Morbilidad y mortalidad de las derivaciones biliodigestivas / Morbidity and mortality in biliary bypasses

Objetivo: Determinar la morbilidad y la mortalidad en las derivaciones biliodigestivas en el servicio de Cirugía general en el Hospital Enrique Cabrera, de enero de 2007 a diciembre de 2011. Material y Métodos: Se realizó una investigación observacional, descriptiva y prospectiva. La muestra fue constituida por 51 pacientes a los que se les realizó una o más derivaciones biliodigestivas. Las variables estudiadas fueron edad, sexo, causa de intervención, tecnica quirúrgica, complicaciones, estado al egreso y causa de muerte. Se calculó la frecuencia de complicaciones y la mortalidad para cada técnica. Resultados: Fueron intervenidos quirúrgicamente 51 pacientes, con un promedio de edad de 57,5 años El tumor de cabeza de páncreas correspondió a 56,9% de los casos y la lesión de vía biliar, a 17,6%. La infección del sitio quirúrgico ocurrió en 33,3%. Fallecieron 50% de los operados por ténica de Whipple. La técnica quirúrgica más utilizada fue la coledocoduodenostomía. La mortalidad fue 11,8% y la principal causa de muerte, la falla multiorgánica. Conclusiones: El tumor de cabeza de páncreas fue la causa de intervención más frecuente La pancreatoduodenectomía de Whipple reportó la mayor morbimortalidad. Las tasas de incidencia de complicaciones y de mortalidad para la cirugía biliodigestiva fueron altas.

Objectives: To determine the morbidity and mortality in biliary bypasses in the Service of General Surgery at the Enrique Cabrera Hospital from January of 2007 to December of 2011. Material and Methods: It was carried out an observational, descriptive and prospective study. The sample constituted by 51 patients who had underwent a biliary bypass. The studied variables were: age, sex, intervention cause, surgical technique, complications, condition at discharge and cause of death. Frequency of complications and mortality were calculated for each technique. Results: Fifty one patients underwent a biliary bypass, age average of 57,5 year-old. The head's pancreas tumor was 56,9% and biliary's ducts lesions 17,6%. Surgical wound infection occurred in 33,3% of cases, and 50% of those who underwent a Whipple's technique died. The more used surgical technique was the choledocoduodenostomy. The mortality was of 11,8% and the main cause of death was multiorganic failure. Conclusions: The head's pancreas tumor was the cause that underwent surgery. The Whipple's pancreatoduodenectomy reported the highest morbidity and mortality. The frequency of complications and mortality for a biliary bypass were high.

Surgical palliation for pancreatic malignancy: practice patterns and predictors of morbidity and mortality.

INTRODUCTION: Most patients with pancreatic cancer present with, or develop, biliary or duodenal obstruction. We sought to characterize palliative surgery utilization in a contemporary cohort and identify patients at high risk of morbidity and mortality. METHODS: The ACS NSQIP database (2005-2011) was queried for patients with a pancreatic malignancy undergoing gastrojejunostomy, biliary bypass, or laparotomy without resection. Univariate analysis and multivariate logistic regression identified factors associated with increased risk of 30-day morbidity or mortality. RESULTS: Operations for the 1,126 patients undergoing palliative bypass were gastrojejunostomy alone (33%), bile duct bypass alone (27%), both (31%), or cholecystojejunostomy (9%). A major complication occurred in 20% and mortality in 6.5% at 30 days. Risk factors for morbidity and mortality were defined in multivariate models. The number of identified risk factors stratified morbidity from 14.8-50% and mortality from 1.6-50% (p < 0.0001 for each). Laparotomy alone (n = 622) was associated with lower morbidity than bypass (12 vs. 20%, p < 0.0001), but equivalent mortality (5 vs. 6.5%, p = 0.21). CONCLUSION: Palliative bypass for pancreatic cancer is associated with a high rate of morbidity and mortality. In select patients, this risk may be prohibitive. Patient selection reflecting predictors of morbidity and mortality may allow for improved outcomes.

Roux-en-Y choledochojejunostomy versus duct-to-duct biliary anastomosis in liver transplantation for primary sclerosing cholangitis: a meta-analysis.

BACKGROUND: Roux-en-Y choledochojejunostomy and duct-to-duct anastomosis are potential methods for biliary reconstruction in liver transplantation (LT) for recipients with primary sclerosing cholangitis (PSC). However, there is controversy over which method yields superior outcomes. The purpose of this study was to evaluate the outcomes of duct-to-duct versus Roux-en-Y biliary anastomosis in patients undergoing LT for PSC. METHODS: Studies comparing Roux-en-Y versus duct-to-duct anastomosis during LT for PSC were identified based on systematic searches of 9 electronic databases and multiple sources of gray literature. RESULTS: The search identified 496 citations, including 7 retrospective series, and 692 patients met eligibility criteria. The use of duct-to-duct anastomosis was not associated with a significant difference in clinical outcomes, including 1-year recipient survival rates (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.65-1.60; P = .95), 1-year graft survival rates (OR, 1.11; 95% CI, 0.72-1.71; P = .64), risk of biliary leaks (OR, 1.23; 95% CI, 0.59-2.59; P = .33), risk of biliary strictures (OR, 1.99; 95% CI, 0.98-4.06; P = .06), or rate of recurrence of PSC (OR, 0.94; 95% CI, 0.19-4.78; P = .94). CONCLUSIONS: There were no significant differences in 1-year recipient survival, 1-year graft survival, risk of biliary complications, and PSC recurrence between Roux-en-Y and duct-to-duct biliary anastomosis in LT for PSC.

Choledochoduodenostomy re-evaluated in the endoscopic and laparoscopic era.

BACKGROUND/AIMS: One of the options for draining an obstructed biliary tree is to form a choledochoduodenostomy (CDD). We evaluate our experience with this procedure with regard to complications (immediate and late), long term patency and patient survival. METHODOLOGY: An analysis was performed on a prospectively maintained database of all patients undergoing CDD under a single surgeon from 1992-2009. Data included pre-operative status, indications for surgery, postoperative morbidity and mortality, and complications. RESULTS: Sixty-eight CDDs were performed (40 male, 28 female). Thirty-seven (54%) were performed for benign disease (group A) and 31 (46%) for malignant disease (histologically confirmed, group B). Patients in group B were older (58 years vs. 69 years, p=0.009), and had higher preoperative bilirubin (58 vs. 156mg/dL, p=0.0003) and alkaline phosphatase (434 vs. 696 U/L, p=0.01). In hospital mortality was 7.5% in group A, and 9% in group B. Patients in group A had a shorter postoperative stay (p=0.008). Long-term mortality was significantly greater in group B (p<0.0001). Long term complications were lower in group A (14%) vs. group B (16%). In group B recurrent jaundice occurred in 3 patients (9.7%), of which 2 were successfully stented at ERCP, and one patient developed ascending cholangitis. CONCLUSIONS: CDD remains a relatively safe and effective surgical option for the treatment of obstructive jaundice in both benign and malignant disease. It remains a very useful tool where ERCP has failed, in patients with unresectable pancreatic malignancies, and in patients with recurrent choledocholithiasis.

Biliary complications in orthotopic liver transplantation using choledochocholedochostomy with a T-tube.

Despite significant advances in orthotopic liver transplantation (OLT), biliary tract reconstruction is still a major source of complications. Choledochocholedochostomy with a T-tube used to be the standard procedure for biliary reconstruction after OLT. However, many centers currently avoid use of the T-tube because of the high incidence of complications. Our aim was to study the biliary complications occurring at our center when end-to-end choledochocholedochostomy (EE-CC) over a T-tube was used as the standard procedure for biliary reconstruction. A retrospective review was conducted of all patients who underwent liver transplantation from February 1, 1996, to April 30, 2010. Only patients requiring any therapy to treat biliary complications were considered, whereas those with concomitant hepatic artery complications were excluded. The study cohort consisted of 743 patients who had EE-CC with a T-tube. Of these, 73 patients (9.8%) experienced any biliary complication. Anastomotic strictures occurred in 17 patients (2.3%), and non-anastomotic strictures in 2 (0.3%). Fifteen patients with anastomotic strictures were successfully treated by dilatation and stenting. Bile leakage was diagnosed in 39 patients (5.2%). Leakage occurred at the anastomosis in 15 patients (2%), and at the exit site of the T-tube in 24 patients (3.2%). Tube opening was the only treatment used in 30 patients with bile leakage (76.9%). Seven patients experienced leaks after elective T-tube removal (1%). Overall, repeat surgery to manage biliary complications was needed in 9 patients (1.2%). The mortality rate from biliary complications was 0.13%. In conclusion, EE-CC with a T-tube was followed by a low incidence of biliary complications. The complication rate after elective T-tube removal and the repeat surgery rate were extremely low. These results might challenge the current trend to avoid T-tube stenting in OLT.

Choledochoduodenostomy is a safe alternative to Roux-en-Y choledochojejunostomy for biliary reconstruction in liver transplantation.

INTRODUCTION: Bile duct reconstruction during liver transplantation is usually performed by a duct-to-duct anastomosis or a Roux-en-Y choledochojejunostomy (CDJ). Direct anastomosis of the bile duct to the duodenum (choledochoduodenostomy-CDD) is another option for biliary reconstruction. This technique has been used with good outcome for the treatment of choledochal cysts, ampullary stenosis, and major bile duct injuries; however, there is little published experience with CDD in liver transplantation. We provide preliminary evidence that CDD is a safe technique for biliary anastomosis in liver transplant recipients. METHODS: From September 2000 to August 2007 a total of 619 adult first-time cadaveric or living donor liver transplants were performed at the University of Colorado Health and Science Center. Bile duct repair was performed by direct end-to-end anastomosis in 466 patients and by choledocoenterostomy in the remaining 153 patients, 82 of whom were cadaveric recipients. The cadaveric choledocoenterostomy patients were divided into two groups: CDD in 25 and CDJ in 57 recipients. RESULTS: There were no significant differences in the 1-year patient or graft survival between the cadaveric groups. The 1-year patient survival was 100% in the CDD group and 97.1% in the CDJ group. The CDD group did not experience more surgical complications compared to the CDJ group. CONCLUSIONS: Choledochoduodenostomy is a safe alternative to CDJ biliary anastomosis when a duct-to-duct anastomosis cannot be performed. There is no significant difference in mortality, graft survival, or biliary complications. In addition, CDD offers the advantage of postoperative access to the billiary system by endoscopy and avoids complications associated with the CDJ bowel anastomosis.

Resultados del tratamiento quirúrgico clásico de la colangitis aguda / Results of the classical surgical treatment of the acute cholangitis

La exploración quirúrgica de la vía biliar seguida de la instalación de una sonda de Kehr ha sido por años el tratamiento de elección de la colangitis aguda (CA) en los servicios de urgencia de nuestro país. El objetivo del presente estudio es mostrar y analizar los resultados de las cirugía clásica en el tratamiento de la CA. Se realizó una versión retrospectiva en base a protocolo tipo de 86 pacientes intervenidos con diagnóstico de CA entre enero de 2003 y diciembre de 2004 en el Hospital Clínico Regional de Valdivia. Los datos fueron analizados mediante planilla Excel. La serie está constituida por 56 pacientes de sexo femenino (65 por ciento) y 30 de sexo masculino (35 por ciento), con una edad promedio de 61.5 años (20-99). El 67 por ciento de los casos era de procedencia urbana. El 32.6 de los pacientes presentaba patología asociada, siendo la más frecuente la hipertensión arterial. El 69 por ciento de los enfermos se interviene dentro de las primeras 24 horas de hospitalización. El 86 por ciento de los casos presentó una colecistolitiasis causal que se resolvió durante el mismo acto quirúrgico. Hubo 5 casos de cáncer vesicular en la serie (5.8 por ciento). El promedio de días de hospitalización fue de 9.1 con rango de 4 a 44 días. Tres pacientes debieron ser reintervenidos, 2 por salida de la coledocostomía y 1 por eventración aguda. 15 pacientes (17.4 por ciento) presentaron complicaciones precoces, siendo la más frecuente la insuficiencia renal aguda. Hubo 3 casos de mortalidad operatoria (3.5 por ciento). Los pacientes mantuvieron en promedio la sonda Kehr por 34.7 días (12-189). El 87 por ciento de los pacientes se realizó la colangiografía ambulatoria. Hubo 7 casos de coledocolitiasis residual (8.1 por ciento), 3 salidas accidentales de la sonda T y 3 pacientes no asisten a control. Según nuestros resultados podemos afirmar que si bien el tratamiento quirúrgico clásico de la CA es efectivo, éste presenta una elevada morbimortalidad.

[Can common bile duct lithiasis be removed laparoscopically without external biliary drainage?]. / Le traitement laparoscopique de la lithiase de la voie biliaire principale sans drainage biliaire externe est-il possible?

AIM OF THE STUDY: To evaluate the indications, feasibility and results of laparoscopic treatment of common bile duct stones without biliary drainage. PATIENTS AND METHODS: Between 1992 and 1999, laparoscopic procedures were performed in 70 consecutive patients, mean age 60 +/- 15 years (range: 18-82). Stone removal was attempted via the cystic duct (n=25) or choledocotomy (n=45). The emptiness of the common bile duct was checked by intraoperative cholangiography or endoscopy. After choledocotomy, closure was performed by interrupted or non-interrupted suture with slowly resorbable thread. Transcystic drainage was used whenever necessary. RESULTS: Nine conversions to laparotomy were necessary (12.8%). Among the 61 patients who had an exclusively laparoscopic procedure, 21 were treated via the transcystic route and 40 through choledocotomy. Biliary endoscopy was possible in only 10 of the 21 patients (47.6%) treated via the transcystic route and in all with choledocotomy. No biliary drainage was used in 16 of the 21 patients treated via the transcystic route and in 39 of the 40 treated through choledocotomy. The 30-day mortality was 1/61 (1.6%). Morbidity was 9.8% and 2 patients underwent a second laparoscopic procedure (one fistula on a choledocotomy suture, one hemoperitoneum of unknown origin). An endoscopic sphincterotomy for residual stone was necessary in 4 patients (4/61, 6.5%), 2 after choledocotomy for an unrecognized stone without biliary drainage. CONCLUSIONS: These results confirm the feasibility of laparoscopic treatment of common bile duct stones and suggest it can be performed without biliary drainage in most cases.

Laparoscopic surgery in patients with human immunodeficiency virus.

Fifteen patients with acquired immune deficiency syndrome (AIDS), and one who tested positive for human immunodeficiency virus but had no AIDS-defining diagnosis, underwent a range of laparoscopic procedures between March 1991 and March 1993. Seven cholecystectomies and one cholecystojejunostomy were performed. Three patients underwent diagnostic laparoscopy after presenting with abdominal emergencies. Two further patients had laparoscopic adhesiolysis and one appendicectomy. A further patient underwent laparoscopically assisted end colostomy and another an inguinal hernia repair, both performed electively. Two patients died in the postoperative period. There was little postoperative morbidity. Six patients died 3-18 months after surgery from progressive AIDS. This early experience suggests that laparoscopic surgery is well tolerated in these patients.

Choledochoduodenostomy and sphincterotomy in the treatment of choledocholithiasis.

Over a 10-year period, 2610 patients underwent operation for biliary lithiasis. Exploratory choledochotomy was indicated in 591 patients (22.6 per cent). This was followed by simple choledochorrhaphy over a T tube in 240 patients (40.6 per cent), transduodenal sphincterotomy and choledochorrhaphy over a T tube in 126 (21.3 per cent), supraduodenal choledochoduodenostomy in 216 (36.5 per cent), and choledochoduodenostomy and transduodenal sphincterotomy in nine (1.5 per cent). Choledochoduodenostomy was performed if the bile duct was more than 12 mm in diameter. The indication for transduodenal sphincterotomy was the presence of a stone impacted in the papilla and/or papillary stenosis. Six patients developed abdominal abscess and three an external biliary fistula following choledochoduodenostomy. There were four abscesses and two episodes of acute pancreatitis in patients undergoing sphincterotomy. There was no difference in mortality rate between the two groups. After a mean follow-up of 5.6 years, 71.5 per cent of patients who underwent choledochoduodenostomy and 75.2 per cent of those who received transduodenal sphincterotomy were asymptomatic. The remainder suffered from dyspepsia, colicky pain or episodes of cholangitis. Nine patients underwent reoperation for residual calculi (six choledochoduodenostomies, three sphincterotomies).

Surgical treatment for cholelithiasis.

In a retrospective study, the results of 1,631 consecutive operations for cholelithiasis were analyzed. With an overall mortality rate of 0.18 percent and a reoperation rate of 1.3 percent, conventional cholecystectomy proved to be a safe method. Mortality proved to be age dependent, with a zero mortality rate for patients less than 60 years of age. Choledochotomy had a 13-fold greater mortality rate than simple cholecystectomy (0.92 versus 0.07 percent). For acute cholecystitis, we observed an unusual zero mortality rate, whereas the mortality rate in chronic cholecystitis was 0.2 percent. All three patients who died had an accompanying cirrhosis of the liver. Morbidity, defined as reoperation during the same period of hospitalization, was mainly the result of retained stones after choledochotomy; endoscopic papillotomy was the treatment of choice. Cholecystectomy remains the "gold standard" in the treatment of cholelithiasis.

Choledochoduodenostomy. Analysis of 71 cases followed for 5 to 15 years.

To investigate the long-term effectiveness of choledochoduodenostomy (CDD), the experience with 71 patients followed for 5 or more years after CDD was analyzed retrospectively. From 1968 to 1984, 134 patients underwent CDD. Eight patients (6%) died in the immediate postoperative period, 55 left the hospital, 8 of them were lost to follow-up, and 47 were followed but died before 5 years elapsed after CDD. The remaining 71 patients form the data base for this analysis: 38 were followed for more than 5 years, 25 were followed for more than 10 years, and 8 were followed for more than 15 years (mean 12.1 years +/- 1.3 SEM). Choledocholithiasis, chronic pancreatitis, and postoperative stricture were the indications for CDD. Cholangitis was observed in only three patients. The diameter of the common bile duct (CBD) was large in most patients (mean 18 mm +/- 0.9 SEM). These results infer that CDD is effective to treat non-neoplastic obstructing lesions of the distal CBD on a long-term basis and that the presence of a dilated CBD (more than 16 mm) that allows the construction of a CDD more than 14 mm is essential to obtain good results.

Long-term results of choledochoduodenostomy in the treatment of choledocholithiasis: assessment of 225 cases.

During a 10-year period 2610 patients were operated on for biliary lithiasis; in 225 (8.6 per cent) cases the operation concluded with a choledochoduodenostomy. The commonest preoperative diagnosis (62.2 per cent) in these 225 patients was choledocholithiasis; 30 patients had previously had a cholecystectomy. After choledochoduodenostomy, 4.0 per cent of patients had an intra-abdominal complication; six patients developed an intra-abdominal abscess and three developed an external biliary fistula. Four patients (1.8 per cent) died, three from pulmonary complications and one from a biliary fistula. After a mean follow-up period of 4.6 years, 71.5 per cent of patients were asymptomatic. The remainder suffered from dyspepsia (15.1 per cent), colicky pain (8.7 per cent) or episodes of cholangitis (4.7 per cent). Endoscopy in the symptomatic patients allowed the following conclusions: (a) no patient with dyspepsia had a problem at the anastomosis; (b) 27 per cent of those with colic had anastomotic stenosis or the sump syndrome; and (c) all patients with cholangitis had anastomotic stenosis and residual calculi.

A comparison of cholecysto- and choledochoenterostomy for obstructing pancreatic cancer.

This report compares the efficacy of cholecystoenterostomy and choledochoenterostomy for relief of biliary obstruction due to pancreatic cancer. From 1976 to 1988, 109 biliary enteric bypass procedures were performed on patients with pancreatic carcinoma considered unresectable at exploration. Sixty-four of these patients underwent cholecystoenteric anastomosis (CCEA) and 45 choledochoenteric anastomosis (CDEA). Thirty-day operative mortality was 6.3 per cent for CCEA and 8.8 per cent for CDEA; the mean length of survival after operation was 7.8 months for CCEA and 8.9 months for CDEA. Of the 64 patients who underwent CCEA, all but two experienced short-term (greater than 60 days) relief of jaundice and pruritus. These patients were found to have an obstructed cystic duct and a cholecystectomy and choledochojejunostomy were performed. Five other patients in the CCEA group had recurrence of jaundice for an overall failure rate of 10.9 per cent. Operative morbidity in this group was 14 per cent. One of the patients in the CDEA group had an early recurrence of jaundice and three others experienced late recurrence, for an overall failure rate of 8.8 per cent. Operative morbidity in this group was 16 per cent. We conclude that these procedures have comparable morbidity and mortality. Although a few patients with cholecystoenteric anastomosis will develop recurrent jaundice, the simplicity of the procedure, the shorter operative time, and the equivalent relief of symptoms make it a useful procedure and one we believe preferable in high-risk patients.

Early and late results following choledochoduodenostomy and choledochojejunostomy.

OBJECTIVE: To evaluate the results and complications of choledochoduodenostomy and choledochojejunostomy for benign and malignant disease and to review them in the light of the survival of the underlying disorders. DESIGN: Retrospective analysis of medical records completed by a thorough inquiry for all patients who were lost to follow-up. SETTING: Referrals for primary and secondary surgery for obstructive biliary disease to a university hospital from 1974-1987. PATIENTS: After exclusion of patients who underwent a pancreaticoduodenectomy for cancer (Whipple procedure) 113 patients were included in the study (choledochoduodenostomy = CD,N = 64 and choledochojejunostomy = CJ, N = 49). A complete follow-up was achieved in 105 of 113 patients (93%). INTERVENTIONS: An inquiry was made at the civil registration office if the patients were alive or not. The general practitioners of the patients who had died were contacted about the cause of death and the possible biliary symptoms preceding death and the patients who were still alive received a questionnaire which scrutinized all possible complications and side effects of the operation. ENDPOINTS: Cholangitis, recurrence of the underlying disease or death of the patient. MEASUREMENTS AND MAIN RESULTS: Operative mortality was 4.7% following CD and 12.2% following CJ. Procedure-related complications were found in 10.9% and 28.6% respectively. Recurrent cholangitis was not seen after CD and in three patients with a CJ (6.1%). Survival following biliodigestive anastomosis for benign obstruction was comparable for age and sex matched survival. CONCLUSIONS: Although CD for choledocholithiasis has largely been replaced by endoscopic papillotomy and although the choice between the two procedures in malignant disease is most frequently dictated by the operative findings, we conclude that the choledochoduodenostomy is a relative simple operation with a low risk of cholangitis.

[Postoperative mortality in surgery of cholelithiasis: a retrospective analysis from the years 1972-1980]. / Postoperative Letalität in der Chirurgie der Cholelithiasis: eine retrospektive Analyse aus den Jahren 1972 bis 1980.

In a retrospective study (1972-1980) we analyzed the postoperative mortality of 2916 consecutive cholecystectomies or interventions on the common bile ducts respectively. The mean age of the patients was 54 years (17-92 years), 63% were older than 60 years; 74% were women. We show that age, histology, intervention, stone localization, sex and concomitant internal diseases influenced the early postoperative mortality. The overall mortality was 0.7% (21 patients), 0.7% in the under 60 years old patients, 1.8% in the older aged group. The mortality in chronic cholecystitis was 0.5%, in acute cholecystitis 2.6%. After simple cholecystectomy we observed a mortality of 0.3%, after cholecystectomy and common bile duct intervention 2.5% (p less than 0.001), and after intervention on the common bile ducts 7.3%. Stones only in the gallbladder were associated with a mortality of 0.3%, cholecysto- and choledocholithiasis with 2.8% and choledocholithiasis alone with 7.3%. The mortality in men was significantly (p less than 0.001) higher as in women (1.2 against 0.6%). In 76% of the deceased we diagnosed preoperatively a concomitant internal disease.

Factors affecting mortality in patients over 70 years of age submitted to surgery for gallbladder or common bile duct stones.

Chile is the country with the highest incidence of gallstone disease in the world. Nearly 44% of the women and 25% of the men over 20 years of age have gallstones. Biliary tract surgery accounts for about 35% of all the operations performed in Chilean general hospitals. The present paper aims at assessing the risk factors associated with a higher mortality in patients over 70 years of age subjected to elective or emergency surgery for gallstones or common bile duct stones. No specific factors of mortality were found in the group of elderly patients subjected to elective cholecystectomy. There was also no correlation between types of cholecystitis and postoperative mortality. However, acute suppurative cholangitis made the postoperative mortality rate increase almost 20-fold in patients with common bile duct stones. The mortality also shows a steep increase (up to 12%) if cholecystectomy is performed in acute cholecystitis. Cholecystostomy seems to be associated with a low mortality risk and hence should be appropriate in exceptionally high-risk patients, but is not considered useful by the authors in necrotic or gangrenous cholecystitis, or in cases with common bile duct stones and cholangitis. Postoperative mortality in patients submitted to cholecystectomy alone seems to depend exclusively on the concomitant presence of medical complications, mainly of a respiratory and cardiovascular nature. Septic complications are important causes of postoperative mortality in emergency cholecystectomy. Patients at high surgical risk are those suspected of cholangitis, those over 80 years of age, and those suffering from Charcot's triad, anemia, uremia, leukocytosis, hyperbilirubinemia or hypoprothrombinemia; in these, an endoscopic procedure could be chosen.

[Secondary and residual choledocholithiasis. Our experience]. / Coledocolitiasis secundaria y residual. Nuestra experiencia.

A retrospective study was made of 780 patients who underwent surgery of the biliary tract for lithiasis between 1973 and 1984; of them, 110 (14.1%) presented secondary choledocholithiasis and 14, residual choledocholithiasis. The decade of highest incidence of choledocholithiasis was 60 to 70 years; the proportion of women-men was 2:1. The predominant symptom was biliary colic, which occurred in 99% of patients; jaundice appeared in 65% of cases. In 5.6% of patients choledocholithiasis was complicated with suppurative cholangitis. The operation most frequently practiced was choledochotomy with extraction of calculi and closure on a Kehr tube, performed in 50% of patients, followed by transduodenal sphincteropapillotomy in 31% of patients. In 32 patients complications occurred during the immediate postoperative period, representing a morbidity of 22.5% and a mortality of 3.2%. The most frequent complications were of infectious nature.