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2.
Am Surg ; 86(8): 1022-1025, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32809851

RESUMO

Laparoscopic cholecystectomy remains one of the most common surgical operations. Common bile duct stones (CBDS) are estimated to be present in 10%-20% of individuals with symptomatic gallstones. Preoperative magnetic resonance cholangiopancreatography (MRCP) and intraoperative cholangiography (IOC) remain the most common methods of evaluation, with subsequent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction if positive for CBDS. We examined our experience with preoperative MRCP versus IOC for the management of the jaundiced patient with cholelithiasis. This is a retrospective single-institution study that examined all laparoscopic cholecystectomies performed over a 15-month period between 2017 and 2018. Outpatient elective cases were excluded from the analysis. Charts were reviewed for demographics, operative details, and whether an MRCP, IOC, or ERCP was performed. Data were evaluated using a 2-sample t-test. A total of 460 patients underwent laparoscopic cholecystectomy over a 15-month period. Of those, 147 underwent either an MRCP or an IOC for clinical suspicion for CBDS. ERCP after MRCP was nontherapeutic in 11/32 (34%) compared with 2/12 (17%) of patients following IOC. The sensitivity and specificity of MRCP were 91% and 80%, respectively, with a positive predictive value of 66% and a negative predictive value of 96%. The sensitivity and specificity of IOC were 83% and 97%, respectively, with a positive predictive value of 83% and a negative predictive value of 97%. MRCP and IOC have unique advantages and disadvantages. MRCP has greater sensitivity, but poor specificity, resulting in unnecessary ERCPs with associated morbidity and increased costs to the patient.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Colangiopancreatografia por Ressonância Magnética , Colecistectomia Laparoscópica , Cálculos Biliares/diagnóstico por imagem , Icterícia Obstrutiva/diagnóstico por imagem , Cuidados Pré-Operatórios/métodos , Procedimentos Desnecessários/estatística & dados numéricos , Colangiografia/métodos , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Humanos , Cuidados Intraoperatórios/métodos , Icterícia Obstrutiva/etiologia , Icterícia Obstrutiva/cirurgia , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade
3.
Gastroenterol. hepatol. (Ed. impr.) ; 43(4): 188-192, abr. 2020. ilus, tab
Artigo em Inglês | IBECS | ID: ibc-190795

RESUMO

BACKGROUND: The presence of hepatolithiasis (HL) is prevalent in eastern countries. It is a clinical entity which is rarely reported in non-surgical series because the standard treatment is the surgical option. Currently, treatment has evolved, with the use of endoscopic techniques being increased and the number of hepatectomies being decreased. SpyGlass™ is a small-calibre endoscopic direct cholangiopancreatoscopy developed to explore and perform procedures in the bile and pancreatic ducts. Single-operator peroral cholangioscopy (POC) is an endoscopic technique useful for treating difficult bile duct stones. AIMS: To assess the usefulness, efficacy, and safety of POC with the SpyGlass™ system in patients with HL. Primary OBJECTIVES: to achieve technical success of the procedure and clinical success of patients with HL. Study design and PATIENTS: Retrospective, single-centre cohort study of patients with HL from April 2012 to August 2018. SpyGlass™ was chosen in symptomatic patients referred from the surgery unit as the first-line procedure. To perform electrohydraulic lithotripsy (EHL), we used a Northgate Autolith IEHL generator with a 0.66-mm biliary probe. RESULTS: We performed a total of 13 procedures in 7 patients with HL. The mean age was 46 years (range 35-65) and 3/7 of patients were female. We achieved technical success in 5/7 cases (71.4%) and clinical success in 4/7 cases (57%). DISCUSSION: SpyGlass™ is safe and effective in the treatment of HL. With these results, we confirm the need for management of patients with HL in a multidisciplinary team. When the endoscopic approach is the option, this procedure must be performed by experts in advanced endoscopy


INTRODUCCIÓN: La presencia de hepatolitiasis (HL) es frecuente en los países orientales. Es una entidad poco descrita en series no-quirúrgicas. El tratamiento estándar para esta entidad es la opción quirúrgica. Actualmente el tratamiento ha evolucionado, aumentando el uso de técnicas endoscópicas y disminuyendo el número de resecciones hepáticas quirúrgicas. SpyGlass™ es un colangiopancreatoscopio endoscópico directo de pequeño calibre desarrollado para explorar y realizar procedimientos en el conducto biliar y pancreático. La colangioscopia peroral de operador único (POC) es una técnica endoscópica útil para tratar los cálculos complejos de las vías biliares. OBJETIVOS: Evaluar la utilidad, la eficacia y la seguridad de la colangioscopia POC con el sistema SpyGlass™ en pacientes con HL. Objetivos primarios: éxito técnico del procedimiento y el éxito clínico de pacientes con HL. DISEÑO: del estudio y pacientes Estudio de cohorte retrospectivo, unicéntrico de pacientes con HL desde abril de 2012 hasta agosto de 2018. SpyGlass™ fue elegido en pacientes sintomáticos remitidos desde la unidad de cirugía como procedimiento de primera línea. Para realizar litotricia electrohidráulica (EHL) se utilizó un generador Northgate Autolith® IEHL con una sonda biliar de 0,66mm. RESULTADOS: Se incluyó en el estudio un total de 13 procedimientos en 7 pacientes con HL. La edad media fue de 46 años (rango: 35-65) y 3/7 de los pacientes eran mujeres. Se logró éxito técnico en 5/7 casos (71,4%) y éxito clínico en 4/7 casos (57%). DISCUSIÓN: SpyGlass™ es seguro y efectivo en el tratamiento de HL. Con estos resultados, confirmamos la necesidad del manejo de pacientes con HL en un grupo multidisciplinar. Cuando el enfoque endoscópico es opción, este procedimiento debe realizarse para endoscopistas avanzados expertos


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Litíase/cirurgia , Colangiografia/métodos , Estudos de Coortes , Colelitíase/cirurgia , Litotripsia/métodos , Resultado do Tratamento , Endoscopia/métodos , Cálculos Biliares/diagnóstico por imagem , Estudos Retrospectivos , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Litotripsia/instrumentação
5.
Cardiovasc Intervent Radiol ; 43(2): 302-310, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31749016

RESUMO

PURPOSE: To investigate the effectiveness of percutaneous approaches to treat bile leak and to propose an anatomical classification of biliary fistula to guide the most appropriate percutaneous approach. MATERIALS AND METHODS: Fifty-six patients with bile leakage after hepatobiliary surgery were included. Based on preoperative images and postoperative fistulogram images, three categories of bile leakage were defined. Every category was treated with non-surgical approaches (internal-external percutaneous drainage, percutaneous/endoscopic biliodigestive anastomosis with rendez-vous technique and biliodigestive percutaneous anastomosis with totally radiologic rendez-vous). RESULTS: In 44/56 (78%) patients, anatomical conformation was "direct communication" (bile ducts upstream from the leak present a direct communication with downstream ducts) and their treatment was conventional percutaneous drainage. In 5/56 (9%), anatomical conformation was "indirect communication" (bile ducts upstream from the leak communicate with downstream ducts through a bile collection) and treatment was percutaneous/endoscopic rendez-vous technique. In 7/56 (12%), anatomical conformation was "no communication" (ducts upstream from the leak are completely excluded from ducts downstream) and treatment was totally radiologic rendez-vous. In 54/56 (96%) during the follow-up, cholangiography revealed complete resolution of the leak without residual stenosis and drains were removed. Complications occurred in 12/56 (21%). Procedure-related mortality was 0%. Ten patients, after > 6 months from resolution of their fistula and drain removal, died due to cancer recurrence. Currently, 44/56 patients (77%) at long-term follow-up (> 12 months) are alive, without bile leak. CONCLUSION: Our classification helps to choose the most proper percutaneous approach in all kinds of bile leakage, even in severe cases; these are safe techniques with a high success rate.


Assuntos
Fístula Biliar/terapia , Doenças do Sistema Digestório/cirurgia , Drenagem/métodos , Complicações Pós-Operatórias/terapia , Adulto , Idoso , Anastomose Cirúrgica , Bile , Ductos Biliares/anatomia & histologia , Ductos Biliares/diagnóstico por imagem , Fístula Biliar/diagnóstico por imagem , Sistema Biliar/diagnóstico por imagem , Procedimentos Cirúrgicos do Sistema Biliar , Colangiografia/métodos , Doenças do Sistema Digestório/diagnóstico por imagem , Feminino , Humanos , Fígado/diagnóstico por imagem , Fígado/cirurgia , Masculino , Pessoa de Meia-Idade , Pâncreas/diagnóstico por imagem , Pâncreas/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Resultado do Tratamento
6.
Surg Endosc ; 34(2): 675-685, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31062156

RESUMO

BACKGROUND: Incisionless fluorescent cholangiography (IFC) has recently been proven feasible, safe, and efficacious as an intraoperative procedure to help identify extrahepatic bile ducts during laparoscopic cholecystectomies (LC). We conducted a pilot survey of 51 surgeons attending an international conference who perform endoscopic cholecystectomies to identify their typical LC practices, and perceptions of IFC. METHODS: An international panel of ten IFC experts, all with > 500 prior IFC procedures and related research publications, convened during the 4th International Congress of Fluorescence-Guided Surgery in Boca Raton, Florida in February 2017. The panel was charged with developing questions about LC practices and experience with IFC, and perceptions regarding its advantages, barriers to use, and indications. These questions then were asked to other congress attendees during one of the didactic sessions using an online polling application. Attendees, who ranged from zero to considerable experience performing IFC, accessed the survey via their portable devices. RESULTS: Of the 51 survey participants, 51% were from North America; 77% identified themselves as general/minimally invasive surgeons, and roughly 60% performed under 50 cholecystectomies/year. Only 12% performed routine intraoperative cholangiography (IOC), while 72.3% routinely performed critical safety reviews. Thirty-five percent estimated that their institution's laparoscopic-to-open surgery conversion rate was > 1% during LC. Roughly 95% of respondents felt that surgeons should have access to a noninvasive method for evaluating extrahepatic biliary structures; 84% felt that the most advantageous characteristic of IFC is the lack of any biliary-tree incision; and 93.3% felt that IFC would have considerable educational value in surgical training programs; and 78% felt that any surgeon who performs LC could benefit. CONCLUSIONS: Surgeons who participated in our survey overwhelmingly recommended the routine use of IFC during laparoscopic cholecystectomy as a complimentary imaging technique. Prospective randomized clinical trials remain necessary to determine whether IFC reduces the incidence of bile duct injuries and other LC complications.


Assuntos
Doenças dos Ductos Biliares/diagnóstico , Ductos Biliares Extra-Hepáticos/diagnóstico por imagem , Colangiografia/métodos , Colecistectomia Laparoscópica/métodos , Percepção , Doenças dos Ductos Biliares/cirurgia , Congressos como Assunto , Feminino , Humanos , Masculino , Projetos Piloto , Estudos Prospectivos , Inquéritos e Questionários
8.
J Pak Med Assoc ; 69(10): 1559-1564, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31622318

RESUMO

Iatrogenic injury to the bile duct is one of the most serious and feared complication of cholecystectomy, with a high mortality ranging between 3-12%. The management of such injuries of the bile duct is far more complicated and prolonged than the procedure itself. A retrospective analysis of 36 patients with bile duct injuries (BDI) was conducted over a period of 7 years, from January 2007 to December 2014. Most of their injuries occurred during open cholecystectomy, 22 rather than laparoscopic 14 and were mostly elective surgeries 34. Most injuries were identified postoperatively in 33 (91.6%) patients, at a median of 3.0 days. Among the modalities used to diagnose and treat these patients, endoscopy was performed in 32 of the cases (88.8%), followed by surgery on 17 (47.2%) patients and radiology on 16 (44.4%) cases. Surgery remains the gold standard for treatment of complete transection of bile duct injuries and long term outcomes are usually good. Endoscopy and radiology has an increasing role in the diagnosis and treatment of a leaking (non-transected) bile duct injury.


Assuntos
Ductos Biliares/cirurgia , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Colecistectomia/efeitos adversos , Adulto , Ductos Biliares/lesões , Colangiografia/métodos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colangiopancreatografia por Ressonância Magnética , Colecistectomia Laparoscópica/efeitos adversos , Procedimentos Cirúrgicos Eletivos , Feminino , Ducto Hepático Comum/cirurgia , Humanos , Doença Iatrogênica , Jejuno/cirurgia , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Período Pós-Operatório , Estudos Retrospectivos
9.
J Pediatr Surg ; 54(12): 2574-2578, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31575415

RESUMO

BACKGROUND: Indocyanine green (ICG) fluorescence imaging is a promising tool for intraoperative decision-making. The aim of this study was to evaluate the utility of near-infrared fluorescence cholangiography (NIR-FCG) with ICG in primary surgery for biliary atresia (BA). METHODS: We performed NIR-FCG with ICG in 10 BA patients and observed the fluorescence of their hilar micro-bile ducts and hilar exudate in order to assess the appropriate level at which to dissect the hilar fibrous corn. We compared the jaundice outcome of 10 patients using NIR-FCG (Group A) to that of 35 historical patients in whom NIR-FCG had not been used (Group B). RESULTS: The mean age of patients was 74.8 days. The classification of BA was type I in two cases and type-III in eight cases. NIR-FCG visualized the hilar micro-bile ducts, and the incidence of positive fluorescence was 80%. The ratio of postoperative normalization of hyperbilirubinemia in Group A was significantly higher than that in Group B (1.0 vs. 0.65, p < 0.05). CONCLUSION: NIR-FCG provided important objectifiable information about the biliary structures in surgery of BA. Although the number of cases was small, our results suggest that NIR-FCG may be useful for improving the outcome of primary surgery for BA. TYPE OF STUDY: Study of Diagnostic Test. LEVEL OF EVIDENCE: Level III.


Assuntos
Ductos Biliares , Atresia Biliar , Colangiografia/métodos , Verde de Indocianina/uso terapêutico , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Ductos Biliares/diagnóstico por imagem , Ductos Biliares/cirurgia , Atresia Biliar/diagnóstico por imagem , Atresia Biliar/cirurgia , Feminino , Humanos , Lactente , Masculino , Imagem Óptica/métodos , Estudos Retrospectivos , Cirurgia Assistida por Computador/métodos
10.
Chirurg ; 90(11): 880-886, 2019 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-31559461

RESUMO

Intraoperative fluorescence angiography and cholangiography with indocyanine green (ICG) are increasingly used in routine hepatobiliary surgery. Its usage is manifold. It improves and facilitates navigation especially in minimal invasive and robotic surgery and therefore increases the safety of the surgical intervention. In laparoscopic cholecystectomy for example, the bileduct anatomy can be easily visualized, even in complicated cholecystitis or anatomical variants without being too time consuming. ICG fluorescence also enables the visualization of vascular structures and perfusion. Anatomical liver resections, for example in hepatocellular carcinoma (HCC), can be performed easily as liver segments and territories can be identified. Anatomical resection is becoming more important, e.g. in the treatment of HCC. Another useful application is the intraoperative detection of bile leakages after liver resection. In particular, the intraoperative control of a biliodigestive anastomosis is possible with ICG fluorescence cholangiography and therefore reduces morbidity. Even primary and secondary liver tumors can be detected with ICG fluorescence. Whereas well-differentiated HCCs homogeneously take up ICG, poorly differentiated HCCs and metastases do not: however, in these cases the adjacent liver parenchyma stores ICG more intensively than healthy liver tissue, which creates a ring-like fluorescence pattern. To conclude, the use of ICG fluorescence in hepatobiliary surgery is diverse but in Germany it is still at the beginning compared to other countries.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/métodos , Carcinoma Hepatocelular , Colangiografia/métodos , Angiofluoresceinografia/métodos , Neoplasias Hepáticas , Sistema Biliar/diagnóstico por imagem , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/cirurgia , Corantes , Alemanha , Humanos , Verde de Indocianina/farmacocinética , Cuidados Intraoperatórios , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/cirurgia
11.
Cardiovasc Intervent Radiol ; 42(12): 1745-1750, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31493058

RESUMO

INTRODUCTION: Biliary duct injuries pose a significant management challenge due to the propensity for recurrent biliary strictures. Development of a modified Roux-en-Y hepaticojejunostomy known as a Hutson-Russell Pouch (HRP) provides a point of entry for repetitive access to the biliary tree. We aim to highlight the effectiveness of using the HRP as an access point for the long-term management of anastomotic and distal biliary strictures, thereby showcasing the value in potential widespread adoption of this modification to a standard surgical procedure. MATERIALS AND METHODS: IRB-approved retrospective study of 36 patients (10 M, 26 F; mean age 55.19 ± 13.94; 15-83) underwent a total of 110 transjejunal cholangiograms. Indications for cholangiogram included cholangitis (n = 38), surveillance (n = 36), and elevated liver enzymes (n = 36). Technical success was defined by the ability to access and intervene in the biliary tree via HRP access. In case of stenosis, the ability to successfully dilate (< 30%) residual stenosis was considered a technically successful procedure. Clinical success was defined by normalization of the liver function tests or resolution of cholangitis. RESULTS: Technical success was achieved in 83/110 (75.45%) of the cases, and clinical success was achieved in 102/110 (98.2%). Transhepatic access was needed in 27/110 (24.5%) of the cases. Interventions performed included balloon cholangioplasty in 104/110 (94.5%), biliary stone removal in 2/110 (1.8%), biliary stent placement in 2/110 (1.8%), and biliary drain placement in 4/110 (3.6%). There were a total of 9/110 complications (8.2%). CONCLUSION: The HRP was an effective access point in the management of recurrent benign biliary strictures in this cohort.


Assuntos
Anastomose em-Y de Roux/métodos , Doenças dos Ductos Biliares/patologia , Doenças dos Ductos Biliares/cirurgia , Colangiografia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças dos Ductos Biliares/diagnóstico por imagem , Ductos Biliares/diagnóstico por imagem , Ductos Biliares/patologia , Ductos Biliares/cirurgia , Estudos de Coortes , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Adulto Jovem
12.
Ann Surg ; 270(3): 519-527, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31415304

RESUMO

INTRODUCTION: Early cholecystectomy shortly after admission for mild gallstone pancreatitis has been proposed based on observational data. We hypothesized that cholecystectomy within 24 hours of admission versus after clinical resolution of gallstone pancreatitis that is predicted to be mild results in decreased length-of-stay (LOS) without an increase in complications. METHODS: Adults with predicted mild gallstone pancreatitis were randomized to cholecystectomy with cholangiogram within 24 hours of presentation (early group) versus after clinical resolution (control) based on abdominal exam and normalized laboratory values. Primary outcome was 30-day LOS including readmissions. Secondary outcomes were time to surgery, endoscopic retrograde cholangiopancreatography (ERCP) rates, and postoperative complications. Frequentist and Bayesian intention-to-treat analyses were performed. RESULTS: Baseline characteristics were similar in the early (n = 49) and control (n = 48) groups. Early group had fewer ERCPs (15% vs 29%, P = 0.038), faster time to surgery (16 h vs 43 h, P < 0.005), and shorter 30-day LOS (50 h vs 77 h, RR 0.68 95% CI 0.65 - 0.71, P < 0.005). Complication rates were 6% in early group versus 2% in controls (P = 0.613), which included recurrence/progression of pancreatitis (2 early, 1 control) and a cystic duct stump leak (early). On Bayesian analysis, early cholecystectomy has a 99% probability of reducing 30-day LOS, 93% probability of decreasing ERCP use, and 72% probability of increasing complications. CONCLUSION: In patients with predicted mild gallstone pancreatitis, cholecystectomy within 24 hours of admission reduced rate of ERCPs, time to surgery, and 30-day length-of-stay. Minor complications may be increased with early cholecystectomy. Identification of patients with predicted mild gallstone pancreatitis in whom early cholecystectomy is safe warrants further investigation.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia Laparoscópica/métodos , Cálculos Biliares/complicações , Tempo de Internação , Pancreatite/etiologia , Pancreatite/cirurgia , Adulto , Fatores Etários , Teorema de Bayes , Colangiografia/métodos , Feminino , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/cirurgia , Humanos , Cuidados Intraoperatórios/métodos , Masculino , Pessoa de Meia-Idade , Pancreatite/fisiopatologia , Admissão do Paciente , Prognóstico , Valores de Referência , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Tempo para o Tratamento , Resultado do Tratamento
13.
Transplant Proc ; 51(8): 2735-2739, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31331720

RESUMO

PURPOSE: We aimed to determine the visibility of bile ducts of the caudate lobe (B1s) and right/left (R/L) dissociation on contrast-enhanced T1-magentic resonance cholangiography after gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid administration (CE-T1-MRC) in live liver donors. MATERIALS AND METHODS: In 300 live liver donors who underwent CE-T1-MRC, the visibility and R/L dissociation of B1 were evaluated. Confidence level of B1 visibility and depiction of the presence of R/L dissociation on axial and coronal reconstruction images were compared. Strength of agreement between R/L dissociation on MRC and that on intraoperative cholangiography was evaluated. RESULTS: At least 1 B1 was visible on CE-T1-MRC in 142 of 300 subjects (47.3%; a total of 195 B1s; 0.64 [SD, 0.80], 0-4 branches per person). Of 195 subjects with visible B1, 55 ducts showed R/L dissociation (28.2%; right-to-left crossover, n = 28; left-to-right crossover, n = 27). The confidence level of B1 visibility on axial images of MRC was significantly higher than that on coronal images of MRC (P < .001). Of 55 B1s with R/L dissociation, axial images were superior to coronal images in depicting B1 crossover in 31 and vice versa in 2 (equal between axial and coronal images in 22). The agreement for R/L dissociation between CE-T1-MRC and intraoperative cholangiography was excellent (κ = 0.819; 95% CI, 0.722-0.917). CONCLUSION: Bile ducts of the caudate lobe with R/L dissociation can be occasionally identified on CE-T1-MRC. Axial reconstruction is superior to coronal counterpart.


Assuntos
Ductos Biliares/diagnóstico por imagem , Colangiografia/métodos , Colangiopancreatografia por Ressonância Magnética/métodos , Transplante de Fígado/métodos , Adulto , Meios de Contraste , Feminino , Gadolínio DTPA , Humanos , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
14.
Rev Esp Enferm Dig ; 111(8): 650-651, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31317754

RESUMO

Bile duct cysts represent congenital abnormalities associated with biliopancreatic maljunction that may undergo malignant degeneration. We report herein the case of a 72-year-old male patient with cholangitis. MR-cholangiography and abdominal CT revealed a mass at the biliary-pancreatic-duodenal crossroads, extrahepatic biliary dilation up to 38 mm, and pancreas divisum. Gastroscopy found an infiltrative bulbar mucosa with adenocarcinoma in biopsy samples, and extrinsic bulging of the second duodenal portion. Endoscopic ultrasound showed a choledochal cystic dilation with solid contents, and FNA findings were nonspecific. ERCP confirmed an adenomatous papilla at the lower portion of the extrinsic formation, and a large cystic, saccular dilation of extrahepatic bile ducts (Todani Ia). Fistulotomy was required for deep cannulation of the proximal biliary tract, and attention was drawn to extruding polypoid lesions originating in the biliary epithelium, identified in biopsies as adenoma with dysplasia. Finally, a diagnosis was made of advanced adenocarcinoma in choledochal cyst.


Assuntos
Adenocarcinoma/patologia , Neoplasias dos Ductos Biliares/patologia , Cisto do Colédoco/patologia , Pâncreas/anormalidades , Idoso , Colangiografia/métodos , Evolução Fatal , Gastroscopia , Humanos , Imagem por Ressonância Magnética/métodos , Masculino , Tomografia Computadorizada por Raios X
15.
Invest Radiol ; 54(9): 572-579, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31261292

RESUMO

OBJECTIVE: The purpose of this work is to determine whether low doses of gadoxetate disodium (Eovist; Bayer Healthcare LLC, Whippany, NJ), a gadolinium-based contrast agent used for magnetic resonance liver imaging, can be visualized for computed tomography (CT) cholangiography using a phantom setup. MATERIALS AND METHODS: Vials containing 4 concentrations of gadoxetate disodium (1.9, 3.4, 4.8, and 9.6 mg Gd/mL) were placed in a 35 × 26-cm water phantom and imaged on 2 CT scanners: Siemens Somatom Flash and Force (Siemens Healthcare, Erlangen, Germany). These concentrations correspond to the estimated concentration in the bile duct for a 40-, 70-, or 100-kg patient, and twice the concentration of a 100-kg patient, respectively. Single-energy (SE) scans were acquired at 70, 80, 90, 100, 120, and 140 kVp, and dual-energy scans were acquired at 90/150Sn (Force) and 100/150 (Flash) for 2 dose levels (CTDIvol 13 and 23 mGy). Virtual monoenergetic images at 50 keV were created (Mono+; Siemens Healthcare, Erlangen, Germany). The mean intensity and standard deviation for each concentration of gadoxetate disodium and the water background were extracted from each image set and used to compute the contrast and contrast-to-noise ratio (CNR). To determine whether the signal provided by gadoxetate disodium was clinically sufficient, the measures were compared with those acquired from 12 clinical CT cholangiography examinations performed with iodine-containing iodipamide meglumine. RESULTS: From the retrospective clinical cohort, mean contrast (± standard deviation) of 239 ± 107 HU and CNR of 12.8 ± 4.2 were found in the bile duct relative to the liver. Comparing these metrics to the gadoxetate disodium samples, the highest concentration (9.6 mg Gd/mL) surpassed these thresholds at all energy levels. The 4.8 mg Gd/mL had sufficient CNR in the Force, but not in the Flash. The 3.4 mg Gd/mL had clinically relevant CNR at low kV of SE (<100 kVp) and 50 keV of dual energy in the Force but was insufficient in the Flash. Images acquired by the Force had a lower noise level and greater CNR compared with the Flash. Similar trends were seen at both dose levels. CONCLUSIONS: Gadoxetate disodium shows promise as a viable contrast agent for CT cholangiography, with CNR similar to those seen clinically with an iodine-based contrast agent. Dual-energy CT or low kV SE-CT is helpful to enhance the signal.


Assuntos
Colangiografia/métodos , Meios de Contraste , Gadolínio DTPA , Aumento da Imagem/métodos , Tomografia Computadorizada por Raios X/métodos , Humanos , Imagens de Fantasmas , Estudos Retrospectivos , Razão Sinal-Ruído
16.
BMJ Open ; 9(6): e029330, 2019 06 09.
Artigo em Inglês | MEDLINE | ID: mdl-31182455

RESUMO

INTRODUCTION: Bile leak is still a major complication after liver resection to be improved. To intraoperatively detect this adverse complication, leak test is commonly performed after hepatic resection. However, by the conventional leak test, it is often difficult to know whether the test reagent reaches to intrahepatic bile duct near cut surface of liver with adequate volume and pressure to identify the existence of bile leak. Thus, in order to perform leak test more accurately, this study aims to evaluate the efficacy and safety of the leak test using contrast-enhanced intraoperative ultrasonic cholangiography (CE-IOUSC), which was reported by our group as a procedure for detection of bile duct. METHODS AND ANALYSIS: The current study is a non-randomised, prospective, off-label, single-arm clinical trial for patients who undergo liver resection. A total of 100 patients will be enrolled. After completion of liver resection, the leak test is performed with CE-IOUSC using Sonazoid as a contrast agent to visualise dye injection into the intrahepatic bile duct. The primary endpoint is the success of the leak test, defined as clear visualisation of intrahepatic bile duct around cut surface by ultrasonography that indicates enough volume of dye injection. Secondary endpoints are postoperative bile leak and all adverse events related to CE-IOUSC. The findings obtained through this study will establish this procedure to assist surgeons for adequately performing the leak test, precisely detecting intraoperative biliary leak strictly and reducing postoperative bile leak. ETHICS AND DISSEMINATION: The protocol is approved by Institutional Review Boards of Kobe University Hospital (No.290069). Our findings will be widely disseminated through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: UMIN000031236 and jRCTs051180027.


Assuntos
Bile , Colangiografia/métodos , Meios de Contraste , Fígado/cirurgia , Ultrassonografia de Intervenção , Adulto , Hepatectomia/efeitos adversos , Hepatectomia/métodos , Humanos , Período Intraoperatório , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Ultrassonografia de Intervenção/métodos
18.
Surg Technol Int ; 34: 129-133, 2019 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-31037715

RESUMO

INTRODUCTION: Needlescopic cholecystectomy (NC) was introduced in the late 1990s. It uses a reduced trocar caliber in an otherwise standard four-port laparoscopic cholecystectomy (LC) and seeks to achieve "scarless" surgery without compromising patient safety. MATERIALS AND METHODS: Between May 2016 and November 2017, 29 patients underwent elective NC at the Department of General Surgery of Sant'Andrea Hospital (La Spezia, Italy). Inclusion criteria were female sex, age between 18 and 45 years, good performance status (ASA 1-2) and BMI lower than 25. Twenty-one patients underwent a standard 4-port technique: 12mm port in the supraumbilical area, 5mm port in the subxiphoid position, 3mm port in the mid-epigastric area and another 3 mm port in the right mid-clavicular position. In 8 patients, 3mm ports were replaced by 2mm angiocath. A Critical View of Safety (CVS) was achieved in all procedures. Intra-operative cholangiography (IOC) via the cystic duct before any transection of the structures was routinely performed in selected cases, such as those with an unclear biliary anatomy or risk factors for main-duct stones. In our institution, laparoscopic transcystic common bile duct (CBD) exploration is routinely performed in CBD lithiasis. RESULTS: The mean operative time was 66.79 min (range 25-120 min). IOC was performed in 12 patients (41.4%) with suspected choledocolythiasis. There was no conversion to conventional laparoscopic cholecystectomy or open cholecystectomy. The mean hospital stay was 1.48 days (1-7 days). A Clavien-Dindo IIIB complication occurred in one patient on the third postoperative day. The mean VAS pain score was 3 (0-7). Closure of the skin with primary intention was achieved in all patients. Mean return to work was 6.76 days (3-15 days) and the mean return to previous physical activity was 12.17 days (4-30 days). All of the patients completed the Scar Satisfaction Questionnaire: 26 (89.7% ) and 3 patients (10.3%) were very satisfied and satisfied, respectively. CONCLUSION: Any effort to reduce invasiveness and improve cosmesis must not jeopardize safety. Our case series demonstrates that needlescopy can be safely associated with intraoperative cholangiography to recognize CBD stones. This technique offers the advantage of minor postoperative pain, better cosmesis results, early return to routine life activities and great satisfaction for the patient. Needlescopy is a valuable and safe alternative that is suitable for elective cholecystectomy in properly selected patients, such as young female patients.


Assuntos
Colecistectomia Laparoscópica/instrumentação , Colecistectomia Laparoscópica/métodos , Adolescente , Adulto , Colangiografia/métodos , Coledocolitíase/cirurgia , Técnicas Cosméticas/instrumentação , Feminino , Humanos , Cuidados Intraoperatórios , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Adulto Jovem
19.
Clin Transplant ; 33(7): e13614, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31125455

RESUMO

BACKGROUND: Biliary complications can result in a significant morbidity for split liver graft recipients. Biliary drainage for segment 1 and 4 is highly variable and could be the source of bile leaks. Use of a bench cholangiogram (BCH) can accurately define the segmental biliary system and identify any significant biliary radicles that need retention or repair during bench preparation of split grafts. This study evaluates the clinical relevance of routine BCH in split liver transplantation (SLT). METHODS: Retrospective review of 100 BCH images performed during ex situ deceased donor SLT between January 2009 and January 2015. The radiographs were reviewed by two surgeons and the biliary anatomy was compared using Huang and Reichert classification. RESULTS: 100 BCH images were reviewed. Variant anatomy was frequently identified in the intrahepatic bile duct system, the number and drainage patterns of segment 1&4 duct was diverse. BCH results guided the line of parenchymal transection to obtain a single segment 2&3 duct in 15 cases. A surgical intervention in the form of suture ligation of significant segment 1 or 4 duct at bench preparation was performed in 6 cases. BCH images guided surgical control of post-operative bile leak in 3 patients. CONCLUSION: Bench cholangiogram is a useful tool to guide liver parenchymal transection and potentially reduce the incidence of biliary complications.


Assuntos
Sistema Biliar/anatomia & histologia , Colangiografia/métodos , Colangiografia/estatística & dados numéricos , Hepatectomia/métodos , Transplante de Fígado , Fígado/cirurgia , Doadores de Tecidos/provisão & distribução , Adolescente , Adulto , Drenagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
20.
J Surg Res ; 242: 318-322, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31129240

RESUMO

BACKGROUND: Laparoscopic intraoperative cholangiogram (IOC) with common bile duct exploration (CBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two therapeutic techniques for choledocholithiasis. The preferred technique is unclear. MATERIALS AND METHODS: We identified subjects who underwent laparoscopic cholecystectomy (LC) and IOC/CBDE or ERCP from July 1, 2006, to December 31, 2016. We retrospectively reviewed 81 patients (≤ 18 y) who received these interventions for suspected choledocholithiasis. Main outcomes analyzed were success of intervention and complications. RESULTS: Of the 81 patients, 21 ERCPs and three endoscopic ultrasounds (EUSs) were performed before LC. Eighteen of 21 (85.7%) patients had stones or sludge cleared by ERCP, whereas 3 (14.3%) had normal common bile ducts without evidence of stones. Five of 24 (20.8%) had significant post-ERCP complications. Seven of 24 (29.2%) had more than one admission. Sixty of 81 patients underwent LC with IOC ± CBDE. Twenty one of 60 (36.2%) were found to have abnormal IOC. Eight of 15 (53.3%) attempted laparoscopic CBDE were successful. Eleven of 21 (52.4%) patients with abnormal IOC had post-LC ERCP (10) and EUS (1). Patients admitted to the Pediatric Surgery service were more likely to undergo LC first than ERCP/EUS (OR 3.46, 95% CI 1.26 to 9.45, P = 0.016). Patients undergoing LC first had a shorter length of stay (mean LOS 5.13 d versus 4.07, median 5.0 versus 3.0 d, P-value < 0.05). CONCLUSIONS: Successful and safe laparoscopic treatment of choledocholithiasis is possible in the pediatric patient. A laparoscopic-first approach to suspected choledocholithiasis may reduce the number of procedures needed in this patient population.


Assuntos
Colangiografia/métodos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colecistectomia Laparoscópica/métodos , Coledocolitíase/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Adolescente , Coledocolitíase/diagnóstico por imagem , Ducto Colédoco/diagnóstico por imagem , Ducto Colédoco/cirurgia , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento
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