Transcript Diapositiva 1

A.O. MONALDI
AZIENDA OSPEDALIERA DI RILIEVO NAZIONALE
E DI ALTA SPECIALIZZAZIONE
U.O.C. DI CHIRURGIA GENERALE
Direttore: Prof. F. Corcione
“La calcolosi
incidentale del
coledoco: tailored
treatment”
F. Corcione
Pancreatite
Subittero
Colangite
Calcolosi colecisto-coledocica
Ittero
Dolore
Asintomatica
Papillotomia trans
duodenale
Rendez-vous
One stage
Open
Calcolosi colecisto-coledocica
Coledocoscopia
Transcistica Transcoledocica
Sequenziale
Sequenziale
inversa
Helical CT cholangiography in the evaluation of the
biliary tract: application to the diagnosis of
choledocholithiasis.
“The sensitivity of this technique (95.5%) was
greater than that with unenhanced CT (60%) and
ultrasonography (27.3%).......... HCT
cholangiography is a reliable technique that is
similar to direct cholangiography in visualizing
biliary anatomy, anatomic variants, and
choledocholithiasis.”
Cabada Giadas T 2002
Magnetic resonance cholangiopancreatography versus
endoscopic retrograde cholangiopancreatography in
the diagnosis of choledocholithiasis.
“MRCP showed a sensitivity of 84%, specificity of 96%,
positive predictive value of 91%, negative predictive value of
93% and diagnostic accuracy of 92% when compared to ERCP
as the gold standard...... MRCP has high sensitivity and high
specificity for stones greater than 5 mm in diameter and
should be performed in preference to ERCP as the first-line
investigation in patients with gallstones and abnormal liver
function tests in the elective setting.”
Griffin N 2003
Calcolosi colecisto-coledocica
Protocolli diagnostici intraoperatori
Colangiografia peroperatoria:
numero e sede dei calcoli
deflusso in duodeno
Ecolaparoscopia: numero e sede dei calcoli
Management of choledocholithiasis in the
time of laparoscopic cholecystectomy.
“No attempt was made to identify
choledocholithiasis intraoperatively.”
Lorimer JW, Lauzon J Am J Surg. 1997
236 patients
cholangiography
7 open (grandi calcoli)
25 (11%) choledocholithiasis
16 postop. ERCP (piccoli calcoli)
2 osservazione
Duensing RA J Gastrointest Surg. 2000
E.A.E.S. multicenter prospective randomized
trial comparing two-stage vs single-stage
management of patients with gallstone
disease and ductal calcul.
“Equivalent success rates and patient morbidity
for two managements options but a significantly
shorter hospital stay with the single stage
treatment. The findings indicate that in fit
patients single-stage laparoscopic treatment is
the better option”
Surg. Endosc 1999
Terapia chirurgica miniinvasiva
calcolosi colecisto-coledocica
Tecnologia:
 Amplificatore di brillanza
 Ecolaparoscopia
 Coledoscopia (3 – 5 mm)
 Cateteri (Dormia, Fogarty, etc.)
 Telecamere ed ottiche ad alta
tecnologia
 Disponibilità endoscopista
Calcolosi colecisto-coledocica
Protocollo personale:
 Pazienti ad alto
rischio anestesiologico
 Pazienti anziani
 Diagnosi dubbia
Sequenziale
Calcolosi colecisto-coledocica
Protocollo personale:
One stage treatment
Colangiografia peroperatoria e/o
Ecolaparoscopia
Coledoco (< 1 cm)
Calcolo papillare
Ipertensione da papillite
Rendez-vous
Coledoco (> 1 cm)
Calcolo unico o multipli con
buon deflusso
Coledocotomia
Estrazione
transcistica
Coledocoscopia
Calcolosi colecisto-coledocica
Esperienza personale:
1 Gennaio 1999 – Dicembre 2004
 Colecist. Laparoscopiche
2720
 Colangio intra
998
(36,7%)
 Ecolaparoscopia
563
(20,7%)
 Calcolosi coledocica
280
(10,3%)
Trattamento sequenziale
41
(14,6%)
Rendez-vous
190
(67,9%)
One stage laparoscopy
48
(17,1%)
 Papillotomia transduod. Lap.
1
(0,35%)
Calcolosi colecisto-coledocica
Esperienza personale: 280 casi
M/F: 112/168
età: 16-89
 Tempi operatori
150 min
(range 90 - 320 min)
 Degenza post-op
6 gg
(range 4 -25 gg)
 Conversioni
3
(1,07%)
Rendez-vous: 190 casi
Vantaggi:
Svantaggi:
- Buona compliance
- Disponibilità
endoscopista
- Tempi ?
- Riduzione
complicanze da
ERCP
- Tempi ?
- Costi
- Problemi medico legali
Coledocotomia ideale: 48 casi
Vantaggi:
Svantaggi:
- One Surgeon
-Tecnologia
- Tempi ?
- Learning curve
- Costi
Papillotomia transduodenale
laparoscopica: 1 caso
Calcolosi colecisto-coledocica in
gastroresecato
Calcolosi colecisto-coledocica
Complicanze:
Esperienza personale:
 Emorragia post.op.
2
(0,71%)
 Coleperitoneo
3
(1,07%)
 Calcolosi “residua”
2
(0,71%)
 Pancreatite post ERCP
14
(5,0%)
 Emorragia g.i.
2
(0,71%)
 Mortalità
2
(0,71%)
Trattamento miniinvasivo della
calcolosi colecisto-coledocica
Conclusioni:
Eclettismo + Tecnologia
Tailored treatment