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

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

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

Rendimiento diagnóstico de las punciones de lesiones biliopancreáticas guiadas por ultrasonido endoscópico con patólogo en sala / Diagnostic performance of endoscopic ultrasound-guided fine needle aspiration of pancreatobiliary lesions with rapid on-site evaluation

Resumen Introducción y objetivos: El ultrasonido endoscópico con punción-aspiración con aguja fina (USE-PAAF) en lesiones neoplásicas biliopancreáticas suele tener un rendimiento alto, que depende de características de la lesión; aspectos técnicos de la USE-PAAF y la experiencia del endoscopista. De los factores menos estudiados es la presencia de patólogo en sala. Se plantea la realización de USE-PAAF con patólogo en sala para disminuir el número de pases, la tasa de muestras inadecuadas y la necesidad de repetir el procedimiento. Material y métodos: Estudio observacional, retrospectivo, con recolección prospectiva de enero de 2018 a junio de 2019, en pacientes adultos sometidos a USE-PAAF. Las muestras obtenidas fueron extendidas y evaluadas en salas de endoscopia por médico patólogo con coloración Diff-Quick y cuando se obtenía una muestra suficiente se enviaba en frasco con formol para bloque celular o biopsias. Resultados: Se realizaron 48 USE-PAAF biliopancreáticas en individuos con una edad mediana de 64 años. Las indicaciones más frecuentes fueron punciones por masa o pseudomasa pancreática (71 % de casos); Se diagnosticaron 35 malignidades (77 % correspondientes a adenocarcinoma, y 14 % a tumores neuroendocrinos). La mediana de tamaño de lesiones fue de 28 mm; el número de pases promedio fue de 3. Se obtuvieron resultados diagnósticos en 89 % frente a 11 % de falsos negativos. Se presentó 1 complicación menor (2,1 %), que fue dolor abdominal. Conclusiones: La USE-PAAF con patólogo en sala tiene alto rendimiento diagnóstico, con escasos resultados falsos negativos. Se requiere una mediana de pases menor, que podría minimizar los riesgos del procedimiento y la necesidad de repetir la prueba.

Abstract Introduction: Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) of pancreatobiliary neoplastic lesions usually has a high performance that depends on the characteristics of the lesion, technical aspects, and expertise of the endoscopist. One of the least studied factors is rapid on-site evaluation with a pathologist in the room. Objective: To perform EUS-FNA with a pathologist in the endoscopy room to reduce the number of passes, the rate of inadequate samples and the need to repeat the procedure. Material and methods: Observational retrospective study with a prospective data collection approach from January 2018 to June 2019 of adult patients undergoing EUS-FNA. The samples obtained were spread and evaluated in endoscopy rooms by a pathologist with Diff-Quick stain, and when a sufficient sample was obtained, it was sent in a vial with formalin for cell block and/or biopsy. Results: 48 pancreatobiliary EUS-FNA were performed in individuals with a median age of 64 years. The most frequent indication was aspiration due to pancreatic mass (71%); 35 malignancies were diagnosed (77% were adenocarcinomas and 14% were neuroendocrine tumors). The median size of the lesions was 28mm, and the average number of passes was 3. Diagnostic results were obtained in 89% vs. 11% of false negatives. There was 1 minor complication (2.1%), which was abdominal pain. Conclusions: EUS-FNA with an in-room pathologist has a high diagnostic performance, with few false negative results. Also, a lower median number of passes is required, minimizing the risks of the procedure and the need for repeating it.

Tumor de Klatskin (colangiocarcinoma hiliar) su morbimortalidad en un servicio de cirugía / Klatskin's tumor (hilar cholangiocarcinoma) his morbi-mortality in a surgery service

RESUMEN Introducción: El tumor de Klatskin es el colangiocarcinoma, más frecuente de la vía biliar siendo responsable de una alta morbimortalidad en los servicios de cirugía. Objetivo: Determinar la morbilidad y la mortalidad por tumor de Klatskin en el Servicio de Cirugía del Hospital Universitario "Manuel Ascunce Domenech". Métodos: Se realizó un estudio descriptivo, prospectivo y observacional de pacientes que ingresaron en el Servicio de Cirugía General con diagnóstico de tumor de Klatskin, entre septiembre de 2018 y enero del 2020. El universo estuvo conformado por 7 pacientes que cumplieron con los criterios de inclusión. Se utilizaron métodos estadísticos descriptivos y cálculos con valores porcentuales. Resultados: La mayor incidencia de los pacientes fue de sexo masculino y de raza blanca, con un 71,4 por ciento y 85,7 por ciento respectivamente. Predominó adenocarcinoma como variedad histológica con un 85,7 por ciento. Tipo II de la clasificación topográfica, el procedimiento de Hess como operación realizada y la bilirragia como complicación prevaleció con un 42,8 por ciento respectivamente. El 85,7 por ciento de los pacientes egresaron vivos y con una cirugía con finalidad curativa. Conclusiones: La mayoría de los pacientes eran masculinos y de color blanco. Más de la mitad de los pacientes fueron clasificados como tipo I y II según clasificación de Bismuth-Corlette. El proceder de Hess, el adenocarcinoma como forma histológica y el estado del egreso vivo predominó en el total de pacientes(AU)

ABSTRACT Introduction: Klatskin's tumor is cholangiocarcinoma, most frequent to occur in the bile duct, being responsible for high morbidity and mortality in surgery departments. Objective: To determine the morbidity and mortality of Klatskin's tumor at the surgery service of Manuel Ascunce Domenech University Hospital. Methods: We carried out a descriptive, prospective and observational study of patients admitted to the general surgery service with a diagnosis of Klatskin's tumor, between September 2018 and January 2020. The study population consisted of seven patients who met the inclusion criteria. Descriptive statistical methods and calculations with percentage values were used. Results: The highest incidence was represented male and white patients, accounting for 71.4 percent and 85.7 percent, respectively. Adenocarcinoma predominated as a histological variety, accounting for 85.7 percent. There was prevalence of type II of topographic classification, the Hess procedure as the performed operation, and bilirrhagia as a complication, accounting for 42.8 percent, respectively. 85.7 percent of the patients were discharged and received surgery for curative purposes. Conclusions: Most of the patients were male and white. More than half of the patients were classified as types I and II, according to the Bismuth-Corlette classification. The Hess procedure, adenocarcinoma as a histological form, and discharge predominated in all patients(AU)

Colangiografía retrógrada realizada con enteroscopia asistida por balón simple en pacientes con anatomía alterada por cirugía en una clínica privada nivel III / Retrograde cholangiography performed with simple balloon-assisted enteroscopy in patients with altered anatomy by surgery in a private level III clinic

RESUMEN Objetivo : Evaluar la utilidad de la colangiografía retrógrada realizada con enteroscopia asistida por balón simple para el manejo de la patología de la via biliar en pacientes con anatomía alterada por cirugía en la Clínica Anglo Americana. Materiales y métodos : El presente es un estudio descriptivo retrospectivo donde se evalúan a todos los pacientes con anatomía alterada que acudieron por problemas de la via biliar para realizarse una colangiografía retrógrada asistida por enteroscopia con balón simple en la Clínica Anglo Americana durante el periodo de enero del 2014 a enero del 2020. Resultados : Realizamos 10 estudios de colangiografía retrógrada asistida por enteroscopia con balón simple. La canulación de la vía biliar fue exitosa en el 80% de nuestros casos, en dos casos no se pudo localizar la via biliar. Los hallazgos de la colangiografía retrógrada fueron litiasis de via biliar en 7 casos, estenosis de la anastomosis biliodigestiva en 5 casos y un ampuloma. Los procedimientos terapeúticos más frecuentes fueron dilatación con balón progresivo CRE de la anastomosis bilioentérica y extracción de litos con canastilla de Dormia. No se presentaron complicaciones asociadas al procedimiento. Conclusión : La colangiografía retrógrada asistida por enteroscopia con balón simple es un método seguro y eficaz para resolver la patología biliar en nuestros pacientes con anatomía alterada.

ABSTRACT Objective : To evaluate the usefulness of retrograde cholangiography performed with simple balloon-assisted enteroscopy for the management of bile duct pathology in patients with altered anatomy by surgery at the Anglo American Clinic. Materials and methods : This is a retrospective descriptive study where all patients with altered anatomy who came for bile duct problems to undergo a retrograde cholangiography assisted by simple balloon enteroscopy at the Anglo American Clinic during the January period from 2014 to January 2020. Results : We performed 10 studies of retrograde cholangiography assisted by simple balloon enteroscopy. Cannulation of the bile duct was successful in 80% of our cases, in two cases the bile duct could not be located. The findings of the retrograde cholangiography were biliary stones in 7 cases, stenosis of the biliodigestive anastomosis in 5 cases, and an ampuloma. The most frequent therapeutic procedures were CRE progressive balloon dilation of the bilioenteric anastomosis and extraction of stones with a Dormia basket. There were no complications associated with the procedure. Conclusion : Retrograde cholangiography assisted by simple balloon enteroscopy is a safe and effective method to resolve biliary pathology in our patients with altered anatomy.

A practical new strategy to prevent bile duct injury during laparoscopic cholecystectomy. A single-center experience with 5539 cases

Abstract Purpose Bile duct injury (BDI) is a catastrophic complication of cholecystectomy, and misidentification of the cystic anatomy is considered to be the main cause. Although several techniques have been developed to prevent BDI, such as the "critical view of safety", the infundibular technique, the rates remain higher during laparoscopic cholecystectomy (LC) than during open surgery. We, here, propose a practical new strategy for ductal identification, that can help to prevent laparoscopic bile duct injury. Methods A retrospective study of 5539 patients who underwent LC from March 2007 to February 2019 at a single institution was conducted. The gallbladder infundibulum was classified by its position located on an imaginary clock with the gallbladder neck as the center point of the dial, 3-o'clock position as cranial, 6-o'clock as dorsal, 9-o'clock as caudal, and 12-o'clock as ventral, as well as the axial position. Patient demographics, pathologic variables and infundibulum classification were evaluated. Detailed analysis of ductal identification based on gallbladder infundibulum position was performed in this study. All infundibulum positions were recorded by intraoperative laparoscopic video or photographic images. Results All the patients successfully underwent LC during the study period. No conversion or serious complications such as biliary injury occurred. Gallbladders with infundibulum of 3-o'clock position, 6-o'clock position, 9-o'clock position, 12-o'clock position, axial position were 12.3%, 23.4%, 28.0%, 4.2%, and 32.1%, respectively. The 3-o'clock and 12-o'clock position were pitfalls that might cause biliary injury. Conclusion The gallbladder infundibulum as a navigator is useful for ductal identification to reduce BDI and improve the safety of LC.

Cavernoma portal complicada con biliopatía secundario a enfermedad de Gaucher tipo 1: reporte de un caso peruano / Cavernoma complicated with biliopatia secondary to type 1 Gaucher disease: report of a Peruvian case

La enfermedad de Gaucher, es un trastorno autosómico recesivo de depósito lisosomal que se caracteriza por deficiencia de la beta-glucocerebrosidasa que lleva a la acumulación de glucosilceramida principalmente en células del sistema fagocítico mononuclear causando afectaciones sistémicas. Se presenta paciente varón de 20 años que cursa con dolor crónico en hipocondrio izquierdo con episodios de sangrados desde hace 3 años y sensación de alza térmica, al examen físico se identificó ictericia y esplenomegalia masiva, sin afectación neurológica. Como apoyo al diagnóstico se mostró osteoporosis severa, pancitopenia y como hallazgo inesperado la presencia de trombosis de vena porta con transformación cavernomatosa complicada con biliopatía portal simulando un tumor de klatskin, los estudios de médula y enzimáticos eran compatibles con enfermedad de Gaucher, por lo cual recibió tratamiento con imiglucerasa realizando seguimiento. Es un caso poco frecuente, de gran interés, heterogeneidad en sus manifestaciones clínicas e inéditas por su complicación, constituyendo un desafío llegar a su diagnóstico de esta enfermedad huérfana.

Gaucher disease is an autosomal recessive lysosomal storage disorder characterized by deficiency of beta-glucosidase that would lead to the accumulation of glucosylceramide mainly in cells of the mononuclear phagocytic system causing systemic effectations. We present a patient of twenty years who is suffering from chronic pain in the left hypochondrium with episodes of bleeding for 3 years and sensation of thermal rise, physical examination revealed jaundice and massive splenomegaly, without neurological involvement. Severe osteoporosis, pancytopenia, and the presence of portal vein thrombosis with cavernomatous transformation complicated by portal biliopathy simulating a klatskin tumor, marrow and enzymatic studies were compatible with Gaucher disease, were shown as unexpected findings. he received treatment with imiglucerase, following up. It is a rare case, of great interest, heterogeneity in its clinical manifestations and unpublished by its complication, constituting a challenge to reach its diagnosis of this orphan disease.

Pancreatitis aguda por Ascaris Lumbricoides: presentación de un caso clínico / Acute pancreatitis due to Ascaris Lumbricoides: presentation of a clinical case

Caso clínico: paciente masculino de 30 años de edad, con dolor abdominal de 24 horas de evolución. A la exploración física, abdomen distendido, doloroso en epigastrio e hipocondrio derecho. Paraclínicos indicaron leucocitosis (12.400/cc), elevación de amilasa 3.2 N, lipasa 6.8 N, PCR de 192 mg/dl y procalcitonina de 0,136 ng/ml. El ultrasonido de abdomen sin signos dilatación de la vía biliar intra y extra hepática. La tomografía simple y contrastada de abdomen reportó un Baltazar C. El dolor epigástrico persistente motivó a la realización de una endoscopia digestiva alta, en la misma que se evidenció un ejemplar de Ascaris enclava-do en la papila duodenal el mismo que fue retirado con una pinza asa para cuerpo extraño. Conclusiones: la parasitosis intestinal es causa importante de obstrucción de la vía biliar y abdomen agudo inflamatorio, que requiere de oportuna atención en el enfermo.

Clinical case: male patient of 30 years of age, with abdominal pain of 24 hours of evolution. Physical examination showed distended abdomen, painful epigastrium and right hypochon-drium. Paraclinics indicated leukocytosis (12,400 / cc), elevation of amylase 3.2 N, lipase 6.8 N, CRP of 192 mg / dl and procalcitonin of 0.136 ng / ml. Ultrasound of the abdomen showed absence of dilation signs of the biliary tract intra and extra hepatic ascariasis. The simple and contrasted abdomen tomography reported a Baltazar C. The persistent epigastric pain moti-vated the performance of an upper digestive endoscopy; it was observed a specimen of asca-ris nestled in the duodenal papilla which was removed with a handle clamp for a foreign body. Conclusions: intestinal parasitosis is an important cause of obstruction of the bile duct and acute inflammatory abdomen, which requires timely attention in the patient.

Puerperal sepsis caused by liver abscess: case report / Sepse puerperal secundária a abscesso hepático: relato de caso

Abstract Introduction: sepsis is a serious public health problem, affecting millions of people in the world each year, with a high mortality rate (one out of four patients) and an increasing incidence. Sepsis is one of the main causes of maternal mortality and an important cause of admission to obstetric intensive care units. Case description: In this study, the authors report the case of a woman having been submitted to cesarean section three days before presenting clinical signs of sepsis and septic shock caused by a liver abscess. The patient had a set of complications secondary to shock, such as thrombocytopenia, coagulopathy, toe ischemia and acute kidney failure. The patient had cholelithiasis and recurrent pain in the right hypochondrium during pregnancy. During hospitalization, the mechanism involved in the development of hepatic abscess was infection of the biliary tract. The patient was treated in an obstetric intensive care unit with antibiotics and drainage of the liver abscess. Progress was favorable and the patient was discharged in good health. Discussion: pyogenic liver abscess during pregnancy and puerperium is a serious condition which represents a diagnostic and therapeutic challenge, with few cases reported. The normally nonspecific clinical and laboratory findings can lead to a late diagnosis, which increases the risk of maternal morbidity and mortality.

Resumo Introdução: a sepse é um problema grave de saúde pública, afetando milhões de pessoas no mundo a cada ano. Apresenta uma alta mortalidade, um em quatro doentes, e vem aumentando sua incidência. É uma das principais causas de mortalidade materna, sendo uma causa importante de admissões emunidades de terapia intensiva obstétrica. Descrição do caso: puérpera, no terceiro dia pós-cesariana, apresentou quadro clinico de sepse e choque séptico secundário a um abscesso hepático piogênico.Evoluiu com complicações secundárias ao choque: plaquetopenia, coagulopatia, isquemia de pododáctilos e insuficiência renal aguda. A paciente era portadora de colelitíase e apresentou repetidas crises álgicas em hipocôndrio direitodurante a gestação.Durante o internamento, ficou definido que a causa do abscesso hepático foi a infecção das vias biliares.Realizou-se tratamento em unidade de terapia intensiva obstétrica, tendo a paciente sido submetida à drenagem do abscesso hepático e antibioticoterapia. A evolução foi satisfatória e a paciente obteve alta em boas condições. Discussão: o abscesso hepático piogênico durante a gravidez e o puerpério é uma condição extremamente grave, com poucos casos relatados, representando um desafio diagnóstico e terapêutico. Como os achados clínicos e laboratoriais são usualmente inespecíficos, um diagnóstico retardado é possível, aumentando os riscos de morbidade e mortalidade materna em casos não tratados precocemente.

Bilioescroto secundario a bilioma retroperitoneal como presentación extremadamente rara de fuga biliar espontánea / Biliscrotum secondary to retroperitoneal biloma, as an extremely rare presentation of spontaneous bile leak

Objetivo. Presentar el segundo caso descrito en la bibliografía de bilioescroto secundario a bilioma retroperitoneal espontáneo y mostrar a su vez de manera escalonada el tratamiento que se le suministró hasta la resolución completa del cuadro. Caso clínico: Varón de 69 años que debutó con dolor escrotal derecho en relación con bilioescroto secundario a bilioma retroperitoneal espontáneo. Discusión: El bilioma retroperitoneal es un hecho poco habitual; generalmente se debe a complicaciones quirúrgicas o de procedimientos invasivos (intervencionismo radiológico, CPRE y esfinterotomía endoscópica), aunque puede ser consecuencia de roturas espontáneas de la vesícula o la vía biliar principal. La bilis en el retroperitoneo puede discurrir hasta el escroto, originando la rara entidad conocida como bilioescroto. Generalmente se presenta simulando una hernia inguinal incarcerada. No existe un manejo estandarizado de esta patología ya que está escasamente descrita.

Objective: To present the second case described in the literature of biliscrotum secondary to spontaneous retroperitoneal biloma and show a sequential treatment that we provided until complete resolution. Clinical case: We report the case of a man 69 years old, who debuted with right scrotal pain related to biliscrotum secondary to spontaneous retroperitoneal biloma. Discussion: The retroperitoneal biloma is a rare event, usually due to surgical or invasive procedures complications (radiological interventionism, ERCP and endoscopic sphincterotomy), although it may be the result of spontaneous rupture of the gallbladder or bile duct. Bile in the retroperitoneum may extend into the scrotum, causing the rare condition known as biliscrotum. Usually it occurs simulating an incarcerated inguinal hernia. Does not exist a standardized management of this condition because is poorly described.

Conducto subvesicular, nomenclatura anatómica para el conducto de Luschka y su importancia clínica. Revisión de tema / Subvesical Ducts, the Anatomical Nomenclature for the Bile Ducts of Luschka and its Clinical Importance. Topic Review

Introducción: El conducto subvesicular fue descrito por Hubert Luschka como pequeños ductos biliares derivados de la pared de la vesícula biliar. Algunos autores lo describen como un ducto que lleva el drenaje desde el parénquima hepático hasta la vesícula, otros utilizan el término describiéndolo como un conducto que drena desde el parénquima hepático hasta las vías biliares extrahepaticas. Se planteó una revisión bibliográfica de la descripción anatómica del epónimo conducto de Luschka y de la terminología anatómica propuesta conducto subvesicular o subvesical, dada su importancia clínica como causa de fuga biliar. Metodología: Se realizó una revisión bibliográfica en bases de datos y bibliotecas electrónicas. Con ventana de tiempo personalizada desde 2006 hasta 2016, se obtuvo un total de 82 artículos, posteriormente se realizó un resumen analítico especializado, seleccionando un total de 46. Resultados: No se encontró consenso en la descripción anatómica del epónimo, ni en la descripción de la terminología internacional. Las lesiones de la vía biliar durante la colecistectomía se presentan como una complicación poco frecuente (0.1 - 1.5%); sin embargo, tienen repercusiones en varios ámbitos y una morbi-mortalidad considerable. Conclusiones: Se evidenció discrepancia en la nomenclatura utilizada para la descripción de estos conductos, puesto que se denomina de manera indiscriminada como conducto de Luschka a todos los ductos biliares que se encuentran en la fosa biliar. La relevancia clínica radica en que es la segunda causa de fuga biliar iatrogénica y la asociación entre el conducto subvesical y carcinomas ductales. Aún se necesitan más estudios principalmente locales para identificar su incidencia y prevenir complicaciones...(AU)

Introduction: The duct was described by Hubert Luschka as small bile ducts derived from the wall of the gallbladder. Some authors describe it as a duct leading to drainage from the hepatic parenchyma to the gallbladder; others use the term to describe it as a conduit draining from the hepatic parenchyma to the extrahepatic bile ducts. This article presents a literature review of the anatomical description of the eponymous Luschka conduit and the proposed anatomical terminology subvesicular or subvesical conduit, given its clinical importance as a cause of biliary leakage. Methodology: A bibliographic review was carried out in databases and electronic libraries. With a customized time window from 2006 to 2016, obtaining a total of 62 articles, a specialized analytical summary was subsequently performed, selecting a total of 46. Results: No consensus was found in the anatomical description of the eponym, nor in the description of the International terminology. Lesions of the biliary tract during cholecystectomy present as a rare complication (0.1 - 1.5%) but have repercussions in several areas and considerable morbidity and mortality. Conclusions: There was a discrepancy in the nomenclature used for the description of these ducts. It is indiscriminately named as the luschka's conduit for all bile ducts found in the biliary fossa. The clinical relevance is that it is the second cause of iatrogenic biliary leakage and the association between the subvesical duct and ductal carcinomas. More local studies are still needed to identify its incidence and prevent complications...(AU)

Introdução: O ducto subvesicular foi descrito por Hubert Luschka como pequenos ductos biliares derivados da parede da vesícula biliar. Alguns autores descrevem isso como um ducto que leva a drenagem do parênquima hepático para a vesícula biliar, outros usam o termo para descrevê-lo como um canal que drena do parênquima hepático para os ductos biliars extra-hepáticos. Foi proposta uma revisão bibliográfica da descrição anatômica do canal epônimo de Luschka e da derivação anatômica proposta subvesicular ou subvesical, dada sua importância clínica como causa de vazamento biliar. Metodologia: foi realizada uma revisão bibliográfica em bancos de dados e bibliotecas eletrônicas. Com uma janela de tempo personalizada de 2006 a 2016, foi obtido um total de 82 artigos, seguido de um resumo analítico especializado, selecionando um total de 46. Resultados: Nenhum consenso foi encontrado na descrição anatômica do epônimo, nem na descrição da terminologia internacional. As lesões do trato biliar durante a colecistectomia apresentam-se como uma complicação rara (0.1 ­ 1.5%); no entanto, têm repercussões em várias áreas e considerável morbidade e mortalidade. Conclusões: houve uma discrepância na nomenclatura utilizada para a descrição desses ductos, uma vez que é indiscriminadamente referido como o canal de Luschka a todos os canais biliares encontrados na fossa biliar. A relevância clínica é que é a segunda causa de vazamento biliar hepático e a associação entre ducto subvesical e carcinomas ductais. Mais estudos locais ainda são necessários para identificar sua incidência e prevenir complicações...(AU)

Seguimiento de pacientes con atresia biliar: cirugía tardía y desarrollo de lagunas biliares / Follow up for a cohort of patients with biliary atresia: late surgery and development of biliary cysts

Las dilataciones quísticas de las vías biliares, conocidas como lagunas biliares, se han descrito en el seguimiento de los pacientes sometidos a portoenterostomía o cirugía de Kasai por atresia de las vías biliares (AVB). Su aparición se ha asociado con el desarrollo de colangitis y consecuentemente a un peor pronóstico. OBJETIVO: Describir las características clínicas y pronóstico de pacientes con AVB, sometidos a cirugía de Kasai, con énfasis en aquellos que desarrollaron lagunas biliares. PACIENTES Y MÉTODO: Estudio retrospectivo de pacientes sometidos a portoenterostomía de Kasai por AVB durante los años 2008 a 2016. Se tabuló la información demográfica y variables asociadas a la portoenterostomía de Kasai, trasplante hepático, lagunas o quistes biliares y episodios de colangitis. Se crearon curvas de Kaplan Meier y comparación mediante el test de Log Rank para evaluar sobrevida global, libre de colangitis y con hígado nativo, considerando un valor p como significativo. RESULTADOS: Se analizó el seguimiento de 13 pacientes. El tiempo promedio de realización del Kasai fue a los 85 meses (rango 42-193, DS 40,3), seis pacientes (46%) fueron sometidos a cirugía de Kasai después de los 90 días de vida por derivación tardía. Cuatro (31%) desarrollaron lagunas biliares múltiples, todos presentaron episodios de colangitis. La sobrevida libre de colangitis fue significativamente menor para los portadores de lagunas biliares. Nueve pacientes (69%) recibieron un trasplante hepático, en promedio a los 16 meses de edad (rango 6-40, DS 12,1), en 3 de ellos la causa fue colangitis recurrente. No se encontraron diferencias significativas en la sobrevida con hígado nativo ni en sobrevida global entre portadores y no portadores de lagunas biliares. CONCLUSIONES: En esta cohorte, la incidencia de lagunas biliares luego de la portoenterostomía es similar a la descrita en la literatura. Los resultados concuerdan con la relación propuesta entre ellas y el desarrollo de colangitis. En los pacientes de nuestra serie, el diagnóstico y derivación de AVB fue realizado tardíamente, determinando un peor pronóstico.

Since the introduction of Kasai’s hepatic portoenterostomy, the prognosis of patients with biliary atresia has improved. The presence of intrahepatic biliary cysts or bile lakes has been reported in some patients after the intervention. Bile lakes have been related to cholangitis and a poor outcome. OBJECTIVE: To describe the clinical features and prognosis of patients with biliary atresia after Kasai portoenterostomy, with special emphasis in those who developed biliary cysts. PATIENTS AND METHOD: Data from a retrospective cohort of 13 patients with biliary atresia with a Kasai portoenterostomy from 2008 to 2016 was analyzed. Demographic variables associated to Kasai portoenterostomy, hepatic transplant, biliary cysts and colangitis episodes were tabulated. Kaplan Meir and Log Rank test were used to evaluate colangitis-free and native liver survival. RESULTS: The mean age at Kasai was 85 months (SD 40.3, 42-193 months), six patients (46%) had a Kasai operation after 90 days of life. Four patients (31%) developed multiple biliary cysts; all of them had at least one episode of cholangitis. Cholangitis-free survival was significantly lower for those who developed bile lakes. Nine patients (69%) underwent liver transplant, 3 of them because of recurrent cholangitis. There were no differences in global survival or native liver survival between patients with or without biliary cysts. CONCLUSIONS: The incidence of biliary cysts after Kasai portoenterostomy in this series is similar to the reported. The results are consistent with the relationship proposed between the development of biliary cysts and cholangitis. Our patients, some already derived for evaluation and liver transplantation, underwent Kasai operation at an advanced age, which determines a poor prognosis.

Perforación espontánea de la vía biliar en un neonato: un hallazgo inesperado: caso clínico / Spontaneous perforation of the bile duct in a neonate: an unexpected finding: case report

La perforación espontánea de la vía biliar extrahepática es rara en recién nacidos. Es una causa quirúrgica de ictericia en este período y la presentación aguda es inusual. OBJETIVO: presentar un caso de perforación espontanea de la vía biliar en un recién nacido por sus graves complicaciones si no se realiza un diagnóstico temprano y oportuno. CASO CLÍNICO: Recién nacido de término de 10 días de vida que consultó por cuadro de rechazo alimentario, fiebre y distensión abdominal de 2 días de evolución, sin ictericia, acolia, ni coluria. En los exámenes de laboratorio se encontró leucopenia, trombocitosis y elevación de la proteína C reactiva, con función hepática normal. La radiografía de abdomen demostró neumoperitoneo, sospechándose enterocolitis necrosante, se realizó laparotomía, encontrándose perforación espontánea de la vía biliar extrahepática y peritonitis biliar. La colangiografía intraoperatoria demostró la vía biliar proximal rescatable y conducto cístico dilatado. Se realizó hepático-yeyunostomía con Y de Roux transmesocolónica y colecistectomía. En el estudio postoperatorio se encontró trombosis portal, por lo que recibió tratamiento anticoagulante. En el control a los ocho meses de edad, la paciente tenía buena tolerancia oral y adecuado incremento ponderal. CONCLUSIONES: La perforación biliar es una entidad rara y más en el período neonatal, condición que la vuelve un reto diagnóstico y terapéutico. El pronóstico dependerá de la intervención temprana y los hallazgos intraoperatorios.

Spontaneous extrahepatic bile duct perforation is rare in newborns. It is a surgical cause of jaundice in this period and the acute presentation is unusual. OBJECTIVE: To report a case of spontaneous bile duct perforation in a newborn due to its serious complications if an early and timely diagnosis is not performed. CLINICAL CASE: A 10-day-old newborn who developed food rejection, fever and abdominal distension without jaundice, acolia, or coluria two days prior of admission. The laboratory tests showed leukopenia, thrombocytosis, increased C-reactive protein, and normal hepatic function. The abdominal x-ray showed pneumoperitoneum, and the diagnosis of necrotizing enterocolitis was made. Laparotomy was performed; extrahepatic bile duct perforation and biliary peritonitis were noted. Intraoperative cholangiography demonstrated rescatable proximal bile duct and dilated cystic duct. Hepatic-jejunostomy was performed with Roux-en-Y and cholecystectomy. In the postoperative study portal thrombosis was found, so he received anticoagulant treatment. At 8 months of age, the patient had enteral feeding tolerance and adequate weight gain. CONCLUSIONS: Biliary perforation is a rare entity and more in the neonatal period, a condition that makes it a diagnostic and therapeutic challenge. The prognosis will depend on early intervention and intraoperative findings.

Utilidad de la CPRE en el diagnóstico y manejo de las complicaciones biliares de la enfermedad hidatídica hepática / Endoscopic colangiopancreatography utility in the diagnosis and management of biliary complications of hepatic hydatid disease

Objetivo Presentar la experiencia sobre la utilidad de la colangiopancreatografía retrógrada endoscópica (CPRE) en el manejo pre- y postoperatorio de pacientes con hidatidosis hepática complicada. Material y método Serie de casos de carácter retrospectivo de 14 pacientes sometidos a CPRE en el Servicio de Cirugía y Endoscopía del Hospital Regional de Coyhaique, desde enero de 2005 a diciembre de 2014. En esta presentación se separan a los pacientes en los cuales la CPRE fue utilizada como diagnóstico de aquellos en los que se utilizó como manejo de la fístula biliar externa. Los pacientes después del alta fueron controlados al mes, 3, 6 meses, para posteriormente realizarlo anualmente. Resultados Hubo 5 pacientes sometidos a CPRE en el preoperatorio. El motivo de consulta fue ictericia y dolor. En todos se encontraron membranas hidatídicas las cuales fueron extraídas. Se realizó esfinterotomía en todos ellos y en solo uno se dejó endoprótesis. Cuatro pacientes fueron estabilizados y operados de manera programada y solo uno no requirió de intervención. En los 9 pacientes con fístula biliar externa, débito > 200 ml, se realizó CPRE en el postoperatorio. El tamaño promedio del quiste fue de 12 cm y 2/3 de ellos eran multivesiculares. La técnica realizada fue quistectomía parcial y en 4/9 se llevó a cabo mediante videolaparoscopía. La indicación de la CPRE se efectúo a los 20 días y el débito promedio fue de 498 ml/día. En todos se realizó esfinterotomía con instalación de endoprótesis. El cierre de la fístula biliar externa aconteció a los 28 días. El seguimiento promedio alcanzó los 6 años y no existió mortalidad en la presente serie. Conclusión Este estudio confirma que la CPRE es un procedimiento útil y seguro en el diagnóstico y tratamiento de las complicaciones biliares de la hidatidosis hepática.

Aim To report the experience with endoscopic colangiopancreatography (ERCP) in the pre and postoperative management of complicated liver hydatidosis. Material and methods Case series retrospective of 14 patients who underwent ERCP in the Department of Surgery and Endoscopy Regional Hospital of Coyhaique, from January 2005 to December 2014. In this presentation, patients are separated in whom ERCP was used as diagnosis of those in which was used as handling external biliary fistula. Patients after discharge were monitored per month, 3, 6 months later to realize it annually Results Five patients consulting for jaundice and pain were subjected to ERCP in the preoperative period. Hydatid membranes were found and extracted in all. A sphincterotomy was performed in all and an endoprosthesis was placed in one. Four patients were operated posteriorly and only one did not require surgery. On 9 patients with an external biliary fistula draining more than 200 ml/day, a postoperative ERCP was carried out. The mean sized of the cyst was 12 cm and two thirds were multi-vesicular. The surgical procedure was a partial cystectomy and in four it was laparoscopic. The mean output of fistulae was 498 ml/day. The ERCP was carried out in the twentieth postoperative day, performing a sphincterotomy and placing an endoprosthesis in all. Fistulae closed at 28 days. Patients were followed for six years and none died. Conclusions ERCP is safe and useful for the diagnosis and management of biliary complications of liver hydatidosis.

An evaluation of the protective effect of an infusion of chilled glucose solution on thermal injury of the bile ducts caused by radiofrequency ablation of the liver

PURPOSE: To evaluate the protective effects of chilling the bile ducts with cold (5°C) 5% glucose solution (GS) during radiofrequency (RF) administration. METHODS: Twenty male pigs (3 mos. old; 25-30 kg) were subjected to RF delivery with chilling (experimental group, N=10) or without chilling (control group, N=10). Half of the animals in each group were euthanized immediately after the operation, and half were euthanized one week later. The following histological variables in relation to the bile ducts were evaluated by a pathologist (blind examiner): degenerative changes to the epithelium; epithelial necrosis; ulceration, regenerative changes of the epithelium; polymorphonuclear neutrophil infiltration; and thermal effects. RESULTS: The experimental group (88 bile ducts examined) showed reduced thermal damage relative to the control group (86 bile ducts examined) as demonstrated by significant differences in the following histopathological parameters: epithelial detachment of biliary epithelium (84.1% vs. 59.3%; p<0.006); elongation/palisade arrangement of nuclei (65.1% vs. 87.5%; p<0.001); pseudo-goblet cells (32.9% vs. 56.8%; p<0.001). CONCLUSION: Infusion of 5% glucose solution (5°C) has a protective effect on bile ducts subjected to heat (95-110°C, 12 min) from radiofrequency thermal ablation device. .

El retrato de una lesión de la vía biliar / Portrait of a Bile Duct Injury

El contacto entre la cirugía y la tecnología tuvo su cúspide a finales del siglo XX con el advenimiento de la cirugía laparoscópica. En 1989 Jacques Perissat presentó su técnica de colecistectomía laparoscópica a la Sociedad Americana de Cirujanos Endoscópicos y Gastrointestinales (SAGES), en Louisville Kentucky. Este evento fue el punto de partida que posteriormente siguió el futuro de la cirugía mínimamente invasiva a nivel mundial. El objetivo de éste artículo, es mostrar los distintos escenarios en los que durante una colecistectomía laparoscópica incluso el cirujano más hábil puede verse inmerso: la identificación de una lesión de la vía biliar.

With the advent of laparoscopic surgery toward the end of the 20th Century, the merging of surgery and technology attained new heights. In 1989 JaquesPerissant presented his technique for laparoscopic cholecystectomy at the meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Louisville , Kentucky. This was the starting point for what was to become in the future the worldwide use of minimally invasive surgery. The aim of this article is to describe those scenarios which, even in the ablest hands, can lead to a bile duct injury during laparoscopic cholecystectomy.

The health-disease process and the family health strategy: the user's perspective / Processo saúde/doença e estratégia de saúde da família: o olhar do usuário / El proceso salud-enfermedad y la estrategia salud de la familia: la perspectiva del usuario

OBJECTIVE: to analyze the meanings Primary Health Care users attribute to their health-disease process and the services used. METHODS: this qualitative research uses the focus group technique to interview two groups of users the service monitors. The first is a group of elderly people and the second of pregnant women. To analyze the meanings, the discourse analysis technique and the reference framework of health promotion are used. RESULTS: the group of elderly, being mostly female arterial hypertension and diabetes mellitus patients, visualizes the health-disease process as the evolution of human existence controlled by divine power, signifying the health service as a blessing in the control of the disease. The Group of young pregnant women signified health as the ability for self-care and disease as the disability for that purposes, considering the Primary Health Care service as responsible for the recovery of individual and family health. FINAL CONSIDERATIONS: the users demonstrated dissatisfaction with bureaucratic and vertical relations present at the health services. In each group, it was observed that the meanings for health and disease and meanings of the health service the users elaborated can be related. .

OBJETIVO: analisar os significados atribuídos pelos usuários da Atenção Primária à Saúde ao seu processo de saúde/doença e aos serviços utilizados. MÉTODOS: pesquisa qualitativa utilizando a técnica do grupo focal para entrevista com dois grupos de usuários acompanhados pelo serviço, sendo o primeiro um grupo de idosos e o segundo, de mulheres gestantes. Para análise dos significados, usou-se a técnica de análise de discurso e referencial da promoção em saúde. RESULTADOS: grupo de idosos, maioria feminina, portadores de hipertensão arterial e diabetes mellitus, visualiza o processo de saúde/doença como evolução da existência humana controlada pelo poder divino, significando o serviço de saúde como uma bênção no controle da doença. O grupo de gestantes jovens significou saúde como capacidade para autocuidado e doença como incapacidade para tal, concebendo o serviço de Atenção Primária como responsável pela recuperação da saúde individual e familiar. CONSIDERAÇÕES FINAIS: os usuários demonstraram insatisfação com relações burocratizadas e verticalizadas presentes no serviço de saúde. Observou-se, em cada grupo, que significados para saúde e doença e significados do serviço de saúde elaborados pelos usuários podem estar relacionados. .

OBJETIVO: analizar los significados atribuidos por los usuarios de la Atención Primaria de la Salud al proceso salud-enfermedad y a los servicios utilizados. MÉTODOS: investigación cualitativa que utiliza la técnica del grupo focal para entrevistar a dos grupos de usuarios acompañados por el servicio, el primer grupo de ancianos y el segundo de mujeres embarazadas. Para el análisis de los significados, fue usada la técnica de análisis de discurso y el referencial de la promoción de la salud. RESULTADOS: grupo de ancianos, mayoría femenina, con hipertensión arterial y diabetes mellitus, entiende el proceso salud-enfermedad como una evolución de la existencia humana controlada por el poder divino, significando al servicio de salud como una bendición para el control de la enfermedad. Para el Grupo de embarazadas jóvenes significó: la salud como una capacidad para el autocuidado y la enfermedad como la incapacidad para eso, concibiendo al servicio de Atención Primaria como responsable por la recuperación de la salud individual y familiar. CONSIDERACIONES FINALES: los usuarios demostraron insatisfacción con las relaciones burocratizadas y verticales, presentes en el servicio de salud. Se observó en cada grupo que los significados para salud y enfermedad y los significados del servicio de salud elaborados por los usuarios pueden estar relacionados. .

Functional priorities reported by parents of children with cerebral palsy: contribution to the pediatric rehabilitation process / Prioridades funcionais identificadas por pais de crianças com paralisia cerebral:contribuições para o processo de reabilitação infantil

Background: Collaborative actions between family and therapist are essential to the rehabilitation process, and they can be a catalyst mechanism to the positive outcomes in children with cerebral palsy (CP). Objectives: To describe functional priorities established by caregivers of CP children by level of severity and age, and to assess changes on performance and satisfaction on functional priorities reported by caregivers, in 6-month interval. Method: 75 CP children, weekly assisted at Associação Mineira de Reabilitação, on physical and occupational therapy services. The following information was collected: gross motor function (Gross Motor Function Classification System-GMFCS) and functional priorities established by caregivers (Canadian Occupational Performance Measure-COPM). Data were collected in two moments, with a 6-month interval. Results: The main functional demands presented by caregivers were related to self-care activities (48.2%). Parents of children with severe motor impairment (GMFCS V) pointed higher number of demands related to play (p=0.0036), compared to the other severity levels. Parents of younger children reported higher number of demands in mobility (p=0.025) and play (p=0.007), compared to other age groups. After 6 months, there were significant increase on COPM performance (p=0.0001) and satisfaction scores (p=0.0001). Conclusions: Parents of CP children identified functional priorities in similar performance domains, by level of severity and age. Orienting the pediatric rehabilitation process to promote changes in functional priorities indentified by caregivers can contribute to the reinforcement of the parent-therapist collaboration. .

Contextualização: Ações colaborativas entre família e terapeuta são essenciais para o processo de reabilitação, podendo constituir mecanismo catalisador de desfechos funcionais positivos para crianças com paralisia cerebral (PC). Objetivos: Descrever prioridades funcionais identificadas por cuidadores de crianças com PC por nível de gravidade e idade e avaliar mudanças no desempenho e satisfação reportadas pelos cuidadores nas prioridades identificadas no intervalo de seis meses. Método: De 75 crianças com PC, atendidas semanalmente naAssociação Mineira de Reabilitação, nos serviços de fisioterapia e de terapia ocupacional, foram coletadas informações referentes à função motora grossa (Sistema de Classificação da Função Motora Grossa-GMFCS) e às prioridades funcionais estabelecidas pelos cuidadores (Medida Canadense de Desempenho Ocupacional-COPM). Os dados foram coletados em dois períodos, com intervalo de seis meses. Resultados: As principais demandas apontadas pelos cuidadores referiram-se às atividades de cuidados pessoais (48,2%). Pais de crianças com comprometimento motor grave (GMFCS V) apresentaram maior número de demandas relacionadas ao brincar (p=0,036), comparadas com outros níveis de comprometimento. Pais de crianças mais jovens reportaram maior número de demandas em mobilidade (p=0,025) e brincar (p=0,007) em relação aos outros grupos etários. Após seis meses, observou-se aumento significativo dos escores de desempenho (p=0,0001) e de satisfação (p=0,0001) da COPM. Conclusões: Pais de crianças com PC identificaram prioridades funcionais em áreas de desempenho semelhantes por nível de gravidade da função motora grossa e por grupo etário. Direcionar o processo ...

O papel da colangiografia intraoperatória na identificação imediata das variações das vias biliares / The role of intraoperative cholangiography in the immediate identification of changes in biliary tract

A colelitíase é uma das doenças mais prevalentes na população adulta. A lesão iatrogênica envolvendo a via biliar constitui-se numa das situações mais temidas pelos cirurgiões, acontecendo tanto durante a cirurgia aberta como na videolaparoscópica. Discute-se as causas determinantes do desenvolvimento destas lesões, assim como a variação anatômica da árvore biliar associado à presença de ductos biliares acessórios ou aberrantes que são lesados inadvertidamente. Os autores relatam dois casos de lesões de ductos biliares acessórios da via biliar, que foram diagnosticados pela realização da colangiografia intraoperatória e corrigidos prontamente durante o procedimento cirúrgico.

Cholelithiasis is one of the most prevalent diseases in the adult population. Iatrogenic injury involving the bile duct constitutes one of the most feared situations by surgeons, occurring both in open surgery as in laparoscopic. Discusses the determinants of the development of these lesions causes, as well as the anatomical variations of the biliary tree associated with the presence of aberrant bile ducts or accessories that are inadvertently injured. The authors report two cases of accessory bile duct lesions of the biliary tract, which were diagnosed by perfoming intraoperative cholangiography and promptly corrected during surgery.

CHOLANGIOSCOPY IN BILE DUCT DISEASE: a case series / Colangioscopia nas afecções biliares: uma série de casos

Context Direct endoscopic visualization of biliopancreatic duct is certainly one of the greatest advances of therapeutic endoscopy. The use of a single-operator cholangioscopy platform (SpyGlass) is a promising technique in the evaluation of diseases such as indeterminate biliary stricture and giant choledocholitiasis. This is the first Brazilian case series using this technology. Methods We report a case series of 20 patients in whom SpyGlass was used with diagnostic and therapeutic intention. Results Most patients were female (60%) and the median age was 48 years (ranging from 14 to 94). Choledocholitiasis was the most common indication (12/20), and electrohydraulic lithotripsy was applied in eight (66%). Electrohydraulic lithotripsy was successful in seven (87.5%) patients. Partial stone fragmentation occurred in one patient with large stone causing stone-choledochal disproportion, which was conducted with biliary plastic stent placement and a second scheduled endoscopic approach in 3 months. In cases of undefined etiology of biliary strictures, it was possible to exclude malignancy due to direct visualization (7/8) or biopsy (1/8). One complication occurred (duodenal perforation) after papillary balloon dilation. Conclusion The use of SpyGlass demonstrated the benefits, especially in cases of large bile duct stones and indeterminate biliary strictures. Other potencial improvements such as reduction on radiation exposure should be confirmed in prospective studies. .

Contexto A visão endoscópica direta das vias biliopancreáticas é certamente um dos maiores avanços na endoscopia terapêutica. O uso da plataforma de colangioscopia de operador-único (SpyGlass) é uma técnica promissora na avaliação de afecções tais como estenoses de etiologia indefinida e coledocolitíase gigante. Essa é a primeira série de casos brasileira utilizando o método. Métodos Reportamos uma série de casos de 20 pacientes nos quais foi realizado Spyglass com objetivos diagnósticos e terapêuticos. Resultados A maioria dos pacientes era do sexo feminino (60%), com idade que variou de 14 a 94 anos (mediana de 48). Coledocolitíase foi a indicação mais comum (12/20) e litotripsia eletrohidráulica foi realizada em oito (66%). Litotripsia eletrohidráulica foi realizada com sucesso em sete (87,5%) pacientes. Fragmentação parcial dos cálculos ocorreu em um paciente com desproporção cálculo-coledociana, sendo conduzido com colocação de prótese plástica e reabordagem endoscópica programada em 3 meses. Nos casos de estenoses biliares de etiologia indeterminada, foi possível a exclusão de malignidade devido a visualização direta (7/8) ou biópsia (1/8). Uma complicação ocorreu (perfuração duodenal) após dilatação balonada da papila. Conclusão Foram demonstrados os benefícios do uso do Spyglass, principalmente nos casos de coledocolitíase gigante e estenoses biliares de etiologia indefinida. Outras potenciais vantagens como a redução da exposição à radiação deve ser confirmada em estudos prospectivos posteriores. .