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.

Cirugía mayor abdominal electiva sin descompresión nasogástrica y con apertura precoz de vía oral / Major Elective Abdominal Surgery without Nasogastric Decompression and with Early Opening of the Oral Route

Introducción: La descompresión con sonda nasogástrica y la vía oral cerrada por varios días, ha sido práctica común tras procedimientos quirúrgicos electivos del tracto digestivo. Los programas para mejorar la recuperación posoperatoria (Enhanced Recovery After Surgery), aconsejan cambiar esta práctica. Objetivo: Evaluar el cumplimiento y repercusión en la evolución posoperatoria de dos acciones del programa en el retiro de la sonda nasogástrica y la apertura de la vía oral el día de la intervención. Métodos: Se realizó un estudio prospectivo, en el Servicio de Cirugía General del Hospital "Hermanos Ameijeiras" de septiembre 2017 a agosto 2020. La muestra fue de 270 pacientes con intervención quirúrgica mayor electiva del colon, hígado, vía biliar o páncreas, a los que se les aplicó el programa para mejorar la recuperación posoperatoria. Resultados: En 79,6 por ciento de pacientes, la sonda nasogástrica se retiró en el quirófano tras la intervención y esto se asoció a más rápida recuperación de la función intestinal, menor estadía, complicaciones, reingresos y reintervenciones. En 60 por ciento se inició la vía oral 6 horas después de la cirugía y 79,6 por ciento toleraban dieta blanda a las 48 horas. Estos pacientes presentaron menos complicaciones y mortalidad. Conclusiones: En el contexto de un programa para mejorar la recuperación posoperatoria, tras cirugía abdominal electiva, el retiro de la sonda nasogástrica el día de la intervención, con apertura precoz de la vía oral y rápida progresión a dieta blanda, son acciones bien toleradas que repercuten positivamente en la evolución posoperatoria(AU)

Introduction: Nasogastric tube decompression, together with the oral route closed for several days, has been a common practice after elective surgical procedures of the digestive tract. Programs to improve postoperative recovery (Enhanced Recovery After Surgery) advise changing this practice. Objective: To assess compliance and impact on postoperative evolution of two program actions for nasogastric tube removal and opening of the oral route on the intervention day. Methods: A prospective study was carried out, from September 2017 to August 2020, in the general surgery service of Hermanos Ameijeiras Hospital. The sample consisted of 270 patients who underwent major elective surgery of the colon, liver, bile duct or pancreas and were applied the program to improve postoperative recovery. Results: In 79.6 percent of patients, the nasogastric tube was removed in the operating room after the intervention, a fact associated with faster recovery of intestinal function, shorter stay, as well as fewer complications, readmissions and reinterventions. In 60 percent of the patients, the oral route was started at six hours after surgery, while 79.6 percent of them tolerated a soft diet at 48 hours. These patients presented fewer complications and mortality. Conclusions: In the context of a program to improve postoperative recovery after elective abdominal surgery, nasogastric tube removal on the intervention day, with early opening of the oral route and rapid progression to a soft diet, are well-tolerated actions that have a positive effect on postoperative evolution(AU)

Lesión quirúrgica de la vía biliar: experiencia en el Hospital José Ramón Vidal de Corrientes / Bile duct injury after cholecystectomy: the experience of Hospital José Ramón Vidal de Corrientes

RESUMEN Antecedentes: la lesión quirúrgica de la vía biliar representa un gran problema de salud y puede surgir ante cualquier cirujano que realice una colecistectomía. Objetivos: el objetivo del trabajo fue presentar nuestra experiencia en reparación de la vía biliar, ana lizando la morbimortalidad y la incidencia de dicha patología en nuestro Servicio. Material y métodos: estudio retrospectivo descriptivo; se tomaron las variables de las historias clínicas de los pacientes en un período de 8 años, de enero de 2011 a julio de 2019 donde fueron admitidos 19 pacientes que presentaron lesión quirúrgica de la vía biliar en el Hospital José Ramón Vidal de la provincia de Corrientes, Argentina. Resultados: 12 pacientes fueron tratados quirúrgicamente mediante hepático-yeyuno anastomosis, 2 por bihepático-yeyuno anastomosis y dos mediante sutura término-terminal bilio-biliar sobre tubo de Kehr. Tres pacientes fueron tratados mediante colocación de stent y dilatación posterior mediante colangiopancreatografia retrógrada endoscópica. Conclusión: los cirujanos deben entrenarse para disminuir al mínimo la posibilidad de una lesión. El objetivo de una colecistectomía debería ser no lesionar la vía biliar.

ABSTRACT Background: Bile duct injury represents a serious health problem and can occur after any cholecystectomy. Objectives: The aim of this study was to report our experience in repairing bile duct injuries analyzing morbidity, mortality and its incidence in our department. Material and Methods: We conducted a retrospective and descriptive study. The information was retrieved form the medical records of 19 patients with bile duct injury hospitalized at the Hospital José Ramón Vidal, Corrientes, Argentina, between January 2011 and July 2019. Results: A Roux-en-Y hepaticojejunostomy was performed in 12 patients, double hepaticojejunostomy in two patients, and two patients were treated with end-to-end ductal anastomosis with suture over a T tube. Three patients underwent endoscopic retrograde cholangiopancreatography with stent placement and dilation. Conclusion: Surgeons should be trained to avoid the possibility of bile duct injury. The main goal of cholecystectomy should be to avoid this complication.

Ascaridiasis hepatobiliar en una adulta joven / Hepatobiliary ascaridiasis in a young adult woman

Se presenta el caso clínico de una paciente de 27 años de edad, con antecedentes de colecistectomía convencional desde hacía 10 meses por aparente colecistitis, quien acudió al Hospital Luis Vernaza de Guayaquil, Ecuador, por presentar ictericia y dolor abdominal. Teniendo en cuenta los hallazgos clínicos, de laboratorio e imagenológicos se le diagnosticó sepsis de foco abdominal, colangitis y coledocolitiasis. Durante la intervención quirúrgica se observó la presencia de 2 Ascaris lumbricoides y cálculo de colesterol en la vía biliar, por lo que se le realizó una derivación bilioentérica. Después de algunas complicaciones como insuficiencia respiratoria y descompensación hemodinámica, la paciente egresó de la institución a los 25 días de operada, con seguimiento por consulta externa durante 2 meses.

The case report of a 27 years patient is presented, with history of conventional cholecystectomy for 10 months due to apparent cholecystitis who went to Luis Vernaza Hospital in Guayaquil, Ecuador, presenting jaundice and abdominal pain. Taking into account the clinical, laboratory and imaging findings a sepsis of abdominal focus, cholangitis and choledocolithiasis was diagnosed. During the surgical intervention the presence of 2 Ascaris lumbricoides and cholesterol calculi in the bile duct was observed, reason why a bilioenteric bypass was carried out. After some complications such as breathing failure and hemodynamic upset, the patient was discharged from the institution 25 days after the surgery, with follow up in outpatient clinics during 2 months.

Há lugar para a avaliação colangioscópica na estenose biliar anastomótica pós-transplante hepático de doador cadáver? / Is there a place for cholangioscopic evaluation of biliary anastomotic stricture after deceased donor liver transplant?

ABSTRACT BACKGROUND Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment. OBJECTIVE On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS). METHODS: Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal. RESULTS: At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence. CONCLUSION: Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.

RESUMO CONTEXTO: As complicações biliares continuam sendo uma das principais causas de morbidade e perda do enxerto após o transplante hepático. O tratamento endoscópico das complicações biliares provou ser eficaz ao longo do tempo, deixando o tratamento cirúrgico restrito a casos de exceção. No entanto, ainda não podemos prever quais pacientes terão maior potencial de se beneficiar da terapia endoscópica. OBJETIVO: Nesta premissa, decidimos realizar este estudo para avaliar o papel e a segurança da colangioscopia peroral de operador único (CPO) no tratamento endoscópico das estenoses anastomóticas biliares (EA) pós-transplante hepático. MÉTODOS: Entre março de 2016 e junho de 2017, 20 pacientes consecutivos encaminhados para tratamento endoscópico da EA biliar foram incluídos neste estudo prospectivo de coorte observacional. Os critérios de inclusão foram idade superior a 18 anos e um transplante hepático de doador falecido realizado há pelo menos 30 dias. Pacientes com estenose biliar não anastomótica, fístula biliar, "cast" síndrome, qualquer terapia endoscópica prévia, gravidez e incapacidade de fornecer consentimento informado foram excluídos. Todos os pacientes foram submetidos à CPO antes da terapia endoscópica com prótese metálica autoexpansível totalmente coberta (PMAEC) e após a sua remoção. RESULTADOS: Na CPO realizada antes do tratamento endoscópico, o orifício de estenose e alterações fibróticas foram visualizadas em todos os pacientes, alterações vasculares e a presença de suturas cirúrgicas em 60%, enquanto alterações inflamatórias agudas em 30%. A CPO foi determinante para a transposição do fio-guia através da estenose em cinco casos. Uma PMAEC foi implantada com sucesso em todos os pacientes. A taxa de resolução da estenose foi de 44,4% (tempo médio de permanência de 372 dias). A recorrência da EA foi de 12,5% (acompanhamento médio de 543 dias). Os eventos adversos foram migração distal (66,6%) e proximal (5,5%) da prótese metálica, oclusão da PMAEC (16,6%), dor abdominal intensa (10%) e pancreatite aguda leve (10%). A CPO foi repetida após a remoção da PMAEC. A colangioscopia realizada após o tratamento endoscópico mostrou alterações fibróticas em todos, exceto em um paciente; alterações vasculares e inflamatórias agudas foram menos frequentes em comparação à CPO inicial. O desaparecimento do material de sutura, observado em todos os casos, foi notável. Nenhum dos achados colangioscópicos foram estatisticamente correlacionados ao resultado do tratamento ou à recorrência de estenose. CONCLUSÃO: A colangioscopia peroral é viável nos pacientes pós-transplante hepático com estenose biliar anastomótica. Os achados colangioscópicos podem ser classificados em alterações inflamatórias agudas, fibróticas e vasculares. A colangioscopia pode ser útil para auxiliar na passagem do fio-guia, mas seu papel geral na mudança de tratamento nos pacientes pós-transplante hepático não foi demonstrado.

Transplante de fígado para tratamento de lesão de via biliar após colecistectomia / Liver transplantation for bile duct injury after cholecystectomy

ABSTRACT BACKGROUND: Bile duct injury is a life-threatening complication that requires proper management to prevent the onset of negative outcomes. Patients may experience repeated episodes of cholangitis, secondary biliary cirrhosis, end-stage liver disease and death. OBJECTIVE: To report a single center experience in iatrogenic secondary liver transplantation after cholecystectomy and review the literature. METHODS: This was a retrospective single center study. Of the 1662 liver transplantation realized, 10 (0.60 %) were secondary to iatrogenic bile ducts injuries due cholecystectomies. Medical records of these patients were reviewed in this study. RESULTS: Nine of 10 patients were women; the median time in waiting list and between cholecystectomy and inclusion in waiting list was of 222 days and of 139.9 months, respectively. Cholecystectomy was performed by open approach in eight (80%) cases and by laparoscopic approach in two (20%) cases. The patients underwent an average of 3.5 surgeries and procedures before liver transplantation. Biliary reconstruction was realized with a Roux-en-Y hepaticojejunostomy in nine (90%) cases. Mean operative time was 447.2 minutes and the median red blood cell transfusion was 3.4 units per patient. Mortality in the first month was of 30%. CONCLUSION: Although the liver transplantation is an extreme treatment for an initially benign disease, it has its well-defined indications in treatment of bile duct injuries after cholecystectomy, either in acute or chronic scenario.

RESUMO CONTEXTO: A lesão da via biliar é uma complicação que pode ameaçar a vida e que requer manejo adequado para prevenir o aparecimento de desfechos negativos. Os pacientes podem apresentar episódios repetidos de colangite, cirrose biliar secundária, doença hepática terminal e até mesmo morte. OBJETIVO: Avaliar a experiência de um único centro em transplante hepático secundário a lesão iatrogênica de via biliar pós-colecistectomia e fazer uma revisão de literatura. MÉTODOS: Este foi um estudo retrospectivo de um único centro. Dos 1662 transplantes de fígado, 10 (0,60%) foram secundários a lesões iatrogênicas das vias biliares devido à colecistectomias. Os prontuários médicos desses pacientes foram revisados neste estudo. RESULTADOS: Nove dos dez pacientes eram mulheres; o tempo médio em lista de espera de transplante e entre colecistectomia e inclusão na lista de espera foi de 222 dias e de 139,9 meses, respectivamente. A colecistectomia foi realizada por abordagem aberta em oito (80%) casos e por abordagem laparoscópica em dois (20%) casos. Os pacientes foram submetidos a uma média de 3,5 cirurgias e procedimentos antes do transplante de fígado e a reconstrução biliar foi realizada com hepaticojejunostomia em Y-de-Roux em nove (90%) casos. O tempo operatório médio foi de 447,2 minutos e a média de transfusão de concentrados de hemácias foi de 3,4 unidades por paciente. Mortalidade no primeiro mês foi de 30%. CONCLUSÃO: Embora o transplante de fígado seja um tratamento extremo para uma doença inicialmente benigna, ele tem suas indicações bem definidas no tratamento de lesões biliares após colecistectomia, seja em um cenário agudo ou crônico.

Melatonin effects on pulmonary tissue in the experimental model of Hepatopulmonary Syndrome / Efeitos da melatonina sobre o tecido pulmonar no modelo experimental de Síndrome Hepatopulmonar

ABSTRACT Objective: To evaluate the pulmonary alterations of animals with Hepatopulmonary Syndrome (HPS) submitted to Biliary Duct Ligature (BDL), as well as the antioxidant effect of Melatonin (MEL). Methods: Sixteen male Wistar rats, divided into four Sham groups: BDL group, Sham + MEL group and BDL + MEL. The pulmonary and hepatic histology, lipoperoxidation and antioxidant activity of lung tissue, alveolar-arterial O2 difference and lung / body weight ratio (%) were evaluated. Results: When comparing the groups, could be observed an increase of vasodilation and pulmonary fibrosis in the BDL group and the reduction of this in relation to the BDL + MEL group. It was also observed significant changes in the activity of catalase, ApCO2, ApO2 in the LBD group when compared to the other groups. Conclusion: The use of MEL has been shown to be effective in reducing vasodilation, fibrosis levels and oxidative stress as well as gas exchange in an experimental HPS model.

RESUMO Objetivo: Avaliar as alterações pulmonares de animais com Síndrome Hepatopulmonar (SHP), submetidos à ligadura de ducto biliar (LDB), bem como o efeito antioxidante da Melatonina (MEL). Métodos: Dezesseis ratos machos da espécie Wistar, divididos em quatro grupos: Sham, Grupo LDB, Grupo Sham + MEL e LDB + MEL. Foram avaliadas a histologia pulmonar e hepática, a lipoperoxidação e atividade antioxidante do tecido pulmonar, diferença álveolo-arterial de O2 e relação peso pulmonar/peso corporal (%). Resultados: Quando comparados os grupos, observamos um aumento da vasodilatação e fibrose pulmonar no grupo LDB e a redução deste em relação ao grupo LDB+MEL. Observamos ainda alterações significativas na atividade da catalase, PaCO2, PaO2 no grupo LBD quando comparado aos demais grupos. Conclusões: A utilização da MEL demonstrou-se eficaz na redução da vasodilatação, níveis de fibrose e estresse oxidativo assim como na troca gasosa em modelo experimental de SHP.

Manejo endoscópico de la estenosis biliar postoperatoria a propósito de un caso / Endoscopic management of postoperative bile duct stricture report of a case

Las estenosis biliares postoperatorias principalmente las post colecistectomía representan la causa más frecuente de estenosis biliares benignas. Presentamos el caso de una paciente del sexo femenino que acude por presentar ictericia, coluria, alzas térmicas y dolor abdominal con el único antecedente de una colecistectomía laparoscópica. Los exámenes de laboratorio presentan un patrón obstructivo colestásico se procede a realizar colangiopancreatografía retrógrada endoscópica (ERCP), observando estenosis de la vía biliar en relación a los clips metálicos. Se realizó dilataciones mecánicas e hidrostáticas de vía biliar además de la colocación, secuencial de dos prótesis biliares de plástico. A los 6 meses se retira las prótesis biliares no evidenciando estenosis en la colangiografía de control. El manejo de las estenosis benignas representa un reto ya sea para el endoscopista, como para el cirujano, la colangiopancreatografía retrógrada endoscópica juega un papel muy importante diagnóstico y terapéutico principalmente con la colocación de prótesis biliares.

Postoperative biliary strictures, mainly post cholecystectomy, represent the most frequent cause of benign biliary stenosis. We present a case of a female patient who presents jaundice, choluria, thermal spikes and abdominal pain with the only history of laparoscopic cholecystectomy. Laboratories with a cholestasic obstructive pattern proceeds to perform endoscopic retrograde cholangiopancreatography (ERCP), observing stenosis of the bile duct in relation to metal clips. Mechanical and hydrostatic dilatations of the bile duct were performed in addition to the sequential placement of two plastic biliary stents. 6 months later biliary stents were removed, not showing stricture area in the control cholangiography. The management of benign strictures represent a challenge for both the endoscopist and the surgeon the endoscopic retrograde cholangiopancreatography plays a very important diagnostic and therapeutic role mainly with the placement of biliary stent.

Manejo mini-invasivo de la litiasis coledociana / MINIMALLY INVASIVE SURGERY OF CHOLEDOCHOLITHIASIS

Choledocholithiasis is one of the more common benign disorders of the biliary tract with multiple features of presentation and several alternatives for its diagnosis and treatment. Our aim was to perform a based-evidence revision to propose a diagnostic and therapeutic algorithm. The raised values of gamma glutamiltranspeptidase, alkaline phosphatase and total bilirubin, are well predictors for a choledocholithiasis. The image evidence for a pre-operative detection with higher sensibility, specificity and better cost-effectiveness is the cholangioresonance. For its intraoperative detection, the cholangiography is the method most frequently used, though cholangioscopy is likewise useful. In the case of a post-operative suspicious, the cholangiography through the T tube is the gold standard. With regard to the treatment of the choledocholithiasis, the different stages are analyzed. depending if the detection was performed pre, intra or postoperatively. As a conclusion, the approach of the choledocholithiasis in one step seems to be better that to perform it in two steps, being the laparoscopic exploration for bile ducts stones more safety than the use of the intraoperative ERCP (endoscopic retrograde cholangiopancreatography) .The postoperative ERCP is not recommended excepting in very selected cases, and the biliodigestive derivations should be reserved only for the primary lithiasis of the common bile duc

Choledochal cyst in the pediatric population: experience of 13 laparoscopic procedures in two years at a single institution / Cisto de colédoco na população pediátrica: experiência de 13 procedimentos laparoscópicos em dois anos de uma única instituição

ABSTRACT Objective: to describe the first 13 cases of laparoscopic correction of common bile duct cyst in the Pequeno Príncipe Hospital, Curitiba, Paraná, Brazil. Methods: we performed a retrospective analysis of medical records of cases of choledochal cyst operated by laparoscopy between March 2014 and September 2016. Results: of the 13 patients, eight were female and the mean age at surgery was 7.8 years. The most common symptom was abdominal pain. The hepaticoduodenal anastomosis was the most used reconstruction technique, in 84.6% of the cases. There was no conversion to laparotomy or intraoperative complications. Only one patient presented anastomotic fistula and was reoperated by laparotomy. All patients were followed up in an outpatient clinic, were asymptomatic and had no episode of cholangitis after surgery, with a mean follow-up of 16 months. Conclusion: laparoscopy is a safe method to correct choledochal cysts, even in younger children, with low rates of complications and low rates of conversion to open surgery when performed by well trained surgeons.

RESUMO Objetivo: descrever os primeiros 13 casos de correção laparoscópica de cisto do ducto biliar comum no Hospital Pequeno Príncipe, Curitiba, Paraná, Brasil. Métodos: análise retrospectiva dos registros médicos em prontuário dos casos de cisto de colédoco operados por via laparoscópica entre março de 2014 e setembro de 2016. Resultados: dos 13 pacientes, oito eram do sexo feminino e a média de idade na ocasião da cirurgia foi de 7,8 anos. O sintoma mais comum foi dor abdominal. A anastomose hepático-duodenal foi a técnica de reconstrução mais utilizada, em 84,6% dos casos. Não houve conversão para laparotomia ou complicações intraoperatórias. Apenas um paciente apresentou fístula da anastomose e foi reoperado por laparotomia. Todos permanecem em acompanhamento ambulatorial, com tempo de seguimento médio de 16 meses, assintomáticos e não apresentaram episódio de colangite após a cirurgia. Conclusão: a laparoscopia é um método seguro para correção dos cistos de colédoco, mesmo em crianças mais jovens, com baixas taxas de complicações e baixas taxas de conversão para cirurgia aberta quando realizada por cirurgiões com bom treinamento.

Lesiones iatrogénicas de las vías biliares / Iatrogenic lesions of the biliary tract

Las lesiones iatrogénicas de las vías biliares (LIVB) representan una complicación quirúrgica grave de la colecistectomía laparoscópica (CL). Ocurre frecuentemente cuando se confunde el conducto biliar con el conducto cístico; y han sido clasificados por Strasberg y Bismuth, según el grado y nivel de la lesión. Alrededor del tercio de las LIVB se reconocen durante la CL, al detectar fuga biliar. No es recomendable su reparación inmediata, especialmente cuando la lesión está próxima a la confluencia o existe inflamación asociada. El drenaje debe establecerse para controlar la fuga de bilis y prevenir la peritonitis biliar, antes de transferir al paciente a un establecimiento especializado en cirugía hepatobiliar compleja. En pacientes que no son reconocidos intraoperatoriamente, las LIVB manifiestan tardíamente fiebre postoperatoria, dolor abdominal, peritonitis o ictericia obstructiva. Si existe fuga biliar, debe hacerse una colangiografía percutánea para definir la anatomía biliar y controlar la fuga mediante stent biliar percutáneo. La reparación se realiza seis a ocho semanas después de estabilizar al paciente. Si hay obstrucción biliar, la colangiografía y drenaje biliar están indicados para controlar la sepsis antes de la reparación. El objetivo es restablecer el flujo de bilis al tracto gastrointestinal para impedir la formación de litos, estenosis, colangitis y cirrosis biliar. La hepáticoyeyunostomía con anastomosis en Y de Roux termino-lateral sin stents biliares a largo plazo, es la mejor opción para la reparación de la mayoría de las lesiones del conducto biliar común.

Iatrogenic bile duct injuries (IBDI) represent a serious surgical complication of laparoscopic cholecystectomy (LC). Often it occurs when the bile duct merges with the cystic duct; and they have been ranked by Strasberg and Bismuth, depending on the degree and level of injury. About third of IBDI recognized during LC, to detect bile leakage. No immediate repair is recommended, especially when the lesion is near the confluence or inflammation is associated. The drain should be established to control leakage of bile and prevent biliary peritonitis, before transferring the patient to a specialist in complex hepatobiliary surgery facility. In patients who are not recognized intraoperatively, the IBDI manifest late postoperative fever, abdominal pain, peritonitis or obstructive jaundice. If there is bile leak, percutaneous cholangiography should be done to define the biliary anatomy, and control leakage through percutaneous biliary stent. The repair is performed six to eight weeks after patient stabilization. If there is biliary obstruction, cholangiography and biliary drainage are indicated to control sepsis before repair. The ultimate aim is to restore the flow of bile into the gastrointestinal tract to prevent the formation of calculi, stenosis, cholangitis and biliary cirrhosis. Hepatojejunostomy with Roux-Y anastomosis termino-lateral without biliary stents long term, is the best choice for the repair of most common bile duct injury.

Lesión de vía biliar en trauma cerrado: nuevas tendencias en lesiones infrecuentes / Biliar injury in closed trauma: new trends in unusual injury

Objetivo: Reportar un caso clínico de lesión de la vía biliar intrapancreática tras traumatismo abdominal cerrado. Caso clínico: Paciente que acude a urgencias por intenso dolor abdominal, tras sufrir traumatismo toraco-abdominal cerrado al caer de una bicicleta. Posteriormente a su ingreso desarrolló fiebre, ictericia y patrón analítico de colestasis. Se solicitó colangiorresonancia magnética donde no se pudo valorar correctamente la vía biliar, pero se evidenció abundante líquido intraabdominal que no correspondía a sangre. Se indicó cirugía urgente ante la sospecha de lesión biliar. Se objetivó lesión de la vía biliar intrapancreática mediante colangiografía intra-operatoria y se decidió colocación de prótesis intrabiliar mediante colangiopancreatografía retrógrada endoscópica (CPRE) intraoperatoria. Conclusión: La cirugía ha sido el tratamiento convencional para la lesión de la vía biliar, pero en la actualidad la CPRE con esfinterotomía y colocación de prótesis intrabiliar es un tratamiento adecuado y resolutivo de este tipo de lesiones pudiéndose considerar como tratamiento de primera línea.

Aim: To report a clinical case of biliar injury intrapancreatic in closed abdominal trauma. Clinical case: Patient who comes to the emergency room by severe abdominal pain after suffering thoraco-abdominal blunt trauma after falling from a bicycle. After his admission he developed fever, jaundice and analytical standards of cholestasis. Magnetic resonance which failed to correctly assess the bile duct was requested but showed plenty of intra-abdominal fluid blood that did not match. Emergency surgery for suspected biliary injury was reported. Intrapancreatic injury bile duct was observed by intraoperative cholangiography and prosthesis was decided intrabiliary by intraoperative endoscopic retrograde cholangiopancreatography (ERCP). Conclusions: Surgery has been the standard treatment for bile duct injury, but now ERCP with sphincterotomy and placement of intrabiliary prosthesis is adequate and operative treatment of these injuries and can be considered as first-line treatment.

Biodegradable biliary stents: a new approach for the management of hepaticojejunostomy strictures following bile duct injury. prospective study / Stent biliar biodegradável: uma nova abordagem para as estenoses hepaticojejunais após lesão do ducto biliar. estudo prospectivo

ABSTRACT Background: Once a biliary injury has occurred, repair is done by a hepaticojejunostomy. The most common procedure is to perform a dilatation with balloon with a success of 70 %. Success rates range using biodegradable stents is from 85% to 95%. Biodegradable biliary stents should change the treatment of this complication. Aim: To investigate the use of biodegradable stents in a group of patients with hepaticojejunonostomy strictures. Methods: In a prospective study 16 biodegradable stents were placed in 13 patients with hepaticojejunostomy strictures secondary to bile duct repair of a biliary surgical injury. Average age was 38.7 years (23-67), nine were female and four male. All cases had a percutaneous drainage before at the time of biodegradable stent placement. Results: In one case, temporary haemobilia was present requiring blood transfusion. In another, pain after stent placement required intravenous medication. In the other 11 patients, hospital discharge was the next morning following stent placement. During the patient´s follow-up, none presented symptoms during the first nine months. One patient presented significant alkaline phosphatase elevation and stricture recurrence was confirmed. One case had recurrence of cholangitis 11 months after the stent placement. 84.6% continued asymptomatic with a mean follow-up of 20 months. Conclusion: The placement of biodegradable stents is a safe and feasible technique. Was not observed strictures caused by the stent or its degradation. It could substitute balloon dilation in strictures of hepaticojejunostomy.

RESUMO Racional: Uma vez que lesão biliar ocorreu, o reparo é feito por hepaticojejunostomia. O procedimento mais comum é efetuar dilatação com balão com sucesso de 70%. As taxas de sucesso utilizando stents biodegradáveis ​​é de 85% a 95%. Stents biliares biodegradáveis ​​devem mudar o tratamento desta complicação. Objetivo: Investigar o uso de stents biodegradáveis em um grupo de pacientes com estenose hepaticojejunal Métodos: Em estudo prospectivo 16 stents biodegradáveis ​​foram colocados em 13 pacientes com estenose de hepaticojejunostomia secundárias usados para reparação do ductos biliares de lesão cirúrgica. A média de idade foi de 38,7 anos (23-67), nove pacientes eram homens e quatro mulheres. Todos os casos tiveram drenagem percutânea antes do momento da colocação de stent biodegradável. Resultados: Em um caso, haemobilia temporária estava presente com necessidade de transfusão de sangue. Em outro, dor após a colocação do stent necessitou de medicação intravenosa. Nos outros 11 pacientes, alta hospitalar foi na manhã seguinte após o procedimento. Durante o seguimento, nenhum apresentou sintomas durante os primeiros nove meses. Um paciente apresentou significativa elevação da fosfatase alcalina por recidiva da estenose. Um caso teve recorrência de colangite 11 meses após a colocação do stent. Continuaram assintomáticos 84,6% com média de acompanhamento de 20 meses. Conclusão: A colocação de stents biodegradáveis ​​é técnica segura e viável. Não foram observadas restrições causadas pelo stent ou pela sua degradação. Stent pode substituir dilatação com balão na estenose de hepaticojejunostomia.

Decreased C-reactive protein induces abnormal vascular structure in a rat model of liver dysfunction induced by bile duct ligation

BACKGROUND/AIMS: Chronic liver disease leads to liver fibrosis, and although the liver does have a certain regenerative capacity, this disease is associated with dysfunction of the liver vessels. C-reactive protein (CRP) is produced in the liver and circulated from there for metabolism. CRP was recently shown to inhibit angiogenesis by inducing endothelial cell dysfunction. The objective of this study was to determine the effect of CRP levels on angiogenesis in a rat model of liver dysfunction induced by bile duct ligation (BDL). METHODS: The diameter of the hepatic vein was analyzed in rat liver tissues using hematoxylin and eosin (H&E) staining. The expression levels of angiogenic factors, albumin, and CRP were analyzed by real-time PCR and Western blotting. A tube formation assay was performed to confirm the effect of CRP on angiogenesis in human umbilical vein endothelial cells (HUVECs) treated with lithocholic acid (LCA) and siRNA-CRP. RESULTS: The diameter of the hepatic portal vein increased significantly with the progression of cirrhosis. The expression levels of angiogenic factors were increased in the cirrhotic liver. In contrast, the expression levels of albumin and CRP were significantly lower in the liver tissue obtained from the BDL rat model than in the normal liver. The CRP level was correlated with the expression of albumin in hepatocytes treated with LCA and siRNA-CRP. Tube formation was significantly decreased in HUVECs when they were treated with LCA or a combination of LCA and siRNA-CRP. CONCLUSION: CRP seems to be involved in the abnormal formation of vessels in hepatic disease, and so it could be a useful diagnostic marker for hepatic disease.

Colangiocarcinoma en tercio medio de la vía biliar principal tratado con cirugía radical en el Hospital Nacional Guillermo Almenara, Lima, Perú / Cholangiocarcinoma in the middle third of the bile duct treated with radical surgery in Guillermo Almenara Hospital, Lima, Peru

Reportamos el caso de una paciente en quien se hizo el diagnóstico inicial de tumoración en vía biliar principal en su tercio medio. Paciente se presentó con baja ponderal de 10 kilogramos en 2 meses y dolor moderado en epigastrio, no ictericia. El paciente fue sometido a cirugía radical de la vía biliar con biopsia por congelación múltiple de bordes quirúrgicos, coledocoscopía intraoperatoria, colangiografía intraoperatoria y reconstrucción con anastomosis bilio-digestiva en Y de Roux transmesocólica, tuvo una recuperación sin complicaciones y alta precoz. El resultado anátomo-patológico evidenció adenocarcinoma tubular moderadamente diferenciado sobre la base de un adenoma. Carcinoma in situ sobre la base del adenoma. Ganglios retroperitoneales, retropancreáticos, pericoledocianos, curvatura menor y arteria hepática negativos. Bordes quirúrgicos y ampliación de bordes proximal y distal libres de neoplasia. Cirugía R0. pT1N0Mx. Estadio 1. Después de los resultados quirúrgicos óptimos es manejado por cirugía de hígado y vías biliares y oncología médica para seguimiento y controles periódicos. Presentamos aquí la secuencia de hechos y una revisión de la literatura...

We report the case of a patient who had the initial diagnosis of tumor in the bile duct in the middle third. Patient presented with lost weight of 10 kilograms in two months and moderate epigastric pain, no jaundice. The patient underwent radical surgery of the bile duct with multiple freeze biopsy surgical margins, intraoperative choledochoscopy, intraoperative cholangiography and reconstruction bilioenteric anastomosis Y Roux transmesocolic, he had a great recovery and early discharge. The pathological results showed moderately differentiated tubular adenocarcinoma on the basis of an adenoma. Negatives retroperitoneal, retropancreatic, pericholedochal, lesser curvature and negative hepatic artery nodes, and extension of surgical margins free of neoplasia proximal and distal edges. R0 surgery. pT1N0Mx. Stage 1. After the optimal surgical outcomes, is managed by liver and biliary tract surgery service and medical oncology service for regular monitoring and controls. We present here the sequence of events and a review of the literature...

Calidad de vida post-reconstrucción de vía biliar / Quality of life after bile duct damage and repair during cholecystectomy

Background: Bile duct reconstruction after surgical lesions during cholecystectomy is a complex procedure with impact on postoperative quality of life. Aim: To compare the quality of life of patients who suffered a bile duct lesion during cholecystectomy with their counterparts in whom bile duct was not damaged. Material and Methods: The SF-36 questionnaire for quality of life was applied to 20 patients aged 44 +/- 16 years (79 percent women), who required a bile duct reconstruction due to lesions during cholecystectomy and to 20 age and gender matched patients subjected to uneventful cholecystectomies. Results: The SF-36 scores obtained for patients subjected to bile duct reconstruction and those with uneventful cholecystectomies were 78.5 +/- 21.5 and 74.1 +/- 16.7 (p = 0.46) respectively for physical function, 75 +/- 22 and 72.5 +/- 28 (p = 0.75) respectively for physical role, 79.6 +/- 23.3 and 66.6 +/- 28.6 respectively (p = 0.12) for emotional role, 60.8 +/- 25.4 and 50.3 +/- 17.4 respectively (p = 0.13) for vitality, 69.2 +/- 22.4 and 56.8 +/- 18.7 respectively (p = 0.06) for mental health, 84.3 +/- 19 and 64.1 +/- 22.1 respectively (p < 0.01) for social role, 74.1 +/- 25.1 and 71.8 +/- 24.7 respectively (p = 0,76) for pain and 57 +/- 24.4 and 56.8 +/- 24,4 respectively (p = 0.97) for general health. Conclusions: No differences in quality of life were observed between patients subjected to bile duct reconstruction and those who experienced uneventful cholecystectomies.

Introducción: La reconstrucción de vía biliar (RVB) secundaria a lesión de vía biliar asociada a cole-cistectomía (LVBAC) es una cirugía compleja y un aspecto importante es la calidad de vida (CV) posterior. El objetivo del presente trabajo es comparar la calidad de vida de una cohorte de pacientes sometidos a RVB por LVBAC con una cohorte de pacientes sometidos a colecistectomía sin incidentes. Material y método: Estudio de calidad de vida realizado en una cohorte concurrente a conveniencia. La cohorte está compuesta por 20 pacientes sometidos a RVB por LVBAC. Para tener un grupo de comparación se eligió una cohorte de pacientes sometidos a colecistectomía sin incidentes. Estas cohortes se parearon 1:1 por edad (+/- 4 años), género y tipo de cirugía. Se aplicó el cuestionario SF-36 con la puntuación propuesta por el grupo RAND de manera personal o telefónica. Se utilizó t-test para la comparación de los promedios de la puntuación. Por ser una cohorte a conveniencia se hizo cálculo de potencia del estudio, que fue del 99 por ciento. Resultados: La cohorte de pacientes de RVB está conformada por 20 pacientes, con una edad promedio de 44 +/- 15,51 años; siendo el 79 por ciento de género femenino. El promedio de seguimiento fue de 68 +/- 44 meses. La puntuación obtenida por los pacientes sometidos a RVB y colecistectomía fue: función física: 78,5 +/- 21,46 vs 74,05 ± 16,69 (p = 0,46); rol físico: 75 +/- 22 vs 72,5 +/- 27,98 (p = 0,75); rol emocional: 79,58 +/- 23,33 vs 66,6 +/- 28,61 (p = 0,12); vitalidad: 60,75 +/- 25,35 vs 50,25 +/- 17,38 (p = 0,13); salud mental: 69,2 +/- 22,36 vs 56,8 +/- 18,65 (p = 0,06); rol social: 84,31+/- 18,98 vs 64,12 +/- 22,11 (p = 0,003); dolor: 74,12 +/- 25,09 vs 71,75 +/- 24,69 (p = 0,76); salud general: 57 +/- 24,35 vs 56,75 +/- 24,40 (p = 0,97). A manera de descripción se hizo una comparación de subgrupos según técnica de Hepp-Couinaud, tiempo de RVB y necesidad de procedimientos percutáneos después de RVB. Conclusión: En el...

Caracterización de pacientes con lesiones quirúrgicas iatrogénicas de las vías biliares / Characterization of patients with surgical iatrogenic injuries of the biliary apparatus

Se realizó un estudio descriptivo de 35 pacientes intervenidos quirúrgicamente mediante las técnicas convencional y laparoscópica, quienes presentaron lesiones iatrogénicas de las vías biliares, en el Servicio de Cirugía General del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" de Santiago de Cuba, en un período de 8 años (2007-2014), con vistas a caracterizarles según algunas variables de interés y determinar la mortalidad asociada. Entre los resultados preponderantes figuraron el sexo femenino y las edades de 35 a 54 años, las lesiones producidas de la colecistectomía videolaparoscópica electiva por litiasis vesicular, las formas clínicas de presentación el absceso intraabdominal con signos de peritonitis e ictericia, cuyo diagnóstico fue confirmado mediante la ecografía. Asimismo, las lesiones de tipo A y C, según la clasificación de Strasberg, fueron las más reiteradas y el procedimiento técnico reparador más común fue el drenaje y lavado de la cavidad abdominal; 88,6 % de los pacientes egresaron vivos y 4 féminas fallecieron (11,4 %), cuya causa de muerte fue el choque séptico. Pudo concluirse que el momento del diagnóstico de estas lesiones se efectuaba tardíamente, y que a pesar de la complejidad de la reparación quirúrgica, existió baja mortalidad.

A descriptive study of 35 surgically treated patients by means of conventional and laparoscopic techniques who presented iatrogenic injuries of the biliary system, was carried out in the General Surgery Service of "Saturnino Lora Torres" Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba, in a 8 year period (2007-2014), with the aim of characterizing them according to some variables of interest and of determining the associated mortality. Among the predominant results there were the female sex and the ages from 35 to 54 years, the produced lesions of the elective videolaparoscopic cholecystectomy for vesicular lithiasis, the clinical forms of presentation the intraabdominal abscess with peritonitis signs and jaundice, diagnosis confirmed by means of the echography. Also, injuries A and C, according to the classification of Strasberg, were those most reiterated and the most common restorative technical procedure was drainage and washing of the abdominal cavity; 88.6% of the patients were discharged alive and 4 female patients died (11.4%) whose cause of death was the septic shock. It could be concluded that the moment of diagnosis for these lesions took place late, and that in spite of the complexity of the surgical repair, there was low mortality.

A Comparison of Preoperative Biliary Drainage Methods for Perihilar Cholangiocarcinoma: Endoscopic versus Percutaneous Transhepatic Biliary Drainage

BACKGROUND/AIMS: Controversy remains over the optimal approach to preoperative biliary drainage in patients with resectable perihilar cholangiocarcinoma. We compared the clinical outcomes of endoscopic biliary drainage (EBD) with those of percutaneous transhepatic biliary drainage (PTBD) in patients undergoing preoperative biliary drainage for perihilar cholangiocarcinoma. METHODS: A total of 106 consecutive patients who underwent biliary drainage before surgical treatment were divided into two groups: the PTBD group (n=62) and the EBD group (n=44). RESULTS: Successful drainage on the first attempt was achieved in 36 of 62 patients (58.1%) with PTBD, and in 25 of 44 patients (56.8%) with EBD. There were no significant differences in predrainage patient demographics and decompression periods between the two groups. Procedure-related complications, especially cholangitis and pancreatitis, were significantly more frequent in the EBD group than the PTBD group (PTBD vs EBD: 22.6% vs 54.5%, p<0.001). Two patients (3.8%) in the PTBD group experienced catheter tract implantation metastasis after curative resection during the follow-up period. CONCLUSIONS: EBD was associated with a higher risk of procedure-related complications than PTBD. These complications were managed properly without severe morbidity; however, in the PTBD group, there were two cases of cancer dissemination along the catheter tract.