Surgery vs. endoscopy competitive or complementary tools for management of post cholecystectomy problems, 10 years experience in major referral center

A prospective work to study and evaluate surgical and endoscopic techniques used in management of post cholecystectomy problems. In the period from Mars 2000 to October 2009, a random sample of 630 patients [366 females and 264 males] were collected from general surgery department, and gastro-intestinal endoscopy unit, Assuit University hospitals, and managed accordingly using surgery in 143 patients, and endoscopy in 482 patients [plus percutaneous techniques in 25 patients]. Endoscopy was very successful. as an initial treatment of 457 patients [73%], as being less invasive, low morbidity and mortality, competitive to surgery in treatment of missed stone [88%], mild to moderate biliary leakage [82%], and biliary stricture [74%].Its success increased by addition of percutaneous techniques in 4%, 2.8% and 8.3% for missed stone, leakage, and stricture respectively. But endoscopy was somewhat complementary to surgery in major leakage, and massive stricture, and surgery was resold to in 15%, and 17% of cases. Surgery remain as the treatment of choice in complex problems, and endoscopy play a complementary role in such cases of transaction, ligation, combined problems of stones, stricture, and leakage [< 40%], compared to 60% for surgery. Bilio-enteric anastomosis was the procedure of choice, done in 86 cases, with stent splintage in unhealthy, or small sized ducts. And stricture complication was encountered in 6% of cases treated by perculaneous rout in 4, and redo surgery in1 case. The learning curve seems influential in both endoscopy and surgery. The cumulative experience increase the success rate of endoscopy from initial 50% to 95% nowadays, also surgery improved with decreased morbidity and mortality as complications encountered was seen in initial experience and decreased with time. Endoscopy was competitive to surgery in simple problems and advised to be the initial treatment choice, but complementary in major leak, ligation, transection, and complex problems, where surgery plays the main role in treatment with its invasiveness, high morbidity and morbidity. Cumulative experience influence endoscopic and surgical treatment of such problems and it is mandatory with other facility and equipment for management of such challenging cases

"Sump syndrome" recidivante após o tratamento endoscópico: relato de caso / Recurrent sump syndrome after endoscopic therapy: case report

A sump syndrome é uma rara complicação, usualmente associada a anastomoses coledocoduodenais, caracterizada por dor internitente, pancreatite e colangite de repetição. Estas manifestações são decorrentes do refluxo de conteúdo gastroentérico para dentro da anastomose biliar e seu acúmulo acima do esfíncter de Oddi. Relato de caso: Descreve-se o caso de uma paciente submetida a uma anastomose coledocoduodenal para o tratamento de litíase da via biliar principal, a qual evoluiu com episódios recorrentes de colangite, microabscesso hepático e choque séptico. Após o insucesso de duas esfincterotomias endoscópicas, optou-se pelo tratamento cirúrgico. Durante o intra-operatório realizous-se uma anastomose duodenojejunal término-lateral em Y de Roux devido à presença de uma reação fibrosa intensa ao nível do pedículo hepático, o que possibilitou a realização de uma anastomose hepaticojejunal término-lateral em Y de Roux. A paciente apresentou excelente evolução, permanecendo assintomática no 32§ mês de pós-operatório. Conclusão: Este procediemnto demonstrou ser uma opção terapêutica eficaz para pacientes com sump syndrome ecorrente após esfincterotomia endoscópica.

Coledocolitiasis postcolecistectomía: Esfinterotomía endoscópica vs reoperación / Postcholecystectomy choledocolythiasis: endoscopic sphyncterotomy vs reoperation

Se compararon en forma prospectiva y randomizada, los resultados de la extracción endoscópica con los de la reoperación, en el tratamiento electivo de la coledocolitiasis postcolecistectomía. Se estudiaron 2 grupos de 50 pacientes, todos con cálculos menores de 15 mm de diámetro. En los pacientes sometidos a extracción endoscópica (Grupo I), durante el primer procedimiento, se logró limpiar la vía biliar en 45/50 pacientes (84 por ciento), quedando cálculos retenidos en 8 (16 por ciento), cifra similar a la obtenida en los del Grupo II, en los que la cirugía logró extraer todos los cálculos en 43/50 pacientes (86 por ciento), persistiendo una litiasis residual en 7 (14 por ciento) (p = 0,683). Sin embargo, la posibilidad de repetir el procedimiento endoscópico (promedio 1,16 ñ 0,4) permitió dejar la vía biliar libre de cálculos en 48/50 casos del Grupo I (96 por ciento) (p < 0,05). En pacientes portadores de una coledocolitiasis postcolecistectomía con cálculos menores de 15 mm, la esfinterotomía endoscópica se asocia a una tasa de éxito significativamente mayor y a una morbilidad y período de hospitalización significativamente menor que la reoperación. En estos enfermos, la extracción endoscópica es el tratamiento de elección