Fístula coledocoduodenal / Choledochoduodenal fistula

La fistulas biliares internas son consideras una complicación poco frecuente de las enfermedad biliar y aún más raras del ulcus duodenal. Constituyen un hallazgo ocasional durante la colangiografía retrograda endoscópica durante el estudio de la enfermedad biliar recurrente. Se relaciona principalmente con la litiasis vesicular complicada. Puede afectar hasta un 2 por ciento del total de los pacientes con enfermedad biliar y se asocia a una mayor incidencia de carcinoma de este sistema. La localización más habitual es entre la vesícula y el duodeno (colecistoduodenal) en un 72 - 80 por ciento de los casos. La coledocoduodenal -la cual se relaciona con el caso a reportar- es de las menos frecuentes, la cual se encuentra solo en 3-5 por ciento. Se presenta a un paciente masculino de 44 años, operado hace 26 años de úlcera duodenal perforada. En octubre de 2015 debutó con íctero ligero, coluria y dolor en hipocondrio derecho, que impresionó hepatitis toxica, cuadro que recurrió en varias ocasiones. Durante el estudio realizado en su última crisis, se halló una fístula coledocoduodenal, se remitió a nuestro centro para tratamiento quirúrgico. Debido a lo infrecuente del caso, se decidió realizar revisión de la literatura actual y su presentación(AU)

Internal biliary fistulas are considered a rare complication of biliary disease and even rarer of duodenal ulcers. They are an occasional finding during endoscopic retrograde cholangiography during the study of recurrent biliary disease. It is mainly related to complicated vesicular lithiasis. It can affect up to 2 percent of all patients with biliary disease and is associated with a higher incidence of carcinoma in this system. The most common localization is between the gallbladder and the duodenum (cholecystoduodenal) in 72-80 percent of cases. The choledocoduodenal type, related to the case to be reported, is the least frequent, which is found in 3-5 percent of the cases. A case is presented of a 44-year-old male patient, operated 26 years ago for perforated duodenal ulcer. In October 2015, the patient debuted with light icterus, choluria and pain to the right hypochondrium, which seemed to be toxic hepatitis, a clincal frame that relapsed in several occasions. During the study performed in his last crisis, a choledochoduodenal fistula was found and he was referred to our center for surgical treatment. Due to the infrequent case, it was decided to review the current literature and its presentation(AU)

Colédoco-duodenostomía guiada por ecoendoscopia en cáncer de páncreas avanzado con obstrucción duodenal / Endoscopic ultrasound-guided choledocho-duodenostomy in advanced pancreatic cancer with duodenal obstruction

La colangiopancreatografía retrógrada endoscópica (CPRE) se considera el tratamiento de primera línea para el drenaje biliar en pacientes con cáncer de páncreas. En los casos de fracaso por CPRE, generalmente se realiza un drenaje biliar transparietohepático o una derivación biliar quirúrgica. En la última década, las indicaciones y la utilidad de la ecoendoscopia en pacientes con cáncer de páncreas han ido creciendo, y se han informado numerosos casos de drenajes biliares guiados por ecoendoscopia como una alternativa al drenaje biliar percutáneo o quirúrgico en fracasos en la CPRE. Nuestro objetivo es comunicar un caso con cáncer de páncreas localmente avanzado que se presentó con ictericia indolora y síndrome coledociano con obstrucción biliar y duodenal, en el que se realizó una colédoco-duodenostomía guiada por ecoendoscopia mediante la colocación de una prótesis metálica autoexpandible.

Endoscopic retrograde cholangiopancreatography (ERCP) is considered the first-approach for biliary drainage. In cases of ERCP failure, patients are usually referred for percutaneous transhepatic biliary drainage or surgical biliary bypass. In the last decade, the indications of endoscopic ultrasound (EUS) in the management of patients with pancreatic cancer have increased, and numerous cases of EUS-guided biliary drainage have been reported in patients with failures during the ERCP. Our goal is to report a patient with locally advanced pancreatic cancer who presented with painless jaundice and cholestasis with biliary and duodenal obstruction. A EUS-guided choledochoduodenostomy was performed by placement of a self-expanding metal stent.

Endoscopic Ultrasound-Guided Biliary Drainage

OBJECTIVE: To demonstrate a comprehensive review of published articles regarding endoscopic ultrasound (EUS)-guided biliary drainage. MATERIALS AND METHODS: Review of studies regarding EUS-guided biliary drainage including case reports, case series and previous reviews. RESULTS: EUS-guided hepaticogastrostomy, coledochoduodenostomy and choledoantrostomy are advanced biliary and pancreatic endoscopy procedures, and together make up the echo-guided biliary drainage. Hepaticogastrostomy is indicated in cases of hilar obstruction, while the procedure of choice is the coledochoduodenostomy or choledochoantrostomy in distal lesions. Both procedures must be performed only after unsuccessful ERCPs. The indication of these procedures must be made under a multidisciplinary view while sharing information with the patient or legal guardian. CONCLUSION: Hepaticogastrostomy and coledochoduodenostomy or choledochoantrostomy are feasible when performed by endoscopists with expertise in biliopancreatic endoscopy. Advanced echo-endoscopy should currently be performed under a rigorous protocol in educational institutions.

Colecistitis aguda en paciente con situs inversus totalis / Acute cholecystitis in a patient with situs inversus totalis

El objetivo del presente reporte es dar a conocer un caso de situs inversus y colecistitis aguda diagnosticado y tratado en el Hospital Al Wahda Mabar Thamar de Yemen. Paciente de sexo femenino, de 50 años, con dolor en epigastrio después de la ingestión de alimentos grasos. Dos días antes de su ingreso incrementa su intensidad y se mantiene en hipocondrio izquierdo, y además, presenta vómitos. Utilizando antibioticoterapia perioperatoria, se realiza incisión subcostal izquierda, y se encuentra colecistitis aguda con dilatación moderada del colédoco. Se realiza colecistectomía y coledocotomía, con buena evolución posoperatoria(AU)

The objective of present paper is to present a case of situs inversus and cholecystitis diagnosed and treated in the Al Wahda Mabar Thamar Hospital of Yemen. A female patient aged 50 with epigastric pain after ingestion of fatty foods; two days before its admission increase its intensity and remains in left hypochondrium and also vomiting. With the use of perioperative antibiotic-therapy, a left subcostal incision is made detecting an acute cholecystitis with a choledochal slight dilatation. A cholecystectomy and choledochotomy with a good postoperative evolution were performed(AU)

Exploración laparoscópica de la vía biliar y manejo actual de la coledocolitiasis: análisis de los primeros 30 casos / Laparoscopic common bile duct exploration and current management of choledocholithiasis

Se trata de un estudio descriptivo, prospectivo, longitudinal que incluyó a 30 pacientes que consultaron con indicaciones de exploración laparoscópica de la vía biliar. Se describe la técnica utilizada para la exploración transcística y por coledocotomía, tanto con guía fluoroscópica como el uso del coledocoscopio. Se estudiaron las variables, efectividad, conversión, tiempo quirúrgico, complicaciones tiempo de hospitalización, litiasis residual. La exploración laparoscópica de la vía biliar fue efectiva en el 84% de los casos. Las causas de conversión fueron cálculos enclavados y cálculos intrahepáticos. El 32% de los casos se resolvió por la vía transcística , mientras que el resto (68%) se resolvió mediante coledocotomía. La morbilidad asociada la técnica fue de 6,6% dada por diarrea postoperatoria y biliperitoneo luego del retiro del tubo en “t”. El tiempo promedio de hospitalización fue de 3,5 días. Sin casos reportados de litiasis residual. La exploración laparoscópica de la vía biliar (ELVB) es una alternativa terapéutica segura y efectiva en el tratamiento de la obstrucción de la vía biliar principal por cálculos. Sin embargo, queda claro que el éxito del procedimiento depende del dominio de técnicas endoscópicas y laparoscópicas avanzadas y la disponibilidad de recursos tecnológicos de primera.

Report the experience in laparoscopic common bile duct exploration in the Surgery Department III of the Hospital Universitario de Caracas. Descriptive, prospective, longitudinal study of patients admitted with indication of laparoscopic common bile duct exploration. We describe the transcystic approach and choledochotomy technique, using fluoroscopic guidance or choledochoscope. Success rate, conversion, operative time, complications, length of stay and residual lithiasis were studied. Laparoscopic common bile exploration was successful in 84% of the patients. Conversión causes were embedded stones and intrahepatic lithiasis. Transcystic approach was used in 32% of the cases and choledochotomy was performed in 68% of the patients. Morbidity rate was 6,6% due to diarrhea and biliary peritonitis after "t" tube removal. Median length of stay was 3,5 days. No cases of residual stones were reported. Laparoscopic common bile duct exploration is a safe and effective procedure in patients with common bile duct obstruction due to choledocholithiasis However, the success rate is in relation with endoscopic and advanced laparoscopic techniques mastery and technologic resources availability.

Fatal Biliary-Systemic Air Embolism during Endoscopic Retrograde Cholangiopancreatography: A Case with Multifocal Liver Abscesses and Choledochoduodenostomy

We report a rare case of a massive fatal embolism that occurred in the middle of endoscopic retrograde cholangiopancreatography (ERCP) and retrospectively examine the significant causes of the event. The patient was a 50-year old female with an uncertain history of previous abdominal surgery for multiple biliary stones 20 years prior. The patient presented with acute right upper quadrant pain. An abdominal computed tomographic (CT) scan revealed the presence of multiple stones in the common bile duct (CBD) and intra-hepatic duct (IHD) with biliary obstruction, multifocal liver abscesses, and air-biliarygram. Emergency ERCP showed a wide and straight opening of choledochoduodenostomy, which may have been created during a previous surgery, and multiple filling defects in the CBD. With the use of a forward endoscope, mud stones were extracted through the opening of the choledochoduodenostomy. Cardiac arrest suddenly developed during the procedure, and despite immediate resuscitation, the patient died due to a massive systemic air embolism. We reviewed previously reported fatal cases and accessed factors facilitating air embolisms in this case.

Large common bile duct stones: evaluation of a therapeutic dilemma

Forty patients [16 males and 24 females] were admitted to the Gastrointestinal Surgery Unit of the Main Alexandria University Hospital. All patients were documented by ultrasound to have large common bile duct [CBD] stones 71=15 mm in largest diameter. To compare the success rate, complications and hospital stay of endoscopic and surgical techniques used in the treatment of large common bile duct stones. The patients were randomly divided into 2 groups [group A] underwent endoscopy and group [B] underwent surgical interference. Each group was 20 in number of patients. The commonest patient's manifestations were abdominal pain and jaundice [100%], 13 patients [33%] had attacks of cholangitis. The mean laboratory test values were insignificant between both groups. The diameter of the CBD stone by the ultrasound ranged from 15 mm to 31 mm in largest diameter with a mean of 18.4 +/- 3.882 mm. Endoscopic management was done successfully in 18 patients [90%] while 2 patients [10%] failed to he managed by endoscopic retrograde cholangio-pancreatography and ERCP and underwent surgical interference. Spontaneous passage of the stones immediately after endoscopic sphincterotomy occurred In 3 patients [15%], Balloon extraction was done in 7 patients [35%,] while Dormia basket was used in 4 patients [20%,]. ERCP failed in 2 patients [10%.]: one of them had very large CBD stone [31 mm] that is largest than the maximum size of the lithotripsy basket. In the second patient, the papilla was almost flat with rudimentary intraluminal part of the CBD that was difficult to cannulate after unsuccessful trial for 40 minutes. The complications occurred in group 2 patients [20%] in the form of cholangitis. The mean hospital stay of group [A] was 1.92 +/- 1.71. Surgical management was done succesfully in 19 patients [95%]. Supraduodenal choledochotomy and T-tube drainage was performed in 6 patients [30%]; one of them [5%] had missed stone and managed by ERCP. Choledocho-duodenostomy was performed in 12 patients [60%] while transduodenal sphincteroplasty was performed in one [5%] patient. Complications occurred in 5 patients [26.3%], which were more than group [A]; in the form of wound infection. biliary leakage hepatic encephalopathy or burst abdomen. Mean hospital stay of group [B] was 10.4 +/- 2.32 days was significantly longer than of group [A]. Post-endoscopic and post-operative tests showed significant decrease in the mean values of liver functions and enzymes. Ultrasonography was done to all successfully managed patients [2 weeks after intervention] and revealed complete clearance of the CBD. ERCP is usually successful in the management of large CBD stones. Hospital stay and complications of endoscopic management are much less than surgical management The surgeon should try endoscopic management of large CBD stones using all its techniques prior to resort to surgical management of large CBD stones

incidence of duodenogastric reflux after cholecystectomy with or without choledochoduodenostomy

Persistence of dyspeptic symptoms after cholecystectomy with choledochoduodenostomy is common. There is evidence that at least some of these symptoms may be attributed to duodenogastric reflux. The aim of the study is to evaluate whether more duodenogastric reflux is found after cholecystectomy plus choledochoduodenostomy than after cholecystectomy alone. Twenty four patients after cholecystectomy plus choledochoduodenostomy, twenty one after cholecystectomy and fiveteen control patients were studied to evaluate whether differences existed in the duodenogastric reflux and whether these were related to morphological damage of the gastric mucosa. Duodenogastic reflux measured by 99m TC-hepatic imino diacetic acid scintigraphy. 5 mci Tc-99m Mebrofenin was used for scanning the hepatobiliary system on a Siemens Icon-Gamma camera with predefined computer software. The stomach was localized using Tc-99m sulphur colloid. Reflux activity in the range of 1-14 percent was considered insignificant. The damage was evaluated histologically by systematic endoscopic biopsy of the antrum and body of the stomach. Thirteen patients after cholecystectomy plus choledochoduodenostomy [54.17%] showed a insignificant duodenogastric reflux <14%. In eleven patients [45.83%] duodenogastric reflux was significant. After cholecystectomy, sixteen patients [76,19%] had insignificant duodenogastric, five patients [23.81%] had significant duodenogastric reflux. The quantitative difference in reflux was insignificant [p>0.05]. Only two patients of control group [13.33%] had significant duodenogastric reflux. There was a statistically difference [p<.05] between control group and patients with cholecystectomy plus choledochoduodenostomy. The distribution of chronic antral atrophic and superficial gastritis was different in the three groups [p<0.05]. Chronic atrophic gastritis was associated with cholecystectomy plus choledochoduodenostomy [p<0.01], while chronic superficial gastritis was more frequent in cholecystectomizedpatien patients. These results suggest that there may be more duodenogastric reflux after cholecystectomy plus choledochoduodenostomy than after cholecystectomy alone, and that may be a correlation between the amount of duodenogastric reflux and the severity of mucosal damage

Coledocorrafia primaria y drenaje biliar interno vs coledocostomía con sonda de Kehr en pacientes con coledocolitiasis / Primary choledochorrhaphy and internal biliary drainage versus choledochostomy with T-tube in patients with Choledocholithiasis

La coledocostomía con sonda de Kehr ha sido el método quirúrgico clásico para el tratamiento de la coledocolitiasis. La coledocorrafia primaria y drenaje biliar interno es otro método terapéutico que evita el uso de sonda de Kehr. El objetivo es comparar ambas técnicas. Estudio de cohorte prospectivo, en el Hospital Regional de Temuco. El análisis se realizó mediante estadística descriptiva y analítica. La cohorte está compuesta por 18 pacientes por grupo. En el grupo de expuestos (coledocorrafia primaria), 100 por ciento son mujeres con promedio de 48,6 años; mientras que en el grupo de no expuestos (sonda Kehr) el 94 por ciento son mujeres con promedio de 52,7 años. La calidad de vida postoperatoria fue significativamente mejor en el grupo de expuestos. El promedio de hospitalización fue de 3 y 4 días en el grupo de expuestos y no expuestos, respectivamente; mientras que las complicaciones se presentaron en el 16,7 por ciento y 38,9 por ciento respectivamente. La serie no tiene mortalidad. Se concluye que la coledocorrafia primaria con drenaje biliar interno es una técnica alternativa con mejor calidad de vida y menor morbilidad postoperatoria que los métodos clásicos.

Choledochoduodenostomy: a viable and safe procedure in patients with obstructive jaundice

A total of 27 patients with jaundice and/or other clinical, ultrasound or laboratory based diagnostic criteria of choledocholithiasis were included in this study. Preoperatively, all patients were well hydrated and received antibiotics perioperatively. Supraduodenal choledochotomy was performed after cholecystectomy. Choledochoduodenostomy was performed using an interrupted stitch with catgut 2/0. There were no mortalities in our series. A few minor problems arose in two of our patients postoperatively. We suggest that Choledochoduodenostomy is a useful operation, technically easy, gives good results and should be practised more often for both primary and secondary gall stones

Choledochocele [type 111 choledochal cyst]: case report and literature review

A twenty-nine year old female, presented with intermittent Jaundice and right hypochondrial pain. On laparatomy a cystic mass at the terminal common bile duct found. Histopathological examination revealed Choledochocele [Type III choledochal cyst]. No post operative complications were encountered. Previously 48 similar cases have been reported in the literature

Choledochoduodenostomy for choledocholithiasis

Choledochoduodenostomy as a method for prevention and treatment of common bile stones has been frequently discussed during the last few years. The introduction of endoscopic sphincterotomy, with excellent results and low morbidity necessitate further evaluation of the indications and the value of this procedure. Thirty [30] patients with a mean age of 56 years have been operated on with choledocholithotomy and subsequent Choledochoduodenostomy. In nineteen [19] of the patients the anastomosis was performed at the primary operation, in eleven [11] at a secondary operation. Ten [10] of the patients had primary bile duct stones, while twenty had multiple stones, either unextractable or with a doubtful clearance. There was no postoperative mortality and only one early complication, a pneumonia. Twenty eight of the 30 patients are free of symptoms postoperatively and have normal liver function tests, and verified open anastomosis. Two patients had recurrent postoperative cholangitis, one due to stricture at the site of anastomosis which was reoperated, and one due to multiple retained stones intrahepatically despite an open anastomosis. In conclusion Choledochoduodenostomy is easy to perform with low morbidity even in old age, high risk patients. It is a safe and effective method in the prevention of retained or recurrent stones

Vegetable threads in the common bile duct

A case report of obstructive jaundice due to a vegetable foreign body in the common bile duct

Coledocoduodenostomía laterolateral: una modificación técnica / Laterolateral choledocoduodenostomy: a technical modification

Se describe una sencilla modificación técnica a la coledocoduodenostomía laterolateral, que consiste en suturar la boca anastomótica en un plano extramucoso para el duodeno, y colocar todos los nudos hacia afuera de la luz. Se señalan los resultados obtenidos en nuestro servicio en los últimos 5 años (1983-1987).En los pacientes operados con esta técnica no se presentaron complicaciones por dehiscencia de sutura. Esta modificacion, además de segura, es de fácil ejecución, por lo que recomendamos su empleo

Infundibulotomía de la ampolla de Vater en cálculo impactado de la papila / Infundibulotomy of the Vater's ampulla at impacted stone in the papilla

La Infundibulotomía o colédoco-duodenostomía endoscópica es una laternativa a la anastomosis bilio-digestiva quirúrgica por obstrucción del ducto-biliar común en casos con cálculo impactado en la ampolla de Vater en los cuales ocasionalmente la esfinterotomía endoscópica por el orificio natural se dificulta. Además se describe su indicación como método de tratamiento paliativo en pacientes ancianos y/o alto riesgo quirúrgico con obstrucción maligna de la porción distal del ducto biliar común