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.

Hepático-gastrostomía guiada por eco endoscopia en obstrucción biliar maligna y gastrectomía subtotal con reconstrucción en Y de Roux / Endoscopic ultrasound-guided hepaticogastrostomy for treatment of malignant biliary obstruction in patient with Roux-en-Y gastrectomy

RESUMEN La colangiopancreatografía retrógrada endoscópica (CPRE) representa el tratamiento de primera línea para el drenaje biliar en pacientes con obstrucción biliar maligna avanzada. Sin embargo, este procedimiento representa un desafío en pacientes con anatomía alterada quirúrgicamente. El ultrasonido endoscópico (USE) permite la toma de muestras de tejido mediante punción aspiración con aguja fina y también representa una alternativa de drenaje biliar al abordaje percutáneo o quirúrgico. Nuestro objetivo es comunicar un caso en el que la ecoendoscopia permitió el diagnóstico definitivo de la recurrencia de la enfermedad oncológica de base y el alivio de la obstrucción biliar en un paciente con anatomía alterada quirúrgicamente.

ABSTRACT Endoscopic retrograde cholangiography with biliary stenting is the generally recognized optimal treatment of malignant biliary obstruction. This procedure, though, is challenging in patients with surgically altered anatomy. Endoscopic ultrasound (EUS) enables tissue sampling by means of fine-needle aspiration and also represents an alternative recourse for biliary drainage in preference to a percutaneous approach. We aimed to report a case in which EUS enabled a definitive diagnosis of the recurrence of oncologic disease and the relief of biliary obstruction in a patient with a surgically altered anatomy.

Seguridad y eficacia del uso de prótesis metálicas autoexpandibles en el manejo de estenosis malignas de la vía biliar irresecables / Safety and efficacy of the use of self-expanding metal stents in the management of unresectable malignant biliary stenosis

Antecedentes: En los últimos años se ha producido un incremento del uso de prótesis metálicas autoexpandibles (SEMS) en pacientes con estenosis malignas irresecables de la vía biliar. Sin embargo, en Perú no se cuentan con reportes sobre la seguridad y eficacia de este procedimiento. Objetivo: Evaluar la seguridad y eficacia del uso de las SEMS en el manejo paliativo de las estenosis malignas de la vía biliar. Materiales y métodos: Cohorte retrospectiva. Se incluyeron a todos los pacientes referidos para colocación de SEMS biliar como parte de un tratamiento paliativo entre enero del 2016 y agosto del 2018. Se obtuvieron las tasas de colocación exitosa de las SEMS, de paliación adecuada de la obstrucción y de complicaciones asociadas al procedimiento. Se evaluó la patencia de la prótesis durante el seguimiento. Se determinó la supervivencia luego de la colocación de la prótesis. Resultados: Se incluyeron 32 pacientes con indicación de manejo paliativo debido a una estenosis maligna irresecable de la vía biliar. El cáncer de páncreas (56,25%) seguido del colangiocarcinoma (31,25%) fueron las etiologías más frecuentes. Se alcanzó una tasa de colocación exitosa en primera intención de 96,97%. La paliación adecuada de la obstrucción biliar se alcanzó en el 100% de los pacientes (p<0,05). Dos SEMStc migraron durante el seguimiento (6,25%) siendo manejados con la colocación de una nueva SEMSnc. Conclusiones: La colocación de SEMS constituye una estrategia segura, con alta tasa de éxito terapéutico en el manejo paliativo de los pacientes con obstrucción maligna de la vía biliar.

Background: In recent years there has been an increase in the use of self-expanding metallic stents (SEMS) in patients with unresectable malignant stenosis of the bile duct. However, in Peru there are no reports on the safety and efficacy of this procedure. Objective: To evaluate the safety and efficacy of the use of SEMS in the palliative management of malignant stenosis of the bile duct. Materials and methods: Retrospective cohort. All patients referred for placement of biliary SEMS as part of a palliative treatment between January 2016 and August 2018 were included. Rates of successful placement of SEMS, adequate palliation of the obstruction, and complications associated with the procedure were obtained. The patency of the prosthesis was evaluated during follow-up. Survival was determined after placement of the prosthesis. Results: We included 32 patients with indication of palliative management due to an unresectable malignant stenosis of the bile duct. Pancreatic cancer (56.25%) followed by cholangiocarcinoma (31.25%) were the most frequent etiologies. A successful first-time placement rate of 96.97% was achieved. Adequate palliation of biliary obstruction was achieved in 100% of patients (p<0.05). Two SEMStc migrated during follow-up (6.25%) being managed with the placement of a new SEMSuc. Conclusions: The placement of SEMS is a safe and effective therapeutic strategy in the palliative management of patients with malignant obstruction of the biliary tract.

Risk of bleeding complications in percutaneous biliary drainage: the paradox of the normal hemostasis / Risco de complicações de sangramento na drenagem biliar percutânea: o paradoxo da hemostase normal

ABSTRACT Background: Percutaneous biliary drainage is a safe procedure. The risk of bleeding complications is acceptable. Frequently, patients with biliary obstructions usually have coagulation disorders thus increasing risk of bleeding. For this reason, patients should always fit the parameters of hemostasis. Aim: To determine whether the percentage of bleeding complications in percutaneous biliary drainage is greater in adults with corrected hemostasis prior to the procedure regarding those who did not require any. Methods : Prospective, observational, transversal, comparative by independent samples (unpaired comparison). Eighty-two patients with percutaneous biliary drainage were included. The average age was 64±16 years (20-92) being 38 male and 44 female. Patients who presented altered hemostasis were corrected and the presence of bleeding complications was evaluated with laboratory and ultrasound. Results: Of 82 patients, 23 needed correction of hemostasis. The approaches performed were: 41 right, 30 left and 11 bilateral. The amount of punctures on average was 3±2. There were 13 (15.8%) bleeding complications, 12 (20%) in uncorrected and only one (4.34%) in the corrected group with no statistical difference. There were no differences in side, number of punctures and type of drainage, but number of passes and the size of drainage on the right side were different. There was no related mortality. Conclusion: Bleeding complications in patients requiring hemostasis correction for a percutaneous biliary drainage was not greater than in those who did not require any.

RESUMO Racional: A drenagem biliar percutânea é procedimento seguro. O risco de complicações hemorrágicas é aceitável. Frequentemente, os pacientes com obstruções biliares apresentam distúrbios de coagulação, aumentando o risco de sangramento. Por esse motivo, eles devem sempre ser adequados aos parâmetros da hemostasia. Objetivo: Determinar se a porcentagem de complicações hemorrágicas na drenagem biliar percutânea é maior em adultos com hemostasia corrigida antes do procedimento em relação àqueles que necessitaram nenhuma. Métodos: Estudo prospectivo, observacional, transversal, comparativo por amostras independentes (comparação não pareada). Oitenta e dois pacientes foram submetidos à drenagem biliar percutânea. A idade média foi de 64±16 anos (20-92), 38 eram homens e 44 mulheres. Os pacientes que apresentaram hemostasia alterada foram corrigidos, e a presença de complicações hemorrágicas foi avaliada com exames laboratoriais e ultrassonográficos. Resultados: Dos 82 pacientes, 23 necessitaram de correção da hemostasia. O acesso à direita foi em 41 casos, 30 à esquerda e 11 bilaterais. A quantidade de punções em média foi de 3±2. Houve 13 (15,8%) complicações hemorrágicas, 12 (20%) no grupo não corrigido e apenas uma (4,34%) no corrigido sem diferença estatística. Não houve diferenças no lado, no número de perfurações e no tipo de drenagem, mas o número de passagens e o tamanho da drenagem no lado direito foram diferentes. Não houve mortalidade. Conclusão: As complicações hemorrágicas em pacientes que necessitam de correção da hemostasia antes da drenagem biliar percutânea não são maiores do que naqueles que não a requerem.

Colangiografía retrógrada endoscópica en pacientes con hepático-yeyunostomía con enteroscopio de doble balón / Endoscopic retrograde cholangiography in patients with hepatic-jejunostomy by double balloon enteroscopy

Introducción: el acceso endoscópico a la vía biliar en pacientes con hepático-yeyunostomía previa resulta un acto complejo por las limitaciones anatómicas que esta cirugía impone. El enteroscopio de doble balón logra el abordaje de esta zona, con posibilidades diagnósticas y terapéuticas.Objetivo: describir los resultados de la exploración endoscópica para el abordaje y tratamiento endoscópico en pacientes con derivación bilio-digestiva. Método: se presenta una serie de 6 casos con derivación bilio-digestiva y elementos clínicos, humorales y ecográficos de obstrucción biliar. Se realizó exploración según técnica de enteroscopia de doble balón para abordar el sitio de derivación y aplicar terapéutica. Resultados: en todos los casos se logró acceder a la hepático-yeyunostomía y se realizó dilatación con Soehendra y en uno de ellos además, con balón neumático. Se extrajeron cálculos en 2 pacientes y en 5 se colocaron prótesis plásticas de 7 Fr. No se presentaron complicaciones. Conclusiones: la enteroscopia de doble balón resultó un proceder útil y seguro para el acceso a la vía biliar en los pacientes con hepático-yeyunostomía(AU)

Introduction: endoscopic access to the bile duct in patients with hepatic-jejunostomy is a complex act upon by the anatomical limitations imposed by this surgery. The double-balloon endoscope approach achieves this area, with diagnostic and therapeutic possibilities. Objective: to describe the results of endoscopic approach in patients with biliary-digestive surgery. Methods: we present a report of 6 cases of biliary-digestive bypass clinical elements, humoral and ultrasound of biliary obstruction. Exploration was performed according to the technique of double balloon enteroscopy to address the referral site and therapeutic applications. Results: in all cases, gains access to the hepatic-jejunostomy and dilation make Soehendra, one of them also with balloon tires. 2 stones were extracted in 5 patients and plastic prosthesis was placed 7 Fr No complications. Conclusions: the double-balloon endoscopy was a useful and safe procedure for access to the bile duct in patients with hepatic-jejunostomy(AU)

Percutaneous Unilateral Biliary Metallic Stent Placement in Patients with Malignant Obstruction of the Biliary Hila and Contralateral Portal Vein Steno-Occlusion

OBJECTIVE: To investigate the outcomes of percutaneous unilateral metallic stent placement in patients with a malignant obstruction of the biliary hila and a contralateral portal vein steno-occlusion. MATERIALS AND METHODS: Sixty patients with a malignant hilar obstruction and unilobar portal vein steno-occlusion caused by tumor invasion or preoperative portal vein embolization were enrolled in this retrospective study from October 2010 to October 2013. All patients were treated with percutaneous placement of a biliary metallic stent, including expanded polytetrafluoroethylene (ePTFE)-covered stents in 27 patients and uncovered stents in 33 patients. RESULTS: A total of 70 stents were successfully placed in 60 patients. Procedural-related minor complications, including self-limiting hemobilia (n = 2) and cholangitis (n = 4) occurred in six (10%) patients. Acute cholecystitis occurred in two patients. Successful internal drainage was achieved in 54 (90%) of the 60 patients. According to a Kaplan-Meier analysis, median survival time was 210 days (95% confidence interval [CI], 135-284 days), and median stent patency time was 133 days (95% CI, 94-171 days). No significant difference in stent patency was observed between covered and uncovered stents (p = 0.646). Stent dysfunction occurred in 16 (29.6%) of 54 patients after a mean of 159 days (range, 65-321 days). CONCLUSION: Unilateral placement of ePTFE-covered and uncovered stents in the hepatic lobe with a patent portal vein is a safe and effective method for palliative treatment of patients with a contralateral portal vein steno-occlusion caused by an advanced hilar malignancy or portal vein embolization. No significant difference in stent patency was detected between covered and uncovered metallic stents.

Colestasis del recién nacido y del lactante / Cholestasis of newborn and infant

Los recién nacidos y lactantes pequeños tienen una inmadurez funcional y anatómica que justifica que las enfermedades hepáticas que se manifiestan en estas edades tengan la ictericia como signo principal y que otros procesos extrahepáticos o sistémicos puedan condicionar colestasis. La colestasis del lactante es un síndrome clínico caracterizado por ictericia, acolia o hipocolia, y coluria, que evoluciona con elevación de la bilirrubina directa y de los ácidos biliares séricos. La evaluación diagnóstica del lactante con colestasis, realizada por un equipo multidisciplinario, debe minimizar la realización de pruebas innecesarias para lograr un diagnóstico correcto en el menor tiempo posible, diferenciar entre colestasis intrahepática o extrahepática y lograr un diagnóstico etiológico, que incluya aquellos procesos que ponen en peligro la vida o requieren un tratamiento específico médico o quirúrgico. El presente trabajo pretende revisar las principales causas, procedimientos diagnósticos y el enfoque terapéutico de la colestasis del recién nacido y del lactante en aras de contribuir a su diagnóstico temprano y su tratamiento adecuado

The small newborns and infants have a functional anatomical immaturity justifying that liver diseases present at these ages have the jaundice as leading sign and that other extra-hepatic or systemic processes may conditioning the Cholestasis. Infant Cholestasis is a clinical syndrome characterized by jaundice, acholia or hypoacholia and choluria evolving with a rise of direct bilirubin and of serum biliary acids. The diagnostic assessment of infant presenting with Cholestasis made by a multidisciplinary staff must to minimize the carrying out of unnecessary tests to obtain an appropriate diagnosis in less time, to differentiate among the intrahepatic or extrahepatic cholestasis and to achieve an etiologic diagnosis including the processes threatening the life or that requiring a medical or surgical specific treatment. The aim of present paper is to review the leading causes, diagnostic procedures and the therapeutical approach of cholestasis en the newborn and in the infant to contribute to its early diagnosis and its appropriate treatment

Anastomosis biliodigestivas laparoscópicas: nuestra experiencia / Laparoscopic biliary anastomosis: our experience

Antecedentes: Actualmente, para la resolución de la obstrucción de la vía biliar ûbenigna o maligna-, se incluyen varias opciones terapéuticas; quirúrgicas, endoscópicas, percutáneas y combinadas.Objetivo: Analizar los resultados en el manejo laparoscópico de la patología biliar que requiera una derivación biliodigestiva.Lugar de aplicación: Centro médico de alta complejidad.Diseño: retrospectivo y descriptivo.Población: 102 pacientes con indicación quirúrgica de derivación biliodigestiva.Material y Método: Revisión de historias clínicas, bases de datos y videos de las anastomosis biliodigestivas, realizadas entre Octubre de 1993 y Agosto de 2005. 102 pacientes con obstrucción de la vía biliar, el 51.6% por patología benigna y 48.4% maligna. Tres procedimientos terapéuticos coledocoduodenoanastomosis (83 casos), hepaticoyeyunoanastomosis (9casos), y colecistoyeyunoanastomosis (1 caso). Fueron incluídos 7 pacientes(29%) con cirugías biliares previas.Resultados: 93 anastomosis biliodigestivas laparoscópicas, debiendo convertir 8.8% (9 casos), 2 por sangrado de arteria hepática propia, 5 por dificultad técnica, 1 por sospecha de cáncer de vesícula y 1 por sospecha de apertura duodenal, El tiempo operatorio promedio fue de 110 minutos (rango 45 a 300). Morbilidad del 21.5% y mortalidad a los 30 días del 5.3%. Estadía hospitalaria promedio 6 días (rango 2 a 36).Conclusión: Todos los indicadores (tiempo quirúrgico, internación, conversión, y tasa de complicaciones) mejoraron con la progresión de la experiencia en el equipo quirúrgico.

Prótesis y paliación / Stents and palliation

El drenaje endoscópico de las neoplasias malignas de la vía biliar es el tratamiento paliativo de elección, con una baja morbilidad y mortalidad. Claramente se benefician del uso de prótesis metálicas auto-expansibles, aquellos pacientes que tienen una sobrevida estimada mayor a 6 meses, en especial quienes tienen obstrucciones distales y cuando existe una colangitis asociada a la obstrucción biliar inicial. En las obstrucciones proximales, hay que utilizar el medio de contraste mínimo y con baja presión de inyección, drenando en lo posible ambos lóbulos, siempre y cuando para lograr esto último, no se requiera de una manipulación excesiva, evitando así, la colangitis segmentaria. La complicación más frecuente es la colangitis aguda, en especial en pacientes con obstrucciones proximales. Se recomienda el uso de antibióticos profilácticos en todos los pacientes, ya que desconocemos en cuáles no vamos a lograr nuestro objetivo.

Perioperative serum beta-2-micro globulin concentration in obstructive jaundice

Obstructive jaundice [OJ] can lead to hepatic and renal impairment. The aim of this study was to measure levels of serum Beta 2 Micro globulin [SB2M] in patients with OJ undergoing explorative surgery for relief of the obstruction and to determine the usefulness of such a measurement as a monitor for renal impairment relative to other measures of renal function. SB2M levels [mg/L] were not above the normal reference range preoperatively [2.39 [1.7-4.8]], intraoperatively [2.2[0.27-3.4], p = 0.08], six hours postoperatively [1.9 [1.03-4.8], p = 0.2] and after 24 hours [1.92 [0.95-4.9], p = 0.4] when compared to preoperative values. None of the patients involved in the study developed acute renal failure or suffered from severe renal or hepatic impairment preoperatively. Urea, creatinine and creatinine clearance [CrCl] perioperative changes were insignificant. Correlation between SB2M and CrCl was significant preoperatively [r = -0.41, p =0.02] but marginally failed to reach statistical significance postoperatively [r = -0.35, p = 0.053]. No significant correlation existed between SB2M and the following creatinine, urea, bilirubin and prothrombin time [PT]. Postoperative 24 hours PT was 12.87 [12-19.67] seconds, this was significantly lower than the preoperative PT 13.46 [12-26] seconds [p = 0.001]. No blood products were used during surgery. OJ was not associated with an increase in serum B2M blood levels. Severe renal failure was not encountered due to stability of the haemodynamic parameters and the guided fluid therapy. Few patients showed some degree of renal dysfunction but this did not develop to failure. This study cannot recommend the routine measurement of SB2M, as it did not add to the existing routine renal function tests. Improvement in PT after relief of OJ indicates the need for an early surgical intervention

Evaluation of long-term results of choledochoduodenostomy for benign biliary obstruction.

The role of choledochoduodenostomy (CDD) in the management of lower common bile duct (CBD) obstruction is controversial because of the long-term complications such as ascending cholangitis, sump syndrome and alkaline reflux gastritis. In spite of the good long-term results observed in some studies, CDD is considered a last trial for lower CBD obstruction. This study was done to analyze the efficacy and long-term results observed in patients who underwent CDD. A total of 21 patients who underwent side-to-side CDD for various causes of lower CBD obstruction from 1992 to 2002 in our institute were analyzed retrospectively. Symptoms, indications and complications were noted from the hospital records. Long-term follow-up evaluation was done through personal communication, examination, and subsequent ultrasonography and endoscopy in symptomatic patients. The most common presenting symptom was abdominal pain (95.2%) and the most frequent indication for CDD was multiple CBD stones (61.9%). Eighteen of the 21 patients (85.7%) had a normal postoperative recovery without any complications. One patient (4.8%) had an anastomotic leak and peritonitis, and 2 (9.5%) had wound infection. Long-term follow-up was possible in only 15 patients as the others were lost to follow-up. Nine patients (60%) were asymptomatic and 6 (40%) were occasionally symptomatic (abdominal pain and bilious vomiting), to an extent which did not affect their day-to-day life. Recurrent or retained stones were not noted, in any patient. All 6 symptomatic patients showed duodenogastric reflux but alkaline reflux gastritis was seen in only 1 patient (6.66%). Anastomotic stoma was patent in all the patients subjected to endoscopy. Features of cholangitis or sump syndrome were not noted in any patient. Side-to-side CDD is a safe and definitive procedure for the decompression of lower CBD obstruction. It has good long term results with infrequent complications.

Biliary tract obstruction due to Fasciola hepatica managed by ERCP

Fascioliasis is a health problem in several countries including the Islamic Republic of Iran. In a review of the medical publications during 1990-2002, only 22 cases of biliary tract obstruction by fasciola hepatica have been reported. Herein, we are adding a new case of fasciola hepatica causing bile duct obstruction and presenting with intermittent colicky pain, eosinophilia and bile duct dilatation. This condition was diagnosed by endoscopic retrograde cholaogiopancreatography [ERCP] and was treated by extemporaneous papillotomy. This case report confirms that in endemic areas, fascioliasis should be included in the list of the differential diagnosis for colicky abdominal pain, eosinophilia and bile duct dilatation. The condition could be concurrently diagnosed and treated by ERCP

A new method for the experimental induction of secundary biliary cirrhosis in wistar rats

The aim of this study was to describe a method for the induction of experimental secondary biliary fibrosis (SBF). Forty-seven Wistar rats were submitted to hepatic duct obstruction (OB group) for thirty days without ligature, section or cannulization causing interruption of biliary flow. This technique was carried out by simple traction of the bile duct passing it through the xiphoid appendix. Nine rats were submitted to a sham operation for bile duct stricture and seven rats comprised the control group. Blood samples were collected for the measurement of total bilirubin (TB), alkaline phosphatase (AP), alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Liver fragments were removed for morphological study. Thirty days after surgery TB, AP, ALT and AST levels were significantly increased in the hepatic duct ligation group compared to the sham operated group and the presence of SBF in the OB group was confirmed by morphological study of the liver. There was technical failure in 31.92 percent cases. The survival was 100 percent at fifteen days and 82.97 percent at the end of the experiment. We concluded that this simple surgical technique may be used to study the consequence of bile duct obstruction which could be a reversible process depending on the obstruction time. This technique can be carried out from cholestasis to fibrosis.

Desarrollo de la colangiografía endoscópica en un servicio de cirugía / Development of endoscopic cholangiography in a surgical service

La colangiopancreatografía endoscópica (CPRE), requiere considerable entrenamiento para realizarla efectivamente. Es el procedimiento de mayor riesgo que desarrollan los cirujanos endoscopistas, con morbilidad de 5 a 10 por ciento y mortalidad hasta 1 por ciento. En mayo de 1997, se diseña el protocolo de la experiencia. Se establece una marcha blanca (etapa 1), período que se termina al alcanzar un 70 por ciento de canulación. Entre mayo de 1997 y julio de 1999, se realizaron 201 CPRE; 52 en etapa 1 y 149 en etapa 2. El promedio de edad fue 62 años. Coledocolitiasis, ictericia obstructiva y colangitis fueron las principales indicaciones. La canulación en etapa inicial se logró en un 65 por ciento, alcanzando en la segunda etapa un 96 por ciento. La papilotomía estándar se logró en etapa inicial en un 27 , llegando a 80 por ciento en etapa 2. En la etapa 1, un 76 por ciento de los casos se terminó en el primer intento, en la etapa 2, esta cifra llegó al 92 por ciento. Las complicaciones observadas fueron hemorragia de papila 4 casos, retención de Dormia 1 y 2 pancreatitis aguda. La mortalidad registrada es de 0,5 por ciento. La colangiopancreatografía endoscópica (CPRE), requiere considerable entrenamiento para realizarla efectivamente. Es el procedimiento de mayor riesgo que desarrollan los cirujanos endoscopistas, con morbilidad de 5 a 10 por ciento y mortalidad hasta 1 por ciento. En mayo de 1997, se diseña el protocolo de la experiencia. Se establece una marcha blanca (etapa 1), período que se termina al alcanzar un 70 por ciento de canulación. Entre mayo de 1997 y julio de 1999, se realizaron 201 CPRE; 52 en etapa 1 y 149 en etapa 2. El promedio de edad fue 62 años. Coledocolitiasis, ictericia obstructiva y colangitis fueron las principales indicaciones. La canulación en etapa inicial se logró en un 65 por ciento, alcanzando en la segunda etapa un 96 por ciento. La papilotomía estándar se logró en etapa inicial en un 27 por ciento, llegando a 80 por ciento en etapa 2. En la etapa 1, un 76 por ciento de los casos se terminó en el primer intento, en la etapa 2, esta cifra llegó al 92 por ciento. Las complicaciones observadas fueron hemorragia de papila 4 casos, retención de Dormia 1 y 2 pancreatitis aguda. La mortalidad registrada es de 0,5 por ciento