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.

Application of indocyanine green fluorescence imaging in biliary tract diseases / 中华消化外科杂志

For the past few years, the indocyanine green fluorescence imaging has been widely used in the diagnosis and treatment of biliary tract diseases. Fluorescence visualization of the biliary system by indocyanine green accurately localize the diseased tissue and identify the biliary structures precisely, which effectively avoids the damage to the natural biliary structure and greatly improves the accuracy and safety of biliary surgery. However, the application of this new technology in biliary surgery is still at the exploratory stage, showing great potential for application while also exposing many problems and controversies. It is believed that with the continuous development and improvement, the indocyanine green fluorescence cholangiography will play a more important role in the diagnosis and treatment of biliary tract diseases in the future, and bring more benefits to patients.

Anatomic classification and reconstruction of right intrahepatic bile duct in the donor liver of split liver trans-plantation / 中华消化外科杂志

Objective:To investigate the anatomic classification and reconstruction of right intrahepatic bile duct in the donor liver of split liver transplantation (SLT).Methods:The retrospective and descriptive study was constructed. The clinical data of 85 patients who underwent SLT in the Third Affiliated Hospital of Sun Yat-sen University from July 2014 to January 2022 were collected. There were 65 males and 20 females, aged 45(range, 1-82)years. Observation indicators: (1) surgical conditions; (2) anatomy of right intrahepatic bile duct; (3) bile duct reconstruction; (4) postoperative biliary complications; (5) follow-up. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range) or M( Q1, Q3).Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Results:(1) Surgical conditions. Of the 85 donor livers, 11 donor livers were split between the left and right hemilivers, and 74 donor livers were split between the classic right trilobe and left lateral lobe. The cold ischemia time of 85 donor livers was 291(273, 354)minutes, and the operation time, anhepatic phase time and volume of intraoperative blood transfusion of 85 recipients were (497±97)minutes, 51(40, 80)minutes and 8(7, 12)U. (2) Anatomy of right intrahepatic bile duct. Of the 85 donor livers, there were 47 donor livers with classic bile duct anatomical model (type 1), of the ratio as 55.3%(47/85), and 38 donor livers with anatomical variants, of the ratio as 44.7%(38/85). Of the 38 donor livers with anatomical variants, 7 donor livers were type 2, 16 donor livers were type 3a, 2 donor livers were type 3b, 2 donor livers were type 3c, 1 donor liver was type 4, 3 donor livers were type 5a, 4 donor livers were type 5b, 3 donor livers were type 6. For bile duct splitting patterns of the 85 donor livers, 84 donor livers were split with the main trunk of common hepatic duct preserving in the right hemiliver or right trilobe, and 1 donor liver were treated with complete left and right hemiliver splitting to preserve the main trunk of the common hepatic duct in the left hemiliver and the right hemiliver in the right hepatic duct (type 1 bile duct anatomical model). There were 84 donor livers with only one bile duct opening, and 1 donor liver with two bile duct openings (type 3c bile duct anatomical model). (3) Bile duct reconstruction. Of the 85 recipients, there were 69 recipients with common bile duct end-to-end anastomosis to common bile duct of donor liver (38 donor livers with type 1 bile duct anatomical model, 5 donor livers with type 2 bile duct anatomical model, 14 donor livers with type 3a bile duct anatomical model, 2 donor livers with type 3b bile duct anatomical model, 1 donor liver with type 4 bile duct anatomical model, 3 donor livers with type 5a bile duct anatomical model, 4 donor livers with type 5b bile duct anatomical model, 2 donor livers with type 6 bile duct anatomical model), 11 recipients with jejunum anastomosis to common bile duct of donor liver (7 donor livers with type 1 bile duct anatomical model, 2 donor livers with type 2 bile duct anatomical model, 1 donor liver with type 3c bile duct anatomical model, 1 donor liver with type 6 bile duct anatomical model), 3 recipients with jejunum anastomosis to common hepatic duct of donor liver (1 donor liver with type 1 bile duct anatomical model, 2 donor livers with type 3a bile duct anatomical model), 1 recipient with jejunum anastomosis to right hepatic duct of donor liver (type 1 bile duct anatomical model), 1 recipient with common hepatic duct end-to-end anastomosis to right posterior branch of donor liver combined with jejunum of the recipient Roux-en-y anastomosis to common hepatic duct of donor liver (type 3c bile duct anatomical model). (4) Postoperative biliary complications. Of the 85 recipients, 6 cases had postoperative biliary complications, with an incidence of 7.1% (6/85). Of the 6 recipients with postoperative biliary complications, there were 5 recipients with donor liver with type 1 bile duct anatomical model, including 3 cases undergoing postoperative biliary stricture with biliary leakage and 2 cases undergoing postoperative biliary anastomotic stricture, 1 recipient with donor liver with type 3b bile duct anatomical model and undergoing postoperative biliary anastomotic stricture and bile leakage in the liver section. Cases with biliary complications were 5 in the 47 recipients with donor liver with classic bile duct anatomical model and 1 in the 38 recipients with donor liver with anato-mical variants, showing no significant difference between them ( P>0.05). (5) Follow-up. There were 83 recipients receiving followed up for 52(12,96)months. During the follow-up period, 2 recipients died due to non-biliary complication factors (1 donor liver with type 1 bile duct anatomical model and 1 donor liver with 3a bile duct anatomical model). Conclusion:The anatomical classification of right intrahepatic bile duct of donor liver in SLT is mainly classical bile duct anatomical model, and the bile duct reconstruction scheme is mainly common bile duct of donor liver end-to-end anasto-mosis to common bile duct of recipient.

Progress in diagnosis and treatment of biliary anastomotic stricture after liver transplantation / 器官移植

In recent years, with the development of organ preservation, surgical techniques, perioperative management and immunosuppression regimens, the success rate of liver transplantation and survival rate of the recipients have been significantly enhanced. Liver transplantation has become the optimal treatment for patients with end-stage liver disease. However, biliary complications still commonly occur after liver transplantation, especially biliary anastomotic stricture. Severe biliary anastomotic stricture will not only increase the cost of treatment, but also lead to graft loss and even affect the survival rate of recipients. Therefore, timely diagnosis and treatment of biliary anastomotic stricture play a significant role in improving the survival rate of liver transplant recipients. In this article, the risk factors, clinical symptoms, diagnosis and treatment of biliary anastomotic stricture after liver transplantation were reviewed, aiming to provide novel ideas for the research, diagnosis and treatment of biliary anastomotic stricture after liver transplantation, and further enhance clinical efficacy of liver transplantation and the quality of life of recipients.

Colangioscopia com litotripsia biliar percutânea a laser para tratamento de cálculos biliares intra-hepáticos: um relato de caso / Percutaneous cholangioscopy and laser biliary lithotripsy for biliary intrahepatic stones management: case report

ABSTRACT Intrahepatic biliary stone disease is a difficult condition to treat, due to anatomical complexity of biliary tract, association with colestasis, and high recurrence rates, with potential short- and long-term complications, such as cholangitis and secondary biliary cirrhosis. Removal of biliary stones via intraductal access can be achieved endoscopically or percutaneously, with preference for cholangioscopy-guided laser lithotripsy in complex cases. The surgical approach, despite its prolonged results, is a more invasive and risky procedure. The authors present a case of cholangioscopy with percutaneous laser biliary lithotripsy as an option for the treatment of intrahepatic biliary stone disease associated with biliary stricture following biliodigestive anastomosis due to bile duct injury following cholecystectomy, a safe and effective alternative with low morbidity and satisfactory outcomes in follow-up.

RESUMO A litíase biliar intra-hepática é uma condição de difícil tratamento, pela complexidade anatômica, pela associação à estase biliar e pelas altas taxas de recidiva, com potenciais complicações a curto e a longo prazo, como quadros de colangite de repetição e cirrose biliar secundária. A remoção de cálculos biliares por acesso intraductal pode ser obtida por via endoscópica ou percutânea, com preferência por litotripsia a laser por colangioscopia em casos complexos. A cirurgia, apesar de apresentar resultados prolongados, apresenta o contraponto de ser mais invasiva e com maiores riscos. Os autores apresentam um caso, e suas imagens, de colangioscopia com litotripsia biliar percutânea a laser como opção para tratamento de litíase biliar intra-hepática associado a estenose biliar secundária a anastomose biliodigestiva por lesão de via biliar pós colecistectomia, uma alternativa segura e eficaz, com baixa morbidade e um resultado satisfatório no seguimento.

Prognostic role of magnetic resonance imaging of the abdomen with intravenous contrast and magnetic resonance cholangiopancreatography in primary sclerosing cholangitis / Papel prognóstico da ressonância magnética do abdome com contraste intravenoso e colangiopancreatografia por ressonância magnética na colangite esclerosante primária

Abstract Objective: To evaluate the usefulness of Anali scores, determined by magnetic resonance imaging, for predicting the prognosis of primary sclerosing cholangitis (PSC) and to analyze interobserver variability, as well as to assess the impact of periportal edema and heterogeneous signal intensity on diffusion-weighted imaging of the liver. Materials and Methods: This was a retrospective cohort study of 29 patients with PSC and baseline magnetic resonance imaging. Anali scores, without gadolinium (0-5 points) and with gadolinium (0-2 points), were calculated by two radiologists. Clinical end-points included liver transplantation, cirrhotic decompensation, and death. We calculated intraclass correlation coefficients (ICCs) for interobserver agreement on the Anali scores, performed Kaplan-Meier survival analysis comparing event-free survival among the score strata, and calculated the areas under receiver operating characteristic curves to determine sensitivity and specificity. Results: Among the patients with a clinical event, the median Anali score was 4 (interquartile range [IQR], 2-5) without gadolinium and 2 (IQR, 1-2) with gadolinium, compared with 1 (IQR, 1.0-2.5) and 1 (IQR, 0.25-1.0), respectively, among those without a clinical event. The ICC was 0.79 (95% confidence interval: 0.57-0.91) for the Anali score with gadolinium and 0.99 (95% confidence interval: 0.98-0.99) for the Anali score without gadolinium. Periportal edema and heterogeneous signal intensity in the liver on diffusion-weighted imaging showed no statistical impact on clinical events (p = 0.65 and p = 0.5, respectively). Conclusion: Anali scores correlate with clinical events in PSC, with a high level of interobserver agreement.

Resumo Objetivo: Avaliar a utilidade dos escores Anali determinados por ressonância magnética para prever o prognóstico da colangite esclerosante primária (CEP), analisar a variabilidade interobservador e avaliar o impacto do edema periportal e do sinal heterogêneo do fígado em imagens ponderadas por difusão. Materiais e Métodos: Estudo retrospectivo de coorte de 29 pacientes com CEP e ressonância magnética de base. Os escores Anali sem gadolínio (0 a 5 pontos) e com gadolínio (0 a 2 pontos) foram calculados por dois radiologistas. Os desfechos clínicos incluíram transplante de fígado, descompensação cirrótica ou morte. Foram realizados coeficiente de correlação intraclasse (CCI) para a concordância interobservador com relação ao escore Anali, análise de sobrevivência de Kaplan-Meier comparando o tempo livre de eventos de acordo com o escore, e área sob a curva característica de operação do receptor para sensibilidade e especificidade. Resultados: Nos pacientes com evento clínico, a mediana do escore Anali sem gadolínio foi 4 (intervalo interquartil [IIQ]: 2-5) e com gadolínio foi 2 (IIQ: 1-2), enquanto nos pacientes sem evento clínico o escore sem gadolínio foi 1 (IIQ:1-2,5) e com gadolínio foi 1 (IIQ: 0,25-1). A concordância interobservador com gadolínio foi CCI = 0,79 (intervalo de confiança 95%: 0,57-0,91) e sem gadolínio foi CCI = 0,99 (intervalo de confiança 95%: 0,98-0,99). O edema periportal (p = 0,65) e o sinal heterogêneo do fígado nas imagens ponderadas por difusão (p = 0,5) não apresentaram impacto nos eventos clínicos. Conclusão: Os escores Anali se correlacionam com eventos clínicos na CEP, com alto grau de concordância interobservador.

Litiasis masiva de la vía biliar intra y extra hepática. Reporte de 2 casos / Massive intra- and extra-hepatic bile duct lithiasis. Report of 2 cases

Resumen La presencia conjunta y masiva de cálculos biliares de la vía biliar, tanto intra como extra hepática, es una rara entidad dentro de la población occidental. A continuación, se presentan 2 casos, los cuales debutan con cuadro clínico de dolor en hipocondrio derecho y con datos clínicos y de laboratorio de obstrucción de la vía biliar, y que mediante estudio de colangio resonancia, se evidencian múltiples litos endoluminales de la vía biliar de manera global, además se muestra del tratamiento de uno de los casos mediante CPRE con evacuación exitosa de los cálculos biliares.

Abstract The joint and massive presence of gallstones from the bile duct, both intra and extra hepatic, is a rare entity within the western population. Two cases are presented below, which debuted with a clinical picture of pain in the right hypo chondrium and with a clinical picture of pain in the right hypochondrium and with clinical and laboratory data of bile duct obstruction, and that by means of a resonance cholangiography study, multiple endoluminal stones of the bile duct are evidenced. Overall, it also shows the treatment of one of the cases by ERCP with successful evacuation of the gallstones.

Colangiografía videolaparoscópica intraoperatoria y colangiopancreatografía retrógrada endoscópica en pacientes con sospecha de colédocolitiasis / Intraoperative Videolaparoscopic Cholangiography and Endoscopic Retrograde Cholangiopancreatography in Patients with Suspected Choledocholithiasis

Introducción: La coledocolitiasis se ha convertido en un problema de salud para el cual existen disímiles opciones de tratamiento. Objetivo: Exponer los resultados obtenidos con la colangiografía videolaparoscópica intraoperatoria y la colangiopancreatografía retrógrada endoscópica en pacientes con sospecha de coledocolitiasis. Métodos: Se realizó un estudio descriptivo retrospectivo en pacientes con sospecha de coledocolitiasis sometidos a colangiografía videolaparoscópica y la colangiopancreatografía endoscópica en el Hospital Militar Clínico Quirúrgico Docente de Camagüey Dr. Octavio de la Concepción y de la Pedraja durante el período de enero de 2015 a diciembre de 2019. El universo lo conformaron los 117 pacientes sometidos a ambos procederes. Se controlaron las variables de sospecha de coledocolitiasis, grupos de edades, sexo, hallazgos imagenológicos, complicaciones e índice de sospecha de coledocolitiasis. Resultados: En la colangiografía videolaparoscópica intraoperatoria fue mayor la posibilidad diagnóstica y menor las complicaciones. El diagnóstico de coledocolitiasis fue mayor en los pacientes sometidos a colangiopancreatografía retrógrada endoscópica, aunque esta no permitió evaluar a pacientes con bajo riesgo. Los pacientes del sexo femenino fueron más frecuentes en ambos grupos y la sospecha de coledocolitiasis se observó en grupo de edades entre 31 y 45 años. Sin embargo, fue normal el hallazgo de las vías biliares en ambos procederes. Conclusiones: Ambos métodos son seguros y útiles en el estudio en pacientes con sospecha de coledocolitiasis, con mayor eficacia diagnóstica para la técnica videolaparoscópica y menos complicaciones. El hallazgo normal de la vía biliar fue el resultado que prevaleció en ambos procederes(AU)

Introduction: Choledocholithiasis has become a health problem for which there are dissimilar treatment options. Objective: To present the results obtained with intraoperative videolaparoscopic cholangiography and endoscopic retrograde cholangiopancreatography in patients with suspected choledocholithiasis. Methods: A retrospective and descriptive study was conducted in patients with suspected choledocholithiasis and submitted to videolaparoscopic cholangiography and endoscopic cholangiopancreatography at Hospital Militar Clínico Quirúrgico Docente Dr. Octavio de la Concepción y de la Pedraja, of Camagüey, during the period from January 2015 to December 2019. The study universe consisted of 117 patients submitted to both procedures. The variables of suspected choledocholithiasis, age groups, sex, imaging findings, complications and index of suspected choledocholithiasis were controlled. Results: Intraoperative videolaparoscopic cholangiography had a higher diagnostic possibility and lower complications. The diagnosis of choledocholithiasis was higher in patients submitted to endoscopic retrograde cholangiopancreatography, although this did not allow the assessment of low-risk patients. Female patients were more frequent in both groups, while suspected choledocholithiasis was observed in patients between 31 and 45 years of age. However, the finding of a normal biliary tract was common to both procedures. Conclusions: Both methods are safe and useful in the study in patients with suspected choledocholithiasis, with greater diagnostic efficacy, as well as fewer complications, for the videolaparoscopic technique. The finding of a normal biliary tract was the prevailing result in both procedures(AU)

Peroral cholangioscopy for the evaluation of bile duct stricture in hepatocellular carcinoma on a preoperative examination / Journal of Rural Medicine

Objective: Bile duct tumor thrombosis in hepatocellular carcinoma (HCC) is a relatively rare event with a poor prognosis. Furthermore, bile duct tumor thrombus in HCC may be misdiagnosed when only imaging modalities are used. The efficiency of peroral cholangioscopy (POCS) in evaluating bile duct lesions has been reported.Patients: We present three cases of HCC with bile duct strictures in which POCS was performed as a preoperative evaluation.Results: In these three cases, diagnosing whether the lesion was a bile duct tumor thrombus on CT and endoscopic retrograde cholangiopancreatography was difficult. We performed POCS in three cases and were able to diagnose the presence of bile duct tumor thrombus of HCC, including differentiation from extrinsic compression of the bile duct.Conclusion: POCS for HCC with bile duct features is useful for the preoperative diagnosis of bile duct tumor thrombus, especially in cases where the surgical procedure depends on the presence of bile duct tumor thrombus.

Research progress of intraoperative cholangiography in laparoscopic cholecystectomy / 国际外科学杂志

With the widespread implementation of laparoscopic cholecystectomy in various levels of medical institutions, surgical complications have also increased. Among them, the incidence of bile duct injury remains high in complex laparoscopic cholecystectomy. The reason for this is that surgeons cannot effectively and accurately identify the relationship between the aberrant bile duct and the cystic duct and the common bile duct, resulting in the accidental injury of the bile duct, resulting in long hospital stays, increased medical costs, and decreased long-term quality of life for patients. Intraoperative cholangiography, as a real-time visual method of biliary presentation, can effectively reduce the incidence of iatrogenic bile duct injury. However, most surgeons do not fully understand the technology of intraoperative cholangiography during cholecystectomy. This article reviews the application of intraoperative cholangiography in laparoscopic cholecystectomy based on the clinical experience of the author′s team and the literature in recent years, with the aim of deepening the understanding of surgeons about intraoperative cholangiography, so as to better apply it to clinical practice and benefit patients.

Diagnosis and treatment of common biliary complications after orthotopic liver transplantation in adults / 器官移植

Liver transplantation has become an effective treatment for end-stage liver diseases. With rapid development of surgical techniques, donor selection, organ preservation and transportation, immunosuppressants and perioperative management, the overall incidence of complications after liver transplantation has been significantly decreased, whereas the incidence of biliary complications remains relatively high. At present, biliary complications after liver transplantation are still an important cause of graft failure. Nevertheless, the pathogenesis, diagnosis and treatment of biliary complications remain controversial, which are also research hotspots in the field of organ transplantation in recent years. In this article, new breakthrough and research progress upon biliary complications after orthotopic liver transplantation in adults were reviewed, aiming to provide theoretical basis for resolving biliary complications-related clinical issues.

Application of indocyanine green cholangiography in accurate identification of the common bile duct in laparoscopic cholecystectomy / 临床肝胆病杂志

Objective To investigate the application of intraoperative indocyanine green (ICG) cholangiography in the accurate identification of the common bile duct since common bile duct injury is a common complication of laparoscopic cholecystectomy (LC), and to reduce the incidence rate of common bile duct injury during LC. Methods A total of 68 patients who underwent LC in Zhuhai People's Hospital from April 2021 to Jane 2021 were enrolled, among whom 56 patients underwent conventional LC and 12 patients underwent LC under the guidance of ICG cholangiography. The common bile duct, cystic duct, and gallbladder were examined by white light laparoscopy for the conventional LC group and near-infrared laparoscopy for the ICG cholangiography group. The propensity score matching method was used to balance the preoperative data between the two groups. The t -test and the chi-square test were used for comparison of intraoperative blood loss, time of operation, length of postoperative hospital stay, and incidence rate of common bile duct injury between the two groups. Results Compared with the conventional LC group, the ICG cholangiography group had significantly lower intraoperative blood loss 3.1±0.9 mL vs 10.8±2.3 mL, t =-22.709, P < 0.05), significantly shorter time of operation (20.2±1.6 min vs 48.3±5.1 min, t =-19.856, P < 0.05) and length of postoperative hospital stay (1.2±0.3 days vs 2.3±0.8 days, t =-19.507, P < 0.05), and a significantly lower incidence rate of complications (0 vs 8.3%, χ 2 =1.287, P < 0.05). Conclusion ICG cholangiography is an effective method to differentiate between the common bile duct and the cystic duct during LC and can prevent common bile duct injury. This method has great advantages in the treatment of patients with gallstones due to its high degree of identification of the biliary tract, long onset time, repeated application, convenient operation, and ability to be combined with intraoperative navigation device.

Design and application of a new type of biliary-intestinal nutrient tube / 中华危重病急救医学

The establishment of a nutritional pathway is the premise and basis of nutritional therapy for patients with malignant tumor. The nasogastric tube, nasoenteric tube, and percutaneous endoscopic gastric/jejunostomy are commonly used clinical pathways for enteral nutrition (EN) therapy. However, these EN pathways are often difficult to establish in patients with malignant obstructive jaundice (MOJ) with pyloric or duodenum primary obstruction. For this reason, a new type biliary-intestinal nutrient tube placed through percutaneous transhepatic cholangiography drainage (PTCD) pathway was designed by the medical staff of hepatobiliary surgery department of Yinchuan First People's Hospital, and National Utility Model Patent of China were obtained (ZL 2020 2 0283951.5, ZL 2020 2 0288938.9). The new biliary-intestinal nutrient tube has two types: double-lumen tube and single-lumen tube, which consists of tube head, tube body, tail ring and developing ring. The double lumen tube realizes bile internal drainage and EN simultaneously through the double lumen structure of the tube body. The single-lumen tube is used for nutrient infusion after bile duct metal stent implantation, which is not limited by the type of nutrient solution. The tail ring of the two types of nutrient tube is placed in the upper jejunum to reduce retrograde infection and unexpected extubation. Compared with the prior art, the utility model has the advantages of simple structure, reasonable design, safe and effective placement through PTCD pathway, and opens up a new EN path for MOJ patients.

Aneurisma de la aorta abdominal asociado a íctero / Aneurysm of the abdominal aorta associated with icterus

El aneurisma de la aorta abdominal como causa de íctero obstructivo es una situación de excepción en la clínica. El objetivo de esta presentación fue exponer la coexistencia del aneurisma de la aorta abdominal y el íctero. Una asociación muy poco frecuente y de difícil diagnóstico, que coloca al cirujano vascular en la toma de una especial conducta terapéutica. La cuidadosa revisión de los antecedentes patológicos y el análisis del comportamiento clínico del paciente permitieron la solución terapéutica adecuada. Se logró demostrar que el íctero obedecía a una lesión maligna de vías biliares conocida como colangiocarcinoma, que concomitó con la existencia de un aneurisma del V segmento aórtico y no fue el resultado de una compresión extrínseca de la dilatación de la aorta, sobre las vías biliares. La conducta quirúrgica, encaminada a erradicar el íctero y evitar la ruptura aneurismática con resección del aneurisma y colocación de prótesis, no resultó posible por lo avanzado de la lesión tumoral y el grado de metástasis ya establecidos. Solo se realizó resección de la vesícula biliar y seguimiento posterior por oncología(AU)

Abdominal aortic aneurysm as a cause of obstructive icterus is an exceptional situation in the clinic. The aim of this presentation was to expose the coexistence of abdominal aortic aneurysm and icterus. A very rare and difficult to diagnose association, which places the vascular surgeon in a special therapeutic approach. The careful review of the pathological history and the analysis of the patient's clinical behavior allowed the appropriate therapeutic solution. It was possible to demonstrate that the icterus was due to a malignant lesion of the biliary tract known as cholangiocarcinoma, which concomitated with the existence of an aneurysm of the V aortic segment and was not the result of extrinsic compression of the dilatation of the aorta on the biliary tract. The surgical procedure, aimed at eradicating the icterus and avoiding aneurysmal rupture with aneurysm resection and prosthesis placement, was not possible due to the advanced tumor lesion and the degree of metastasis already established. Only gallbladder resection was performed and subsequent follow-up by oncology(AU)

Estudio complementario de la patología biliar complicada y el manejo de la litiasis coledociana en dos tiempos / Complementary evaluation of complicated gallstone disease and two-stage management of choledochal lithiasis

RESUMEN Antecedentes: la litiasis biliar tiene una prevalencia actual en Occidente del 10-20%. El 7-16% de los pacientes presentan también coledocolitiasis. El diagnóstico preoperatorio de coledocolitiasis es difícil de establecer. Objetivo: establecer nuestra experiencia en el estudio de la patología biliar complicada y el manejo de la coledocolitiasis en dos tiempos, como terapéutica de elección. Material y métodos: estudio prospectivo, observacional. Pacientes con patología biliar sometidos a procedimientos en el Servicio de Cirugía General del Hospital Vidal, desde el 30/06/2019 al 30/12/2019. Resultados: la ecografía hepato-bilio-pancreática (HPB) es específica, con exactitud del 80,9% y sensibilidad del 50%. La colangio resonancia magnética (CRNM) es 100% específica, tiene exactitud del 84,6% y sensibilidad de 67%. La colangio pancreatografía retrógrada endoscópica (ERCP -por sus siglas en inglés-), durante la primera colangiografía mostró en el 100% litiasis coledociana, pero, luego del tratamiento, la colangiografía de "control" muestra 0% de sensibilidad, 100% especificidad, con exactitud del 15,4%. En los hallazgos intraoperatorios, el cístico dilatado en asociación con alteraciones humorales ha demostrado una sensibilidad del 100%, especificidad del 90% y tasa de exactitud de 93,6%. Conclusión: la colangiografía intraoperatoria (CIO) es el procedimiento de referencia ("gold standard") en el abordaje de la patología biliar complicada, siendo su uso sistemático. La asociación entre alteraciones de parámetros humorales y el cístico dilatado resulta un parámetro con alto valor predictivo para la presencia de litiasis coledociana.

ABSTRACT Background: Nowadays, the prevalence of gallstones ranges between 10 and 20% in Western world, and 7-16% of the patients also present choledocholithiasis. The preoperative diagnosis of choledocholithiasis is difficult. Objective: To establish our experience in the evaluation of complicated gallstone disease and two-stage management of choledochal lithiasis as standard or care. Material and methods: This prospective and observational study included patients hospitalized with gallstone disease undergoing procedures in the Department of General Surgery of Hospital Vidal from June 30, 2019, to December 30, 2019. Results: Ultrasound of the liver, biliary tract and pancreas was specific, with accuracy of 80.9% and sensitivity of 50%. Magnetic resonance cholangiopancreatography (MRCP) had a sensitivity of 100%, accuracy of 84.6% and sensitivity of 67%. As for endoscopic retrograde cholangiopancreatography (ERCP), the diagnosis of choledocholithiasis was made in 100% of the cases during the first cholangiography while "control" cholangiography had a sensitivity of 0%, specificity of 100% and accuracy of 15.4%. The presence of a dilated cystic duct intraoperatively in association with abnormal biochemical parameters had a sensitivity of 100%, specificity of 90%, and accuracy of 93.6%. Conclusion: Intraoperative cholangiography (IOC) is the gold standard procedure for the management of complicated gallstone disease. The association of biochemical parameters and a dilated cystic duct has high predictive value for choledochal lithiasis.

Application of near infrared region Ⅱ fluorescence imaging in hepatobiliary surgery / 中华消化外科杂志

Near infrared region Ⅱ (NIR-Ⅱ) fluorescence imaging has made progress in clinical application in recent years and has shown a higher image quality, tumor sensitivity and deeper tissue imaging capability compared to near infrared region Ⅰ imaging in liver neoplasms and biliary tract system. As a real-time intraoperative imaging technology, which can provide high signal to background ratio and deeper tissue penetration, NIR-Ⅱ is able to shorten the duration of operation while improve the safety and therapeutic effect of surgery. It has a great prospect and expanding ability. With the development of a bunch of novel NIR-Ⅱ fluorophores, it is expected to play more important roles in hepatocellular carcinoma targeted imaging, evaluation of bile duct perfusion, distal choledochal imaging and so on. The authors review the progress in the application of NIR-Ⅱ fluorescence imaging in hepatobiliary surgery.

Colangiografía intraoperatoria: curva de aprendizaje en una Residencia de Cirugía General / Intraoperative cholangiography: Learning curve in a General Surgery residency

RESUMEN Antecedentes: el uso de la colangiografía intraoperatoria dinámica (CIOd) durante la colecistectomía laparoscópica (Colelap) sigue siendo un tema en discusión. Objetivos: Este trabajo tiene como objetivo describir y evaluar la curva de aprendizaje y los hallazgos en la CIOd durante las colecistectomías laparoscópicas realizadas por residentes de Cirugía General, incluyéndola como herramienta para una colecistectomía segura, así como entrenamiento para el de sarrollo de habilidades y destrezas. Material y métodos: se incluyeron pacientes con indicación de colecistectomía laparoscópica pro gramada o de urgencia. En las cirugías se realizó tracción según Hunter, visión crítica de seguridad y CIOd sistemática, por un residente mayor y la CIOd por un residente inferior, tutorizado por cirujano de planta. Se evaluaron curva de aprendizaje, tiempos operatorios, relación del tiempo de CIOd con el tiempo de duración de la Colelap (CIO/CX), redisección del cístico y litiasis cística y coledociana. Resultados: se operaron 456 pacientes durante un año (2017-2018). Se observó que, independiente mente de quien realice la CIOd, los residentes pudieron mejorar su curva de aprendizaje, objetiván dose tiempos más cortos para la Colelap, CIOd y la relación CIO/CX. Los coeficientes de aprendizaje fueron mejores en cirugías más complejas en relación con el semestre. El 5,26% presentó litiasis cole dociana (n = 24); de estas, 66,7% tenían litiasis cística (n = 16) y 25% colecistitis (n = 6) asociadas. Todas se resolvieron por vía transcística. No hubo conversiones y se realizó CIOd en el 100%. Conclusión: la CIOd es un procedimiento ideal para ser practicado de manera sistemática durante la Residencia, porque da el entrenamiento necesario para el manejo de la vía transcística, permite evitar una lesión quirúrgica de vía biliar mayor y el diagnóstico de coledocolitiasis.

ABSTRACT Background: The use of dynamic intra-operative cholangiography (dIOC) during laparoscopic cholecystectomy (Lap Chole) remains a topic under discussion. Objectives: This study aims to describe and evaluate the learning curve and findings in the dIOC during laparoscopic cholecystectomies performed by Residents of General Surgery, including it as a tool for a safe cholecystectomy, as well as training for the development of skills and abilities. Material and methods: Patients with indication of scheduled or emergency laparoscopic cholecystectomy were included. In the surgeries, traction was performed according to Hunter, critical safety vision and systematic dIOC, by a senior Resident and the dIOC by a less trained resident, tutored by a staff surgeon. Learning curve, operative times, dIOC time relationship with Lap Chole duration time (IOC/LC), repeated cystic dissection, cystic lithiasis and choledocholithiasis were evaluated. Results: 456 patients were operated for one year (2017-2018). It was observed that regardless of who performs the dIOC, they were able to improve their learning curve, objectifying shorter times for Lap Chole, dIOC and the IOC/LC relationship. The learning coefficients were better in complex surgeries in relation to the semester. 5.26 % had choledocholithiasis (n = 24), of these, 66.7% had cystic lithiasis (n = 16) and 25% associated cholecystitis (n = 6). All were resolved trancystically. There were no conversions and dIOC was performed in 100% of cases. Conclusion: The dIOC is an ideal procedure to be practiced systematically during residency. Because it gives the necessary training for the management of the transcystic pathway, allows avoiding an upper bile duct injury and the diagnosis of choledocholithiasis.

Tratamiento endoscópico de las estenosis poscolescistectomía de la vía biliar / Endoscopic treatment of postcholecystectomy bile duct stenosis

Introducción: La estenosis de la vía biliar es una afección poco frecuente, pero con serias repercusiones en la morbilidad de los pacientes. La gran mayoría ocurre después de la cirugía hepatobiliar: la colecistectomía es la más común de estas cirugías. El reconocimiento temprano y el enfoque multidisciplinario adecuado es la piedra angular para lograr obtener resultados finales óptimos. Objetivo: Describir el tratamiento endoscópico de los pacientes con estenosis poscolescistectomía atendidos en el Instituto de Gastroenterología (Cuba). Métodos: Se realizó un estudio retrospectivo descriptivo de los pacientes con diagnóstico de estenosis biliar poscolescitectomía. Se determinaron variables sociodemográficas, clínicas y endoscópicas de interés. Resultados: Se estudiaron 16 pacientes. Predominaron las mujeres menores de 50 años. El 75 % de los pacientes tenían antecedente de colecistectomía laparoscópica. Las estenosis biliares tipo I y III, según la clasificación de Bismuth, fueron las más usuales. El tratamiento endoscópico mediante colangiografía retrógrada endoscópica (CPRE) con colocación de múltiples prótesis plásticas fue la conducta terapéutica más empleada. Conclusiones: En las estenosis poscolescitectomía los procedimientos endoscópicos se han convertido en el tratamiento de elección, como un procedimiento menos invasivo, con baja morbilidad y mortalidad, con evidentes resultados comparables a los logrados con procedimientos quirúrgicos no endoscópicos(AU)

Introduction: Bile duct stenosis is an infrequent condition, but it seriously affects patient morbidity. The vast majority of cases occur after hepatobiliary surgery, cholecystectomy being the most common of such surgeries. Early recognition and an appropriate multidisciplinary approach are the cornerstones to achieve optimal final results. Objective: Describe the endoscopic treatment of patients with postcholecystectomy stenosis cared for at the Institute of Gastroenterology in Cuba. Methods: A retrospective descriptive study was conducted of the patients diagnosed with postcholecystectomy bile duct stenosis. Determination was made of sociodemographic, clinical and endoscopic variables of interest. Results: A total 16 patients were studied. There was a predominance of women aged under 50 years. 75% of the patients had a history of laparoscopic cholecystectomy. The most common bile duct stenoses were types I and III by Bismuth's classification. The most frequent therapeutic management was endoscopic treatment by endoscopic retrograde cholangiography (ERCP) with placement of multiple plastic prostheses. Conclusions: Endoscopic procedures have become the treatment of choice in postcholecystectomy stenosis. They are less invasive, their morbidity and mortality are low, and their results are comparable to those of non-endoscopic surgical procedures(AU)

Tratamiento endoscópico de las estenosis poscolescistectomía de la vía biliar / Endoscopic treatment of postcholecystectomy bile duct stenosis

Introducción: La estenosis de la vía biliar es una afección poco frecuente, pero con serias repercusiones en la morbilidad de los pacientes. La gran mayoría ocurre después de la cirugía hepatobiliar: la colecistectomía es la más común de estas cirugías. El reconocimiento temprano y el enfoque multidisciplinario adecuado es la piedra angular para lograr obtener resultados finales óptimos. Objetivo: Describir el tratamiento endoscópico de los pacientes con estenosis poscolescistectomía atendidos en el Instituto de Gastroenterología (Cuba). Métodos: Se realizó un estudio retrospectivo descriptivo de los pacientes con diagnóstico de estenosis biliar poscolescitectomía. Se determinaron variables sociodemográficas, clínicas y endoscópicas de interés. Resultados: Se estudiaron 16 pacientes. Predominaron las mujeres menores de 50 años. El 75 por ciento de los pacientes tenían antecedente de colecistectomía laparoscópica. Las estenosis biliares tipo I y III, según la clasificación de Bismuth, fueron las más usuales. El tratamiento endoscópico mediante colangiografía retrógrada endoscópica (CPRE) con colocación de múltiples prótesis plásticas fue la conducta terapéutica más empleada. Conclusiones: En las estenosis poscolescitectomía los procedimientos endoscópicos se han convertido en el tratamiento de elección, como un procedimiento menos invasivo, con baja morbilidad y mortalidad, con evidentes resultados comparables a los logrados con procedimientos quirúrgicos no endoscópicos(AU)

Introduction: Bile duct stenosis is an infrequent condition, but it seriously affects patient morbidity. The vast majority of cases occur after hepatobiliary surgery, cholecystectomy being the most common of such surgeries. Early recognition and an appropriate multidisciplinary approach are the cornerstones to achieve optimal final results. Objective: Describe the endoscopic treatment of patients with postcholecystectomy stenosis cared for at the Institute of Gastroenterology in Cuba. Methods: A retrospective descriptive study was conducted of the patients diagnosed with postcholecystectomy bile duct stenosis. Determination was made of sociodemographic, clinical and endoscopic variables of interest. Results: A total 16 patients were studied. There was a predominance of women aged under 50 years. 75 percent of the patients had a history of laparoscopic cholecystectomy. The most common bile duct stenoses were types I and III by Bismuth's classification. The most frequent therapeutic management was endoscopic treatment by endoscopic retrograde cholangiography (ERCP) with placement of multiple plastic prostheses. Conclusions: Endoscopic procedures have become the treatment of choice in postcholecystectomy stenosis. They are less invasive, their morbidity and mortality are low, and their results are comparable to those of non-endoscopic surgical procedures(AU)