Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr.

2 [ISSN 1584 – 9341]

CLINICA
CLINICA DE
DE CHIRURGIE
CHIRURGIE COLEDOCUL CHIRURGICAL CLASIC
CARITAS
CARITAS ŞI COLEDOCUL ENDOSCOPIC

Prof. Dr. Eugen Brătucu

Clinica Chirurgie, Spital Caritas
Universitatea de Medicină şi Farmacie Bucureşti

SURGICAL
SURGICAL VERSUS VERSUS ENDOSCOPICENDOSCOPIC CHOLEDOCUS CHOLEDOCUS –– Litiaza coledociana
INDICATION,
INDICATION, TECHNIQUES,
TECHNIQUES, RESULTS RESULTS (Abstract):
(Abstract): The
The treatment
treatment
of
of lithiasis
lithiasis ofof the
the main
main biliary
biliary duct
duct isis still
still controversial.
controversial. There
There are
are “LAUDATIO” - CHIRURGIA MINIINVAZIVA
different
different criterias
criterias for
for the
the types
types ofof treatment:
treatment: endoscopic,
endoscopic, surgical
surgical
minimally
minimally invasive
invasive techniques
techniques or or open
open surgery.
surgery. Based
Based to
to the
the experience
experience “SILENCE” - CHIRURGIA CLASICA
of
of Caritas
Caritas Department
Department of of Surgery,
Surgery, this
this paper
paper reviews
reviews the
the indications
indications
and
and thethe results
results ofof the
the treatment
treatment of of lithiasis
lithiasis ofof main
main biliary
biliary duct.
duct.
Conclusion:
Conclusion: Open Open surgery
surgery was was performed
performed in in 50%
50% ofof cases.
cases. This
This CENUSAREASA?
approach
approach is is also
also indicated
indicated after
after failure
failure of of laparoscopic
laparoscopic technique,
technique, but
but
the
the gold
gold standard
standard of of the
the treatment
treatment ofof the
the lithiasis
lithiasis of
of main
main biliary
biliary duct
duct is
is
the
the minimally
minimally invasive
invasive procedures
procedures (laparoscopic
(laparoscopic techniques
techniques and and
1. O IGNORAM?
ERCP).
ERCP). 2. CE PERFORMANTE MAI ARE?
3. CE FEL DE SERVICII MAI ADUCE?
KEY
KEY WORDS:
WORDS: BILIARY
BILIARY LITHIASIS,
LITHIASIS, ERCP,
ERCP, LAPAROSCOPY
LAPAROSCOPY

ƒNU ESTE UN ELOGIU AL CHIRURGIEI CLASICE

ƒLOCUL CHIRURGIEI CLASICE

Coledocul litiazic =
chirurgie clasica
Chirurgia laparoscopica
1970 - OGOSHI -> ERCP

1974 - CLASSEN -> SE

1976 - COTTON -> Clearance endoscopic

Dezobstructia Coledocolitotomie
transcistica

COLEDOC ENDOSCOPIC

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Litiaza coledociana
Litiaza coledociana

“PRIMADONNA”
„ CHIRURGIE - LAPAROSCOPICA SI CLASICA

CHIRURGIE CLASICA „ ENDOSCOPIE

„ RADIOLOGIE
’’CENUSAREASA’’

RADIOLOGIA RADIOLOGIA
LAPAROSCOPIA LAPAROSCOPIA
INTERVENTIONALA INTERVENTIONALA

COLEDOC COLEDOC
CHIRURGICAL CHIRURGICAL

CO CO
LE EVITAREA LE EVITAREA
EN DO EN DO
DO C COLEDOCOTOMIEI DO C COLEDOCOTOMIEI
SC SC
OP OP
IC IC

COLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICA COLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICA

CHIRURGIE CLASICA
RADIOLOGIA
LAPAROSCOPIA
INTERVENTIONALA
30%
COLEDOC
CHIRURGICAL

LAPARO - ENDOSCOPIE

CO
LE EVITAREA
EN DO
DO C COLEDOCOTOMIEI
SC
OP
IC
GOLD
• COLECISTECTOMIE LAPARO
STANDARD • DEZOBSTRUCTIE LAPARO-ENDOSCOPICA
COLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICA ’’HOLLY PLAN’’

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CHIRURGIA LAPARO TRATAMENTUL LITIAZEI

SI CLASICA COLEDOCIENE

TIMP VEZICULAR -> COLECISTECTOMIA

MIJLOACE PROPRII DE ENDOSCOPIE
INTRAOPERATORIE

‹ Colangiografie TIMP COLEDOCIAN -> DEZOBSTRUCTIA

‹ Ultrasonografie
‹ Coledocoscopie

CHIRURGIA COLEDOCIANA
MORTALITATE 1987 CLASICA

AUTORI CHIRURGIE DEZOBSTRUCTIE „ “AB INITIO”

‹ COLECISTECTOMIE CONVERTITA 5-7%
CLASICA ENDOSCOPICA
J. L. DUPAS 9% 3,4% ‹ LITIAZE COMPLEXE

K. H. 3,1% 3.8% „ DE SECUNDA INTENTIE

SCHRIEFFERS ‹ ESEC ENDOSCOPIC

J. P. 4,3% 5,8% ‹ ESEC LAPAROSCOPIC

NEOPTOLEMOS

TIMP VEZICULAR TIMP COLEDOCIAN LITIAZA COLEDOCIANA

DEZOBSTRUCTIE 8% esec
ƒLITIAZA MIGRATA
95% COLECISTECTOMI ENDOSCOPICA
LITIAZA SIMPLA
E ƒCALCULI RESTANT
DEZOBSTRUCTIE
LAPAROSCOPICA ƒSTENOZA ODDI
LAPAROSCOPICA
ƒ TRANSCISTIC - 23% esec
ƒLITIAZA AUTOHTONA
ƒ COLEDOCOTOMIE – 7,3% esec
ƒPANLITIAZA
ƒLITIAZA INTRAHEPATICA
COLECISTECTOMIE DEZOBSTRUCTIE LITIAZA ƒLITIAZA DUPA ABD
5%
CLASICA ENDOSCOPICA COMPLEXA ƒSTENOZE CBP
DEZOBSTRUCTIE ƒPANCREATITA CR. COMPRESIVA
CLASICA ƒFISTULE BILIOBILIARE SI BILIODIGESTIVE
ƒDILATATII CHISTICE CONGENITALE
7 BRISBANE METROPOLITAN ƒDIVERTICULI VATERIENI?
HOSPITALS

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DEZOBSTRUCTIA
SOLUTII TERAPEUTICE
COLEDOCIANA COLECIST LAPARO + DEZOBSTRUCTIE TRANSCISTICA

ESEC 30%
LAPAROSCOPIA ASOCIAT ENDOSCOPIA ESEC 7%

DEZOBSTRUCTIE COLEDOCOTOMIE DEZOBSTRUCTIE

SECVENTIAL RENDEZ - VOUS ENDOSCOPICA PRE CL LAPARO ENDOSCOPICA
30% ESEC
7,3% ESEC 8% ESEC

17% MORBIDITATE 13% MORBIDITATE

ESEC
40%
37% ESEC 45% ESEC

CHIRURGIE CLASICA
DEZOBSTRUCTIE CLASICA REZOLVA ESECURILE LAPARO-ENDOSCOPICE

MORBIDITATE 1959 - 1998 - 40 DE ANI

DEZOBSTRUCTIE DEZOBSTRUCTIE
17% 13% 10015 INTERVENTII PE CAI BILIARE
TRANSCISTICA ENDOSCOPICA
BENIGN 66.7%
BILIRAGIE 14,6% 0% 2127 INTERVENTII CBP (21,2%)
MALIGN 33,3%
PANCREATITA 7,3% 8,8% 1420 LEZIUNI BENIGNE CBP
BRISBANE
2006 • 982 LITIAZE CBP – 69%
CALCULI RESTANTI 2,4% 4,4%
• 438 ALTE LEZIUNI CBP – 31%
REOPERATI 7,3% 6,6%
7 REINTERVENTII DUPA S O - 0,7%
ESEC = 33% ESEC = 30% 4 DECESE SPECIFICE S O - 0,85%

CHIRURGIE CLASICA DE SECUNDA INTENTIE = 30% 42 REINTERVENTII DUPA DEZOBSTRUCTIE

50% + DRENAJ / DEZOBSTRUCTIE + ABD
CHIRURGIE CLASICA DE PRIMA INTENTIE = 10%
4,2%

CLINICA CHIRURGIE CARITAS DEZOBSTRUCTIE COLEDOCIANA

IAN 1997 - SEPT 2006 ABORD MIGRATA RESTANTA AUTOHTONA AUTOHTONA
TERAPEUTIC + RESTANTA

LITIAZE CBP = 347 CAZURI CLEARENCE 49,5% 89,7% 73,8%

ENDOSCOPIC X
LITIAZA MIGRATA = 282 CAZURI -> 81,2% CLEARENCE 50,5% 10,3% 26,2% 6,62%
CHIRURGICAL
• MIGRATA - 204 CAZURI - 58,7% CLASIC

• RESTANTA - 78 CAZURI - 22,4%

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

49,3%
AB INITIO = 36,3%
LITIAZA MIGRATA SI AUTOHTONA = 23 CAZURI -> 6,6%
CLEARENCE CHIR CLASIC = 50,7%
ESEC ENDOSCOPIC = 22,6%

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ESEC ENDOSCOPIC
22,6%

CRITERII DE SELECTIE
LITIAZA MIGRATA - 30,6%
PE GRUPE DE INDICATIE
LITIAZA RESTANTA - 10,2%
TERAPEUTICA
LITIAZA AUTOHTONA - 26,2%

• CLEARENCE ENDOSCOPIC 49,3%

• CLEARENCE CHIRURGICAL CLASIC 50,7%

INDICATIE
INDICATIE TERAPEUTICA
TERAPEUTICA
CRITERII DE
GRUP II SELECTIE
GRUP I
CRITERII DE
SELECTIE - Tentative nereusite de
LITIAZA dezobstructie laparo-endoscopice
COLEDOC
SIMPLA la pacientii din GRUP I
ENDOSCOPIC - Litiaza coledociana migrata - Duoden exclus chirurgical
COLEDOC
CHIRURGICAL
- Calculi coledocieni restanti
LITIAZA - Fistule bilio-biliare
LITIAZA - Fistule coledoco – digestive
- I-a recidiva dupa dezobstructie COMPLEX
SIMPLA laparo-endoscopica - Alte situatii complexe
A

INDICATIE CRITERII DE
TERAPEUTICA SELECTIE

GRUP III - Litiaza coledociana recidivanta ( > 1

recidiva)

- Litiaze intrahepatice primitive sau Grup I

secundare

- Panlitiaza
COLEDOC
CHIRURGICAL - Stenoze iatrogene asociate cu litiaza Coledoc endoscopic
LITOGEN - Stenoze sclero-inflamatorii asociate
cu litiaza

- Coexistenta dilatatiilor chistice

congenitale intra si/sau extrahepatice
LITIAZA COMPLEXA
- Diverticuli juxtavaterieni asociati
litiazei CBP

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Litiaza CBP migrata Litiaza CBP migrata

Litiaza CBP migrata Litiaza CBP migrata

Diverticul de fereastra duodenala Diverticul de fereastra duodenala

Litiaza CBP restanta Litiaza CBP restanta

Diverticul de fereastra duodenala Diverticul de fereastra duodenala

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Litiaza CBP restanta

autohtonizata

Grup II

Coledoc chirurgical

Litiaza CBP migrata

Litiaza CBP migrata
Diverticul de fereastra duodenala
Fistula colecisto-duodenala
Fistula colecisto-coledociana

Litiaza CBP dublu recidivata

Grup III

Coledoc chirurgical
litogen

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Litiaza autohtona CBP

Stenoza CBP postoperatorie
Diverticul de fereastra duodenala
Litiaza autohtona
Status post PSE

Stenoza CBP postoperatorie Colangita sclero-inflamatorie

Litiaza autohtona Litiaza intra si extrahepatica

Diverticul de fereastra duodenala

Megacoledoc litiazic Dilatatie congenitala CBP

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Diverticul de fereastra duodenala

Dilatatie congenitala CBP
Control postop
Algoritm terapeutic in
litiaza coledociana

GRUP II

GRUP I COLEDOC CHIRURGIE

CHIRURGICAL DESCHISA

COLEDOC REZOLVARE
1-a RECIDIVA LITIAZA LITIAZA
ENDOSCOPIC ENDOSCOPICA
MIGRATA AUTOHTONA

ESEC DEZOBSTRUCTIE
+ RECIDIVA ACD
DRENAJ EXTERN
CHIRURGIE
DESCHISA RECIDIVA

GRUP II ESEC

CONCLUZII
GRUP III „ Chirurgia clasica pentru dezobstructie coledociana se aplica in
aproximativ 50% din litiazele coledociene:
coledociene: de prima intentie (10%), de
secunda intentie (40%).
A 2-a
HJS”Y” „ Ea corecteaza esecurile,
esecurile, accidentele si incidentele chirurgiei
RECIDIVA
miniinvazive.
miniinvazive. Totodata ea este folosita “ab initio”
initio” in cazurile cele mai
dificile:
dificile: litiazele complexe.
complexe.
COLEDOC
CHIRURGICA RECIDIVA „ Calitatile dezobstructiei miniinvazive confera acesteia aureola de “gold
L LITOGEN standard”
standard” in chirurgia litiazei coledociene.
coledociene.
A 3-a „ Atunci cand nu se obtine efectul scontat - dezobstructia - prin
RECIDIVA “strategia fericita”
fericita” (miniinvaziva),
miniinvaziva), ramane ultima intentie:
intentie: chirurgia
CHIRURGIE DESCHISA
clasica.
clasica.
HJS DE VIZITARE
LITIAZA „ Chirurgia miniinvaziva si cea clasica se deruleaza in mod secvential,
secvential,
INTRAHEPATICA fiecare cu compartimentul ei.
ei.
„ Chirurgia clasica nu mai este astazi o “primadonna”
primadonna” dar ramane o
“solutie salvatoare”
salvatoare” careia trebuie sa-
sa-i iertam dezavantajele.
dezavantajele.

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