RESUMO
RESUMEN La colecistectomía laparoscópica es el tratamiento de elección para la litiasis vesicular sintomática. Aunque la tasa de complicaciones es baja, las lesiones de la vía biliar representan un grave problema. La asociación con una lesión vascular (lesión compleja) genera un impacto adicional, disminuyendo la calidad de vida y la sobrevida a largo plazo. Presentamos el caso de una paciente con lesión compleja por compromiso vascular del pedículo hepático derecho que desarrolló una atrofia del parénquima correspondiente. Ante la ausencia de complicaciones sépticas, el tratamiento no operatorio pudo realizarse en forma exitosa.
ABSTRACT Laparoscopic cholecystectomy is considered the standard of care for symptomatic cholelithiasis. Although the rate of complications is low, bile duct injuries represent a serious problem. The association with vascular injury (complex injury) poses an additional impact by reducing the quality of life and long-term survival. We report the case of a female patient with complex injury due to vascular involvement of the right hepatic pedicle who developed right liver atrophy. Non-operative management was successful due to the absence of septic complications.
Assuntos
Humanos , Feminino , Adulto , Ductos Biliares/lesões , Colecistectomia Laparoscópica/efeitos adversos , Complicações Intraoperatórias , Pancreatite/cirurgia , Ductos Biliares/diagnóstico por imagem , Fístula Biliar/diagnóstico por imagem , Tratamento Conservador , Ducto Hepático Comum/diagnóstico por imagem , Fígado/diagnóstico por imagemRESUMO
INTRODUCTION: Duplicity of the common bile duct (BCBD) is an unusual congenital disorder. CASE REPORT: A 80-year-old woman with duplication of the common bile duct with retrograde endoscopic cholangiopancreatography (ERCP) who did not resolve the symptoms. DISCUSSION: Our case is a variant of type IV to the classification of DCBC. The MR cholangiography and presurgical ERCP allows assessment of the bile ducts, their caliber, and assessment of abnormalities. The treatment before DCBC will depend on the clinic and the type of opening of the CBCA. CONCLUSIONS: It is important to perform a pre-surgical study and during surgery with CIO.
INTRODUCCIÓN: La duplicidad del conducto biliar común (DCBC) es una alteración congénita insólita. CASO CLÍNICO: Mujer de 80 años con duplicación de la vía biliar común con colangiopancreatografía retrógrada endoscópica (CPRE) que no dilucida la clínica. DISCUSIÓN: Este caso es una variante del tipo IV de la clasificación de DCBC. La colangiorresonancia y la CPRE prequirúrgica permiten valorar las vías biliares, su calibre y las anormalidades. El tratamiento depende de la clínica y el tipo de apertura del conducto biliar común accesorio. CONCLUSIONES: Es importante realizar estudio prequirúrgico y durante la operación con colangiografía intraoperatoria.
Assuntos
Ducto Colédoco/anormalidades , Ducto Colédoco/cirurgia , Idoso de 80 Anos ou mais , Embolectomia com Balão , Colangiografia , Colangiopancreatografia Retrógrada Endoscópica , Colecistite/tratamento farmacológico , Colecistite/cirurgia , Doença Crônica , Terapia Combinada , Ducto Colédoco/diagnóstico por imagem , Feminino , Ducto Hepático Comum/anormalidades , Humanos , Imageamento por Ressonância Magnética , Próteses e Implantes , Esfinterotomia Endoscópica , Tomografia Computadorizada por Raios X , Ácido Ursodesoxicólico/uso terapêuticoRESUMO
Treatment of bile ducts injuries (BDI) treatment, combining minimally access surgical techniques, although their benefits, has been scarcely reported. We described a combined laparoscopic-endoscopic procedure, carried out in a patient with postoperative right hepatic duct (RHD) injury associated to laparoscopic cholecystectomy. Based on a clinical case description, we illustrate the surgical technique and assess their applicability and results. A biliary fistula was identified employing laparoscopic cholangiography and a metallic clip applied, producing RHD occlusion, was retrieved under fluoroscopic guidance. A biliary "rendezvous" maneuver was done for positioning an endoscopic biliary stent. The biliary fistula disappeared within two weeks and during 40-months of follow-up the patient remains asymptomatic. Laparoscopic-endoscopic approach, although technically demanding, resulted effective to treat this patient. A Continuous follow-up is essential for evaluating the long-term results.
Assuntos
Fístula Biliar/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia Laparoscópica/efeitos adversos , Ducto Hepático Comum/lesões , Laparoscopia/métodos , Complicações Pós-Operatórias/cirurgia , Adulto , Fístula Biliar/diagnóstico por imagem , Fístula Biliar/etiologia , Feminino , Ducto Hepático Comum/diagnóstico por imagem , Ducto Hepático Comum/cirurgia , Humanos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/diagnóstico por imagemRESUMO
RESUMEN El tratamiento de las lesiones quirúrgicas de las vías biliares (LQVB), empleando procedimientos quirúrgicos de mínimo acceso en forma conjunta, a pesar de sus beneficios, ha sido escasamente reportado. Describimos el tratamiento combinado láparoendoscópico, en una paciente con fístula biliar y estenosis postoperatoria del conducto hepático derecho (CHD). Con base en la descripción de un caso clínico, ilustramos la técnica quirúrgica y evaluamos su aplicabilidad y resultados. Empleando colangiografía laparoscópica, identificamos la fistula biliar y demostramos la oclusión del CHD por un clip metálico, el cual fue retirado mediante guía fluoroscópica. Realizamos maniobra de "rendezvous" biliar y colocamos de prótesis plástica endoscópica. La fístula biliar resolvió en 12 días y a 40 meses de seguimiento, la paciente permanece sin alteraciones. El abordaje láparo-endoscópico, aunque técnicamente demandante, resultó efectivo para el tratamiento de esta paciente. Su seguimiento es fundamental y de especial interés, a fin de evaluar los resultados a largo plazo.
ABSTRACT Treatment of bile ducts injuries (BDI) treatment, combining minimally access surgical techniques, although their benefits, has been scarcely reported. We described a combined laparoscopic-endoscopic procedure, carried out in a patient with postoperative right hepatic duct (RHD) injury associated to laparoscopic cholecystectomy. Based on a clinical case description, we illustrate the surgical technique and assess their applicability and results. A biliary fistula was identified employing laparoscopic cholangiography and a metallic clip applied, producing RHD occlusion, was retrieved under fluoroscopic guidance. A biliary "rendezvous" maneuver was done for positioning an endoscopic biliary stent. The biliary fistula disappeared within two weeks and during 40-months of follow-up the patient remains asymptomatic. Laparoscopic-endoscopic approach, although technically demanding, resulted effective to treat this patient. A Continuous follow-up is essential for evaluating the long-term results.
Assuntos
Adulto , Feminino , Humanos , Complicações Pós-Operatórias/cirurgia , Fístula Biliar/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia Laparoscópica/efeitos adversos , Laparoscopia/métodos , Ducto Hepático Comum/lesões , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/diagnóstico por imagem , Fístula Biliar/etiologia , Fístula Biliar/diagnóstico por imagem , Ducto Hepático Comum/cirurgia , Ducto Hepático Comum/diagnóstico por imagemRESUMO
Purpose: To analyze the preoperative serum matrix metalloproteinase-9 (MMP-9) levels and prognosis of patients with hilar cholangiocarcinoma (HC) undergoing radical resection. Methods: Preoperative serum MMP-9 levels in patients with HC undergoing radical resection were detected by enzyme-linked immunosorbent assay (ELISA). The ROC curve assay was used to analyze the preoperative serum MMP-9 level to determine the most valuable cut-off point. The relationship between MMP-9 and clinicopathological features of HC patients was analyzed. Kaplan-Meier method was used to analyze the prognostic factors, and COX regression model was used to analyze the independent risk factors affecting prognosis. Results: Preoperative serum MMP-9 levels were significantly elevated in the death patients compared with the survival patients. The most valuable cut-off point for preoperative serum MMP-9 for prognosis was 201.93 ng/mL. Preoperative serum MMP-9 was associated with Bismuth-Corlette classification) and lymph node metastasis. Kaplan-Meier analysis showed that MMP-9, Bismuth-Corlette classification, Lymph node metastasis, Portal vein invasion, Hepatic artery invasion, Liver invasion, Incised margin, and Preoperative biliary drainage were related to prognosis. Cox regression model confirmed that hepatic artery invasion, liver invasion, incised margin, and MMP-9 have the potential to independence predicate prognosis in HC patients. Conclusion: Preoperative serum MMP-9 has high predictive value for prognosis and is an independent influencing factor for the prognosis of patients with hilar cholangiocarcinoma.(AU)
Assuntos
Humanos , Metaloproteinase 9 da Matriz/análise , Tumor de Klatskin/diagnóstico , Ducto Hepático Comum/enzimologia , Neoplasias dos Ductos Biliares/diagnóstico , Prognóstico , Período Pós-OperatórioRESUMO
SUMMARY: Given that the gallbladder and the biliary tract are subject to multiple anatomical variants, detailed knowledge of embryology and its anatomical variants is essential for the recognition of the surgical field when the gallbladder is removed laparoscopically or by laparotomy, even when radiology procedures are performed. During a necropsy procedure, when performing the dissection of the bile duct is a rare anatomical variant of the bile duct, in this case the cystic duct joins at the confluence of the right and left hepatic ducts giving an appearance of trident. This rare anatomical variant in the formation of common bile duct is found during the exploration of the bile duct during a necropsy procedure, it is clear that the wrong ligation of a common hepatic duct can cause a great morbi-mortality in the postsurgical of biliary surgery. This rare anatomical variant not previously described is put in consideration to the scientific community. Anatomical variants of the biliary tract are associated with high rates of morbidity and mortality, causing serious bile duct injuries. Only the surgical skill of the surgeon and his open mind to the possibilities of abnormalities make the performance of cholecystectomy a safe procedure.
RESUMEN: Dado que la vesícula biliar y el tracto biliar están sujetos a múltiples variantes anatómicas, el conocimiento detallado de la embriología y sus variantes anatómicas es esencial para el reconocimiento del campo quirúrgico cuando la vesícula biliar se extirpa laparoscópicamente o por laparotomía, incluso cuando se realizan procedimientos de radiología. Durante un procedimiento de necropsia, se realiza la disección del conducto biliar y se observa una variante anatómica inusual del conducto biliar; en este caso, el conducto cístico se une a la confluencia de los conductos hepáticos derecho e izquierdo dando una apariencia de tridente. Esta rara variante anatómica en la formación del conducto biliar común puede causar una gran morbimortalidad en la cirugía biliar asociado a una ligadura incorrecta. Esta extraña variante anatómica no descrita anteriormente se reporta a la comunidad científica, debido a que las variantes anatómicas del tracto biliar se asocian con altas tasas de morbilidad y mortalidad, al causar lesiones graves en el conducto biliar. Solo la habilidad quirúrgica del cirujano y su mente abierta a las posibilidades de variaciones anatómicas hacen que la realización de la colecistectomía sea un procedimiento seguro.
Assuntos
Humanos , Ductos Biliares Extra-Hepáticos/anatomia & histologia , Vesícula Biliar/anatomia & histologia , Fígado/anatomia & histologia , Colecistectomia , Ducto Cístico/anatomia & histologia , Dissecação , Variação Anatômica , Ducto Hepático Comum/anatomia & histologiaRESUMO
Mucinous cystic neoplasm of the liver (MCN-L) and intraductal papillary mucinous neoplasm of the bile duct (IPMN-B) are diagnoses that were classified by the World Health Organization in 2010 as mucin-producing bile duct tumors of the hepatobiliary system. The preoperative differential diagnosis between these two entities is difficult; the presence of a communication with the bile duct is usually considered as a typical sign of IPMN-B. However, the presence of an ovarian-like stroma (OLS) has been established to define the diagnosis of MCN-L. We present the case of a 33-year-old woman with a rapid progression of a cystic tumor of the liver. In 2 years, the lesion increased from 27 to 64 mm and a dilation of the left hepatic duct appeared. Percutaneous transhepatic drainage with a biopsy was performed. No malignant cells were found on biopsy. Because of the rapid progression of the cystic tumor and unclear malignant potential, left hemihepatectomy was performed. Even though tumor masses were present in the biliary duct, on the basis of the presence of OLS, histology finally confirmed MCN-L with intermediate-grade intraepithelial dysplasia to high-grade intraepithelial dysplasia. The patient is currently under oncologic follow-up with no signs of recurrence of the disease. We present a rare case where MCN-L caused a dilation of the left hepatic duct, a sign that is usually a characteristic of IPMN-B.
Assuntos
Neoplasias dos Ductos Biliares/diagnóstico , Ducto Hepático Comum/patologia , Neoplasias Hepáticas/diagnóstico , Neoplasias Císticas, Mucinosas e Serosas/diagnóstico , Adulto , Neoplasias dos Ductos Biliares/patologia , Biópsia , Carcinoma in Situ/complicações , Carcinoma in Situ/diagnóstico , Carcinoma in Situ/patologia , Carcinoma in Situ/cirurgia , Colangiografia , Diagnóstico Diferencial , Dilatação Patológica , Progressão da Doença , Feminino , Hepatectomia , Humanos , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Imageamento por Ressonância Magnética , Neoplasias Císticas, Mucinosas e Serosas/complicações , Neoplasias Císticas, Mucinosas e Serosas/patologia , Neoplasias Císticas, Mucinosas e Serosas/cirurgia , Valor Preditivo dos Testes , Tomografia Computadorizada por Raios X , Carga TumoralRESUMO
BACKGROUND: Percutaneous biliary balloon dilation (PBBD) stands as a safe, useful, and inexpensive treatment procedure performed on patients with benign anastomotic stricture of Roux-en-Y hepatojejunostomy (BASH). However, the optimal mode of application is still under discussion. METHODS: A retrospective cohort study was conducted including patients admitted between 2008 and 2015 with diagnosis of BASH. Patients were divided into 2 groups: group I (n = 22), included patients treated after the implementation of an institutional protocol of 3 PBBD sessions within a fixed time interval and group II (n = 24) consisted of our historical control of patients who underwent one or 2 dilation sessions. Patency at one-year post procedure was assessed with the classification proposed by Schweizer. Symptomatic response to treatment was analyzed using the Terblanche classification. RESULTS: Patients in group I exhibited more excellent/good results (90 vs. 50%, p = 0.003) and less poor results (5 vs. 42%, p = 0.005) according to the Schweizer classification and more grade I/excellent results according to Terblanche classification (p = 0.003). Additionally, group I showed lower serum total bilirubin (p = 0.001), direct bilirubin (p = 0.002), alkaline phosphatase (p = 0.322), aspartate aminotransferase (p = 0.029), and alanine aminotransferase (p = 0.006). CONCLUSION: A protocol of 3 consecutive PBBD sessions within a fixed time interval may yield a high rate of patency, with a positive clinical, biochemical, and radiological impact on patients with BASH.
Assuntos
Dilatação/métodos , Ducto Hepático Comum/cirurgia , Jejuno/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alanina Transaminase/sangue , Fosfatase Alcalina/sangue , Anastomose Cirúrgica/efeitos adversos , Aspartato Aminotransferases/sangue , Bilirrubina/sangue , Protocolos de Ensaio Clínico como Assunto , Constrição Patológica/sangue , Constrição Patológica/etiologia , Constrição Patológica/terapia , Dilatação/efeitos adversos , Feminino , Humanos , Jejunostomia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Polycystic liver disease is an autosomal dominant disorder commonly associated with autosomal dominant polycystic kidney disease. It is a rare disease that usually occurs asymptomatically in 85% of cases and diagnosis is incidentally. We present the case of 57 years old woman with progressive pruritus and jaundice secondary to stenosis of the common hepatic duct and common bile by liver cyst, rare presentation which only has been documented in case reports: Deepak, et al., Wittig, et al. and Howard, et al.1-3.