Estudio complementario de la patología biliar complicada y el manejo de la litiasis coledociana en dos tiempos / Complementary evaluation of complicated gallstone disease and two-stage management of choledochal lithiasis

RESUMEN Antecedentes: la litiasis biliar tiene una prevalencia actual en Occidente del 10-20%. El 7-16% de los pacientes presentan también coledocolitiasis. El diagnóstico preoperatorio de coledocolitiasis es difícil de establecer. Objetivo: establecer nuestra experiencia en el estudio de la patología biliar complicada y el manejo de la coledocolitiasis en dos tiempos, como terapéutica de elección. Material y métodos: estudio prospectivo, observacional. Pacientes con patología biliar sometidos a procedimientos en el Servicio de Cirugía General del Hospital Vidal, desde el 30/06/2019 al 30/12/2019. Resultados: la ecografía hepato-bilio-pancreática (HPB) es específica, con exactitud del 80,9% y sensibilidad del 50%. La colangio resonancia magnética (CRNM) es 100% específica, tiene exactitud del 84,6% y sensibilidad de 67%. La colangio pancreatografía retrógrada endoscópica (ERCP -por sus siglas en inglés-), durante la primera colangiografía mostró en el 100% litiasis coledociana, pero, luego del tratamiento, la colangiografía de "control" muestra 0% de sensibilidad, 100% especificidad, con exactitud del 15,4%. En los hallazgos intraoperatorios, el cístico dilatado en asociación con alteraciones humorales ha demostrado una sensibilidad del 100%, especificidad del 90% y tasa de exactitud de 93,6%. Conclusión: la colangiografía intraoperatoria (CIO) es el procedimiento de referencia ("gold standard") en el abordaje de la patología biliar complicada, siendo su uso sistemático. La asociación entre alteraciones de parámetros humorales y el cístico dilatado resulta un parámetro con alto valor predictivo para la presencia de litiasis coledociana.

ABSTRACT Background: Nowadays, the prevalence of gallstones ranges between 10 and 20% in Western world, and 7-16% of the patients also present choledocholithiasis. The preoperative diagnosis of choledocholithiasis is difficult. Objective: To establish our experience in the evaluation of complicated gallstone disease and two-stage management of choledochal lithiasis as standard or care. Material and methods: This prospective and observational study included patients hospitalized with gallstone disease undergoing procedures in the Department of General Surgery of Hospital Vidal from June 30, 2019, to December 30, 2019. Results: Ultrasound of the liver, biliary tract and pancreas was specific, with accuracy of 80.9% and sensitivity of 50%. Magnetic resonance cholangiopancreatography (MRCP) had a sensitivity of 100%, accuracy of 84.6% and sensitivity of 67%. As for endoscopic retrograde cholangiopancreatography (ERCP), the diagnosis of choledocholithiasis was made in 100% of the cases during the first cholangiography while "control" cholangiography had a sensitivity of 0%, specificity of 100% and accuracy of 15.4%. The presence of a dilated cystic duct intraoperatively in association with abnormal biochemical parameters had a sensitivity of 100%, specificity of 90%, and accuracy of 93.6%. Conclusion: Intraoperative cholangiography (IOC) is the gold standard procedure for the management of complicated gallstone disease. The association of biochemical parameters and a dilated cystic duct has high predictive value for choledochal lithiasis.

Litiasis coledociana: resultados de la colangiografa intraoperatoria en nuestro medio / Choledocholithiasis: results of the intraoperative cholangiography in our community

The term choledocholithiasis refers to a condition when a gallstone or gallstones become lodged within any duct of the bile system. We can find pigment gallstones, cholesterol gallstones and mixed. During surgery to remove the gallbladder you may have a procedure called intraoperative cholangiogram to look for gallstones that may be in the common bileduct. Stones in the bile ducts are classified as either primary (arising the novo), secondary (migrating from the gallbladder), recurrent (reforming after biliary tract surgery) or retained (overlooked at the time of surgery). The prevalence of choledocholithiasis in patients with simptomatic gallbladder lithiasis can be a reason for enlargement of the hospital stay, and eventually in the complexity on the prevented surgical procedure. Our aim was to investigate its prevalence in our Hospital, and the results with the empoyement of the intraoperative cholangiography accordin to our surgical protoco, and the recognized guideliness from other Centers. The results obtained are discused

Innovative hybrid technique for bile duct exploration in the treatment of choledocholithiasis

Introduction: Common bile stone disease (CBDS) is frequent and has potentially severe complications, such as acute biliary pancreatitis and cholangitis. Unnecessary and unplanned procedures should be avoided, so before choosing the best treatment of common bile duct lithiasis it is essential to have a proper diagnose. CBDS is currently treated by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic bile duct exploration (LCBDE). Results: The aim of this article is to present an innovative hybrid technique for common bile duct exploration, as an option for cases where the laparoscopic approach is not resolutive, avoiding the need for conversion to open approach technique. Conclusions: The hybrid technique has the same benefits as open and laparoscopic techniques, but without increasing material costs and with good resolution in complex cases of common bile duct stones. (AU)

Colangiopancreatografía retrógrada endoscópica en gestante de 35, 4 semanas con colangitis por litiasis coledociana / Endoscopic retrograde cholangiopancreatography in 35.4-weeks pregnant women with cholangitis caused by choledocholithiasis

La colangitis aguda puede definirse como el síndrome caracterizado por signos y síntomas de infección sistémica con origen en el árbol biliar. Se produce por la presencia de bacterias en la bilis junto a un aumento de la presión intrabiliar por una obstrucción, siendo la coledocolitiasis la causa más frecuente. El tratamiento de esta entidad se basa en la combinación del drenaje biliar y la administración de antibióticos. Esta entidad infrecuente en gestantes, aparece en una gestante con 35,4 semanas de gestación, que llega a la institución de salud por fiebre referida, vómitos, dolor epigástrico e íctero, se le realiza ultrasonido abdominal constatando dilatación de vía biliar y leucograma alterado con predominio de los segmentados, con stab y gránulos tóxicos; lo cual permite realizar diagnóstico de colangitis. Se realizó una colangiopancreatografía retrógrada endoscópica mediante la técnica convencional, con la paciente en decúbito lateral izquierdo oblicuo. Se utilizó arco en C y las imágenes fueron interpretadas por el endoscopista, con un mínimo de radiación. Se realizó canulación selectiva de la vía biliar y opacificó, observando dilatación de las vías biliares intrahepáticas, colédoco dilatado de 15mm, en cuyo interior se observa defecto de lleno ovoide. Se realizó esfinterotomía amplia y se extrajo cálculo pardo de 1cm de diámetro y varios litios pequeños, acompañados de abundante contenido biliar y pus blanquecino. Posterior a la colangiopancreatografía retrógrada endoscópica la paciente evoluciona de forma satisfactoria.

Acute cholangitis may be defined as the syndrome characterized by signs and symptoms of systemic infection originated in the biliary tree). The presence of bacteria in the bile together with the increment of the intra-biliary pressure due to an obstruction produces it; choledocholithiasis is the most frequent cause. The treatment of this entity is based on the combination of the biliary drainage and antibiotics administration. This entity, infrequent in pregnant women, appears in a pregnant woman with 35.4 weeks of pregnancy, who visited the health institution referring fever, vomits, epigastric pain and jaundice. An abdominal ultrasound showed biliary way dilatation and the leukogram was altered with predominance of the segmented ones, stab and toxic granules, allowing arriving to the diagnosis of cholangitis. An endoscopic retrograde cholangiopancreatography was carried out using the conventional technique, with the patient in oblique right lateral decubitus. An arc in C was used and the endoscopist interpreted the obtained images; with a minimum radiation, a selective cannulation of the biliary way was made and made it opaque, observing dilatation of the intra-hepatic biliary ways, dilated common bile duct of 15 cm. Inside it, it was observed an ovoid defect of filling; a wide sphincterotomy was developed and a brown calculus of 1 cm of diameter and several little ones, accompanied by abundant biliary substance and whitish pus were extracted. After the endoscopic retrograde cholangiopancreatography the patient had a satisfactory evolution.

Morbilidad postoperatoria por colangiografía endoscópica retrógrada con o sin papilotomía ulterior: serie de casos / Postoperative morbidity by endoscopic retrograde cholangiography with or without ulterior papillotomy: series of cases

La patología biliar litiásica es frecuente en nuestro país, con prevalencias entre 30% y 50%; y la ictericia obstructiva secundaria a coledocolitiasis (IOC), constituye un motivo de consulta frecuente en los servicios de urgencia. Por otra parte, la papilotomía endoscópica (PE) post colangiografía retrógrada endoscópica (CRE), constituye el tratamiento de elección en estos casos; sin embargo, es un procedimiento no exento de complicaciones. El objetivo de este estudio, es describir la MPO e identificar posibles factores de riesgo (FR) asociados a MPO, en pacientes con IOC, sometidos a PE. Serie de casos retrospectiva, de pacientes con IOC, a quienes se les realizó CRE y ulterior PE. La variable resultado fue desarrollo de MPO (hemorragia, perforación y pancreatitis). Otras variables de interés fueron canulación, dificultad de ésta, desarrollo de PE, uso de pre corte y mortalidad. La recolección de datos se realizó mediante una pauta ad-hoc, en la que se registraron las variables extraídas desde el protocolo operatorio y la ficha clínica. Se aplicó estadística descriptiva y analítica (Chi2 de Pearson y exacto de Fisher) para estimar fuerza de asociación. Se intervinieron 200 pacientes. La Media de edad fue de 60±18 años; 62% eran mujeres (n= 124). Se registró MPO en 32 casos (16,0%): Perforación (0,5%), pancreatitis (2,0%) y hemorragia (13,5%). La serie no registró mortalidad. No se logró objetivar asociación entre la variable "canulación difícil" y las variables hemorragia (p= 0,214); pancreatitis (p= 0,519); ni perforación (p= 1). Sin embargo, se verificó asociación entre el desarrollo de hemorragia y la realización de PE (p= 0,017). La hemorragia es la MPO más frecuente en esta serie; y la PE es un FR para el desarrollo de hemorragia.

Bileduct stones is prevalent in our country, with prevalences between 30% and 50%; and obstructive jaundice secondary to choledocholithiasis (OJC), is a frequent reason of consultation in emergency services. Furthermore, endoscopic papillotomy (EP) post ERCP is the treatment of choice in these cases; however, it is not free of complications (POM). The aim of this study is to describe POM and identify potential risk factors (RF) associated with POM in patients with OJC, underwent PE. Retrospective case series of patients with OJC, who underwent ERCP and subsequent PE. Outcome variable was the development of POM (bleeding, perforation, and pancreatitis). Other variables of interest were cannulation, difficulty of this, developing PE, using precut and mortality. Data collection was performed by an ad-hoc pattern in which the variables extracted from surgical protocols and clinical data were recorded. Descriptive and analytical statistics (Pearson Chi2 and Fisher's exact test) were applied to assess strength of association. 200 patients were operated. The mean age was 60±18 years; 62% were women (n = 124). MPO was recorded in 32 cases (16.0%): perforation (0.5%), pancreatitis (2.0%) and bleeding (13.5%). The series does not record mortality. It was not possible to objectify association between "difficult cannulation" and the variables bleeding (p= 0.214); pancreatitis (p= 0.519); and perforation (p= 1). However, association between bleeding and performing PE (p= 0.017) was observed. Hemorrhage is the most common cause of MPO in this series; and PE is a RF for the development of bleeding.

Clinical Features and Outcomes of Endoscopic Treatment for Stones in Stemware-Shaped Common Bile Ducts: A Multicenter Data Analysis

BACKGROUND/AIMS: Various anatomical features of the biliary tree affect ability to remove difficult common bile duct (CBD) stones. In this study, we evaluated the clinical characteristics and outcomes of the endoscopic treatment of stones in stemware-shaped CBDs. METHODS: Thirty-four patients with a stone and a stemware-shaped CBD who were treated at different tertiary referral centers from January 2008 to December 2012 were studied retrospectively. When stone removal failed, percutaneous or direct peroral cholangioscopic lithotripsy, endoscopic retrograde biliary drainage, or surgery was performed as a second-line procedure. RESULTS: The overall success rate of the first-line procedure was 41.2%. Five of the 34 patients (14.7%) experienced procedure-related complications. No procedure-related mortality occurred. Mechanical lithotripsy was required to completely remove stones in 13 patients (38.2%). Conversion to a second-line procedure was required in 20 patients (58.8%). Mechanical lithotripsy was needed in 75% and 66.7% of those with a stone size of or =1 cm, respectively. Stone recurrence occurred in two patients (9.1%) after 6 months and 27 months, respectively. CONCLUSIONS: The endoscopic treatment of stones in a stemware-shaped CBD is challenging. The careful assessment of difficult CBD stones is required before endoscopic procedures.

Bilioma espontâneo: relato de caso e revisão da literatura / Spontaneous biloma: a case report and literature review

Bilioma é qualquer coleção de bile fora das vias biliares. Geralmente, resulta de complicações cirúrgicas e trauma abdominal. A ocorrência espontânea é rara, ocasionalmente associada a coledocolitíase. Relata-se um caso de bilioma espontâneo, cujo diagnóstico foi confirmado radiologicamente. À laparotomia, observou-se bilioma retroperitoneal. A colangiografia transoperatória não evidenciou fístula. Após drenagem, o paciente teve boa evolução e alta hospitalar.

Biloma is defined as any collection of bile outside the biliary tree, usually resulting from surgery complications and abdominal trauma. Spontaneous occurrence of bilomas is rare, occasionally associated with choledocolithiasis. The present report describes a case of spontaneous biloma, whose diagnosis was radiologically confirmed. At laparotomy, the presence of a retroperitoneal biloma was observed. Intraoperative cholangiography has not demonstrated the presence of fistula. After drainage, the patient progressed well and was discharged.

Rupture of Right Hepatic Duct into Hydatid Cyst

Echinococcal disease can develop anywhere in the human body. The liver represents its most frequent location. Hepatic hydatid cysts may rupture into the biliary tract, thorax, peritoneum, viscera, digestive tract or skin. We report a rare case with rupture of the right hepatic duct into a hydatid cyst in a woman with known hydatid disease and choledocholithiasis. The increased intra-luminal pressure in the biliary tree caused the rupture into the adjacent hydatid cyst. The creation of the fistula between the right hepatic duct and the hydatid cyst decompressed the biliary tree, decreased the bilirubin levels and offered a temporary resolution of the obstructive jaundice. Rupture of a hydatid cyst into the biliary tree usually leads to biliary colic, cholangitis and jaundice. However, in case of obstructive jaundice due to choledocholithiasis, it is possible that the cyst may rupture by other way around while offering the patient a temporary relief from his symptoms.

Curso de atualização em emergências médicas: aula 20: colangite aguda: diagnóstico e terapêutica / Updating medical emergencies course: class 20: acute cholangitis: diagnostic and therapeutic

A colangite aguda corresponde à infecção ascendente das vias biliares e geralmente está relacionada com as bactérias entéricas - gram-negativas, anaeróbios e enterococos. O fator patogênico mais importante é o obstrutivo, pois a presença de bactérias na bile não é suficiente para causar infecção das vias biliares se não estiver presente o componente obstrutivo. Dentre eles, a coledocolitíase é o principal elemento em cerca de 70% a 80% dos casos. Clinicamente, a tríade clássica - febre com calafrios, dor do hipocêndrio direito e icterícia - descrita por Charcot em 1877 manifesta-se em cerca de 70% a 80% dos pacientes. A ultrassonografia abdominal (e mais raramente a colangiopancreatografia por ressonância magnética) deve ser o método de escolha, por ser hábil em detectar dilatação da via biliar acima do local da obstrução e também por poder revelar sua causa. A terapêutica da colangite bacteriana aguda deve alicerçar-se na ressuscitação volêmica, antibioticoterapia e desobstrução da via biliar com consequente drenagem, sendo esta última a pedra angular da terapia emergencial da colangite aguda, que pode ser feita por via endoscópica (CPRE) ou transparietal (PTC).

Acute cholangitis corresponds to the ascending infection of the biliary tract and is usually associated with enteric bacteria - gram-negative, anaerobes and enterococci. The most important pathogenic factor is the obstruction because the presence of bacteria in bile is not sufficient to cause infection of the biliary tract in the absence of one obstructive component. Among these, choledocholithiasis is the main element in about 70% to 80% of cases. Clinically, the classic triad - fever with chills, pain in the right hypochondrium and jaundice - described by Charcot in 1877, manifests itself in about 70% to 80% of patients. The abdominal ultrasound (and, less frequently, magnetic resonance cholangiopancreatography) should be the method of choice because it is able to detect bile duct dilation above the site of the obstruction and also to reveal its cause. The treatment of acute bacterial cholangitis must be based on fluid resuscitation, antibiotics and clearing of the bile duct with subsequent drainage, the latter being the cornerstone of emergency therapy of acute cholangitis, which can be performed endoscopically (ERCP) or transparietal (PTC).

Logros y retos de la colecistectomía laparoscópica en Cuba / Achievements and challenges of the laparoscopic cholecystectomy in Cuba

Objetivo: conocer los resultados de la generalización de la colecistectomía laparoscópica en Cuba. Métodos: se realizó un estudio retrospectivo y descriptivo a través de una encuesta completada por 16 grupos de cirugía de mínimo acceso de hospitales universitarios en 9 provincias del país para definir carácter, conversiones, conducta ante litiasis de la vía biliar, morbilidad y mortalidad perioperatoria. Resultados: se obtuvieron datos relacionados con 56 878 intervenciones realizadas, desde los inicios de la actividad en esos servicios, hasta noviembre de 2007, y se definió carácter, conversiones, conducta ante litiasis de la vía biliar, morbilidad y mortalidad perioperatoria. El acceso laparoscópico se usó en 80,7 por ciento de los casos, electivo en 97,1 por ciento, con índices de conversión de 1,4 por ciento, morbilidad de 0,58 por ciento y mortalidad de 0,10 por ciento. Predominó, ante el hallazgo de litiasis coledociana, el convertir y explorar de forma convencional. Conclusiones: los resultados de la generalización de la colecistectomía laparoscópica en Cuba son excelentes, pero es necesario extender su uso como arsenal en el tratamiento de las complicaciones de la litiasis biliar(AU)

Objective: to know the results from the standardization of the laparoscopic cholecystectomy in Cuba. Methods: a descriptive and retrospective study was conducted be means of a survey completed by 16 groups of minimal access surgery from university hospital in 9 provinces of our country to define the character, conversions, behavior in face of biliary tract lithiasis, perioperative morbidity and mortality. Results: it was possible to obtain data related to 56 878 surgical interventions performed from the onset of activity in these centers up to November, 2007 defining the character, conversions, behavior in face of a biliary tract lithiasis and perioperative morbidity and mortality. The laparoscopic approach was used in the 80,7 percent of cases, elective in the 97,1 percent, with conversion rates of 1,4 percent, morbidity of 0,58 percent and mortality of 0,10 percent. There was predominance of conversion and exploration of conventional for in face of the choledochal lithiasis finding. Conclusions: results of standardization of laparoscopic cholecystectomy in Cuba are excellent, but it is necessary to extend its use as a tool in the treatment of the biliary lithiasis complications(AU)

Microlithiasis of the gallbladder: role of endoscopic ultrasonography in patients with idiopathic acute pancreatitis / Microcolecistolitíase: papel da ecoendoscopia em pacientes com pancreatite aguda sem causa aparente

OBJECTIVES: Causes may be found in most cases of acute pancreatitis, however no etiology is found by clinical, biological and imaging investigations in 30 percent of these cases. Our objective was to evaluate results from endoscopic ultrasonography (EUS) for diagnosis of gallbladder microlithiasis in patients with unexplained (idiopathic) acute pancreatitis. METHODS: Thirty-six consecutive non-alcoholic patients with diagnoses of acute pancreatitis were studied over a five-year period. None of them showed signs of gallstones on transabdominal ultrasound or tomography. We performed EUS within one week of diagnosing acute pancreatitis. Diagnosis of gallbladder microlithiasis on EUS was based upon findings of hyperechoic signals of 0.5-3.0 mm, with or without acoustic shadowing. All patients (36 cases) underwent cholecystectomy, in accordance with indication from the attending physician or based upon EUS diagnosis. RESULTS: Twenty-seven patients (75 percent) had microlithiasis confirmed by histology and nine did not (25 percent). EUS findings were positive in twenty-five. Two patients had acute cholecystitis diagnosed at EUS that was confirmed by surgical and histological findings. In two patients, EUS showed cholesterolosis and pathological analysis disclosed stones not detected by EUS. EUS diagnosed microlithiasis in four cases not confirmed by surgical treatment. In our study, sensitivity, specificity and positive and negative predictive values to identify gallbladder microlithiasis (with 95 percent confidence interval) were 92.6 percent (74.2-98.7 percent), 55.6 percent (22.7-84.7 percent), 86.2 percent (67.4-95.5 percent) and 71.4 percent (30.3-94.9 percent), respectively. Overall EUS accuracy was 83.2 percent. CONCLUSIONS: EUS is a very reliable procedure to diagnose gallbladder microlithiasis and should be used for the management of patients with unexplained acute pancreatitis. This procedure should be part of advanced endoscopic evaluation.

OBJETIVOS: Cerca de 30 por cento dos doentes com PA rotulada como sem causa aparente apresentam colecistomicrolitíase (cálculos com até 3 mm). Não há, no momento, consenso quanto ao melhor método propedêutico para diagnosticá-lo e, entre os propostos, nenhum apresenta alta sensibilidade. A ecoendoscopia (EE) é excelente no diagnóstico da pancreatite crônica incipiente e microcálculos da vesícula biliar (MCV) ou colédoco. São poucas as referências na literatura internacional e nenhuma na nacional a respeito do emprego da EE na PA. O objetivo deste trabalho é o de estabelecer o valor da EE no diagnóstico da colecistomicrolitíase em doentes com PA sem causa aparente. MÉTODOS: Trinta e seis pacientes com o diagnóstico de PA sem causa aparente foram consecutivamente estudados durante cinco anos. Dos enviados para exame ecoendoscópico, 21 mulheres e 15 homens com média de idade de 41,6 anos. Todos haviam sido submetidos antes a pelo menos um US e uma TC, que não revelaram alterações na via bílio-pancreática e 63,9 por cento deles tinham apresentado mais de um episódio de PA. O diagnóstico da colecistomicrolitíase pela EE realizada até uma semana durante o surto de PA baseou-se no tamanho do cálculo (até 3 mm, inclusive) e hiperecogeneicidade com ou sem sombra acústica. Todos os doentes foram colecistectomizados, após o exame ecoendoscópico. RESULTADO: O exame das peças cirúrgicas mostrou que 27 (75 por cento) doentes apresentavam MCV e nove (25 por cento) não. A EE levou a erro no diagnóstico da microlitíase em seis (16,8 por cento) casos, quatro casos de falsos-positivos e dois casos de falsos-negativos. Em 30 casos (83,2 por cento) houve confirmação dos seus resultados. A sensibilidade, a especificidade, os valores preditivos positivo, negativo e a acurácia (com intervalo de confiança de 95 por cento) para a EE no diagnóstico dos MCV foram: 92,6 por cento (74,2 a 98,7 por cento), 55,6 por cento (22,7 a 84,7 por cento), 86,2 por cento (67,4 ...

Parásitos de fasciola hepática intracoledociano / Common bile duct fasciolasis: report of one case

La fasciolasis es una enfermedad parasitaria producida por el tremátodo digeneo Fasciola hepática. Durante la fase crónica de la enfermedad los parásitos pueden entran en los conductos biliares, y ser causa de ictericia obstructiva, colangitis, pancreatitis y otras complicaciones. Se presenta el caso clínico de una paciente intervenida por sospecha de colelitiasis y colédocolitiasis, a la cual durante la exploración coledociana intraoperatoria le fueron extraídos múltiples parásitos adultos de Fasciola hepática. Este hallazgo sólo fue aclarado posteriormente en la biopsia diferida. Se realiza una revisión breve del tema, métodos de diagnóstico, tratamiento médico y alternativas quirúrgicas de tratamiento.

Fasciolasis is a zoonotic disease caused by the digenean trematode Fasciola hepatica. During the chronic phase of the disease the parasites invade the main biliary ducts, causing obstructive jaundice, cholangitis, pancreatitis and other complications. We report a 75 years old female, operated due to the suspicion of a choledocholithiasis. During the exploration of the choledochus, adult F. hepatica parasites were extracted. The pathology report of the parasites confirmed the diagnosis.

Etiological spectrum of obstructive Jaundice

The objective of this study was to determine the etiological spectrum of obstructive jaundice in this part of the world. This prospective study was carried out at Liaquat National Hospital, Karachi from March 1997 to February 2001 and later at Isra University Hospital, Hyderabad from January 2003 to December 2006. Sixty five patients with obstructive jaundice were included in this study. The data was collected with respect to patient's identity, age, gender and cause of the obstructive jaundice. Fifty seven percent of patient had malignant obstructive jaundice and carcinoma of head of pancreas being the leading cause of malignant obstructive jaundice. Forty three percent patients had benign causes of obstructive jaundice, choledocholithiasis being the most common benign cause. Choledocholithiasis and malignancy are the two major causes of obstructive jaundice

Duplication of the Extrahepatic Bile Duct in Association with Choledocholithiasis as Depicted by MDCT

We report here on an extremely rare case of duplicated extrahepatic bile ducts that was associated with choledocholithiasis, and this malady was visualized by employing the minimum intensity projection images with using multi-detector row CT. The presence of duplicated extrahepatic bile ducts with a proximal communication, and the ducts were joined distally and they subsequently formed a single common bile duct, has not been previously reported.

Ileo biliar colónico: una causa poco frecuente de obstrucción intestinal, presentación de caso / Colonic gallstone ileus: a rare cause of intestinal obstruction, case report

Introducción: El íleo biliar es una complicación poco frecuente en la historia natural de la coledocolitiasis y representa una causa inusual de obstrucción intestinal.Objetivo: Presentación de caso y revisión bibliográfica.Lugar: Hospital Polivalente de Alta ComplejidadMaterial y Métodos: Presentación de caso. Revisión de literatura.Caso Clínico: Muejer 73 años, con diagnóstico de abdomen agudo oclusivo.Conclusión: El íleo biliar es una causa poco frecuente de oclusión intestinal. Es fundamental para el diagnóstico su sospecha.

Benign obstruction of the common hepatic duct (Mirizzi syndrome): diagnosis and operative management

RACIONAL: A síndrome de Mirizzi, é complicação rara da colelitíase de longa duração, caracterizada pelo estreitamento do ducto hepático comum devido a mecanismo de compressão e/ou inflamação por cálculos biliares impactados no infundíbulo da vesícula biliar ou no ducto cístico. OBJETIVO: Descrever série de oito enfermos consecutivos com síndrome de Mirizzi de uma única instituição, submetidos ao tratamento cirúrgico e comentar seus aspectos com ênfase no diagnóstico e tratamento. MÉTODO: Quatro mulheres e quatro homens, com média de idade de 61,6 anos (42 a 82 anos), foram operados com síndrome de Mirizzi entre 1997 e 2003. Avaliaram-se a apresentação clínica, os resultados dos exames laboratoriais e de imagem, os achados operatórios, a presença de coledocolitíase, o tipo de síndrome de Mirizzi de acordo com a classificação de Csendes, a escolha do procedimento operatório e as complicações pós-operatórias. RESULTADOS: Os sintomas mais freqüentes foram dor abdominal (87,5%) e icterícia (87,5%). Todos os doentes apresentaram exames de função hepática alterados. O diagnóstico da síndrome de Mirizzi foi intra-operatório em sete (87,5%) doentes, e pré-operatório em um (12,5%). Observou-se fístula colecistocoledociana associada à coledocolitíase em três (37,5%) casos. A síndrome de Mirizzi foi classificada como tipo I em cinco (71,4%) doentes, tipo II em um (14,3%), tipo III em um (12,5%), e tipo IV em outro (12,5%). A colecistectomia, como procedimento cirúrgico isolado, foi realizada em quatro (50,0%) doentes. Um (12,5%) enfermo foi submetido a colecistectomia parcial e fechamento do orifício fistuloso com a região central do infundíbulo. Dois (25,0%) enfermos foram submetidos a colecistectomia e anastomose coledocoduodenal látero-lateral e outro (12,5%) a anastomose coledocoduodenal látero-lateral, deixando-se a vesícula biliar in situ. Sete (87,5%) doentes evoluíram sem complicações pós-operatórias e obtiveram alta hospitalar em boas condições. Um (12,5%) enfermo apresentou, no pós-operatório, sepse por abscesso sub-hepático, sendo re-operado. Não houve mortalidade operatória. CONCLUSÕES: O diagnóstico pré-operatório da síndrome de Mirizzi é difícil e é necessário elevado índice de suspeita para evitar lesões da árvore biliar. O problema pode se tornar evidente apenas no momento da operação na forma de aderências firmes ao redor do triângulo de Calot. O sucesso do tratamento está relacionado ao reconhecimento...