clinica de chirurgie coledocul chirurgical · pdf filelitiaza coledociana...

CLINICA DE CHIRURGIECARITAS

CLINICA DE CHIRURGIECLINICA DE CHIRURGIECARITASCARITAS COLEDOCUL CHIRURGICAL CLASIC

ŞI COLEDOCUL ENDOSCOPICCOLEDOCUL CHIRURGICAL CLASIC

ŞI COLEDOCUL ENDOSCOPIC

Prof. Dr. Eugen BrătucuClinica Chirurgie, Spital Caritas

Universitatea de Medicină şi Farmacie Bucureşti

Prof. Dr. Eugen BrătucuClinica Chirurgie, Spital Caritas

Universitatea de Medicină şi Farmacie Bucureşti

SURGICAL VERSUS ENDOSCOPIC CHOLEDOCUS –INDICATION, TECHNIQUES, RESULTS (Abstract): The treatmentof lithiasis of the main biliary duct is still controversial. There are different criterias for the types of treatment: endoscopic, surgicalminimally invasive techniques or open surgery. Based to the experienceof Caritas Department of Surgery, this paper reviews the indicationsand the results of the treatment of lithiasis of main biliary duct. Conclusion: Open surgery was performed in 50% of cases. Thisapproach is also indicated after failure of laparoscopic technique, but the gold standard of the treatment of the lithiasis of main biliary duct isthe minimally invasive procedures (laparoscopic techniques andERCP).

KEY WORDS: BILIARY LITHIASIS, ERCP, LAPAROSCOPY

SURGICAL VERSUS ENDOSCOPIC CHOLEDOCUS –INDICATION, TECHNIQUES, RESULTS (Abstract): The treatmentof lithiasis of the main biliary duct is still controversial. There are different criterias for the types of treatment: endoscopic, surgicalminimally invasive techniques or open surgery. Based to the experienceof Caritas Department of Surgery, this paper reviews the indicationsand the results of the treatment of lithiasis of main biliary duct. Conclusion: Open surgery was performed in 50% of cases. Thisapproach is also indicated after failure of laparoscopic technique, but the gold standard of the treatment of the lithiasis of main biliary duct isthe minimally invasive procedures (laparoscopic techniques andERCP).

KEY WORDS: BILIARY LITHIASIS, ERCP, LAPAROSCOPY

Litiaza coledocianaLitiaza coledociana“LAUDATIO” - CHIRURGIA MINIINVAZIVA“LAUDATIO” - CHIRURGIA MINIINVAZIVA

“SILENCE” - CHIRURGIA CLASICA“SILENCE” - CHIRURGIA CLASICA

CENUSAREASA?CENUSAREASA?

1. O IGNORAM?

2. CE PERFORMANTE MAI ARE?

3. CE FEL DE SERVICII MAI ADUCE?

1. O IGNORAM?

2. CE PERFORMANTE MAI ARE?

3. CE FEL DE SERVICII MAI ADUCE?

NU ESTE UN ELOGIU AL CHIRURGIEI CLASICE

LOCUL CHIRURGIEI CLASICE

NU ESTE UN ELOGIU AL CHIRURGIEI CLASICE

LOCUL CHIRURGIEI CLASICE

Coledocul litiazic = chirurgie clasica

Coledocul litiazic = chirurgie clasica

1970 - OGOSHI -> ERCP1970 - OGOSHI -> ERCP

1974 - CLASSEN -> SE1974 - CLASSEN -> SE

1976 - COTTON -> Clearance endoscopic1976 - COTTON -> Clearance endoscopic

COLEDOC ENDOSCOPICCOLEDOC ENDOSCOPIC

Chirurgia laparoscopicaChirurgia laparoscopica

DezobstructiatranscisticaDezobstructiatranscistica ColedocolitotomieColedocolitotomie

Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]

185

Litiaza coledocianaLitiaza coledociana

“PRIMADONNA”

CHIRURGIE CLASICA

’’CENUSAREASA’’

“PRIMADONNA”

CHIRURGIE CLASICA

’’CENUSAREASA’’

Litiaza coledocianaLitiaza coledociana

CHIRURGIE - LAPAROSCOPICA SI CLASICA

ENDOSCOPIE

RADIOLOGIE

CHIRURGIE - LAPAROSCOPICA SI CLASICA

ENDOSCOPIE

RADIOLOGIE

LAPAROSCOPIALAPAROSCOPIA

COLEDOC

CHIRURGICAL

COLEDOC

CHIRURGICAL

COLEDOC ENDOSCOPIC

COLEDOC ENDOSCOPIC

RADIOLOGIA INTERVENTIONALA


COLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICACOLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICA

EVITAREA COLEDOCOTOMIEI



COLEDOC

CHIRURGICAL

COLEDOC

CHIRURGICAL

COLEDOC ENDOSCOPIC

COLEDOC ENDOSCOPIC







COLEDOC

CHIRURGICAL

COLEDOC

CHIRURGICAL

COLEDOC ENDOSCOPIC

COLEDOC ENDOSCOPIC






CHIRURGIE CLASICA

30%

CHIRURGIE CLASICA

30%

• COLECISTECTOMIE LAPARO

• DEZOBSTRUCTIE LAPARO-ENDOSCOPICA

• COLECISTECTOMIE LAPARO

• DEZOBSTRUCTIE LAPARO-ENDOSCOPICA

LAPARO - ENDOSCOPIELAPARO - ENDOSCOPIE

GOLDSTANDARDGOLDSTANDARD

’’HOLLY PLAN’’’’HOLLY PLAN’’


186

CHIRURGIA LAPARO SI CLASICA

CHIRURGIA LAPARO SI CLASICA

MIJLOACE PROPRII DE ENDOSCOPIE INTRAOPERATORIE

ColangiografieUltrasonografieColedocoscopie

MIJLOACE PROPRII DE ENDOSCOPIE MIJLOACE PROPRII DE ENDOSCOPIE INTRAOPERATORIEINTRAOPERATORIE

ColangiografieColangiografieUltrasonografieUltrasonografieColedocoscopieColedocoscopie

TRATAMENTUL LITIAZEI COLEDOCIENETRATAMENTUL LITIAZEI COLEDOCIENE

TIMP VEZICULAR -> COLECISTECTOMIATIMP VEZICULAR -> COLECISTECTOMIA

TIMP COLEDOCIAN -> DEZOBSTRUCTIATIMP COLEDOCIAN -> DEZOBSTRUCTIA

MORTALITATE 1987MORTALITATE 1987

AUTORI CHIRURGIE CLASICA

DEZOBSTRUCTIE ENDOSCOPICA

J. L. DUPAS 9% 3,4%

K. H. SCHRIEFFERS

3,1% 3.8%

J. P. NEOPTOLEMOS

4,3% 5,8%

AUTORI CHIRURGIE CLASICA


J. L. DUPAS 9% 3,4%

K. H. SCHRIEFFERS

3,1% 3.8%

J. P. NEOPTOLEMOS

4,3% 5,8%

CHIRURGIA COLEDOCIANA CLASICA

“AB INITIO”COLECISTECTOMIE CONVERTITA 5-7%LITIAZE COMPLEXE

DE SECUNDA INTENTIEESEC ENDOSCOPICESEC LAPAROSCOPIC

“AB INITIO”COLECISTECTOMIE CONVERTITA 5-7%LITIAZE COMPLEXE

DE SECUNDA INTENTIEESEC ENDOSCOPICESEC LAPAROSCOPIC

TIMP VEZICULARTIMP VEZICULAR TIMP COLEDOCIANTIMP COLEDOCIAN

95%95% COLECISTECTOMIE LAPAROSCOPICA

COLECISTECTOMIE LAPAROSCOPICA

DEZOBSTRUCTIE ENDOSCOPICADEZOBSTRUCTIE ENDOSCOPICADEZOBSTRUCTIE LAPAROSCOPICADEZOBSTRUCTIE LAPAROSCOPICA

TRANSCISTIC - 23% esecTRANSCISTIC - 23% esec

COLEDOCOTOMIE – 7,3% esecCOLEDOCOTOMIE – 7,3% esec

5%5% COLECISTECTOMIE CLASICACOLECISTECTOMIE CLASICA

DEZOBSTRUCTIE CLASICADEZOBSTRUCTIE CLASICA

DEZOBSTRUCTIE ENDOSCOPICADEZOBSTRUCTIE ENDOSCOPICA

8% esec8% esec

7 BRISBANE METROPOLITANHOSPITALS

7 BRISBANE METROPOLITANHOSPITALS

LITIAZA COLEDOCIANALITIAZA COLEDOCIANA

LITIAZA SIMPLALITIAZA SIMPLA

LITIAZA COMPLEXALITIAZA COMPLEXA

LITIAZA MIGRATACALCULI RESTANTSTENOZA ODDI

LITIAZA MIGRATACALCULI RESTANTSTENOZA ODDI

LITIAZA AUTOHTONAPANLITIAZALITIAZA INTRAHEPATICALITIAZA DUPA ABD

LITIAZA AUTOHTONAPANLITIAZALITIAZA INTRAHEPATICALITIAZA DUPA ABD

STENOZE CBPPANCREATITA CR. COMPRESIVAFISTULE BILIOBILIARE SI BILIODIGESTIVEDILATATII CHISTICE CONGENITALEDIVERTICULI VATERIENI?

STENOZE CBPPANCREATITA CR. COMPRESIVAFISTULE BILIOBILIARE SI BILIODIGESTIVEDILATATII CHISTICE CONGENITALEDIVERTICULI VATERIENI?


187

DEZOBSTRUCTIA COLEDOCIANA

DEZOBSTRUCTIA COLEDOCIANA

LAPAROSCOPIALAPAROSCOPIA ASOCIATASOCIAT ENDOSCOPIAENDOSCOPIA

SECVENTIALSECVENTIAL RENDEZ - VOUSRENDEZ - VOUS

ESECESEC

DEZOBSTRUCTIE CLASICADEZOBSTRUCTIE CLASICA

40%40%

SOLUTII TERAPEUTICESOLUTII TERAPEUTICE

ESECESEC 30%30%

COLEDOCOTOMIE LAPARO

COLEDOCOTOMIE LAPARO



7,3% ESEC

17% MORBIDITATE

7,3% ESEC

17% MORBIDITATE

8% ESEC

13% MORBIDITATE

8% ESEC

13% MORBIDITATE

ESECESEC

CHIRURGIE CLASICACHIRURGIE CLASICAREZOLVA ESECURILE LAPARO-ENDOSCOPICEREZOLVA ESECURILE LAPARO-ENDOSCOPICE

COLECIST LAPAROCOLECIST LAPARO ++ DEZOBSTRUCTIE TRANSCISTICADEZOBSTRUCTIE TRANSCISTICA

7%7%

DEZOBSTRUCTIE ENDOSCOPICA PRE CL

30% ESEC

DEZOBSTRUCTIE ENDOSCOPICA PRE CL

30% ESEC

37% ESEC37% ESEC 45% ESEC45% ESEC

DEZOBSTRUCTIE TRANSCISTICADEZOBSTRUCTIE TRANSCISTICA

DEZOBSTRUCTIE ENDOSCOPICADEZOBSTRUCTIE ENDOSCOPICA17%17% 13%13%

BILIRAGIEBILIRAGIE 14,6%14,6% 0%0%

PANCREATITAPANCREATITA 7,3%7,3% 8,8%8,8%

CALCULI RESTANTICALCULI RESTANTI 2,4%2,4% 4,4%4,4%

REOPERATIREOPERATI 7,3%7,3% 6,6%6,6%

ESEC = 33%ESEC = 33% ESEC = 30%ESEC = 30%

CHIRURGIE CLASICA DE SECUNDA INTENTIE = 30% CHIRURGIE CLASICA DE SECUNDA INTENTIE = 30%

CHIRURGIE CLASICA DE PRIMA INTENTIE = 10%CHIRURGIE CLASICA DE PRIMA INTENTIE = 10%50%50%

MORBIDITATE MORBIDITATE

BRISBANE2006

1959 - 1998 - 40 DE ANI1959 - 1998 - 40 DE ANI10015 INTERVENTII PE CAI BILIARE10015 INTERVENTII PE CAI BILIARE

2127 INTERVENTII CBP (21,2%) 2127 INTERVENTII CBP (21,2%) BENIGN 66.7%BENIGN 66.7%

MALIGN 33,3%MALIGN 33,3%1420 LEZIUNI BENIGNE CBP1420 LEZIUNI BENIGNE CBP

• 982 LITIAZE CBP – 69%

• 438 ALTE LEZIUNI CBP – 31%

• 982 LITIAZE CBP – 69%

• 438 ALTE LEZIUNI CBP – 31%

7 REINTERVENTII DUPA S O - 0,7%

4 DECESE SPECIFICE S O - 0,85%

7 REINTERVENTII DUPA S O - 0,7%

4 DECESE SPECIFICE S O - 0,85%

42 REINTERVENTII DUPA DEZOBSTRUCTIE + DRENAJ / DEZOBSTRUCTIE + ABD

4,2%

42 REINTERVENTII DUPA DEZOBSTRUCTIE + DRENAJ / DEZOBSTRUCTIE + ABD

4,2%

CLINICA CHIRURGIE CARITASIAN 1997 - SEPT 2006

CLINICA CHIRURGIE CARITASIAN 1997 - SEPT 2006

LITIAZE CBP = 347 CAZURILITIAZE CBP = 347 CAZURI

LITIAZA MIGRATA = 282 CAZURI -> 81,2%LITIAZA MIGRATA = 282 CAZURI -> 81,2%

• MIGRATA - 204 CAZURI - 58,7%

• RESTANTA - 78 CAZURI - 22,4%

• MIGRATA - 204 CAZURI - 58,7%

• RESTANTA - 78 CAZURI - 22,4%

LITIAZA AUTOHTONA = 42 CAZURI -> 12,1%LITIAZA AUTOHTONA = 42 CAZURI -> 12,1%

LITIAZA MIGRATA SI AUTOHTONA = 23 CAZURI -> 6,6%LITIAZA MIGRATA SI AUTOHTONA = 23 CAZURI -> 6,6%

DEZOBSTRUCTIE COLEDOCIANA

ABORD TERAPEUTIC

MIGRATA RESTANTA AUTOHTONA AUTOHTONA + RESTANTA

CLEARENCE ENDOSCOPIC

49,5% 89,7% 73,8% X CLEARENCE CHIRURGICAL CLASIC

50,5% 10,3% 26,2% 6,62%

CLEARENCE ENDOSCOPIC = 49,3%

CLEARENCE CHIR CLASIC = 50,7%AB INITIO = 36,3%

ESEC ENDOSCOPIC = 22,6%


188

ESEC ENDOSCOPICESEC ENDOSCOPIC22,6%22,6%

LITIAZA MIGRATA - 30,6%LITIAZA MIGRATA - 30,6%

LITIAZA RESTANTA - 10,2%LITIAZA RESTANTA - 10,2%

LITIAZA AUTOHTONA - 26,2%LITIAZA AUTOHTONA - 26,2%

• CLEARENCE ENDOSCOPIC 49,3%

• CLEARENCE CHIRURGICAL CLASIC 50,7%

• CLEARENCE ENDOSCOPIC 49,3%

• CLEARENCE CHIRURGICAL CLASIC 50,7%

CRITERII DE SELECTIEPE GRUPE DE INDICATIE

TERAPEUTICA

CRITERII DE SELECTIEPE GRUPE DE INDICATIE

TERAPEUTICA

COLEDOC ENDOSCOPIC

COLEDOC ENDOSCOPIC

GRUP IGRUP I

INDICATIE TERAPEUTICA


CRITERII DE SELECTIE


- Litiaza coledociana migrata

- Calculi coledocieni restanti

- I-a recidiva dupa dezobstructielaparo-endoscopica

- Litiaza coledociana migrata

- Calculi coledocieni restanti

- I-a recidiva dupa dezobstructielaparo-endoscopica


COLEDOC CHIRURGICAL

COLEDOC CHIRURGICAL

GRUP IIGRUP II





- Tentative nereusite de dezobstructie laparo-endoscopicela pacientii din GRUP I- Duoden exclus chirurgical

- Tentative nereusite de dezobstructie laparo-endoscopicela pacientii din GRUP I- Duoden exclus chirurgical


- Fistule bilio-biliare- Fistule coledoco – digestive- Alte situatii complexe

- Fistule bilio-biliare- Fistule coledoco – digestive- Alte situatii complexe

LITIAZA COMPLEX

A

LITIAZA COMPLEX

A

COLEDOC CHIRURGICAL

LITOGEN

COLEDOC CHIRURGICAL

LITOGEN

GRUP IIIGRUP III





- Litiaza coledociana recidivanta ( > 1 recidiva)

- Litiaze intrahepatice primitive sausecundare

- Panlitiaza

- Stenoze iatrogene asociate cu litiaza

- Stenoze sclero-inflamatorii asociatecu litiaza

- Coexistenta dilatatiilor chisticecongenitale intra si/sau extrahepatice

- Diverticuli juxtavaterieni asociatilitiazei CBP

- Litiaza coledociana recidivanta ( > 1 recidiva)

- Litiaze intrahepatice primitive sausecundare

- Panlitiaza

- Stenoze iatrogene asociate cu litiaza

- Stenoze sclero-inflamatorii asociatecu litiaza

- Coexistenta dilatatiilor chisticecongenitale intra si/sau extrahepatice

- Diverticuli juxtavaterieni asociatilitiazei CBP

LITIAZA COMPLEXALITIAZA COMPLEXA

Grup I

Coledoc endoscopic

Grup I

Coledoc endoscopic


189

Litiaza CBP migrataLitiaza CBP migrata Litiaza CBP migrataLitiaza CBP migrata

Litiaza CBP migrataDiverticul de fereastra duodenala




Litiaza CBP restantaDiverticul de fereastra duodenala





190

Litiaza CBP restantaautohtonizata

Litiaza CBP restantaautohtonizata

Grup II

Coledoc chirurgical

Grup II

Coledoc chirurgical


Fistula colecisto-coledociana


Fistula colecisto-coledocianaLitiaza CBP migrata

Fistula colecisto-duodenalaLitiaza CBP migrata

Fistula colecisto-duodenala

Grup III

Coledoc chirurgical litogen

Grup III

Coledoc chirurgical litogen

Litiaza CBP dublu recidivataLitiaza CBP dublu recidivata


191

Litiaza autohtona CBPDiverticul de fereastra duodenala

Status post PSE

Litiaza autohtona CBPDiverticul de fereastra duodenala

Status post PSEStenoza CBP postoperatorie

Litiaza autohtonaStenoza CBP postoperatorie

Litiaza autohtona

Stenoza CBP postoperatorieLitiaza autohtona

Stenoza CBP postoperatorieLitiaza autohtona

Colangita sclero-inflamatorieLitiaza intra si extrahepaticaColangita sclero-inflamatorieLitiaza intra si extrahepatica

Megacoledoc litiazicMegacoledoc litiazic Diverticul de fereastra duodenalaDilatatie congenitala CBP

Diverticul de fereastra duodenalaDilatatie congenitala CBP


192


Control postop


Control postopAlgoritm terapeutic in

litiaza coledocianaAlgoritm terapeutic in

litiaza coledociana

GRUP IGRUP I

COLEDOC ENDOSCOPIC

COLEDOC ENDOSCOPIC

REZOLVARE ENDOSCOPICA

REZOLVARE ENDOSCOPICA 1-a RECIDIVA1-a RECIDIVA

ESECESEC

CHIRURGIE DESCHISA

CHIRURGIE DESCHISA

GRUP IIGRUP II

GRUP IIGRUP II

COLEDOC CHIRURGICAL

COLEDOC CHIRURGICAL

CHIRURGIE DESCHISA

CHIRURGIE DESCHISA

LITIAZA MIGRATALITIAZA

MIGRATA

DEZOBSTRUCTIE+

DRENAJ EXTERN

DEZOBSTRUCTIE+

DRENAJ EXTERNRECIDIVARECIDIVA

LITIAZA AUTOHTONA

LITIAZA AUTOHTONA

ACDACD

RECIDIVARECIDIVA

ESECESEC

GRUP IIIGRUP III

COLEDOC CHIRURGICAL LITOGEN

COLEDOC CHIRURGICAL LITOGEN

RECIDIVARECIDIVA

A 2-a RECIDIVA

A 2-a RECIDIVAHJS”Y”HJS”Y”

CHIRURGIE DESCHISAHJS DE VIZITARE

CHIRURGIE DESCHISAHJS DE VIZITARE

LITIAZA INTRAHEPATICA

LITIAZA INTRAHEPATICA

A 3-a RECIDIVA

A 3-a RECIDIVA

CONCLUZIIChirurgiaChirurgia clasicaclasica pentrupentru dezobstructiedezobstructie coledocianacoledociana se se aplicaaplica in in aproximativaproximativ 50% din 50% din litiazelelitiazele coledocienecoledociene: de prima : de prima intentieintentie (10%), de (10%), de secundasecunda intentieintentie (40%).(40%).

Ea Ea corecteazacorecteaza esecurileesecurile, , accidenteleaccidentele sisi incidenteleincidentele chirurgieichirurgieiminiinvaziveminiinvazive. . TotodataTotodata ea ea esteeste folositafolosita ““abab initioinitio”” in in cazurilecazurile celecele maimaidificiledificile: : litiazelelitiazele complexecomplexe..

CalitatileCalitatile dezobstructieidezobstructiei miniinvaziveminiinvazive conferaconfera acesteiaacesteia aureolaaureola de de ““gold gold standardstandard”” in in chirurgiachirurgia litiazeilitiazei coledocienecoledociene..

AtunciAtunci candcand nunu se se obtineobtine efectulefectul scontatscontat -- dezobstructiadezobstructia -- prinprin““strategiastrategia fericitafericita”” ((miniinvazivaminiinvaziva), ), ramaneramane ultimaultima intentieintentie: : chirurgiachirurgiaclasicaclasica..

ChirurgiaChirurgia miniinvazivaminiinvaziva sisi ceacea clasicaclasica se se deruleazaderuleaza in mod in mod secventialsecvential, , fiecarefiecare cu cu compartimentulcompartimentul eiei..

ChirurgiaChirurgia clasicaclasica nunu maimai esteeste astaziastazi o o ““primadonnaprimadonna”” dardar ramaneramane o o ““solutiesolutie salvatoaresalvatoare”” careiacareia trebuietrebuie sasa--ii iertamiertam dezavantajeledezavantajele..


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