Lesión quirúrgica de vía biliar compleja. Manejo conservador / Complex bile duct injury. Conservative management

RESUMEN La colecistectomía laparoscópica es el tratamiento de elección para la litiasis vesicular sintomática. Aunque la tasa de complicaciones es baja, las lesiones de la vía biliar representan un grave problema. La asociación con una lesión vascular (lesión compleja) genera un impacto adicional, disminuyendo la calidad de vida y la sobrevida a largo plazo. Presentamos el caso de una paciente con lesión compleja por compromiso vascular del pedículo hepático derecho que desarrolló una atrofia del parénquima correspondiente. Ante la ausencia de complicaciones sépticas, el tratamiento no operatorio pudo realizarse en forma exitosa.

ABSTRACT Laparoscopic cholecystectomy is considered the standard of care for symptomatic cholelithiasis. Although the rate of complications is low, bile duct injuries represent a serious problem. The association with vascular injury (complex injury) poses an additional impact by reducing the quality of life and long-term survival. We report the case of a female patient with complex injury due to vascular involvement of the right hepatic pedicle who developed right liver atrophy. Non-operative management was successful due to the absence of septic complications.

Lesión quirúrgica del conducto hepático derecho: tratamiento combinado laparoscópico-endoscópico / Right hepatic bile duct injury: a single stage combined laparoscopic-endoscopic treatment

RESUMEN El tratamiento de las lesiones quirúrgicas de las vías biliares (LQVB), empleando procedimientos quirúrgicos de mínimo acceso en forma conjunta, a pesar de sus beneficios, ha sido escasamente reportado. Describimos el tratamiento combinado láparoendoscópico, en una paciente con fístula biliar y estenosis postoperatoria del conducto hepático derecho (CHD). Con base en la descripción de un caso clínico, ilustramos la técnica quirúrgica y evaluamos su aplicabilidad y resultados. Empleando colangiografía laparoscópica, identificamos la fistula biliar y demostramos la oclusión del CHD por un clip metálico, el cual fue retirado mediante guía fluoroscópica. Realizamos maniobra de "rendezvous" biliar y colocamos de prótesis plástica endoscópica. La fístula biliar resolvió en 12 días y a 40 meses de seguimiento, la paciente permanece sin alteraciones. El abordaje láparo-endoscópico, aunque técnicamente demandante, resultó efectivo para el tratamiento de esta paciente. Su seguimiento es fundamental y de especial interés, a fin de evaluar los resultados a largo plazo.

ABSTRACT Treatment of bile ducts injuries (BDI) treatment, combining minimally access surgical techniques, although their benefits, has been scarcely reported. We described a combined laparoscopic-endoscopic procedure, carried out in a patient with postoperative right hepatic duct (RHD) injury associated to laparoscopic cholecystectomy. Based on a clinical case description, we illustrate the surgical technique and assess their applicability and results. A biliary fistula was identified employing laparoscopic cholangiography and a metallic clip applied, producing RHD occlusion, was retrieved under fluoroscopic guidance. A biliary "rendezvous" maneuver was done for positioning an endoscopic biliary stent. The biliary fistula disappeared within two weeks and during 40-months of follow-up the patient remains asymptomatic. Laparoscopic-endoscopic approach, although technically demanding, resulted effective to treat this patient. A Continuous follow-up is essential for evaluating the long-term results.

Hepatic duct stones masquerading as Klatskin tumour.

We report woman who presented with painless progressive jaundice following cholecystectomy. Radiological investigations indicated proximal bile duct obstruction suggestive of hilar malignancy. Exploratory laparatomy revealed bilateral hepatic duct stone causing obstruction.

Evaluation of various diagnostic signs on percutaneous transhepatic cholangiography in obstructive jaundice.

Twenty patients of obstructive jaundice were subjected to percutaneous transhepatic cholangiography (PTC) of which 17 were operated on. Patients were divided in 4 groups according to the site of obstruction. The diagnostic signs observed were: Complete block with interface having convexity downwards (4), convexity upwards (3), biconcave caudal cut off (6), smooth edged cut off (one), irregular edged cut off (one) and non-specific appearance (one); incomplete block with interface having convexity upwards (one); biconcave caudal cut off (2) and multiple smooth central filling defects (2). In one case there was incomplete obstruction at two sites giving rise to two different signs. PTC was 100% correct in accurately telling the site of lesion. As regards the nature of the lesion the diagnosis on PTC was found correct in 15 out of 17 cases (88.5%).