Duplicación del colédoco asociado a unión biliopancreática anómala: Reporte de caso / Common bile duct duplication associated with anomalous biliopancreatic junction: A case report

Introducción. La duplicación del colédoco es una anomalía congénita poco frecuente. En la mayoría de los casos este defecto se asocia a cálculos en la vía biliar, unión pancreatobiliar anómala, pancreatitis, cáncer gástrico o colangiocarcinoma. Por esta razón, el diagnóstico y el tratamiento temprano son importantes para evitar las complicaciones descritas a futuro. Métodos. Se presenta el caso de una paciente de 30 años, con antecedente de pancreatitis aguda, con cuadro de dolor abdominal crónico, a quien se le realizaron varios estudios imagenológicos sin claro diagnóstico. Fue llevada a manejo quirúrgico en donde se documentó duplicación del colédoco tipo II con unión pancreatobiliar anómala. Resultados. Se hizo reconstrucción de las vías biliares y hepatico-yeyunostomía, con adecuada evolución postoperatoria y reporte final de patología sin evidencia de tumor. Conclusión. El diagnóstico se hace mediante ecografía endoscópica biliopancreática, colangiorresonancia o colangiopancreatografía retrógrada endoscópica. El tratamiento depende de si está asociado o no a la presencia de unión biliopancreática anómala o cáncer. Si el paciente no presenta patología neoplásica, el tratamiento quirúrgico recomendado es la resección del conducto con reconstrucción de las vías biliares.

Introduction. Double common bile duct is an extremely rare congenital anomaly. This anomaly may be associated with bile duct stones, anomalous biliopancreatic junction, pancreatitis, bile duct cancer, or gastric cancers. Thus, early diagnosis and treatment is important to avoid complications. Clinical case. We report a rare case of double common bile duct associated with an anomalous biliopancreatic junction in a 30-year-old female, with prior history of acute pancreatitis, who presented with chronic abdominal pain. She underwent several imaging studies, without clear diagnosis. She was taken to surgical management where duplication of the type II common bile duct was documented with anomalous pancreatobiliary junction. Results. Reconstruction of the bile ducts and hepatico-jejunostomy were performed, with adequate postoperative evolution and final pathology report without evidence of tumor. Conclusion. Diagnosis is usually performed by an endoscopic ultrasound, magnetic resonance cholangiopancrea-tography, or endoscopic retrograde cholangiopancreatography. Treatment depends on the presence of anomalus biliopancreatic junction or concomitant cancer. In cases without associated malignancy, resection of bile duct and biliary reconstruction is the recommended surgical treatment.

Colangioscopia com litotripsia biliar percutânea a laser para tratamento de cálculos biliares intra-hepáticos: um relato de caso / Percutaneous cholangioscopy and laser biliary lithotripsy for biliary intrahepatic stones management: case report

ABSTRACT Intrahepatic biliary stone disease is a difficult condition to treat, due to anatomical complexity of biliary tract, association with colestasis, and high recurrence rates, with potential short- and long-term complications, such as cholangitis and secondary biliary cirrhosis. Removal of biliary stones via intraductal access can be achieved endoscopically or percutaneously, with preference for cholangioscopy-guided laser lithotripsy in complex cases. The surgical approach, despite its prolonged results, is a more invasive and risky procedure. The authors present a case of cholangioscopy with percutaneous laser biliary lithotripsy as an option for the treatment of intrahepatic biliary stone disease associated with biliary stricture following biliodigestive anastomosis due to bile duct injury following cholecystectomy, a safe and effective alternative with low morbidity and satisfactory outcomes in follow-up.

RESUMO A litíase biliar intra-hepática é uma condição de difícil tratamento, pela complexidade anatômica, pela associação à estase biliar e pelas altas taxas de recidiva, com potenciais complicações a curto e a longo prazo, como quadros de colangite de repetição e cirrose biliar secundária. A remoção de cálculos biliares por acesso intraductal pode ser obtida por via endoscópica ou percutânea, com preferência por litotripsia a laser por colangioscopia em casos complexos. A cirurgia, apesar de apresentar resultados prolongados, apresenta o contraponto de ser mais invasiva e com maiores riscos. Os autores apresentam um caso, e suas imagens, de colangioscopia com litotripsia biliar percutânea a laser como opção para tratamento de litíase biliar intra-hepática associado a estenose biliar secundária a anastomose biliodigestiva por lesão de via biliar pós colecistectomia, uma alternativa segura e eficaz, com baixa morbidade e um resultado satisfatório no seguimento.

Prognostic role of magnetic resonance imaging of the abdomen with intravenous contrast and magnetic resonance cholangiopancreatography in primary sclerosing cholangitis / Papel prognóstico da ressonância magnética do abdome com contraste intravenoso e colangiopancreatografia por ressonância magnética na colangite esclerosante primária

Abstract Objective: To evaluate the usefulness of Anali scores, determined by magnetic resonance imaging, for predicting the prognosis of primary sclerosing cholangitis (PSC) and to analyze interobserver variability, as well as to assess the impact of periportal edema and heterogeneous signal intensity on diffusion-weighted imaging of the liver. Materials and Methods: This was a retrospective cohort study of 29 patients with PSC and baseline magnetic resonance imaging. Anali scores, without gadolinium (0-5 points) and with gadolinium (0-2 points), were calculated by two radiologists. Clinical end-points included liver transplantation, cirrhotic decompensation, and death. We calculated intraclass correlation coefficients (ICCs) for interobserver agreement on the Anali scores, performed Kaplan-Meier survival analysis comparing event-free survival among the score strata, and calculated the areas under receiver operating characteristic curves to determine sensitivity and specificity. Results: Among the patients with a clinical event, the median Anali score was 4 (interquartile range [IQR], 2-5) without gadolinium and 2 (IQR, 1-2) with gadolinium, compared with 1 (IQR, 1.0-2.5) and 1 (IQR, 0.25-1.0), respectively, among those without a clinical event. The ICC was 0.79 (95% confidence interval: 0.57-0.91) for the Anali score with gadolinium and 0.99 (95% confidence interval: 0.98-0.99) for the Anali score without gadolinium. Periportal edema and heterogeneous signal intensity in the liver on diffusion-weighted imaging showed no statistical impact on clinical events (p = 0.65 and p = 0.5, respectively). Conclusion: Anali scores correlate with clinical events in PSC, with a high level of interobserver agreement.

Resumo Objetivo: Avaliar a utilidade dos escores Anali determinados por ressonância magnética para prever o prognóstico da colangite esclerosante primária (CEP), analisar a variabilidade interobservador e avaliar o impacto do edema periportal e do sinal heterogêneo do fígado em imagens ponderadas por difusão. Materiais e Métodos: Estudo retrospectivo de coorte de 29 pacientes com CEP e ressonância magnética de base. Os escores Anali sem gadolínio (0 a 5 pontos) e com gadolínio (0 a 2 pontos) foram calculados por dois radiologistas. Os desfechos clínicos incluíram transplante de fígado, descompensação cirrótica ou morte. Foram realizados coeficiente de correlação intraclasse (CCI) para a concordância interobservador com relação ao escore Anali, análise de sobrevivência de Kaplan-Meier comparando o tempo livre de eventos de acordo com o escore, e área sob a curva característica de operação do receptor para sensibilidade e especificidade. Resultados: Nos pacientes com evento clínico, a mediana do escore Anali sem gadolínio foi 4 (intervalo interquartil [IIQ]: 2-5) e com gadolínio foi 2 (IIQ: 1-2), enquanto nos pacientes sem evento clínico o escore sem gadolínio foi 1 (IIQ:1-2,5) e com gadolínio foi 1 (IIQ: 0,25-1). A concordância interobservador com gadolínio foi CCI = 0,79 (intervalo de confiança 95%: 0,57-0,91) e sem gadolínio foi CCI = 0,99 (intervalo de confiança 95%: 0,98-0,99). O edema periportal (p = 0,65) e o sinal heterogêneo do fígado nas imagens ponderadas por difusão (p = 0,5) não apresentaram impacto nos eventos clínicos. Conclusão: Os escores Anali se correlacionam com eventos clínicos na CEP, com alto grau de concordância interobservador.

Endoscopic Retrograde Cholangiopancreatography in Children: Nine Years' Experience at Santa Fe Foundation in Bogota, Colombia.

INTRODUCTION: Experience in the use of diagnostic and/or therapy of endoscopic retrograde cholangiopancreatography (ERCP) in children is limited. This is due to the underdiagnosis of pancreaticobiliary disease in the pediatric population and specialist personnel in this procedure. OBJECTIVE: To determine the safety and success rate of ERCP in children at Hospital Fundación Santa Fe de Bogotá between January 2007 and June 2015. METHODOLOGY: This was an observational, descriptive, retrospective case series study of patients under 18 years, who underwent ERCP between January 2007 and June 2015. The following variables were analyzed: indication, duration, type of procedure, rate of success, and complications. RESULTS: A total of 30 patients were included, in whom 65 ERCP procedures were performed. Successful cannulation was achieved in 52 of the 65 procedures (80%). Among the complications that occurred, there were four cases of pancreatitis (6.2%), two cases of bleeding (3.1%), and one case of bacteremia (1.5%), and in most cases (58 in total, 89.2%), there were no complications. DISCUSSION: The pediatric gastroenterology group of the Fundación Santa Fe de Bogotá has obtained good results in performing ERCP in the pediatric population with a success rate of 80% associated with a null mortality rate. There is enough literature available to conclude that performing ERCP in the pediatric population maintains an adequate success rate and a low complication rate. In all the studies evaluated, a null mortality rate was found, so it is considered that this procedure is safe in patients under 18 years of age.

Litiasis masiva de la vía biliar intra y extra hepática. Reporte de 2 casos / Massive intra- and extra-hepatic bile duct lithiasis. Report of 2 cases

Resumen La presencia conjunta y masiva de cálculos biliares de la vía biliar, tanto intra como extra hepática, es una rara entidad dentro de la población occidental. A continuación, se presentan 2 casos, los cuales debutan con cuadro clínico de dolor en hipocondrio derecho y con datos clínicos y de laboratorio de obstrucción de la vía biliar, y que mediante estudio de colangio resonancia, se evidencian múltiples litos endoluminales de la vía biliar de manera global, además se muestra del tratamiento de uno de los casos mediante CPRE con evacuación exitosa de los cálculos biliares.

Abstract The joint and massive presence of gallstones from the bile duct, both intra and extra hepatic, is a rare entity within the western population. Two cases are presented below, which debuted with a clinical picture of pain in the right hypo chondrium and with a clinical picture of pain in the right hypochondrium and with clinical and laboratory data of bile duct obstruction, and that by means of a resonance cholangiography study, multiple endoluminal stones of the bile duct are evidenced. Overall, it also shows the treatment of one of the cases by ERCP with successful evacuation of the gallstones.

Colangiografía videolaparoscópica intraoperatoria y colangiopancreatografía retrógrada endoscópica en pacientes con sospecha de colédocolitiasis / Intraoperative Videolaparoscopic Cholangiography and Endoscopic Retrograde Cholangiopancreatography in Patients with Suspected Choledocholithiasis

Introducción: La coledocolitiasis se ha convertido en un problema de salud para el cual existen disímiles opciones de tratamiento. Objetivo: Exponer los resultados obtenidos con la colangiografía videolaparoscópica intraoperatoria y la colangiopancreatografía retrógrada endoscópica en pacientes con sospecha de coledocolitiasis. Métodos: Se realizó un estudio descriptivo retrospectivo en pacientes con sospecha de coledocolitiasis sometidos a colangiografía videolaparoscópica y la colangiopancreatografía endoscópica en el Hospital Militar Clínico Quirúrgico Docente de Camagüey Dr. Octavio de la Concepción y de la Pedraja durante el período de enero de 2015 a diciembre de 2019. El universo lo conformaron los 117 pacientes sometidos a ambos procederes. Se controlaron las variables de sospecha de coledocolitiasis, grupos de edades, sexo, hallazgos imagenológicos, complicaciones e índice de sospecha de coledocolitiasis. Resultados: En la colangiografía videolaparoscópica intraoperatoria fue mayor la posibilidad diagnóstica y menor las complicaciones. El diagnóstico de coledocolitiasis fue mayor en los pacientes sometidos a colangiopancreatografía retrógrada endoscópica, aunque esta no permitió evaluar a pacientes con bajo riesgo. Los pacientes del sexo femenino fueron más frecuentes en ambos grupos y la sospecha de coledocolitiasis se observó en grupo de edades entre 31 y 45 años. Sin embargo, fue normal el hallazgo de las vías biliares en ambos procederes. Conclusiones: Ambos métodos son seguros y útiles en el estudio en pacientes con sospecha de coledocolitiasis, con mayor eficacia diagnóstica para la técnica videolaparoscópica y menos complicaciones. El hallazgo normal de la vía biliar fue el resultado que prevaleció en ambos procederes(AU)

Introduction: Choledocholithiasis has become a health problem for which there are dissimilar treatment options. Objective: To present the results obtained with intraoperative videolaparoscopic cholangiography and endoscopic retrograde cholangiopancreatography in patients with suspected choledocholithiasis. Methods: A retrospective and descriptive study was conducted in patients with suspected choledocholithiasis and submitted to videolaparoscopic cholangiography and endoscopic cholangiopancreatography at Hospital Militar Clínico Quirúrgico Docente Dr. Octavio de la Concepción y de la Pedraja, of Camagüey, during the period from January 2015 to December 2019. The study universe consisted of 117 patients submitted to both procedures. The variables of suspected choledocholithiasis, age groups, sex, imaging findings, complications and index of suspected choledocholithiasis were controlled. Results: Intraoperative videolaparoscopic cholangiography had a higher diagnostic possibility and lower complications. The diagnosis of choledocholithiasis was higher in patients submitted to endoscopic retrograde cholangiopancreatography, although this did not allow the assessment of low-risk patients. Female patients were more frequent in both groups, while suspected choledocholithiasis was observed in patients between 31 and 45 years of age. However, the finding of a normal biliary tract was common to both procedures. Conclusions: Both methods are safe and useful in the study in patients with suspected choledocholithiasis, with greater diagnostic efficacy, as well as fewer complications, for the videolaparoscopic technique. The finding of a normal biliary tract was the prevailing result in both procedures(AU)

Prognostic role of magnetic resonance imaging of the abdomen with intravenous contrast and magnetic resonance cholangiopancreatography in primary sclerosing cholangitis.

Objective: To evaluate the usefulness of Anali scores, determined by magnetic resonance imaging, for predicting the prognosis of primary sclerosing cholangitis (PSC) and to analyze interobserver variability, as well as to assess the impact of periportal edema and heterogeneous signal intensity on diffusion-weighted imaging of the liver. Materials and Methods: This was a retrospective cohort study of 29 patients with PSC and baseline magnetic resonance imaging. Anali scores, without gadolinium (0-5 points) and with gadolinium (0-2 points), were calculated by two radiologists. Clinical end-points included liver transplantation, cirrhotic decompensation, and death. We calculated intraclass correlation coefficients (ICCs) for interobserver agreement on the Anali scores, performed Kaplan-Meier survival analysis comparing event-free survival among the score strata, and calculated the areas under receiver operating characteristic curves to determine sensitivity and specificity. Results: Among the patients with a clinical event, the median Anali score was 4 (interquartile range [IQR], 2-5) without gadolinium and 2 (IQR, 1-2) with gadolinium, compared with 1 (IQR, 1.0-2.5) and 1 (IQR, 0.25-1.0), respectively, among those without a clinical event. The ICC was 0.79 (95% confidence interval: 0.57-0.91) for the Anali score with gadolinium and 0.99 (95% confidence interval: 0.98-0.99) for the Anali score without gadolinium. Periportal edema and heterogeneous signal intensity in the liver on diffusion-weighted imaging showed no statistical impact on clinical events (p = 0.65 and p = 0.5, respectively). Conclusion: Anali scores correlate with clinical events in PSC, with a high level of interobserver agreement.

Objetivo: Avaliar a utilidade dos escores Anali determinados por ressonância magnética para prever o prognóstico da colangite esclerosante primária (CEP), analisar a variabilidade interobservador e avaliar o impacto do edema periportal e do sinal heterogêneo do fígado em imagens ponderadas por difusão. Materiais e Métodos: Estudo retrospectivo de coorte de 29 pacientes com CEP e ressonância magnética de base. Os escores Anali sem gadolínio (0 a 5 pontos) e com gadolínio (0 a 2 pontos) foram calculados por dois radiologistas. Os desfechos clínicos incluíram transplante de fígado, descompensação cirrótica ou morte. Foram realizados coeficiente de correlação intraclasse (CCI) para a concordância interobservador com relação ao escore Anali, análise de sobrevivência de Kaplan-Meier comparando o tempo livre de eventos de acordo com o escore, e área sob a curva característica de operação do receptor para sensibilidade e especificidade. Resultados: Nos pacientes com evento clínico, a mediana do escore Anali sem gadolínio foi 4 (intervalo interquartil [IIQ]: 2­5) e com gadolínio foi 2 (IIQ: 1­2), enquanto nos pacientes sem evento clínico o escore sem gadolínio foi 1 (IIQ:1­2,5) e com gadolínio foi 1 (IIQ: 0,25­1). A concordância interobservador com gadolínio foi CCI = 0,79 (intervalo de confiança 95%: 0,57­0,91) e sem gadolínio foi CCI = 0,99 (intervalo de confiança 95%: 0,98-0,99). O edema periportal (p = 0,65) e o sinal heterogêneo do fígado nas imagens ponderadas por difusão (p = 0,5) não apresentaram impacto nos eventos clínicos. Conclusão: Os escores Anali se correlacionam com eventos clínicos na CEP, com alto grau de concordância interobservador.

Common bile duct pressure after open intraoperative instrumentation in patients with uncomplicated choledocholithiasis.

BACKGROUND: Common bile duct pressure (CBDP) after surgical exploration has not been fully detailed. The objective was to describe the changes of CBDP after open surgical exploration in patients with choledocholithiasis, considering clinical scenarios in remote locations. MATERIAL AND METHODS: A before-after study was designed. Patients with choledocholithiasis who required an open cholecystectomy with exploration of bile ducts were included in the study. Open cholecystectomy was performed and perioperative T-tube CBDP was registered immediately after the procedure and weekly thereafter, with a 6 week follow-up. Control T-tube cholangiogram was performed at week 6 to exclude residual stones. Data were analyzed with T test for paired samples. RESULTS: Thirteen patients were included (age range, 17-69 years; 38.69 ± 17.97). Mean CBDP (cm H2O) registered were as follows: Initial = 19.5, week 1 = 16.2, week 2 = 14.3, week 3 = 13.0, week 4 = 12.1, week 5 = 11.1, and week 6 = 9.7. There were significant differences shown when comparing week 2 (p = 0.05), week 3 (p = 0.036), week 4 (p = 0.023), week 5 (p = 0.010), and week 6 (p = 0.004) with the initial value. CONCLUSIONS: CBDP decreases between 2nd and 3rd post-operative weeks. The use of choledochomanometry is useful in clinical scenarios with no access to imaging or interventionism facilities as in remote populations or rural locations.

ANTECEDENTES: La presión del conducto biliar común (PCBC) después de exploración quirúrgica no ha sido totalmente detallada. El objetivo fue describir los cambios de la PCBC tras exploración por coledocolitiasis. MATERIAL Y MÉTODOS: Estudio de antes y después, en pacientes con coledocolitiasis, que requirieron colecistectomía con exploración de vías biliares, registrando la PCBC por 6 semanas. Con colangiografía por sonda en T en la semana seis. Análisis con T de Student para muestras pareadas. RESULTADOS: Se incluyeron 13 pacientes (rango 17-69 años; 38,69 ± 17,97). Las presiones medias del CBC fueron: Inicial = 19.5, semana 1 = 16.2, semana 2 = 14.3, semana 3 = 13.0, semana 4 = 12.1, semana 5 = 11.1 y semana 6 = 9.7. Se mostraron diferencias significativas al comparar la semana 2 (p = 0.05), la semana 3 (p = 0.036), la semana 4 (p = 0.023), la semana 5 (p = 0.010) y la semana 6 (p = 0.004) contra el valor inicial. DISCUSIÓN: La PCBC disminuye entre la segunda y la tercera semana posoperatoria. La coledocomanometría muestra ser útil en escenarios clínicos sin acceso a intervencionismo como en poblaciones remotas o localidades rurales.

Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.

BACKGROUND: Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts. AIM: To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts. METHODS: Data from 1289 endoscopic retrograde cholangiopancreatography (ERCP) procedures were obtained from two prospective studies. While 258 cases had difficult stones (> 1 cm, multiple > 8, impacted, or having a thin distal duct), 191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy. Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number. Primary outcomes were clearance rate at first ERCP and complications. RESULTS: Of the 191 patients (122 women and 69 men; mean age: 60 years) who underwent biliary dilation for difficult stones, 113 (59%) had a nondilated or tapered distal duct. Patients with a dilated distal duct were older than those with nondilated distal ducts (mean 68 and 52 years of age, respectively; P < 0.05), had more stones (median 4 and 2 stones per patient, respectively; P < 0.05), and had less need for additional mechanical lithotripsy (6.4% vs 25%, respectively; P < 0.05). Clearance rate at first ERCP was comparable between patients with a dilated (73/78; 94%) and nondilated distal ducts (103/113; 91%). Procedures were faster in patients with a dilated distal duct (mean 17 vs 24 min, respectively; P < 0.005). Complications were similar in both groups (6.4% vs 7.1%, respectively). CONCLUSION: Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.

Fluorescence Guided Cholecystectomy by a Single Group: Initial 47 Procedures Experience in Mexico.

Introduction: Fluorescence guided surgery (FGS) for biliary surgery uses indocyanine green (ICG), a specific dye that is eliminated almost exclusively by the liver and biliary system, making it very useful for an adequate and safe visualization of biliary tract structures. Methods: We present our experience with FGS for cholecystectomy multiport and single port, including all patients older than 18 years of age, with diagnosis of cholecystitis (acute and chronic), from October 18, 2018 to December 30, 2021. Results: A total of 47 patients were managed with FGS cholecystectomy, mean age was 61.2 (± 17.7) years, 31 (65.9%) were female and 16 (34.1%) males. Twenty-four (51.1%) were emergency procedures, due to acute cholecystitis, of which 10 (41.7%) presented with an infected gallbladder (Parkland 3 to 5) and three (12.5%) presented with related acute pancreatitis, the remaining 23 (48.9%) cases were elective surgeries, due to chronic cholecystitis. Visualization of laparoscopic fluorescence of the biliary ducts was achieved in 45 of the 47 patients (95.7%). Mean time for biliary tract structures visual identification was 8 minutes and 40 seconds (± 7 minutes, 20 seconds), fluorescence allowed the visualization of biliary tract anatomical variants in two patients. Discussion: The reported rate of biliary structures visualization using ICG is relatively variable, ranging from 25% to 100%, in our group it was 95.7% due to our protocol. Conclusions: ICG utilization for cholecystectomy is very useful and helps for a safe procedure even in difficult surgeries, we believe that it should be used in everyday practice.

Choleperitoneum secondary to isolated subserosal gallbladder injury due to blunt abdominal trauma - A case report.

When dealing with rare traumatic injuries, surgeons might have difficulty diagnosing them and choosing the most appropriate management when no consensus exist on the best course of action. In such circumstances, drawing on the experience of colleagues can be of great value. Traumatic injuries of the gallbladder are unusual and might not be readily identifiable neither in imaging studies nor during surgery. Retrograde cholangiography plays an important role in correctly diagnosing these injuries and guiding decision-making. We report a case of a subserosal perforation due to blunt trauma to the abdomen, which was identified intraoperatively after a transcystic retrograde cholangiogram was performed and managed successfully with formal cholecystectomy.

Factors predictive of the successful treatment of choledocholithiasis.

BACKGROUND: Choledocholithiasis is a common complication of cholelithiasis, occurring in up to 18% of patients. Multiple treatments are often performed during the course of the management of choledocholithiasis, sometimes without success. Our study was performed identify the factors predictive of the success of treatment with retrograde endoscopic cholangiopancreatography (ERCP). METHODS: This was a retrospective, case-control study that used data from a biliary disease database at Hospital de Clínicas de Porto Alegre (HCPA). Demographic, clinical, radiological and procedure-related variables were compared between patients with successful biliary clearance after one ERCP procedure (Group 1) and those with unsuccessful biliary clearance after one ERCP procedure (Group 2). RESULTS: Three hundred twenty patients were included in Group 1, while 254 were included in Group 2. Multivariate analysis showed that older age, previous biliary exploration, elevated serum total bilirubin, choledocholithiasis above the level of the confluence of the hepatic ducts, stones retained in the cystic duct or Mirizzi syndrome, dilatation of the bile duct diagnosed during ERCP, and the need for suprapapillary opening were independently associated with the failure of the first ERCP to achieve bile duct clearance. The performance of imaging at the same institution prior to the procedure and the retention of stones in the duodenal papilla were associated with the success of endoscopic treatment. CONCLUSIONS: The variables identified in this study, when considered in conjunction with the results of previously published studies, can be used to guide the choice of therapeutic methods for patients with choledocholithiasis in the future, given the significant difference in outcomes between the two groups. In the future, a prospective study should be performed to determine whether the same factors are predictive of the success of other methods of treatment (surgical or percutaneous).

Aneurisma de la aorta abdominal asociado a íctero / Aneurysm of the abdominal aorta associated with icterus

El aneurisma de la aorta abdominal como causa de íctero obstructivo es una situación de excepción en la clínica. El objetivo de esta presentación fue exponer la coexistencia del aneurisma de la aorta abdominal y el íctero. Una asociación muy poco frecuente y de difícil diagnóstico, que coloca al cirujano vascular en la toma de una especial conducta terapéutica. La cuidadosa revisión de los antecedentes patológicos y el análisis del comportamiento clínico del paciente permitieron la solución terapéutica adecuada. Se logró demostrar que el íctero obedecía a una lesión maligna de vías biliares conocida como colangiocarcinoma, que concomitó con la existencia de un aneurisma del V segmento aórtico y no fue el resultado de una compresión extrínseca de la dilatación de la aorta, sobre las vías biliares. La conducta quirúrgica, encaminada a erradicar el íctero y evitar la ruptura aneurismática con resección del aneurisma y colocación de prótesis, no resultó posible por lo avanzado de la lesión tumoral y el grado de metástasis ya establecidos. Solo se realizó resección de la vesícula biliar y seguimiento posterior por oncología(AU)

Abdominal aortic aneurysm as a cause of obstructive icterus is an exceptional situation in the clinic. The aim of this presentation was to expose the coexistence of abdominal aortic aneurysm and icterus. A very rare and difficult to diagnose association, which places the vascular surgeon in a special therapeutic approach. The careful review of the pathological history and the analysis of the patient's clinical behavior allowed the appropriate therapeutic solution. It was possible to demonstrate that the icterus was due to a malignant lesion of the biliary tract known as cholangiocarcinoma, which concomitated with the existence of an aneurysm of the V aortic segment and was not the result of extrinsic compression of the dilatation of the aorta on the biliary tract. The surgical procedure, aimed at eradicating the icterus and avoiding aneurysmal rupture with aneurysm resection and prosthesis placement, was not possible due to the advanced tumor lesion and the degree of metastasis already established. Only gallbladder resection was performed and subsequent follow-up by oncology(AU)

Estudio complementario de la patología biliar complicada y el manejo de la litiasis coledociana en dos tiempos / Complementary evaluation of complicated gallstone disease and two-stage management of choledochal lithiasis

RESUMEN Antecedentes: la litiasis biliar tiene una prevalencia actual en Occidente del 10-20%. El 7-16% de los pacientes presentan también coledocolitiasis. El diagnóstico preoperatorio de coledocolitiasis es difícil de establecer. Objetivo: establecer nuestra experiencia en el estudio de la patología biliar complicada y el manejo de la coledocolitiasis en dos tiempos, como terapéutica de elección. Material y métodos: estudio prospectivo, observacional. Pacientes con patología biliar sometidos a procedimientos en el Servicio de Cirugía General del Hospital Vidal, desde el 30/06/2019 al 30/12/2019. Resultados: la ecografía hepato-bilio-pancreática (HPB) es específica, con exactitud del 80,9% y sensibilidad del 50%. La colangio resonancia magnética (CRNM) es 100% específica, tiene exactitud del 84,6% y sensibilidad de 67%. La colangio pancreatografía retrógrada endoscópica (ERCP -por sus siglas en inglés-), durante la primera colangiografía mostró en el 100% litiasis coledociana, pero, luego del tratamiento, la colangiografía de "control" muestra 0% de sensibilidad, 100% especificidad, con exactitud del 15,4%. En los hallazgos intraoperatorios, el cístico dilatado en asociación con alteraciones humorales ha demostrado una sensibilidad del 100%, especificidad del 90% y tasa de exactitud de 93,6%. Conclusión: la colangiografía intraoperatoria (CIO) es el procedimiento de referencia ("gold standard") en el abordaje de la patología biliar complicada, siendo su uso sistemático. La asociación entre alteraciones de parámetros humorales y el cístico dilatado resulta un parámetro con alto valor predictivo para la presencia de litiasis coledociana.

ABSTRACT Background: Nowadays, the prevalence of gallstones ranges between 10 and 20% in Western world, and 7-16% of the patients also present choledocholithiasis. The preoperative diagnosis of choledocholithiasis is difficult. Objective: To establish our experience in the evaluation of complicated gallstone disease and two-stage management of choledochal lithiasis as standard or care. Material and methods: This prospective and observational study included patients hospitalized with gallstone disease undergoing procedures in the Department of General Surgery of Hospital Vidal from June 30, 2019, to December 30, 2019. Results: Ultrasound of the liver, biliary tract and pancreas was specific, with accuracy of 80.9% and sensitivity of 50%. Magnetic resonance cholangiopancreatography (MRCP) had a sensitivity of 100%, accuracy of 84.6% and sensitivity of 67%. As for endoscopic retrograde cholangiopancreatography (ERCP), the diagnosis of choledocholithiasis was made in 100% of the cases during the first cholangiography while "control" cholangiography had a sensitivity of 0%, specificity of 100% and accuracy of 15.4%. The presence of a dilated cystic duct intraoperatively in association with abnormal biochemical parameters had a sensitivity of 100%, specificity of 90%, and accuracy of 93.6%. Conclusion: Intraoperative cholangiography (IOC) is the gold standard procedure for the management of complicated gallstone disease. The association of biochemical parameters and a dilated cystic duct has high predictive value for choledochal lithiasis.

Rectal diclofenac for prevention of post-endoscopic retrograde cholangiography pancreatitis.

BACKGROUND: Acute pancreatitis is an important complication of endoscopic retrograde cholangiography (ERC), occurring between 1-10% of patients. Several randomized controlled trials and meta-analyses have demonstrated the effectiveness of nonsteroidal anti-inflammatories (NSAIDs) such as diclofenac and indomethacin as a post-ERC pancreatitis (PEP) prophylaxis. The aim is to determine if the rectal diclofenac use reduces the PEP rate. METHODS: Retrospective cohort study. Subjects were included who underwent ERC for different indications in a tertiary center between January 2015 and June 2016. Two groups were analyzed: group A (without diclofenac use) and group B (with use of diclofenac as PEP prophylaxis). Biodemographic, technical and mortality variables were measured. RESULTS: The total cohort was 116 patients, 67 in group A and 49 in group B. The average age was 61.9±17.8 and 58.3±15.8 years, respectively (P=0.2606). Gender distribution showed a women predominance in both groups (P=0.933). Of the technical variables measured, the precut showed a statistically significant relationship to PEP (P=0.013). Of the total cohort, 8.6% developed acute pancreatitis after an ERC: four in group A and six in group B (P=0.196). In those who developed PEP (n=10), six patients developed severe acute pancreatitis (SAP). The average hospitalization for PEP was 32.2±34 days (P=0.881). No patients died, not were there any adverse reactions to the drug. CONCLUSIONS: Rectal diclofenac administered at the beginning of the ERC did not reduce the PEP rate in this patients cohort.

Intraoperative cholangiography with filling defects: comparative complication analysis of postoperative transcystic duct (TCD) catheter maintenance.

BACKGROUND: This is a retrospective cohort of patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography (IOC) with positive findings for filling defects. We comparatively assessed differences in complication risks for patients that had their cholangiography catheter maintained in its transcystic duct (TCD) position postoperatively. This is a practice proposed to overcome the limited availability of Endoscopic Retrograde Cholangiopancreatography (ERCP) as well as to avoid surgical exploration of the common bile duct. METHODS: Retrospective medical record review of all positive IOC from January 2015 to December 2018 were assessed. Patients' demographic and perioperative data from the hospital stay period in which the cholecystectomy occurred until the last surgical ambulatory visit for perioperative characteristics were compared between groups (with vs. without TCD catheter). Complications were operationalized using the Clavien-Dindo scale. RESULTS: Univariate analysis of complications showed a 2.4-fold risk increase in complications (95% CI 1.13-5.1) between comparison groups. Number of ERCPs (18 vs. 30), and MRCPs (5 vs. 17) were not significantly different between maintaining or not the TCD catheter postop, respectively. Stratified analysis followed by exact logistic regression supported the findings that maintaining the TCD catheter postoperatively increased complication rates (OR = 5.34, 95% CI 1.22, 29.83, p = 0.022), adjusting for potential confounders. CONCLUSION: The maintenance of the TCD catheter postoperatively did not prove to be effective in significantly reducing the number of ERCP nor associated complications. Also, outcomes inherited from the practice caused adverse events that surpassed its potential benefits. Moreover, expectant follow-up is reasonable for patients with evidence of common bile duct stones, even in setting with limited resource availability. We do not recommend this practice, even in settings where there are limited resources of more modern management of choledocholithiasis.

Colangiografía intraoperatoria: curva de aprendizaje en una Residencia de Cirugía General / Intraoperative cholangiography: Learning curve in a General Surgery residency

RESUMEN Antecedentes: el uso de la colangiografía intraoperatoria dinámica (CIOd) durante la colecistectomía laparoscópica (Colelap) sigue siendo un tema en discusión. Objetivos: Este trabajo tiene como objetivo describir y evaluar la curva de aprendizaje y los hallazgos en la CIOd durante las colecistectomías laparoscópicas realizadas por residentes de Cirugía General, incluyéndola como herramienta para una colecistectomía segura, así como entrenamiento para el de sarrollo de habilidades y destrezas. Material y métodos: se incluyeron pacientes con indicación de colecistectomía laparoscópica pro gramada o de urgencia. En las cirugías se realizó tracción según Hunter, visión crítica de seguridad y CIOd sistemática, por un residente mayor y la CIOd por un residente inferior, tutorizado por cirujano de planta. Se evaluaron curva de aprendizaje, tiempos operatorios, relación del tiempo de CIOd con el tiempo de duración de la Colelap (CIO/CX), redisección del cístico y litiasis cística y coledociana. Resultados: se operaron 456 pacientes durante un año (2017-2018). Se observó que, independiente mente de quien realice la CIOd, los residentes pudieron mejorar su curva de aprendizaje, objetiván dose tiempos más cortos para la Colelap, CIOd y la relación CIO/CX. Los coeficientes de aprendizaje fueron mejores en cirugías más complejas en relación con el semestre. El 5,26% presentó litiasis cole dociana (n = 24); de estas, 66,7% tenían litiasis cística (n = 16) y 25% colecistitis (n = 6) asociadas. Todas se resolvieron por vía transcística. No hubo conversiones y se realizó CIOd en el 100%. Conclusión: la CIOd es un procedimiento ideal para ser practicado de manera sistemática durante la Residencia, porque da el entrenamiento necesario para el manejo de la vía transcística, permite evitar una lesión quirúrgica de vía biliar mayor y el diagnóstico de coledocolitiasis.

ABSTRACT Background: The use of dynamic intra-operative cholangiography (dIOC) during laparoscopic cholecystectomy (Lap Chole) remains a topic under discussion. Objectives: This study aims to describe and evaluate the learning curve and findings in the dIOC during laparoscopic cholecystectomies performed by Residents of General Surgery, including it as a tool for a safe cholecystectomy, as well as training for the development of skills and abilities. Material and methods: Patients with indication of scheduled or emergency laparoscopic cholecystectomy were included. In the surgeries, traction was performed according to Hunter, critical safety vision and systematic dIOC, by a senior Resident and the dIOC by a less trained resident, tutored by a staff surgeon. Learning curve, operative times, dIOC time relationship with Lap Chole duration time (IOC/LC), repeated cystic dissection, cystic lithiasis and choledocholithiasis were evaluated. Results: 456 patients were operated for one year (2017-2018). It was observed that regardless of who performs the dIOC, they were able to improve their learning curve, objectifying shorter times for Lap Chole, dIOC and the IOC/LC relationship. The learning coefficients were better in complex surgeries in relation to the semester. 5.26 % had choledocholithiasis (n = 24), of these, 66.7% had cystic lithiasis (n = 16) and 25% associated cholecystitis (n = 6). All were resolved trancystically. There were no conversions and dIOC was performed in 100% of cases. Conclusion: The dIOC is an ideal procedure to be practiced systematically during residency. Because it gives the necessary training for the management of the transcystic pathway, allows avoiding an upper bile duct injury and the diagnosis of choledocholithiasis.

Tratamiento endoscópico de las estenosis poscolescistectomía de la vía biliar / Endoscopic treatment of postcholecystectomy bile duct stenosis

Introducción: La estenosis de la vía biliar es una afección poco frecuente, pero con serias repercusiones en la morbilidad de los pacientes. La gran mayoría ocurre después de la cirugía hepatobiliar: la colecistectomía es la más común de estas cirugías. El reconocimiento temprano y el enfoque multidisciplinario adecuado es la piedra angular para lograr obtener resultados finales óptimos. Objetivo: Describir el tratamiento endoscópico de los pacientes con estenosis poscolescistectomía atendidos en el Instituto de Gastroenterología (Cuba). Métodos: Se realizó un estudio retrospectivo descriptivo de los pacientes con diagnóstico de estenosis biliar poscolescitectomía. Se determinaron variables sociodemográficas, clínicas y endoscópicas de interés. Resultados: Se estudiaron 16 pacientes. Predominaron las mujeres menores de 50 años. El 75 % de los pacientes tenían antecedente de colecistectomía laparoscópica. Las estenosis biliares tipo I y III, según la clasificación de Bismuth, fueron las más usuales. El tratamiento endoscópico mediante colangiografía retrógrada endoscópica (CPRE) con colocación de múltiples prótesis plásticas fue la conducta terapéutica más empleada. Conclusiones: En las estenosis poscolescitectomía los procedimientos endoscópicos se han convertido en el tratamiento de elección, como un procedimiento menos invasivo, con baja morbilidad y mortalidad, con evidentes resultados comparables a los logrados con procedimientos quirúrgicos no endoscópicos(AU)

Introduction: Bile duct stenosis is an infrequent condition, but it seriously affects patient morbidity. The vast majority of cases occur after hepatobiliary surgery, cholecystectomy being the most common of such surgeries. Early recognition and an appropriate multidisciplinary approach are the cornerstones to achieve optimal final results. Objective: Describe the endoscopic treatment of patients with postcholecystectomy stenosis cared for at the Institute of Gastroenterology in Cuba. Methods: A retrospective descriptive study was conducted of the patients diagnosed with postcholecystectomy bile duct stenosis. Determination was made of sociodemographic, clinical and endoscopic variables of interest. Results: A total 16 patients were studied. There was a predominance of women aged under 50 years. 75% of the patients had a history of laparoscopic cholecystectomy. The most common bile duct stenoses were types I and III by Bismuth's classification. The most frequent therapeutic management was endoscopic treatment by endoscopic retrograde cholangiography (ERCP) with placement of multiple plastic prostheses. Conclusions: Endoscopic procedures have become the treatment of choice in postcholecystectomy stenosis. They are less invasive, their morbidity and mortality are low, and their results are comparable to those of non-endoscopic surgical procedures(AU)

Tratamiento endoscópico de las estenosis poscolescistectomía de la vía biliar / Endoscopic treatment of postcholecystectomy bile duct stenosis

Introducción: La estenosis de la vía biliar es una afección poco frecuente, pero con serias repercusiones en la morbilidad de los pacientes. La gran mayoría ocurre después de la cirugía hepatobiliar: la colecistectomía es la más común de estas cirugías. El reconocimiento temprano y el enfoque multidisciplinario adecuado es la piedra angular para lograr obtener resultados finales óptimos. Objetivo: Describir el tratamiento endoscópico de los pacientes con estenosis poscolescistectomía atendidos en el Instituto de Gastroenterología (Cuba). Métodos: Se realizó un estudio retrospectivo descriptivo de los pacientes con diagnóstico de estenosis biliar poscolescitectomía. Se determinaron variables sociodemográficas, clínicas y endoscópicas de interés. Resultados: Se estudiaron 16 pacientes. Predominaron las mujeres menores de 50 años. El 75 por ciento de los pacientes tenían antecedente de colecistectomía laparoscópica. Las estenosis biliares tipo I y III, según la clasificación de Bismuth, fueron las más usuales. El tratamiento endoscópico mediante colangiografía retrógrada endoscópica (CPRE) con colocación de múltiples prótesis plásticas fue la conducta terapéutica más empleada. Conclusiones: En las estenosis poscolescitectomía los procedimientos endoscópicos se han convertido en el tratamiento de elección, como un procedimiento menos invasivo, con baja morbilidad y mortalidad, con evidentes resultados comparables a los logrados con procedimientos quirúrgicos no endoscópicos(AU)

Introduction: Bile duct stenosis is an infrequent condition, but it seriously affects patient morbidity. The vast majority of cases occur after hepatobiliary surgery, cholecystectomy being the most common of such surgeries. Early recognition and an appropriate multidisciplinary approach are the cornerstones to achieve optimal final results. Objective: Describe the endoscopic treatment of patients with postcholecystectomy stenosis cared for at the Institute of Gastroenterology in Cuba. Methods: A retrospective descriptive study was conducted of the patients diagnosed with postcholecystectomy bile duct stenosis. Determination was made of sociodemographic, clinical and endoscopic variables of interest. Results: A total 16 patients were studied. There was a predominance of women aged under 50 years. 75 percent of the patients had a history of laparoscopic cholecystectomy. The most common bile duct stenoses were types I and III by Bismuth's classification. The most frequent therapeutic management was endoscopic treatment by endoscopic retrograde cholangiography (ERCP) with placement of multiple plastic prostheses. Conclusions: Endoscopic procedures have become the treatment of choice in postcholecystectomy stenosis. They are less invasive, their morbidity and mortality are low, and their results are comparable to those of non-endoscopic surgical procedures(AU)