Prevalence of Persistent Common Bile Duct Stones in Acute Biliary Pancreatitis Remains Stable Within the First Week of Symptoms.

BACKGROUND: Acute biliary pancreatitis (ABP) is often associated with persistent common bile duct (CBD) stones. The best strategy in terms of timing of surgery is still controversial. The aim of the current study is to describe the prevalence of persistent common bile duct (CBD) stones in ABP during the first week of symptoms at a high-volume referral center. STUDY DESIGN: Single-institution retrospective analysis of a prospectively collected database. Patients with diagnosis of ABP who underwent laparoscopic cholecystectomy (LC) between January 2009 and December 2019 were extracted. RESULTS: Two hundred thirty-one patients were included. Cholecystectomy was performed laparoscopically in 230 (99.57%) patients. Intraoperative cholangiogram was performed in all patients. Two hundred nine (90%) patients had surgery within the first 7 days. Global prevalence of persistent CBD stones during IOC was 19.91% (95% CI 14.96-25.65). No significant association between timing to surgery and presence of CBD stones was found for the first week since the initial attack (p=0.28). Prevalence of CBD stones was significantly higher after day 7 (p=0.007 and 0.005). Positive findings in preoperative MRCP are significantly related to intraoperative CBD stones (p=0.0001). Mild postoperative complications (CD I/II) were present in 21 patients (9.09%). No difference was found in morbidity between CBD stones group and non-CBD stones group (p=0.48). We observed no severe complications nor mortality. CONCLUSIONS: In patients with mild acute biliary pancreatitis, the prevalence of persistent CBD stones does not change within the first 7 days since the onset of symptoms. This fact may have major clinical relevance when deciding the optimal therapeutic strategy in this population.

Colecistitis aguda en vesícula biliar izquierda. Presentación de un caso resuelto en forma segura por vía laparoscópica / Acute cholecystitis in a left sided gallbladder safely managed by laparoscopic surgery

RESUMEN La vesícula izquierda (VI) es una rara anomalía de la vía biliar que, cuando enferma, no suele dar sín tomas diferentes de aquella normoposicionada, haciendo infrecuente su diagnóstico preoperatorio. Presentamos el caso de una colecistitis aguda en un paciente con VI, resuelto en forma segura por vía laparoscópica. Un paciente ingresa por un cuadro típico de colecistitis aguda. Como hallazgo in traoperatorio se constata una vesícula biliar inflamada, ubicada en posición siniestra. Se modificó la ubicación de los puertos de trabajo y se realizó colangiografía transvesicular por punción, antes de iniciar la disección del hilio vesicular. Luego de identificar el conducto cístico, se realizó colangiografía transcística que confirmó la anatomía de la vía biliar completa y expedita. Se completó la colecistec tomía laparoscópica en forma segura. El hallazgo de una VI obliga al cirujano a cambiar la técnica de una colecistectomía laparoscópica. Esta anomalía incrementa el riesgo de lesiones de la vía biliar. La disección cuidadosa del hilio vesicular logrando una visión crítica de seguridad y el uso de colangiogra fía intraoperatoria son de extrema importancia para una colecistectomía segura.

ABSTRACT Left-sided gallbladder (LSGB) is a rare bile duct abnormality, usually found during a cholecystectomy. Symptoms usually do not differ from those of a normally positioned gallbladder, making the preoperative diagnosis extremely uncommon. We report the case of an acute cholecystitis in a patient whit LSGB, safely managed with laparoscopic surgery. A 24-year-old male patient was admitted to our institution with clinical and radiological signs of acute cholecystitis. The intraoperative finding of an acute cholecystitis in a LSGB made us modify ports positioning and a cholangiograhy was done by direct puncture of the gallbladder before hilum dissection. After the cystic duct was identified, a transcystic cholangiography was performed which confirmed a complete and clear bile duct anatomy and laparoscopic cholecystectomy was safely completed. The intraoperative finding of a LSGB makes the surgeon change some aspects of the usual technique to perform a safe cholecystectomy as LSGB significantly increases the risk of common bile duct injuries. Meticulous dissection of the gallbladder hilum to achieve a critical view of safety and the systematic use of intraoperative cholangiography are extremely important to perform a safe laparoscopic cholecystectomy.

Laparoscopic cholecystectomy in acute mild gallstone pancreatitis: how early is safe?

The surgical strategy to resolve the underlying biliary pathology in patients with acute gallstone pancreatitis (AGP) remains controversial. The aim of this study was to evaluate the safety and effectiveness of early laparoscopic cholecystectomy (ELC) in patients with mild AGP. A retrospective cohort of consecutive patients diagnosed with mild AGP according to the Atlanta Guidelines from January 2009 to July 2019 was selected. Patients were assigned to surgery on the first available surgical shift, 48 h after the symptoms onset. Univariate analysis was performed to determine the association between AGP and grades of Balthazar (A, B and C) with time to surgery, days of hospitalization and postoperative complications. From 239 patients evaluated, 238 (99.58%) were operated by laparoscopic approach. Intraoperative cholangiogram was performed routinely. Choledocholithiasis, if present, was successfully treated by laparoscopic common bile duct exploration in all cases. A significant association was found between Balthazar grades and time to surgery (median of 3 days, p = 0.003), with length hospitalization and from surgery to discharge, with median of 4 days (p = 0.0001) and 2 days (p = 0.003), respectively. Mild postoperative complications (CD I/II) were observed in 22/239 patients (9.2%). This represents 2% of patients with grade A of Balthazar, 9% of grade B and 14% of grade C (p = 0.016). We observed no severe complications or mortality. ELC with routine intraoperative cholangiogram, performed on the first available surgical shift 48 h after the symptoms of pancreatitis onset, is a viable, effective and safe strategy for the resolution of mild AGP and its underlying biliary pathology in a single procedure.

Colangiografía oral y la atresia duodenal / Oral cholangiography and duodenal atresia

Se presenta el caso de un recién nacido masculino con síndrome de Down, que presentó al nacimiento vómito biliar y al examen físico ictericia y hepatomegalia leve. Los estudios radiológicos simple de abdomen y la serie gastrointestinal mostraron al duodeno dilatado y cambios inflamatorios de la mucosa. Esta imagen es conocida como la imagen en “doble burbuja” y es común en la obstrucción duodenal congénita. Simultáneamente fueron visualizados la vesícula biliar y el colédoco, siendo este hallazgo poco usual. Se le efectuó corrección del defecto mediante el procedimiento de Kimura.

A newborn male patient with trisomy-21 presented with bilious hemesis. The patient was icteric with slight hepatomegaly. Simple abdominal X-ray and upper gastrointestinal series with barium showed a dilated duodenal loop and inflammatory changes involving the duodenal mucosa. This image known as [quot ]double bubble[quot ] is characteristic of congenital duodenal obstruction. Simultaneously the gallbladder and choledochus were visualized. The former X-ray finding is very unusual. An uneventful Kimura procedure was performed.