Duplicación del colédoco asociado a unión biliopancreática anómala: Reporte de caso / Common bile duct duplication associated with anomalous biliopancreatic junction: A case report

Introducción. La duplicación del colédoco es una anomalía congénita poco frecuente. En la mayoría de los casos este defecto se asocia a cálculos en la vía biliar, unión pancreatobiliar anómala, pancreatitis, cáncer gástrico o colangiocarcinoma. Por esta razón, el diagnóstico y el tratamiento temprano son importantes para evitar las complicaciones descritas a futuro. Métodos. Se presenta el caso de una paciente de 30 años, con antecedente de pancreatitis aguda, con cuadro de dolor abdominal crónico, a quien se le realizaron varios estudios imagenológicos sin claro diagnóstico. Fue llevada a manejo quirúrgico en donde se documentó duplicación del colédoco tipo II con unión pancreatobiliar anómala. Resultados. Se hizo reconstrucción de las vías biliares y hepatico-yeyunostomía, con adecuada evolución postoperatoria y reporte final de patología sin evidencia de tumor. Conclusión. El diagnóstico se hace mediante ecografía endoscópica biliopancreática, colangiorresonancia o colangiopancreatografía retrógrada endoscópica. El tratamiento depende de si está asociado o no a la presencia de unión biliopancreática anómala o cáncer. Si el paciente no presenta patología neoplásica, el tratamiento quirúrgico recomendado es la resección del conducto con reconstrucción de las vías biliares.

Introduction. Double common bile duct is an extremely rare congenital anomaly. This anomaly may be associated with bile duct stones, anomalous biliopancreatic junction, pancreatitis, bile duct cancer, or gastric cancers. Thus, early diagnosis and treatment is important to avoid complications. Clinical case. We report a rare case of double common bile duct associated with an anomalous biliopancreatic junction in a 30-year-old female, with prior history of acute pancreatitis, who presented with chronic abdominal pain. She underwent several imaging studies, without clear diagnosis. She was taken to surgical management where duplication of the type II common bile duct was documented with anomalous pancreatobiliary junction. Results. Reconstruction of the bile ducts and hepatico-jejunostomy were performed, with adequate postoperative evolution and final pathology report without evidence of tumor. Conclusion. Diagnosis is usually performed by an endoscopic ultrasound, magnetic resonance cholangiopancrea-tography, or endoscopic retrograde cholangiopancreatography. Treatment depends on the presence of anomalus biliopancreatic junction or concomitant cancer. In cases without associated malignancy, resection of bile duct and biliary reconstruction is the recommended surgical treatment.

Innovación en técnica quirúrgica: Dos técnicas no convencionales para el tratamiento de la coledocolitiasis / Innovative surgical techniques. Two non-conventional techniques for the treatment of choledocholithiasis

RESUMEN La litiasis vesicular asociada a coledocolitiasis puede tener distintos tratamientos, endoscópicos o quirúrgicos, dependiendo del paciente, el entrenamiento del personal médico y de la disponibilidad de instrumental. Ninguno ha demostrado estar exento de complicaciones. Presentamos dos técnicas tendientes a mejorar los resultados del tratamiento quirúrgico de la coledocolitiasis. Una es la extracción transcística de coledocolitiasis y stent, en pacientes que fueron tratados endoscópicamente por colangitis, tendiente a resolver el problema (la litiasis vesicular, la coledocolitiasis y el stent) en un solo tiempo por cirugía laparoscópica. La segunda es una nueva indicación de una técnica ya descripta, la dilatación papilar anterógrada con balón, utilizada en este caso para disminuir las fugas biliares tras un cierre primario de colédoco.

ABSTRACT Cholelithiasis associated with choledocholithiasis may have different treatments, either by endoscopy or surgery, depending on the patient, level of training of the medical staff and availability of instruments. None of them is free of complications. We report two non-conventional techniques aimed at improving the results of the management of choledocholithiasis. Transcystic removal of common bile duct stones and stent in patients who underwent endoscopic treatment for cholangitis is one of these new techniques to manage cholelithiasis, choledocholithiasis and stent removal in a single procedure through laparoscopy. The second technique is a new indication of a previously described procedure, antegrade balloon papillary dilation to reduce biliary leaks after primary closure of the common bile duct.

Laparoscopic Common Bile Duct Exploration for Treatment of Common Bile Duct Stones:Clinical Analysis of 158 Cases / 中国医学科学院学报

Objective To evaluate the safety and effectiveness of laparoscopic common bile duct exploration in the treatment of common bile duct stones. Methods A retrospective analysis was conducted for 158 patients with cholecystolithiasis and choledocholithiasis admitted to the Number One Hospital of Zhangjiakou from January 2015 to December 2019.The patients were assigned into three groups according to the diameters of cystic duct and common bile duct,degrees of abdominal infection and tissue edema,and operation method.Group A(16 cases):laparoscopic cholecystectomy,transcystic choledochoscopic exploration for stone removal;Group B(94 cases):laparoscopic cholecystectomy,common bile duct incision exploration combined with choledochoscopy for stone removal,T tube drainage;Group C(48 cases):laparoscopic cholecystectomy,common bile duct incision exploration combined with choledochoscopy for stone removal,primary closure of the common bile duct.The operation time,residual rate of stones,and complication(bleeding,bile leakage,and wound infection) rate were compared between groups. Results The operation time of groups A,B,and C was(95.1±14.7),(102.2±18.1),(110.1±16.4) minutes,respectively,which showed no statistical difference between each other(F=0.020,P=0.887).One case in group A had residual stones,while no residual stone appeared in groups B and C.The overall stone clearance rate was 99.4% and the overall complication rate was 1.9%.There was no perioperative death. Conclusion It is generally safe and effective to carry out laparoscopic cholecystectomy and common bile duct exploration for stone removal in suitable populations.

Quiste de colédoco con sintomatología obstructiva en embarazada / Common bile duct cyst with obstructive symptoms in a pregnant woman

Los quistes de colédoco son poco comunes, en los países occidentales se ha reportado una incidencia de 1 por cada 100 mil nacidos vivos. En países asiáticos, esta incidencia es mayor, 1 por 100 nacidos vivos. Son usualmente diagnosticados durante la infancia y en el 25 % de los pacientes se presentan durante su vida adulta. Es inusual que se presenten durante el embarazo, sobre todo, que se manifieste durante el primer trimestre. Se realizó un informe de caso con presentación inusual del cuadro clínico no causal, de una embarazada en su primer trimestre con sintomatología obstructiva, evolucionando a colangitis. se realizan exámenes de gabinete como ultrasonografía abdominal y exámenes de laboratorio revelando obstrucción, además de realizarse colangioresonancia y ultrasonografía endoscópica dando como resultado quiste de colédoco tipo 1C, se realiza drenaje. Posteriormente al alta hospitalaria, la paciente presenta nuevamente cuadro de colangitis, se realiza drenaje endoscópico, sin embargo, presenta aborto

Choledochal cysts are rare, in western countries an incidence of 1 per 100,000 live births has been reported. In Asian countries, this incidence is higher 1 per 100 live births. They are usually diagnosed during childhood and in 25 % of patients they present during their adult life. It is unusual for them to occur during pregnancy, especially during the first trimester. A case report was made with an unusual presentation of the non-causal clinical picture, of a pregnant woman in her first trimester with obstructive symptoms, evolving to cholangitis. Cabinet examinations such as abdominal ultrasonography are performed, resulting in type 1C common bile duct cyst. Drainage is performed After discharge from the hospital, the patient presents again with cholangitis, endoscopic drainage is performed, however, she has abortion

Importancia de la vena cística en la colecistectomía laparoscópica / Importance of the cystic vein in laparoscopic cholecystectomy

Resumen Objetivo: Existen diferencias en la descripción de la vena cística en la literatura, en muchas ocasiones sin considerarla un elemento importante. Consideramos que es de vital importancia describir la presencia de la vena cística como elemento significativo que puede alterar la vista crítica de seguridad (VCS) durante las colecistectomías y asimismo, originar errores. Materiales y Método: Entre el 1° de enero de 2014 hasta el 31 de diciembre de 2018, se evaluó la presencia de la vena cística durante la disección del triángulo hepatocístico en las colecistectomías. Resultados: 397 colecistectomías laparoscópicas fueron realizadas, en 30 casos se evidenciaron elementos adicionales en el triángulo hepatocístico que requirieron una disección prolija, la cual después de seguir su trayecto y al evaluar otros reparos anatómicos como el surco de Rouvière y la visualización de la vía biliar, se consideró debido a sus características que se trataba de una vena cística en 8 casos (2%). Discusión: La vena cística es una estructura anatómica cuya existencia se debe tener en mente por parte del cirujano que realiza la colecistectomía laparoscópica, porque puede aparecer como un elemento significativo alterando la vista crítica de seguridad. Aunque en nuestra serie como elemento significativo es del 2%, otras series la describen con una frecuencia mucho mayor. Conclusión: Es necesario realizar más estudios sobre la presencia e importancia como reparo anatómico debido a su valor para prevenir lesiones de la vía biliar y como factor de confusión en la vista crítica de seguridad.

Aim: There are differences in the description of the cystic vein in the literature, often without considering it an important element. We consider it vital to describe the presence of the cystic vein as a significant element that can disturb the critical view of safety during cholecystectomies, and also cause mistakes. Materials and Method: Between January 1, 2014 and December 31, 2018, the presence of the cystic vein during the dissection of the cystohepatic triangle in cholecystectomies was evaluated. Results: 397 laparoscopic cholecystectomies were performed, in 30 cases additional elements were evidenced in the cystohepatic triangle, which required a careful dissection, which after following its path and when evaluating other anatomical repairs such as the Rouvière sulcus and the visualization of the biliary tract, it was considered due to its characteristics that it was a cystic vein in 8 cases (2%). Discussion: The cystic vein is an anatomical structure whose existence must be kept in mind by the surgeon who performs laparoscopic cholecystectomy, because it can appear as a significant element altering the critical view of safety. Although in our series as a significant element it is 2%, other series describe it with a much higher frequency. Conclusion: It is necessary to carry out more studies on the presence and importance as an anatomical repair due to its value to prevent bile duct injuries and as a factor of confusion in the critical safety view.

Reporte de Caso Clínico: Migración de cálculo dificultoso / Case Report: Migration of Large Gallstone

INTRODUCCIÓN: La coledocolitiasis es una patología con alta tasa de migración al duodeno de cálculos pequeños. No obstante, la migración asintomática de cálculos mayores a 1 cm (macrolitiasis) es atípica. A continuación, presentamos un caso de migración de un macrocálculo ubicado en colédoco medio. CASO CLÍNICO: Presentamos el caso de un hombre de 27 años que consulta por epigastralgia postprandial de 4 meses de evolución. La ecografía abdominal mostró barro biliar y un macro-cálculo en colédoco, con Colangio-RM se confirmó diagnóstico. Se decidió realizar una colecistectomía laparoscópica, con colangiografía intraoperatoria (CIO). EVOLUCIÓN: Durante la colecistectomía laparoscópica, no se evidenció cálculos en la colangiografía intraoperatoria, ante la discordancia entre las imágenes preoperatorias la CIO, se realizó instrumentación transcística con canastilla de Dormia, sin extracción de cálculos. El paciente evolucionó favorablemente, sin complicaciones dadas por la migración del macro-cálculo. Se realizó CRM posquirúrgica, sin evidencia de imágenes endoluminales en la vía biliar. CONCLUSIÓN: La patología biliar es dinámica, pudiendo presentar migración litiásica, aún en macro cálculos o cálculos de difícil manejo. Si bien la ecografÍa y la CRM tienen alta sensibilidad para su diagnóstico; la CIO es fundamental para hacer diagnóstico y tratamiento de la patología litiásica resolviéndola en un solo tiempo operatorio evitando procedimientos múltiples.(au)

BACKGROUND: Common bile duct lithiasis is a pathology with a high rate of migration of small stones to the duodenum. However, asymptomatic migration of stones larger than 1cm (macrolithiasis) is atypical. We present a case of migration of a macrocalculus located in the middle of the common bile duct. CASE REPORTS: We present the case of a 27-years-old man, who consulted for postprandial epigastric pain, that started 4 months ago. Abdominal ultrasound showed biliary sludge and common bile duct macrocalculus, with Cholangio-MRI the diagnosis was confirmed. A laparoscopic cholecystectomy with intraoperative cholangiography was performed. EVOLUTION: During the laparoscopic cholecystectomy, no stones were evidenced in the intraoperative cholangiograpy. Due to the disagreement between the preoperative IOC images, transcystic instrumentation with a Dormia basket was performed, without stone extraction. The patient had a favorably evolution, without complications due to the stone migration. Postoperative MRC was performed, without evidence of endoluminal images in the bile duct. CONCLUSIONS: Biliary pathology is dynamic, with the possibility of gallstone migration, even for large gallstones and complicated cases. Although ultrasound and MRI have high sensitivy for diagnosis; IOC is essential to diagnose and treat lithiasic pathology, resolving it in a single operating time, avoiding multiple procedures.

Coledocolitiasis y exploración laparoscópica dela vía biliar. Un estudio de cohorte / Choledocholithiasis and laparoscopic exploration of the bile duct. A cohort study

Introducción. La coledocolitiasis es la presencia de cálculos en las vías biliares. En la mayoría de los casos se trata mediante la colangio pancreatografía retrógrada endoscópica y menos comúnmente por intervención quirúrgica laparoscópica. El objetivo de este estudio fue describir una cohorte retrospectiva de pacientes sometidos a exploración laparoscópica de la vía biliar. Métodos. Se incluyeron pacientes intervenidos entre los años 2014 y 2018, en dos instituciones de nivel III en Cali, Colombia, referidos para valoración por cirugía hepatobiliar, por dificultad para la extracción de los cálculos por colangio pancreatografia retrograda endoscópica, debido al tamaño, la cantidad, o la dificultad para identificar o canular la papila duodenal. Resultados. De los 100 pacientes incluidos, se encontró que el 72 % fueron mujeres, con rango de edad entre 14 y 92 años. Al 39 % de los pacientes se les extrajo un solo cálculo y al 16 % 10 cálculos. Un 12 % presentaron cálculos gigantes (mayores de 2,5 cm de ancho) y un 44 % presentaron litiasis múltiple. Al 69 % de los pacientes se les realizó colecistectomía. El porcentaje de éxito de limpieza de la vía biliar por laparoscopia fue del 95 %.Discusión. La exploración laparoscópica de la vía biliar es una técnica posible, reproducible, segura y con excelentes resultados para el manejo de la coledocolitiasis

Introduction. Choledocholithiasis is the presence of stones in the bile ducts. In most cases it is treated by endoscopic retrograde cholangio pancreatography and less commonly by laparoscopic surgery. The objective of this study was to describe a retrospective cohort of patients who underwent laparoscopic exploration of the bile duct.Methods. The study included patients operated between 2014 and 2018, in two level III institutions in Cali, Colombia, referred for evaluation for hepato-biliary surgery, due to difficulty in removing stones by endoscopic retrograde pancreatography cholangiography, due to the size, quantity, or difficulty of identifying or cannulating the duodenal papilla. Results. Out of the 100 patients included, it was found that 72% were women, with an age range between 14 and 92 years. A single stone was removed from 39% of patients and 10 stones from 16%; 12% had giant stones (greater than 2.5 cm wide), and 44% had multiple stones; 69% of the patients underwent cholecystectomy. Laparoscopic bile duct cleaning success rate was 95%. Discussion. Laparoscopic exploration of the bile duct is a possible, reproducible, and a safe technique with excellent results for the management of choledocholithiasis

Colecistectomía segura: ¿Qué es y cómo hacerla? ¿Cómo lo hacemos nosotros? / Safe cholecystectomy: What is it and how to do it? How do we do it?

La colecistectomía laparoscópica es uno de los procedimientos más realizados a nivel mundial. La técnica laparoscópica se considera el estándar de oro para la resolución de la patología de la vesícula biliar secundaria a litiasis, y aunque es un procedimiento seguro, no se encuentra exenta de complicaciones. La complicación más grave es la lesión de la vía biliar, que, aunque es poco frecuente, con una incidencia de 0,2 a 0,4%, conduce a una disminución en la calidad de vida y contribuye a un aumento en la morbi-mortalidad. El objetivo de este artículo es reportar nuestra técnica quirúrgica, enfatizando los principios del programa de cultura para una colecistectomía segura, propuesta y descrita por the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), para minimizar los riesgos y obtener un resultado quirúrgico satisfactorio

Laparoscopic cholecystectomy is one of the most performed procedures worldwide. The laparoscopic technique is considered the gold standard for the resolution of gallbladder pathology secondary to lithiasis, and although it is a safe procedure, it is not without complications. The most serious complication is the injury to the bile duct, which, although rare, with an incidence of 0.2% to 0.4%, leads to a decrease in quality of life and contributes to an increase in morbidity and mortality. The objective of this article is to report our surgical technique, emphaszing the principles of the program for a safe cholecystectomy, proposed and described by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), to minimize the risks and obtain a satisfactory surgical result

Litiasis del hepatocolédoco / Common bile duct stones

RESUMEN Anteriormente, cuando se diagnosticaba litiasis en la vía biliar, el procedimiento consistía en una co lecistectomía, coledocotomía, extracción de los cálculos y colocación de un drenaje de Kehr. En otros casos se podía hacer papiloesfinteroplastia o una derivación biliodigestiva. Actualmente tenemos mu chas herramientas diagnósticas y terapéuticas como la colangiorresonancia, la pancreatocolangio grafía retrógrada endoscópica, la cirugía laparoscópica de la vía biliar, la ecoendoscopia y la ecografía intraoperatoria. Los procesos de decisiones son más complejos y sin un sustento con evidencia con cluyente. Tenemos estudios que enfocan parceladamente el tema, por lo que, dependiendo de si el diagnóstico se hace antes o durante la colecistectomía laparoscópica, el cirujano empleará su sentido común individualizando cada caso. El manejo ideal de la litiasis de la vía biliar sigue siendo motivo de controversia. Decidir por un manejo endoscópico, laparoscópico o convencional requiere logística, entrenamiento y juicio clínico adecua dos. La cirugía convencional sigue siendo una opción vigente.

ABSTRACT Previously, when a surgeon diagnosed bile duct lithiasis, he/she performed cholecystectomy, chole docotomy, stone removal and placement of a Kehr's "T" tube. Some cases might require sphinctero plasty or bilio-digestive bypass. Nowadays, magnetic resonance cholangiopancreatography, endosco pic retrograde cholangiopancreatography, endoscopic ultrasound and intraoperative ultrasound have emerged as diagnostic and therapeutic tools. Decision-making processes are complex and there is no conclusive evidence supporting them. Many studies have focused on the matter with a non-compre hensive approach so that each surgeon will use his/her common sense for each individual case. The optimal management of the common bile duct is still controversial. Deciding on endoscopic, lapa roscopic or conventional management requires adequate training and clinical judgment. Conventional surgery is still in valid option.

Colecistogastrostomía guiada por ultrasonografía endoscópica en un paciente con cáncer pancreático: primer caso en Colombia (con video) / Endoscopic ultrasonography-guided cholecystogastrostomy in a patient with pancreatic cancer: the first case in Colombia (with video)

Resumen El tratamiento actual para la obstrucción biliar maligna es la derivación biliar no quirúrgica con propósito paliativo. La cirugía tiene indicaciones específicas en pacientes con patología maligna con propósito curativo. Sin embargo, la obstrucción duodenal y del conducto biliar intra o extrahepático no dilatado hace que esta cirugía y el procedimiento endoscópico guiado por ultrasonografía endoscópica (USE) sean difíciles de realizar. Presentamos nuestra experiencia con el primer caso en Colombia, un país latinoamericano del tercer mundo. Consistió en una colecistogastrostomía guiada por USE, a partir de la utilización de una endoprótesis luminal (Lumen-apposing metal stents, LAMS) (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, Estados Unidos) de 15 mm × 10 mm, en un paciente masculino con cáncer pancreático inoperable e invasión duodenal con conducto colédoco dilatado. La colecistogastrostomía guiada por USE podría ser considerada como una opción de más importancia para la descompresión biliar que el drenaje percutáneo, ya que es superior en términos de viabilidad técnica, seguridad y eficacia en casos específicos de estenosis ampular e invasión duodenal. Además, puede ser realizada en países del tercer mundo, cuando se cuenta con el entrenamiento y los instrumentos adecuados. La endoprótesis metálica totalmente recubierta, aplicada a luz (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, Estados Unidos), es ideal para la colecistogastrostomía guiada por USE, a fin de minimizar complicaciones como fugas biliares. Se necesitan estudios comparativos adicionales para validar los beneficios de esta técnica.

Abstract The current treatment of malignant biliary obstruction is non-surgical biliary diversion with palliative intent. The surgery having specific indications in patients with malignant pathology with curative intent. However, duodenal obstruction and non-dilated intra- or extrahepatic bile duct make these surgical and endoscopic procedures guided by EUS difficult. We present our experience with the first case in Colombia, a third-world country in Latin America, of a cholecystogastrostomy guided by endoscopic ultrasound (EUS) in a patient with unresectable pancreatic cancer and duodenal invasion with dilated common bile duct using a luminal stent (LAMS) (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, USA) 15 mm × 10 mm. EUS-guided cholecystogastrostomy should be considered as an option for biliary decompression of greater importance than percutaneous drainage since it is superior in terms of technical feasibility, safety and efficacy in specific cases of ampullary stenosis and duodenal invasion. In addition, it can be done in third world countries when it has the appropriate training and implements. The fully covered metal stent applied to light (HOT AXIOS stent, Xlumena Inc.; Mountain View, CA, USA) is ideal for EUS guided cholecystogastrostomy to minimize complications such as bile leakage. Additional comparative studies are needed to validate the benefits of this technique.

Normal ultrasonographic dimensions of the gallbladder and common bile duct in neonates

Background: Ultrasound (US) is the first choice of imaging in neonates presenting with persistent jaundice to exclude surgically correctable causes and differentiate obstructive from nonobstructive causes. Previous studies on normal dimensions of gallbladder (GB) and common bile duct (CBD) recruited adults and children spread across a wide age group.Aims: This study aimed to determine GB and CBD normal dimensions in a large homogeneous neonatal population as well as guide decision regarding pre-US fasting in neonates who require GB evaluation.Materials and Methods: Five hundred and twenty-eight healthy newborns were recruited between May 2009 and May 2011. The widest intraluminal anterior-posterior diameters of GB and CBD were measured. Neonatal age in days, sex, birth weight, weight and height, gestational age at delivery, and time interval since last feed recorded.Results: The mean age was 9.56 ± 7.66 days, and 50.6% were males. The mean CBD diameter was 1.16 ± 1.61 mm while the mean GB diameter was 4.42 ± 2.16 mm. GB and CBD were clearly seen and measurable in 297 (55.8%) neonates and 237 (44.38%) neonates, respectively. There was a significant correlation between CBD diameter and GB diameter (P = 0.04) but no correlation with any demographic parameter. GB visualization was not dependent on time interval from last feed.Conclusion: Mean neonatal values for CBD and GB were established, but neonates have a wider range of GB diameters compared with older children, so GB diameter may not be a reliable parameter for neonatal GB pathologies. GB visualization was not dependent on time interval from last feed; hence, a recent feed should not delay emergency scans, especially in ill neonates

Rhabdomyosarcoma of the common bile duct mimicking choledochal cyst: a rare cause of obstructive jaundice / 中国当代儿科杂志

Extrahepatic biliary tract tumors are rare and among them rhabdomyosarcoma is most common. Rhabdomyosarcoma is a soft tissue malignant musculoskeletal tumor and is a very rare malignancy of the common bile duct in children. It usually presents as obstructive jaundice and/or pruritus. If there is no local invasion to the adjacent tissues, the radiological appearance of the tumor lesion is like a choledochal cyst. So the diagnosis is usually made at surgery or by preoperative biopsy. It is important to diagnose early and differentiate it from choledochal cyst and start treatment as early as possible for long time survival of the patient. This case report presented a case of a 10-year-old boy with recurrent onset of obstructive jaundice and fever preoperatively who was diagnosed as choledochal cyst and postoperatively as embryonal rhabdomyosarcoma of the common bile duct. After surgical resection and postoperative chemotherapy, the child had a good prognosis. So it is crucial to know that this rare tumor can mimic congenital choledochal cyst and it should be considered in the differential diagnosis of obstructive jaundice in children.

Palliative Measures with Ethanol Gallbladder Ablation and Endobiliary Radiofrequency Ablation Followed by Endoscopic Biliary Stent Placement in an Advanced Case of Common Bile Duct Cancer: A Case Report / 대한소화기학회지

Endobiliary radiofrequency ablation (RFA) is a procedure performed widely to induce locoregional tumor control by the transfer of thermal energy to the lesion and subsequent tumor necrosis. A 72-year-old male with a prior history of acute calculous cholangitis and perforated cholecystitis was admitted to the Kyungpook National University Hospital complaining of fever and nausea. He had an indwelling percutaneous transhepatic gallbladder drainage (PTGBD) catheter from the previous episode of perforated cholecystitis. An abdominal CT scan showed marked dilation of both the intrahepatic and extrahepatic bile ducts. Common bile duct cancer was confirmed histologically after an endobiliary biopsy. A surgical resection was considered to be the initial treatment option. During open surgery, multiple metastatic nodules were present in the small bowel mesentery and anterior abdominal wall. Resection of the tumor was not feasible, so endobiliary RFA was performed prior to biliary stenting. Cholecystectomy was required for the removal of the PTGBD catheter, but the surgical procedure could not be performed due to a cystic ductal invasion of the tumor. Instead, chemical ablation of the gallbladder (GB) with pure ethanol was performed to breakdown the GB mucosa. Palliative treatment for a biliary obstruction was achieved successfully using these procedures. In addition, a PTGBD catheter was removed successfully without significant side effects. As a result, an improvement in the patient's quality of life was accomplished.

Complicaciones y factores de riesgo en pacientes sometidos a colagiopancreatografía retrógrada endoscópica en una clínica de tercer nivel de Medellín desde el 2014 hasta el 2017 / Complications and risk factors in patients undergoing endoscopic retrograde cholangiopancreatography in a third level clinic in Medellín from 2014 to 2017

Introducción. La colangiopancreatografía retrógrada endoscópica es la herramienta de elección para el manejo de una gran cantidad de enfermedades pancreáticas y biliares. Al ser un procedimiento invasivo, trae consigo riesgos que aumentan la morbimortalidad en los pacientes en quienes se practica. El objetivo de este estudio fue analizar las complicaciones más prevalentes relacionadas con el procedimiento, de los pacientes de una institución de tercer nivel de Medellín, entre los años 2014 y 2017.Métodos. Se presenta un estudio observacional, retrospectivo y analítico. Se analizaron las historias clínicas de los pacientes sometidos a colangiopancreatografía retrógrada endoscópica con diagnóstico de enfermedades biliares y pancreáticas. La información fue analizada usando estadística descriptiva e inferencial, mediante análisis univariado y multivariado, y se calculó la razón de momios (odds ratio, OR) con un intervalo de confianza del 95 %; se tomó como significativo un valor de p inferior a 0,25 en los análisis bivariados.Resultados. En los 1.546 pacientes sometidos a colangiopancreatografía retrógrada endoscópica, la edad promedio fue de 57,6 ± 19.3 años y el 59,1 % eran mujeres. Las complicaciones identificadas fueron: pancreatitis en 57 pacientes (3,7 %), sangrado en 28 (1,8 %), perforación en 8 (0,5 %) y mortalidad no discriminada de 42 pacientes (2,7 %). Como factores de riesgo con significancia estadística, se encontraron la papilotomía y el contraste del conducto de Wirsung (OR=3 y OR=3,55, respectivamente).Discusión. Los resultados obtenidos se encuentran en concordancia con los de la literatura mundial, con tasas de complicaciones y mortalidad similares. Por otra parte, el perfil sociodemográfico de la población de estudio difiere de las cifras internacionales, con predominancia de la enfermedad estudiada en edades mayores y con mayor cantidad de comorbilidades

Introduction: Endoscopic retrograde cholangiopancreatography is the tool for the management of a large number of pancreatic and biliary diseases. Being an invasive procedure, it brings risks that increase morbidity and mortality in patients in whom it is practiced. The objective of this study was to analyze the most prevalent complications related to the procedure of the patients of a third level institution in Medellin between 2014 and 2017.Methods: An observational, retrospective and analytical study is presented. The information was analyzed using descriptive and inferential statistics, by univariate and multivariate analysis, and the odds ratio (odds ratio, OR) was calculated with a 95% confidence interval; a value of p less than 0.25 was taken as significant in the bivariate analyzes. Results: In the 1,546 patients who underwent endoscopic retrograde cholangiopancreatography, the average age was 57.6 ± 19.3 years and 59.1% were women. The complications identified were: pancreatitis in 57 patients (3.7%), bleeding in 28 (1.8%), perforation in 8 (0.5%) and non-discriminated mortality of 42 patients (2.7%). As risk factors with statistical significance, papillotomy and Wirsung duct contrast were found (OR = 3 and OR = 3.55, respectively).Discussion: The results obtained are consistent with those of the world literature, with similar complication and mortality rates. On the other hand, the sociodemographic profile of the study population differs from international figures, with a predominance of the disease studied in older ages and with a greater number of comorbidities

Colangiopancreatografia retrógrada endoscópica para cálculos no ducto biliar comum: overview de revisões sistemáticas e estudos econômicos / Endoscopic retrograde cholangiopancreatography for common bile duct calculi: overview of systematic reviews and economic assessments

Objetivo: Avaliar a eficácia, segurança e custo-efetividade da colangiopancreatografia retrógrada endoscópica (CPRE) comparada à exploração laparoscópica do ducto biliar comum (ELDBC) para coledocolitíase. Métodos: Foi realizada uma busca eletrônica nas bases de dados Medline, The Cochrane Library, Lilacs e Center for Reviews and Dissemination por revisões sistemáticas e estudos econômicos que reportassem dados sobre a comparação entre a CPRE e a ELDBC em pacientes com coledocolitíase. Uma busca complementar foi realizada nas referências dos estudos incluídos, periódicos, resumos de congresso e Google Acadêmico. A seleção foi realizada por dois pesquisadores independentes. Além da síntese qualitativa, uma ressíntese quantitativa para os desfechos primários foi conduzida em Review Manager® 5.3 utilizando um modelo de efeitos randômicos. Resultados: Foram incluídos 15 estudos (9 revisões sistemáticas e 6 estudos econômicos). Não foi demonstrada diferença estatisticamente significativa entre a colecistectomia laparoscópica (CL)+CPRE e a CL+ELDBC em termos de remoção dos cálculos do colédoco (88,5% vs. 92,8%; RR = 0,97, valor-p = 0,08; N = 1.881), morbidade pós-operatória (14,1% vs. 13,8%; RR = 0,98, valor-p = 0,88; N = 1.469), mortalidade (0,8% vs. 0,2%; RR = 2,13, valor-p = 0,33; N = 1.471), cálculos retidos (7,3% vs. 5,8%; RR = 1,17, valor-p = 0,40; N = 1.731), conversão para outros procedimentos (8,7% vs. 6,7%; RR = 1,20, valor-p = 0,55; N = 1.287), duração do procedimento (MD = 10,91, valor-p = 0,61; N = 717) ou tempo de hospitalização (MD = 1,31, valor-p = 0,10; N = 757). A literatura de custo-efetividade é dividida, com alguns estudos favorecendo a CL+CPRE e outros, a CL+ELDBC. Conclusão: Não é possível concluir sobre a superioridade da ELDBC sobre a CPRE ou vice-versa para a remoção de cálculos no colédoco.

Objective: To evaluate the efficacy, safety and cost-effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) compared to laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis. Methods: An electronic search was conducted in the Medline, The Cochrane Library, Lilacs and Center for Reviews and Dissemination databases for systematic reviews and economic studies that reported data on the comparison between ERCP and LCBDE in patients with choledocholithiasis. A complementary search was conducted on references of included studies, journals, conference abstracts and Google Scholar. The selection was performed by two independent reviewers. In addition to the qualitative synthesis, a quantitative re-synthesis for primary outcomes was conducted in Review Manager® 5.3 using a random effects model. Results: Fifteen studies (9 systematic reviews and 6 economic studies) were included. There was no statistically significant difference between laparoscopic cholecystectomy (LC)+ERCP and LC+LCBDE in terms of removal of choledochal stones (88.5% vs. 92.8%, RR = 0.97, p-value = 0.08; N = 1,881), morbidity (14.1% vs. 13.8%, RR = 0.98, p-value = 0.88; N = 1,469), mortality (0.8% vs. 0,2%; RR = 2.13, p-value = 0.33, N = 1,471), retained stones (7.3% vs. 5.8%, RR = 1.17, p-value = 0.40; N = 1,731), conversion to other procedures (8.7% vs. 6.7%, RR = 1.20, p-value = 0.55, N = 1,287), duration of the procedure (MD = 10.91, p = 0.61, N = 717) or hospital stay (MD = 1.31, p-value = 0.10, N = 757). The cost-effectiveness literature is divided. Some studies favor LC+ERCP and others LC+LCBDE. Conclusion: It is not possible to conclude on the superiority of the LCBDE on ERCP or vice-versa for choledocholithiasis

Eficacia de la colangiopancreatografía por resonancia magnética para el diagnóstico de coledocolitiasis de probabilidad intermedia / Efficacy of cholangiopancreatograghy by magnetic resonance in the diagnosis of choledocholithiasis of intermediate probability

Introducción. La coledocolitiasis de probabilidad intermedia es una condición con gran morbilidad por el riesgo de pancreatitis y colangitis, y se requiere el estudio de la vía biliar para su enfoque diagnóstico y terapéutico. Actualmente, el método de referencia para su diagnóstico y tratamiento, es un examen invasivo, la colangiopancreatografía retrógrada endoscópica (CPRE), que no siempre lleva a un diagnóstico positivo de coledocolitiasis, pero sí implica exponer a los pacientes a sus riesgos. Por esta razón, la colangiopancreatografía por resonancia magnética (CPRM) ha tomado importancia en el diagnóstico, ya que es un examen no invasivo y con menor riesgo de complicaciones, por lo que se pretende evaluar su uso en la coledocolitiasis de probabilidad intermedia. Métodos. Se llevó a cabo un estudio de pruebas diagnósticas en una muestra de pacientes con coledocolitiasis de probabilidad intermedia, en la Fundación Salud El Bosque, entre enero de 2012 y agosto de 2015. Resultados. Se incluyeron 151 pacientes con diagnóstico de coledocolitiasis de probabilidad intermedia. Se evaluaron las características de la CPRM, la cual mostró sensibilidad de 88 %, especificidad de 79 %, valor predictivo positivo (VPP) de 88 % y valor predictivo negativo (VPN) de 96 %, con un índice de exactitud de 94,7 %. Conclusiones. La CPRM es un examen con un rendimiento adecuado en la evaluación de los pacientes con coledocolitiasis de probabilidad intermedia. En estos casos permite obviar la CPRE diagnóstica. El impacto de la dilatación de la vía biliar sumada a otras alteraciones del perfil hepático, no se puede establecer con este estudio

Introduction. Patients with intermediate probability of choledocholithiasis exhibit a highly morbid pathology due to the risk of developing pancreatitis and cholangitis; it demands the study of the bile duct for appropriate diagnostic and therapeutic approach. Currently, the gold standard for its diagnosis and treatment is an invasive examination, ERCP, which not always ends with positive diagnosis of choledocholithiasis, exposing the patient to the associated risks. This is why magnetic resonance cholangiopancreatography has acquired importance in the diagnosis, for it is a non-invasive procedure with lesser risk of complications. For this reason we decided to evaluate its use in mid-probability choledocholithiasis. Methods. A study of the diagnostic tests was carried out in a sample of 151 patients with intermediate probability of choledocholithiasis at our center, Fundación Salud El Bosque (Bogotá, Colombia), in the period 2012-2015. Results: A total of 151 patients with the diagnosis of choledocholithiasis of intermediate probability were included, evaluating the characteristics of the MRCP, which showed sensitivity of 88%, specificity 79%, PPV88% and NPV 96%, with an accuracy index of 94.7%. Conclusions. MRCP is a test that exhibits adequate performance in the evaluation of patients with intermediate probability of choledocholithiasis, avoiding the performance of ERCP. It confirms its previous use when faced with mid-chance choledocholithiasis. The diagnostic impact of dilation of the bile duct and other alterations of the liver profile can not be established with this study