Lesiones iatrogénicas de las vías biliares / Iatrogenic lesions of the biliary tract

Las lesiones iatrogénicas de las vías biliares (LIVB) representan una complicación quirúrgica grave de la colecistectomía laparoscópica (CL). Ocurre frecuentemente cuando se confunde el conducto biliar con el conducto cístico; y han sido clasificados por Strasberg y Bismuth, según el grado y nivel de la lesión. Alrededor del tercio de las LIVB se reconocen durante la CL, al detectar fuga biliar. No es recomendable su reparación inmediata, especialmente cuando la lesión está próxima a la confluencia o existe inflamación asociada. El drenaje debe establecerse para controlar la fuga de bilis y prevenir la peritonitis biliar, antes de transferir al paciente a un establecimiento especializado en cirugía hepatobiliar compleja. En pacientes que no son reconocidos intraoperatoriamente, las LIVB manifiestan tardíamente fiebre postoperatoria, dolor abdominal, peritonitis o ictericia obstructiva. Si existe fuga biliar, debe hacerse una colangiografía percutánea para definir la anatomía biliar y controlar la fuga mediante stent biliar percutáneo. La reparación se realiza seis a ocho semanas después de estabilizar al paciente. Si hay obstrucción biliar, la colangiografía y drenaje biliar están indicados para controlar la sepsis antes de la reparación. El objetivo es restablecer el flujo de bilis al tracto gastrointestinal para impedir la formación de litos, estenosis, colangitis y cirrosis biliar. La hepáticoyeyunostomía con anastomosis en Y de Roux termino-lateral sin stents biliares a largo plazo, es la mejor opción para la reparación de la mayoría de las lesiones del conducto biliar común.

Iatrogenic bile duct injuries (IBDI) represent a serious surgical complication of laparoscopic cholecystectomy (LC). Often it occurs when the bile duct merges with the cystic duct; and they have been ranked by Strasberg and Bismuth, depending on the degree and level of injury. About third of IBDI recognized during LC, to detect bile leakage. No immediate repair is recommended, especially when the lesion is near the confluence or inflammation is associated. The drain should be established to control leakage of bile and prevent biliary peritonitis, before transferring the patient to a specialist in complex hepatobiliary surgery facility. In patients who are not recognized intraoperatively, the IBDI manifest late postoperative fever, abdominal pain, peritonitis or obstructive jaundice. If there is bile leak, percutaneous cholangiography should be done to define the biliary anatomy, and control leakage through percutaneous biliary stent. The repair is performed six to eight weeks after patient stabilization. If there is biliary obstruction, cholangiography and biliary drainage are indicated to control sepsis before repair. The ultimate aim is to restore the flow of bile into the gastrointestinal tract to prevent the formation of calculi, stenosis, cholangitis and biliary cirrhosis. Hepatojejunostomy with Roux-Y anastomosis termino-lateral without biliary stents long term, is the best choice for the repair of most common bile duct injury.

A Unique Use of a Double-Pigtail Plastic Stent: Correction of Kinking of the Common Bile Duct Due to a Metal Stent

A 72-year-old man with jaundice by ampullary adenocarcinoma was treated at our hospital. For biliary decompression, a transpapillary, fully covered, self-expandable metal stent (FCSEMS) was deployed. Four days later, the patient developed acute cholangitis. Endoscopic carbon dioxide cholangiography revealed kinking of the common bile duct above the proximal end of the FCSEMS. A 7-F double-pigtail plastic stent was therefore placed through the FCSEMS to correct the kink, straightening the common bile duct (CBD) and improving cholangitis. This is the first report of a unique use of a double-pigtail plastic stent to correct CBD kinking. The placement of a double-pigtail plastic stent can correct CBD kinking, without requiring replacement or addition of a FCSEMS, and can lead to cost savings.

Expanded polytetrafluoroethylene in canine bile duct injury: a critical analysis / Politetrafluoroetileno expandido na lesão do ducto biliar em cães: uma análise crítica

PURPOSE: Analyze the morphological and structural outcomes of a patch of expanded polytetrafluoroethylene in the treatment of an iatrogenic injury of the common bile duct. METHODS: In Group 1 (Sham), 7 dogs underwent 3 laparotomies with intervals of 30 days between them. In Group 2, 10 dogs underwent transient common bile duct obstruction. After 30 days, this biliary occlusion was undone and a patch of expanded polytetrafluoroethylene replaced a fragment removed from the duct's wall. Thirty days after this last surgery, cholangiographic assessment of prosthesis patency and macro and microscopic evaluation of the biliary tract were performed. Daily clinical inspection completed the study outcomes. The Wilcoxon non-parametric test was used for statistical analysis. RESULTS: In all dogs enlargement of the biliary tree diameter was observed 30 and 60 days after the first surgical procedure. Partial adhesion of the patch to the common bile duct as a free luminal foreign body was found in 6 dogs. The prosthesis was completely integrated to surrounding tissue in the remaining four. CONCLUSION: Although a feasible option for the treatment of biliary duct iatrogenic lesions, the expanded polytetrafluoroethylene prosthesis must be used with caution considering the potential risks for complications.

OBJETIVO: Analisar, evolutivamente, a morfologia e a estrutura de um fragmento de politetrafluoretileno expandido utilizado no tratamento de uma lesão iatrogênica do ducto biliar comum. MÉTODOS: No grupo 1 (Simulação), sete cães foram submetidos a três laparotomias com intervalos de 30 dias entre elas. No grupo 2, em dez cães realizou-se uma obstrução tansitória do ducto biliar comum. Após 30 dias, a oclusão biliar foi desfeita e um fragmento da parede ductal foi substituído por um retalho de politetrafluoretileno expandido. Trinta dias após esta última operação, foram efetuadas uma avaliação colangiográfica da perviedade da prótese e uma análise macro e microscópica do trato biliar. Inspeções clínicas diárias completaram o estudo evolutivo. O teste não paramétrico de Wilcoxon foi utilizado para análises estatísticas. RESULTADOS: Decorridos 30 e 60 dias do primeiro procedimento cirúrgico, observou-se, em todos os cães, aumento do diâmetro da árvore biliar. Em seis cães verificou-se a presença do fragmento da prótese parcialmente aderido à parede do ducto biliar comum e também solta no lúmen da via biliar. A prótese estava completamente integrada aos tecidos circunvizinho nos demais quarto animais. CONCLUSÃO: A prótese de politetrafluoretileno expandido apresenta-se como uma opção factível para o tratamento das lesões iatrogênicas do ducto biliar, entretanto, deve ser utilizada com cautela, considerando o risco potencial de complicações.

Reconstrucción de lesiones de la vía biliar principal: la evolución hacia la técnica de Hepp-Couinaud / Surgical repair of bile duct injuries: experience in 25 patients

Background: Bile duct injury (BDI) is a complex problem, where adequate reconstruction has an impact on quality of life of patients. Aim: To describe the experience and results of bile duct reconstruction in BDI at reference center. Material and Methods: Retrospective review of 25 patients aged 44 +/- 14 (76 percent females) with BDI that were subjected to a surgical repair in a regional hospital between January 2000 and June 2009. The protocol, repair technique and postoperative morbidity and mortality are described. Results: In 40 percent of cases, the injury occurred during laparoscopic cholecystectomy. The repair was performed using a Roux-en-Y hepato-jejunostomy (RYHJ) in 20 patients. In 14 patients (70 percent), the modified Hepp-Couinaud technique was used. Thirty two percent of patients had postoperative complications and one patient died due to a sepsis and liver failure. One patient presented RYHJ stenosis that was managed with percutaneous dilatation. Conclusions: The majority of patients of this series were managed using a RYHJ with the Hepp-Couinaud technique, with acceptable results in terms of postoperative morbidity and stenosis.

Introducción: La lesión de vía biliar (LVB) es una complicación de enfrentamiento complejo, donde una adecuada reconstrucción tiene impacto en la calidad de vida de los pacientes. Objetivo: Describir la experiencia y resultados de la reconstrucción de via biliar por LVB en un centro de referencia. Material y Método: Diseño de estudio: Cohorte retrospectiva. Período de estudio: Enero de 2000 a Junio de 2009. Población: Pacientes mayores de 18 años con LVB que fueron sometidas a reconstrucción de vía biliar por el equipo de cirugía hepatopancreática y biliar del Hospital Regional de Temuco. Maniobra: Se describe el protocolo de evaluación y la técnica de reconstrucción. Resultados: La cohorte está constituida por 25 pacientes. La edad promedio es 44 +/- 13,7 años y el 76 por ciento género femenino. La lesión se produjo más frecuentemente en una colecistectomía laparoscópica (40 por ciento). La reparación se ha realizado con hepaticoyeyuno anastomosis en Y de Roux (HPYA) en 20 pacientes, utilizando la técnica de Hepp-Couinaud modificada en el 70 por ciento de ellos. Ocho pacientes presentaron alguna morbilidad asociada a la reparación y un paciente falleció en el postoperatorio. Un paciente presentó estenosis de HPYA cuya terapia fue dilataciones por vía percutanea. Conclusión: La HPYA con técnica de Hepp-Couinaud es la técnica más utilizada por nuestro equipo en la reconstrucción de vía biliar por LVB con resultados aceptables en términos de morbilidad postoperatoria y estenosis.

Estenosis biliares benignas: experiencia 77 casos / Benign biliary strictures: experience 77 cases

Se presenta la experiencia de los autores con 77 casos de estenosis biliares benignas tratadas en Unidad de Cirugía Hepática, Biliar y trasplante de hígado del Hospital Universitario de Maracaibo. Desde agosto de 1989 hasta diciembre de 2009, fueron registrados 77 casos de estenosis biliares benignas. Se tipificaron según la clasificación de Bismuth. 83,12% (64) de los pacientes habían sido colecistectomizados (estenosis post-iatrogenia durante este procedimiento): 41 (53,25%) abiertas y 23 (29,87%) laparoscópicas. 89,61 (69) de los pacientes consultaron por ictericia, 62,34% fiebre y 58,44% dolor abdominal. 9% (7) presentó estenosis Bismuth I, 22% (17) tipo II, 44,16% (34) tipo III y 24,68% (19) tipo IV. A todos se les realizó exploración biliar quirúrgica y anastomosis mucosa-mucosa con Y-Roux, tipo Hepp-Couinaud en 70 (87,5%) de los pacientes. La mortalidad fue 2,6% (2) paciente en el transoperatorio. Se presentaron en el peri-operatorio 19 (24,39%) complicaciones en 17 (22%) pacientes: 12 (15,6%) mayores y 7 (8,79%) menores. En un seguimiento promedio de 49 meses, 7-79% (6) pacientes presentaron re-estenosis de la derivación bilioentérica. El mayor porcentaje de estenosis biliares benignas son posteriores a procedimientos quirúrgicos, principalmente colecistectomia. La anastomosis bilioentérica tipo Hepp-Couinaud se realizó en el mayor número de pacientes con excelentes resultados.

Present experience of the authors with 77 cases of bening biliary strictures. From August of 1989 to December of 2009, 77 patients were recorded. Classification of Bismuth was used to classificate the strictures 64 (83,12%) patients were cholecistectomizated (stricture by iatrogenia during this procedure): 41 (53,25%) open and 23 (29,87%) laparoscopic. 89,61% (69) consulted by jaundice, 62,34 by fever and 58,44% by abdominal pain. 9%(7) had stricture Bismuth 1,22% (17) type II, 44,16% (34) type III and 24,68% (19) type IV. All patients were summated to surgical biliary exploration and mucous-mucous biliary anastomosis with Y-Roux. Hepp-Couinaud type in 70 (87,7%) of the patients. Perioperative mortality was 2,6% (2). Perioperative complications were 19 (24,39%) in 17 (22%) patients: 12 (15,6%) mayor and 7(8,79%) minors. In medial following of 49 months, 7,79% (6) presented re-stricture of bilio-enteric anastonosis. The majority of the strictures were due to surgical procedures. Hepp-Couinaud anastomosis was performed in almost all the patients with excellent outcome.

Laparoscopic cholecystectomy; common bile duct injury after learning curve

To determine the frequency of common bile duct [CBD] injury in laparoscopic cholecystectomy in our settings, in my last 500 cases, after going through the learning curve associated CBD injuries. Descriptive study. Surgical Unit-I, Rawalpindi General Hospital and the author's Surgical Clinics from January 2003 to December 2008. Five hundred patients undergoing laparoscopic cholecystectomy by the same surgeon were included. The important variables included demographic data, intra operative time and findings, frequency of CBD injury and post operative hospital stay. There were 419 [83.8%] females and 81 [16.2%] males with mean age 45.04 +/- 11.03 years. 294 [58.8%] patients had chronic cholecystitis with cholelithiasis and were admitted through Out Patient Department whereas 206 [41.2%] were admitted through Accident and Emergency Department with acute cholecystitis. Abdominal ultrasound showed multiple calculi in 351 [70.2%] patients and 149 [29.8%] patients had single calculus preoperatively. Empyema was found in 97 [19.4%] cases whereas adhesions were present in 182 [36.4%] patients. In our study frequency of CBD injury was 1%. Mean operating time was 35 minutes. 96.8% of the patients were discharged within 48 hrs of operation. Laparoscopic Cholecystectomy in our set up proved to be a safe procedure, having frequency of CBD injury of only 1% and a short hospital stay 493 [96.8%] being discharged in less than 2 days

Complications of laparoscopic cholecystectomy in acute cholecystitis

To assess the clinical outcome of laparoscopic cholecystectomy in the management of acute cholecystitis. Descriptive study. Surgical Units II and III of Chandka Medical College Hospital Larkana, from 01.10.2003 up to 31.12.07. In this study 100 consecutive cases of clinically and sonologically confirmed acute cholecystitis who underwent early laparoscopic cholecystectomy [within 07 days of attack] were included. Patients with symptoms of more than one week duration or those with associated diseases were excluded. There was female preponderance with male to female ratio 1:4.5. Mean age was 45.75 years [SD +/- 11.99 years]. Most of the patients were received within 24 hours after the onset of symptoms. Ultrasound revealed edematous gall bladder [GB] in 24 cases, contracted GB in ten, empyema in eight, perforated GB in four. Fifty four patients had acute cholecystitis with cholelithiasis. Peroperative complications were minor bleeding in 6 patients, minor injury to liver bed in 3, major bleeding occurred in two cases that required conversion to open surgery .Other findings which delayed the procedure or required conversion were adhesions with omentum, stomach, colon, CBD, and distorted anatomy of Calot's triangle and CBD injury. The conversion rate was 6% among them two were due to bleeding, two with friable adhesions, one with obscure anatomy. Stone in CBD could not be detected on ultrasound in one case and CBD injury occurred in one. The minimum time taken for the procedure was 50 minutes. No mortality occurred in this series. Emergency / early cholecystectomy is reliable, safe and cost effective modality, in the management of acute cholecystitis. It results in accelerated recovery, negligible wound infection or related complications, and less postoperative pain. Certain factors are responsible for conversions which are obscure anatomy, bleeding, adhesions, and CBD, injury

Proposal of a new technique for bile duct reconstruction after iatrogenic injury: study in dogs and review of the literature

PURPOSE: Interposition of a jejunal tube between the common bile duct and duodenum. METHODS: Five adult mongrel dogs of both sexes, weighing on average 22.3 kg (18 to 26.5 kg), were used. Obstructive jaundice was induced by ligation of the distal common bile duct. After one week, a 2.5-cm long jejunal tube was fabricated from a segment of the loop removed 15 cm from the Treitz angle and interposed between the common bile duct and duodenum. RESULTS: The animals presented good clinical evolution and no complications were observed. After 6 weeks, complete integration was noted between the bile duct mucosa, tube and duodenum and a significant reduction in total bilirubin and alkaline phosphatase was observed when compared to the values obtained one week after ligation of the common bile duct. CONCLUSION: The jejunal tube interposed between the dilated bile duct and duodenum showed good anatomic integration and reduced total bilirubin and alkaline phosphatase levels in the animals studied.

OBJETIVO: Interposição de um tubo de jejuno entre o colédoco e o duodeno. MÉTODOS: Foram utilizados cinco cães adultos, sem raça definida, de ambos os sexos, com peso médio de 22,3 Kg (18 e 26,5 Kg). Após provocar icterícia obstrutiva pela ligadura do colédoco distal, após uma semana, praticou-se confecção do tubo de jejuno de 2,5 cm de extensão, que foi realizado com um segmento de alça retirado a 15 cm do ângulo de Treitz e a interposição do tubo entre o colédoco e o duodeno. RESULTADOS: Os animais tiveram boa evolução clínica e não apresentaram complicações. Notou-se total integração entre a mucosa da via biliar, do tubo e do duodeno e redução significativa dos valores da bilirrubina total e da fosfatase alcalina após seis semanas, quando comparado com os valores após uma semana de ligadura do colédoco. CONCLUSÃO: O tubo de jejuno interposto entre a via biliar dilatada e o duodeno, apresentou boa integração anatômica e reduziu os níveis de bilirrubina total e fosfatase alcalina dos animais estudados.

Crystal-associated cholangiopathy in sheep grazing Brachiaria decumbens containing the saponin protodioscin

An outbreak of hepatogenous photosensitization is reported in a flock of 28 sheep grazing Brachiaria decumbens in Mato Grosso do Sul State, Central-Western Brazil. Seven lambs and an adult sheep were affected and 6 of them died. Two surviving affected lambs and one lamb without clinical signs had increased serum values of gamma glutamyltransferase, bilirubin, and cholesterol. In two adult unaffected sheep those parameters were within normal values. An adult sheep submitted to necropsy presented moderate body condition, unilateral corneal opacity, drying of the muzzle, moderate jaundice, increased lobular pattern of the liver, and a distended gallbladder. Histological lesions were epithelial degeneration, necrosis, and hyperplasia of small bile ducts. Mild amounts of foamy macrophages were observed, mainly in the centroacinar zone. Diffuse swelling and vacuolation were observed in hepatocytes. Crystal negative images were found within bile ducts, foamy macrophages, and the lumen of some renal tubules. The heart showed multifocal areas of degeneration and necrosis of the muscle fibers. Pasture samples (Brachiaria decumbens) contained 2.36 percent of protodioscin. No Pithomyces chartarum spores were found in the pasture. Samples from a similar neighboring B. decumbens pasture grazed by cattle without photosensitization contained 1.63 percent of protodioscin isomers. Outbreaks of photosensitization caused by Brachiaria spp. are common in cattle in the Brazilian Cerrado (savanna) with about 51 million hectares of Brachiaria spp pastures. Sheep farming has been recently developed in this region, and the number of sheep is increasing significantly. Because sheep are more susceptible than cattle to lithogenic saponins, poisoning by Brachiaria should be an important limiting factor for the sheep industry.

Um surto de fotossensibilização hepatógena é descrito em um rebanho de 28 ovinos mantidos em pastagem de Brachiaria decumbens no Estado de Mato Grosso do Sul, região Centro-Oeste do Brasil. Sete cordeiros e uma ovelha adulta foram afetados e seis deles morreram. Dois cordeiros com sinais clínicos e um cordeiro, aparentemente sem sinais clínicos, apresentaram elevação na atividade sérica de gama glutamil-transferase, e nos valores de bilirrubina e colesterol. Em dois animais adultos que não apresentavam sinais clínicos, esses parâmetros estavam dentro dos valores normais. Uma ovelha adulta submetida à necropsia apresentou moderada condição corporal, opacidade de córnea unilateral, focinho ressecado, moderada icterícia, padrão lobular hepático evidente e vesícula biliar acentuadamente distendida e repleta. As lesões histológicas consistiram de degeneração epitelial, necrose e hiperplasia de ductos biliares. Havia discreta quantidade de macrófagos espumosos, principalmente na região centroacinar, e tumefação e vacuolização difusas dos hepatócitos. Foram observadas imagens negativas de cristais dentro dos ductos biliares, macrófagos espumosos e lúmen de alguns túbulos renais. O coração apresentou áreas multifocais de degeneração e necrose de fibras musculares. Amostras da pastagem (B. decumbens) apresentaram 2,36 por cento de protodioscina e nenhum esporo de Pithomyces chartarum foi encontrado na pastagem. Amostras de uma pastagem vizinha semelhante (B. decumbens), que havia sido pastejada por bovinos que não desenvolveram fotossensibilização, apresentaram 1,63 por cento de protodioscina. Surtos de fotossensibilização causados por espécies de Brachiaria são comuns em bovinos no Cerrado brasileiro onde há aproximadamente 51 milhões de hectares plantados com essa gramínea. A criação de ovinos nesta região ganhou recente impulso e o número de ovinos vem aumentando significativamente. Como os ovinos são mais suscetíveis que os bovinos à intoxicação...

Estrategia terapéutica en el diagnóstico postoperatorio de lesión de un conducto hepático anómalo / Persistant biliary fistula from annomalous hepatic duct injury postoperative and useful therapeutic strategy

Antecedentes: La presencia de un conducto hepático anómalo derecho (CHA) es un factor de riesgo de lesión quirúrgica ductal en la colecistectomía. Se han descrito distintas alternativas terapéuticas en esta lesión. Objetivo: Analizar la estrategia diagnóstica postoperatoria y las ventajas de un tratamiento combinado percutáneo y quirúrgico. Lugar de aplicación: Hospital público de referencia y nivel terciario. Diseño: Series de casos consecutivos. Población: Cuatro pacientes con lesión de un CHA sobre 4850 colecistectomizados entre marzo de 2000 y marzo de 2005. Método: Evaluación retrospectiva. Resultados: Tres pacientes tuvieron lesión de conductos anómalos de los segmentos VI y VII (dos aberrantes y uno accesorio) y el cuarto una lesión de un conducto aberrante del segmento VI. Tres enfermos presentaron una fístula biliar externa y el cuarto se operó de urgencia por sospecha de perforación visceral bloqueada. En un paciente la fístula biliar cerró espontáneamente a los dos meses; en los otros fracasó el tratamiento endoscópico y fueron operados electivamente previa contemporización biliar percutánea del sector hepático aislado. En ambos pacientes y en el operado de urgencia se reparó el conducto mediante una hepaticoyeyunostomía en Y de Roux. La media de seguimiento fue de 13.5 meses. Todos evolucionaron asintomáticos y sin colestasis. Conclusión: En la fístula biliar persistente por lesión de un CHA y fracaso endoscópico, la contemporización con un drenaje biliar percutáneo y cirugía electiva es una estrategia factible y útil en el pre, intra y postoperatorio

population based study on mishaps during laparoscopic cholecystectomy in qatar: 10 years experience

In order to determine the national incidence of adverse events following laparoscopic cholecystectomy [LC] the records were reviewed retrospectively of 4861 patients who underwent LC over a period of ten years [1993-2003]. The most serious non-biliary complication was trocar injury of major vessels in three cases. Other non-biliary complications included duodenal perforation during dissection of the Calot's triangle, small bowel injury while inserting the umbilical port and trocar site hernia. Adverse biliary events included common bile duct injury, common hepatic duct injury, bile leakage from the cystic duct and one instance of the migration of an endoloop into the common bile duct. Conversion to open cholecystectomy was required in 109 cases. Although LC may be associated with various adverse sequelae, these are rare and should not deter surgeons and patients

Exploración laparoscópica de la vía biliar: primera experiencia en el Hospital Universitario de Caracas / Laparoscopic exploration of the biliary tract: first experience at the Hospital Universitario de Caracas

El objetivo de este trabajo es presentar la experiencia inicial en la exploración laparoscópica de la vía biliar en pacientes con coledocolitiasis. Se evalúan cuatro casos de pacientes con coledocolitiasis a quienes se les realizó exploración de vía biliar por laparoscopia. Servicio de Cirugía III. Hospital Universitario de Caracas. El ultrasonido y las pruebas de funcionalismo hepático hicieron sospechar la presencia de cálculos en la vía biliar. En todos los casos se realizó colangiografía intraoperatoria, la cual constató la presencia de coledocolitiasis. Posteriormente se realizó exploración de la vía biliar por laparoscopia, por vía transcística con cesta de Dormia bajo control fluoroscópico, siendo esta vía efectiva en el 50 por ciento de los casos, el resto de los casos requirió realización de coledocotomía y uno de ellos se convirtió por la presencia de cálculo enclavado en la ampolla y dificultades técnicas. El tiempo operatorio promedio para la exploración transcística y transcoledociana fue de 105 y 210 minutos respectivamente. La única complicación asociada al procedimiento correspondió a un caso de diarrea postoperatoria. La evolución postoperatoria fue satisfactoria en todos los casos. La exploración laparoscópica de la vía biliar parece ser un procedimiento seguro y efectivo para el tratamiento de la coledocolitiasis, sin embargo, es importante tomar en cuenta la experiencia del equipo quirúrgico y la disponibilidad del instrumental para realizar el procedimiento. Es necesario proseguir con el estudio para continuar con el desarrollo de la técnica y establecer conclusiones definitivas.

Conversión en colecistectomía laparoscópica. Experiencia hospital San Martín de Quillota, 8 años después / Conversion in laparascopic cholecystectomy. Experience of hospital San Martín de Quillota, 8 years later

La colecistectomía laparoscópica se realiza en nuestro país 1990 y en el Hospital San Martín de Quillota desde 1992. Se realizó un estudio sobre las causas de conversión de colecistectomía laparoscópica a colecistectomía clásica, transcurrido un tiempo de aprendizaje por el staff de cirujanos, comparando las causas de conversión con un estudio previo realizado en el Hospital San Martín de Quillota entre 1992-1995. Se evaluaron las cirugías efectuadas entre julio del 2000 hasta marzo 2002, sumando 799 casos, de los cuales 45 debieron ser convertidos. Se evaluaron las variables edad, sexo, antecedentes mórbidos, clínica, ecografía, diagnóstico pre y post operatorio, tiempo operatorio, anatomía patológica, complicaciones posteriores y las causas de la conversión. En nuestro estudio del total de cirugías, un 5,6 por ciento de los casos debieron ser convertidos, en comparación con el índice de conversión de un 7,8 por ciento obtenido en el mismo centro hace 8 años. De las cuasas de conversión se observó una variación con respecto al estudio preliminar. En este último, la principal causa de conversión fue la dificultad técnica (29,2 por ciento), en cambio en el estudio actual fue el plastrón vesicular (37 por ciento de los casos). Nuestros resultados, al igual como los de otros autores, reflejan la transición entre la dificultad técnica y el hallazgo de plastrón como la primera causa de conversión, una vez transcurrido la curva de aprendizaje de esta técnica.

Hepatopulmonary Syndrome Induced by Common Bile Duct Ligation in a Rabbit Model: Correlation between Pulmonary Vascular Dilatation on Thin-Section CT and Angiography and Serum Nitrite Concentration or Endothelial Nitric Oxide Synthase (eNOS) 1 Expression

OBJECTIVE: To investigate the correlation between radiologic vascular dilatation and serum nitrite concentration and eNOS expression in the endothelial cell and pneumocyte in a rabbit model of hepatopulmonary syndrome induced by common bile duct ligation (CBDL). MATERIALS AND METHODS: Thin-section CT scans of the lung and pulmonary angiography were obtained 3 weeks after CBDL (n=6), or a sham operation (n=4), and intrapulmonary vasodilatation was assessed. The diameter and tortuosity of peripheral vessels in the right lower lobe by thin-section CT and angiography at the same level of the right lower lobe in all subjects were correlated to serum nitrite concentration and eNOS (endothelial nitric oxide synthase) expression as determined by immunostaining. RESULTS: The diameters of pulmonary vessels on thin-section CT were well correlated with nitrite concentrations in serum (r = 0.92, p < 0.001). Dilated pulmonary vessels were significantly correlated with an increased eNOS expression (r = 0.94, p < 0.0001), and the severity of pulmonary vessel tortuosity was found to be well correlated with serum nitrite concentration (r = 0.90, p < 0.001). CONCLUSION: The peripheral pulmonary vasculature in hepatopulmonary syndrome induced by CBLD was dilated on thin-section CT and on angiographs. Our findings suggest that peripheral pulmonary vascular dilatations are correlated with serum nitrite concentrations and pulmonary eNOS expression.

Inadvertent choledochotomy during Frey's procedure: management options.

We report the occurrence of inadvertent injury to the intra-pancreatic common bile duct in 3 of 9 patients undergoing Frey's procedure for chronic pancreatitis with inflammatory mass in the head. In one case, the choledochotomy was extended and anastomosed to the cored-out parenchyma. In the other two, after lateral pancreatico-jejunostomy, hepatico-jejunostomy was performed using the same Roux loop.

Posterior segment duct injury in laparoscopic cholecystectomy.

We report a 34-year-old woman with posterior segment duct injury during laparoscopic cholecystectomy. The diagnosis was made by intra- and postoperative cholangiogram. The injured duct was repaired over a T-tube. The patient recovered uneventfully.

audit of laparoscopic cholecysstectomies performed at PNS Shifa

Open cholecystectomy used to be the gold standard for more than 100 years, now this has been taken over by laparoscopic cholecystectomy. The operation has proved its worth because of little post operative pain, minimal scar, reduced hospital stay [1-2 days] and convalescence 1 to 2 weeks as compared to open cholecystectomy. The only problem seems to be the proper training of surgeons for safety of the patient to avoid common bile duct [CBD] and other injuries