Doble colédoco, variante anatómica infrecuente de la vía biliar. Presentación de caso / Double common bile duct, a rare anatomical variant of the bile tract. Case report

Introducción: la presencia de un conducto colédoco doble es una variante anatómica infrecuente con menos de 200 casos publicados en la literatura hasta la fecha, siendo fundamental los estudios preoperatorios que se le deben realizar a los pacientes, a fin de tener la sospecha o el diagnóstico confirmado, no sólo de la variante anatómica, sino de la patología asociada, siendo estas la coledocolitiasis y las patologías malignas del árbol biliar las más frecuentes, aunque gran parte de los casos son hallazgos incidentales e intraoperatorios.Caso clínico : se presenta el caso de masculino de 81 años de edad, con antecedente de colecistectomía 20 años previos, con diagnóstico de síndrome ictérico obstructivo, y estudios de colangiorresonancia y CPRE que reportan coledocolitiasis. Se decide llevar a acto quirúrgico y se diagnóstica la presencia de conducto colédoco doble como hallazgo. Se realiza derivación biliodigestiva de tipo hepaticoyeyunoanastomosis más ligadura de conducto colédoco accesorio con evolución satisfactoria, con alta médica a los 5 días posteriores, y resultado de biopsia negativo para malignidad.Conclusión : el doble colédoco debe ser adecuadamente diagnosticado y estudiado, así no se confirme el diagnóstico preoperatorio los pacientes deben acudir con estos estudios realizados al acto quirúrgico, ya que, dicho tratamiento dependerá fundamentalmente de la patología asociada(AU)

Introduction: the presence of a double common bile duct is an infrequent anatomical variant with less than 200 cases published in the literature to the date, and preoperative studies that must be performed on patients are essential in order to have the suspicion or diagnosis confirmed, not only of the anatomical variant, but also of the associated pathology, these being choledocholithiasis and malignant pathologies of the biliary tract the most frequent, although most of the cases are incidental and intraoperative findings.Clinical case : the case of an 81-year-old male is presented, with a history of cholecystectomy 20 years prior, with a diagnosis of obstructive icteric syndrome, and magnetic resonance cholangiography and ERCP studies that reported choledocholithiasis. It was decided to carry out surgery and the presence of double common bile duct was diagnosed as a finding. Biliodigestive derivation hepaticojejunoanastomosis type and accessory common bile duct ligation was performed with satisfactory evolution, with medical discharge 5 days later, and biopsy result negative for malignancy.Conclusion : the double common bile duct should be properly diagnosed and studied, even if the preoperative diagnosis is not confirmed, patients should attend the surgical procedure with these studies, since said treatment will depend fundamentally on the associated pathology(AU)

The influence of periampullary diverticula on ERCP for treatment of common bile duct stones.

In order to evaluate the effectiveness of various methods we applied to decrease the influence of periampullary diverticula (PAD) on the success rate and complications of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of common bile duct (CBD) stones, we enrolled patients with CBD stones who had been treated by ERCP in our hospital between January 2015 and December 2018. According to the presence of PAD, the patients were divided into a PAD group and a non-PAD group. The rate of complete stone removal in the first session, the rate of overall stone removal, the frequency of application of mechanical lithotripsy, and procedure-related complications, including bleeding, hyperamylasemia, pancreatitis, perforation, and infection of biliary tract were recorded. A total of 183 cases, including 72 cases in the PAD group and 111 cases in the non-PAD group were enrolled. There was no statistical difference between the two groups regarding gender (P = 0.354). However, regarding age, there was a statistical difference (P = 0.002), and the incidence of PAD increased with age. There were 5 (6.9%) cases in the PAD group and 14 (12.6%) cases in the non-PAD group where mechanical lithotripsy was applied. There were 59 (81.9%) cases in the PAD group and 102 (91.9%) cases in the non-PAD group where there was complete removal of CBD stones in the first session, and there were 68 (94.4%) cases in the PAD group and 107 (96.4%) cases in the non-PAD group where there was complete removal of all stones. In the PAD group, there were 0 cases (0%) with gastrointestinal bleeding, 0 cases (0%) with gastrointestinal perforation, 13 cases (18.1%) with post-ERCP hyperamylasemia, 3 cases (4.2%) with post-ERCP pancreatitis, and 4 cases (5.6%) with biliary tract infection. In the non-PAD group, 1 case (0.9%) had gastrointestinal bleeding, 0 cases had gastrointestinal perforation, 18 cases (16.2%) had post-ERCP hyperamylasemia, 5 cases (4.5%) had post-ERCP pancreatitis, and 11 cases (9.9%) had biliary tract infection. This retrospective study showed that there was a statistical difference between the two groups regarding complete removal of CBD stones in the first session and application of mechanical lithotripsy (both P < 0.05), but no statistical difference according to the rates of overall stone removal and the complications (P > 0.05), which means that we can reduce the influence of PAD on ERCP for treatment of common bile duct stones.

Holmium laser lithotripsy improves the rate of successful transcystic laparoscopic common bile duct exploration.

PURPOSE: Transcystic laparoscopic common bile duct exploration (LCBDE) seems safer than transductal LCBDE and is associated with fewer biliary complications. It has traditionally been limited to smaller bile duct stones however. This study aimed to assess the ability of laser-assisted bile duct exploration by laparoendoscopy (LABEL) to increase the rate of successful transcystic LCBDE in patients with bile duct stones at the time of laparoscopic cholecystectomy. METHODS: Patients undergoing LCBDE between 2014 and 2018 were retrospectively analysed. Baseline demographic and medical characteristics were recorded, as well as intra-operative findings and post-procedure outcomes. Standard LCBDE via the transcystic route was initially attempted in all patients, and LABEL was only utilised if there was failure to achieve transcystic duct clearance. The transductal route was utilised for failed transcystic extraction. RESULTS: One hundred and seventy-nine consecutive patients underwent LCBDE; 119 (66.5%) underwent unaided transcystic extraction, 29 (16.2%) required LABEL to achieve transcystic extraction and 31 (17.3%) failed transcystic extraction (despite the use of LABEL in 7 of these cases) and hence required conversion to transductal LCBDE. As such, LABEL could be considered to increase the rate of successful transcystic extraction from 66.5% (119/179) to 82.7% (148/179). Patients requiring LABEL were however more likely to experience major complications (CD III-IV 5.6% vs 0.7%, p = 0.042) although none were specifically attributable to the laser intra-operatively. CONCLUSIONS: LABEL is an effective adjunct to LCBDE that improves the rate of successful transcystic extraction.

Recurrencia de coledocolitiasis tras exploración laparoscópica de la vía biliar principal / Choledocholithiasis recurrence following laparoscopic common bile duct exploration

Introducción: La coledocolitiasis puede tratarse mediante abordaje endoscópico por colangiopancreatografía endoscópica retrógrada o realizando una exploración laparoscópica de la vía biliar principal (ELVBP) durante la colecistectomía. La recurrencia de la coledocolitiasis y sus factores de riesgo tras extracción endoscópica han sido ampliamente investigados. Nuestro objetivo es analizar los factores de riesgo asociados con la recurrencia de cálculos en la vía biliar principal después de una ELVBP. Métodos: Los pacientes que se sometieron a ELVBP desde febrero de 2004 a julio de 2016 fueron examinados en un análisis univariante y multivariante para estudiar la asociación de recurrencia de coledocolitiasis con las siguientes variables: sexo; edad; presencia de hepatopatía; dislipemia, obesidad, o diabetes mellitus; cirugía abdominal previa; presencia de colecistitis, colangitis o pancreatitis al diagnóstico; pruebas de función hepática preoperatorias, número de cálculos recuperados; método de limpieza y cierre del conducto biliar común; presencia de litiasis coledocianas impactadas o intrahepáticas; conversión a cirugía abierta y morbilidad postoperatoria. Resultados: Se incluyeron 156 pacientes. La tasa de recurrencia de la coledocolitiasis fue del 14,1%, con un tiempo medio de recurrencia de 38,18 meses. La edad fue el único factor de riesgo independiente para la recurrencia de cálculos en el análisis univariante y multivariante. Ningún paciente menor de 55 años desarrolló nuevos cálculos en la vía biliar principal, y el 86,4% de las recurrencias se produjo en pacientes mayores de 65 años. Conclusiones: La edad es el único factor de riesgo independiente asociado a la recurrencia de coledocolitiasis después de ELVBP. Diferentes mecanismos en el desarrollo de cálculos en la vía biliar principal pueden estar presentes para pacientes más jóvenes y de edad más avanzada

Introduction: Choledocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE. Methods: Patients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity. Results: A total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65. Conclusions: Age is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients

Choledocholithiasis recurrence following laparoscopic common bile duct exploration. / Recurrencia de coledocolitiasis tras exploración laparoscópica de la vía biliar principal.

INTRODUCTION: Choledocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE. METHODS: Patients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity. RESULTS: A total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65. CONCLUSIONS: Age is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients.

Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia.

The prevalence of gallstones is 10% to 15% in adults. Individuals with acute cholecystitis present with right upper quadrant pain, fever, and leukocytosis. Management includes supportive care and cholecystectomy. The prevalence of choledocholithiasis is 10% to 20%, and serious complications include cholangitis and gallstone pancreatitis. The goal of management in individuals with choledocholithiasis consists of clearing common bile duct stones. Acute ascending cholangitis is a life-threatening condition involving acute inflammation and infection of the common bile duct. Treatment includes intravenous fluids, analgesia, intravenous antibiotics, and biliary drainage and decompression. Biliary dyskinesia includes motility disorders resulting in biliary colic in the absence of gallstones.

Coledocolitiasis como causa de elevación importante del marcador tumoral CA 19-9 / Significantly elevated CA 19-9 levels in a patient with choledocholithiasis

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Five hundred consecutive laparoscopic common bile duct explorations: 5-year experience at a single institution.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity in the treatment of choledocholithiasis. Bile leakage remains a major cause of postoperative morbidity. The aim of this study was to report 5-year results of 500 LCBDEs and identify risk factors associated with bile leakage. METHODS: Five hundred consecutive LCBDEs performed in one institution from September 2011 to June 2016 were reviewed. Patients' clinical data were retrospectively collected and analyzed. Univariable and multivariable analysis of bile leakage was performed by logistic regression. RESULTS: We found stones (n = 388) or bile sludge (n = 71) in 459 patients (92%) on exploration, leaving 41 patients (8%) without stones. Operative time was 128 min in the first 250 LCBDEs, and this decreased to 103 min in the second 250 LCBDEs (P = 0.0004). Four hundred and eight (82%) procedures were completed with primary closure after choledochotomy; the rate of primary closure increased significantly in the second 250 patients compared with the first (88 vs 76%; P = 0.0005), whereas T-tube placement (2 vs 6%; P = 0.0225) and transcystic approach (7 vs 12%; P = 0.0464) decreased, respectively. Stone clearance was successful in 495 patients (99%). Overall morbidity was 5%, and bile leakage occurred in 17 patients (3.4%). Two patients died from bile leakage. The median follow-up was 24 months with stone recurrence occurred in two patients and bile duct stricture in one patient. Univariable analysis identified diameter of the common bile duct (CBD), stone clearance, and T-tube insertion as risk factors related to bile leakage. Multivariable analysis taking these three factors into account identified non-dilated CBD (risk ratio (RR) = 9.87; P = 0.007) and failure in stone clearance (RR = 11.88; P = 0.024) as significant risk factors. CONCLUSIONS: Bile leakage following LCBDE is associated with diameter of the CBD and stone clearance. LCBDE would be safer in proficient laparoscopic surgeons with a careful selection of patients.

Opciones terapéuticas actuales en el manejo de la coledocolitiasis asociada a colecistolitiasis / Current therapeutic options in the management of choledocholithiasis associated with cholecyllithiasis

The term Choledocholithiasis refers to the presence of biliary stones in the extrahepatic bile ducts, which are found in 5 to 10% of patients undergoing cholecystectomy for gallstones. Nowadays, with the adoption of the laparoscopic cholecystectomy(LC) as a standard, multiple minimally invasive treatment options for bile duct stones are feasible, with no consensus to date on the procedure of choice. The two stage endoscopic techniques involve the use of Endoscopic Retrograde Cholangiopancreatography(ERCP) before or after performing a LC, which has the main advantage of separating the bile duct procedure from the LC. However, the need for two separate anesthesia times, the possibility of blank or failed ERCP, and the chance for calculi migration between procedures increase the length of hospital stay and associated costs. The single stage procedures include the Laparoscopic Bile Duct Exploration (LBDE), and more recently, the performance of a laparoscopy guided intraoperative ERCP(Rendez Vous). The LBDE, when performed by an experienced surgical team, is an effective and safe technique. Nonetheless, it is considered a technically demanding procedure, whose results cannot be extrapolated to the general surgical community. Recently, the Rendez Vous has become a treatment alternative that simplifies both the surgical and the endoscopic procedures, decreases morbidity, and requires a single anesthesia time. On the downside, Rendez Vous technique involves complex operating room (OR) logistics, requiring both a trained surgical and endoscopic team at the same time. (AU)

A Randomized, Clinical Trial Involving Different Surgical Methods Affecting the Sphincter of Oddi in Patients With Choledocholithiasis.

AIM: The purpose of the current study was to compare pressure changes in the sphincter of Oddi (SO) and stone recurrence after surgery in patients with choledocholithiasis who underwent laparoscopic common bile duct exploration during laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (EST) with LC, which may provide clinical evidence for choledocholithiasis patients to choose the appropriate surgical approach. MATERIALS AND METHODS: Fifty-one patients with choledocholithiasis were randomized to the EST/LC (group A 26 cases) or laparoscopic common bile duct exploration during LC group (group B 25 cases). We performed SO manometry during surgery and 3 months postoperatively on all patients. In addition, the duodenobiliary reflux test was performed during the third month postoperatively. All patients were followed for 24 to 30 months. RESULTS: In group A, the SO basal and contraction pressures were 30.88±16.11 and 77.46±23.62 mm Hg intraoperatively and 10.34±10.27 and 45.65±24.77 mm Hg 3 months postoperatively, respectively. In group B, the SO basal and contraction pressures were 27.80±15.88 and 73.96±23.99 mm Hg intraoperatively and 15.43±7.36 and 59.56±22.61 mm Hg 3 months postoperatively, respectively. During the third month postoperatively, duodenobiliary reflux was demonstrated in 16 of 26 and 7 of 25 patients in groups A and B, respectively (P<0.05). During follow-up, the stone recurrence rates were 6 of 26 in group A and 1 of 25 in group B (P<0.05). CONCLUSIONS: After EST, the SO basal and contraction pressures decreased, and the duodenobiliary reflux and stone recurrence rates increased. Thus, EST should be selected with care.

Direct peroral cholangioscopy with a conventional videogastroscope in a transplanted patient with anastomotic stricture and choledocholithiasis

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[Contact lithotripsy in treatment of choledocholithiasis].

It was suggested to use contact ultrasonic lithotripsy in lumen of common bile duct during laparoscopic surgery in order to preserve the sphincter apparatus of major duodenal papilla. Waveguide with original structure was used for lithotripsy performing. Waveguide's total length is 400 mm. It has a radially curved 40 degrees broken part with diameter of 6 mm cone rolling in working portion with diameter of 4 mm and length of 60 mm for introduction in common bile duct. There is concave lens on waveguide working portion end with diameter of 1 mm. A lens permits concentrating the waves beam in longitudinal direction avoiding its scattering and minimizing the impact on surrounding tissues. Lithotripsy efficiency was proved in the in vitro (n=68) and in vivo (n=20) experiments. Such structure of waveguide permits to penetrate in lumen of common bile duct through dilated cystic duct or choledochendysis for calculi fragmentation.

Prevalence of normal liver tests in patients with choledocholithiasis undergoing endoscopic retrograde cholangiopancreatography.

BACKGROUND/AIMS: Abnormal liver chemistry tests are a hallmark of common bile duct (CBD) stones. There is little information, however, on the prevalence of and predictors for normal liver chemistry tests in such patients. METHODS: Over an 11-year period, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) at our Center were prospectively identified. Patients in this study were those with CBD stones found at ERCP and where the indication for ERCP was CBD stones seen on imaging studies or when CBD stones were highly suspected based upon clinical presentation and radiographic and laboratory findings. Liver chemistry tests were recorded from those taken at the time of initial presentation as well as the time closest to ERCP. RESULTS: Of a total of 5,133 patients undergoing ERCP during the study period, the indication was suspicion for CBD stones or for radiographically identified CBD stones in 476 and 593, respectively, with 115 patients having both indications. Of these 1184 patients, 765 had CBD stones of whom 541 had liver tests. Of these 541, 29 patients (5.4%) were found to consistently have normal liver chemistry tests. Multivariate analysis identified two factors predictive of normal liver tests including age >55 years and the presence of abdominal pain. CONCLUSIONS: Although rare, liver tests can be normal in patients with CBD stones. Patients most likely to have normal liver tests included older patients and those with abdominal pain.

Dynamic changes of common bile duct diameter during an episode of biliary colic, documented by ultrasonography.

Common bile duct stones frequently accompany gallstones and can be identified by a variety of imaging modalities. Little is known about the time course of dilatation of the common bile duct after acute obstruction or of normalization after spontaneous passage of an obstructing stone. We describe a case showing rapid fluctuations in common bile duct diameter during 72 hours in a patient presenting with epigastric pain and vomiting. Initial emergency bedside ultrasonography revealed a distended gallbladder, a dilated common bile duct (17 mm), and an obstructing stone. Five hours later, ultrasonography performed in the radiology suite showed a normal common bile duct diameter (4 mm) and no obstructing stone. The patient was admitted, and during the course of hospitalization different imaging modalities reported fluctuations in common bile duct measurements, ranging from 4 mm on computed tomography to 14 mm on endoscopic retrograde cholangiopancreatography. This case demonstrates disappearance of an obstructing stone with normalization of a highly distended common bile duct during 5 hours, highlighting that gallstone disease may be highly dynamic, with the possibility of rapid changes of common bile duct diameter. Emergency physicians, who frequently depend on ultrasonography to diagnose biliary disease, should be wary of the potential for rapid changes of sonographic findings in these patients.

Prótesis metálicas autoexpandibles totalmente recubiertas en el tratamiento de coledocolitiasis difíciles / Fully covered self-expanding metal stents in the management of difficult common bile duct stones

Introducción y objetivos: las prótesis biliares plásticas suelen emplearse tras una sesión de CPRE sin extracción completa de coledocolitiasis. En ocasiones, el calibre de drenaje con estas prótesis puede ser insuficiente. Presentamos nuestra experiencia en la utilización de prótesis metálicas autoexpandibles totalmente recubiertas (PMATR) en coledocolitiasis no extraídas. Pacientes y métodos: se insertó una PMATR (Wallflex biliar) en algunos pacientes con coledocolitiasis difíciles no extraídas tras una sesión de CPRE cuando se consideró que la esfinterotomía biliar y una prótesis plástica no aportaban un calibre de drenaje adecuado. Resultados: estudio retrospectivo en el que se utilizó una PMATR en 29 pacientes, edad media 81 años. Las coledocolitiasis no pudieron extraerse por la esfinterotomía biliar debido a su gran tamaño (n = 18) o por la presencia de estenosis distal inflamatoria (n = 11). Se consideró que era preciso el mayor drenaje biliar con el menor tiempo posible de CPRE debido a la situación de inestabilidad clínica de los pacientes y/o a la mala tolerancia a la sedación consciente administrada por el endoscopista. Se obtuvo un drenaje biliar adecuado en todos los casos. Las PMATR se retiraron tras una mediana de 199,5 días en 16 pacientes, obteniéndose una extracción completa de las coledocolitiasis en 15 (93,7%). No se extrajeron las PMATR en los 13 restantes debido a su situación clínica, manteniéndose una conducta expectante. Conclusiones: en casos seleccionados, la utilización de PMATR extraíbles es una buena opción para obtener un drenaje biliar adecuado y rápido en coledocolitiasis difíciles. El mayor coste de estas prótesis precisa que se individualice su utilización(AU)

Background and objectives: plastic biliary stents are often used after an ERCP session without complete common bile duct stones (CBDS) extraction. Sometimes, the volume of biliary drainage with these stents may be insufficient. We present our experience with the use of fully covered self-expanding metal stents (FCSEMS) in the setting of incomplete CBDS extraction. Patients and methods: after an ERCP session with difficult CBDS not completely removed, biliary FCSEMS (Wallflex) were inserted in some patients when it was deemed that biliary sphincterotomy and a single plastic stent would not provide an adequate drainage. Results: a retrospective study was performed. Biliary FCSEMS were inserted in 29 patients, mean age 81 years. CBDS could not be extracted through a biliary sphincterotomy due to its large size (n = 18) or because of the presence of inflammatory distal strictures (n = 11). The greatest biliary drainage with shortest ERCP time was considered mandatory due to clinical instability of patients and/or poor tolerance to conscious sedation administered by the endoscopist. Successful biliary drainage was obtained in all cases. FCSEMS were removed after a median of 199.5 days in 16 patients with a complete CBDS extraction in 15 (93.7%). FCSEMS were not removed in the remaining 13 patients due to their clinical condition, and a wait-and-see strategy was undertaken. Conclusions: in selected cases, utilization of removable FCSEMS can be a good option for a quick and adequate biliary drainage in the setting of difficult CBDS. Because of the higher cost of these stents its use needs to be individualized(AU)

[Usefulness of endoscopic ultrasonography in the diagnosis of choledocholithiasis and inflammatory biliary strictures].

Results of the diagnosis of endoscopic ultrasonography (USG) in 58 patients with suspected choledocholithiasis were analyzed. Bile duct stones were diagnosed by USG in 54 patients, including 5 patients in combination with terminal bile duct strictures. The sensitivity, specificity and accuracy of the USG method in detecting choledocholithiasis were 96.3, 100 and 96.5% respectively.

[Ultrasonography in the diagnosis of cholelithiasis and its complications].

The author presents the results of ultrasound investigation (USI) of 419 patients with cholecystocholedocholithiasis. The diagnostic accuracy of USI methods in patients with calculous cholecystitis was 98.8%. Direct signs of visualization of concrements in the common bile duct (CBD) were found but in 68.5% of patients. On the basis of USI results the common bile stones were found in 287 (68.5%) patients. The concrements omitted in transabdominal USI were diagnosed using endoscopic retrograde cholangiopancreaticography, magnetic resonance cholangio-pancreaticography, endoscopic ultrasonography as well as in operative intervention.

Dilatación con balón asociada a esfinterotomía, evaluación de eficacia y seguridad en un hospital terciario / Safety and efficacy of large balloon sphincteroplasty in a third care hospital

Introducción y objetivos: la dilatación con balón de gran tamaño asociada a esfinterotomía es un recurso cada vez más utilizado en la extracción de coledocolitiasis de gran tamaño. El objetivo de este estudio es evaluar la eficacia y seguridad de la dilatación con balones mayores de 10 mm en un entorno de práctica clínica habitual. Pacientes y métodos: estudio prospectivo en un hospital terciario. Todos los pacientes en los que se realizó dilatación con balón mayor de 10 mm asociado a esfinterotomía entre julio de 2007 y marzo de 2011 se incluyeron prospectivamente en una base de datos incluyendo aspectos clínicos, del procedimiento, resultados y complicaciones. El éxito del procedimiento se definió como la extracción de todos los cálculos presentes documentada como ausencia de defectos de repleción en la colangiografía final y la ausencia de signos clínicos y/o radiológicos tras la CPRE sugestivos de persistencia de litiasis. La presencia de pancreatitis, colangitis, perforación y hemorragia post-CPRE también se documentó. Resultados: se realizaron 120 procedimientos en 109 pacientes diferentes, con balones entre 10 y 20 mm de diámetro. La tasa de éxito fue del 91% en el primer intento y del 96,7% tras dos procedimientos. La litotricia mecánica solo se necesitó en un caso (0,8%). La tasa de complicaciones fue del 4,2% debido a cinco casos de hemorragia post-CPRE en pacientes de alto riesgo de sangrado. Conclusión: la dilatación con balón asociada a esfinterotomía en condiciones de práctica clínica habitual muestra una tasa de éxito excelente con un índice de complicaciones reducido(AU)

Background and aims: large balloon sphincteroplasty (LBS) associated with sphincterotomy (ES) has gained acceptance as a useful tool in extracting difficult bile duct stones. Our purpose was to evaluate the efficacy and safety of LBS with balloons >=10 mm in clinical practice setting. Patients and methods: unicentre prospective study in a tertiary care hospital. All patients who underwent LBS associated with ES between July 2007 and March 2011 were included prospectively in a database recording clinical aspects, procedure data, outcome and complications. Success is the main outcome defined as complete stone removal documented by absence of any filling defect during a final occlusion cholangiogram and absence of clinical or radiological findings after the ERCP consistent with remaining stones. Complications as pancreatitis, cholangitis, post-ERCP bleeding, perforation and others were also measured. Results: one hundred twenty procedures were made in 109 patients with balloons ranging from 10 to 20 mm. Success rate was 91% in the first attempt and 96.7% after two procedures. Mechanical lithotripsy was only needed in one case (0.8%). Complication rate was 4.2% due to five cases of post-ERCP bleeding in high risk patients. Conclusion: large balloon sphincteroplasty associated to sphincterotomy in clinical practice is a very effective and safe technique(AU)

[Effects of Jinhuang Yidan Granule on the bile compositions of primary bile duct pigment calculus patients].

OBJECTIVE: To study the effects of Jinhuang Yidan Granule (JYD) on the bile compositions of primary bile duct pigment calculus patients. METHODS: Sixty-six patients with primary bile duct pigment calculus were randomly assigned to the control group (who took no Chinese medicine) and the JYD group (who took JYD). The bile from T-tube during the operation, 3, 10, and 40 days after medication were examined. The contents of bile acids, bilirubin (conjugated bilirubin, mono-conjugated bilirubin), glucoprotein, calcium ion, beta-glucuronidase, superoxide radical anion, and other components were detected and compared. RESULTS: Three days after taking JYD, the total bile acids increased, the total bilirubin and beta-glucuronidase decreased, showing statistical significance when compared with the control group (P < 0.05). In the JYD group, the total bile acid increased, the total bilirubin, the conjugated bilirubin, the mono-conjugated bilirubin, glucoprotein, calcium ion, beta-glucuronidase, superoxide radical anions decreased 10 and 40 days after medication, showing statistical significance when compared with the control group (P < 0.05, P < 0.01). The level of the total bile acid increased, the levels of the total bilirubin, the conjugated bilirubin, the mono-conjugated bilirubin, glucoprotein, calcium ion, beta-glucuronidase, superoxide radical anions decreased after 40-day medication in the two groups, showing statistical significance when compared with the peri-operative indices of the same group (P < 0 05, P < 0.01). CONCLUSIONS: JYD could significantly improve the pathologic bile compositions of the bile duct calculus, improve the environment of the biliary tract, showing certain preventive and therapeutic effects on bile pigment calculus of the primary bile duct calculus. Better effects may be obtained by long-term taking.