ABSTRACT Background: Common bile duct (CBD) stones are known to complicate 10-15% of gallstone diseases. Endoscopic retrograde cholangiopancreatography (ERCP) is the therapeutic modality of choice for bile duct clearance in CBD stones but may fail to achieve stone clearance. This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. Objective: This prospective study was done to identify the predictors of failure of CBD clearance with ERCP. Methods: All consecutive patients with bile duct stones undergoing ERCP at a tertiary care center were prospectively included from October 2020 to October 2021. The study’s primary outcome was to identify and analyze factors that could predict the failure of complete CBD clearance. Results: A total of 120 patients (50.8% males, median age: 53.5 years) were included in the final analysis. Successful clearance of CBD stones during the index procedure was achieved in 70% of patients. At a cut-off stone diameter of >10.5 mm and CBD diameter of >12.5 mm, the AUC was 0.890 and 0.884, respectively, to predict failed clearance of CBD. On multivariate analysis, stone diameter ≥15 mm [odds ratio (OR) 16.97, 95% confidence interval (CI): 1.629-176.785], location of stones in hepatic ducts (OR 7.74, 95%CI: 2.041-29.332), presence of stricture distal to stone (OR 6.99, 95%CI: 1.402-34.726) and impacted stone (OR 21.61, 95%CI: 1.84-253.058) were independent predictors of failed bile duct clearance. Conclusion: Stone size and location are independent predictors of failed bile duct clearance. The endoscopist should consider these factors while subjecting a patient to biliary ductal clearance to plan additional intervention. Background (CBD 1015% 1015 10 15% 15 10-15 diseases (ERCP Objective Methods 202 2021 studys s Results 12 50.8% 508 50 8 (50.8 males age 535 53 5 53. years analysis 70 cutoff cut off 105 >10. 125 >12. 0890 0 890 0.89 0884 884 0.884 respectively ≥1 odds OR 1697 16 97 16.97 95 CI (CI) 1.629176.785, 1629176785 1.629 176.785 , 1 629 176 785 1.629-176.785] 774 7 74 7.74 95%CI 95CI 2.04129.332, 204129332 2.041 29.332 2 041 29 332 2.041-29.332) 699 6 99 6.99 1.40234.726 140234726 1.402 34.726 402 34 726 1.402-34.726 2161 21 61 21.61 1.84253.058 184253058 1.84 253.058 84 253 058 1.84-253.058 Conclusion intervention 101 10-1 20 50.8 (50. >10 >12 089 89 0.8 088 88 0.88 ≥ 169 9 16.9 (CI 629176 1.629176.785 162917678 1629 1.62 176785 176.78 62 17 78 1.629-176.785 77 7.7 04129 2.04129.332 20412933 2041 2.04 29332 29.33 04 33 2.041-29.332 69 6.9 40234 1.40234.72 14023472 1402 1.40 34726 34.72 40 3 72 1.402-34.72 216 21.6 84253 1.84253.05 18425305 184 1.8 253058 253.05 25 05 1.84-253.05 10- 50. (50 >1 08 0. 16. 62917 1.629176.78 16291767 162 1.6 17678 176.7 1.629-176.78 7. 0412 2.04129.33 2041293 204 2.0 2933 29.3 2.041-29.33 6. 4023 1.40234.7 1402347 140 1.4 3472 34.7 4 1.402-34.7 21. 8425 1.84253.0 1842530 18 1. 25305 253.0 1.84-253.0 (5 > 6291 1.629176.7 1629176 1767 176. 1.629-176.7 2.04129.3 204129 2. 293 29. 2.041-29.3 1.40234. 140234 14 347 34. 1.402-34. 842 1.84253. 184253 2530 253. 1.84-253. ( 1.629176. 162917 1.629-176. 2.04129. 20412 2.041-29. 1.40234 14023 1.402-34 1.84253 18425 1.84-253 1.629176 16291 1.629-176 2.04129 2.041-29 1.4023 1.402-3 1.8425 1842 1.84-25 1.62917 1.629-17 2.0412 2.041-2 1.402- 1.842 1.84-2 1.6291 1.629-1 2.041- 1.84- 1.629-

RESUMO Contexto: Cálculos do ducto biliar comum (CDC) são conhecidos por complicar 10-15% das doenças de cálculos biliares. A colangiopancreatografia retrógrada endoscópica (CPRE) é a modalidade terapêutica de escolha para a limpeza do CDC, mas pode falhar na sua remoção. Objetivo: Este estudo prospectivo foi realizado para identificar os previsores de falha na limpeza do CDC com CPRE. Métodos: Pacientes consecutivos com cálculos no ducto biliar submetidos a CPRE em um centro de atendimento terciário foram incluídos prospectivamente de outubro de 2020 a outubro de 2021. O principal resultado do estudo foi identificar e analisar fatores que poderiam prever a falha na limpeza completa do CDC. Resultados: Um total de 120 pacientes (50,8% homens, idade média: 53,5 anos) foram incluídos na análise final. A limpeza bem-sucedida dos cálculos de CDC durante o procedimento inicial foi alcançada em 70% dos pacientes. Com um diâmetro de corte de cálculos >10,5 mm e de diâmetro de CDC de >12,5 mm, a AUC foi de 0,890 e 0,884, respectivamente, para prever a falha na limpeza do CDC. Na análise multivariada, diâmetro da cálculos ≥15 mm [razão de chances (OR) 16,97, intervalo de confiança de 95% (IC): 1,629-176,785], localização dos cálculos nos ductos hepáticos (OR 7,74, IC95%: 2,041-29,332), presença de estreitamento distal ao cálculo (OR 6,99, IC95%: 1,402-34,726) e cálculo impactado (OR 21,61, IC95%: 1,84-253,058) foram previsores independentes de falha na limpeza do ducto biliar. Conclusão: O tamanho e a localização dos cálculos são previsores independentes de falha na limpeza do ducto biliar. O endoscopista deve considerar esses fatores ao submeter um paciente à limpeza ductal biliar para planejar intervenção adicional. Contexto (CDC 1015% 1015 10 15% 15 10-15 biliares (CPRE remoção Objetivo Métodos 202 2021 Resultados 12 50,8% 508 50 8 (50,8 homens média 535 53 5 53, anos final bemsucedida bem sucedida 70 105 >10, 125 >12, 0890 0 890 0,89 0884 884 0,884 respectivamente multivariada ≥1 razão OR 1697 16 97 16,97 95 IC (IC) 1,629176,785, 1629176785 1,629 176,785 , 1 629 176 785 1,629-176,785] 774 7 74 7,74 IC95% IC95 2,04129,332, 204129332 2,041 29,332 2 041 29 332 2,041-29,332) 699 6 99 6,99 1,40234,726 140234726 1,402 34,726 402 34 726 1,402-34,726 2161 21 61 21,61 1,84253,058 184253058 1,84 253,058 84 253 058 1,84-253,058 Conclusão adicional 101 10-1 20 50,8 (50, >10 >12 089 89 0,8 088 88 0,88 ≥ 169 9 16,9 (IC 629176 1,629176,785 162917678 1629 1,62 176785 176,78 62 17 78 1,629-176,785 77 7,7 IC9 04129 2,04129,332 20412933 2041 2,04 29332 29,33 04 33 2,041-29,332 69 6,9 40234 1,40234,72 14023472 1402 1,40 34726 34,72 40 3 72 1,402-34,72 216 21,6 84253 1,84253,05 18425305 184 1,8 253058 253,05 25 05 1,84-253,05 10- 50, (50 >1 08 0, 16, 62917 1,629176,78 16291767 162 1,6 17678 176,7 1,629-176,78 7, 0412 2,04129,33 2041293 204 2,0 2933 29,3 2,041-29,33 6, 4023 1,40234,7 1402347 140 1,4 3472 34,7 4 1,402-34,7 21, 8425 1,84253,0 1842530 18 1, 25305 253,0 1,84-253,0 (5 > 6291 1,629176,7 1629176 1767 176, 1,629-176,7 2,04129,3 204129 2, 293 29, 2,041-29,3 1,40234, 140234 14 347 34, 1,402-34, 842 1,84253, 184253 2530 253, 1,84-253, ( 1,629176, 162917 1,629-176, 2,04129, 20412 2,041-29, 1,40234 14023 1,402-34 1,84253 18425 1,84-253 1,629176 16291 1,629-176 2,04129 2,041-29 1,4023 1,402-3 1,8425 1842 1,84-25 1,62917 1,629-17 2,0412 2,041-2 1,402- 1,842 1,84-2 1,6291 1,629-1 2,041- 1,84- 1,629-

ABSTRACT Purpose: To investigate the clinical characteristics of symptomatic cholecystolithiasis and laparoscopic cholecystectomy complications in pediatric patients. Methods: The medical records of 50 children and adolescents who underwent laparoscopic cholecystectomy were analyzed. We evaluated gender, age, body mass index, preoperative clinical aspects, perioperative complications, and gallstone composition. Results: Among the patients, 33 (66%) were female, and 17 (34%) were male. The mean age was 11.4 ± 3.6. All patients were diagnosed with cholecystolithiasis by abdominal ultrasonography. Twelve patients (24%) had hematological disease: eight (16%) with sickle cell anemia and four (8%) with hereditary spherocytosis. Thirteen patients (26%) were obese. Twelve patients (24%) had complicated biliary disease. During the intraoperative period, three patients (6%) had excessive bleeding in the hepatic hilum, and one had an accidental injury to the common bile duct. Three (6%) postoperative complications (acute pancreatitis, common bile duct stenosis, and intestinal obstruction) were observed. Among 28 patients (56%), 25 (50%) had cholesterol gallstones, and three (6%) had bile pigment gallstones. Conclusions: The evolution of cholecystolithiasis in the pediatric population can present serious complications, emphasizing the need to avoid temporizing cholecystolithiasis in children and adolescents because laparoscopic cholecystectomy in this group is safe, with low complication rates. Purpose Methods 5 analyzed gender index aspects composition Results 3 66% 66 (66% female 1 34% 34 (34% male 114 11 4 11. 36 6 3.6 ultrasonography 24% 24 (24% disease 16% 16 (16% 8% 8 (8% spherocytosis 26% 26 (26% obese period 6% (6% hilum acute pancreatitis stenosis obstruction observed 2 56%, 56 56% , (56%) 50% (50% gallstones Conclusions safe rates (66 (34 3. (24 (16 (8 (26 (6 (56% (50 (3 (2 (1 ( (56 (5

BACKGROUND: Magnetic resonance imaging (MRI) is widely regarded as the gold standard for assessment of the bile ducts in patients with bile duct injuries (BDIs). This case series aims to highlight the shortcomings of this imaging modality and demonstrate how it may overestimate the injury severity. METHODS: Three patients treated at Groote Schuur Hospital and the University of Cape Town in whom MRI/magnetic resonance cholangiopancreatography (MRCP) overestimated the severity of BDI were included in the study. Demographic characteristics, clinical presentation, blood results and imaging findings are presented. RESULTS: All patients had an MRI/MRCP done which assessed the BDIs as major complete cut-off of the proximal common hepatic duct with substance loss. Subsequent direct cholangiography showed minor injuries and all three patients were successfully managed with endoscopic stenting. CONCLUSION: Major BDIs are complex, and assessment of severity is intricate and may be overestimated. These patients are best managed in high-volume multidisciplinary team settings.

Resumen Introducción: se describe el caso de una paciente con una metástasis apendicular como primera manifestación encontrada de un colangiocarcinoma. Síntomas principales: expresado con dolor abdominal, ictericia, hiporexia y coluria. Métodos y resultados: se documentó un plastrón apendicular histológicamente compatible con adenocarcinoma apendicular metastásico, estrechez del conducto hepático común, con alta sospecha de colangiocarcinoma, corroborado luego con la realización de una colangiopancreatografía retrógrada endoscópica. Conclusiones: los tumores apendiculares metastásicos son una presentación infrecuente y poco estudiada, donde los secundarios a neoplasia de vía biliar se han reportados de forma muy escasa en la literatura.

Abstract Introduction: We describe the case of a patient with appendiceal metastasis as the first manifestation of a cholangiocarcinoma. Main symptoms: Abdominal pain, jaundice, hyporexia, and choluria. Methods and results: We documented an appendiceal plastron histologically compatible with metastatic appendiceal adenocarcinoma, common hepatic duct stricture, and a suspected cholangiocarcinoma, later corroborated by endoscopic retrograde cholangiopancreatography. Conclusions: Metastatic appendiceal tumors are an infrequent and poorly studied manifestation, whereas those secondary to bile duct neoplasia have rarely been reported in the literature.

SUMMARY: Adverse events (AE) contribute significantly to postoperative morbidities and comorbidities. Many AEs occur due to a lack of anatomical knowledge and its variants. Latrogenic bile duct injuries, for instance, represent a serious surgical complication of laparoscopic cholecystectomy. Anatomical knowledge for the identification and adequate drainage of all ducts is relevant and fundamental in order to avoid future errors. The objective of the study was to morphometrically analyze the bile ducts in adult human corpses. 13 livers were extracted from adult human corpses to obtain the ducts: choledochal, common hepatic and cystic. After morphological analysis, duct measurements (length and diameter) were continued using a digital caliper. The data obtained were tabulated in SPSS 21 program, performing descriptive analysis with mean and standard deviation. The averages of bile ducts were 61.05 (± 16.43) mm in length and 3.86 (± 0.72) mm in diameter. The cystic duct length and diameter averages were 33.59 (± 12.29) mm and 3.40 (± 0.79) mm, respectively. The common hepatic ducts had an average of 30.02 (± 7.19) mm in length and 3.74 (± 1.18) mm in diameter. The analyzed samples presented different values ?? from those already described in the literature, where the length of the cystic ducts was greater, while the length of the common hepatic ducts was numerically smaller. This work is very significant, as the morphometric variability of the bile ducts allows for varying morphological situations that can compromise the hepatobiliar physiology.

RESUMEN: Los eventos adversos (EA) contribuyen significativamente a las morbilidades y comorbilidades postoperatorias. Muchos EA se deben a la falta de conocimiento de la anatomía y sus variaciones. Por ejemplo, las lesiones iatrogénicas de las vías biliares representan una complicación quirúrgica grave de la colecistectomía laparoscópica. El conocimiento anatómico para la identificación y drenaje adecuado de todos los conductos es relevante y fundamental para evitar futuros errores. El objetivo del estudio fue analizar morfométricamente las vías biliares en cadáveres humanos adultos. Se extrajeron 13 hígados de cadáveres humanos adultos y se retiraron los conductos: colédoco, hepático común y cístico. Después del análisis morfológico, se continuó con las mediciones de los conductos (longitud y diámetro) utilizando un calibrador digital. Los datos fueron tabulados en el programa SPSS 21, mediante análisis descriptivos con media y desviación estándar. Los promedios de las vías biliares fueron de 61,05 (± 16,43) mm de longitud y 3,86 (± 0,72) mm de diámetro. Los promedios de longitud y diámetro del conducto cístico fueron 33,59 (± 12,29) mm y 3,40 (± 0,79) mm, respectivamente. Los conductos hepáticos comunes tenían un promedio de 30,02 (± 7,19) mm de longitud y 3,74 (± 1,18) mm de diámetro. Las muestras analizadas presentaron valores diferentes a los ya descritos en la literatura, donde la longitud de los conductos císticos era mayor, mientras que la longitud de los conductos hepáticos comunes fue numéricamente menor. Este trabajo es significativo, debido a que la variabilidad morfométrica de las vías biliares y permite identificar situaciones morfológicas que pueden comprometer la fisiología hapatobiliar.

Resumen: En octubre de 2019 atendimos la rara asociación de abscesos hepáticos piógenos con síndrome de Mirizzi tipo V en una paciente de 49 años con dolor abdominal y síndrome ictérico. Se le detectó mediante estudios clínicos de laboratorio, endoscópico y radiológico, una obstrucción biliar secundaria a lito de 2 cm en el hepático común, neumobilia, fiebre, leucocitosis y una severa respuesta inflamatoria sistémica, lo cual requirió cirugía. Durante la intervención se tuvieron hallazgos de vesícula escleroatrófica, fístulas dobles al hepático común y duodeno. El caso fue solucionado con colecistectomía, cierre de fístula colecistoduodenal y derivación biliodigestiva hepático-yeyuno con técnica de Hepp. Los abscesos del lóbulo derecho del hígado fueron documentados y drenados por radiología intervencionista guiada por ultrasonido y tomografía computarizada. Se requirió de cuidados intensivos, antibióticos y nutrición parenteral total, permaneciendo 50 días en dos hospitales y egresada a consulta externa para seguimiento mediante ultrasonido de los abscesos y continuación de antibióticos de acuerdo a los cultivos. No se reportó malignidad en la vesícula biliar escleroatrófica. Conclusión: el síndrome de Mirizzi se clasifica en cinco tipos de acuerdo a Csendes y Beltrán, el tipo V es el menos común y se divide en Va y Vb dependiendo de la presencia o no de algún tipo de fístula colecistoentérica con o sin íleo biliar, respectivamente. Proponemos agregar una clasificación Vc cuando además de lo anterior, exista afección hepática por abscesos u otra patología asociada en el hígado, ya que la obstrucción y colangitis que provoca esta enfermedad es la responsable de este cuadro específico.

Abstract: In October of 2019 we treated a rare combination of pyogenic liver abscess and Mirizzi syndrome (MS) type V in a 49 years-old female patient with abdominal pain and jaundice. We detected through laboratory, endoscopic and radiologic studies, a biliary obstruction due to a 2 cm biliary gallstone located in the common hepatic duct, pneumobilia, fever, leukocytosis and a severe inflammatory response, hence, surgery was required. During the intervention we found a scleroatrophic gallbladder, double fistulae to common hepatic duct and the duodenum. The case was solved with a cholecystectomy, closure of cholecistoduodenal fistulae, and a biliodigestive derivation with a yeyunal-hepatic anastomoses with Hepp technique. The right lobe liver abscesses were documented and drained by interventional radiology under ultrasound and CT guidance. Our patient required intensive care, antibiotics and total parenteral nutrition. She remained for 50 days in two hospitals and was discharged to outpatient care to continue observation of the liver abscesses with ultrasound and continued with antibiotics according to the results of the bacterial culture. Negative malignancy was reported for the scleroatrophic gallbladder. Conclusion: the Mirizzi syndrome, is classified in five types according to Csendes and Beltrán, type V is the less common and it is divided in Va and Vb, depending on the presence of any type of colecyto-enteric fistulae with or without gallstone ileus, respectively. We propose the addition of a Vc classification when additionally to the case described before, evidence of liver abscess or another associated liver pathology is found, since the obstruction and cholangitis are consequence of this specific case.

RESUMO CONTEXTO: Cirurgia hepatobiliar e trauma hepático são causas frequentes de fístulas biliares, e esta temida complicação pode ser manejada de forma segura através da colangiopancreatografia retrógrada endoscópica (CPRE). O procedimento consiste em esfincterotomia isolada, passagem de prótese biliar ou combinação das duas técnicas, porém a forma ideal permanece incerta. OBJETIVO: O objetivo desse estudo é comparar a realização de esfincterotomia isolada versus locação de prótese biliar no tratamento de fístulas pós-cirúrgicas e traumáticas. MÉTODOS: Foram analisados de forma retrospectiva 31 CPREs com diagnóstico final de “fístula biliar”. A informação colhida incluía dados demográficos dos pacientes, etiologia das fístulas e detalhes dos procedimentos. As técnicas de tratamentos foram divididas em dois grupos: esfincterotomia isolada vs esfincterotomia associada a locação de prótese biliar. Foram analisados os volumes dos drenos abdominais cirúrgicos antes e depois de cada procedimento e o número de dias necessários para que ocorresse cessação da drenagem pelo dreno abdominal cirúrgico após a CPRE. RESULTADOS: Um total de 31 pacientes (18 homens e 3 mulheres; idade média de 51 anos) com fístulas biliares foram avaliados. Colecistectomia laparoscópica foi a etiologia da fístula em 14 (45%) casos, seguida de colecistectomia convenvional em 9 (29%) pacientes, trauma hepático em 5 (16%) pacientes, e hepatectomia secundária a neoplasia em 3 (9,7%) pacientes. As localizações mais frequentes das fístulas foram: coto do ducto císticos com 12 (38,6%) casos, seguido de ducto hepático comum em 10 (32%) casos, ducto colédoco em 7 (22%) cases e leito hepático em 2 (6,5%) casos. 71% dos pacientes foram tratados com esfincterotomia associada a passagem de prótese biliar e 29% com esfincterotomia isolada. Houve diferença estatística em relação ao volume drenado antes e depois de ambos os procedimentos (P<0,05). Entretanto, quando comparada esfincterotomia isolada e esfincterotomia associada a passagem de prótese biliar, em relação ao volume drenado e ao número de dias necessários para cessação da drenagem, não houve diferença estatística em ambos os casos (P>0,005). CONCLUSÃO: A CPRE permanece como tratamento de primeira linha no tratamento de fístulas biliares, sem diferença entra a esfincterotomia isolada versus esfincterotomia associada a passagem de prótese biliar.

ABSTRACT BACKGROUND: Hepatobiliary surgery and hepatic trauma are frequent causes of bile leaks and this feared complication can be safely managed by endoscopic retrograde cholangiopancreatography (ERCP). The approach consists of sphincterotomy alone, biliary stenting or a combination of the two but the optimal form remains unclear. OBJECTIVE: The aim of this study is to compare sphincterotomy alone versus sphincterotomy plus biliary stent placement in the treatment of post-surgical and traumatic bile leaks. METHODS: We retrospectively analyzed 31 patients with the final ERCP diagnosis of “bile leak”. Data collected included patient demographics, etiology of the leak and the procedure details. The treatment techniques were divided into two groups: sphincterotomy alone vs. sphincterotomy plus biliary stenting. We evaluated the volume of the abdominal surgical drain before and after each procedure and the number of days needed until cessation of drainage post ERCP. RESULTS: A total of 31 patients (18 men and 3 women; mean age, 51 years) with bile leaks were evaluated. Laparoscopic cholecystectomy was the etiology of the leak in 14 (45%) cases, followed by conventional cholecystectomy in 9 (29%) patients, hepatic trauma in 5 (16%) patients, and hepatectomy secondary to neoplasia in 3 (9.7%) patients. The most frequent location of the leaks was the cystic duct stump with 12 (38.6%) cases, followed by hepatic common duct in 10 (32%) cases, common bile duct in 7 (22%) cases and the liver bed in 2 (6.5%) cases. 71% of the patients were treated with sphincterotomy plus biliary stenting, and 29% with sphincterotomy alone. There was significant difference between the volume drained before and after both procedures (P<0.05). However, when comparing sphincterotomy alone and sphincterotomy plus biliary stenting, regarding the volume drained and the days needed to cessation of drainage, there was no statistical difference in both cases (P>0.005). CONCLUSION: ERCP remains the first line treatment for bile leaks with no difference between sphincterotomy alone vs sphincterotomy plus stent placement.

ABSTRACT Previously, when a surgeon diagnosed bile duct lithiasis, he/she performed cholecystectomy, chole docotomy, stone removal and placement of a Kehr’s “T” tube. Some cases might require sphinctero plasty or bilio-digestive bypass. Nowadays, magnetic resonance cholangiopancreatography, endosco pic retrograde cholangiopancreatography, endoscopic ultrasound and intraoperative ultrasound have emerged as diagnostic and therapeutic tools. Decision-making processes are complex and there is no conclusive evidence supporting them. Many studies have focused on the matter with a non-compre hensive approach so that each surgeon will use his/her common sense for each individual case. The optimal management of the common bile duct is still controversial. Deciding on endoscopic, lapa roscopic or conventional management requires adequate training and clinical judgment. Conventional surgery is still in valid option.

RESUMEN Anteriormente, cuando se diagnosticaba litiasis en la vía biliar, el procedimiento consistía en una co lecistectomía, coledocotomía, extracción de los cálculos y colocación de un drenaje de Kehr. En otros casos se podía hacer papiloesfinteroplastia o una derivación biliodigestiva. Actualmente tenemos mu chas herramientas diagnósticas y terapéuticas como la colangiorresonancia, la pancreatocolangio grafía retrógrada endoscópica, la cirugía laparoscópica de la vía biliar, la ecoendoscopia y la ecografía intraoperatoria. Los procesos de decisiones son más complejos y sin un sustento con evidencia con cluyente. Tenemos estudios que enfocan parceladamente el tema, por lo que, dependiendo de si el diagnóstico se hace antes o durante la colecistectomía laparoscópica, el cirujano empleará su sentido común individualizando cada caso. El manejo ideal de la litiasis de la vía biliar sigue siendo motivo de controversia. Decidir por un manejo endoscópico, laparoscópico o convencional requiere logística, entrenamiento y juicio clínico adecua dos. La cirugía convencional sigue siendo una opción vigente.

Abstract Introduction: Bile duct injury (BDI) is a devastating complication after a cholecystectomy. Laparoscopic management has become a mainstay approach because of the advantages offered to patients; nevertheless, outcomes after repair are influenced by the center, the surgeon's experience, and the type of reconstruction. Materials and methods: Patients with common BDI managed at a referral center from January 2013 to June 2018 with a novel modified and simplified laparoscopic technique for a hepatic duct jejunostomy with a Roux-en-Y reconstruction were retrospectively reviewed. Results: Twenty patients had a BDI (20/5430-0.3%), 8 (40%) had intraoperative diagnosis, and 12 (60%) patients with diagnosis before 72 h. Type E Strasberg classification, the predominant BDI was Strasberg E1 (65%), the average surgery time was 146.5 min (115-178 min), the average intraoperative bleeding was 15-50 cc. The overall complication rate was 10 % (2/20), 1 (5%) patient required, there were no mortalities, and the mean hospital stay was 5 days. One (5%) patient presented bile leak (Type SE4), and 1 (5%) patient required intensive care unit admission after reintervention. Long-term follow-up showed no bile duct stricture, cholangitis, or recurrent choledocholithiasis up to 5 years after the procedure and with a minimum of 1 year minimum follow-up. Conclusions: This simplified laparoscopic approach to bile duct reconstruction with Roux-en-Y anastomoses appears to be an effective and safe alternative to reconstructive open bile duct surgery, offering to patients the benefits of laparoscopic surgery with a low complication rate.

Resumen Antecedentes: La lesión del conducto biliar es una complicación devastadora tras una colecistectomía. El tratamiento laparoscópico se ha convertido en un enfoque principal debido a las ventajas ofrecidas a los pacientes; sin embargo, los resultados después de la reparación están influenciados por el centro, la experiencia del cirujano y el tipo de reconstrucción. Método: Se revisaron retrospectivamente los pacientes con lesión del conducto biliar tratados con reconstrucción biliar en un centro de referencia, desde enero de 2013 hasta junio de 2018, por vía laparoscópica con una técnica modificada y simplificada con hepatoyeyunostomía en Y de Roux. Resultados: Veinte pacientes de 5,430 tenían lesión del conducto biliar (0,3%), 8 (40%) tuvieron diagnóstico intraoperatorio y 12 (60%) diagnóstico antes de las 72 horas. Todos con una clasificación de Strasberg tipo E, con predominio de E1 (65%). El tiempo quirúrgico promedio fue de 146,5 (rango 115-178) minutos y el sangrado intraoperatorio promedio fue de 15-50 cm3. La tasa general de complicaciones fue del 10% (2/20); 1 (5%) paciente requirió reintervención. No hubo mortalidad y la estancia hospitalaria media fue de 5 días. Un paciente (5%) presentó fuga biliar (tipo SE4) y 1 (5%) paciente requirió ingreso en la unidad de cuidados intensivos después de la reintervención. El seguimiento fue de hasta 5 años tras el procedimiento, con un mínimo de 1 año, y no se han documentado estenosis del conducto biliar, colangitis ni coledocolitiasis recurrente. Conclusión: Este enfoque laparoscópico simplificado para la reconstrucción del conducto biliar con anastomosis en Y de Roux parece ser una opción efectiva y segura a la cirugía reconstructiva del conducto biliar abierta, ofreciendo a los pacientes los beneficios de la cirugía laparoscópica y con una baja tasa de complicaciones.

Abstract Ascaris lumbricoides is a nematode that causes gastrointestinal diseases, with a higher prevalence in developing countries and in children. Biliary ascariasis is more common in adults, its prevalence is associated with poor sanitary conditions and humid soil conditions. We present the case of a 34-year-old female patient, with a history of choledocholithiasis resolved by retrograde endoscopic cholangiopancreatography (ERCP), who presented right hypochondrium pain of 1 month of evolution. Laboratory tests reported abnormal liver function tests. The fluoroscopic image revealed a choledochal dilation (14.3 mm) and left hepatic duct dilation, with multiple radiolucent images agglomerated in the proximal portion, consistent with choledocholithiasis; it was also noticed the presence of an elongated and motile radiolucent image consistent with a worm. A new ERCP was made, using the Dormia basket for the extraction of the stone, which also captured the worm.

Resumen Ascaris lumbricoides es un nematodo que causa enfermedades gastrointestinales, con una mayor prevalencia en los países en desarrollo y en niños. La ascariasis biliar es más común en adultos, su prevalencia se asocia con condiciones sanitarias deficientes y condiciones húmedas del suelo. Se presenta el caso de una paciente femenina de 34 años, con antecedentes de coledocolitiasis resuelta por colangiopancreatografía retrógrada endoscópica (CPRE), quien presentó dolor en hipocondrio derecho de un mes de evolución. Los exámenes de laboratorio reportaron alteración en las pruebas de funcionamiento hepático. La imagen fluoroscópica reveló una dilatación del colédoco (14.3 mm) y dilatación del conducto hepático izquierdo, con múltiples imágenes radiolúcidas aglomeradas en la porción proximal, consistentes con coledocolitiasis; también se notó la presencia de una imagen radiolúcida alargada y móvil consistente con un verme. Se realizó una nueva CPRE, utilizando la cesta de Dormia para la extracción del lito, que también capturó al verme.

Abstract: Objective: To present the case of a patient with choledochal cyst and its treatment, due to its low frequency and the high risk of developing cholangiocarcinoma. Presentation: A 26-year-old female with clinical signs of abdominal pain in the right hypochondrium and epigastrium, intolerance to cholecystokinetics, conjunctival jaundice, arrived to urgency with treatment analgesics, USG reporting normal vesicle, normal liver, proximal choledocholum 7 mm, dilated distal common bile duct of 35 mm with microliths inside, are admitted to the floor requesting exams reporting CBC, BC, TP, normal TPT, normal LFT, ERCP is reported, and type I choledochal cyst is scheduled for surgical intervention With the resection of the choledochal cyst and cholecystectomy as well as Roux-en-Y hepaticojejunostomy with prolene 3-0, a 6 x 4 cm choledochal cyst is found ranging from the common hepatic to pancreas, evolving satisfactorily, tolerating the oral route on the fourth day of surgery, leaving on the 7th day, is seen in the consultation, with discomfort of the surgery; being anicteric and with well-healed surgical wound, normal control USG. Control exams with normal CBC, BC, TP, TPT and LFT. Conclusions: It is an infrequent condition. One is found in 100,000 to 150,000, predominantly in Asian countries 20 to 30% is diagnosed in adults. It has a high incidence of developing cholangiocarcinoma, hence the importance of cyst resection. Type I continues to be the most frequent, reporting in the world literature.

Resumen: Objetivo: Presentar el caso de un paciente con quiste de colédoco y su tratamiento, debido a su baja frecuencia y al riesgo elevado a desarrollar colangiocarcinoma. Presentación: mujer de 26 años con cuadro clínico de dolor abdominal en hipocondrio derecho y epigastrio, intolerancia a los colecistoquinéticos, además de ictericia conjuntival, acude a urgencias manejándose con analgésicos, se efectúa ultrasonido de hígado y vías biliares reportando vesícula normal, hígado normal, colédoco proximal de 7 mm, colédoco distal dilatado de 35 mm con microlitos en su interior. Se ingresa a piso y se solicitan exámenes de laboratorio, los cuales se reportaron normales. Se efectúa colangiopancreatografía retrógrada endoscópica reportando quiste de colédoco fusiforme tipo I, por lo que se programa para cirugía efectuándole resección del quiste más colecistectomía y hepaticoyeyunoanastomosis en Y de Roux con prolene del 3-0. Se encuentra quiste de colédoco de 6 x 4 cm que abarca desde el hepático común hasta páncreas. Evolucionó de manera satisfactoria, tolerando vía oral al cuarto día de operada, egresándose al séptimo día; es vista en la consulta con molestias propias de la cirugía, pero se encuentra anictérica y con herida quirúrgica bien cicatrizada, ultrasonido de control normal. Exámenes de laboratorio de control normales. Conclusiones: Es un padecimiento poco frecuente. Se encuentra un caso entre 100,000 a l50,000, de predominio en los países asiáticos; 20 a 30% se diagnostica en adultos. Tiene una incidencia elevada de desarrollar colangiocarcinoma, de ahí la importancia de la resección del quiste. El tipo I continúa siendo el más frecuente, reportándose así en la literatura mundial.

RESUMO Racional: Colangiocarcinoma é neoplasia agressiva que geralmente exige drenagem biliar paliativa. A terapia fotodinâmica (TFD) tem sido descrita como tratamento adjunto bem-sucedido para tratar obstrução biliar maligna. Objetivo: Descrever o emprego do colangioscópio digital para ajudar a fornecer luz de laser durante sessão de TFD biliar usando fonte de luz desenvolvida localmente. Método: Paciente recebe fotossensibilizador intravenoso 24 h antes do procedimento que começa com duodenoscopia regular. Após a identificação da papila principal e da canulação retrógrada, o colangioscópio digital é introduzido no ducto biliar comum. Em seguida, o exame colangioscópico ajuda a identificar a estenose neoplásica. Sob visualização direta, o cateter de iluminação avança através do colangioscópio. Reposicionamento é feito a cada centímetro. Ao final colangioscopia avalia o ducto biliar quanto ao resultado imediato e a eventos adversos. Resultado: Este procedimento foi aplicado em um homem de 82 anos devido à icterícia obstrutiva nos últimos dois meses. EUS e CPRE revelaram dilatação grave do ducto biliar comum associada à coledocolitíase. Além disso, havia dilatação do ducto hepático até massa sólida hipoecóica bem circunscrita, medindo 1,8x2 cm, comprimindo o ducto hepático comum. Ela foi considerada irressecável e paciente encaminhado para tratamento paliativo com TFD que permaneceu assintomático por três meses. Morreu devido a complicações 15 meses após a sessão de TFD. Conclusão: A TFD biliar guiada por colangioscopia digital é viável e parece segura e eficaz como modalidade auxiliar na paliação de colangiocarcinoma extra-hepático.

ABSTRACT Background: Cholangiocarcinoma is an aggressive neoplasm that usually requires palliative biliary drainage. Photodynamic therapy (PDT) has been described as a successful adjunct treatment to malignant biliary obstruction. Aim: To describe the use of digital cholangioscope to help provide laser light during biliary PDT session using locally developed light source. Method: Patient receives intravenous photosensitizer 24 h before the procedure. It starts with a regular duodenoscopy. After identification of the major papilla and retrograde cannulation, the digital cholangioscope is introduced into the common bile duct. Then, the cholangioscopic examination helps to identify the neoplastic stricture. Under direct visualization lighting catheter is advanced through the cholangioscope. Repositioning is recommended every centimeter to cover all strictured area. At the end of the procedure, a final cholangioscopy assesses the bile duct for the immediate result and adverse events. Result: This procedure was applied in one 82-year-old male due to obstructive jaundice in the last two months. EUS and ERCP revealed a severe dilation of the common bile duct associated with choledocholithiasis. Besides, was revealed dilation of hepatic duct up to a well-circumscribed hypoechoic solid mass measuring 1.8x2 cm compressing the common hepatic duct. The mass was deemed unresectable and the patient was referred for palliative treatment with PDT. He remained asymptomatic for three months. He perished due to complications 15 months after the PDT session. Conclusion: Digital cholangioscopy-guided biliary PDT is feasible and seems safe and effective as an adjunct modality in the palliation of extrahepatic cholangiocarcinoma.

OBJECTIVE: To identify the best mode for diagnosing and treating the patients with choledochal cysts. METHODS: A retrospective study was performed with medical records of patients diagnosed with choledochal cysts from January 1994 to December 2017. In all cases, the diagnosis was based on ultrasound examination. All the patients underwent cyst resection and were divided in two groups: bile enteric anastomosis in the high portion of the common hepatic duct or in the dilated lower portion. RESULTS: Eighty-one cases were studied. The age of presentation was 4 y 2 mo ± 4 y 1 mo, and the age for the surgical treatment was 5 y 5 mo ± 4 y 6 mo. In 61 cases, US was the only image examination performed. There were 67 cases of Todani type I (82.7%), 13 cases of type IV (16.0%) and one case of type III (1.2%). Nine patients (29.0%) in the first period and 2 patients (4.0%) in the second period presented with postoperative complications (p=0.016). CONCLUSION: In patients with choledochal cysts, US is the only necessary diagnostic imaging. Performing the bile enteric anastomosis in the lower portion of the common hepatic duct is safer and has a lower risk of complications.

ABSTRACT Choledocholithiasis or presence of calculus in the extra hepatic main bile duct in the majority of cases is endoscopic resolution by endoscopic retrograde cholangiography (ERCP); but in certain cases, the surgical resolution is indicated due to the disproportion between the calculus/choledocho and other factors that make endoscopic resolution difficult or impossible. The objective of this work is to present the laparoscopic video resolution of a patient with a diagnosis of bile duct stones, with a history of cholecystectomy 12 years earlier. This is a 69-year-old female patient with epigastric pain, 30 days of evolution, accompanied by nausea, vomiting, jaundice and choluria. At hospital admission, she presented moderate acute cholangitis and a large bile duct stone, corroborated with ERCP, due to disproportion of the size of the calculus and common bile duct. Surgicallaparoscopic treatment was performed.

RESUMEN La coledocolitiasis o presencia de litos en la vía biliar principal extra hepática en la mayoría de los casos es de resolución endoscópica mediante la Colangiopancreatografía retrograda endoscópica (CPRE); pero en ciertos casos la, la resolución quirúrgica es la indicada debido a las desproporciones entre calculo/luz coledociana y otros factores que hacen difícil o imposible la resolución endoscópica. El objetivo de este trabajo es presentar la resolución video laparoscópica de una paciente con diagnóstico de colédoco-litiasis de gran tamaño, con antecedente de colecistectomía 12 años antes. Se trata de una paciente femenina, de 69 años con clínica de dolor en epigastrio, de 30 días de evolución, acompañado de nauseas, vómitos, ictericia y coluria. Al ingreso hospitalario presentaba una colangitis aguda moderada, y una litiasis en el colédoco de gran tamaño, corroborado con una CPRE, por desproporción del tamaño del cálculo y el colédoco, se realizó la extracción por vía quirúrgica video laparoscópica.

Introdução: A CPRE é o exame preferencial para a remoção de cálculos biliares e pancreáticos. Em situações de cálculos difíceis foram propostas novas modalidades terapêuticas como a litotrícia electro-hidráulica (LEH) e a litotrícia por laser (LL). Recentemente a disponibilidade da colongioscopia de operador-único tornaram estas técnicas mais acessíveis e fáceis de realizar. Procuramos avaliar a eficácia clínica de litotrícia guiada por colangioscopia recorrendo à LEH ou à LL em doentes com cálculos biliares e pancreáticos difíceis. Métodos: Estudo prospetivo, conduzido em 2 Hospitais associados à Universidade e englobando 17 doentes consecutivos com cálculos difíceis biliares e pancreáticos, estes doentes foram tratados com litotrícia guiada por colangioscopia recorrendo a LEH ou LL. Analisamos a limpeza completa dos ductos, bem como o impato do número de pedras e localização no sucesso clínico, associada à avaliação das 2 técnicas de litotrícia e complicações desta abordagem terapêutica. Resultados: Doze doentes (70.6%) tinham cálculos no colédoco/hepático comum, 2 doentes (17.6%) tinham um cálculo único no coto do cístico e 3 doentes (17.6%) apresentavam cálculos pancreáticos. Dezasseis (94.1%) doentes foram tratados com sucesso numa única sessão e o restante (5.9%) doente necessitou de 3 sessões incluído LEH, LL e litotrícia mecânica para obter limpeza dos ductos. Onze doentes foram tratados com LL e obtiveram sucesso clínico numa única sessão com uma fibra única de laser. Seis doentes foram tratados com LEH: 4 doentes obtiveram sucesso clínico numa única sessão com 1 fibra; 1 doente necessitou de 2 fibras para obter limpeza ductal numa sessão única. O último doente falhou a limpeza dos ductos com duas fibras de LEH e necessitou de sessão adicional com Laser (uma fibra) para obter fragmentação adequada dos cálculos. As complicações foram ligeiras em 6/17 (35.2%) doentes e incluíram febre (n = 4), dor (n = 1) e pancreatite ligeira (n = 1). Conclusões: A litotrícia guiada por colangioscopia com recurso a LEH ou LL em doentes com cálculos difíceis biliares e pancreáticos é muito eficaz e está associada a complicações transitórias e ligeiras. Existe clara necessidade de realizar estudos comparativos entre LEH e LL.

Background and Aims: Endoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones. Methods: This is a prospective clinical study - conducted at two affiliated universityhospitals - of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated the efficacy of the two techniques used for cholangioscopyguided lithotripsy and procedural complications. Results: Twelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (n = 3), pain (n = 1), and mild pancreatitis (n = 1). Conclusions: Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.