40 years of treatment for primary biliary cholangitis

La colangitis biliar primaria es una enfermedad hepática autoinmune que conduce a la destrucción progresiva de los conductos biliares intrahepáticos, lo que aumenta el riesgo de desarrollar cirrosis e hipertensión portal. Actualmente, el ácido ursodesoxicólico es el medicamento de primera línea para el tratamiento de esta entidad. Este medicamento desplaza los ácidos biliares hidrofóbicos y aumenta las concentraciones de ácidos biliares hidrofílicos en la bilis, lo cual favorece la integridad de los conductos biliares, adicionalmente, tiene efectos antiinflamatorios y propiedades inmunomo-duladoras y antiapoptóticas. En los últimos 40 años, numerosos ensayos clínicos han respaldado la eficacia clínica del ácido ursodesoxicólico y su seguridad cuando se utiliza en pacientes con colan-gitis biliar primaria. Se realiza una revisión del ácido ursodesoxicólico en el contexto de colangitis biliar primaria, se describe su historia, mecanismos de acción, efectos secundarios y dosificación. Finalmente, se menciona su uso en situaciones especiales como son el embarazo y la lactancia

Primary biliary cholangitis is an autoimmune liver disease that leads to progressive destruction of intrahepatic bile ducts, increasing the risk of developing cirrhosis and portal hypertension. Currently, ursodeoxycholic acid is the first-line drug for the treatment of this condition. This drug displaces hy-drophobic bile acids and increases concentrations of hydrophilic bile acids in the bile, which favors the integrity of the bile ducts, additionally, it has anti-inflammatory effects and immunoprotective and antiapoptotic properties. Over the past 40 years numerous clinical trials have supported the clinical efficacy of ursodeoxycholic acid and its safety when used in patients with primary biliary cholangitis. A review of ursodeoxycholic acid in the context of primary biliary cholangitis is carried out, and its history, mechanisms of action, side effects and dosage are described. Finally, its use in special situations such as pregnancy and lactation are discussed.

Síndrome biliar obstructivo no litiásico o de Lemmel. ¿Es tan infrecuente como parece? / Non-lithiasic obstructive biliary syndrome or Lemmel's syndrome. Is it as rare as it seems?

Introducción. Aproximadamente el 5 % de los divertículos duodenales pueden causar síntomas y el 1 % presentar complicaciones, siendo la colangitis la más frecuente. El síndrome de Lemmel corresponde a un tipo de ictericia obstructiva intermitente, asociado a la presencia de divertículos periampulares y disfunción del esfínter de Oddi, sin presencia de coledocolitiasis. Método. Se realizó una revisión sistemática de la literatura en Pubmed, Google Académico y ProQuest, con los términos: síndrome de Lemmel, divertículo duodenal sintomático e ictericia obstructiva intermitente. Resultados. Se encontraron 38 casos, siendo España el país con mayor número, seguido de México, Japón y Colombia. No hay diferencias de distribución con respecto al género. El tratamiento más frecuentemente empleado fue la colangio pancreatografia retrógrada endoscópica. Conclusión. El síndrome de Lemmel es poco frecuente, sin un cuadro clínico especifico, con un incremento en los casos informados en los últimos años, posiblemente debido a la mejor disponibilidad de métodos diagnósticos. Es más frecuente en pacientes en la octava década de la vida y su tratamiento generalmente es endoscópico

Introduction. Approximately 5% of duodenal diverticula can cause symptoms and 1% have complications, cholangitis being the most common. Lemmel syndrome corresponds to a type of intermittent obstructive jaundice, associated with the presence of peri-ampullary diverticula and sphincter of Oddi dysfunction, without choledocholithiasis. Method. A systematic review of the literature was carried out in Pubmed, Google Scholar, ProQuest, with the terms: Lemmel syndrome, symptomatic duodenal diverticulum, and intermittent obstructive jaundice.Results. 38 cases were found, Spain being the country with the highest number, followed by Mexico, Japan and Colombia. There are no differences in distribution with respect to gender. The most frequently used treatment was endoscopic retrograde cholangiopancreatography.Conclusion. Lemmel syndrome is a rare disease, without a specific clinical presentation, with an increase in reported cases in recent years possibly due to the better availability of diagnostic methods. It is more frequent in patients in the eighth decade of life and its treatment is generally endoscopic

Morbilidad por lesión de la vía biliar en un servicio de cirugía / Morbility due to Bile Duct Lesion in a Surgery Service

Introducción: Las lesiones iatrogénicas de las vías biliares representan una complicación quirúrgica grave de la colecistectomía. Objetivo: Determinar la morbilidad de las lesiones de la vía biliar en el servicio de cirugía del Hospital Universitario "Manuel Ascunce Domenech". Métodos: Se realizó un estudio descriptivo, prospectivo y observacional de pacientes que ingresaron en el servicio de cirugía del Hospital Universitario "Manuel Ascunce Domenech" con diagnóstico de lesión de la vía biliar, desde septiembre del 2018 hasta enero del 2022. El universo estuvo conformado por 12 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: La mayor incidencia de los pacientes fue del sexo femenino y de piel blanca, con un 61,4 por ciento y 85,7 por ciento, respectivamente. Predom inó el tipo de cirugía convencional y diagnóstico intraoperatorio con un 66,7 por ciento y 50 por ciento, respectivamente. El tipo E1 y E2 de la clasificación de Strasberg y la hepaticoyeyunostomía fue la operación con mayor frecuencia con un 66,7 por ciento. La bilirragia fue la complicación que predominó con el 70 por ciento. Conclusiones: La mayoría de los pacientes son del sexo femenino y de piel blanca, donde la cirugía convencional y el diagnóstico intraoperatorio son los hallazgos más frecuentes. Más de la mitad de los pacientes son clasificados como tipo E1 y tipo E2 según clasificación de Strasberg. La hepaticoyeyunostomía en Y de Roux y en asa de Braum transmesocólica es el proceder realizado en casi la totalidad de los pacientes. La fuga biliar es la complicación más frecuente(AU(

Introduction: Iatrogenic bile duct lesions represent a serious surgical complication of cholecystectomy. Objective: To determine the morbility of bile duct lesions in the surgical service of Hospital Universitario "Manuel Ascunce Domenech". Methods: A descriptive, prospective and observational study was carried out with patients admitted to the surgery service of Hospital Universitario "Manuel Ascunce Domenech" with a diagnosis of bile duct lesion, from September 2018 to January 2022. The study universe consisted of twelve patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: The highest incidence of patients corresponded to the female sex and the white skin, accounting for 61.4 percent and 85.7(Percent(, respectively. Conventional surgery and intraoperative diagnosis predominated, accounting for 66.7 % and 50 %, respectively. Types E1 and E2 according to the Strasberg classification, together with hepaticojejunostomy, was the most frequent surgery type, accounting for 66.7 %. Biliary bleeding was the predominant complication, accounting for 70 %. Conclusions: Most of the patients belong to the female sex and have white skin, in which cases conventional surgery and intraoperative diagnosis are the most frequent findings. More than half of the patients are classified as types E1 or E2 according to the Strasberg classification. Transmesocolic Braun loop and Roux-en-Y hepaticojejunostomy is the procedure performed in almost all patients. Biliary leakage is the most frequent complication(AU)

Lesiones de vía biliar poscolecistectomía: conducta terapéutica actual / Post Cholecystectomy Bile Duct Injuries: Current Therapeutic Option

Resumen La colecistolitiasis es una condición común en Chile. La complicación más frecuente de esta condición es la colecistitis aguda. Aproximadamente 60.000 colecistectomías son realizadas anualmente en nuestro país, convirtiéndola en una de las patologías digestivas más frecuentes. El tratamiento de la colelitiasis ha evolucionado las últimas dos décadas. Con el desarrollo de la laparoscopía a final de 1980, la colecistectomía abierta fue definitivamente sustituida en los 90 por la vía laparoscópica. Desafortunadamente, la generalización de este procedimiento produjo un aumento en la incidencia de lesiones de vía biliar, aumentando desde una 0,1-0,2% hasta un 0,5-0,7%. Si bien, con el progresivo entrenamiento de los cirujanos en la cirugía mínimamente invasiva esta cifra ha disminuido nuevamente, la LVB aún constituye una de las complicaciones más graves en cirugía, generando gran impacto en la calidad de vida del paciente, e incluso costos en salud que pueden llegar a ser devastadores. El manejo de una lesión de vía biliar es, para muchos cirujanos, un desafío quirúrgico, que para su resolución requiere de las habilidades y experiencia de un cirujano hepatobiliar y derivación a centros de salud especializados. Sin duda, la acción más importante es extremar de manera rutinaria las medidas de prevención. Sin embargo, una vez que la lesión se ha producido, el futuro del paciente depende, directamente, del buen criterio del cirujano, tanto para realizar un diagnóstico temprano, como del enfrentamiento terapéutico que realice. El objetivo de este trabajo es dar a conocer diferentes conductas preventivas y terapéuticas cuando esta complicación se presenta.

Calculous biliary disease is a common condition in Chile. Over 60.000 cholecystectomies are performed annually, making gallstone disease one of the most common digestive health problems. The treatment of calculous biliary disease has evolved over the last 2 decades. With the development of laparoscopic technology in the late 1980s, new techniques for cholecystectomy were introduced. By the early 1990s, laparoscopic cholecystectomy had replaced open cholecystectomy in the operative management of gallbladder stone disease. Unfortunately, the widespread application of laparoscopic cholecystectomy has led to a concurrent rise in the incidence of major bile duct injuries. Reports have estimated the incidence has risen from 0.1-0.2 to 0.5-0.7%. Although, exponential training of surgeons in minimally invasive surgery has led to decrease this numbers again, bile duct injuries still constitute one of the most serious complications in surgery, generating a great impact on the patient's quality of life, and even health costs that can be devastating. The management of patients following major bile duct injurie is a surgical challenge, often requiring the skills of experienced hepatobiliary surgeons at tertiary referral centers. In this setting, the most important action is to routinely maximize prevention measures. However, once injury has occurred, patient's future depends directly on the correct judgment of the surgeon, both to make an early diagnosis and to choose the best therapeutic confrontation. The objective of this article is to present the different preventive and therapeutic options available when this complication occurs.

Variante anatómica de la vía biliar durante la colecistectomía laparoscópica / Anatomical variant of the bile duct during laparoscopic cholecystectomy / Variante anatômica do ducto biliar durante colecistectomia laparoscópica

Se presenta la colangiografía intraoperatoria obtenida durante la colecistectomía laparoscópica de una paciente de 58 años con el diagnóstico de colecistitis aguda.

Calidad de vida posterior a reconstrucción de vía biliar / Quality of life of patients who underwent a bile duct reconstruction

BACKGROUND: Bile duct reconstruction (BDR) secondary to bile duct injury during cholecystectomy (BDIC) is a complex surgery, and an important issue is the quality of life (QL) after the procedure. AIM: To compare the QL of a cohort of patients who underwent BDR due to BDIC with a cohort of patients who underwent a cholecystectomy without incidents. MATERIAL AND METHODS: The cohort was composed of 32 patients aged 47 ± 18 years (78% women) who underwent BDR due to BDIC. For purposes of comparison, a cohort of patients who underwent a cholecystectomy without incident was chosen. These cohorts were paired 1:1 by age (± 1 year), gender and type of surgery. The SF-36 quality of life survey was applied in person or by telephone. The score was calculated as proposed by the RAND group. RESULTS: The cohort of BDR patients was comprised of 32 patients, with an average age of 47 ± 17.6 years, with a predominance of women (78%). The mean number of hospitalization days among BDR patients was 20 ± 11.8. The average follow-up was 7 ± 5 years. The mean score of patients undergoing RVB or cholecystectomy without complications was evaluated, without finding differences in the score of the different domains of the SF-36 scale. Conclusions: In the present study no significant differences were found in QL between the patients with BDIC who underwent BDR and patients who underwent a cholecystectomy without complications.

Lesión quirúrgica de vía biliar compleja. Manejo conservador / Complex bile duct injury. Conservative management

RESUMEN La colecistectomía laparoscópica es el tratamiento de elección para la litiasis vesicular sintomática. Aunque la tasa de complicaciones es baja, las lesiones de la vía biliar representan un grave problema. La asociación con una lesión vascular (lesión compleja) genera un impacto adicional, disminuyendo la calidad de vida y la sobrevida a largo plazo. Presentamos el caso de una paciente con lesión compleja por compromiso vascular del pedículo hepático derecho que desarrolló una atrofia del parénquima correspondiente. Ante la ausencia de complicaciones sépticas, el tratamiento no operatorio pudo realizarse en forma exitosa.

ABSTRACT Laparoscopic cholecystectomy is considered the standard of care for symptomatic cholelithiasis. Although the rate of complications is low, bile duct injuries represent a serious problem. The association with vascular injury (complex injury) poses an additional impact by reducing the quality of life and long-term survival. We report the case of a female patient with complex injury due to vascular involvement of the right hepatic pedicle who developed right liver atrophy. Non-operative management was successful due to the absence of septic complications.

Controversias en cirugía: colelitiasis y coledocolitiasis ¿Exploración de vías biliares laparoscópica más colecistectomía laparoscópica (cirugía en un paso) o CPRE y colecistectomía laparoscópica (cirugía en dos pasos)? / Controversies in surgery: Cholelithiasis and choledocholithiasis - Laparoscopic bile duct exploration plus laparoscopic cholecystectomy (one-step surgery) or ERCP and laparoscopic cholecystectomy(two-step surgery)?

Introducción. La colelitiasis tiene una prevalencia del 15 % y el 21 % tendrá coledocolitiasis al momento de la colecistectomía, con 50 % de probabilidad de presentar complicaciones asociadas. Desde el advenimiento de la colecistectomía laparoscópica, el abordaje de la coledocolitiasis ha sido endoscópico, usualmente en un tiempo diferente al vesicular, sin embargo, los avances en laparoscopia han permitido explorar la vía biliar común por la misma vía, pudiendo realizar ambos procedimientos en el mismo tiempo de forma segura. Métodos. Se realizó una búsqueda de la literatura existente con relación al enfoque para el manejo de la colecisto-coledocolitasis en un paso comparado con dos pasos. Resultados. Existe evidencia que demuestra mayor efectividad del abordaje en dos pasos, con CPRE y posterior colecistectomía laparoscópica, sobre el abordaje en un paso, especialmente en la tasa de fuga biliar y de cálculos retenidos. El enfoque en un paso con exploración de vías biliares y colecistectomía laparoscópica en el mismo tiempo es seguro, con alta tasa de éxito, baja incidencia de complicaciones, menor estancia hospitalaria y costos. Conclusión. El abordaje laparoscópico en un solo paso es un procedimiento seguro y eficaz para el manejo de la colecisto-coledocolitiasis, con el beneficio de estancia hospitalaria menor, sin embargo, se requieren habilidades técnicas avanzadas en cirugía laparoscópica. En nuestro medio ya existe una infraestructura para el manejo híbrido con CPRE y colecistectomía laparoscópica, pudiéndose realizar ambos en el mismo tiempo, para reducir estancia y costos.

Introduction. Cholelithiasis has a prevalence of 15%, and 21% will have choledocholithiasis at the time of cholecystectomy, with a 50% probability of presenting associated complications. Since the advent of laparoscopic cholecystectomy, the approach to choledocholithiasis has been endoscopic, normative at a different time than the gallbladder; however, advances in laparoscopy have made it possible to explore the common bile duct by the same route, being able to perform both procedures in a single time safely. Methods. A search of the existing literature was performed regarding the one-step approach compared to the two-step approach for the management of cholelithiasis and choledocholithiasis. Results. There is evidence that demonstrates greater effectiveness of the two-step approach with ERCP and subsequent laparoscopic cholecystectomy over the one-step approach, especially in the rate of bile leak and the incidence of retained stones. The one-step approach with bile duct exploration and laparoscopic cholecystectomy at the same time is safe, with a high success rate, low incidence of complications, shorter hospital stay, and lower costs. Conclusion. The one-step laparoscopic approach is a safe and effective procedure for the management cholelithiasis and concomitant choledocholithiasis, with the benefit of a shorter hospital stay; however, advanced technical skills in laparoscopic surgery are required. In our environment there is already an infrastructure for hybrid management with ERCP and laparoscopic cholecystectomy, both of which can be performed at the same time to reduce hospital stay and costs.

Dilataciones quísticas congénitas de las vías biliares (segunda parte). Vías biliares extrahepáticas / Congenital bile duct cystic dilatations (part 2). Extrahepatic bile ducts

RESUMEN Las dilataciones quísticas congénitas de la vía biliar extrahepática son infrecuentes, principalmente en Occidente, y afectan sobre todo a niños pero son poco comunes en adultos. El diagnóstico requiere un alto índice de sospecha y suele llevarse a cabo con estudios colangiográficos de los cuales la CRMN es, en la actualidad, el de mayor utilidad. Es conocido el aumento de malignización de estas dilataciones, por lo que el tratamiento completo de la bolsa quística es obligatorio.

ABSTRACT Congenital dilatation of extrahepatic bile ducts is rare in the Western countries and is more common in children than in adults. The diagnosis requires high level of suspicion and is made by cholangiography tests, among which MRCP is the most useful nowadays. Malignant transformation of these cystic dilatations is well-known; therefore, complete resection of the cystic pouch is mandatory.

Morfología de las lesiones iatrogénicas de la vía biliar: aspectos diagnósticos y terapéuticos / Morphology of iatrogenic lesions of the bile duct: diagnostic and therapeutic options

RESUMEN: Las lesiones iatrogénicas de las vías biliares (LIVB), en el curso de una colecistectomía laparoscópica (CL), son complicaciones que causan resultados inesperados para cirujanos un incremento en los riesgos de los pacientes (morbilidad y mortalidad), afectando su calidad de vida. Asimismo, causan situaciones difíciles desde el punto de vista técnico para el cirujano que debe repararlas desde un punto de vista técnico. El objetivo de este manuscrito fue resumir la información referente a las LIVB y describir su morfología y opciones diagnóstico-terapéuticas.

SUMMARY: Iatrogenic Bile duct injuries (IBDI), during laparoscopic cholecystectomy (CL), are complications that cause unexpected results for surgeons, an increment in patient risks (morbidity and mortality), and affect the patient´s quality of life. At the same time, they create difficult situations for the repairing surgeon from a technical point of view. The aim of this manuscript was to summarize the information regarding IBDI and to describe its morphology and diagnostic-therapeutic options.

Morphometric study of extra-hepatic biliary pathways: study in human corpses / Estudio morfométrico de las vías biliares extrahepáticas: estudio en cadáveres humanos

SUMMARY: Adverse events (AE) contribute significantly to postoperative morbidities and comorbidities. Many AEs occur due to a lack of anatomical knowledge and its variants. Latrogenic bile duct injuries, for instance, represent a serious surgical complication of laparoscopic cholecystectomy. Anatomical knowledge for the identification and adequate drainage of all ducts is relevant and fundamental in order to avoid future errors. The objective of the study was to morphometrically analyze the bile ducts in adult human corpses. 13 livers were extracted from adult human corpses to obtain the ducts: choledochal, common hepatic and cystic. After morphological analysis, duct measurements (length and diameter) were continued using a digital caliper. The data obtained were tabulated in SPSS 21 program, performing descriptive analysis with mean and standard deviation. The averages of bile ducts were 61.05 (± 16.43) mm in length and 3.86 (± 0.72) mm in diameter. The cystic duct length and diameter averages were 33.59 (± 12.29) mm and 3.40 (± 0.79) mm, respectively. The common hepatic ducts had an average of 30.02 (± 7.19) mm in length and 3.74 (± 1.18) mm in diameter. The analyzed samples presented different values ?? from those already described in the literature, where the length of the cystic ducts was greater, while the length of the common hepatic ducts was numerically smaller. This work is very significant, as the morphometric variability of the bile ducts allows for varying morphological situations that can compromise the hepatobiliar physiology.

RESUMEN: Los eventos adversos (EA) contribuyen significativamente a las morbilidades y comorbilidades postoperatorias. Muchos EA se deben a la falta de conocimiento de la anatomía y sus variaciones. Por ejemplo, las lesiones iatrogénicas de las vías biliares representan una complicación quirúrgica grave de la colecistectomía laparoscópica. El conocimiento anatómico para la identificación y drenaje adecuado de todos los conductos es relevante y fundamental para evitar futuros errores. El objetivo del estudio fue analizar morfométricamente las vías biliares en cadáveres humanos adultos. Se extrajeron 13 hígados de cadáveres humanos adultos y se retiraron los conductos: colédoco, hepático común y cístico. Después del análisis morfológico, se continuó con las mediciones de los conductos (longitud y diámetro) utilizando un calibrador digital. Los datos fueron tabulados en el programa SPSS 21, mediante análisis descriptivos con media y desviación estándar. Los promedios de las vías biliares fueron de 61,05 (± 16,43) mm de longitud y 3,86 (± 0,72) mm de diámetro. Los promedios de longitud y diámetro del conducto cístico fueron 33,59 (± 12,29) mm y 3,40 (± 0,79) mm, respectivamente. Los conductos hepáticos comunes tenían un promedio de 30,02 (± 7,19) mm de longitud y 3,74 (± 1,18) mm de diámetro. Las muestras analizadas presentaron valores diferentes a los ya descritos en la literatura, donde la longitud de los conductos císticos era mayor, mientras que la longitud de los conductos hepáticos comunes fue numéricamente menor. Este trabajo es significativo, debido a que la variabilidad morfométrica de las vías biliares y permite identificar situaciones morfológicas que pueden comprometer la fisiología hapatobiliar.