Trend in predictive factors of choledocholithiasis: the key to the management of pediatric patients with suspected gallstones. / Tendencia en los factores predictivos de coledocolitiasis: la clave para el manejo de pacientes pediátricos con sospecha de cálculos en la vía biliar.

OBJECTIVES: To reduce the overuse of magnetic resonance cholangiopancreatography and the rates of non-therapeutic endoscopic retrograde cholangiopancreatography in pediatric patients suspected of choledocholithiasis. MATERIALS AND METHODS: Retrospective study of patients suspected of choledocholithiasis between January 2010 and June 2023. Patients with cholangitis or two or more of the following predictive factors of choledocholithiasis in initial laboratory tests and ultrasound were categorized as high-risk group: total bilirubin level ≥ 2 mg/dl, common bile duct > 6 millimeters on ultrasound; and detection of choledocholithiasis by ultrasound. Patients were recategorized according to the results of the second set of laboratory and ultrasound analysis. Confirmatory modalities (magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and/or intraoperative cholangiography) were used to evaluate the presence of choledocholithiasis. Finally, we assessed the predictive capability of both the initial high-risk group and the group after recategorization. RESULTS: A total of 129 patients were included. After initial studies, 72 (55.8%) patients were classified into the high-risk group. After recategorization, only 29 (22.5%) patients were included in this group. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the initial high-risk group were 89.3%, 53.5%, 34.7%, 94.7%, and 61.2%, respectively, while after recategorization, they were 82.1%, 94.1%, 79.3%, 95.0%, and 91.5%, respectively. CONCLUSIONS: Recategorization of the risk of choledocholithiasis would significantly improve the diagnostic accuracy of choledocholithiasis and help reduce the overuse of more complex and unnecessary studies/procedures.

OBJETIVOS: Disminuir la sobre indicación de la colangiorresonancia y las tasas de colangiopancreatografía retrógrada endoscópica o terapéuticas en pacientes pediátricos con sospecha de coledocolitiasis. MATERIAL Y METODOS: Estudio retrospectivo de pacientes con sospecha de coledocolitiasis entre enero de 2010 y junio de 2023. Los pacientes con colangitis o dos o más de los siguientes factores predictivos de coledocolitiasis en las pruebas de laboratorio y ecografía iniciales, se categorizaron como grupo de alto riesgo: nivel de bilirrubina total ≥ 2 mg/dl, colédoco > 6 milímetros en ecografía; y la detección de coledocolitiasis por ecografía. Los pacientes fueron recategorizados de acuerdo a los resultados del segundo conjunto de análisis de laboratorio y ecografía. Para evaluar la presencia de coledocolitiasis se utilizaron modalidades confirmatorias (colangiorresonancia, colangiopancreatografía retrógrada endoscópica y/o colangiografía intraoperatoria). Finalmente, evaluamos la capacidad predictiva tanto del grupo de alto riesgo inicial como del grupo después de la recategorización. RESULTADOS: Se incluyeron 129 pacientes. Luego de los estudios iniciales, 72 (55,8%) pacientes se clasificaron en el grupo de alto riesgo. Luego de la recategorización, solo 29 (22,5%) pacientes fueron incluidos dentro de este grupo. La sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo y precisión diagnóstica del grupo de alto riesgo inicial fueron de 89,3%, 53,5%, 34,7%, 94,7% y 61,2%, mientras que luego de la recategorización fueron de 82,1%, 94,1%, 79,3%, 95,0% y 91,5%, respectivamente. CONCLUSIONES: La recategorización del riesgo de coledocolitiasis, mejoraría significativamente la precisión diagnóstica de coledocolitiasis y ayudaría a disminuir la sobre indicación de estudios/procedimientos complejos e innecesarios.

Correlation between miR-210 and serum levels of GGT, ALP and AST in patients with choledocholithiasis.

The purpose of this study was to explore the association between miR-210 and serum GGT, ALP and AST levels in patients with choledocholithiasis. The clinical data of 82 patients with biliary stones admitted to the hospital from May 2020 to May 2022 were collected and divided into observation group (n=40) and control group (n=42) according to whether asymptomatic combined. The relative expression level of miR-210 was measured by RT-PCR, serum GGT, ALP, and AST by rate method, and the correlation of miR-210 expression level with serum GGT, ALP, AST and the diagnostic value for choledochal stones was analyzed. The relative expression of serum GGT, ALP, AST and miR-210 were all higher than the control group (P <0.05); the relative expression level of miR-210 and serum GGT, ALP and AST, 0.756, 0.832, 0.326, r = P <0.05), 0.782, 0.776, 0.681, 0.568, respectively. Serum miR-210 level was upregulated in patients with choledocholithiasis, and its expression was positively correlated with serum GGT, ALP, and AST, which can be used for early auxiliary diagnosis of choledocholithiasis.

Development and validation of a predictive model for choledocholithiasis.

BACKGROUND: Gallstone-related conditions affect a significant portion of the population, with varying prevalence among different ethnic groups. Complications such as pancreatitis and cholangitis are associated with the presence of common bile duct (CBD) stones. Existing guidelines for diagnosing choledocholithiasis lack precision, leading to excessive use of invasive procedures like endoscopic retrograde cholangiopancreatography (ERCP). METHODS: A prospective study was conducted at Hospital Central "Dr. Ignacio Morones Prieto," involving 374 patients in the development cohort and 154 patients in the validation cohort. Patients meeting inclusion criteria underwent biochemical testing and ultrasonography. A predictive scoring system was developed using logistic regression and validated in an independent cohort. Clinical and laboratory variables were collected, and model performance was assessed using receiver-operator characteristic (ROC) curves. RESULTS: The predictive model incorporated variables such as age, pancreatitis, cholangitis, bilirubin levels, and CBD stone presence on ultrasound. The model demonstrated an area under the ROC curve (AUC) of 93.81% in the validation dataset. By adjusting the threshold defining high-risk probability to 40%, the model improved specificity and sensitivity compared to existing guidelines. Notably, the model reclassified patients, leading to a more accurate risk assessment. CONCLUSIONS: The developed algorithm accurately predicts choledocholithiasis non-invasively in patients with symptomatic gallstones. This tool has the potential to reduce reliance on costly or invasive procedures like magnetic resonance cholangiopancreatography and ERCP, offering a more efficient and cost-effective approach to patient management. The user-friendly calculator developed in this study could streamline diagnostic procedures, particularly in resource-limited healthcare settings, ultimately improving patient care.

[Diagnostic performance of biliopancreatic endosonography in patients with intermediate risk of choledocholithiasis]. / Rendimiento diagnóstico de la endosonografía biliopancreática en pacientes con riesgo intermedio de coledocolitiasis.

OBJECTIVE: Determine the sensitivity and specificity of the ESBP for diagnosis in patients with intermediate risk of choledocholithiasis, referred to the specialized surgical Gastroenterology center of Unión de Cirujanos SAS - Oncologists of the West Zentria group - Manizales - Colombia between March 01, 2020 to January 31, 2022. MATERIALS AND METHODS: Retrospective cross-sectional study in patients with intermediate risk for choledocholithiasis. The diagnostic performance of ESBP was calculated and confirmed with ERCP. Negative ESBPs were followed up by telephone. RESULTS: 752 cases with ESBP were analyzed, of which 43.2% (n=325) were positive and 56.8% (n=427) were negative. ERCP was performed in positive cases who accepted the procedure (n=317); 73.5% (n:233) were positive for choledocholithiasis, 25.8% (n=82) tumors and 0.6% (n=2) biliary roundworms. Patients with positive ESBP underwent ERCP. S= 98.3% (95% CI: 95.7-99.5) was obtained; E= 88.1% (95% CI: 79.2-94.1); PPV = 95.8% (95% CI: 92.4-98.0); NPV = 94.9% (95% CI: 87.4-98.7). The AUC of ESBP was 0.9319 (95% CI 0.8961-0.967). CONCLUSION: In patients with intermediate risk for choledocholithiasis, ESBP is a useful diagnostic option in the study of pancreatic pathologies, extrahepatic biliary tree, and the identification of biliary microlithiasis; Therefore, it also allows us to complement it with a therapeutic intervention such as ERCP in a single time.

Urgent one-stage endoscopic treatment for choledocholithiasis related moderate to severe acute cholangitis: A propensity score-matched analysis.

BACKGROUND: During emergency endoscopic retrograde cholangiopancreatography (ERCP), the safety and feasibility of performing one-stage endoscopic treatment for patients with acute cholangitis (AC) due to choledocholithiasis are unclear. AIM: To investigate the safety and feasibility of one-stage endoscopic treatment for moderate to severe AC. METHODS: We enrolled all patients diagnosed with moderate to severe cholangitis due to common bile duct stones from January 2019 to July 2023. The outcomes were compared in this study between patients who underwent ERCP within 24 h and those who underwent ERCP 24 h later, employing a propensity score (PS) framework. Our primary outcomes were intensive care unit (ICU) admission rates, ICU length of stay, and duration of antibiotic use. RESULTS: In total, we included 254 patients and categorized them into two groups based on the time elapsed between admission and intervention: The urgent group (≤ 24 h, n = 102) and the elective group (> 24 h, n = 152). Ninety-three pairs of patients with similar characteristics were selected by PS matching. The urgent ERCP group had more ICU admissions (34.4% vs 21.5%, P = 0.05), shorter ICU stays (3 d vs 9 d, P < 0.001), fewer antibiotic use (6 d vs 9 d, P < 0.001), and shorter hospital stays (9 d vs 18.5 d, P < 0.001). There were no significant differences observed in adverse events, in-hospital mortality, recurrent cholangitis occurrence, 30-d readmission rate or 30-d mortality. CONCLUSION: Urgent one-stage ERCP provides the advantages of a shorter ICU stay, a shorter duration of antibiotic use, and a shorter hospital stay.

Symptomatic gallstone disease: Recurrence patterns and risk factors for relapse after first admission, the RELAPSTONE study.

BACKGROUND: Delayed cholecystectomy in patients with symptomatic gallstone disease is associated with recurrence. Limited data on the recurrence patterns and the factors that determine them are available. OBJECTIVE: We aimed to determine the pattern of relapse in each symptomatic gallstone disease (acute pancreatitis, cholecystitis, cholangitis, symptomatic choledocholithiasis, and biliary colic) and determine the associated factors. METHODS: RELAPSTONE was an international multicenter retrospective cohort study. Patients (n = 3016) from 18 tertiary centers who suffered a first episode of symptomatic gallstone disease from 2018 to 2020 and had not undergone cholecystectomy during admission were included. The main outcome was relapse-free survival. Kaplan-Meier curves were used in the bivariate analysis. Multivariable Cox regression models were used to identify prognostic factors associated with relapses. RESULTS: Mean age was 76.6 [IQR: 59.7-84.1], and 51% were male. The median follow-up was 5.3 months [IQR 2.1-12.4]. Relapse-free survival was 0.79 (95% CI: 0.77-0.80) at 3 months, 0.71 (95% CI: 0.69-0.73) at 6 months, and 0.63 (95% CI: 0.61-0.65) at 12 months. In multivariable analysis, older age (HR = 0.57; 95% CI: 0.49-0.66), sphincterotomy (HR = 0.58, 95% CI: 0.49-0.68) and higher leukocyte count (HR = 0.79; 95% CI: 0.70-0.90) were independently associated with lower risk of relapse, whereas higher levels of alanine aminotransferase (HR = 1.22; 95% CI: 1.02-1.46) and multiple cholelithiasis (HR = 1.19, 95% CI: 1.05-1.34) were associated with higher relapse rates. CONCLUSION: The relapse rate is high and different in each symptomatic gallstone disease. Our independent predictors could be useful for prioritizing patients on the waiting list for cholecystectomies.

Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis.

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

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

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

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

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

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

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

ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis

Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.

Puntos críticos en la evaluación y tratamiento de octogenarios con colecistolitiasis / Critical points in the evaluation and treatment of octogenarians with colecistolitiasis

Resumen Introducción: Existe una tendencia global al envejecimiento y con ello un aumento de patologías asociadas. En Chile la prevalencia de la colelitiasis o colecistolitiasis aumenta con la edad, siendo la cole-cistectomía una de las cirugías más frecuentes. Existen escasos estudios latinoamericanos referentes a la realidad de la población octogenaria expuesta a este problema. Objetivo: Estudiar la morbimortalidad posoperatoria en pacientes octogenarios operados de colecistectomía. Definir la precisión de distintas herramientas diagnósticas preoperatorias, estudiar variables operatorias y precisar costos hospitalarios. Materiales y Método: Estudio observacional retrospectivo de la ficha clínica electrónica del Hospital Clínico de la Universidad de Chile, entre enero de 2012 y mayo de 2017. Se incluyeron pacientes con edad igual o mayor a 80 años, en quienes se realizó una colecistectomía electiva o de urgencia por patología benigna. Resultados: Se incluyeron 145 pacientes, 51,7% fueron mujeres, el promedio de edad fue de 84,1 años y un 74,5% presentaba comorbilidades. El 62,1% de los casos ingresó por urgencia. 26,2% de toda la muestra presentó coledocolitiasis. La colecistectomía fue laparoscópica en 73,8% de la muestra global, la tasa de conversión fue de 14,5% en población de urgencia y 1,8% en población electiva (p = 0,009). La población operada totalmente por vía laparoscópica con coledocolitiasis fue resuelta en un 95,2% a través de Rendez-vous, con una tasa de éxito del 100%. La tasa de complicaciones fue de 17,9% siendo en su mayoría médicas, la mortalidad quirúrgica fue de 2,1%, siendo todos casos de urgencia. El costo promedio de atención en salud hospitalaria fue de $5.888.104 pesos chilenos (U$9.000). Conclusión: El paciente octogenario con colecistolitiasis representa un desafío quirúrgico, dado un mayor número de comorbilidades, un cuadro clínico más agresivo y una elevada tasa de coledocolitiasis. Es aconsejable valorar el abordaje mínimamente invasivo y realizar una colangiografía intraoperatoria de rutina.

Introduction: There is a global tendency to aging and associated pathologies. In Chile, the prevalence of cholecystolithiasis increases with age, cholecystectomy is one of the most frequent surgeries in the contry. There are few latinamerican studies regarding the reality of the elderly exposed to this problem. Objective: Study postoperative morbimortality in octogenarian patients undergoing cholecystectomy. Define the accuracy of different preoperative diagnostic tools, study operative variables and specify hospital costs. Materials and Method: Retrospective observational study of the Clinical Hospital of the University of Chile, between January 2012 and May 2017. Patients with age equal to or greater than 80 years were included, in whom an elective or emergency cholecystectomy was performed for benign pathology. Results: A total of 145 patients were included, 51.7% were women, the average age was 84.1 years, and 74.5% had comorbidities. The admission was throw the emergency department in 62.1% of the cases. Choledocholithiasis was diagnosed in 26.2% of the entire sample. Cholecystectomy was fully laparoscopic in 73.8% of the overall sample, the conversion rate was 14.5% in the emergency population and 1.8% in the elective population (p = 0.009). The population operated fully laparoscopically, that had choledocholithiasis, was resolved in 95.2% through Rendezvous technique, with a 100% clearance rate of common bile duct. The complication rate was 17.9%, most being medical. The surgical mortality was 2.1%, all cases operated from emergency. The average cost of hospital health care was $5,888,104.3 Chilean pesos (U$9.000). Conclusion: The octogenarian patient with cholecystolithiasis represents a surgical challenge, given a greater number of comorbidities, a more aggressive clinical setting and a high rate of choledocolithiasis. It is advisable to assess the minimally invasive approach and perform routine intraoperative cholangiography. In the postoperative period, the cardiopulmonary status and the infectious complications of the surgical site should be monitored closely.

Shock séptico secundario a síndrome de Mirizzi resuelto en 2 tiempos / Septic shock secondary to Mirizzi syndrome resolved in two stages

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Guía de práctica clínica para el diagnóstico y manejo de la colelitiasis, colecistitis aguda y coledocolitiasis: guía en versión extensa / Clinical practice guide for the diagnosis and management of cholelithiasis, acute cholecystitis and choledocholithiasis: an extensive version guide

Este documento abarca el diagnóstico y manejo de la colelitiasis, colecistitis aguda y coledocolitiasis.

Precisión de los predictores de la ASGE en el diagnóstico de coledocolitiasis en un hospital público de Lima, Perú / Accuracy of ASGE predictors in diagnosis of coledocolithiasis in a public hospital of Lima, Peru

Antecedentes: Habitualmente se utilizan los predictores propuestos por la Sociedad Americana de Endoscopía Gastrointestinal (ASGE) para predecir la presencia y manejo de coledocolitiasis. Objetivo: Evaluar el rendimiento y precisión de los predictores de coledocolitiasis propuestos por la ASGE. Materiales y métodos: Estudio prospectivo y longitudinal realizado en un hospital de tercer nivel desde enero del 2015 hasta junio del 2017. Se incluyeron a todos los pacientes con probabilidad alta e intermedia de coledocolitiasis y que fueron sometidos a colangiopancreatografía retrógrada endoscópica (CPRE) según los criterios propuestos por la ASGE. Resultados: Se analizó un total de 246 pacientes con sospecha de coledocolitiasis. De los 228 pacientes con criterios de alta probabilidad, 144 (63,2% = rendimiento) tenían coledocolitiasis en la CPRE con una precisión de 62% (sensibilidad: 94,1% y especificidad: 9,7%). Entre los 18 pacientes con criterios de probabilidad intermedia: 9 (50% = rendimiento) tenían coledocolitiasis con una precisión de 38% (sensibilidad: 5,9% y especificidad: 90,3%). En el análisis multivariado la presencia de cálculo en el colédoco por ecografía (OR: 1,937; IC 95% 1,048- 3,580; p=0,035) y la edad mayor de 55 años (OR: 2,121; IC 95% 1,101-4,088; p=0,025) fueron los predictores más fuertes para coledocolitiasis. Conclusiones: La aplicación de los criterios de la ASGE para predecir probabilidad de coledocolitiasis, en nuestra población tiene un rendimiento mayor del 50%; sin embargo, se necesita mejorar estos parámetros para evitar una realización innecesaria de CPRE.

Background: The predictors proposed by the American Society of Gastrointestinal Endoscopy (ASGE) are commonly used to predict the presence and management of choledocholithiasis. Objective: To evaluate the performance and precision of the predictors of choledocholithiasis proposed by ASGE. Materials and methods: Prospective and longitudinal study performed at a third level hospital during January 2015 to June 2017. All patients with high and intermediate probability of choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included according to the criteria proposed by the ASGE. Results: A total of 246 patients with suspected choledocholithiasis were analyzed. Of the 228 patients with high probability criteria 144 (63.2% = performance) had choledocholithiasis in ERCP with an accuracy of 62% (sensitivity: 94.1% and specificity: 9.7%). Among the 18 patients with intermediate probability criteria, 9 (50% = performance) had choledocholithiasis with an accuracy of 38% (sensitivity: 5.9% and specificity: 90.3%). In the multivariate analysis, the presence of stone in the bile duct by ultrasonography (OR: 1.937, 95% CI 1.048-3.580, p=0.035) and age 55 and over (OR: 2.121, 95% CI, 1.101-4.088, p=0.025) were the strongest predictors for choledocholithiasis. Conclusions: The application of the criteria of the ASGE to predict the probability of choledocholithiasis, in our population has a performance greater than 50%, however, it is necessary to improve these parameters to avoid an unnecessary performance of ERCP.

Diagnostic and therapeutic cholangioscopy in biliary diseases: a prospective study in Peru / Uso diagnóstico y terapéutico de la colangioscopía en enfermedades de la vía biliar: un estudio prospectivo en Perú

Introduction: Cholangioscopy is a test that allows the evaluation of the biliary epithelium. It is used for diagnosis and management of biliary diseases. Objectives: Determine the success rate of complete removal of difficult stones with the use of laser lithotripsy through cholangioscopy as well as its complications. Determine the visual impression accuracy of bile duct injuries. Materials and methods: This is a prospective and descriptive study. We included 39 patients between July 2016 and July 2017 with diagnosis of difficult stones in the biliary tract and indeterminate stenosis of the biliary tract that were submitted to cholangioscopy. Results: Success rate of complete removal of difficult stones was 65.3%, there was one complication. Two laser sessions were required in 4 of the 17 patients who obtained complete removal of the stones. The visual impression accuracy of lesions in the bile duct to determine malignancy coincided in all cases with the final diagnosis of the patient. Conclusions: Laser lithotripsy allows a safe and effective treatment of the difficult stones of the bile duct. Precession of visual impression of lesions in the bile duct is very high.

Introducción: La colangioscopía es un examen que permite evaluar la luz biliar, el epitelio biliar y sirve para diagnóstico y manejo de enfermedades de la vía biliar. Objetivos: Determinar la tasa de éxito de remoción completa de cálculos difíciles con el uso de litotripcia con láser a través de la colangioscopía asi como las complicaciones de ésta. Determinar la precisión de impresión visual de lesiones de la vía bilar. Materiales y métodos: Estudio prospectivo, descriptivo. Se incluyeron a 39 pacientes entre Julio 2016 a Julio 2017 con diagnóstico de cálculo difícil en la vía biliar y estenosis indeterminada de la vía biliar que fueron sometidos a colangioscopía. Resultados: La tasa de éxito de remoción completa de cálculos difíciles fue de 65,3% con una complicación. Se requirió de dos sesiones con láser en 4 de los 17 pacientes que obtuvieron remoción completa de cálculos. La precisión de impresión visual de lesiones en la vía biliar para determinar malignidad coincidió en todos los casos con el diagnóstico final del paciente. Conclusiones: La colangioscopía con uso de litotripcia con láser permite un tratamiento seguro y eficaz en los cálculos difíciles de la vía biliar. La precesión de la impresión visual de lesiones en la vía biliar es muy alta.

Rendimiento de los criterios predictivos de la ASGE en el diagnóstico de coledocolitiasis en el Hospital Edgardo Rebagliati Martins / Performance of ASGE predictive criteria in diagnosis of choledocholithiasis in the Edgardo Rebagliati Martins Hospital

Antecedentes: En el Perú no se cuenta con ningún estudio que evalúe el rendimiento de la guía clínica actual orientada a estratificar a los pacientes según probabilidad de presentar coledocolitiasis. Objetivos: Evaluar el rendimiento de los criterios predictivos propuestos por la Sociedad Americana de Endoscopía Gastrointestinal (ASGE) en el diagnóstico de coledocolitiasis. Materiales y métodos: Cohorte retrospectiva realizada en el hospital Rebagliati. Se incluyeron a todos los pacientes con sospecha de coledocolitiasis que contaron con una colangiopancreatografía retrógrada endoscópica (CPRE) entre julio del 2014 y junio del 2015. Se evaluaron los predictores de coledocolitiasis propuestos por la ASGE y el rendimiento diagnóstico de las categorías de riesgo. Resultados: Se incluyeron 118 pacientes que cumplieron con los criterios de inclusión. En el análisis multivariado sólo la edad >55 años (OR:3,07, [IC 95: 1,14-8,31], p=0,027) y el hallazgo de litiasis en la vía biliar común mediante ecografía (OR: 1,68 [IC 95%: 1,09-2,59], p=0,018) se asociaron a la existencia de coledocolitiasis en la CPRE. Los rendimientos de las categorías de riesgo elevado y de riesgo intermedio fueron de 75,82% y 70,37% respectivamente. El rendimiento de la categoría de riesgo elevado mejoró a 85,90% utilizando un segundo set de pruebas de laboratorio control. Conclusiones: El rendimiento de los predictores y las categorías de riesgo propuestos por la ASGE en el diagnóstico de coledocolitiasis es aceptable en nuestro hospital, acorde con los estándares propuestos; sin embargo, creemos que aún debe mejorar para evitar el uso de CPREs diagnósticas.

Background: In Peru, there are still no local studies designed for evaluating the performance of clinical guidelines designed to stratify patients according to probability of choledocholithiasis. Objectives: To evaluate the performance of predictive criteria proposed by the American Society for Gastrointestinal Endoscopy (ASGE) in diagnosis of choledocholithiasis. Materials and methods: A retrospective cohort study conducted in a hospital in Lima (Rebagliati hospital). Were included all patients with suspected choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) between July 2014 and June 2015. Predictors of choledocholithiasis proposed by the ASGE and the diagnostic performance of the risk categories were evaluated. Results: 118 patients met the inclusion criteria. In multivariate analysis, only age >55 years (OR: 3.07 [95: 1.14-8.31], p = 0.027) and the finding of stones in the common bile duct by abdominal ultrasound (OR: 1.68 [95% CI: 1.09-2.59], p = 0.018) were associated with the presence of choledocholithiasis on ERCP. The performance of the high and intermediate risk categories were 75.82% and 70.37% respectively. The performance of the high-risk category improved to 85.90% using a second set of biochemical markers. Conclusions: The performance of the predictors and risk categories proposed by the ASGE in diagnosis of choledocholithiasis is acceptable in our hospital, according to the proposed standards; however, it must be further improved to prevent the use of diagnostic ERCP.

Apresentação de forma rara de coledocolitíase e análise de conflitos gerados pela solicitação de exames complementares / A rare form of choledocholithiasis and an analysis of conflicts generated by request of complementary tests

Coledocolitíase refere-se à presença de cálculos no ducto biliar comum e é secundário à passagem de cálculos da vesícula biliar para o ducto colédoco. A associação dos critérios clínicos, laboratoriais e ultrassonográficos determina sensibilidade de 98% para o diagnóstico de coledocolitíase. A sensibilidade para detectar cálculos segundo os exames de imagens pouco varia entre as técnicas disponíveis, representando acurácia de 90% para ultrassonografia abdominal. A medicina avança continuamente através de novos meios de diagnóstico. À medida que novas tecnologias surgem, anamnese e exame físico aprofundado são desvalorizados. Quanto mais exames forem solicitados, maior a chance de resultados falso-positivos, e resultados mal interpretados podem ocasionar adiamentos e cancelamentos de procedimentos essenciais. O relato refere-se a uma paciente do sexo feminino apresentando icterícia, febre, dor em hipocôndrio direito, transaminases excessivamente elevadas e ultrassom abdominal compatível com cálculo na vesícula biliar e material no colédoco terminal. O relato objetiva evidenciar que a integração entre história, exames físicos e laboratoriais é fundamental para se determinar quais exames adicionais solicitar. A paciente apresentava quadro de coledocolitíase e colangite evidenciados ao exame físico e testes complementares. Entretanto, solicitou-se colangiorressonância ­ desnecessariamente ­ para confirmação diagnóstica a uma paciente sem condições financeiras para investigação adicional. É indiscutível que os modernos recursos tecnológicos proporcionam meios necessários para diagnóstico mais preciso. Deve-se basear em critérios clínicos, laboratoriais e ultrassonográficos na investigação de coledocolitíase. Os exames são como a própria denominação se dá (complementares), e eles servem para auxiliar, complementar o raciocínio médico, e não para, sozinhos, realizar o diagnóstico (AU)

Choledocholithiasis refers to the presence of stones in the common bile duct and is secondary to the passage of calculi from the gallbladder to the common bile duct. The association of clinical, laboratory and ultrasonographic criteria determines a 98% sensitivity for the diagnosis of choledocholithiasis. The sensitivity to detect stones according to imaging varies little across the available techniques, representing an accuracy of 90% for abdominal ultrasonography. Medicine advances continuously through new diagnostic means. As new technologies emerge, anamnesis and in-depth physical examination are devalued. The more tests are requested, the greater the chance of false-positive results, and misinterpreted results may lead to delays and cancellations of essential procedures. The report refers to a female patient with jaundice, fever, right hypochondrium pain, excessively elevated transaminases, and abdominal ultrasound consistent with stone in the gallbladder and material in the terminal bile duct. The aim of the report is to show that the integration between history, physical and laboratory tests are fundamental to determine which additional tests to request. The patient had a picture of choledocholithiasis and cholangitis evidenced on physical examination and complementary tests. However, cholangio resonance was requested ­ unnecessarily ­ for diagnostic confirmation to a patient who could not afford further investigation. It is indisputable that modern technological resources provide the means needed for more accurate diagnosis. The investigation of choledocholithiasis should be based on clinical, laboratory and ultrasonographic criteria. The tests are like the denomination itself (complementary), and they serve to aid, complement the medical reasoning, and not to make the diagnosis alone (AU)

Biliotórax: una complicación tardía poco frecuente de la colangitis recurrente / Cholethorax: An unusual delayed complication of recurrent cholangitis

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