Litiasis vesicular asintomática: ¿expectar o intervenir?. Revisión de literatura / Asymptomatic biliary lithiasis . Expectant behaviour or active treatment?

Contexto: La litiasis vesicular asintomática es un cuadro clínico cuyo abordaje terapéutico resulta controversial. Objetivos: Definir qué pacientes con litiasis vesicular son asintomáticos, identificar riesgos y beneficios de la conducta expectante en pacientes asintomáticos, mencionar qué grupos de pacientes asintomáticos se beneficia con la cirugía preventiva. Material y métodos: Se realizó una revisión de trabajos publicados en la plataforma. Pubmed para identificar y analizar aquellos que consideramos más representativos sobre litiasis vesicular asintomática, y así describir la conducta más apropiada ante dicha situación. Resultados: Al realizar la revisión de artículos con bajo nivel de evidencia (C-D) observamos que par la litiasis vesicular asintomática la conducta expectante es la más recomendada. Sin embargo varios trabajos hacen referencia a grupos de pacientes seleccionados que debido a su condición de base se beneficiarían con la cirugía. Conclusiones: Con la información obtenida de los artículos analizados se concluye que No está recomendada de forma rutinaria la colecistectomía profiláctica en los pacientes con litiasis asintomática; los pacientes que se benefician de la cirugía y en los cuales la indicación de colecistectomía es clara son: pacientes con riesgo elevado de desarrollar cáncer de vesícula (existencia de pólipos vesiculares con crecimiento rápido o mayor de 1 cm, vesícula en porcelana, cáculo mayor de 3 cm, mujer joven de origen ameroindio) y pacientes con mayor riesgo de desarrollar coplicaciones como son los jóvenes con anemia hemolítica crónica. El procedimiento quirúrgico iindicado es la colecistectomía por vía laparoscópica, siendo éste el procedimiento quirúrgico con menor tasa de morbimortalidad y mejor recuperarción postoperatoria disponibe (AU)

The presence of stones in the gallbladder is a condition relatively common in many parts of the world, being present in 10% to 15% of the adult population, and the presence of stones in the gallbladder afficts more than 21.9 % of the population of the city of Buenos Aires. When patients present with symptoms of biliary lithiasis, there is consense toward the surgical removal. But in the patients with asymptomatic gallstones that have no pain and do not have compications, the management of these silent gallstones is somewhat controversial. Data coupled with results suggesting that persons's life expectancy is not increased by prophylactic cholecystectomy, have discouraged surgical tratment of gallstones unless symptoms are present. The aim of this report was to determine which patients with biliary lithiasis should be considered as asymptomatic patients, and to consider which group of the expectant management in asymptomatic patients, and to consider which group of these patients can be beneficiated with a preventive cholecystectomy. A revision of the literature was performed, considering the management of the asymptomatic gallstone disease, whether if it should be preferable the expectant management or instead an active treatment. The expectant management was the mos recommended procedure fot these patients (AU)

Recent Advances in Management of Chronic Pancreatitis / 대한소화기학회지

Treatment for chronic pancreatitis (CP) should be started early to prevent further pancreatic fibrosis and managed with a multidisciplinary approach to prevent complications and to maintain a good quality of life. The management strategies of CP can be divided into medical, endoscopic, and surgical treatment. The role of pancreatic enzymes and antioxidants for pain relief is not clearly defined, but their role in maintaining nutritional support by correcting exocrine insufficiency is well established. Endoscopic treatment is applied for resolution of pancreatic or bile duct strictures, clearance of pancreatic duct stones, and pseudocyst drainage. Endosonography-guided celiac plexus or celiac ganglia block for pain relief are known to be safe procedures but evidence for their effectiveness is still lacking. Surgery is commonly recommended when endoscopic therapy fails or there is suspicion of malignancy. New evidence-based guidelines for the management of CP are needed.

Is endoscopic sphincterotomy plus large-balloon dilation a better option than endoscopic large-balloon dilation alone in removal of large bile duct stones? A retrospective comparison study.

Background: Several comparison studies have demonstrated that endoscopic sphincterotomy (EST) combined with large-balloon dilation (LBD) may be a better option than EST alone to manage large bile duct stones. However, limited data were available to compare this combination method with LBD alone in removal of large bile duct stones. Objective: To compare EST plus LBD and LBD alone for the management of large bile duct stones, and analyze the outcomes of each method. Patients and Methods: Sixty-one patients were included in the EST plus LBD group, and 48 patients were included in the LBD alone group retrospectively. The therapeutic success, clinical characteristics, procedure-related parameters and adverse events were compared. Results: Compared with EST plus LBD, LBD alone was more frequently performed in patients with potential bleeding diathesis or anatomical changes (P = 0.021). The procedure time from successful cannulating to complete stone removal was shorter in the LBD alone group significantly (21.5 vs. 17.3 min, P = 0.041). The EST plus LBD group and the LBD alone group had similar outcomes in terms of overall complete stone removal (90.2% vs. 91.7%, P = 1.000) and complete stone removal without the need for mechanical lithotripsy (78.7% vs. 83.3%, P = 0.542). Massive bleeding occurred in one patient of the EST plus LBD group, and successfully coagulated. Postoperative pancreatitis did not differ significantly between the EST plus LBD group and the LBD alone group (4.9% vs. 6.3%; P = 1.000). Conclusion: Endoscopic sphincterotomy combined with LBD offers no significant advantage over LBD alone for the removal of large bile duct stones. LBD can simplify the procedure compared with EST plus LBD in terms of shorten the procedure time.

[Retained common bile duct stones after endoscopic sphincterotomy temperary and longtern treatment with biliary stenting]

Endoscopic extraction of biliary tract stones is safe and effective. When the procedure is not successful, the use of a biliary stent can be a solution. To prospectively analyse the usefulness of a stenting in management of biliary obstruction due to choledocolithiasis. All patients referred to our endoscopic unit from January 2005 to January 2008, for management of bile duct stone are studied. We included patients subjected to an endoscopic insertion of a biliary stent. Of 414 patients with choledocolithiasis, 51 failed to have their ducts cleared with the first endoscopic retrograde cholangiopancreatography [ERCP]: 25 patients [6%] were referred to surgical stone removal. Twenty six consecutive patients had endoscopic insertion of a 10 Fr biliary stent: There were 12 men and 14 women ranging in age from 35 to 102 years [median age 68 years]. The indications for stent placement in common bile duct stone were mainly the endoscopic portal hypertension, elderly patients or with a short life expectancy. Twenty four patients [88%] are symptom free after stenting. Six patients [23%] had duct clearance after a median of 3 sessions at a mean of 13 months [range 3-48 months]. In 3 patients endoprosthesis was inserted as a permanent therapy of biliary obstruction. Cholangitis occurred in 5 patients, early in two cases and later at a mean of 18 months [range 6-24 months] in 3 patients and was managed endoscopically by stent replacement and fluid antibiotics. These data favor temporary use of biliary endoprostheses in patients with endoscopically irretrievable bile duct stones until the definitive treatment is carried out. However, as a permanent therapy, late complications occur in many patients and the risk increases proportionally in time. Therefore, permanent biliary stenting should preferably be restricted to patients unfit for elective treatment at a later stage and with a short life expectancy

Exploración laparoscópica de la vía biliar y manejo actual de la coledocolitiasis: análisis de los primeros 30 casos / Laparoscopic common bile duct exploration and current management of choledocholithiasis

Se trata de un estudio descriptivo, prospectivo, longitudinal que incluyó a 30 pacientes que consultaron con indicaciones de exploración laparoscópica de la vía biliar. Se describe la técnica utilizada para la exploración transcística y por coledocotomía, tanto con guía fluoroscópica como el uso del coledocoscopio. Se estudiaron las variables, efectividad, conversión, tiempo quirúrgico, complicaciones tiempo de hospitalización, litiasis residual. La exploración laparoscópica de la vía biliar fue efectiva en el 84% de los casos. Las causas de conversión fueron cálculos enclavados y cálculos intrahepáticos. El 32% de los casos se resolvió por la vía transcística , mientras que el resto (68%) se resolvió mediante coledocotomía. La morbilidad asociada la técnica fue de 6,6% dada por diarrea postoperatoria y biliperitoneo luego del retiro del tubo en “t”. El tiempo promedio de hospitalización fue de 3,5 días. Sin casos reportados de litiasis residual. La exploración laparoscópica de la vía biliar (ELVB) es una alternativa terapéutica segura y efectiva en el tratamiento de la obstrucción de la vía biliar principal por cálculos. Sin embargo, queda claro que el éxito del procedimiento depende del dominio de técnicas endoscópicas y laparoscópicas avanzadas y la disponibilidad de recursos tecnológicos de primera.

Report the experience in laparoscopic common bile duct exploration in the Surgery Department III of the Hospital Universitario de Caracas. Descriptive, prospective, longitudinal study of patients admitted with indication of laparoscopic common bile duct exploration. We describe the transcystic approach and choledochotomy technique, using fluoroscopic guidance or choledochoscope. Success rate, conversion, operative time, complications, length of stay and residual lithiasis were studied. Laparoscopic common bile exploration was successful in 84% of the patients. Conversión causes were embedded stones and intrahepatic lithiasis. Transcystic approach was used in 32% of the cases and choledochotomy was performed in 68% of the patients. Morbidity rate was 6,6% due to diarrhea and biliary peritonitis after "t" tube removal. Median length of stay was 3,5 days. No cases of residual stones were reported. Laparoscopic common bile duct exploration is a safe and effective procedure in patients with common bile duct obstruction due to choledocholithiasis However, the success rate is in relation with endoscopic and advanced laparoscopic techniques mastery and technologic resources availability.

Laparoscopic Cholecystectomy at the Korle Bu Teaching Hospital; Accra; Ghana: an Initial Report

BACKGROUND: Laparoscopic cholecystectomy (LC) the preferred treatment for gallstones was not available in Ghana until 2005. OBJECTIVE: To report experience from Ghana of laparoscopic cholecystectomy in the treatment of galestones. METHODS: In a prospective study of patients with gallstones; information was obtained on demography; duration of various stages of the operation; analgesia and complication of patients with gallstones. All patients had general anaesthesia using endotracheal intubation; muscle relaxant and intermittent positive pressure ventilation. A standard four-trocar technique and maximum pneumoperitoneum pressure of 14mmHg were maintained during surgery. RESULTS: There were 50 women and two men aged 17-72 years (mean 44.2 years). All had symptomatic gallstones treated by interval LC. The main indications were biliary colic 23(44) and previous cholecystitis 15(29). There were scars from previous abdominal surgery in 22 (42); mainly pfannenstiel. The Verres needle was used to obtain pneumoperitoneum in 40 (77). Only one patient (1.9) had the operation converted to open cholecystectomy. Most patients; 47/51 (92); were discharged in 24 hours. The mean durations of various stages were: anaesthesia (110 minutes); pneumo-peritoneum (67.5 minutes) and reverse trendelenburg (47.8 minutes). The mean operating time reduced from 81 to 68 minutes in the last 20 patients. Complications were sore throat 11(21.6); infection of the umbilical wound 3(5.9); right shoulder tip pain (3; 5.9) and bile leak 1(2). There was no peri-operative mortality. CONCLUSION: Elective laparoscopic cholecystectomy can be performed with good results in patients with symptomatic gallstones in Accra

Endoscopic laser lithotripsy for complicated bile duct stones: is cholangioscopic guidance necessary?

BACKGROUND: Endoscopic papillotomy is successful in more than 95 percent of the cases of choledocholithiasis. For patients with difficult bile duct stones not responding to mechanical lithotripsy, different methods for stone fragmentation have been developed. AIM: To compare the results of laser lithotripsy with a stone-tissue recognizing system, when guided by fluoroscopy only or by cholangioscopy. METHODS: Between 1992 and 2002 we have treated 89 patients with difficult bile duct stones by endoscopic retrograde cholangiopancreatography and laser lithotripsy. Unsuccessful extracorporeal shock-wave lithotripsy and electrohydraulic were also performed before laser in 35 percent and 26 percent of the cases, respectively. RESULTS: Laser was effective in 79.2 percent of 72 patients guided by cholangioscopy and in 82.4 percent of 17 cases steered by fluoroscopy. The median number of impulses in the latter was 4,335 and 1,800 with the former technique. Two parameters influenced the manner of laser guidance. In cases of stones situated above a stricture, cholangioscopic control was more effective (64.7 percent vs. 31.9 percent). When the stones were in the distal bile duct, fluoroscopic control was more successful. CONCLUSION: In cases of difficult stones in the distal bile duct, laser lithotripsy under fluoroscopic control is very effective and easily performed. Cholangioscopic guidance should be recommended just in cases of intrahepatic stones or in patients with stones situated proximal to a bile duct stenosis. In these cases, cholangioscopy should be performed either endoscopically or percutaneously.

RACIONAL: A papilotomia endoscópica é efetiva em mais de 95 por cento dos casos de coledocolitíase . Para pacientes com cálculos de difícil extração (gigantes ou proximais a uma estenose), que não respondem à litotripsia mecânica, diferentes métodos de fragmentação foram desenvolvidos. OBJETIVO: Comparar os resultados da litotripsia à laser com um sistema de reconhecimento cálculo-tecido, quando guiada por fluoroscopia somente ou por colangioscopia. MÉTODOS: Entre 1992 e 2002 foram tratados 89 pacientes com cálculos biliares de difícil extração pela colangiopancreatografia endoscópica retrógrada e litotripsia à laser. Litotripsia extracorpórea e eletro-hidráulica sem sucesso foram executados antes do laser em 35 por cento e 26 por cento dos casos, respectivamente. RESULTADOS: O laser foi efetivo em 79,2 por cento dos 72 pacientes guiados por colangioscopia e, em 82,4 por cento dos 17 casos guiados por fluoroscopia. A média de impulsos do último foi de 4 335 e da primeira técnica de 1 800. Dois parâmetros influenciaram o modo de orientação da litotripsia à laser. Nos casos de cálculos situados proximais a uma estenose, o controle colangioscópico foi mais efetivo (64,7 por cento vs 31,9 por cento). Quando os cálculos estavam na via biliar distal, o controle fluoroscópico era mais efetivo. CONCLUSÃO: Nos casos de cálculos biliares de difícil extração na via biliar distal, litotripsia à laser com controle fluoroscópico é muito efetiva e de fácil execução. A orientação colangioscópica deve ser recomendada somente nos casos de cálculos intra-hepáticos ou em pacientes com cálculos situados proximamente a uma estenose de via biliar. Nesses casos, colangioscopia pode ser executada tanto por via endoscópica quanto percutânea.

Percutaneous Treatment of Extrahepatic Bile Duct Stones Assisted by Balloon Sphincteroplasty and Occlusion Balloon

OBJECTIVE: To describe the technical feasibility and usefulness of extrahepatic biliary stone removal by balloon sphincteroplasty and occlusion balloon pushing. MATERIALS AND METHODS: Fifteen patients with extrahepatic bile duct stones were included in this study. Endoscopic stone removal was not successful in 13 patients, and two patients refused the procedure due to endoscopy phobia. At first, all patients underwent percutaneous transhepatic biliary drainage (PTBD). A few days later, through the PTBD route, balloon assisted dilatation for common bile duct (CBD) sphincter was performed, and then the stones were pushed into the duodenum using an 11.5 mm occlusion balloon. Success rate, reason for failure, and complications associated with the procedure were evaluated. RESULTS: Eight patients had one stone, five patients had two stones, and two patients had more than five stones. The procedure was successful in 13 patients (13/15). In 12 of the patients, all stones were removed in the first trial. In one patient, residual stones were discovered on follow-up cholangiography, and were subsequently removed in the second trial. Technical failure occurred in two patients. Both of these patients had severely dilated CBD and multiple stones with various sizes. Ten patients complained of pain in the right upper quadrant and epigastrium of the abdomen immediately following the procedure, but there were no significant procedure-related complications such as bleeding or pancreatitis. CONCLUSION: Percutaneous extrahepatic biliary stone removal by balloon sphincteroplasty and subsequent stone pushing with occlusion balloon is an effective, safe, and technically feasible procedure which can be used as an alternative method in patients when endoscopic extrahepatic biliary stone removal was not successful.

Tratamiento percutáneo de la litiasis biliar mediante dilatación papilar: esfinteroplastía anterógrada percutánea / Percutaneous treatment of biliary lithiasis with papillary dilation

Antecedentes: La dilatación papilar con balón (esfinteroplastía) ha sido empleada como método novedoso por vía endoscópica para la extracción de cálculos biliares pequeños. Objetivos: Analizar nuestra experiencia con diversos métodos percutáneos hasta adoptar la esfinteroplastía como método electivo, y evaluar los resultados. Lugar de aplicación: Instituto privado de salud. Diseño: Estudio retrospectivo de comparación de 2 series. Población: 132 procedimientos percutáneos por litiasis residual de la vía biliar. Método: Se evalúan 2 series sucesivas en el tiempo, en las que se emplearon métodos percutáneos distintos. Serie A: 31 pacientes, se efectúa predilatación papilar y pulsión del cálculo atrapado en una canastilla modificada al duodeno. Serie B: 101 pacientes, se emplea la sobredilatación papilar con balón (esfinteroplastía) y expulsión por lavado al duodeno. Resultados: En 5 casos (3,8 por ciento) la patología litiásica no pudo ser resuelta. La litiasis residual fue tratada mediante el pasaje al duodeno en 127 pacientes (96,2 por ciento). Las complicaciones que se presentaron fueron: Serie A: 12,8 por ciento, Serie B: 1,9 por ciento. Estas consistieron en: pancreatitis aguda, coleperitoneo y absceso hepático. La hiperamilasemia fue frecuente. No existió mortalidad en este estudio. Conclusiones: El tratamiento percutáneo de la litiasis residual es altamente efectivo. Hemos adoptado la esfinteroplastía como método electivo por su efectividad, sencillez técnica, bajo costo y baja morbilidad

Utilidad de la litotripsia extracorpórea en el tratamiento de la colédocolitiasis difícil / Shock wave extracorporeal lithotripsy in giant or difficult bile duct stones

La litotripsia con ondas de choque extracorpóreas, es un recurso poco disponible que ha demostrado ser un elemento útil en el manejo de la colédocolitiasis difícil, cuando se combina con métodos endoscópicos, sus resultados son satisfactorios, con porcentajes de éxito global del 70 al 80 por ciento y con una baja morbilidad y mortalidad.

Manejo endoscópico de la colédocolitiasis / Endoscopic management of common bile duct stones

Introducción: En la literatura existe una incidencia de colédocolitiasis del 10-25 por ciento en pacientes con colelitiasis y del 10-15 por ciento en colecistectomizados. El tratamiento endoscópico de estos pacientes tiene éxito hasta del 90 por ciento al realizar esfinterotomía y utilizar canastillas tipo Dormia. Material y Métodos: Se realizó un estudio observacional, longitudinal y retrospectivo, incluimos a pacientes con diagnóstico de colédocolitiasis confirmado mediante colangiografía endoscópica. Resultados: Se realizó esfinterotomía en 206 y precorte en 20; la morfología de la papila de Vater fue considerada como normal en el 81 por ciento. Los métodos de extracción fueron en su mayoría a través de la canastilla tipo Dormia. Se logró el aclaramiento de la vía biliar en el 91 por ciento y la complicación más frecuente fue hemorragia secundaria a esfinterotomía 5.3 por ciento.

Esfinterotomía guíada indicaciones y prevalencia en el Hospital Regional 1o. de Octubre ISSSTE / Guided sphynctherotomy. indications and prevalence

Objetivo: Determinar las indicaciones de la esfinterotomía guiada (ESG) durante la colangiopancreatografía endoscópica (CPE), así como su prevalencia en el servicio de endoscopia del Hospital Regional 1o. de Octubre del ISSSTE. Materiales y Métodos: Se realizó un estudio retrospectivo, descriptivo y longitudinal de pacientes sometidos a (CPE), durante el período de tiempo comprendido entre mayo de 1998 a abril de 1999, seleccionando aquellos casos donde se realizó ESG posterior a intentos fallidos de canulación profunda y de difícil acceso a la vía biliar. Resultados: De un total de 308 CPE, fue necesario efectuar esfinterotomía (ES) en 125 (40 por ciento); de las cuales en 22 (18 por ciento) requirieron de canulación guiada profunda secundaria a intentos fallidos o de difícil acceso. Las indicaciones de la ESG y hallazgos de la colangiopancreatografía fueron: estenosis de la vía biliar extrahepática en cinco (23 por ciento), colédocolitiasis en cuatro (18 por ciento), colangiocarcinoma en tres (14 por ciento), cáncer de cabeza de páncreas en dos (8 por ciento), cáncer de la papila en uno (4 por ciento), tumor de Klatskin en uno (4 por ciento), divertículo yuxtapapilar en dos (8 por ciento), fístula de la vía biliar en uno (4 por ciento), vía biliar y pancreática normal en tres (14 por ciento). Conclusiones: La ESG es un procedimiento alternativo para la canulación profunda de difícil acceso, formando parte de la terapéutica de la vía biliopancreática, ya que permite un mejor control de la ES disminuyendo el riesgo de complicaciones y siendo por lo consiguiente de gran utilidad en pacientes con neoplasia biliar, con cálculos coledocianos impactados o de gran tamaño, en situaciones de estenosis de la vía biliar, en presencia de divertículo yuxtapapilar, y procesos fistulosos de la vía biliar.

Manejo actual de la coledocolitias / Present coledocholithiasis management

Se describe la frecuencia de la coledocolitiasis y se analizan las diferentes opciones terapéuticas disponibles. Desde el punto de vista no quirúrgico, son descritas en general las tecnicas, su frecuencia de éxito y complicaciones, así como las ventajas principales para la colangiopancreatografía retrograda endoscópica convencional, la litotripsia mecánica, electrohidráulica y con rayo láser se menciona la utilidad de la litotripsia extracospórea, la colocación de prótesis endobiliares y el manejo disolutivo con mono-octanoína. En el paciente posoperado y con presencia de sonda en T en el colédoco, resulta de gran utilidad el abordaje radiológico intervencionista. Por otro lado, las opciones quirúrgicas se han enriquecido con la cirugía laparoscópica o de invasión mínima, cuyo desarrollo ofrece una exploración transoperatoria tan eficaz como la de la cirugía abierta. Finalmente, se discute la elección de alguna opción dependiendo de factores como la edad, el sexo, etcétera