[Knowing an infrequent complication of endoscopic retrograde cholangiopancreatography]. / Conociendo una complicación poco frecuente de la colangiopancreatografía retrógrada endoscópica.

OBJECTIVE: Describe the clinical and tomographic characteristics in relation to the extra peritoneal distribution of collections and air in patients with periampullary perforation after performing endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy. MATERIALS AND METHODS: Observational, descriptive study in patients with periampullary perforation after ERCP with or without sphincterotomy, treated in the Pancreas Surgery Service at Edgardo Rebagliati Martins Hospital, Lima, Peru between January 2013 and January 2015. RESULTS: Ten patients with periampullary perforation after ERCP were included. 40% were male. The mean age was 47.2 years. 100% showed abdominal pain, fever 70%, 60% had jaundice, oral intolerance and vomiting. In 100% of cases the description of the procedure was for choledocolithiasis. Difficult cannulation is described in 80% of cases. Air or fluid was found in 90% in the right anterior pararenal space and the right perirenal, and the place where air or liquid is distributed less frequently was right extraperitoneal pelvis with 20%, in no caserevealed air in the mediastinum. CONCLUSIONS: The finding of a liquid collection and / or air in the retroperitoneal space right after ERCP without further involvement of the pancreatic gland should make us think of periampullary perforation, especially if you are in the right anterior pararenal space and perirenal space. This entity we call bilioretroperitoneo.

Conociendo una complicación poco frecuente de la colangiopancreatografía retrógrada endoscópica / Knowing an infrequent complication of endoscopic retrograde cholangiopancreatography

Objetivo: Describir las características clínicas y tomográficas en relación a la distribución extra peritoneal de colecciones y aire seguida de perforación periampular luego de la realización de colangiopancreatografía retrograda endoscópica (CPRE) con o sin esfinterotomía. Materiales y métodos: Estudio observacional, descriptivo y transversal, en pacientes con perforación periampular, después de CPRE con o sin enfinterotomía, tratados en el Servicio de Cirugía de Páncreas del Hospital Edgardo Rebagliati Martins, Lima, Perú, entre enero del 2013 y enero del 2015. Resultados: Se incluyeron 10 pacientes con perforación periampular, después CPRE. El 40% fue de sexo masculino. La edad media fue de 47,2 años. El 100% presento dolor abdominal, el 70% fiebre, el 60% presentó ictericia, intolerancia oral y vómitos. En el 100% de los casos la indicación del procedimiento fue por litiasis coledociana. Se describe canulación difícil en el 80% de los casos. Se encontró aire o líquido en el 90% en los espacios pararrenal anterior derecho y el perirrenal derecho, y el lugar en donde se distribuyó el aire o liquido con menor frecuencia fue la pelvis extra peritoneal derecha con el 20%, en ningún caso se evidenció aire en el mediastino. Conclusiones: El hallazgo de una colección líquida y/o aire en el espacio retroperitoneal derecho, después de CPRE, sin mayor afección de la glándula pancreática, debe hacernos pensar en perforación periampular, sobre todo si se encuentra en el espacio pararrenal anterior derecho y el espacio perirrenal derecho. A esta entidad nosotros la hemos denominado bilioretroperitoneo.

Objective: Describe the clinical and tomographic characteristics in relation to the extra peritoneal distribution of collections and air in patients with periampullary perforation after performing endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy. Materials and methods: Observational, descriptive study in patients with periampullary perforation after ERCP with or without sphincterotomy, treated in the Pancreas Surgery Service at Edgardo Rebagliati Martins Hospital, Lima, Peru between January 2013 and January 2015. Results: Ten patients with periampullary perforation after ERCP were included. 40% were male. The mean age was 47.2 years. 100% showed abdominal pain, fever 70%, 60% had jaundice, oral intolerance and vomiting. In 100% of cases the description of the procedure was for choledocolithiasis. Difficult cannulation is described in 80% of cases. Air or fluid was found in 90% in the right anterior pararenal space and the right perirenal, and the place where air or liquid is distributed less frequently was right extraperitoneal pelvis with 20%, in no case revealed air in the mediastinum. Conclusions: The finding of a liquid collection and / or air in the retroperitoneal space right after ERCP without further involvement of the pancreatic gland should make us think of periampullary perforation, especially if you are in the right anterior pararenal space and perirenal space. This entity we call bilioretroperitoneo.

Perforation of the Papilla of Vater in Wire-Guided Cannulation.

Background. WGC in ERCP is considered a safe technique, although rare complications can occur. One unique complication of WGC is the perforation of the papilla of Vater by the guidewire. Subjects and Methods. Of 2032 patients who underwent ERCP at our department between January 2010 and December 2014, we selected 208 patients who underwent WGC for naïve papilla as subjects. A detailed examination of patients in whom a perforation occurred was conducted, and risk factors for perforations were investigated. Results. The perforation was observed in 7 of 208 patients (3.4%). All patients recovered with conservative treatment without the need for surgery. The perforation rate was significantly higher in the patients with juxtapapillary duodenal diverticula than those without diverticula (12.5% versus 0.6%, p < 0.001). Cannulation of the bile duct was ultimately achieved in 5 of 7 patients; PSP was performed for 4 of these patients. Conclusion. Caution must be exercised when dealing with patients who have a juxtapapillary duodenal diverticula because they are at higher risk of perforations. Because these are small perforations made by a wire, most of them heal with conservative treatment. However, perforations can make cannulation difficult, and PSP may be useful for deep cannulation.

Immediate detection of endoscopic retrograde cholangiopancreatography-related periampullary perforation: fluoroscopy or endoscopy?

AIM: To investigate the causes and intraoperative detection of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations to support immediate or early diagnosis. METHODS: Consecutive patients who underwent ERCP procedures at our hospital between January 2008 and June 2013 were retrospectively enrolled in the study (n = 2674). All procedures had been carried out using digital fluoroscopic assistance with the patient under conscious sedation. For patients showing alterations in the gastrointestinal anatomy, a short-type double balloon enteroscope had been applied. Cases of perforation had been identified by the presence of air in or leakage of contrast medium into the retroperitoneal space, or upon endoscopic detection of an abdominal cavity related to the perforated lumen. For patients with ERCP-related perforations, the data on medical history, endoscopic findings, radiologic findings, diagnostic methods, management, and clinical outcomes were used for descriptive analysis. RESULTS: Of the 2674 ERCP procedures performed during the 71-mo study period, only six (0.22%) resulted in perforations (male/female, 2/4; median age: 84 years; age range: 57-97 years). The cases included an endoscope-related duodenal perforation, two periampullary perforations related to endoscopic sphincterotomy, two periampullary perforations related to endoscopic papillary balloon dilation, and a periampullary or bile duct perforation secondary to endoscopic instrument trauma. No cases of guidewire-related perforation occurred. The video endoscope system employed in all procedures was only able to immediately detect the endoscope-related perforation; the other five perforation cases were all detected by subsequent digital fluoroscope applied intraoperatively (at a median post-ERCP intervention time of 15 min). Three out of the six total perforation cases, including the single case of endoscope-related duodenal injury, were surgically treated; the remaining three cases were treated with conservative management, including trans-arterial embolization to control the bleeding in one of the cases. All patients recovered without further incident. CONCLUSION: ERCP-related perforations may be difficult to diagnose by video endoscope and digital fluoroscope detection of retroperitoneal free air or contrast medium leakage can facilitate diagnosis.

Resección endoscópica de adenoma gigante de la ampolla de Vater con crecimiento intraductal: a propósito de un caso / Endoscopic resection of a giant adenoma of the ampulla of vater with intraductal growth: report of a case

Los tumores ampulares representan un grupo diverso aunque infrecuente de lesiones ubicadas en la confluencia de los conductos pancreático y biliar. Representan el 1-2% de los tumores del tracto digestivo, estos pueden ser benignos y malignos. Entre los tumores benignos, el adenoma es el más frecuente y su incidencia oscila entre 0,04 y 0,12%. Pueden ser sésiles o pediculados e histológicamente diferenciarse en tubulares, túbulo-vellosos y vellosos. Debido a su potencial maligno, el tratamiento recomendado es la resección bien sea quirúrgica o endoscópica; esta última indicada en tumores menores de 4,5cm. Se reporta el caso de paciente masculino de 78 años quien consultó por ictericia, dolor abdominal y pérdida de peso de 2 meses de evolución. Se realizó ultrasonido y tomografía abdominal que reportan imagen sólida en confluente biliopancreático. Se realizó duodenoscopia encontrando tumoración ampular de 6 centímetros de diámetro de aspecto velloso. Dada la edad y comorbilidades del paciente se decidió ampulectomía endoscópica parcelar. En la colangiografía retrograda endoscópica se observó imagen de defecto en tercio distal de colédoco por lo que se procedió a extraer con balón de Fogarty, obteniéndose masa tumoral de aspecto velloso pediculada la cual es resecada sin complicaciones. El hallazgo histopatológico reportó adenoma túbulo-velloso con displasia de bajo grado y en controles endoscópicos e histológicos de seguimiento a los 10 meses del procedimiento no se ha evidenciado recidiva tumoral y clínicamente el paciente se encuentra asintomático y en buenas condiciones generales

Ampullary tumors represent a various group but uncommon lesions located at the confluence of the pancreatic and bile ducts. They account for 1 to 2% of the digestive tract tumors, they may be benign and malignant. Among benign tumors, the adenoma is the most common and its incidence ranges from 0.04 a 0.12%. They can be sessile or pedunculated and histologically differentiated tubular, tubulo villous and villous. Because of its malignant potential, the recommended treatment is surgical resection or endoscopic either, the latter indicated in tumors less 4.5 cm. A case of 78 years old male patient who consulted with jaundice, abdominal pain and two months weight loss. It performed abdominal ultrasound and CT reporting in confluent biliopancreatic solid image. Duodenoscopy was performed finding ampullary tumor six inches diameter appearance fluffy. Considering patient age and comorbidities, it decided parcel endoscopic ampullectomy. In endoscopic retrograde cholangiography, defect image was observed in distal choledochal, so we proceeded to extract with Fogarty Balloon, giving pedunculated villous tumor, which is removed without complications. The histopathological finding was tubule villous adenoma, with low grade dysplasia. In endoscopic and histologycal controls up to procedure ten months, is not clinically evidence tumor recurrence and the patient is asymptomatic in good general conditions

Application of the OTSC system for the closure of fistulas, anastomosal leakages and perforations within the gastrointestinal tract.

Until recently there has been no technique available which reproducibly and safely allowed endoscopic closures of penetrating defects within the digestive tract. With the new "over the scope clipping system" (OTSC system®), which regarding design and function is similar to a bear-trap, a method is available for the endoscopic closure of fistulas and perforations. Here, we present a series of 10 patients, in whom different penetrating defects within the digestive tract could be closed in 9 of 10 cases successfully by the OTSC system®: fistulas (esophagotracheal, esophagopleural, gastrocutaneous and colovesical), perforations (after mucosectomy, after papillotomy and PEG misplacement) and anastomosal leakages (after gastrotomy and gastrectomy). In another case we demonstrate our first experience with the OTSC system® for the prevention of perforations during deep endoscopic R 0 resection of a T 1(sm1)G1 sigmoideal cancer after initial R 1 resection.

Management of endoscopic retrograde cholangiopancreatography-related perforation.

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation occurs in 0.1-1.8% of patients after therapeutic ERCP. It is a serious complication with a high mortality. However, little evidence exists in the medical literature and the optimal management remains unclear. This review aims to critically evaluate the optimal management of therapeutic ERCP-related perforation.

Traumatic duodenal necrosis with avulsion of Vater's papilla in a child.

Blunt duodenal trauma with avulsion of the papilla of Vater is an extremely uncommon injury in children. The usual management of these injuries relies on complex reconstructive procedures and bypasses. We report the case of a 6-year-old girl with near total traumatic duodenal necrosis and avulsion of Vater's papilla managed by a simple physiological montage avoiding pancreatic resections and gastrointestinal bypasses.

[Needle-knife sphincterotomy for biliary access: a prospective study]. / Esfinterotomía de aguja como técnica de acceso a la vía biliar: estudio prospectivo.

OBJECTIVE: Needle-knife sphincterotomy (NKS) is used to achieve biliary access when routine cannulation methods have been unsuccessful. The aim of this study was to analyze the results of NNS in patients with an inaccessible common bile duct (difficult cannulation) using standard techniques in endoscopic retrograde cholangiopancreatography and the factors associated with the success of this procedure and complications. MATERIAL AND METHODS: We performed a prospective study of 72 patients who underwent NKS performed by the same endoscopist (J.E.) because of difficult cannulation of the common bile duct between January 1998 and December 2004. The results were analyzed in terms of successful biliary access, whether this was achieved in one or more sessions, its possible association with the underlying disease, and the incidence and severity of complications. RESULTS: Seventy-two NKS were performed from a total of 1062 sphincterotomies (6.7%). A total of 77.7% of the patients underwent prior implantation of a pancreatic prosthesis (NKS-PP). The final diagnosis was: choledocholithiasis (31.9%), cancer of the pancreas (16.6%), cholangiocarcinoma (13.8%), benign stenosis (8.3%), dysfunction of the sphincter of Oddi (6.9%), normal (6.9%), and miscellaneous (13.8%). Cannulation was successful in 87.5% (63/72), and was achieved in the first session in 73% (46/63). Biliary access was achieved in 72.7% of patients (16/22) with biliopancreatic neoplasms versus 94% (47/50) of those with other diagnoses (p = 0.03). Eleven patients (15.2%) presented 12 complications (16.6%) (6 pancreatitis, 4 cholangitis, 1 papillary hemorrhage, and 1 portal vein filling). The use of a pancreatic prosthesis was related to a higher success rate and significantly fewer complications (p = 0.03). CONCLUSIONS: NKS-PP can be a safe procedure in patients with difficult cannulation of the common bile duct. The presence of biliopancreatic neoplasm is a risk factor for failure to achieve biliary access compared with other diagnoses. The complication rate was similar to that found in other studies. No cases of severe pancreatitis or perforations were found.

Esfinterotomía de aguja como técnica de acceso a la vía biliar: estudio prospectivo / Needle-knife sphincterotomy for biliary access: a prospective study

Objetivo: La esfinterotomía de aguja es una técnica empleada para conseguir el acceso a la vía biliar, cuando los métodos de canulación habituales han fallado. El objetivo ha sido analizar los resultados de la realización de la esfinterotomía de aguja en pacientes con inaccesibilidad a la vía biliar (canulación difícil) mediante técnicas estándar en colangiopancreatografía retrógrada endoscópica, y los factores asociados con el éxito y complicaciones. Material y métodos: Estudio prospectivo que incluye a 72 pacientes entre enero de 1998 y diciembre de 2004, sometidos a esfinterotomía de aguja por canulación difícil de la vía biliar por el mismo endoscopista (J.E.). Los resultados se analizaron respecto al éxito en acceder a la vía biliar, su consecución en una o más sesiones, su posible relación con la enfermedad de base y la incidencia y gravedad de las complicaciones. Resultados: Se realizaron 72 esfinterotomías de aguja de un total de 1.062 esfinterotomías (6,7%). En el 77,7% de los pacientes se colocó previamente una prótesis pancreática. El diagnóstico final fue: coledocolitiasis en el 31,9%; cáncer de páncreas en el 16,6%; colangiocarcinoma en el 13,8%; estenosis benigna en el 8,3%; disfunción del esfínter de Oddi en el 6,9%; normal en el 6,9%, y miscelánea en el 13,8%. Se obtuvo éxito en la canulación en el 87,5% (63/72), y se consiguió en la primera sesión en el 73% (46/63). Se logró el acceso biliar en el 72,7% de los casos (16/22) de neoplasia biliopancreática, frente al 94% (47/50) en pacientes con otros diagnósticos (p = 0,03). Once pacientes (15,2%) presentaron 12 complicaciones (16,6%) (6 pancreatitis, 4 colangitis, 1 hemorragia papilar y 1 relleno de la vena porta). El uso de prótesis pancreática se relacionó con un porcentaje mayor de éxito y menor de complicaciones, alcanzando significación estadística en esta última (p = 0,03).Conclusiones: La esfinterotomía de aguja con prótesis pancreática puede ser un procedimiento seguro en pacientes con canulación difícil de la vía biliar. La presencia de neoplasia biliopancreática es un factor de riesgo de no consecución del acceso biliar frente a otros diagnósticos. La incidencia de complicaciones está en consonancia con otros estudios, y no se han hallado pancreatitis graves ni perforaciones

Objective: Needle-knife sphincterotomy (NKS) is used to achieve biliary access when routine cannulation methods have been unsuccessful. The aim of this study was to analyze the results of NNS in patients with an inaccessible common bile duct (difficult cannulation) using standard techniques in endoscopic retrograde cholangiopancreatography and the factors associated with the success of this procedure and complications. Material and methods: We performed a prospective study of 72 patients who underwent NKS performed by the same endoscopist (J.E.) because of difficult cannulation of the common bile duct between January 1998 and December 2004. The results were analyzed in terms of successful biliary access, whether this was achieved in one or more sessions, its possible association with the underlying disease, and the incidence and severity of complications. Results: Seventy-two NKS were performed from a total of 1062 sphincterotomies (6.7%). A total of 77.7% of the patients underwent prior implantation of a pancreatic prosthesis (NKS-PP). The final diagnosis was: choledocholithiasis (31.9%), cancer of the pancreas (16.6%), cholangiocarcinoma (13.8%), benign stenosis (8.3%), dysfunction of the sphincter of Oddi (6.9%), normal (6.9%), and miscellaneous (13.8%). Cannulation was successful in 87.5% (63/72), and was achieved in the first session in 73% (46/63). Biliary access was achieved in 72.7% of patients (16/22) with biliopancreatic neoplasms versus 94% (47/50) of those with other diagnoses (p = 0.03). Eleven patients (15.2%) presented 12 complications (16.6%) (6 pancreatitis, 4 cholangitis, 1 papillary hemorrhage, and 1 portal vein filling). The use of a pancreatic prosthesis was related to a higher success rate and significantly fewer complications (p = 0.03). Conclusions: NKS-PP can be a safe procedure in patients with difficult cannulation of the common bile duct. The presence of biliopancreatic neoplasm is a risk factor for failure to achieve biliary access compared with other diagnoses. The complication rate was similar to that found in other studies. No cases of severe pancreatitis or perforations were found

[Prevention, diagnosis and treatment of iatrogennic lesions of biliary tract during laparoscopic cholecystectomy. Management of papila injury after invasive endoscopy. Part 1. Prevention and diagnosis of bile duct injuries]. / Prevence, diagnostika a chirurgická lécba poranení zlucovodu behem laparoskopické cholecystektomie. Lécení poranení papily v dusledku invazivní endoskopie. Cást 1.--Prevence a diagnostika poranení zlucovodu.

INTRODUCTION: Endoscopic invasive procedures in 70th and 80th years leaded to decrease reoperations on biliary tree. Iatrogenic injury of the biliary tract have increased in incidence in the first decade with the introduction of laparoscopic cholecystectomy. Athough a number of factors have been identified with a high risk of injury ( and number of technical steps have been emphasized to avoid these injury, the incidence of the bile duct injury has reached at least double the rate observed with open cholecystectomy. Cholecystectomy is most frequently performed abdominal operation and the most serious complication associated with this procedure is accidental injury to the common bile duct (0.3-0.4%). This preventable technical error has tradicionally been thought to occur in one or more of three situations: 1. When the operator attempts to clip or ligate a bleeding cystic artery and also clips the common hepatic duct (Fig. 3a). 2. When too much traction has been exerted on the gallbladder so that the common bile duct has tented up into an albow, which was either tied off with ligature or clipped (Fig. 3b). 3. When anatomic anomalies were not recognized and the wrong structure is divided, for example, when the cystic duct winds anterior to the common bile duct and enters on the left side, or when the cystic duct joins the right hepatic duct rather than the junction of the common hepatic and the common bile ducts (Fig. 1, 2, 3cd). In anatomical incertain cases is discussed about cholangiography and cholecystocholangiography during laparoscopy cholecystectomy. Most patients sustained a bile duct injury are recognized in the weeks folloving laparoscopic cholecystectomy. Careful preoperative preparation should include control of sepsis by draining any bile collections or fistulas and komplete cholangiography. Long-term results are best achieved in specialized hepatobiliary centres performing biliary reconstruction with a Roux-Y hepaticojejunostomy. Success rates over 90% have been reported from several centres to date with intermediate follow-up. Papila injury increased with introduction of a invasive endoscopy. Risk of deadly retroperitoneal inflamation is very high. Injury require same surgery procedure as duodenum injury. OWN EXPERIENCES: In an article a review of experiences of the 1st surgery department of General hospital in Prague since 1971 in 1 017 reoperations on biliary tree was carried out. There was in 311 patients 164 hepatohepatostomies and 147 hepaticojejunostomies used (Tab. 1). By laparoscopic injuries were high hilar injuries (Bismuth IV) in last decade and hepaticojejunostomy was done in all cases. Died 6%, long term results are acceptable by injured patients with hepaticohepaticostomies in 70%, by hepaticojejunostomies in 90%. Reoperated were 10% patients (Tab. 1). Remnant patients were dilated endoscopicaly. Postoperatively morbidity was high, above 26%. In years 1995-2003 were 8 patients with papila injury and inflamation in retroperitoneum operated as a injured duodenum (Tab. 2). CONCLUSIONS: Better experiences with treatment of injured biliary tree and papila are in centres interested in hepatobilliary surgery which knowledge anatomy of hilus of liver and can make wide hepaticojejunostomy. Transfer of drained injured patient to centre is possible.