Comparative evaluation of magnetic resonance cholangiopancreatography and perioperative cholangiography in patients with suspect choledocholithiasis / Avaliação comparativa da colangiopancreatografia por ressonância magnética e da colangiografia peroperatória na suspeita de coledocolitíase

ABSTRACT Background: Cholelithiasis is a highly prevalent condition, and choledocholitiasis is a high morbidity complication and requires accurate methods for its diagnosis. Aim: To evaluate the population of patients with suspected choledocholitiasis and check the statistical value of magnetic resonance cholangiopancreatography, ultrasonography, the laboratory and the clinic of these patients comparing them to the results obtained by perioperative cholangiography. Methods: This is a retrospective cohort study, which were evaluated 76 patients with cholelithiasis and suspected choledocholithiasis. Results: It was observed that the presence of dilatation of the biliary tract or choledocholithiasis in the ultrasonography was four and eight times increased risk of perioperative cholangiography for positive choledocholithiasis, respectively. For each unit increased in serum alkaline phosphatase was 0.3% increased the risk of perioperative cholangiography for positive choledocholithiasis. In the presence of dilatation of the bile ducts in the ultrasonography was four times greater risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. In the presence of pancreatitis these patients had five times higher risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. On the positive magnetic resonance cholangiopancreatography presence to choledocholithiasis was 104 times greater of positive perioperative cholangiography for choledocholithiasis. Conclusions: The magnetic resonance cholangiopancreatography is a method with good accuracy for propedeutic follow-up for the diagnosis of choledocholithiasis, consistent with the results obtained from the perioperative cholangiography; however, it is less invasive, with less risk to the patient and promote decreased surgical time when compared with perioperative cholangiography.

RESUMO Racional: A colelitíase é afecção de alta prevalência, sendo a coledocolitíase complicação de elevada morbidade e que necessita de métodos acurados para seu diagnóstico. Objetivo: Avaliar o perfil populacional de pacientes com suspeita de coledocolitíase e verificar o valor estatístico da colangiopancreatografia por ressonância magnética, da ultrassonografia, dos exames laboratoriais e da clínica desses pacientes e compará-los aos resultados obtidos pela colangiografia peroperatória. Métodos: Trata-se de estudo longitudinal, de coorte, retrospectivo, no qual foram avaliados 76 pacientes com diagnóstico de colelitíase e suspeita de coledocolitíase. Resultados: Observou-se que na presença de dilatação das vias biliares ou coledocolitíase na ultrassonografia havia risco quatro e oito vezes maior, respectivamente, de colangiografia peroperatória positiva para coledocolitíase. Para cada unidade de aumento na fosfatase alcalina sérica houve aumento em 0,3% no risco de colangiografia peroperatória positiva para coledocolitíase. Na presença de dilatação das vias biliares na ultrassonografia ou clínica de pancreatite havia risco quatro e cinco vezes maior, respectivamente, de colangiopancreatografia por ressonância magnética positiva para coledocolitíase. Na presença de colangiopancreatografia por ressonância magnética positiva para coledocolitíase o risco foi 104 vezes maior de colangiografia peroperatória positiva para coledocolitíase. Conclusão: A colangiopancreatografia por ressonância magnética para seguimento propedêutico tem boa acurácia para o diagnóstico de coledocolitíase, e concordante com os resultados obtidos na colangiografia peroperatória. O método é menos invasivo, com menores riscos ao paciente e com diminuição do tempo cirúrgico dispendido para realização da colangiografia peroperatória.

Clinical Observation of the Efficacy of Endoscopic Retrograde Cholangiopancreatography on Elder Choledocholithiasis and Its Effects on the Levels of TNF-α, IL-1, and IL-6

SUMMARY OBJECTIVE: We conducted this study to investigate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) on elder choledocholithiasis and its effects on the levels of TNF-α, IL-1, and IL-6. METHODS: Elder patients with choledocholithiasis were enrolled in this study, and according to the surgical methods, they were divided into the ERCP group and the surgical group. After treatment, we compared the efficacy of these two methods on patients, inflammatory responses indicated by the levels of TNF-α, IL-1, and IL-6, and the complications. RESULTS: No statistical significance was identified in the difference of the success rate in removal between the two groups (98% vs. 94%), but indicators of the ERCP group, including the surgical duration (28.5±12.8) min, remission duration of abdominal pain (1.2±0.2) d, recession time of jaundice (2.0±0.3) d, postoperative bedridden time (1.4±0.2) d, treatment time of the anti-infection (1.5±0.2) d, length of stay in hospital (6.5±0.3) d, levels of TNF-α (2.1±0.2) μg/L, IL-1 (6.3±0.8) μg/L, IL-6 (2.8±0.3) μg/L, and the incidence rate of complications (1.8%), were all significantly lower than those in the surgical group (p<0.05). CONCLUSION: In the treatment of choledocholithiasis, ERCP is excellent in controlling the trauma, accelerating the recovery duration, reducing the occurrence of complications and ameliorating the inflammatory responses. Thus, it is an ideal choice for choledocholithiasis.

RESUMO OBJETIVO: Realizamos este estudo para investigar a eficácia clínica da colangiopancreatografia retrógrada endoscópica (ERCP) na coledocolitíase idosa e seus efeitos nos níveis de TNF-α, IL-1 e IL-6. MÉTODOS: Pacientes idosos com coledocolitíase foram matriculados neste estudo. De acordo com os métodos cirúrgicos, eles foram divididos em grupo ERCP e grupo cirúrgico. Após o tratamento, comparamos a eficácia desses dois métodos em pacientes, respostas inflamatórias indicadas pelos níveis de TNF-α, IL-1 e IL-6 e as complicações. RESULTADOS: Não houve significância estatística na diferença da taxa de sucesso na remoção entre os dois grupos (98% versus 94%), mas indicadores do grupo ERCP, incluindo a duração cirúrgica (28,5 ± 12,8) min, duração da remissão da dor abdominal (1,2 ± 0,2) d, tempo de recessão de icterícia (2,0 ± 0,3) d, tempo pós-operatório (1,4 ± 0,2) d, tempo de tratamento da infecção (1,5 ± 0,2) d, duração da internação (6,5 ± 0,3) d, níveis de TNF-α (2,1 ± 0,2) μg / L, IL-1 (6,3 ± 0,8) μg / L, IL-6 (2,8 ± 0,3) μg / L e a taxa de incidência de complicações (1,8 %) foram todos significativamente inferiores aos do grupo cirúrgico (p<0,05). CONCLUSÃO: No tratamento da coledocolitíase, a ERCP é excelente no controle do trauma, acelerando a duração da recuperação, reduzindo a ocorrência de complicações e melhorando as respostas inflamatórias. Assim, é uma escolha ideal para a coledocolitíase.

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

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

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

Dilatación con balón de gran diámetro en el manejo de coledocolitiasis de difícil extracción: experiencia clínica / Large balloon dilation for removal of choledocholithiasis difficult to extract: clinical experience

Objetivo: Describir la experiencia clínica con la técnica de dilatación de la esfinterotomía papilar con balones de gran diámetro en pacientes con coledocolitiasis de difícil extracción. Materiales y métodos: Estudio retrospectivo, diseño descriptivo. Serie de Casos. Se analizaron las historias clínicas de 18 pacientes que fueron sometidos a colangiopancreatografía retrograda endoscópica (CPRE) más dilatación papilar con balón de gran diámetro (DPBGD) por presentar coledocolitiasis de gran tamaño (≥15 mm), desproporción de diámetro entre cálculo y colédoco distal y/o papila yuxtadiverticular. Se emplearon balones dilatadores CRETM entre 12 y 20mm de diámetro. Se consignaron datos como éxito del procedimiento, uso de litotricia; así como complicaciones durante el procedimiento. Resultados: La edad promedio fue 66,1 años. Hubo predominio del género femenino (66,7%). El tamaño promedio de los cálculos en vía biliar fue de 16,7 mm. Las indicaciones de DPBGD fueron: coledocolitiasis gigante (12 pacientes, 66,7%), discordancia entre el diámetro del cálculo y el colédoco distal (6 pacientes, 33,3%). El diámetro de los balones de dilatación más frecuentemente empleados fueron: 15 mm (8 pacientes, 44,4%), 18 mm (5 pacientes, 27,8%), 12 mm (3 pacientes, 16,7%) y 20 mm (2 pacientes, 11,1%). Se consiguió la extracción completa de los cálculos en 15 pacientes (83,3%). Se precisó litotricia en 4 pacientes (22,2%). Hubo 3 pacientes en los que la extracción con balón fue frustra, realizándose manejo quirúrgico. Se reportó 1 caso de pancreatitis aguda leve (5,5%). Conclusiones: Los resultados demuestran que la dilatación con balón es una alternativa segura y eficaz en el manejo de los cálculos en vía biliar de difícil extracción

Objective: The aim of this study was to report the initial experience of the combined use of biliary sphincterotomy plus balloon dilatation of the papilla for management of large stones. Materials and methods: Design: Retrospective, descriptive. This study included 18 patients in whom a hydrostatic dilatation of the papilla with large balloons was performed between June 2012 and April 2014. Patients had multiple large stones, tapered distal common bile duct, previous sphincterotomy, or peri/ intradiverticular papilla. CRE™ dilatation balloons with diameters ranging from 12 to 20 mm were used. Data were recorded as successful procedure, use of lithotripsy and complications during the procedure. Results: The average age was 66.1 years. There was a predominance of the female gender (66.7%). The average size of the bile duct stones was 16.7 mm. The main indications were: giant choledocholithiasis (12 patients, 66.7%) and tapered distal common bile duct (6 patients, 33.3%). The dilatation balloons diameter used were: 15 mm (8 patients, 44.4%), 18 mm (5 patients, 27.8%), 12 mm (3 patients, 16.7%) and 20 mm (2 patients, 11.1%). Complete stone clearance was achieved in 15 patients (83.3%). Lithotripsy was performed in 4 patients (22.2%). There were 3 patients in whom the removal with balloon was unsuccessful, performed surgical management. It was reported 1 case of mild acute pancreatitis (5.5%). Conclusions: The results show that endoscopic papillary large balloon dilation after sphincterotomy is a safe and effective technique for treatment of difficult bile duct stones

Microbiological analysis of bile in patients with benign and malignant biliopancreatic diseases and its consequences / Análise microbiológica da bile em pacientes com doenças biliopancreáticas benignas e malignas e suas consequências

ABSTRACT Background Bactibilia has several consequences to human health. Objetive Assessing the bile microbiology of patients with biliopancreatic diseases in order to identify bacteria and their possible infectious complications. Methods Retrospective study of 30 bile culture samples from patients with benign and malignant biliopancreatic diseases. The samples were assessed to set the bile microbiological flora and to search for its possible link with comorbidity, carcinogenesis and postoperative infectious complications. Results Thirty bile samples from patients at mean age ≈57.7 years, mostly female (n=18), were assessed. Bactibilia was found in 12 cases, mostly in patients with benign diseases (n=8), older than 50 years (n=23) and female (n=10). Adenocarcinoma of the duodenal papilla (n=9) and cholelithiasis (n=8) were the most common diseases. Escherichia coli (n=5) and Klebsiella sp (n=3) were predominantly found in patients with benign diseases; and Klebsiella sp (n=2) and Streptococcus sp (n=2) were prevalent in cancer patients. There were postoperative infectious complications in seven cases, five of them in bactibilia-associated patients (P=0.084). Conclusion Bactibilia was found in 12 samples and Escherichia coli and Klebsiella sp were most often identified in patients with benign diseases, as well as Streptococcus sp and Klebsiella sp in cancer patients. There was a trend of higher postoperative infectious complication incidence in patients with bactibilia.

RESUMO Contexto Bacteriobilia pode produzir várias consequências para a saúde humana. Objetivo Avaliar a microbiologia da bile de pacientes com doenças biliopancreáticas para identificar bactérias e possíveis consequências. Métodos Estudo retrospectivo microbiológico. Trinta amostras de bile de pacientes com doenças biliopancreáticas benignas e malignas foram avaliadas para determinar a flora microbiológica da bile e procurar alguma possível relação dessa com comorbidades, carcinogênese e complicações infecciosas pós-operatórias. Resultados As amostras de bile foram avaliadas em pacientes, com idade média ≈57,7 anos, a maioria mulheres (n=18). Evidenciou-se bacteriobilia em 12 casos, a maioria em pacientes com doenças benignas (n=8); pacientes com mais de 50 anos (n=23) e mulheres (n=10). As doenças mais comuns foram o adenocarcinoma de papila duodenal (n=9) e a colelitíase (n=8). Escherichia coli (n=5) e Klebsiella sp (n=5) foram as bactérias mais identificadas em pacientes com doenças benignas; sendo a Klebsiella sp (n=2) e o Streptococcus sp (n=2) as que predominaram nos pacientes com cânceres. As complicações pós-operatórias exclusivamente infecciosas ocorreram em sete casos, sendo em cinco desses associados à bacteriobilia (P=0,084). Conclusão Bacteriobilia foi evidenciada em 12 amostras, sendo as bactérias mais identificadas Escherichia coli e Klebsiella sp em pacientes com doenças benignas; e Streptococcus sp e Klebsiella sp nos pacientes com câncer. Existiu uma tendência a maior incidência de complicações infecciosas pós-operatórias em pacientes com bacteriobilia.

Morbilidad postoperatoria por colangiografía endoscópica retrógrada con o sin papilotomía ulterior: serie de casos / Postoperative morbidity by endoscopic retrograde cholangiography with or without ulterior papillotomy: series of cases

La patología biliar litiásica es frecuente en nuestro país, con prevalencias entre 30% y 50%; y la ictericia obstructiva secundaria a coledocolitiasis (IOC), constituye un motivo de consulta frecuente en los servicios de urgencia. Por otra parte, la papilotomía endoscópica (PE) post colangiografía retrógrada endoscópica (CRE), constituye el tratamiento de elección en estos casos; sin embargo, es un procedimiento no exento de complicaciones. El objetivo de este estudio, es describir la MPO e identificar posibles factores de riesgo (FR) asociados a MPO, en pacientes con IOC, sometidos a PE. Serie de casos retrospectiva, de pacientes con IOC, a quienes se les realizó CRE y ulterior PE. La variable resultado fue desarrollo de MPO (hemorragia, perforación y pancreatitis). Otras variables de interés fueron canulación, dificultad de ésta, desarrollo de PE, uso de pre corte y mortalidad. La recolección de datos se realizó mediante una pauta ad-hoc, en la que se registraron las variables extraídas desde el protocolo operatorio y la ficha clínica. Se aplicó estadística descriptiva y analítica (Chi2 de Pearson y exacto de Fisher) para estimar fuerza de asociación. Se intervinieron 200 pacientes. La Media de edad fue de 60±18 años; 62% eran mujeres (n= 124). Se registró MPO en 32 casos (16,0%): Perforación (0,5%), pancreatitis (2,0%) y hemorragia (13,5%). La serie no registró mortalidad. No se logró objetivar asociación entre la variable "canulación difícil" y las variables hemorragia (p= 0,214); pancreatitis (p= 0,519); ni perforación (p= 1). Sin embargo, se verificó asociación entre el desarrollo de hemorragia y la realización de PE (p= 0,017). La hemorragia es la MPO más frecuente en esta serie; y la PE es un FR para el desarrollo de hemorragia.

Bileduct stones is prevalent in our country, with prevalences between 30% and 50%; and obstructive jaundice secondary to choledocholithiasis (OJC), is a frequent reason of consultation in emergency services. Furthermore, endoscopic papillotomy (EP) post ERCP is the treatment of choice in these cases; however, it is not free of complications (POM). The aim of this study is to describe POM and identify potential risk factors (RF) associated with POM in patients with OJC, underwent PE. Retrospective case series of patients with OJC, who underwent ERCP and subsequent PE. Outcome variable was the development of POM (bleeding, perforation, and pancreatitis). Other variables of interest were cannulation, difficulty of this, developing PE, using precut and mortality. Data collection was performed by an ad-hoc pattern in which the variables extracted from surgical protocols and clinical data were recorded. Descriptive and analytical statistics (Pearson Chi2 and Fisher's exact test) were applied to assess strength of association. 200 patients were operated. The mean age was 60±18 years; 62% were women (n = 124). MPO was recorded in 32 cases (16.0%): perforation (0.5%), pancreatitis (2.0%) and bleeding (13.5%). The series does not record mortality. It was not possible to objectify association between "difficult cannulation" and the variables bleeding (p= 0.214); pancreatitis (p= 0.519); and perforation (p= 1). However, association between bleeding and performing PE (p= 0.017) was observed. Hemorrhage is the most common cause of MPO in this series; and PE is a RF for the development of bleeding.

Evaluación de la seguridad de la CPRE en pacientes de la tercera edad: experiencia de un hospital universitario en Bogotá / Evaluation of the Safety of ERCP in Older Patients in the Experience of a University Hospital in Bogota

Antecedentes: la colangiopancreatografía retrógrada endoscópica (CPRE) es el método de elección en el manejo de la coledocolitiasis; sin embargo, existen controversias sobre su seguridad en el adulto mayor. Objetivo: determinar si hay mayor riesgo de complicaciones con la realización de la CPRE en el manejo de la coledocolitiasis en pacientes mayores de 70 años de edad valorados en el Hospital Universitario Clínica San Rafael (HUCSR). Metodología: se realizó un estudio analítico de corte transversal que incluyó pacientes que ingresaron al servicio de urgencias del HUCSR durante el período de 1 año (2011-2012) con diagnóstico de coledocolitiasis. La información demográfica, clínica y paraclínica, así como los hallazgos del procedimiento, fueron analizados teniendo en cuenta dos grupos de pacientes (mayores y menores de 70 años de edad). Se llevó a cabo un análisis estadístico univariado y bivariado. Resultados: se incluyó un total de 171 pacientes. La presencia de comorbilidades (es decir, diabetes e hipertensión arterial), los niveles de bilirrubina directa y de transaminasas fueron variables asociadas significativamente con los pacientes con edad mayor o igual a los 70 años. Se presentaron complicaciones relacionadas con el procedimiento, siendo la más frecuente la pancreatitis pos-CPRE y la hemorragia pospapilotomía; sin embargo, no estuvieron relacionadas con la edad de los pacientes. Conclusión: la CPRE es segura en pacientes con coledocolitiasis. La edad mayor de 70 años no incrementa la mortalidad relacionada con el procedimiento.

Background: Although endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for management of choledocholithiasis, there are still controversies about its safety for elderly patients. Objective: To determine whether there is increased risk of complications from ERCP in the management of choledocholithiasis in patients over 70 years valued at University Hospital Clínica San Rafael (HUCSR). Methodology: A cross-sectional analytical study that included patients admitted to the emergency department of HUCSR during the period of one year (2011-2012) with a diagnosis of choledocholithiasis was performed. The demographic, clinical and paraclinical findings and procedure were analyzed taking into account two groups of patients (older and younger than 70 years). Univariate statistical analysis was performed and bivariate. Results: A total of 171 patients were included. The presence of comorbidities (eg, diabetes and hypertension), the levels of direct bilirubin and transaminases were variables significantly associated with patients with greater than or equal to 70 years old. Procedure-related complications were presented the most frequent post-ERCP pancreatitis and post papilotomy bleeding; however, were not related to patient age. Conclusion: ERCP is safe in patients with choledocholithiasis. Age over 70 years does not increase the mortality associated with the procedure.

Coledocolitiasis en el Hospital Edgardo Rebagliati Martins (2010-2011): incidencia, factores de Riesgo, aspectos diagnósticos y terapéuticos / Choledocholithiasis in Edgardo Rebaglitti Martins Hospital: Lima-Peru: 2010-2011: incidence, risk factors, diagnostic and therapeutic aspects

OBJETIVO: Determinar la incidencia, frecuencia de factores de riesgo, aspectos diagnóstico (clínicos, bioquímica, imágenes) y terapéuticos de la coledocolitiasis. Pacientes y Métodos : Análisis descriptivo y prospectivo de 51 pacientes, quienes firmaron consentimiento informado para estudio de coledocolitiasis por CPRE (colangiopancreatografía retrograda endoscópica). Resultados : De 51 pacientes, en 36 (70.6%) se confirma coledocolitiasis por CPRE. Su incidencia fue de 10.4%. Edad promedio de 63.75 años, IMC promedio de 25.59 Kg/m2 y 55.6% fueron mujeres. La dolorabilidad se presentó en el 94.4% de los pacientes con coledocolitiasis. El promedio de BT (bilirrubina total) en el grupo de coledocolitiasis fue de 5.8 mg/dl al ingreso y 4.2 mg/dl en hospitalización. 11.1% debutaron con pancreatitis y 30.6% con colangitis. En el 68.7% de los pacientes con colangitis se confirmó coledocolitiasis. La especificidad de la ecografía fue 0.80 (IC95% 0.6-1). La especificidad de la colangioresonancia (CRM) fue de 0.25 (IC 95% 0.17-0.67). De los 51 pacientes con CPRE, 4 (7.80%) presentaron pancreatitis, 1 (1.96%) colangitis y 2 (3.92%) sangrado Conclusiones: La coledocolitiasis afecta a personas mayores, sexo femenino y con sobrepeso, con una incidencia de 10.4%. La dolorabilidad fue el síntoma más frecuente. La bilirrubina total fue mayor a 4mg/dl en pacientes con coledocolitiasis. Las complicaciones de coledocolitiasis (pancreatitis y colangitis) fueron más frecuentes que la reportada en la literatura. Tanto la especificidad de colangitis para coledocolitiasis, la especificidad de la ecografía y la especificidad de la CRM fueron menores a la reportada en la literatura. Las complicaciones de CPRE fueron levemente mayores que la reportada en la literatura.

OBJECTIVE: to determine the incidence, frequency of risk factors, diagnostic aspects (clinics, biochemical, and images) and therapeutic aspects of the choledocholithiasis. Patients and methods: Descriptive and prospective analysis of 51 patients who signed informed consent for study of choledocholithiasis by ERCP (endoscopic retrograde cholangiopancreatography). Results : Of the 51 patients, 36 (70.6%) confirmed choledocholithiasis by ERCP. It sincidence was 10.4%. The mean age was 63.75 years, BMI 25.59 kg/m2 and 55.6% were women. Abdominal pain was present in 94.4% of patients. Total bilirubin in the group with choledocholithiasis was 5.8 mg / dl at baseline and 4.2 mg / dl in hospitalization. 11.1% debuted with pancreatitis and 30.6% with cholangitis. In 68.7% of patients with cholangitis was confirmed choledocholithiasis by ERCP. The specificity of ultrasound was 0.80 (95% CI0.6- 1). The specificity of the nuclear magnetic resonance was 0.25 (95% CI 0.17-0.67). Of the 51 patients with ERCP, 4 (7.80%) do pancreatitis, 1 (1.96%) cholangitis and 2 (3.92%) bleeding. Conclusions. Choledocholithiasis occurs in older people, female and overweight with an incidence of 10.4%. Abdominal pain is the most common symptom. A total bilirubin more than 4mg/dl occurs in patients with choledocholithiasis. The complications of choledocholithiasis (pancreatitis and cholangitis) were more frequent than reported in the literature. Both thespecificity of cholangitis for choledocholithiasis, the specificity of ultrasound and the specificity of the nuclear magnetic resonance were lower than reported in the literature. ERCP complications were slightly higher than that reported in the literature.

Síndrome de Mirizzi: estudo de 11 casos / Mirizzis syndrome: report of eleven cases

Objetivo: descrever série de onze pacientes com síndrome de Mirizzi, submetidos a tratamento cirúrgico, comentando os aspectos etiopatogênicos e apresentação clínica, com ênfase no diagnóstico e tratamento. Métodos: estudo retrospectivo de onze pacientes consecutivos submetidos a tratamento cirúrgico. Foram considerados para apreciação: aspectos demográfico, clínicos, laboratoriais, meios diagnósticos, achados intraoperatórios, classificação dos doentes de acordo com Csendes et al., tática cirúrgica empregada e evolução pós-operatória. Resultados: dez pacientes (91,0%) eram mulheres e um (9,0%) homem. Os seguintes sintomas foram observados: dor e icterícia em todos os pacientes, colúria em nove (81,0%), náuseas e vômitos em sete (63,0%), acolia fecal em cinco (45,0%) e tumor palpável em um (9,0%). Os exames de laboratório mostraram leucocitose igual ou superior a 15.000 /mm3 em 45,0%. A bilirrubina total variou de 3,1 a 19,0 mg/dl. A ultrassonografia feita em todos pacientes mostrou presença de colelitíase e dilatação de V.B. em 77,7% e vesícula escleroatrófica em 27,0%. A tomografia computadorizada abdominal foi realizada em 9,0% e colangiopancreatografia em 18,0%. Os casos foram classificados, segundo Csendes, em: tipo I (quatro), tipo II (dois), tipo III (três) e tipo IV (dois) pacientes. Todos foram operados por cirurgia convencional. Destes, quatro (36,0%) apresentavam colangite, sendo três (27,0%) operados na urgência e um outro evoluiu com colangite durante a investigação, sendo operado no 19 dia. Os demais foram internados e operados eletivamente. Realizou-se: colecistectomia e derivação biliodigestiva em seis pacientes (54,0%), colecistectomia e coledocotomia em três (27,0%) e colecistectomia simples em dois casos (18%). No pós-operatório, nove (82,0%) evoluíram bem e tiveram alta hospitalar. Dois pacientes (18,0%) foram a óbito. Conclusões: todos os pacientes apresentavam sinais e sintomas de icterícia obstrutiva e em quase metade o hemograma era infeccioso. Apenas em três casos houve suspeita diagnóstica no pré-operatório. Os pacientes estáveis, sem infecção, que permitiram melhor investigação evoluíram favoravelmente. O tratamento da síndrome de Mirizzi é cirúrgico, variando a tática de acordo com o tipo da lesão.

Objectives: to report a series of eleven patients with Mirizzis syndrome submitted to surgical treatment. The authors present the etiopathogenic and clinical aspects of the disease. Methods: retrospective study of the eleven patients consecutive submitted to surgical treatment. The authors analysed the demografic, clinical and laboratory data, as well as intraoperative findings. They also classified the lesion according to Csendes classification, and presented the surgical management and post-operative follow-up. Results: there were 10 female patients (91.0 %) and 1 male patient (9.0%). Symptoms and signs were diffuse upper abdominal pain and jaundice in all patients, choluria in 9 (81%), nausea and vomit in 7 (63%), fecal acholia in 5 (45.0%) and a palpable tumor in 1 patient (9.0%). The laboratory exams showed leucocytosis equal or superior to 15.000/mm³ (45%) and the plasma bilirrubin varied between 3.1 mg/dL and 19.0 mg/dL. Ultrasonography showed in all patients the presence of cholelithiasis. There was dilation of gallbladder in 77.5% of the cases and scleroatrophic gallbladder in 27.0% patients. CT scan was realized in 9.0% and cholangiopancreatography in 18% of patients. The cases were classified according to Csendes classification. There were four type I, two type II, three type III and two type IV. All eleven cases were managed by classical open technique. Four patients (36%) presented with cholangitis; three of these patients had emergency operations and one presented cholangitis during the workup investigation, being operated on day 19 of admission. The others had elective operations. The surgical operations were: cholecystectomy and biliodigestive deviation in 6 patients (54%), cholecystectomy and choledochotomy in 3 patients (27%) and only cholecystectomy in 2 patients (18%). The postoperative course was uneventful in 9 patients (82%), but 2 patients (18%) died. Conclusion: all patients presented symptoms and signs of obstructive jaundice, and nearly half of these had infectious hemogram. The diagnosis of Mirizzis syndrome was suspected in only three patients. A complete diagnostic investigation was possible only in stable patients without infection, and these patients had a favorable course. Treatment of Mirizzis syndrome is surgical and the choice of operative approach varies according to the type of lesion.

Microlithiasis of the gallbladder: role of endoscopic ultrasonography in patients with idiopathic acute pancreatitis / Microcolecistolitíase: papel da ecoendoscopia em pacientes com pancreatite aguda sem causa aparente

OBJECTIVES: Causes may be found in most cases of acute pancreatitis, however no etiology is found by clinical, biological and imaging investigations in 30 percent of these cases. Our objective was to evaluate results from endoscopic ultrasonography (EUS) for diagnosis of gallbladder microlithiasis in patients with unexplained (idiopathic) acute pancreatitis. METHODS: Thirty-six consecutive non-alcoholic patients with diagnoses of acute pancreatitis were studied over a five-year period. None of them showed signs of gallstones on transabdominal ultrasound or tomography. We performed EUS within one week of diagnosing acute pancreatitis. Diagnosis of gallbladder microlithiasis on EUS was based upon findings of hyperechoic signals of 0.5-3.0 mm, with or without acoustic shadowing. All patients (36 cases) underwent cholecystectomy, in accordance with indication from the attending physician or based upon EUS diagnosis. RESULTS: Twenty-seven patients (75 percent) had microlithiasis confirmed by histology and nine did not (25 percent). EUS findings were positive in twenty-five. Two patients had acute cholecystitis diagnosed at EUS that was confirmed by surgical and histological findings. In two patients, EUS showed cholesterolosis and pathological analysis disclosed stones not detected by EUS. EUS diagnosed microlithiasis in four cases not confirmed by surgical treatment. In our study, sensitivity, specificity and positive and negative predictive values to identify gallbladder microlithiasis (with 95 percent confidence interval) were 92.6 percent (74.2-98.7 percent), 55.6 percent (22.7-84.7 percent), 86.2 percent (67.4-95.5 percent) and 71.4 percent (30.3-94.9 percent), respectively. Overall EUS accuracy was 83.2 percent. CONCLUSIONS: EUS is a very reliable procedure to diagnose gallbladder microlithiasis and should be used for the management of patients with unexplained acute pancreatitis. This procedure should be part of advanced endoscopic evaluation.

OBJETIVOS: Cerca de 30 por cento dos doentes com PA rotulada como sem causa aparente apresentam colecistomicrolitíase (cálculos com até 3 mm). Não há, no momento, consenso quanto ao melhor método propedêutico para diagnosticá-lo e, entre os propostos, nenhum apresenta alta sensibilidade. A ecoendoscopia (EE) é excelente no diagnóstico da pancreatite crônica incipiente e microcálculos da vesícula biliar (MCV) ou colédoco. São poucas as referências na literatura internacional e nenhuma na nacional a respeito do emprego da EE na PA. O objetivo deste trabalho é o de estabelecer o valor da EE no diagnóstico da colecistomicrolitíase em doentes com PA sem causa aparente. MÉTODOS: Trinta e seis pacientes com o diagnóstico de PA sem causa aparente foram consecutivamente estudados durante cinco anos. Dos enviados para exame ecoendoscópico, 21 mulheres e 15 homens com média de idade de 41,6 anos. Todos haviam sido submetidos antes a pelo menos um US e uma TC, que não revelaram alterações na via bílio-pancreática e 63,9 por cento deles tinham apresentado mais de um episódio de PA. O diagnóstico da colecistomicrolitíase pela EE realizada até uma semana durante o surto de PA baseou-se no tamanho do cálculo (até 3 mm, inclusive) e hiperecogeneicidade com ou sem sombra acústica. Todos os doentes foram colecistectomizados, após o exame ecoendoscópico. RESULTADO: O exame das peças cirúrgicas mostrou que 27 (75 por cento) doentes apresentavam MCV e nove (25 por cento) não. A EE levou a erro no diagnóstico da microlitíase em seis (16,8 por cento) casos, quatro casos de falsos-positivos e dois casos de falsos-negativos. Em 30 casos (83,2 por cento) houve confirmação dos seus resultados. A sensibilidade, a especificidade, os valores preditivos positivo, negativo e a acurácia (com intervalo de confiança de 95 por cento) para a EE no diagnóstico dos MCV foram: 92,6 por cento (74,2 a 98,7 por cento), 55,6 por cento (22,7 a 84,7 por cento), 86,2 por cento (67,4 ...

Endoprótesis biliar en el manejo transitorio de la coledocolitiasis / Endoscopic biliary stents for the temporary management of choledocholithiasis

Background: Endoscopic extraction of biliary tract stones is safe and effective. When the procedure is not successful, the use of a temporary stent can be a solution. Aim: To prospectively analyze the usefulness of endoscopic biliary stents in the temporary management of biliary obstruction due to choledocholithiasis. Material and methods: Analysis of 51 consecutive patients (age range 21-88 years, 34 females) with common bile duct stones that, from January 1999 to December 2001, were subjected to an endoscopic insertion of a biliary stent. Results: The indications for stent placement were a large stone in 40 patients (78%), the insecurity of a complete biliary tract cleaning in eight (16%) and technical difficulties in three (6%). Twenty seven patients (52.9%) were jaundiced and 17 (33.3%) had cholangitis. The prostheses remained in place until definitive resolution of the choledocholithiasis in 47 patients (92%) and migrated in 4 (8%). Bilirubin levels became normal in all cases with jaundice and infection resolved in all those with cholangitis. The definitive treatment of choledocholithiasis was done endoscopically in 28 patients (58%) and surgically in 20 (42%). Three patients were lost from follow up. Of these, one patient (2%) died 14 months later due to a recurrent cholangitis. The remaining two patients were asymptomatic and with the prostheses still in place 522 and 560 days post stent placement. Conclusions: When the immediate endoscopic resolution of choledocholithiasis is not possible, temporary stenting is a simple and safe therapeutic alternative that allows patients to be free of obstructive complications until the definitive treatment is carried out.

Sepsis de origen biliar: ¿alternativa diagnóstica en pacientes con colangitis aguda de orígen litiásico? / Sepsis of biliary origin: alternative diagnostic in patients with acute cholangitis of lithiasic origin?

Introducción: Las múltiples definiciones para la colangitis aguda de origen litiásico (CA) no cuentan con estudios de validación y reproducibilidad. El objetivo de este estudio es proponer y validar metodológicamente una nueva definición de CA: sepsis de origen biliar (SB). Material y método: Estudio de pruebas diagnósticas, utilizando como prueba de referencia la triada de Charcot. Se incluyeron pacientes con coledocolitiasis, con y sin colangitis; y pacientes con sospecha de coledocolitiasis intervenidos quirúrgicamente en el Hospital Regional de Temuco en el período noviembre de 2001 a noviembre de 2002. La definición SB fue basada en el consenso de estados inflamatorios agudos, realizándole la adición de una variable que pudiera sugerir el origen biliar del cuadro. El cálculo del tamaño de la muestra se realizó con base en una sensibilidad de la triada de Charcot de 75 por ciento y especificidad de 80 por ciento, con un nivel de confianza de 95 por ciento. El tamaño de muestra fue de 97 pacientes. Resultados: Se estudiaron 120 pacientes, 84 con diagnóstico de CA y 36 pacientes con diagnóstico de coledocolitiasis, sin signos de sepsis. Las propiedades diagnósticas de la definición SB fueron: sensibilidad 96 por ciento, especificidad 100 por ciento, valor predictivo positivo 100 por ciento y valor predictivo negativo 92 por ciento. Conclusiones: La definición SB tiene una buena evaluación en cuanto a las propiedades de una prueba diagnóstica en comparación con la triada de Charcot para el diagnóstico de colangitis aguda. En la práctica clínica diaria la definición SB podría incorporar al concepto colangitis aguda.