Lesiones de vía biliar poscolecistectomía: conducta terapéutica actual / Post Cholecystectomy Bile Duct Injuries: Current Therapeutic Option

Resumen La colecistolitiasis es una condición común en Chile. La complicación más frecuente de esta condición es la colecistitis aguda. Aproximadamente 60.000 colecistectomías son realizadas anualmente en nuestro país, convirtiéndola en una de las patologías digestivas más frecuentes. El tratamiento de la colelitiasis ha evolucionado las últimas dos décadas. Con el desarrollo de la laparoscopía a final de 1980, la colecistectomía abierta fue definitivamente sustituida en los 90 por la vía laparoscópica. Desafortunadamente, la generalización de este procedimiento produjo un aumento en la incidencia de lesiones de vía biliar, aumentando desde una 0,1-0,2% hasta un 0,5-0,7%. Si bien, con el progresivo entrenamiento de los cirujanos en la cirugía mínimamente invasiva esta cifra ha disminuido nuevamente, la LVB aún constituye una de las complicaciones más graves en cirugía, generando gran impacto en la calidad de vida del paciente, e incluso costos en salud que pueden llegar a ser devastadores. El manejo de una lesión de vía biliar es, para muchos cirujanos, un desafío quirúrgico, que para su resolución requiere de las habilidades y experiencia de un cirujano hepatobiliar y derivación a centros de salud especializados. Sin duda, la acción más importante es extremar de manera rutinaria las medidas de prevención. Sin embargo, una vez que la lesión se ha producido, el futuro del paciente depende, directamente, del buen criterio del cirujano, tanto para realizar un diagnóstico temprano, como del enfrentamiento terapéutico que realice. El objetivo de este trabajo es dar a conocer diferentes conductas preventivas y terapéuticas cuando esta complicación se presenta.

Calculous biliary disease is a common condition in Chile. Over 60.000 cholecystectomies are performed annually, making gallstone disease one of the most common digestive health problems. The treatment of calculous biliary disease has evolved over the last 2 decades. With the development of laparoscopic technology in the late 1980s, new techniques for cholecystectomy were introduced. By the early 1990s, laparoscopic cholecystectomy had replaced open cholecystectomy in the operative management of gallbladder stone disease. Unfortunately, the widespread application of laparoscopic cholecystectomy has led to a concurrent rise in the incidence of major bile duct injuries. Reports have estimated the incidence has risen from 0.1-0.2 to 0.5-0.7%. Although, exponential training of surgeons in minimally invasive surgery has led to decrease this numbers again, bile duct injuries still constitute one of the most serious complications in surgery, generating a great impact on the patient's quality of life, and even health costs that can be devastating. The management of patients following major bile duct injurie is a surgical challenge, often requiring the skills of experienced hepatobiliary surgeons at tertiary referral centers. In this setting, the most important action is to routinely maximize prevention measures. However, once injury has occurred, patient's future depends directly on the correct judgment of the surgeon, both to make an early diagnosis and to choose the best therapeutic confrontation. The objective of this article is to present the different preventive and therapeutic options available when this complication occurs.

Variante anatómica de la vía biliar durante la colecistectomía laparoscópica / Anatomical variant of the bile duct during laparoscopic cholecystectomy / Variante anatômica do ducto biliar durante colecistectomia laparoscópica

Se presenta la colangiografía intraoperatoria obtenida durante la colecistectomía laparoscópica de una paciente de 58 años con el diagnóstico de colecistitis aguda.

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.

Perforación de sigma secundaria a migración de prótesis biliar / Sigma Perforation Secondary to Migration of Biliary Prosthesis

RESUMEN Introducción: La migración de una prótesis en la vía biliar es una complicación muy poco frecuente que normalmente se expulsa de forma natural, pero en raras ocasiones puede cursar con complicaciones severas. Objetivo: Describir una complicación rara por migración de una prótesis biliar. Caso clínico: Se presenta un paciente de sexo masculino de 75 años, portador de stent biliar que presenta una perforación de sigma secundaria a migración de la prótesis. Conclusiones: Las migraciones protésicas deben vigilarse y si no se eliminan de manera espontánea o el paciente presenta síntomas, se debe proceder a su retirada endoscópica o quirúrgica(AU)

ABSTRACT Introduction: Migration of a prosthesis in the bile duct is a very rare complication normally expelled in a natural way, but on rare occasions it can lead to severe complications. Objective: To describe a rare complication due to migration of biliary prosthesis. Clinical case: A case is presented of a 75-year-old male patient with a biliary stent who presented a sigmoid perforation secondary to migration of the prosthesis. Conclusions: Prosthetic migrations should be monitored and, if they are not eliminated spontaneously or the patient presents with symptoms, they should be removed endoscopically or surgically(AU)

Choledochal cysts in children: How to Diagnose and Operate on

OBJECTIVE: To identify the best mode for diagnosing and treating the patients with choledochal cysts. METHODS: A retrospective study was performed with medical records of patients diagnosed with choledochal cysts from January 1994 to December 2017. In all cases, the diagnosis was based on ultrasound examination. All the patients underwent cyst resection and were divided in two groups: bile enteric anastomosis in the high portion of the common hepatic duct or in the dilated lower portion. RESULTS: Eighty-one cases were studied. The age of presentation was 4 y 2 mo ± 4 y 1 mo, and the age for the surgical treatment was 5 y 5 mo ± 4 y 6 mo. In 61 cases, US was the only image examination performed. There were 67 cases of Todani type I (82.7%), 13 cases of type IV (16.0%) and one case of type III (1.2%). Nine patients (29.0%) in the first period and 2 patients (4.0%) in the second period presented with postoperative complications (p=0.016). CONCLUSION: In patients with choledochal cysts, US is the only necessary diagnostic imaging. Performing the bile enteric anastomosis in the lower portion of the common hepatic duct is safer and has a lower risk of complications.

Lesión de vía biliar en trauma cerrado: nuevas tendencias en lesiones infrecuentes / Biliar injury in closed trauma: new trends in unusual injury

Objetivo: Reportar un caso clínico de lesión de la vía biliar intrapancreática tras traumatismo abdominal cerrado. Caso clínico: Paciente que acude a urgencias por intenso dolor abdominal, tras sufrir traumatismo toraco-abdominal cerrado al caer de una bicicleta. Posteriormente a su ingreso desarrolló fiebre, ictericia y patrón analítico de colestasis. Se solicitó colangiorresonancia magnética donde no se pudo valorar correctamente la vía biliar, pero se evidenció abundante líquido intraabdominal que no correspondía a sangre. Se indicó cirugía urgente ante la sospecha de lesión biliar. Se objetivó lesión de la vía biliar intrapancreática mediante colangiografía intra-operatoria y se decidió colocación de prótesis intrabiliar mediante colangiopancreatografía retrógrada endoscópica (CPRE) intraoperatoria. Conclusión: La cirugía ha sido el tratamiento convencional para la lesión de la vía biliar, pero en la actualidad la CPRE con esfinterotomía y colocación de prótesis intrabiliar es un tratamiento adecuado y resolutivo de este tipo de lesiones pudiéndose considerar como tratamiento de primera línea.

Aim: To report a clinical case of biliar injury intrapancreatic in closed abdominal trauma. Clinical case: Patient who comes to the emergency room by severe abdominal pain after suffering thoraco-abdominal blunt trauma after falling from a bicycle. After his admission he developed fever, jaundice and analytical standards of cholestasis. Magnetic resonance which failed to correctly assess the bile duct was requested but showed plenty of intra-abdominal fluid blood that did not match. Emergency surgery for suspected biliary injury was reported. Intrapancreatic injury bile duct was observed by intraoperative cholangiography and prosthesis was decided intrabiliary by intraoperative endoscopic retrograde cholangiopancreatography (ERCP). Conclusions: Surgery has been the standard treatment for bile duct injury, but now ERCP with sphincterotomy and placement of intrabiliary prosthesis is adequate and operative treatment of these injuries and can be considered as first-line treatment.

Recurrent acute pancreatitis caused by pancreatic biliary maljunction due to long common channel / Pancreatitis aguda recurrente causada por deficiente unión pancreático-biliar debido a un colédoco largo

The pancreatic biliary maljunction is a rare anomaly that affects mainly females, defined as an anatomical maljunction of the pancreatic duct and the biliary duct confluence, and may be a rare cause of recurrent acute pancreatitis. In order to early diagnosis and prompt treatment, ERCP has an important role in it

La Malformación de la unión biliopancreática es una afección rara y ocurre más en mujeres jóvenes. Es una causa de pancreatitis aguda de causa no conocida. CPRE es una herramienta eficiente para el diagnóstico y también para ser de la terapéutica

Biliary Cast Syndrome in Non-Liver Surgery Patients / 대한소화기학회지

Biliary cast describes the presence of casts within the biliary tree. It is resultant sequel of cholangitis and hepatocyte damage secondary to bile stasis and bile duct injury. Biliary cast syndrome was first reported in patient undergone liver transplantation. The pathogenesis of biliary cast is not clearly identified, but proposed etiologic factors include post-transplant bile duct damage, ischemia, biliary infection, or post-operative biliary drainage tube. Although biliary casts are uncommon, most of biliary cast syndrome are reported in the liver transplant or hepatic surgery patients. A few reports have been published about non-transplant or non-liver surgery biliary cast. We report two cases of biliary cast syndrome in non-liver surgery patients.

Colangiografía transoperatoria en colecistectomía laparoscópica: ¿sistemática o selectiva? / Transoperative cholangiography in laparoscopic cholecystectomy: Systematical or selective?

Se realizó un estudio comparativo en pacientes operados de colecistectomía laparoscópica, con el empleo de la indicación de la colangiografía transoperatoria, en 151 pacientes por el método de selección y en 456 de forma sistemática. En los 2 grupos se utilizaron los mismos criterios de inclusión. El tiempo quirúrgico medio en ambos fue inferior de 1 hora. Se comprobó que con el entrenamiento se logran índices de factibilidad por encima del 90 porciento, lo cual es similar a la cirugía abierta. La realización de la colangiografía de forma sistemática detectó un mayor tanto por ciento de litiasis no sospechada en la vía biliar principal; diagnosticó afecciones del colédoco no litiásicas; identificó anomalías potencialmente peligrosas y detectó iatrogenias sobre la vía biliar principal durante el transoperatorio. Se concluye que en la colecistectomía laparoscópica la colangiografía transoperatoria debe realizarse de forma sistemática (AU)

A comparative study of 451 patients operated on of laparoscopic cholecystectomy by using transoperative selective cholangiography in 151 individuals and systematical cholangiography in 456 was conducted. The same inclusion criteria were used in both groups. The average surgical time was inclusion criteria were used in both groups. The average surgical time was lower than an hour in these 2 groups. It was proved that feasibility indexes over 90 percent, similar to those of open surgery, are attained with training. The systematical cholangiography allowed to find a higher percent of unsuspected lithiasis in the main biliary tract, to diagnose nonlithiasic affections of the choledochus, to identify potentially dangerous anomalies and to detect iatrogenies on the main biliary tract during the transoperative. It was concluded that in the laparoscopic cholecystectomy the transoperative cholangiography should be systematically made(AU)