Comparative evaluation of three laparoscopic cholecystectomy techniques in rabbit's model

Purpose: The aim of this randomized study was to compare the complications and perioperative outcome of three different techniques of laparoscopic cholecystectomy (LC). Changes in the liver function test after LC techniques were investigated. Also, we compared the degree of postoperative adhesions and histopathological changes of the liver bed. Methods: Thirty rabbits were divided into three groups: group A) Fundus-first technique by Hook dissecting instrument and Roeder Slipknot applied for cystic duct (CD) ligation; group B) conventional technique by Maryland dissecting forceps and electrothermal bipolar vessel sealing (EBVS) for CD seal; group C) conventional technique by EBVS for gallbladder (GB) dissection and CD seal. Results: Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. Gamma-glutamyl transferase and alkaline phosphatase levels increased (p ≤ 0.05) on day 3 postoperatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. Conclusions: LC can be performed using different techniques, although the use of EBVS is highly recommended.

Hotspots and difficulties of biliary surgery in older patients / 中华医学杂志(英文版)

With the accelerated aging society in China, the incidence of biliary surgical diseases in the elderly has increased significantly. The clinical characteristics of these patients indicate that improving treatment outcomes and realizing healthy aging are worthy of attention. How to effectively improve the treatment effect of geriatric biliary surgical diseases has attracted widespread attention. This paper reviews and comments on the hotspots and difficulties of biliary surgery in older patients from six aspects: (1) higher morbidity associated with an aging society, (2) prevention and control of pre-operative risks, (3) extending the indications of laparoscopic surgery, (4) urgent standardization of minimally invasive surgery, (5) precise technological progress in hepatobiliary surgery, and (6) guarantee of peri-operative safety. It is of great significance to fully understand the focus of controversy, actively make use of its favorable factors, and effectively avoid its unfavorable factors, for further improving the therapeutic effects of geriatric biliary surgical diseases, and thus benefits the vast older patients with biliary surgical diseases. Accordingly, a historical record with the highest age of 93 years for laparoscopic transcystic common bile duct exploration has been created by us recently.

Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhage

Acute hemorrhagic cholecystitis is a rare, life-threatening condition that can be further complicated by perforation of the gallbladder. We describe a patient with clinical and radiologic findings of acute cholecystitis with a gallbladder rupture and massive intra-abdominal bleeding. Our patient is a 67-year-old male who presented with an ischemic stroke and was treated with early tissue plasminogen activator. His hospital course was complicated by a fall requiring posterior spinal fusion surgery. He recovered well, but several days later developed subxiphoid and right upper quadrant pain and an episode of hemobilia and melena. A computed tomography scan revealed an inflamed, distended gallbladder with indistinct margins and a large hematoma in the gallbladder fossa extending to the right paracolic gutter. The patient also developed hemodynamic instability concerning for hemorrhagic shock. He underwent an emergent laparoscopic converted to open subtotal fenestrating cholecystectomy with abdominal washout for management of his acute hemorrhagic cholecystitis with massive intra-abdominal hemorrhage. Prompt recognition of this lethal condition in high-risk patients is crucial for optimizing patient care.

Guidelines for diagnosis and treatment of acute biliary tract infections(2021) / 中华外科杂志

To further improve the standard of diagnosis and treatment of acute biliary tract infections in China, the Branch of Biliary Surgery, Society of Surgery, Chinese Medical Association has revised the guidelines for the diagnosis and treatment of acute biliary tract infections (2011).The guidelines describe the risk factors of acute biliary tract infections, propose diagnostic methods and severity classification criteria, and define the treatment of acute biliary tract infections and the standardized application of antibiotics. The treatment of acute biliary tract infection should be combined with surgical care, antimicrobial therapy and systemic management, and should be completed under the guidance of experienced surgical specialist. Reasonable selection of diagnosis and treatment measures, accurate understanding of surgical procedures and standardized use of antibiotics can achieve maximum treatment result for acute biliary tract infection.

Técnica de linfadenectomía y resección del lecho vesicular laparoscópica por cáncer vesícula biliar incidental / Lymphadenectomy technique and laparoscopic vesicular bed resection for incidental gallbladder cancer

Resumen El cáncer de vesícula es infrecuente a nivel mundial, a diferencia de su alta incidencia en Chile. Su pronóstico es malo en general, y dependerá de su forma de presentación, siendo mejor en los casos diagnosticados después de una colecistectomía laparoscópica por patología benigna. La reintervención, que incluye la resección hepática y linfadenectomía, es el pilar de la terapia curativa en esta neoplasia. Presentamos la descripción de la técnica quirúrgica realizada en los pacientes con cáncer de vesícula de diagnóstico incidental, en el Servicio de Cirugía de Clínica Alemana de Santiago y en el Hospital de la Fuerza Aérea de Chile. El abordaje laparoscópico representa una alternativa quirúrgica válida en el tratamiento de pacientes con cáncer de vesícula biliar diagnosticados después de la colecistectomía. La estandarización de la técnica debiera contribuir a su mayor empleo y a la obtención de buenos resultados desde un punto de vista oncológico.

Gallbladder cancer is considered an infrequent disease but in Chile has a higher incidence. Prognostic is considered dismal except in those patients in whom the diagnosis is performed after the cholecystectomy specimen study. Reoperation with gallbladder bed resection and lymphadenectomy is considered the treatment in patients with incidental cases. We show the way this operation is performed in Clinica Alemana of Santiago and in the Air Force Hospital. The laparoscopic approach is an alternative to those patients in whom the diagnosis was done after the cholecystectomy. Laparoscopy allows to accomplish same objectives and to obtain identical results that the open approach. The technical standardization should contribute to spread its employment and to improve the results.

Choledochal cysts in children: How to Diagnose and Operate on

OBJECTIVE: To identify the best mode for diagnosing and treating the patients with choledochal cysts. METHODS: A retrospective study was performed with medical records of patients diagnosed with choledochal cysts from January 1994 to December 2017. In all cases, the diagnosis was based on ultrasound examination. All the patients underwent cyst resection and were divided in two groups: bile enteric anastomosis in the high portion of the common hepatic duct or in the dilated lower portion. RESULTS: Eighty-one cases were studied. The age of presentation was 4 y 2 mo ± 4 y 1 mo, and the age for the surgical treatment was 5 y 5 mo ± 4 y 6 mo. In 61 cases, US was the only image examination performed. There were 67 cases of Todani type I (82.7%), 13 cases of type IV (16.0%) and one case of type III (1.2%). Nine patients (29.0%) in the first period and 2 patients (4.0%) in the second period presented with postoperative complications (p=0.016). CONCLUSION: In patients with choledochal cysts, US is the only necessary diagnostic imaging. Performing the bile enteric anastomosis in the lower portion of the common hepatic duct is safer and has a lower risk of complications.

Resultados iniciales de un programa de cirugía hepato-bilio-pancreática laparoscópica en el Hospital Regional de Talca / Initial results of a laparoscopic hepato-biliary-pancreatic surgery program at the Regional Hospital of Talca

Resumen Introducción: La cirugía laparoscópica es la vía de abordaje de elección para el tratamiento de múltiples patologías abdominales, sin embargo, su desarrollo en la cirugía hepato-bilio-pancreática (HBP) ha sido más lento y heterogéneo. Objetivo: Presentar los resultados de la implementación y desarrollo de un programa de cirugía HBP laparoscópica en el Hospital de Regional de Talca. Materiales y Método: Estudio de serie de casos que incluye a todos los pacientes operados por una patología HBP por vía laparoscópica como acceso a la cavidad abdominal en el Hospital Regional de Talca entre el 1 de junio de 2014 y el 30 de junio de 2016. Resultados: Fueron 42 pacientes, 25 (59,5%) de sexo femenino. La mediana de edad fue 58 años (IQ25-75 38-64 años). 22 (52,4%) tuvo una cirugía abdominal previa en la mayoría de ellos por vía abierta. 22 (52,4%) pacientes fueron intervenidos por patología maligna. La indicación más frecuente fue la cirugía radical por cáncer de vesícula biliar en 10 (23,8%) casos y la hidatidosis hepática (HH) en 7 (16,7%). 1 (2,4%) paciente portador de una HH requirió de una conversión a laparotomía. 5 (11,9%) presentaron alguna morbilidad posoperatoria, 2 de ellos > III de Clavien. La mediana de recuperación funcional fue de 1 día (1-2) y la de estadía posoperatoria de 3 días (3-4). No hubo mortalidad a 90 días. Con una mediana de seguimiento de 26,5 (18-33) meses, 4 (19%) de los 21 pacientes oncológicos intervenidos con intención curativa presentaron recurrencia de la enfermedad, la mayoría de ellos sistémica y el 95% está libre de recurrencia a los 24 meses. Conclusiones: La implementación y el desarrollo de la cirugía hepato-bilio-pancreática (HBP) por vía laparoscópica puede efectuarse en hospitales de referencia regional con los mismos estándares y resultados internacionales.

Introduction: Laparoscopic surgery is the preference access for the treatment of various abdominal pathologies, however, its development in hepato-biliary-pancreatic (HBP) surgery has been slower and heterogeneous. Aim: Present the results of the implementation and development of a laparoscopic HBP surgery program at the Regional Hospital of Talca. Materials and Method: Case series study in which were included all patients submitted to laparoscopic surgery for treatment of HPB pathology as access to the abdominal cavity in the Regional Hospital of Talca between June 1, 2014 and June 30, 2016. Results: There were 42 patients, 25 (59.5%) female. The median age was 58 years (IQ25-75 38-64 years). 22 (52.4%) had previous abdominal surgery in most of them by open route. 22 (52.4%) patients were operated on for malignant pathology. The most frequent indication was radical surgery for gallbladder cancer in 10 (23.8%) cases and hepatic hydatidosis (HH) in 7 (16.7%). 1 (2.4%) patient carrying a HH required a conversion to laparotomy. 5 (11.9%) presented some postoperative morbidity, 2 of them > Clavien III. The median functional recovery was 1 day (1-2) and the postoperative stay was 3 days (3-4). There was no mortality at 90 days. With a median follow-up of 26.5 (18-33) months, 4 (19%) of the 21 oncological patients operated on with curative intent presented recurrence of the disease, most of them systemic and 95% free from recurrence at 24 months. Conclusions: Implementation and development of HBP surgery by laparoscopy is feasible and it can be performed in regional referral hospitals with the same international standards and results.

A consensus statement on the standardized application of antibacterial agents in biliary tract surgery (2019) / 中华外科杂志

The standardized application of antibacterial agents in the treatment of biliary tract diseases is of great significance.On the basis of international and domestic guidelines and consensuses, combining with the actual situation of Chinese biliary tract infection, Study Group of biliary Tract Surgery in Chinese Society of Surgery of Chinese Medical Association and Enhanced Recovery After Surgery Committee of Chinese Research Hospital Association and Editorial Board of Chinese Journal of Surgery organized experts to make recommendations which adopted a problem-oriented approach on the severity grade of biliary tract infection, the protocol of specimen examination, the use of antibiotics, the indication of drug withdrawal, the agents application strategy of drug-resistant bacteria infection and special situation to guide surgeons getting the accurate judgement of the severity of biliary tract infection and the formulation of standard protocols for the use of antibacterial agents on the premise of following the bacteriological and drug resistance monitoring information.

Detalles técnicos de la doble anastomosis hepático-yeyuno en Y de Roux, con base en la descripción de un caso / Technical details of double Roux-en-Y hepaticojejunostomy based on a clinical case description

La anastomosis hepático-yeyuno en Y de Roux se considera la técnica de elección para tratar lesiones quirúrgicas de la vía biliar, como su sección o resección. La pérdida de confluencia de los conductos hepáticos principales derecho e izquierdo es uno de los factores que incrementan la complejidad técnica durante el procedimiento y, en algunos de estos pacientes, se requiere una doble anastomosis hepático-yeyuno para garantizar resultados satisfactorios a largo plazo. Se describen los aspectos técnicos y los resultados posoperatorios del tratamiento quirúrgico empleado, con base en la intervención de una paciente con una lesión quirúrgica de la vía biliar y pérdida de la confluencia de los conductos hepáticos. La evolución de la paciente fue satisfactoria y se mantiene asintomática después de 12 meses de seguimiento. A pesar de ser una técnica compleja, la doble anastomosis hepático-yeyuno en Y de Roux resultó una opción segura de tratamiento en esta paciente

Roux-en-Y hepato-jejunostomy (RYHJ) is the technique of choice for the surgical treatment of bile duct injuries (BDI), such as section or resection. The loss of the hepatic confluence (LHC) increases the technical difficulties during the procedure and, in some of these patients, a doble-RYHJ is required to achieve a long term successful result. We report the technical aspects of the surgical technique as well as the results, based on the case of a young female patient with BDI and LHC. The patient shows a satisfactory evolution and remains asymptomatic during the 12 months of follow up. Double RYHJ, although technically demanding, resulted a safe option for treating this patient

The “Bilio-Papillary Z Line”: Proposal for a Novel Quality Indicator of Direct Cholangioscopy

No abstract available.

Drenaje biliar transparietohepático: experiencia en el Hospital Universitario y Centro Médico de Caracas / Transhepatic Biliary Drainage: University Hospital and Medical Center of Caracas experience

Introducción: El drenaje biliar transparietohepático (DTPH) es un procedimiento terapéutico, temporal o definitivo, mediante el cual se cateteriza la vía biliar para descomprimirla. Indicaciones: Imposibilidad de resolver la patología biliar por otros métodos (CPRE), tratar la vía biliar en anastomosis bilioentéricas (estenosis), localización y tratamiento de fístulas biliares o patología maligna. Objetivos: Evaluar la experiencia de la Unidad de Radiología Intervencionista del Hospital Universitario de Caracas (HUC) y Centro Medico de Caracas (CMC) en el manejo de DTPH. Método: Estudio retrospectivo, analítico, de corte transversal, con muestreo no probabilístico e intencional. Se procesó estadísticamente la casuística obtenida de la combinación de pacientes atendidos en el CMC entre 2002 y 2017, y en el HUC entre 2010 y 2017, en una población de 528 pacientes, de los cuales 174 fueron reintervenidos, para un total de 702 casos de ambas instituciones. Se utilizó el equipo de arco en "C" fluoroscopia. Se procesaron datos en IBM SPSS 22.0. Resultados: 702 casos, promedio de edad 54±2. El 58,7 %, mujeres (n = 310). Principal incidencia de etiología de patología maligna n = 329 pacientes (62,3 %), seguido por patología benigna encabezada por estenosis posquirúrgica biliodigestiva en n = 191 pacientes (36,1 %). La patología maligna en mayor porcentaje la constituye el ADC de páncreas con n = 156 (29,5 %). En los procedimientos realizados se obtuvo un mayor porcentaje de drenaje interno-externo 48 % (n = 254).Conclusiones: El DTPH constituye una técnica efectiva con poco índice de complicaciones para tratamiento de ictericia obstructiva. La experiencia evaluada ha resultado estadísticamente óptima con buenos resultados.

Introduction: Biliary transparietohepatic drainage (BTHD) is a therapeutic element, temporary or definitive, through which the biliary path is accessed, being able toleave a catheter to decompress it. Indications: Impossibility of resolving biliary pathology by other methods (ERCP), treating the biliary tract in biliary-enteric anastomosis (stenosis), location and treatment of biliary fistulas or malignant pathology. Objectives: evaluate the experience of the interventional radiology unit of the University Hospital of Caracas (UHC) and Medical Center of Caracas (MCC) in the management of BTHD. Method: Retrospective, descriptive, cross-sectional study, with non-probabilistic and intentional sampling. The casuistry from the combination of patients in MCC period 2002 to 2017, and UHC from 2010 to 2017 was statistically processed. 528 patients were obtained, of which 174 were operated on, making 702 cases performed in both institutions. Arc equipment fluoroscopy was used. Data was processed in IBM SPSS 22.0. Results: 702 cases, average age 54 ± 2. 58.7% of female patients n = 310. Main incidence of malignant pathological etiology n = 329 patients (62.3%), followed by benign pathology headed by postsurgical stenosis of biliodigestive in n = 191 patients (36.1%). The malignant pathology with highest percentage is pancreatic ADC with n = 156 (29.5%). Procedures performed obtained a greater percentage of internal external drainage 48% n = 254. Conclusions: BTHD is an effective technique with a low rate of complications for the treatment of obstructive jaundice. Our experience has been statistically optimal with good results.

Intrahepatic, Perihilar and Distal Cholangiocarcinoma: Management and Outcomes

Abstract: Introduction and aims. Cholangiocarcinomas are a heterogeneous group of tumors that can be classified into three clinically distinct types of cancers, intrahepatic, perihilar and distal cholangiocarcinoma. The inconsistent use of nomenclature for these cancers has obscured a true knowledge of the epidemiology, natural history and response to therapy of these cancers. Our aims were to define demographic characteristics, management and outcomes of these three distinct cancer types. Materials and methods. A retrospective study of patients enrolled in an institutional cancer registry from 1992 to 2010. Median survival was compared between different treatment modalities over three time periods for the three types of cholangiocarcinoma at different stages of the disease using Kaplan Meyer analysis. Results. 242 patients were identified. All cases were reviewed and classified into intrahepatic (90 patients), distal (48 patients) or perihilar (104 patients) cholangiocarcinomas. These cancers differed in median age of onset, gender distribution, median survival and stage. 13.8% of patients presented with stage I, 5.8% with stage II, 9.6% with stage III, 28% with stage IV, with 41.8% having unknown stage. The overall median survival was 15.8 months, and was 23, 25, 14, and 4.5 months for stages I, II, III, and IV respectively. Surgery improved survival in both early and advanced stages. Multimodality therapies further improved outcomes, particularly for perihilar cholangiocarcinoma. Conclusion. Perihilar, distal and intrahepatic cholangiocarcinoma vary in their presentation, natural history and therapeutic approach to management. A consistently applied classification is essential for meaningful interpretation of studies of these cancers.

Conducto subvesicular, nomenclatura anatómica para el conducto de Luschka y su importancia clínica. Revisión de tema / Subvesical Ducts, the Anatomical Nomenclature for the Bile Ducts of Luschka and its Clinical Importance. Topic Review

Introducción: El conducto subvesicular fue descrito por Hubert Luschka como pequeños ductos biliares derivados de la pared de la vesícula biliar. Algunos autores lo describen como un ducto que lleva el drenaje desde el parénquima hepático hasta la vesícula, otros utilizan el término describiéndolo como un conducto que drena desde el parénquima hepático hasta las vías biliares extrahepaticas. Se planteó una revisión bibliográfica de la descripción anatómica del epónimo conducto de Luschka y de la terminología anatómica propuesta conducto subvesicular o subvesical, dada su importancia clínica como causa de fuga biliar. Metodología: Se realizó una revisión bibliográfica en bases de datos y bibliotecas electrónicas. Con ventana de tiempo personalizada desde 2006 hasta 2016, se obtuvo un total de 82 artículos, posteriormente se realizó un resumen analítico especializado, seleccionando un total de 46. Resultados: No se encontró consenso en la descripción anatómica del epónimo, ni en la descripción de la terminología internacional. Las lesiones de la vía biliar durante la colecistectomía se presentan como una complicación poco frecuente (0.1 - 1.5%); sin embargo, tienen repercusiones en varios ámbitos y una morbi-mortalidad considerable. Conclusiones: Se evidenció discrepancia en la nomenclatura utilizada para la descripción de estos conductos, puesto que se denomina de manera indiscriminada como conducto de Luschka a todos los ductos biliares que se encuentran en la fosa biliar. La relevancia clínica radica en que es la segunda causa de fuga biliar iatrogénica y la asociación entre el conducto subvesical y carcinomas ductales. Aún se necesitan más estudios principalmente locales para identificar su incidencia y prevenir complicaciones...(AU)

Introduction: The duct was described by Hubert Luschka as small bile ducts derived from the wall of the gallbladder. Some authors describe it as a duct leading to drainage from the hepatic parenchyma to the gallbladder; others use the term to describe it as a conduit draining from the hepatic parenchyma to the extrahepatic bile ducts. This article presents a literature review of the anatomical description of the eponymous Luschka conduit and the proposed anatomical terminology subvesicular or subvesical conduit, given its clinical importance as a cause of biliary leakage. Methodology: A bibliographic review was carried out in databases and electronic libraries. With a customized time window from 2006 to 2016, obtaining a total of 62 articles, a specialized analytical summary was subsequently performed, selecting a total of 46. Results: No consensus was found in the anatomical description of the eponym, nor in the description of the International terminology. Lesions of the biliary tract during cholecystectomy present as a rare complication (0.1 - 1.5%) but have repercussions in several areas and considerable morbidity and mortality. Conclusions: There was a discrepancy in the nomenclature used for the description of these ducts. It is indiscriminately named as the luschka's conduit for all bile ducts found in the biliary fossa. The clinical relevance is that it is the second cause of iatrogenic biliary leakage and the association between the subvesical duct and ductal carcinomas. More local studies are still needed to identify its incidence and prevent complications...(AU)

Introdução: O ducto subvesicular foi descrito por Hubert Luschka como pequenos ductos biliares derivados da parede da vesícula biliar. Alguns autores descrevem isso como um ducto que leva a drenagem do parênquima hepático para a vesícula biliar, outros usam o termo para descrevê-lo como um canal que drena do parênquima hepático para os ductos biliars extra-hepáticos. Foi proposta uma revisão bibliográfica da descrição anatômica do canal epônimo de Luschka e da derivação anatômica proposta subvesicular ou subvesical, dada sua importância clínica como causa de vazamento biliar. Metodologia: foi realizada uma revisão bibliográfica em bancos de dados e bibliotecas eletrônicas. Com uma janela de tempo personalizada de 2006 a 2016, foi obtido um total de 82 artigos, seguido de um resumo analítico especializado, selecionando um total de 46. Resultados: Nenhum consenso foi encontrado na descrição anatômica do epônimo, nem na descrição da terminologia internacional. As lesões do trato biliar durante a colecistectomia apresentam-se como uma complicação rara (0.1 ­ 1.5%); no entanto, têm repercussões em várias áreas e considerável morbidade e mortalidade. Conclusões: houve uma discrepância na nomenclatura utilizada para a descrição desses ductos, uma vez que é indiscriminadamente referido como o canal de Luschka a todos os canais biliares encontrados na fossa biliar. A relevância clínica é que é a segunda causa de vazamento biliar hepático e a associação entre ducto subvesical e carcinomas ductais. Mais estudos locais ainda são necessários para identificar sua incidência e prevenir complicações...(AU)

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.

Vesícula biliar a la izquierda del ligamento falciforme en ausencia de situs inversus: 'sinistraposición' / Gall bladder located to the left of the falciform ligament without situs inversus: "sinistraposition"

La vesícula biliar ubicada a la izquierda del ligamento falciforme, en ausencia de situs inversus, también denominada 'sinistraposición', es una rara anomalía anatómica. Aunque es poco frecuente, se considera importante que todo cirujano se familiarice con este hallazgo, ya que la cirugía puede convertirse en un verdadero desafío técnico. En varios informes de casos, se ha documentado el manejo seguro de la 'sinistraposición' cuando es hallada de forma incidental durante una colecistectomía laparoscópica convencional. Así pues, este procedimiento puede practicarse de forma segura, aunque la lesión de la vía biliar no es inusual, dado que la asociación de estos casos a anomalías del árbol biliar y de la vena porta intrahepática no es despreciable. En el presente artículo se presenta el caso de un paciente con colelitiasis sintomática y ecografías que no reportaron la posición anómala de la vesícula biliar. Fue sometido a colecistectomía laparoscópica programada, en la cual se encontró una vesícula biliar ubicada en el segmento III del hígado, aparentemente no asociada a otras alteraciones biliares extrahepáticas. El procedimiento se realizó por vía laparoscópica multipuerto, sin complicaciones para el paciente, quien hasta el momento se encuentra asintomático.

The gallbladder located to the left of the falciform ligament in absence of situs inversus, called sinistraposition, is a rare anatomic anomaly. Although infrequent, it is important that surgeons become familiar with this finding, for surgery can become a real technical challenge. Several case reports have documented the safe handling of sinistraposition when found incidentally during conventional laparoscopic cholecystectomy. We report the case of patient with asymptomatic cholecystectomy and ultrasound echography that did not report the anomalous location of the gallbladder. Elective laparoscopic cholecystectomy was performed, encountering a gallbladder located in the segment III of the liver, with no apparent associated extrahepatic biliary anomalies. The procedure was carried out by a multiport approach, without complications, and so far the patient is asymptomatic.

Primeras experiencias con drenaje biliar percutáneo de urgencia en la colangitis aguda / First experiences in performing urgent percutaneous biliary drainage for acute cholangitis

Introducción: la obstrucción biliar es motivo frecuente de morbilidad en los pacientes con metástasis hepáticas, adenopatías periportales y cáncer hepatobiliopancreático. La colangitis aguda es la complicación más temida, debido a su mortalidad. En este trabajo se presentan los primeros abordajes percutáneos realizados por cirujanos del Hospital Clínicoquirúrgico Hermanos Ameijeiras como herramienta para el tratamiento urgente de esta entidad. Objetivo: caracterizar el drenaje percutáneo transparietohepático de urgencia en pacientes con colangitis aguda e ictericia obstructiva. Métodos: se realizó un estudio descriptivo, prospectivo y aplicado con 30 pacientes atendidos de esta forma en dicha institución entre enero de 2008 y diciembre de 2010. Resultados: el diagnóstico etiológico preponderante fue el de tumor maligno de la cabeza del páncreas. La localización baja de la lesión duplicó a la localización alta. La mejoría clínica de la ictericia se evidenció en la mayoría de los pacientes después de una semana tras el procedimiento: el drenaje percutáneo constituyó el método definitivo en el 73,3 por ciento de los pacientes. Las edades medias para los distintos diagnósticos etiológicos exhibieron diferencias estadísticamente significativas. No hubo complicaciones ni mortalidad relacionadas con el procedimiento. Conclusiones: el drenaje biliar percutáneo guiado por ultrasonido es una herramienta útil y segura para el tratamiento de urgencia de la colangitis aguda. Es un método que pueden realizar los cirujanos generales con entrenamiento adecuado y específico, y tiene asociadas pocas complicaciones(AU)

Introduction: bile duct obstruction is a frequent source of morbidity among patients with liver metastasis, periportal lymph nodes and hepatobilopancreatic cancer. Acute cholangitis is the most feared complication because of its mortality. The present paper showed the first percutaneous approaches performed by surgeons in Hermanos Ameijeiras clinical and surgical hospital as a tool for treatment of this urgent complication. Objective: to characterize the urgent transparietohepatic bile drainage performed on patients with acute cholangitis and obstructive jaundice. Methods: this is a prospective, descriptive and applied study with 30 patients cared for in this institution from January 2008 through December 2010. Results: the most frequent etiology was malignancy of the pancreas head; the lower location of the lesion doubled the upper location. Most of the patients clinically improved their jaundice problems after one week of procedure. The percutaneous drainage was the definitive procedure in 73.3 percent of patients. Average ages for the various etiologic diagnoses showed statistically significant differences. There were no complications or death related with the procedure. Conclusions: US-guided percutaneous biliary drainage is a safe useful tool for the urgent treatment of acute cholangitis, it can be performed by general surgeons with specific adequate training and has few associated complications(AU)

Vigencia de la cirugía biliar abierta / Validity of open biliary surgery

En la actualidad, en la formación de los cirujanos en cirugía biliar se ha verticalizado el entrenamiento en colecistectomía laparoscópica, minimizando la formación en cirugía abierta, necesaria por la posibilidad de la conversión quirúrgica y por la presencia de casos complejos. El objetivo de este artículo es presentar una discusión científica sobre la importancia de la formación en cirugía biliar compleja, sobre la base de una situación clínica específica: una paciente con antecedentes de una cirugía compleja en el abdomen superior que consistió en la resección hepática y la reparación de la aorta abdominal, el duodeno y el estómago. La paciente presentó una litiasis biliar complicada, situación que obligó a la intervención abierta, con la cual se obtuvo un resultado satisfactorio. La colecistectomía videolaparoscópica es un procedimiento seguro y eficaz en las colecistopatías litiásicas y alitiásica, y la colecistectomía abierta o tradicional queda como alternativa de la primera, pero es indispensable un entrenamiento básico formativo en ella, no solo por una potencial conversión quirúrgica, sino por la posibilidad de encontrar situaciones como la aquí presentada.

At present times, the formation of surgeons in the field of biliary surgery has increased training in laparoscopic cholecystectomy and reduced training in open surgery which is necessary for the surgical conversion possibilities and the presence of complex cases. The objective of this article was to present a scientific discussion about the importance of the formation of specialists in complex biliary surgery, on the basis of a specific clinical case. This is the case of a woman with a history of complex upper abdomen surgery comprising liver resection and repair of the abdominal aorta, the duodenum and the stomach. The patient presented with complicated biliary lithiasis that forced the physicians to perform open biliary surgery; the result was satisfactory. Laparoscopic cholecystectomy is a safe and effective procedure in lithiasis and alithiasis cholecystopathy whereas open or traditional cholecystectomy remains as an alternative to the former. However, it is indispensable to provide basic formative training in open cholecystectomy, not only because of potential surgical conversion but because of likelihood of situations similar to the one presented here.

Drenagem biliar na paliação dos tumores malignos da confluência biliopancreática: estudo comparativo das abordagens cirúrgica e endoscópica ecoguiada / Biliary drainage in the palliative management of malignant tumors in the biliopancreatic junction: a comparative study of surgical and endosonography-guided approaches

Introdução: A maioria dos pacientes acometidos pela neoplasia que envolve a confluência biliopancreática é diagnosticada em fase avançada. A Colangiopancreatografia Retrógrada Endoscópica (CPRE) é o método de escolha para a drenagem da via biliar obstruída. Todavia, existe um índice de insucesso em torno de 10%. Nesses casos, técnicas alternativas serão aplicadas, como drenagem percutânea trans-hepática e drenagens cirúrgicas. Objetivo: Avaliar o sucesso técnico, clínico, qualidade de vida e sobrevida da drenagem biliar pela cirurgia convencional e técnica endoscópica ecoguiada em pacientes portadores de neoplasia maligna da confluência biliopancreática. Método: No período de abril de 2010 a setembro de 2013, foram estudados 32 pacientes portadores de neoplasia maligna da confluência biliopancreática. Todos os que foram incluídos nesse estudo apresentaram falha na drenagem biliar por CPRE. Três deles foram excluídos por insucesso técnico (falha na confecção da anastomose hepaticojejunal e da formação da fístula coledocoduodenal ecoguiada). O Grupo I foi formado por 15 pacientes submetidos à Hepaticojejunostomia (HJT) em "Y" de Roux e derivação gastrojejunal. O Grupo II foi formado por 14 pacientes submetidos à coledocoduodenostomia ecoguiada (CDT). O sucesso clínico foi avaliado pela queda da bilirrubina sérica total em mais de 50% nos sete primeiros dias após o procedimento. A qualidade de vida foi avaliada pelo questionário SF-36 e a sobrevida pela curva de Kaplan-Meier. Resultados: O sucesso técnico foi de 93,75% (15/16) no Grupo I e de 87,5% (14/16) no Grupo II (p = 0,598). O sucesso clínico ocorreu em 14 (93,33%) pacientes pertencentes ao Grupo I e em 10 (71,43%) do Grupo II. Não houve diferença estatisticamente significativa (p = 0,169). O comportamento médio dos escores de qualidade de vida foi estatisticamente igual entre as técnicas ao longo do seguimento (p > 0,05 Técnica * Momento). Houve alteração média estatisticamente significativa ao...

Introduction: Most patients with neoplasm in the biliopancreatic junction are diagnosed at an advanced stage. Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage of obstructed biliary tract. However, there is a failure rate of about 10%. In such cases, alternative techniques, such as, percutaneous transhepatic drainage and surgical drainage are applied. Aim: To evaluate the technical and clinical success, quality of life and patient survival of biliary drainage by conventional surgery and endosonography-guided technique in patients with malignant neoplasm of the biliopancreatic junction. Methodology: From April 2010 to September 2013, 32 patients with malignant neoplasm of the biliopancreatic junction were studied. All patients included in this study had failed biliary drainage by ERCP. Three patients were excluded due to technical failure (failure in the construction of hepatico-jejuno anastomosis and formation of endosonography-guided choledochoduodenal fistula). Group I comprised of 15 patients who underwent Roux-en-Y hepaticojejunostomy (HJT) and gastrojejunal bypass. Group II consisted of 14 patients who underwent endosonography-guided choledochoduodenostomy (CDT). Clinical success was assessed by the decrease of more than 50% in total serum bilirubin in the first seven days after the procedure. Quality of life was assessed by SF-36 questionnaire and survival by Kaplan-Meier curve. Results: Technical success rate was 93.75% (15/16) in group I and 87.5% (14/16) in group II (p = 0.598). Clinical success occurred in 14 (93.33%) patients in group I and 10 (71.43%) patients in group II. There was no significant statistically difference (p = 0.169). The average quality of life score were statistically equal between the techniques during follow-up (p > 0.05 * Technical Moment). There were statistically significant mean changes during follow-up of functional capacity score, physical health, pain, social...