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3.
Acta Biomed ; 93(1): e2022020, 2022 Mar 14.
Artigo em Inglês | MEDLINE | ID: mdl-35315388

RESUMO

In patients with symptomatic intrahepatic biliary lithiasis, the treatment is usually discussed by a multidisciplinary team. Although hepatectomy is considered as definitive treatment, when lobar atrophy is absent, endoscopic procedures are frequently proposed as first-line treatment due the low invasiveness and for sparing liver parenchyma. Percutaneous route is used in case of peroral approach failure. We present a case of recurrent symptomatic intrahepatic biliary lithiasis of the right posterior hepatic duct, sustained by downstream biliary stenosis. Peroral cholangioscopy failed to visualize the stone for the accompanying stenosis. Thus, the patient was successfully treated with percutaneous transhepatic lithotripsy performed with Spyglass direct visualization system II (Boston Scientific Inc., Natick, Massachusetts, USA). During the procedure, the biopsy of the biliary stenosis revealed fibrosis, which was treated by cholangioplasty with cutting balloon. After 15 months, the patient is asymptomatic, with moderate residual stenosis in absence of calculi at follow-up magnetic resonance cholangiography.


Assuntos
Litíase , Litotripsia , Ductos Biliares Intra-Hepáticos , Colangiografia , Constrição Patológica/etiologia , Humanos , Litíase/etiologia , Litíase/terapia , Litotripsia/efeitos adversos , Litotripsia/métodos
4.
Syst Rev ; 11(1): 36, 2022 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-35241165

RESUMO

BACKGROUND: Laparoscopic cholecystectomy has become the standard surgical approach in the treatment of cholelithiasis. Diverse surgical techniques and different imaging modalities have been described to evaluate the biliary anatomy and prevent or early detect bile duct injuries. X-ray intraoperative cholangiography (IOC) and near infrared indocyanine green fluorescent cholangiography (NIR-ICG) are safe and feasible techniques to assess biliary anatomy. The aim of this systematic review will be to evaluate if NIR-ICG can visualize extrahepatic biliary anatomy more efficiently and safer than IOC in minimally invasive cholecystectomy for gallstone disease. METHODS: Literature search will be performed via MEDLINE (PubMed), Embase, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science Core Collection from 2009 to present. All randomized controlled clinical trials and prospective non-randomized controlled trials which report on comparison of NIR-ICG versus IOC will be included. All patients over 18 years old who require elective or urgent minimally invasive cholecystectomy (undergoing NIR-ICG during this procedure) due to gallstone disease both acute and chronic will be included. Since BDI has a low incidence, the primary outcome will be the ability to visualize extrahepatic biliary anatomy and the time to obtain relevant images of these structures. Two researchers will individually screen the identified records, according to a list of inclusion and exclusion criteria. Bias of the studies will be evaluated with the Newcastle-Ottawa score for non-randomized studies and with The Cochrane Risk of Bias Tool for randomized controlled trials. Quality of evidence for all outcomes will be determined with the GRADE system. The data will be registered in a predesigned database. If selected studies are sufficiently homogeneous, we will perform a meta-analysis of reported results. In the event of a substantial heterogeneity, a narrative synthesis will be provided. Subgroup analysis will be used to investigate possible sources of heterogeneity. DISCUSSION: Understanding the benefits of this technique is critical to ensuring policymakers can make informed decisions as to where preventive efforts should be focused regarding specific imaging techniques. If ICG is proven to be faster and non-invasive, its routine use could be encouraged. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020177991 .


Assuntos
Colangiografia , Colecistectomia Laparoscópica , Colelitíase , Adolescente , Colangiografia/métodos , Colecistectomia Laparoscópica/métodos , Colelitíase/cirurgia , Corantes , Humanos , Verde de Indocianina , Metanálise como Assunto , Estudos Prospectivos , Revisões Sistemáticas como Assunto
5.
Surg Endosc ; 36(6): 4442-4451, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35194663

RESUMO

OBJECTIVE: To test the hypothesis that ICG fluorescence cholangiography (ICG-FC) helps to identify critical structures during laparoscopic cholecystectomy (LC) and hence reduce biliary injuries and conversions. In LC, biliary injury and conversion often happen if the biliary anatomy is misidentified. METHODS: This was a single-center randomized controlled trial from 2017 to 2019. Patients with acute cholecystitis requiring LC were assessed for eligibility for the trial. Patients in the trial were randomized to undergo either conventional LC (conventional arm) or LC with ICG-FC (ICG arm). Conversion rate and biliary injury incidence were outcome measures. RESULTS: Totally 92 patients participated (46 patients in each arm). The median age was 61 years in both arms (p = 0.472). The conventional arm had 22 men and 24 women; the ICG arm had 24 men and 22 women (p = 0.677). The two arms were comparable in all perioperative parameters. The time from ICG injection to surgery was 67 (16-1150) min. Both arms had an 8.7% conversion rate (p = 1.000). The median operative time was 140.5 min in the conventional arm and 149.5 min in the ICG arm (p = 0.086). The complication rate was 15.2% in the former and 10.9% in the latter (p = 0.536), and both had a 2.2% bile leakage rate. The median hospital stay was 3.5d in the former and 4.0d in the latter (p = 0.380). CONCLUSION: ICG-FC did not make any difference in conversion or complication rate. Its routine use in LC is questionable. However, it may be helpful in difficult cholecystectomies and may be used as an adjunct. TRIAL REGISTRATION: The trial was registered with the Institutional Review Board of University of Hong Kong/Hospital Authority Hong Kong West Cluster ( http://www.med.hku.hk/en/research/ethics-and-integrity/human-ethics ). REGISTRATION NUMBER: UW17-492.


Assuntos
Sistema Biliar , Colecistectomia Laparoscópica , Colangiografia , Colecistectomia , Colecistectomia Laparoscópica/efeitos adversos , Feminino , Humanos , Verde de Indocianina , Masculino , Pessoa de Meia-Idade
6.
Medicine (Baltimore) ; 101(8): e28829, 2022 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-35212280

RESUMO

RATIONALE: Gallbladder cancer is the most common malignancy of the biliary tree. Despite this, the only curative therapy remains surgical resection of the lesion achieving microscopically clear margins before malignant spread has occurred. Gallbladder duplication is an uncommon anatomical variance which occurs globally. It can present in a range of ways dependent on the embryological origin of the variance. CASE: A 52-year-old female presented for planned laparoscopic cholecystectomy in the context of cholelithiasis resulting in recurrent biliary colic. The patient had no personal history of malignancy or significant medical comorbidities. DIAGNOSIS: Intraoperatively, the patient was found to have Y-insertion variation of gallbladder duplication. Histopathology of the resected gallbladders showed an incidental invasive gallbladder adenocarcinoma affecting one of the gallbladders. INTERVENTION: Both gallbladders were laparoscopically resected en-bloc. OUTCOMES: The patient underwent oncology staging, which found no evidence of metastatic spread. Regular surveillance is attended with no recurrence of disease identified. CONCLUSION: There are few reported cases detailing the occurrence of gallbladder adenocarcinoma in the presence of duplication of the gallbladder. This case demonstrates the clinical benefit of R0 surgical resection of gallbladder cancer, whilst highlighting the difficulties of diagnosing duplication of the gallbladder or gallbladder adenocarcinoma.


Assuntos
Adenocarcinoma/patologia , Colecistectomia Laparoscópica/métodos , Neoplasias da Vesícula Biliar/patologia , Vesícula Biliar/diagnóstico por imagem , Adenocarcinoma/diagnóstico , Adenocarcinoma/cirurgia , Colangiografia , Cólica , Feminino , Vesícula Biliar/patologia , Vesícula Biliar/cirurgia , Neoplasias da Vesícula Biliar/diagnóstico , Neoplasias da Vesícula Biliar/cirurgia , Humanos , Achados Incidentais , Pessoa de Meia-Idade
7.
BMC Gastroenterol ; 22(1): 12, 2022 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-34996384

RESUMO

BACKGROUND: X-ray cholangiography is of great value in the imaging of biliary tract diseases; however, occupational radiation exposure is unavoidable. Moreover, clinicians must manually inject the contrast dye, which may result in a relatively high incidence of adverse reactions due to unstable injection pressure. Thus, there is a need to develop a novel remote-controlled cholangiography injection device. METHODS: Patients with external biliary drainage requiring cholangiography were included. A remote-controlled injection device was developed with three major components: an injection pump, a pressure sensor, and a wireless remote-control panel. Image quality, adverse reactions, and radiation dose were evaluated. RESULTS: Different kinds of X-ray cholangiography were successfully and smoothly performed using this remote-controlled injection device in all patients. The incidence of adverse reactions in the device group was significantly lower than that in the manual group (4.17% vs. 13.9%, P = 0.001), and increasing the injection pressure increased the incidence of adverse reactions. In addition, the device helped operators avoid ionizing radiation completely. CONCLUSIONS: With good control of injection pressure (within 10 kPa), the remote-controlled cholangiography injection device could replace the need for the doctor to inject contrast agent with good security and effectivity. It is expected to be submitted for clinical application.


Assuntos
Doenças Biliares , Colangiografia , China , Meios de Contraste/efeitos adversos , Drenagem , Humanos
8.
Hepatobiliary Pancreat Dis Int ; 21(2): 145-153, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35031229

RESUMO

BACKGROUND: There are few randomized controlled trials with sufficient statistical power to assess the effectiveness of intraoperative cholangiography (IOC) in the detection and treatment of common bile duct injury (BDI) or retained stones during cholecystectomy. The best evidence so far regarding IOC and reduced morbidity related to BDI and retained common bile duct stones was derived from large population-based cohort studies. Population-based studies also have the advantage of reflecting the outcome of the procedure as it is practiced in the community at large. However, the outcomes of these population-based studies are conflicting. DATA SOURCES: A systematic literature search was conducted in 2020 to search for articles that contained the terms "bile duct injury", "critical view of safety", "bile duct imaging" or "retained stones" in combination with IOC. All identified references were screened to select population-based studies and observational studies from large centers where socioeconomic or geographical selections were assumed not to cause selection bias. RESULTS: The search revealed 273 references. A total of 30 articles fulfilled the criteria for a large observational study with minimal risk for selection bias. The majority suggested that IOC reduces morbidity associated with BDI and retained common bile duct stones. In the short term, IOC increases the cost of surgery. However, this is offset by reduced costs in the long run since BDI or retained stones detected during surgery are managed immediately. CONCLUSIONS: IOC reduces morbidity associated with BDI and retained common bile duct stones. The reports reviewed are derived from large, unselected populations, thereby providing a high external validity. However, more studies on routine and selective IOC with well-defined outcome measures and sufficient statistical power are needed.


Assuntos
Doenças dos Ductos Biliares , Colecistectomia Laparoscópica , Cálculos Biliares , Doenças dos Ductos Biliares/cirurgia , Ductos Biliares/cirurgia , Colangiografia/métodos , Colecistectomia/efeitos adversos , Colecistectomia Laparoscópica/métodos , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/cirurgia , Humanos , Cuidados Intraoperatórios , Estudos Observacionais como Assunto
10.
Pediatr Transplant ; 26(2): e14160, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34633121

RESUMO

BACKGROUND: Endoscopic and PTB interventions are common nonsurgical interventions for biliary anastomotic strictures that occur after liver transplantation. When these nonsurgical interventions fail, surgical re-anastomosis is considered; however, this is quite invasive and can cause additional injury that may lead to graft loss. We report a case in which conventional nonsurgical interventions failed, but a new method that involve the use of a transseptal needle-a device to create a transseptal left-heart access during cardiac catheter interventions-was successfully used in recanalization of the hepaticojejunal anastomotic obstruction. CASE: A 21-year-old man, who had received living-donor liver transplantation for biliary atresia at the age of 23 months presented with recurrent cholangitis and liver dysfunction due to a biliary anastomotic stricture of the hepaticojejunostomy. Therapeutic interventions for biliary stricture, including the PTB approach, double-balloon enteroscopic approach, and rendezvous approach failed. We then performed needle puncture of the anastomotic obstruction using a transseptal needle and succeeded in recanalizing the complete anastomotic obstruction. To perform the procedures safely, we evaluated the organ and needle positions using biplane fluoroscopy and placed a balloon in the afferent jejunal limb as a target for puncture. The 12 Fr catheter via the biliary route was removed 7 months after the procedure, without using a catheter, there was no recurrent stricture or cholangitis for 26 months. CONCLUSION: Using a transseptal needle to manage hepaticojejunal anastomotic obstruction can reduce the number of patients who need surgical re-anastomosis.


Assuntos
Colestase/terapia , Jejunostomia/métodos , Transplante de Fígado , Agulhas , Complicações Pós-Operatórias/terapia , Anastomose Cirúrgica , Atresia Biliar/cirurgia , Colangiografia , Colestase/diagnóstico por imagem , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/terapia , Fluoroscopia , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Punções , Radiografia Intervencionista , Tomografia Computadorizada por Raios X , Adulto Jovem
11.
Eur Radiol ; 32(3): 1709-1717, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34505194

RESUMO

OBJECTIVES: To investigate transcholecystic management of extrahepatic duct (EHD) stones using balloon ampulloplasty in patients who are poor candidates for endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) and assess its efficacy and safety. METHODS: Forty-one patients who were unable to undergo ERCP or had failed ERCP with non-dilated intrahepatic ducts (IHD) between February 2019 and October 2020 were retrospectively enrolled. After clinical improvement with percutaneous cholecystostomy (PC), EHD stones were managed through cystic duct passage, guidewire unwinding, sheath insertion, and EHD stone removal using balloon ampulloplasty. If the transcholecystic route failed, a transhepatic approach was used according to the pre-existing cholangiogram obtained via PC. We evaluated the technical success rate and complications of each step. RESULTS: The technical success rate for the transcholecystic-only approach was 80.5%. The remaining cases were successfully managed with transhepatic conversion. Multiple stone removal sessions were required in 22% of the cases. One patient with combined IHD stones was initially converted to a transhepatic approach without any transcholecystic removal trial. The technical success rates for each step were as follows: cystic duct passage (38/40, 95%), guidewire unwinding (36/38, 94.7%), sheath insertion (36/36, 100%), and stone removal using balloon ampulloplasty (33/36, 91.7%). The overall clinical success was 97.6% (40/41) without major procedure-related complications. Thereafter, cholecystectomy was successfully performed in patients with concomitant gallstones (n = 20). No postprocedural complications occurred during the follow-up (1-70 days). CONCLUSIONS: Percutaneous EHD stone removal through transcholecystic and transhepatic routes after PC is effective and safe in poor candidates for PTBD or ERCP. KEY POINTS: • This study shows the safety and efficacy of extrahepatic duct (EHD) stones in patients who are poor candidates for initial percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiopancreatography. • The overall technical success for the transcholecystic-only approach was 80.5% (33/41). Including transhepatic conversions, it was 100% (41/41). Stone removal was successful in one session in 78% (32/41) of the patients and in multiple sessions in 28.1% (9/41) of the patients. • Balloon ampulloplasty with stone expulsion using an occlusion balloon catheter is also a safe and effective method for removing EHD stones.


Assuntos
Colecistostomia , Cálculos Biliares , Colangiografia , Colangiopancreatografia Retrógrada Endoscópica , Cálculos Biliares/complicações , Cálculos Biliares/diagnóstico por imagem , Cálculos Biliares/cirurgia , Humanos , Estudos Retrospectivos , Resultado do Tratamento
12.
Gastrointest Endosc ; 95(2): 327-338, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34499905

RESUMO

BACKGROUND AND AIMS: EUS, MRCP, and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied. METHODS: We developed a decision tree for diagnosing IPC (base-case probability, 50%; range, 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested were laparoscopic cholecystectomy with IOC (LC-IOC), MRCP, single-session EUS + ERCP, and separate-session EUS + ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by assigning utility scores to health states, average proportion of true-positive diagnosis of IPC, and the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB) and average cost per true-positive diagnosis. RESULTS: LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true-positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategies 2 (MRCP), 3 (single-session EUS + ERCP), and 4 (separate-session EUS + ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses. CONCLUSIONS: For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten hospital LOS. Our findings may be used to design institutional and organizational management protocols.


Assuntos
Colecistectomia Laparoscópica , Coledocolitíase , Colangiografia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia Laparoscópica/métodos , Coledocolitíase/diagnóstico por imagem , Análise Custo-Benefício , Humanos , Probabilidade
13.
Surg Endosc ; 36(3): 2197-2207, 2022 03.
Artigo em Inglês | MEDLINE | ID: mdl-34816304

RESUMO

BACKGROUND: Post-cholecystectomy transected bile ducts (TBDs) are not amenable to standard endoscopic management. Combined ERCP and endosonography (CERES) including EUS-guided hepaticoenterostomy enhance therapeutic biliary endoscopy. CERES treatment of post-cholecystectomy TBDs is evaluated. METHODS: Among 165 consecutive patients who underwent ERCP for post-cholecystectomy bile duct injury (Amsterdam A/B/C/D grades [%] = 47/30/7/16) between January 2009-November 2020 at a tertiary-care center, 10/26 (38%) with TBDs (6 female; 32-92 years old) underwent CERES before attempted endoscopic repair (staged CERES, n = 7) or surgical repair (preoperative CERES, n = 1), or as destination therapy (definitive CERES, n = 2). Short-term clinical success rate, final clinical success rate and comprehensive complication index (CCI) were retrospectively determined. Additionally, number of follow-up procedures, adverse events, recurrences, final patency grades and definitive cure rate were determined in patients with staged CERES. RESULTS: Index CERES (hepaticogastrostomy, 60%; hepaticoduodenostomy, 40%) achieved bile leak and jaundice resolution in 10 patients (100% short-term clinical success rate). Overall, 9/10 patients maintained good/excellent biliary drainage over a median 3.2 years without any unplanned percutaneous/surgical procedures (90% final clinical success rate; median CCI = 8.7). Staged CERES using recanalization (n = 6) or diversion (n = 1) strategies achieved Grade A patency in 5/7 (71%) patients after a median of 2 follow-up procedures over a median 12-month treatment period; 2 failed recanalization patients were salvaged by indefinite hepaticoenterostomy stent or elective surgery, respectively. Among staged CERES, 2 treatment-related cholangitis occurred (29%) and 2 recurring strictures (29%) developed over a median 8.4 year follow-up; recurring strictures were endoscopically remodeled (n = 1) or indefinitely stented (n = 1); final Grade A/B biliary patency was achieved in 5/7 (71%) and definitive cure in 4/7 (57%). CONCLUSIONS: CERES controls acute symptoms in selected post-cholecystectomy TBD patients allowing subsequent staged endoscopic therapy. Definitive cure or long-term biliary drainage is possible in most cases and elective surgery can be facilitated in the remainder.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Endossonografia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ductos Biliares/diagnóstico por imagem , Ductos Biliares/lesões , Ductos Biliares/cirurgia , Colangiografia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia , Drenagem/métodos , Endossonografia/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Resultado do Tratamento
14.
Am Surg ; 88(2): 201-204, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33502230

RESUMO

INTRODUCTION: Although gallbladder disease is more common in women, there is a trend toward more complicated cases in male patients. METHODS: All cholecystectomies captured by the National Surgical Quality Improvement Program database for the year 2016 were reviewed. This encompassed 38 736 records. Records were reviewed for age, sex, procedure performed, operative time, postoperative diagnosis, functional status, American Society of Anesthesiologists (ASA) class, preoperative lab values (total bilirubin, alkaline phosphatase, white blood cell count, and aspartate aminotransferase. Descriptive and inferential statistical analyses were conducted. RESULTS: Male patients are more likely to undergo cholecystectomy for a diagnosis of cholecystitis, gallstone pancreatitis, or cholangitis than women who are more likely to carry a diagnosis of biliary dyskinesia. The average operative time increases for both sexes as the patients become older. The average operative time is higher for men than women in all age groups and the variance becomes greater as the patients become older. Age, sex, postoperative diagnosis, ASA class, and functional status were all independently significant in predicting operative time. There was no difference in need for cholangiogram between the sexes. Female patients were more likely to have their cholecystectomy completed laparoscopically and they were more likely to have their surgery performed as an outpatient. CONCLUSION: These data show that women were more likely to present with uncomplicated gallbladder disease, while men were more likely to present with complicated gallbladder disease. This suggests that male patients present at a more advanced stage of disease.


Assuntos
Colecistectomia/estatística & dados numéricos , Doenças da Vesícula Biliar/epidemiologia , Fatores Etários , Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Análise de Variância , Discinesia Biliar/epidemiologia , Discinesia Biliar/cirurgia , Cálculos/epidemiologia , Cálculos/cirurgia , Colangiografia/estatística & dados numéricos , Colangite/epidemiologia , Colangite/cirurgia , Colecistectomia/métodos , Colecistectomia Laparoscópica/estatística & dados numéricos , Colecistite/epidemiologia , Colecistite/cirurgia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Doenças da Vesícula Biliar/cirurgia , Humanos , Masculino , Duração da Cirurgia , Pancreatite/epidemiologia , Distribuição por Sexo , Fatores Sexuais
15.
Surg Endosc ; 36(1): 550-558, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-33528666

RESUMO

BACKGROUND: Open conversion rates during laparoscopic cholecystectomy vary depending on many factors. Surgeon experience and operative difficulty influence the decision to convert on the grounds of patient safety but occasionally due to technical factors. We aim to evaluate the difficulties leading to conversion, the strategies used to minimise this event and how subspecialisation influenced conversion rates over time. METHODS: Prospectively collected data from 5738 laparoscopic cholecystectomies performed by a single surgeon over 28 years was analysed. Routine intraoperative cholangiography and common bile duct exploration when indicated are utilised. Patients undergoing conversion, fundus first dissection or subtotal cholecystectomy were identified and the causes and outcomes compared to those in the literature. RESULTS: 28 patients underwent conversion to open cholecystectomy (0.49%). Morbidity was relatively high (33%). 16 of the 28 patients (57%) had undergone bile duct exploration. The most common causes of conversion in our series were dense adhesions (9/28, 32%) and impacted bile duct stones (7/28, 25%). 173 patients underwent fundus first cholecystectomy (FFC) (3%) and 6 subtotal cholecystectomy (0.1%). Morbidity was 17.3% for the FFC and no complications were encountered in the subtotal cholecystectomy patients. These salvage techniques have reduced our conversion rate from a potential 3.5% to 0.49%. CONCLUSION: Although open conversion should not be seen as a failure, it carries a high morbidity and should only be performed when other strategies have failed. Subspecialisation and a high emergency case volume together with FFC and subtotal cholecystectomy as salvage strategies can reduce conversion and its morbidity in difficult cholecystectomies.


Assuntos
Colecistectomia Laparoscópica , Ductos Biliares , Colangiografia , Colecistectomia , Colecistectomia Laparoscópica/efeitos adversos , Humanos
16.
Surg Endosc ; 36(1): 461-467, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-33523267

RESUMO

BACKGROUND: Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis. METHODS: All patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification. RESULTS: A total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8-4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery. CONCLUSIONS: Based on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested.


Assuntos
Colecistectomia Laparoscópica , Coledocolitíase , Colangiografia/métodos , Colecistectomia Laparoscópica/métodos , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/cirurgia , Humanos , Cuidados Intraoperatórios/métodos , Estudos Retrospectivos
17.
Dig Dis ; 40(1): 85-96, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-33684915

RESUMO

BACKGROUND: In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography. Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP pancreatitis and failure of the whole procedure. SUMMARY: Recommendations for biliary cannulation can be divided into (a) measures to reduce the likelihood of a difficult papilla situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a) Careful inspection of the papillary anatomy and optimizing its accessibility by scope positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guidewire rather than a standard catheter with a standard guidewire should be used in most situations. (b) The most important rescue techniques are needle-knife precut, double-guidewire technique, and transpancreatic sphincterotomy. In few cases, anterograde cannulation techniques are needed. To this regard, the EUS-guided biliary drainage followed by rendezvous is increasingly used as an alternative to percutaneous transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European Society for Gastrointestinal Endoscopy (ESGE) algorithm on biliary cannulation is proposed.


Assuntos
Pancreatite , Esfinterotomia Endoscópica , Cateterismo , Colangiografia , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Humanos , Estudos Retrospectivos , Resultado do Tratamento
18.
Surg Endosc ; 36(2): 1355-1361, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34013391

RESUMO

BACKGROUND: Percutaneous transhepatic gallbladder drainage (PTGBD) is an important procedure for initial treatment of severe acute cholecystitis (AC) that is contraindicated for early laparoscopic cholecystectomy (LC). We presented our primary experience on a new approach of cholangiography via PTGBD (PTGBD-C) for preoperative delineation of biliary anatomy. METHODS: A retrospective analysis was conducted on 93 patients who received PTGBD followed by LC for AC, with allocation into 2 groups that were PTGBD with (PTGBD-C group, 32 patients) or without (PTGBD-N group, 61 patients) cholangiography. All the clinical data, including demographics, cholangiography findings, operations, and complications, were collected and analyzed. RESULTS: Cholangiography was attempted in 32 patients with a success of 31 cases, and the most common complication was transient fever in 3 patients. PTGBD-C group of patients showed significantly less operation time (83.2 ± 22.32 vs. 106.5 ± 40.25 min, P = 0.041) and conversion rate (0 vs. 2). There was no statistical difference in terms of postoperative hospitalization and complications. CONCLUSIONS: PTGBD-C is a feasible and safe procedure for severe AC patients with delayed LC. It has advantages of direct cholangiography, being easy to perform and cost-effective, thus should be considered for clinical usage.


Assuntos
Colecistectomia Laparoscópica , Colecistite Aguda , Colangiografia , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/métodos , Colecistite Aguda/cirurgia , Drenagem/métodos , Vesícula Biliar/cirurgia , Humanos , Estudos Retrospectivos , Resultado do Tratamento
19.
Hepatobiliary Pancreat Dis Int ; 21(1): 50-55, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33966994

RESUMO

BACKGROUND: Recurrent common bile duct (CBD) stone is a long-term sequalae among patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stone extraction. Data regarding risk factors for recurrent CBD stone are scarce. We aimed to identify predictors of recurrent CBD stone. METHODS: We performed a retrospective case-controlled study from January 2010 to December 2019. Inclusion criteria included patients who had recurrent CBD stone at least 6 months after the index ERCP, in which complete stone extraction was performed and normal cholangiogram was obtained. Overall, 457 patients were included. Forty-two patients (9.2%) had recurrent CBD stone, and 415 patients (90.8%) did not have recurrent CBD stone. RESULTS: In univariate analysis, male sex [odds ratio (OR) = 0.49, P = 0.033] was a protective factor, while endoscopic stone extraction by basket vs. balloon (OR = 2.55, P = 0.005), older age (OR = 1.03, P = 0.003), number of CBD stones (OR = 1.99, P = 0.037), size of CBD stone (OR = 4.06, P = 0.003) and mechanical lithotripsy (OR = 9.22, P = 0.004) were risk factors for recurrent CBD stone. In multivariate logistic regression analysis, mechanical lithotripsy [OR = 9.73, 95% confidence interval (CI): 1.69-55.89, P = 0.010], basket clearance vs. combined basket and balloon (OR = 18.25, 95% CI: 1.05-318.35, P = 0.046) and older age (OR = 1.02, 95% CI: 1.00-1.05, P = 0.023) were risk factors, and male sex (OR = 0.39, 95% CI: 0.19-0.81, P = 0.012) was a protective factor. CONCLUSIONS: We identified modifiable and non-modifiable risk factors for recurrent CBD stone. Taking into consideration those factors might aid in minimizing the CBD stone recurrence risk.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Ducto Colédoco/diagnóstico por imagem , Cálculos Biliares/cirurgia , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Colangiografia , Ducto Colédoco/cirurgia , Feminino , Cálculos Biliares/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Esfinterotomia Endoscópica
20.
Lasers Surg Med ; 54(2): 305-310, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34490931

RESUMO

BACKGROUND AND OBJECTIVES: Bile duct injury during laparoscopic cholecystectomy has an incidence rate of 1%-2% and commonly appears under conditions of severe inflammation, adhesion, or unexpected anatomical variations. Despite the difficulties and rising concerns of identifying bile duct during surgeries, surgeons do not have a specific modality to identify bile duct except intraoperative cholangiography. While no biliary-specific fluorescent dye exists for clinical use, our team has previously described the development of a preclinical biliary-specific dye, BL-760. Here, we present our study of laparoscopic cholecystectomy using the fluorescent dye in a swine model. STUDY DESIGN/MATERIALS AND METHODS: With an approval from Institutional Animal Care and Use Committee, two 20-25 kg swine underwent laparoscopic abdominal surgery using a Food and Drug Administration-cleared fluorescent laparoscopic system. Images of the liver and gallbladder were taken both before and after intravenous injection of the novel fluorescent dye. The dye was dosed at 60 µg/kg and injected via the ear vein. The amount of time taken to visualize fluorescence in the biliary tract was measured. Fluorescent signal was observed after injection, and target-to-background ratio (TBR) of the biliary tract to surrounding cystic artery and liver parenchyma was measured. RESULTS: Biliary tract visualization under fluorescent laparoscopy was achieved within 5 min after the dye injection without any adverse effects. Cystic duct and extrahepatic duct were clearly visualized and identified with TBR values of 2.19 and 2.32, respectively, whereas no fluorescent signal was detected in liver. Cystic duct and artery were successfully ligated by an endoscopic clip applier with the visual assistance of highlighted biliary tract images. Laparoscopic cholecystectomy was completed within 30 min in each case without any complications. CONCLUSIONS: BL-760 is a novel preclinical fluorescent dye useful for intraoperative identification and visualization of biliary tract. Such fluorescent dye that is exclusively metabolized by liver and rapidly excreted into biliary tract would be beneficial for all types of hepato-biliary surgeries. With the validation of additional preclinical data, this novel dye has potential to be a valuable tool to prevent any iatrogenic biliary injuries and/or bile leaks during laparoscopic abdominal and liver surgeries.


Assuntos
Sistema Biliar , Colecistectomia Laparoscópica , Animais , Ductos Biliares/diagnóstico por imagem , Ductos Biliares/lesões , Ductos Biliares/cirurgia , Colangiografia/métodos , Colecistectomia Laparoscópica/métodos , Corantes Fluorescentes , Suínos , Estados Unidos
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