New Technique of Endoscopic Sphincterotomy with Iso-Tome(R) to Incise the Distal Papillary Roof in Patients with Choledocholiths and Choledochoduodenal Fistula

BACKGROUND/AIMS: It is sometimes difficult to incise the distal papillary roof (PR) completely in patients with choledocholiths and choledochoduodenal fistula (CDF). The Iso-Tome(R) (MTW-Endoskopie W. Haag KG), which is helpful in preventing electrical leakage, has good orientation capabilities and can be easily placed at the orifice of the CDF or ampulla of Vater (AV). We aimed to evaluate the efficacy of endoscopic sphincterotomy (ES) with the Iso-Tome(R) for cutting the distal PR. METHODS: Between May 2003 and July 2012, 35 patients were analyzed retrospectively. The distal PR was cut downward and/or upward using the Iso-tome(R) until the pink intrapapillary mucosa was fully exposed. Downward incisions were performed from the opening of the CDF to the orifice of the AV; upward incisions were performed in reverse. RESULTS: Spontaneous or artificial CDF occurred in four and 31 patients, respectively. The technical and therapeutic success rates were 94.3% (33/35) and 94.3% (33/35), respectively. There was no case of electrical damage to the pink intrapapillary mucosa. Adverse events occurred in 2.9% (1/35; 1, mild bleeding) of patients. CONCLUSIONS: The new technique of ES with the Iso-tome(R) is feasible and useful for effectively incising the distal PR in patients with CDF and choledocholiths.

New Technique of Endoscopic Sphincterotomy with Iso-Tome(R) to Incise the Distal Papillary Roof in Patients with Choledocholiths and Choledochoduodenal Fistula

BACKGROUND/AIMS: It is sometimes difficult to incise the distal papillary roof (PR) completely in patients with choledocholiths and choledochoduodenal fistula (CDF). The Iso-Tome(R) (MTW-Endoskopie W. Haag KG), which is helpful in preventing electrical leakage, has good orientation capabilities and can be easily placed at the orifice of the CDF or ampulla of Vater (AV). We aimed to evaluate the efficacy of endoscopic sphincterotomy (ES) with the Iso-Tome(R) for cutting the distal PR. METHODS: Between May 2003 and July 2012, 35 patients were analyzed retrospectively. The distal PR was cut downward and/or upward using the Iso-tome(R) until the pink intrapapillary mucosa was fully exposed. Downward incisions were performed from the opening of the CDF to the orifice of the AV; upward incisions were performed in reverse. RESULTS: Spontaneous or artificial CDF occurred in four and 31 patients, respectively. The technical and therapeutic success rates were 94.3% (33/35) and 94.3% (33/35), respectively. There was no case of electrical damage to the pink intrapapillary mucosa. Adverse events occurred in 2.9% (1/35; 1, mild bleeding) of patients. CONCLUSIONS: The new technique of ES with the Iso-tome(R) is feasible and useful for effectively incising the distal PR in patients with CDF and choledocholiths.

Estenosis crítica de conducto hepático común por anillo vascular: reporte de un caso / Common bile duct stricture caused by vascular ring: A case report

Introduction: The most common congenital malformations of the bile duct are biliary atresia and choledochal cyst. In addition, the most common liver anatomical variation is the right hepatic artery aberration. The goal of this study is to characterize a patient with this disease and propose the hepatoduodenal anastomosis as surgical treatment. Case report: One-month-old patient with suspected congenital biliary atresia due to progressive jaundice and acholia since birth. Liver tests consistent with a cholestatic pattern and brain MRI scan consistent with biliary atresia. Periods of decreased bilirubin and sporadic slight pigmentation of depositions were described. The surgical finding was a bile duct stricture due to a vascular ring caused by aberrant right hepatic artery. Resection of bile duct and hepatic-duodenal bypass were performed. The patient evolved satisfactorily from this condition. Conclusion: There are few reports of biliary obstruction due to vascular malformations. It is important to keep in mind that not all neonatal jaundice episodes are caused by biliary atresia or choledo-chal cyst. The clinical course, laboratory tests and imaging should be considered and in the case of suspicion, further exploration should take place.

Introducción: Las malformaciones congénitas de la vía biliar más frecuentes son la atresia de vías biliares y quiste de colédoco. Por otro lado, la variante anatómica hepática más común es la aberración de la arteria hepática derecha. El objetivo es caracterizar un paciente portador de esta patología y plantear la hepato-duodeno anastomosis como tratamiento quirúrgico. Caso clínico: Paciente de 1 mes de edad, con sospecha de Atresia de Vía Biliar congénita por ictericia progresiva y acolia desde recién nacido. Pruebas hepáticas concordantes con un patrón colestásico y resonancia magnética compatible con atresia de vías biliares. Evolucionó con períodos de descenso de bilirrubina y leve pigmentación, esporádica, de deposiciones. El hallazgo quirúrgico fue una estenosis crítica de vía biliar a nivel del conducto hepático común debido a un anillo vascular por una arteria hepática derecha aberrante. Se realizó una sección de vía biliar y una derivación hepato-duodenal. Evolucionó con una resolución completa de su patología. Conclusión: Existen pocos reportes de obstrucción de vía biliar por malformaciones vasculares. Es importante tener presente que no todas las ictericias neonatales son por atresia de vías biliares o quiste de colédoco. Se debe considerar la evolución clínica, laboratorio e imágenes, y si existen sospechas, explorar.

Mirizzi: o homem e a síndrome / Mirizzi: the man and the syndrome

A síndrome de Mirizzi é uma importante complicação da doença calculosa biliar. Pablo Luís Mirizzi, de Córdoba, Argentina, descreveu uma condição hoje conhecida como síndorme de Mirizzi, em 1948. Ele dedicou sua vida à Cirurgia e aos estudantes.

Mirizzi syndrome is an important complication of gallstone disease. Pablo Luís Mirizzi, from Córdoba, Argentina, described a condition now know as the Mirizzi syndrome, in 1948. He dedicated his life to surgery and his students.

Reconstrucción de lesiones de la vía biliar principal: la evolución hacia la técnica de Hepp-Couinaud / Surgical repair of bile duct injuries: experience in 25 patients

Background: Bile duct injury (BDI) is a complex problem, where adequate reconstruction has an impact on quality of life of patients. Aim: To describe the experience and results of bile duct reconstruction in BDI at reference center. Material and Methods: Retrospective review of 25 patients aged 44 +/- 14 (76 percent females) with BDI that were subjected to a surgical repair in a regional hospital between January 2000 and June 2009. The protocol, repair technique and postoperative morbidity and mortality are described. Results: In 40 percent of cases, the injury occurred during laparoscopic cholecystectomy. The repair was performed using a Roux-en-Y hepato-jejunostomy (RYHJ) in 20 patients. In 14 patients (70 percent), the modified Hepp-Couinaud technique was used. Thirty two percent of patients had postoperative complications and one patient died due to a sepsis and liver failure. One patient presented RYHJ stenosis that was managed with percutaneous dilatation. Conclusions: The majority of patients of this series were managed using a RYHJ with the Hepp-Couinaud technique, with acceptable results in terms of postoperative morbidity and stenosis.

Introducción: La lesión de vía biliar (LVB) es una complicación de enfrentamiento complejo, donde una adecuada reconstrucción tiene impacto en la calidad de vida de los pacientes. Objetivo: Describir la experiencia y resultados de la reconstrucción de via biliar por LVB en un centro de referencia. Material y Método: Diseño de estudio: Cohorte retrospectiva. Período de estudio: Enero de 2000 a Junio de 2009. Población: Pacientes mayores de 18 años con LVB que fueron sometidas a reconstrucción de vía biliar por el equipo de cirugía hepatopancreática y biliar del Hospital Regional de Temuco. Maniobra: Se describe el protocolo de evaluación y la técnica de reconstrucción. Resultados: La cohorte está constituida por 25 pacientes. La edad promedio es 44 +/- 13,7 años y el 76 por ciento género femenino. La lesión se produjo más frecuentemente en una colecistectomía laparoscópica (40 por ciento). La reparación se ha realizado con hepaticoyeyuno anastomosis en Y de Roux (HPYA) en 20 pacientes, utilizando la técnica de Hepp-Couinaud modificada en el 70 por ciento de ellos. Ocho pacientes presentaron alguna morbilidad asociada a la reparación y un paciente falleció en el postoperatorio. Un paciente presentó estenosis de HPYA cuya terapia fue dilataciones por vía percutanea. Conclusión: La HPYA con técnica de Hepp-Couinaud es la técnica más utilizada por nuestro equipo en la reconstrucción de vía biliar por LVB con resultados aceptables en términos de morbilidad postoperatoria y estenosis.

Comparative study of management of common bile duct stone, our experience of 20 patients at sir Ganga Ram hospital Lahore

To compare different methods of management of CBD stones at Sir Ganga Ram Hospital Lahore i.e ERCP with pappilotomy, Sphinterotomy or removal through Dormia's Basket and Open Cholecystectomy with choledochotomy. It was observational comparative Study. The adult patients having CBD stones. One years i.e. from 15[th] June 2008 to 15[th] June 2009. The mode of management of these patients for common bile duct stones was absorved. The out come and complications of both techniques were compared. Total 20 patients were included in the study. Out of them 12 were managed by open cholecystectomy and choledochotomy and the remaing 8 were treated by doing endoscopic retrograde cholangiopancreaticogram [ERCP]. The out come of both techniques were than compared. In our Hospital the majority of the patients of CBD stones are being managed by open technique i.e. open cholecystectomy and choledochotomy along with T-tube insertion, which is contrary to the approach of developed countries i.e. endoscopic and laproscopic approach

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.

Experiencia en tratamiento del síndrome de Mirizzi / Mirizzi Syndrome

Antecedentes: Los trastornos del drenaje del árbol biliar, agrupados bajo la denominación de Síndrome de Mirizzi (SM), resultan de alteraciones de la unión cístico-coledociana debidas a procesos inflamatorios secundarios a cálculos biliares. Los cambios anatómicos pueden facilitar lesiones de la vía biliar durante la colecistectomía. Material y Método: 32 casos de SM fueron intervenidos entre 1994 y 2004 sobre un total de 3250 colecistectomías; estos casos fueron seleccionados para un estudio descriptivo y retrospectivo que estudia la frecuencia, características clínicas, diagnóstico, táctica quirúrgica y resultados inmediatos. Resultados: La frecuencia del SM es del 1 por ciento; la serie comprende 3 varones y 29 mujeres con edad media de 48 años (r 23-84). Treinta pacientes refirieron dolor cólico, 22 ictericia y 18 fiebre. En 25 de ellos se comprobó hiperbilirrubinemia. La ecografía mostró colecistolitiasis en todos y dilatación de las vías biliares en 18 casos. Siete pacientes tenían lesión de tipo I, 19 de tipo II; 2 de tipo III y 4 pacientes tipo IV (Clasificación de Csendes). En las lesiones de tipo I y II se realizó la colecistectomía: en 2 de ellos se asoció una plastia del colédoco. En las lesiones tipo III se practicó la derivación bilio-digestiva. En las de tipo IV, se efectuaron 2 anastomosis bilio-digestivas y 2 plastias de la vía biliar. Fallecieron 2 pacientes por complicaciones sépticas. Conclusión: El SM fue encontrado en una ocasión por cada 100 colecistectomías; el diagnóstico preoperatorio es difícil; el laboratorio y la ecografía orientan poco. En el adulto mayor, con ictericia obstructiva reciente, la colangiografía se revela fundamental antes de la colecistectomía.

Risk factors and techniques affecting surgical outcome of therapeutic endoscopic retrograde cholangiopancreatography difficulties.

OBJECTIVE: To analyze the therapeutic endoscopic retrograde cholangiopancreatography (ERCP) difficulties and complications experienced by a general surgeon and identify risk factors and technique affecting surgical outcome. MATERIAL AND METHOD: A retrospective review was carried out in 88 consecutive ERCP operated with four different indications on patients in Nakornping General Hospital by a surgeon trained from Nippon Medical School, Japan. RESULTS: The patients average age was 57.2 years. Fifty-four patients had common bile duct stone and 43 of them were successfully removed. Endoscopic sphincterotomy (EST) was the most frequent procedure needed to combine with the stone extraction (23 in 43). Twenty-two distal common bile duct obstructions unable to be diagnosed by ultrasound or computed tomography were operated on and found to be unvarying proportion of tumor, stone or stricture. Among these 6 biopsy and 12 treatments were concurrently made. Eight bile fistula and four cholangitis were indicated for endoscopic drainage. Only one serious bleeding was complicated. Two perforations were discovered in the present series and none required laparotomy repair of duodenum. Eighteen of the 88 failed to be operated on and most of them were within first four-month learning curve. Duodenal diverticulum was a common failure factor. The pre-procedure unknown diagnosis relates to an insignificant risk 2.4 times complications of the known (RR = 2.4, p = 0.31). Three patients (3.4%), all over 70 years old, succumbed late after ERCP due to sepsis and myocardial infarction, compared to those age under 70 is a significant risk factor (p = 0.059). Age over 50 seems to result in a higher pancreatitis complication (3 versus none under 50) but not statistically significant (p = 0.405). CONCLUSION: Skill and synchronous assistance are important factors for success of ERCP but a more unpredictable outcome and complications were encountered for the preoperative undiagnosable obstructive jaundice. Hot and slow sphincterotomy would minimize the bleeding complication. Duodenal diverticulum and those operated on for late obstruction were risk factors in patients with EST perforations. Pondering to be minimally by invasive, advanced age still contributes to a higher complication and mortality risk in the surgical treatment of ERCP.

Jejunal serosal onlay flap for repair of large common bile duct defect in Mirizzi's syndrome.

Reconstruction of the common bile duct (CBD) has been performed using a variety of materials, ranging from synthetic i.e. teflon, to autogenous tissues such as veins, arteries, appendix, ureter, gallbladder, duodenum, etc. The onlay jejunal serosal patch has been commonly used to cover defects because of duodenal ulcer perforations and injuries. To the best of our knowledge, the use of this technique for choledochoplasty in Mirrizi syndrome has not been reported. We present a case of Mirrizi syndrome type III, in whom nearly three fourths of the CBD was eaten away by a large gallstone and the repair was done using an onlay serosal patch of the jejunum.

Cystic dilatation of the common bile duct in adults: report of five cases and review of literature

The authors report five cases of cystic dilatation of the common bile duct Type I (TodaniÆs classification) in adults patients, in Division of General Surgery of a University Hospital, treated over a- 25-year- period from 1974 to 1999, among 16.057 operations, and not previously published. Diagnosis was obtained by operative cholangiogram (OC) in the first case, percutaneous transhepatic cholangiogram on the second one (PTHC) and by ultrasonography (US), endoscopic retrograde cholangiopancreatography (ERCP), and operative cholangiogram (OC), respectively, on the last three cases. The second patient had an adenocarcinoma arising in the cystic wall associated with peritoneal metastasis. The first two cases were treated by internal drainage and the last three by excision of the cysts and bilioenteric anastomoses. Classification, incidence, etiology, diagnosis, malignization and surgical treatment of biliary cystic disease (BCD) were revised, with the conclusion that resection must be the preferable method of treatment, when possible, especially due to the concern of malignization.

Icterícia cirúrgica / Surgery icterus

O autor analisa o mecanismo da excreção da bilirrubina e da formação da icterícia. Expõe os exames complementares úteis ao diagnóstico e tratamento da icterícia obstrutiva extra-hepática

Resecciones hepáticas con ligadura de los pedículos portales según el Código Glissoniano / Hepatectomy with ligature of the portal pedicles using Glissonian code

Se presenta la experiencia de 5 años con hepatectomías realizadas en el Hospital Clínico San Borja Arriarán, siguiendo la técnica del Código Glissoniano propuesta por Takasaki, de Tokyo. Son 41 pacientes: 12 hombres y 29 mujeres. Se realizaron 23 resecciones de los segmentos IV y V; 8 resecciones de los segmentos II y III; una resección del segmento VI; una resección del segmento V y VIII; 5 hepatectomías derechas y 3 hepatectomías izquierdas. La resección hepática, siguiendo esta técnica facilita la intervención al lograr delimitar los segmentos en forma notable, gracias a la demarcación isquémica obtenida con la ligadura selectiva de los pedículos. Por otro lado, si bien es cierto que el hígado normal soporta un tiempo de isquemia total prolongado sin problemas, no sucede lo mismo con hígados insuficientes con daño hepático crónico como ocurre habitualmente en los enfermos con hepatoma. En estos casos, el clampeo selectivo logra una resección con poca pérdida sanguínea y protección del parénquima hepático

Anastomose colédoco-duodenal realizada em doentes com coledocolitíase e com estreitamento inflamatório do colédoco / Choledocho-duodenal anastomosis performed in patients with choledocholithiasis and biliary inflammatory stricture

Desde sua introdução por Riedel (1888) a anastomose colédoco-duodenal foi amplamente praticada por autores europeus e parcialmente aceita pelos americanos e ingleses. Estes últimos relutaram na sua indicação por causa dos riscos de colangite aguda ascendente, da gastrite alcalina decorrente do refluxo bilioso duodeno-gástrico e da síndrome do escoamento ("sump syndrome"). Durante 10 anos (1988 a 1998) realizamos 25 anastomoses colédoco-duodenais, das quais, látero-lateral (n = 21) e término-lateral (n = 4), praticadas em doentes com coledocolitíase e com estreitamento do colédoco distal. Todos tinham sido tratados previamente por esfincterotomia endoscópica e drenagem biliar em sessões consecutivas (média = 3,4). Um doente tinha cirrose biliar secundária a crises de colangite e hipertensão portal por ocasião da derivação biliodigestiva. Três doentes apresentavam síndrome de Mirizzi tipo II e estenose do colédoco. Não houve mortalidade operatória e as complicações nesse período estiveram relacionadas a pneumonia (n = 2) e infecção da ferida operatória (n = 2). Complicações tardias observadas entre um e nove anos após o procedimento cirúrgico relacionaram-se a gastrite alcalina leve (n = 4), "sump syndrome" (n = 2) e cólicas abdominais (n = 5). Esses pacientes foram controlados com medicação clínica e procedimentos endoscópicos mediante anastomose para remoção de cálculos e resíduos alimentares no colédoco. Um paciente morreu 1,5 ano após a derivação bilioduodenal por hemorragia digestiva alta por varizes esôfago-gástricas e insuficiência hepática ocasionadas pela cirrose biliar secundária e colangite. Outro paciente morreu um ano após a cirurgia por pancreatite aguda. Nesse paciente a colangiopancreatografia pós-operatória revelou cálculos no coto distal do colédoco, o qual estava desfuncionalizado, em razão de anastomose término-lateral. Os procedimentos endoscópicos não foram capazes de remover esses cálculos por causa da estenose do colédoco distal. As conclusões deste estudo sugerem que a indicação da anastomose biliodigestiva na estenose do colédoco não deve ser retardada em função da insistência praticada após completa remoção dos cálculos das vias biliares; essa anastomose permite procedimentos endoscópicos pós-operatórios.