Morbilidad y mortalidad de las derivaciones biliodigestivas / Morbidity and mortality in biliary bypasses

Objetivo: Determinar la morbilidad y la mortalidad en las derivaciones biliodigestivas en el servicio de Cirugía general en el Hospital Enrique Cabrera, de enero de 2007 a diciembre de 2011. Material y Métodos: Se realizó una investigación observacional, descriptiva y prospectiva. La muestra fue constituida por 51 pacientes a los que se les realizó una o más derivaciones biliodigestivas. Las variables estudiadas fueron edad, sexo, causa de intervención, tecnica quirúrgica, complicaciones, estado al egreso y causa de muerte. Se calculó la frecuencia de complicaciones y la mortalidad para cada técnica. Resultados: Fueron intervenidos quirúrgicamente 51 pacientes, con un promedio de edad de 57,5 años El tumor de cabeza de páncreas correspondió a 56,9% de los casos y la lesión de vía biliar, a 17,6%. La infección del sitio quirúrgico ocurrió en 33,3%. Fallecieron 50% de los operados por ténica de Whipple. La técnica quirúrgica más utilizada fue la coledocoduodenostomía. La mortalidad fue 11,8% y la principal causa de muerte, la falla multiorgánica. Conclusiones: El tumor de cabeza de páncreas fue la causa de intervención más frecuente La pancreatoduodenectomía de Whipple reportó la mayor morbimortalidad. Las tasas de incidencia de complicaciones y de mortalidad para la cirugía biliodigestiva fueron altas.

Objectives: To determine the morbidity and mortality in biliary bypasses in the Service of General Surgery at the Enrique Cabrera Hospital from January of 2007 to December of 2011. Material and Methods: It was carried out an observational, descriptive and prospective study. The sample constituted by 51 patients who had underwent a biliary bypass. The studied variables were: age, sex, intervention cause, surgical technique, complications, condition at discharge and cause of death. Frequency of complications and mortality were calculated for each technique. Results: Fifty one patients underwent a biliary bypass, age average of 57,5 year-old. The head's pancreas tumor was 56,9% and biliary's ducts lesions 17,6%. Surgical wound infection occurred in 33,3% of cases, and 50% of those who underwent a Whipple's technique died. The more used surgical technique was the choledocoduodenostomy. The mortality was of 11,8% and the main cause of death was multiorganic failure. Conclusions: The head's pancreas tumor was the cause that underwent surgery. The Whipple's pancreatoduodenectomy reported the highest morbidity and mortality. The frequency of complications and mortality for a biliary bypass were high.

Manejo cirúrgico da síndrome de Mirizzi / Surgical management of Mirizzi syndrome

RACIONAL: Síndrome de Mirizzi é rara condição encontrada em pacientes com colelitíase de longa data, variando de 0,3 - 3 por cento nos pacientes submetidos à colecistectomia. Se não reconhecida no pré-operatório pode implicar em significativa morbimortalidade. OBJETIVO: Descrever série de cinco pacientes consecutivos com síndrome de Mirizzi submetidos à cirurgia e comentar as suas características clínicas. MÉTODO: Revisão retrospectiva de cinco pacientes com síndrome de Mirizzi, entre janeiro de 2002 e junho de 2008. Foram avaliados: a apresentação clínica, resultados laboratoriais, avaliação pré-operatória, achados cirúrgicos, presença de coledocolitíase, classificação da síndrome de Mirizzi, escolha do procedimento operatório e suas complicações. RESULTADOS: Quatro pacientes eram mulheres (80 por cento) e a média de idade foi 53,4 anos (38 a 62 anos). Os sintomas mais freqüentes foram dor abdominal (100 por cento) e náuseas / vômitos (100 por cento). Todos os pacientes com icterícia apresentaram alterações da função hepática (40 por cento) e apenas um, sem icterícia, tinha bioquímica hepática alterada. O diagnóstico de síndrome de Mirizzi foi intra-operatório em todos (100 por cento) casos. A associação entre fístula coledocociana e coledocolitíase foi observada em três pacientes (60 por cento). Quanto à classificação, encontrou-se dois pacientes com tipo I e um paciente em cada um dos tipos II, III, IV. A colecistectomia foi realizada em todos os pacientes, sendo parcial em três (60 por cento). A anastomose coledocoduodenal foi realizada em dois pacientes, sendo do tipo látero-lateral. A coledojejunoanastomose ocorreu em um único caso (tipo IV). Evolução pós-operatória sem alterações ocorreu em dois casos (40 por cento) recebendo alta em boas condições. Um paciente apresentou sepse no pós-operatório secundário a abscesso subhepático evoluindo ao óbito no 2º dia de pós-relaparotomia. CONCLUSÃO: Apesar do diagnóstico pré-operatório ser raro nos pacientes com síndrome de Mirizzi, ela deve ser suspeitada na colelitíase crônica e prontamente identificada no intra-operatório para evitar lesões biliares inadvertidas. Apesar da era da colecistectomia laparoscópica, o método aberto deve ser o de escolha.

BACKGROUND: Mirizzi syndrome is a rare complication of long standing cholelithiasis and was reported in 0,3 - 3 percent of patients undergoing cholecystectomy. If not recognized preoperatively, it can result in significant morbidity and mortality. AIM: To describe a series of five consecutive patients with Mirizzi syndrome submitted to surgical treatment and to comment on then aspects clinics. METHODS: A retrospective review of five consecutives cases of Mirizzi syndrome that arose between January 2002 and June 2008 was performed. The following items were evaluated: clinical presentation, laboratory results, preoperative evaluation, operative findings, presence of choledocholithiasis, type of Mirizzi syndrome according to the classification by Csendes, choice of operative procedures, and complications. RESULTS: Four patients were women (80 percent) and a mean age was 53,4 years (38 to 62 years. The most frequent symptoms were abdominal pain (100 percent) and nausea and vomiting (100 percent) The patients with jaundice presented altered hepatic function tests (40 percent) and only one without jaundice presented altered hepatic function. The diagnosis of Mirizzi syndrome was intra-operative in all patients (100 percent). Cholecystecholedochal fistula associated with choledocholithiasis was observed in three (60 percent) cases. Mirizzi syndrome was classified as Csendes type I in two (40 percent) patients, type II in one (20 percent), type III in one (20 percent) and type IV in another (20 percent). Cholecystectomy was performed in all patients (100 percent), however, the partial cholecystectomy was observed in three (60 percent). Two (40 percent) patients were submitted to side-to-side choledochoduodenostomy and another (20 percent) to choledochojejunoanastomosis. Two (40 percent) patients had an uneventful recovery and were discharged in good conditions. One (20 percent) patient presented a postoperative sepsis due to a sub-hepatic abscess and was reoperated. This patient to die. CONCLUSIONS: The preoperative diagnosis of Mirizzi syndrome is a challenge. A high index of clinical suspicion is required to make an intra-operative diagnosis, which leads to good surgical planning to treat the condition. Open surgery is the gold standard.

Nonoperative Versus Operative Treatment of Obstructive Jaundice in Unresectable Pancreatic Cancer

Despite advances in diagnostic technology, pancreatic carcinoma is usually unresectable at the time of operation. The most common problem facing the surgeon today is determining the best method of palliation for biliary obstruction. The objectives of this study were to identify the role of nonoperative treatment for obstructive jaundice in pancreatic cancer and to compare the recurrence and survival period of operative and nonoperative treatment group. During the period of September 1987 to February 1995, a operative or nonoperative treatment was performed in 65 patients with obstructive jaundice in pancreatic carcinoma, at the Department of Surgery, Korea University, College of Medicine. We classified the patients into pancreatic resection(n=12), operative bypass(n=22), and nonoperative biliary bypass(n=31) groups according to the procedure performed. And we separated the nonoperative biliary bypass into endoscopic(n=10) and percutaneous drainage(n=21) groups. There were no significant differences with respect to the mortality within the 1st month and admission period. The type of procedure had influence on the survival of 78.3%, 57.1%, and 48.1% for resection, operative bypass and nonoperative biliary bypass, respectively. During follow-up, the difference was found with respect to the recurrence of jaundice and the morbidity within the 1st month. In conclusion, in patients with unresectable pancreatic cancer, surgical bypass procedure would be more efficient for relief of biliary obstruction than nonoperative biliary drainage. Nonoperative biliary drainage for obstructive jaundice of pancreatic cancer should be used only when the patient was not a candidate for operation.