The Diagnosis and Treatment of Acute Cholecystitis: A Comprehensive Narrative Review for a Practical Approach.

Acute cholecystitis (AC), generally associated with the presence of gallstones, is a relatively frequent disease that can lead to serious complications. For these reasons, AC warrants prompt clinical diagnosis and management. There is general agreement in terms of considering early laparoscopic cholecystectomy (ELC) to be the best treatment for AC. The optimal timeframe to perform ELC is within 72 h from diagnosis, with a possible extension of up to 7-10 days from symptom onset. In the first hours or days after hospital admission, before an ELC procedure, the patient's medical management comprises fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics. Additionally, concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated. The importance of ELC is related to the frequent recurrence of symptoms and complications of gallstone disease in the interval period between the onset of AC and surgical intervention. In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation. Critically ill patients, who are unfit for surgery, may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD). A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients. In this review, we provide a practical diagnostic and therapeutic approach to AC, even in specific clinical situations, based on evidence from the literature.

Results during the learning curve in the laparoscopic common bile duct exploration for choledocolithiasis.

OBJECTIVES: To analyze the results obtained in terms of efficacy and safety during the learning curve of a surgical team in the technique of laparoscopic common bile duct exploration with cholecystectomy (LCBDE+LC) using choledochoscopy for the treatment of patients with cholelithiasis and choledocolithiasis or common bile duct stones (CBDS) (CDL). METHODS: Single-center prospective analysis of patients treated with LCBDE+LC during the first 4 years of implementation of the technique. A descriptive and comparative analysis was carried out between groups according to the transcystic (TCi) or transcolecocal (TCo) approach, and also evolutionary by periods. The effectiveness of the technique was evaluated using the variable success rate and safety through the analysis of the overall complication rate and the bile leak rate as the most frequent adverse effect. RESULTS: A total of 78 patients were analyzed. The most frequent approach was TCo (62%). The overall success rate was 92%. The TCi group had a shorter operating time, a lower overall complications rate and a shorter hospital stay. The TCo approach was related to a higher rate of clinically relevant bile leak (8%). Complex cases increased significantly during the learning curve without effect on the overall results. CONCLUSIONS: LCBDE+LC is an effective and safe technique during the learning curve. Its results are comparable to those published by more experienced groups and do not present significant differences related to the evolution during learning period.

Effectiveness of double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (DBE-ERCP): A multicenter real-world study.

BACKGROUND AND AIMS: To investigate the effectiveness of double-balloon enteroscope-assisted retrograde cholangiopancreatography (DBE-ERCP) in patients with gastrointestinal surgically altered anatomy (SAA). METHODS: From May 2013 to October 2021, all consecutive patients undergoing DBE-ERCP in three gastroenterological referral centers in Northern Italy were enrolled in the study. Patients were assessed regarding their medical history, previous surgery, time from previous surgery to the DBE-ERCP procedure, and the success or failure of DBE-ERCP. RESULTS: Fifty-three patients (60% men, median age 65 (23-89) years) undergoing 67 DBE-ERCP procedures (1-3 DBE-ERCP per patient) were enrolled. Reasons for SAA included orthotopic liver transplantation (23%), ulcers (15%), malignancies (43%), difficult cholecystectomy (17%), and other causes (2%). Types of surgery included Roux-en-Y biliodigestive anastomosis (45%), Roux-en-Y gastrectomy (32%), pancreaticoduodenectomy (17%), and Billroth II gastrectomy (6%). The overall DBE-ERCP success rate was 86%. The type of surgery, indications, and the length of time between previous surgery and DBE-ERCP were not statistically associated with DBE-ERCP success. The DBE-ERCP success rate increased from 2018 to 2021. CONCLUSIONS: DBE-ERCP is a successful procedure in challenging patients with SAA. The improvement in results over time indicates the necessity of adequate training and of centralizing patients in referral centers.

Controversias en cirugía: colelitiasis y coledocolitiasis ¿Exploración de vías biliares laparoscópica más colecistectomía laparoscópica (cirugía en un paso) o CPRE y colecistectomía laparoscópica (cirugía en dos pasos)? / Controversies in surgery: Cholelithiasis and choledocholithiasis - Laparoscopic bile duct exploration plus laparoscopic cholecystectomy (one-step surgery) or ERCP and laparoscopic cholecystectomy(two-step surgery)?

Introducción. La colelitiasis tiene una prevalencia del 15 % y el 21 % tendrá coledocolitiasis al momento de la colecistectomía, con 50 % de probabilidad de presentar complicaciones asociadas. Desde el advenimiento de la colecistectomía laparoscópica, el abordaje de la coledocolitiasis ha sido endoscópico, usualmente en un tiempo diferente al vesicular, sin embargo, los avances en laparoscopia han permitido explorar la vía biliar común por la misma vía, pudiendo realizar ambos procedimientos en el mismo tiempo de forma segura. Métodos. Se realizó una búsqueda de la literatura existente con relación al enfoque para el manejo de la colecisto-coledocolitasis en un paso comparado con dos pasos. Resultados. Existe evidencia que demuestra mayor efectividad del abordaje en dos pasos, con CPRE y posterior colecistectomía laparoscópica, sobre el abordaje en un paso, especialmente en la tasa de fuga biliar y de cálculos retenidos. El enfoque en un paso con exploración de vías biliares y colecistectomía laparoscópica en el mismo tiempo es seguro, con alta tasa de éxito, baja incidencia de complicaciones, menor estancia hospitalaria y costos. Conclusión. El abordaje laparoscópico en un solo paso es un procedimiento seguro y eficaz para el manejo de la colecisto-coledocolitiasis, con el beneficio de estancia hospitalaria menor, sin embargo, se requieren habilidades técnicas avanzadas en cirugía laparoscópica. En nuestro medio ya existe una infraestructura para el manejo híbrido con CPRE y colecistectomía laparoscópica, pudiéndose realizar ambos en el mismo tiempo, para reducir estancia y costos.

Introduction. Cholelithiasis has a prevalence of 15%, and 21% will have choledocholithiasis at the time of cholecystectomy, with a 50% probability of presenting associated complications. Since the advent of laparoscopic cholecystectomy, the approach to choledocholithiasis has been endoscopic, normative at a different time than the gallbladder; however, advances in laparoscopy have made it possible to explore the common bile duct by the same route, being able to perform both procedures in a single time safely. Methods. A search of the existing literature was performed regarding the one-step approach compared to the two-step approach for the management of cholelithiasis and choledocholithiasis. Results. There is evidence that demonstrates greater effectiveness of the two-step approach with ERCP and subsequent laparoscopic cholecystectomy over the one-step approach, especially in the rate of bile leak and the incidence of retained stones. The one-step approach with bile duct exploration and laparoscopic cholecystectomy at the same time is safe, with a high success rate, low incidence of complications, shorter hospital stay, and lower costs. Conclusion. The one-step laparoscopic approach is a safe and effective procedure for the management cholelithiasis and concomitant choledocholithiasis, with the benefit of a shorter hospital stay; however, advanced technical skills in laparoscopic surgery are required. In our environment there is already an infrastructure for hybrid management with ERCP and laparoscopic cholecystectomy, both of which can be performed at the same time to reduce hospital stay and costs.

Percutaneous stone removal using a compliant balloon after papillary balloon dilatation.

PURPOSE: To evaluate the safety and efficacy of percutaneous stone removal using a compliant balloon after papillary balloon dilatation. MATERIAL AND METHODS: Between March 2014 and May 2020, 123 patients with choledocholithiasis, in whom endoscopy was unsuccessful, were enrolled in this study. The ampulla of Vater was dilated using a noncompliant balloon, and stone removal was attempted via a pushing maneuver using an endoscopic stone extraction balloon. Clinical and technical success rates, complications, and risk factors for failure and complications were evaluated. RESULTS: Biliary stones were completely removed in 118 of 123 patients. Major complications occurred in five patients. One patient experienced duodenal bleeding, which was successfully treated by endoscopy. Hemobilia occurred in three patients, which required transfusion, and one patient experienced four days of abdominal pain. Minor complications, including self-limiting pain, effusion, minimal hemobilia, elevated amylase and fever, occurred in 21 patients. Stone size was the only significant risk factor associated with the rate of complications (Odds ratio: 1.14, 95% confidence interval = 1.04, 1.26). Bilirubin and white blood cell levels significantly decreased after the procedure. CONCLUSION: Percutaneous stone removal using a compliant balloon after papillary balloon dilatation is a safe and effective method in patients in whom endoscopic or surgical treatment is not feasible. Abbreviations: ERCP: endoscopic retrograde cholangiopancreatography; PTBD: percutaneous transhepatic biliary drainage.

Long-Term Outcomes of Elderly Patients Managed Without Early Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography and Sphincterotomy for Choledocholithiasis.

Background Prophylactic cholecystectomy following endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-S) remains the gold standard management of choledocholithiasis. Some clinicians propose ERCP-S alone as the definitive management in the elderly, given perioperative complication risks. This retrospective cohort study aimed to assess the long-term efficacy and safety of non-operative management of choledocholithiasis in adults aged ≥70. Methodology A total of 252 patients aged ≥70 underwent ERCP from 2004 to 2014 at a single institution. The rates of cholecystectomy, ERCP, complications, and mortality were gathered. Data were linked to a provincial health database to capture follow-up visits to alternate hospitals. Predictors of operation, recurrence, and mortality were analyzed using multivariable regression. Results Following ERCP, of the 252 patients, 33 (13.1%) underwent prophylactic cholecystectomy within three months, while 219 (86.9%) were initially managed conservatively. Of the 219 patients, 147 (67.1%) experienced no further choledocholithiasis after conservative management, while 23 (10.5%) patients underwent cholecystectomy. The mean follow-up was 2.9 years. Delayed operative patients were younger (mean age: 77.56 vs. 82.90; p < 0.001) and had lower Charlson Comorbidity Index (CCI) (1.04 vs. 1.84; p = 0.030). When adjusted for age, CCI score, and sex, cholecystectomy was associated with increased survival, with an odds ratio of 0.48 (95% confidence interval = 0.26-0.90; p = 0.021). Perioperative complications occurred in 7/56 (12.5%) patients. Conclusions Recurrent choledocholithiasis is common in elderly patients. Despite recurrent symptoms, these patients are unlikely to undergo cholecystectomy. Surgeons operate on patients with greater life expectancy and fewer comorbidities with high success despite advanced patient age. Future prospective studies should examine objective criteria for prophylactic cholecystectomy in this population, given purported safety and benefits.

Choledocholithiasis in elderly patients with gallbladder in situ - is ERCP sufficient?

INTRODUCTION: Along with increased life expectancy, the proportion of elderly patients with choledocholithiasis will increase and with this, the need for endoscopic cholangiopancreatography (ERCP). Current recommendations suggest laparoscopic cholecystectomy in all patients with choledocholithiasis to prevent biliary events. However, adherence to these recommendations is low, especially in older patients. METHODS: Retrospective study that included non-cholecystectomized patients aged > =75 years who underwent ERCP for choledocholithiasis from 2013-2016 (n = 131). A new biliary event was defined as the need for a new ERCP, cholecystitis, cholangitis or gallstone pancreatitis. AIM: The aim of this study was to compare the outcomes of new biliary events and mortality in cholecystectomized vs non-cholecystectomized patients after ERCP. RESULTS: Cholecystectomy was performed in 22% of the patients (92% laparoscopic). The post-cholecystectomy complication rate was 13% and the mortality rate was 7%. During the follow-up period (669 ± 487 days) a new biliary event occurred in 20% of patients - 10% new ERCP, 9% cholecystitis, 9% cholangitis and 2% pancreatitis. Cholecystectomized patients had fewer events (7% vs 24%, p = .048) and longer time to event (p = .016). There was no statistically significant difference in all-cause mortality (14% vs 27%, p = .13), mortality related to lithiasis (0% vs 9%, p = .11) or time to mortality from all causes (p = .07) and related to biliary events (p = .07). CONCLUSIONS: In this group of elderly patients, cholecystectomy after ERCP prevented the occurrence of new biliary events but resulted in a non-statistically significant difference in mortality.

Trans-Gastric ERCP After Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis.

BACKGROUND: Trans-oral endoscopic access to the pancreaticobiliary system is challenging after Roux-en-Y gastric bypass (RYGB). Trans-gastric ERCP (TG-ERCP) has emerged as a viable option to manage patients with symptomatic post-RYBG choledocolithiasis. The aim of this systematic review and meta-analysis was to examine the outcomes of TG-ERCP to better define the risk-benefit ratio of this procedure and to guide clinical decision-making. METHODS: A literature search was conducted to identify all reports on ERCP after RYGB. Pubmed, MEDLINE, Embase, and Cochrane databases were thoroughly consulted matching the terms "ERCP" AND "gastric bypass." Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were calculated using Freeman-Tukey double arcsine transformation and DerSimonian-Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I2-index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders. RESULTS: Thirteen papers published between 2009 and 2017 matched the inclusion criteria. Eight hundred fifty patients undergoing 931 procedures were included. The most common clinical indications for TG-ERCP were biliary (90%) and pancreatic (10%). The majority of patients underwent an initial laparoscopic approach (90%). Same-day ERCP was successfully achieved in 703 cases (75.5%). Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were 99% (95% CI = 98-100%), 3.1% (95% CI = 1.0-5.8%), 3.4% (95% CI = 1.7-5.5%), and 14.2% (95% CI = 8.5-20.8%), respectively. CONCLUSION: TG-ERCP is a safe and effective therapeutic option in patients with symptomatic post-RYGB choledocolithiasis.

Single-stage procedure for the treatment of cholecysto-choledocolithiasis: a surgical procedures review.

While laparoscopic cholecystectomy is generally accepted as the treatment of choice for simple gallbladder stones, in cases in which common bile duct stones are also present, clinical and diagnostic elements, along with intraoperative findings, define the optimal means of treatment. All available options must be accessible to the surgical team which must necessarily be multidisciplinary and include a surgeon, an endoscopist, and a radiologist in order to identify the best option for a truly personalized surgery. This review describes the different techniques and approaches used based on distinctive recommendations and factors, according to the specific cases treated and the results achieved.

Non-traumatic perforation of common hepatic duct: Case report and review of literature HP.

INTRODUCTION: Non-traumatic biliary perforation other than the gallbladder is extremely rare and most commonly seen in children in association with congenital biliary anomalies. We present a rare case of choledocholithiasis that progressed to spontaneous perforation of the common hepatic duct probably from ischemic necrosis caused by impaction of large biliary stones. CASEREPORT: A 62-year-old female presented with diarrhea and jaundice. She was found to have two 2.5cm stones in the common hepatic duct. Stones could not be extracted by ERCP, and placement of biliary stent was done to restore patency. The patient was lost to follow up and returned after three months with a new onset of similar symptoms. At that time ERCP and a stent change were done without resolution of the symptoms. Patient then underwent an open exploration and was found to have a free perforation in the lateral aspect of the common hepatic duct just at the bifurcation of the right and left hepatic radicals. Through this perforation stones were both extracted and cholangiogram showed free flow with the distal biliary stent. The stent was nowhere near the site of perforation which appeared to be caused by pressure necrosis from the impacted stones. CONCLUSION: Impacted stones in the biliary tree need to be extracted to avoid pressure necrosis and spontaneous perforation. ERCP and stent placement should be used only as temporizing measures to manage the acute obstructive phase. Definitive surgical intervention must follow initial biliary decompression to extract the impacted biliary stones and avoid complications.

A case report of choledocholithiasis 33 years after cholecystectomy.

INTRODUCTION: Choledocholithiasis after cholecystectomy is rare and often attributed to surgical clip migration and subsequent nidus formation. PRESENTATION OF CASE: This case demonstrates choledocholithiasis following cholecystectomy with a latency period of 33 years. DISCUSSION: The patient presented with pain of the right upper quadrant (RUQ). Subsequent abdominal-pelvic CT imaging revealed dilation of the common bile duct. Further Endoscopic Retrograde Cholangiopancreatography was indicative of choledocholithiasis. Additional findings included a long cystic duct remnant and surgical clips in the RUQ. CONCLUSION: The patient underwent biliary sphincterotomy and sludge and stone fragments were swept from the biliary tree. To our knowledge, a latency of 33 years between cholecystectomy and choledocholithiasis has never been reported before, at least not in a patient without coexisting duodenal diverticulum, a condition associated with lithiasis of the common bile duct. Our case raises discussion of potential etiologies for such long latency, including surgical clip migration, remnant cystic duct lithiasis, and primary choledocholithiasis; and further details the incidence of such long latency periods following cholecystectomy.

Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy.

AIM: To assess the role of laparoscopic ultrasound (LUS) as a substitute for intraoperative cholangiography (IOC) during cholecystectomy. METHODS: We present a MEDLINE and PubMed literature search, having used the key-words "laparoscopic intraoperative ultrasound" and "laparoscopic cholecystectomy". All relevant English language publications from 2000 to 2016 were identified, with data extracted for the role of LUS in the anatomical delineation of the biliary tract, detection of common bile duct stones (CBDS), prevention or early detection of biliary duct injury (BDI), and incidental findings during laparoscopic cholecystectomy. Data for the role of LUS vs IOC in complex situations (i.e., inflammatory disease/fibrosis) were specifically analyzed. RESULTS: We report data from eighteen reports, 13 prospective non-randomized trials, 5 retrospective trials, and two meta-analyses assessing diagnostic accuracy, with one analysis also assessing costs, duration of the examination, and anatomical mapping. Overall, LUS was shown to provide highly sensitive mapping of the extra-pancreatic biliary anatomy in 92%-100% of patients, with more difficulty encountered in delineation of the intra-pancreatic segment of the biliary tract (73.8%-98%). Identification of vascular and biliary variations has been documented in two studies. Although inflammatory disease hampered accuracy, LUS was still advantageous vs IOC in patients with obscured anatomy. LUS can be performed before any dissection and repeated at will to guide the surgeon especially when hilar mapping is difficult due to fibrosis and inflammation. In two studies LUS prevented conversion in 91% of patients with difficult scenarios. Considering CBDS detection, LUS sensitivity and specificity were 76%-100% and 96.2%-100%, respectively. LUS allowed the diagnosis/treatment of incidental findings of adjacent organs. No valuable data for BDI prevention or detection could be retrieved, even if no BDI was documented in the reports analyzed. Literature analysis proved LUS as a safe, quick, non-irradiating, cost-effective technique, which is comparatively well known although largely under-utilized, probably due to the perception of a difficult learning curve. CONCLUSION: We highlight the advantages and limitations of laparoscopic ultrasound during cholecystectomy, and underline its value in difficult scenarios when the anatomy is obscured.

Percutaneous transhepatic holmium laser lithotripsy of a large common bile duct stone.

A 58-year-old woman presented with a 4 cm obstructing choledocolith within the proximal common bile duct. She had an extensive operative history resulting in common bile duct to jejunum anastomosis after cholecystectomy. Endoscopic retrograde cholangiopancreatography (ERCP) removal was unsuccessful, and surgical exploration was contraindicated due to multiple comorbidities. Interventional radiologist placement of bilateral transhepatic ureteral access sheaths allowed Urologist evaluation of the biliary tract by ureteroscope. Holmium laser lithotripsy was performed with successful fragmentation of the stone and clearance of the obstruction, without complication. The case is relevant to the growing literature on the management of refractory biliary stones after failed ERCP.

Laparoscopy-Assisted Trans-Gastric Rendez-vous for the Treatment of Common Bile Duct Stones in Patients with Prior Roux-en-Y Gastric Bypass.

BACKGROUND: Common bile duct (CBD) stones in a Roux-en-Y gastric bypass (RYGB) represent a major challenge for ERCP due to long-limb anatomy. Trans-gastric approach has been proposed but entails high ERCP-related risks. Laparoscopy assisted trans-gastric rendez-vous (LATG-RV) is a one-step procedure that may lower the risks of these patients. METHODS: We describe our initial experience in four patients with past history of RYGB and CBD stones. RESULTS: All patients underwent LATG-RV and had successful CBD stone clearance. Postoperative course was uneventful with normal amylase levels. Average procedure time was 105 min and postoperative stay 2 days. CONCLUSION: LATG-RV is a safe and effective procedure for the clearance of CBD stones in RYGB patients. It may have fewer complications and shorter operative time than regular trans-gastric ERCP.

Role and timing of endoscopy in acute biliary pancreatitis.

The role and timing of endoscopy in the setting of acute biliary pancreatitis (ABP) is still being debated. Despite numerous randomized trials have been published, there is an obvious lack of consensus on the indications and timing of endoscopic retrograde cholangiopancreatography (ERCP) in ABP in meta-analyses and nationwide guidelines. The present editorial has been written to clarify the role of endoscopy in ABP. In clinical practice the decision to perform an ERCP is often based on biochemical and radiological criteria despite they already have been shown to be unreliable predictors of common bile duct stone presence. Endoscopic ultrasonography (EUS) is not currently a worldwide standard diagnostic procedure early in the course of acute biliary pancreatitis, but it has been shown to be accurate, safe and cost effective in diagnosing biliary obstructions compared with magnetic resonance cholangiopancreatography and ERCP and therefore in preventing unnecessary ERCP and its related complications. Early EUS in ABP allows, if appropriate, immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Early endoscopic ultrasonography in acute biliary pancreatitis: A prospective pilot study.

AIM: To investigate the clinical usefulness of early endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis (ABP). METHODS: All consecutive patients entering the emergency department between January 2010 and December 2012 due to acute abdominal pain and showing biochemical and/or radiological findings consistent with possible ABP were prospectively enrolled. Patients were classified as having a low, moderate, or high probability of common bile duct (CBD) stones, according to the established risk stratification. Exclusion criteria were: gastrectomy or patient in whom the cause of biliary obstruction was already identified by ultrasonography. All enrolled patients underwent EUS within 48 h of their admission. Endoscopic retrograde cholangiopancreatography was performed immediately after EUS only in those cases with proven CBD stones or sludge. The following parameters were investigated: (1) clinical: age, sex, fever; (2) radiological: dilated CBD; and (3) biochemical: bilirubin, AST, ALT, gGT, ALP, amylase, lipasis, PCR. Association between presence of CBD stone at EUS and the individual predictors were assessed by univariate logistic regression. Predictors significantly associated with CBD stones (P < 0.05) were entered in a multivariate logistic regression model. RESULTS: A total of 181 patients with pancreatitis were admitted to the emergency department between January 2010 and December 2012. After exclusion criteria a total of 71 patients (38 females, 53.5%, mean age 58 ± 20.12 years, range 27-89 years; 33 males, 46.5%, mean age 65 ± 11.86 years, range 41-91 years) were included in the present study. The probability of CBD stones was considered low in 21 cases (29%), moderate in 26 (37%), and high in the remaining 24 (34%). The 71 patients included in the study underwent EUS, which allowed for a complete evaluation of the target sites in all the cases. The procedure was completed in a mean time of 14.7 min (range 9-34 min), without any notable complications.The overall CBD stone frequency was 44% (31 of 71), with a significant increase from the group at low pretest probability to that at moderate (OR = 5.79, P = 0.01) and high (OR = 4.25, P = 0.03) pretest probability. CONCLUSION: Early EUS in ABP allows, if appropriate, immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.

Bilioma espontâneo: relato de caso e revisão da literatura / Spontaneous biloma: a case report and literature review

Bilioma é qualquer coleção de bile fora das vias biliares. Geralmente, resulta de complicações cirúrgicas e trauma abdominal. A ocorrência espontânea é rara, ocasionalmente associada a coledocolitíase. Relata-se um caso de bilioma espontâneo, cujo diagnóstico foi confirmado radiologicamente. À laparotomia, observou-se bilioma retroperitoneal. A colangiografia transoperatória não evidenciou fístula. Após drenagem, o paciente teve boa evolução e alta hospitalar.

Biloma is defined as any collection of bile outside the biliary tree, usually resulting from surgery complications and abdominal trauma. Spontaneous occurrence of bilomas is rare, occasionally associated with choledocolithiasis. The present report describes a case of spontaneous biloma, whose diagnosis was radiologically confirmed. At laparotomy, the presence of a retroperitoneal biloma was observed. Intraoperative cholangiography has not demonstrated the presence of fistula. After drainage, the patient progressed well and was discharged.

Avaliação da positividade da colangiografia peroperatória em pacientes submetidos à colecistectomia laparoscópica eletiva / Assessment of positive perioperative cholangiography in patients undergoing elective laparoscopic cholecystectomy

OBJETIVO: A colecistectomia laparoscópica é o tratamento de escolha para pacientes com colecistopatia calculosa, embora o manejo da coledocolitíase associada ainda permaneça assunto controverso. O presente estudo baseou-se na análise prospectiva de pacientes submetidos à colecistectomia eletiva com colangiografia peroperatória, pretendendo assim avaliar a positividade do exame contrastado das vias biliares em pacientes com colelitíase sem indicação para colangiografia. MÉTODOS: Foram incluídos, no estudo, 100 pacientes cujos parâmetros clínicos, laboratoriais e de imagem feitos até no máximo 10 dias antes da colecistectomia não apresentaram qualquer alteração no pré-operatório e, portanto, considerados pacientes insuspeitáveis para coledocolitíase. As colangiografias foram analisadas e examinadas pela equipe cirúrgica, pelo radiologista e pelos autores deste estudo. Os laudos foram comparados e correlacionados com achados clínicos e laboratoriais prévios dos pacientes. RESULTADOS: A incidência de coledocolitíase insuspeitável no pré-operatório foi de apenas um único caso entre 100 pacientes sem indicação para o exame (1% de positividade). CONCLUSÃO: Com base neste material, pode-se concluir que o emprego da colangiografia seletiva é segura e deve ser empregada no tratamento da colecistite calculosa.

OBJECTIVE: To evaluate the positivity of cholangiography in patients without formal indication of this exam undergoing elective cholecystectomy. METHODS: We included, in the study, 100 patients whose clinical, laboratory and imaging not older than 10 days before the operation showed no change and therefore kept us unsuspicious of choledocholithiasis. The cholangiographies were analyzed and examined by the surgical team, the radiologist and the authors. The reports were compared and correlated with patients' previous clinical and laboratory findings. RESULTS: The incidence of preoperatively unsuspected choledocholithiasis was only one case (1%). CONCLUSION: The use of selective cholangiography is safe and should be used in the treatment of calculous cholecystitis.

Evaluación del manejo interdisciplinario de una serie de 53 pacientes con hepatolitiasis / Evaluation of interdisciplinary care of a series of 53 patients with hepatholithiasis

Objetivos: Evaluar, en una serie de enfermos con hepatolitiasis, el resultado del manejo interdisciplinario. Pacientes y métodos: Durante 8 años se valoraron, en un estudio retrospectivo, 53 pacientes con diagnóstico de hepatolitiasis. Resultados: Se estudiaron 23 hombres (43%) y 30 mujeres con una edad promedio de 50 ± 15 años (25 a 83 años). Predominó el dolor (94%), seguido de ictericia (68%) y fiebre (57%). Según la clasificación de Tsunoda, 6 pacientes eran Tsunoda I, 12 Tsunoda II, 4 Tsunoda III y 5 Tsunoda IV. El compromiso más frecuente fue del lóbulo izquierdo (36%) o bilateral (34%). La colangiografía endoscópica tuvo éxito en el 64% y solo se manejaron 4 pacientes por la vía transparietohepática (2 éxitos). Se operaron 35 pacientes (66%) y lo más frecuente fue la hepatectomía izquierda en 40% (7 con asa subcutánea) seguida por hepaticoyeyunostomía con asa subcutánea (26%). Se realizaron cuatro trasplantes ortotópicos de hígado que evolucionan asintomáticos en pacientes con complicaciones por cirrosis. Las complicaciones postoperatorias tempranas fueron del 40%, la más frecuente la infección del sitio operatorio (14%) y cálculos residuales (9%). La complicación tardía más usual fue la litiasis residual (23%). El 80% de los pacientes operados están asintomáticos comparados con el 72% de los no operados. No hubo mortalidad quirúrgica. Conclusiones: La hepatolitiasis es una entidad con manejos no bien estandarizados, entre ellos, la opción quirúrgica cursa con buenos resultados, mejoría clínica y poca morbimortalidad; con el apoyo interdisciplinario dado la radiología intervencionista y la endoscopia biliar.

Objectives: Evaluate the results of interdisciplinary care in a series of patients with hepatolithiasis. Patients and Methods: A retrospective study of 53 patients with hepatolithiasis who were evaluated over an eight year period. Results: 23 men (43%) and 30 women were studied. The average age was 50 ± 15 years (range: 25-83 years). Pain was the predominant symptom (94%), followed by jaundice (68%) and fever (57%). According to the Tsunoda classification, 6 patients were Tsunoda I, 12 were Tsunoda II, 4 were Tsunoda III, and 5 were Tsunoda IV. Left lobe hepatolithiasis was most frequent (36%), followed by bilateral hepatolithiasis (34%). Endoscopic cholangiography was successful in 64% of patients. Only 4 patients were treated by percutaneous cholangiography, with 2 successes. 35 patients (66%) were operated on. The most frequent surgery was left hepatectomy with subcutaneous loop in 7 patients (40%), followed by hepatojejunostomy with subcutaneous loop (26%). Four orthotopic liver transplantations with good evolution were performed in patients with cirrhotic complications. 40% had early complications. Most frequent were infection of the operative site (14%) and residual stones (9%). The most frequent delayed complication was residual lithiasis (23%). 80% of the patients who underwent surgery were asymptomatic compared with 72% of those who did not undergo surgery. There were no mortalities resulting from surgery. Conclusions: Hepatolithiasis is a disease which does not have a well standardized treatment. Surgery is an alternative with good results, clinical improvement and low morbidity and mortality rates when there is interdisciplinary including interventionist radiology and biliary endoscopy.