Article

Anastomosis biliodigestivas en la litiasis biliar

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  • centre hospitalier de saint brieuc
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Abstract

Las anastomosis biliodigestivas para el tratamiento de la litiasis de la vía biliar principal son derivaciones internas entre el pedículo de ésta y el duodeno (coledocoduodenostomía) o un asa de yeyuno excluida (coledocoyeyunostomía). Sus indicaciones son actualmente muy escasas: se limitan a las litiasis voluminosas y múltiples, en especial intrahepáticas, en una vía biliar con un diámetro muy grande que permita un tratamiento completo y definitivo sobre todo en los pacientes ancianos y debilitados. La intervención más sencilla y rápida es la coledocoduodenostomía laterolateral. La coledocoyeyunostomía terminolateral sobre un asa excluida en Y implica la sustitución de la vía biliar, y sus indicaciones son aún más infrecuentes. La prevención de la estenosis anastomótica exige una vía biliar de diámetro superior a 10 mm, con paredes sanas y un afrontamiento perfecto de la mucosa. Por vía laparoscópica, sólo la anastomosis coledocoduodenal puede efectuarse en condiciones similares a las de la laparotomía.

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... La construcción de una hepaticoyeyunoanastomosis es un método quirúrgico de bypass frecuentemente realizado para la resolución de condiciones patológicas de los conductos biliares extrahepáticos, la cual permite el drenaje biliar hacia el intestino delgado. (1,2) Existen varias complicaciones que se pueden presentar asociadas a estas técnicas como son la fuga biliar y fístula biliar (complicaciones tempranas); dentro de las complicaciones a largo plazo de este tipo de anastomosis se encuentra la estenosis, la cual puede llevar a múltiples hospitalizaciones y procedimientos para su resolución. (3,4). ...
... The construction of an hepaticojejunostomy is a surgical method of bypass used for the resolution of pathological conditions of the extrahepatic bile ducts, which allows biliary drainage into the small intestine. (1,2) There are several complications Introducción La hepático-yeyuno anastomosis en "Y" de Roux es el procedimiento de elección demostrado por varios estudios para la reconstrucción biliar posterior a una lesión biliar, ya que es segura, con baja morbilidad y resultados durables a largo plazo, sin embargo hay condiciones postoperatorias que aún son inevitables como la litiasis intrahepática, colangitis por reflujo y la estenosis de la anastomosis. La incidencia de estenosis tiene una tasa 6.87% a los 2-13 años de seguimiento y una prevalencia de hasta el 25% y se acompaña de varias complicaciones significativas como: cirrosis biliar, hipertensión portal, falla hepática y colangitis recurrente. ...
Article
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The construction of an hepaticojejunostomy is a surgical method of bypass used for the resolution of pathological conditions of the extrahepatic bile ducts, which allows biliary drainage into the small intestine. (1,2) There are several complications that can occur in this technique, such as bile leak and biliary fistula (early complications); one of the long-term complications, is stenosis, which can lead to multiple hospitalizations and major procedures for its resolution. (3,4) Previously, the great problem of stenosis after biliodigestive bypasses was that several major surgeries were needed to manage it. Therefore, it is increasingly necessary to develope new techniques with less morbidity. (5) This new approach has already been implemented in 82 cases of biliary reconstruction, through an access loop direct to the bile duct, through which endoscopic therapy can be performed. First patient case, 27 years old with Strasberg E4 biliary lesion, hepatoejejunostomy was performed with subaponeurotic loop and formation of neoconfluence, 18 months after surgery, asymptomatic jaundice and bile duct dilatation were detected by cholangioresonance. A successful endoscopic dilation was performed through it. However, at 20 months after the dilation it occurs again. It was necessesary to perform another endoscopic dilation through the subaponeurotic loop, being a succesful treatment after 20 months follow up. Second patient case, a 51 year old patient with Strasberg E3 biliary lesión, we performed hepaticojejunostomy with subaponeurotic loop. During postoperative follow-up, asymptomatic jaundice was documented at 24 months and dilatation of the biliary tract by cholangioresonance was evidenced. An endoscopic dilation was performed through the subaponeurotic loop with success. He has remained under surveillance for 36 months without recurrence. The technique of hepaticojejunostomy with a subaponeurotic loop, allows easy access and minimal invasive procedures to the biliodigestive anastomosis for its rehabilitation in case of stenosis.
... Esto permite un tratamiento completo y definitivo, principalmente en pacientes ancianos. De acuerdo con Lechaux, en esta anastomosis termino-lateral, para la exclusión yeyunal se emplea el método del asa en Y que implica la sustitución de la vía biliar, y se tienen algunas variantes a esta técnica como la confección de un asa yeyunal en Y por sutura automática 51 . ...
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Introducción. La coledocolitiasis es la presencia de cálculos en las vías biliares. En la mayoría de los casos se trata mediante la colangio pancreatografía retrógrada endoscópica y menos comúnmente por intervención quirúrgica laparoscópica. El objetivo de este estudio fue describir una cohorte retrospectiva de pacientes sometidos a exploración laparoscópica de la vía biliar. Métodos. Se incluyeron pacientes intervenidos entre los años 2014 y 2018, en dos instituciones de nivel III en Cali, Colombia, referidos para valoración por cirugía hepato-biliar, por dificultad para la extracción de los cálculos por colangio pancreatografia retrograda endoscópica, debido al tamaño, la cantidad, o la dificultad para identificar o canular la papila duodenal. Resultados. De los 100 pacientes incluidos, se encontró que el 72 % fueron mujeres, con rango de edad entre 14 y 92 años. Al 39 % de los pacientes se les extrajo un solo cálculo y al 16 % 10 cálculos. Un 12 % presentaron cálculos gigantes (mayores de 2,5 cm de ancho) y un 44 % presentaron litiasis múltiple. Al 69 % de los pacientes se les realizó colecistectomía. El porcentaje de éxito de limpieza de la vía biliar por laparoscopia fue del 95 %. Discusión. La exploración laparoscópica de la vía biliar es una técnica posible, reproducible, segura y con excelentes resultados para el manejo de la coledocolitiasis.
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Introducción: La panlitiasis se define como la presencia de múltiples cálculos en el trayecto de la vía biliar. El manejo consiste en realizar una colangiopancreatografía retrógrada endoscópica (CPRE), la exploración de la vía biliar o la anastomosis biliodigestiva (ABD), ya sea coledocoduodenoanastomosis o hepaticoyeyunoanastomosis. Objetivo: Describir el caso clínico de un paciente con panlitiasis biliar, abordando la presentación clínica, los métodos diagnósticos, el tratamiento y la evolución, con el propósito de ofrecer un recurso sólido a la comunidad médica. Presentación del caso: Se presenta un paciente de 60 años colecistectomizado hace 13 años portador de anastomosis bilioentérica con panlitiasis recidivante, se realizó un lavado de la vía biliar con salida de cálculos y pus del interior, finalmente se colocó una sonda Kehr junto con tratamiento clínico. Presentó una evolución favorable. Discusión: Este caso reveló una panlitiasis a la exploración de las vías biliares bajo visión endoscópica, a pesar de que no se encontró obstrucción, el paciente tenía antecedente de colecistectomía y contaba con una derivación hepático-yeyunal por lesión iatrogénica. La decisión del tratamiento debe ser multidisciplinaria ya que cada caso es único y dependerá de las características del paciente y las condiciones clínicas individuales. Conclusiones: La panlitiasis coledociana recidivante requirió un control farmacológico estricto para evitar recurrencia y la subsecuente exploración de la vía biliar que incrementa la morbimortalidad del paciente. Es importante el seguimiento médico continuo del paciente y la predisposición con la que cuenta para la formación de litos, pudiendo ser prevenidos, identificados y tratados de manera oportuna.
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Only 10% to 20% of pancreatic tumors are resectable at the time of diagnosis. Patients with advanced disease have a median survival of 4.9 months. Palliation is often required for biliary or duodenal obstruction, or both, and for pain. Optimal palliation should guarantee the shortest possible hospital stay and as long a survival as possible with a good quality of life. In recent years, treatment options for palliation of biliary and duodenal obstruction due to pancreatic cancer have broadened. Endoscopic and percutaneous biliary stenting have been shown to be successful tools for safe palliation of high-risk patients. Nevertheless, fit patients with unresectable pancreatic cancer benefit from surgery, which allows long-lasting biliary and gastric drainage. While laparoscopic cholecystojejunostomy and gastroenterostomy in patients with advanced pancreatic cancer have been widely reported, laparoscopic hepatico-jejunostomy has been rarely described. In this article, we describe our technique of laparoscopic hepatico-jejunostomy and gastrojejunostomy. We also discuss current evidence on the indications for these procedures in patients with unresectable pancreatic cancer.
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The feasibility of laparoscopic resection of choledochal cyst and hepaticojejunostomy in children is still unclear. This report presents the author's experience with a first series of patients. Data from 11 consecutive children (median age 17.5 months, SD 22, range 2 to 70) with choledochal cyst scheduled for laparoscopy were collected prospectively. There were nine type I and 2 type V cysts according to Todani's classification. All except one patient had intermittent jaundice or recurrent pancreatitis. The laparoscopic technique included excision of the cyst. A Roux-en-Y anastomosis was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. After repositioning of the bowel an end-to-side hepaticojejunostomy was carried out laparoscopically. The procedures were carried out in nine children without intraoperative events and a median duration of 289 min (SD 62). In two patients, the operation was converted after 60 and 90 min due to a lack of overview at the dorsal margin with problems in separation of the portal vein. Oral food intake was started within 2 days and tolerated well in all except one patient, in whom biliar fluid from the drain led to laparoscopic reevaluation on day 1. A small leak was resutured and the patient was discharged on day 5. In one patient, recurrent cholangitis and a dilated Roux-en-Y loop led to correction of some kinking of the loop via laparotomy after 3 months. All other patients are well with bile-stained stools after a mean follow-up of 13 months. Laparoscopic resection of congenital choledochal cyst and choledochojejunostomy in children is feasible. We feel that there is a considerable learning curve with the technique. Future studies will have to prove the feasibility of laparoscopic Roux-en-Y bowel anastomosis without the need for bowel exteriorization.
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Intrahepatic lithiasis (IHL) is a very rare disease in Europe and no gold-standard treatment has yet been codified. The aim of our study is to report our personal experience of IHL detected in 20 patients (6 males [30%] and 14 females [70%]) between January 1982 and December 1991. Eleven (55%) of these cases presented with only IHL, 7 cases (35%) had IHL associated with gallbladder or common bile duct stones, while 2 (10%) were affected by secondary IHL caused by previous biliodigestive anastomosis-induced stricture. The diagnosis was determined by cholangiography in all patients, by ultrasound in 94.7%, and by computed tomography in 70%. The surgical procedures used were as follows: liver resection in 12 patients (60%); various types of biliodigestive anastomosis in 6 cases (30%); choledocholithotomy with a simultaneous removal of stones from the hepatic duct in 2 patients (10%). The intraoperative mortality rate was nil. Complications consisted of 2 subphrenic abscesses, 1 septicemia, and 1 bowel occlusion. Two patients (10%) dropped out of the follow-up, 2 (10%) died 2 years after surgery for reasons not connected with the disease, 1 (5%) died from suppurative cholangitis 6 months after surgery, 2 (10%) had recurrent stones and were treated by extracorporeal lithotripsy and endoscopic stone removal, while the remaining 13 patients (65%) are symptom-free at follow-up which varied between 6 months and 11 years. Liver resection is the treatment of choice when IHL is confined to one lobe of the liver. When IHL affects the entire liver, a resection of the main involved area should be performed whenever possible. Other options include hepatoduodenal anastomosis using the interposed jejunal loop to enable endoscopic or combined treatment of recurrent stones.
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Biliodigestive anastomoses cause major anatomico-functional changes, such as the suppression of sphincter mechanisms and bile flow diversion. In order to avoid these drawbacks, the authors have, for some years, had recourse to bile diversion with the aid of a jejunal loop interposed between the bile duct and the duodenum. This procedure, known as hepatico-jejuno-duodenoplasty (HJDP) offers the advantage of a stable and efficient bile flow into the duodenum in accordance with the excluded loop principle. The procedure is always feasible and presents no particular technical difficulties. The authors have assessd the results of forty HJDP with a mean followup of 42 months. The major (5%) and minor (30%) complications are commonly encountered in biliary surgery. Comparison of the results with those obtained with other biliodigestive anastomoses, justifies pursuit of this clinical experiment, in the authors' view.
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Robotic telemanipulation systems have been introduced recently to enhance the surgeon's dexterity and visualization in videoscopic surgery in order to facilitate refined dissection, suturing, and knot tying. The aim of this study was to demonstrate the technical feasibility of performing a safe and efficient robot-assisted handsewn laparoscopic intestinal anastomosis in a pig model. Thirty intestinal anastomoses were performed in pigs. Twenty anastomoses were performed laparoscopically with the da Vinci robotic system (robot-assisted group), the remaining 10 anastomoses by laparotomy (control group). OR time, anastomosis time and complications were recorded. Effectiveness of the laparoscopic anastomoses was evaluated by postoperative observation of 10/20 pigs of the robot-assisted group for 14 days and by testing mechanical integrity in all pigs by measuring passage, circumference, number of stitches, and bursting pressure. These parameters and anastomosis time were compared to the anastomoses performed in the control group. In all cases of the robot-assisted group the procedure was completed laparoscopically. The only perioperative complication was an intestinal perforation, caused by an assisting instrument. The median procedure time was 77 min. Anastomosis time was longer in the laparoscopic cases than in the controls (25 vs 10 min; p <0.001). Postoperatively, one pig developed an ileus, based on a herniation of the spiral colon through a trocar-port. For this reason it was terminated on the sixth postoperative day. All anastomoses of the robot-assisted group were mechanically intact and all parameters were comparable to those of the control group. Technical feasibility of performing a safe and efficient robot-assisted laparoscopic intestinal anastomosis in a pig model was repeatedly demonstrated in this study, with a reasonable time required for the anastomosis.
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Biliary reconstruction represents a relatively untested frontier in laparoscopy. Retrospective review of all patients who underwent laparoscopic biliary operations at Legacy Health System from 1998 to 2003. Seven patients underwent laparoscopic biliary reconstruction. Indications included benign calculous disease in 4 patients, benign stricture on 1 patient, choledochal cyst in 1 patient, and malignant biliary obstruction in 1 patient. Operations performed included choledochoduodenostomy, hepaticojejunostomy, stricturoplasty, choledochal cyst excision with hepaticojejunostomy, and cholecystojejunostomy. Median operative time was 300 minutes. Median hospital stay was 4 days. One perioperative complication of a bowel obstruction required reoperation. Median follow-up was 15 months. One patient died of metastatic cancer 8 months after surgery. All other patients are symptom free with no signs of stricture or recurrent biliary obstruction. Laparoscopic biliary reconstruction represents a viable treatment option in carefully selected patients.
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Roux-en-Y choledochojejunostomy (RYCJ) is frequently used for biliary bypass surgery. However, reports on laparoscopic RYCJ are scarce. Between February 1997 and February 2002, laparoscopic RYCJ was performed in 6 patients with a recurrent common bile duct (CBD) stone or a benign biliary stricture. The first procedure involved the laparoscopic preparation of the CBD. The Roux limb prepared with an endo-GIA was brought up near the proximal CBD. An end-to-side choledochojejunostomy was then performed using an intracorporeal suture. Jejunojejunostomy was performed using an endo-GIA. The mean operating time was 358.3 minutes. A postoperative complication occurred in 1 patient who had an episode of melena, which resolved spontaneously. All patients were free of symptoms during the follow-up period (27.5 months). Laparoscopic RYCJ may be a useful option, especially in the treatment of benign biliary disease.
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Choledochoduodenostomy is a well-established procedure and is indicated in patients with multiple ductal calculi and dilated common bile duct (≥2.0 cm) because these patients require drainage for good long-term results without recurrence of jaundice or cholangitis [2, 9]. The technique most commonly used is that of a side-to-side hand-sutured anastomosis between the supraduodenal common bile duct and the duodenum. The merit of this technique is its simplicity, although it is prone to duodenobiliary reflux and to occasional symptomatic inspissation with food debris causing cholangitis (sump syndrome). It is the technique that has been adopted by most centers for laparoscopic choledochoduodelaostomy [3–8]. The alternative operation, transection choledochoduodenostomy, excludes the distal (transpancreatic) segment of the bile duct from the end-to-side anastomosis of the transected common bile duct with the second part of the duodenum. The long-term results of this procedure are excellent [1], and for this reason we have used it for laparoscopic drainage of the common bile duct in six elderly patients (four females and two males; age range, 61–72 years) with multiple occluding ductal calculi and grossly dilated bile duct. Three of these patients (including the one shown in the multimedia video) were admitted acutely with bacterial cholangitis and required emergency insertion of pigtail stent to overcome the acute septic illness. There were no conversions. The first operation lasted 4 h but the operating times in the last two patients were 2.0 and 2.5 h. The results have been excellent, with no deaths and a low postoperative morbidity (chest infection in one patient) and median postoperative hospital stay of 5 days.
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In patients with non-resectable peri-ampullary cancer, optimization of quality of life is an important goal. Although endoscopic palliation is widely used, the proponents of laparoscopic biliary bypass claim that this procedure alters management towards surgery. However, the evidence base for selection of laparoscopic bypass is limited and the aim of this report is to scrutinize the available evidence in order to assess the current role of this procedure. A computerised literature search was made of the Medline database for the period from January 1966 to December 2004. Searches identified 12 reports of laparoscopic palliation for peri-ampullary cancer. These reports were retrieved and data analysed in the following categories: type of bypass; combination with other procedures; complication and outcome. Laparoscopic cholecystoenterostomy is the commonest form of laparoscopic biliary bypass practiced. Of the 52 reported cases undergoing laparoscopic biliary bypass, 40 underwent laparoscopic cholecystojejunostomy, 6 laparoscopic choledochoduodenostomy and 6 underwent laparoscopic hepaticoje- junostomy. Current evidence does not justify the incorporation of laparoscopic biliary bypass techniques into contemporary evidence-based management algorithms for patients with non-resectable periampullary cancer.
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