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

Calcolosi colecisto-coledocica

Asintomatica

Pancreatite

Dolore Ittero

Subittero Colangite

Calcolosi colecisto-coledocica

Sequenziale

Papillotomia trans duodenale

Sequenziale inversa

Coledocoscopia

Rendez-vous

Open

One stage

Transcistica Transcoledocica

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

Colangiografia peroperatoria:

Ecolaparoscopia: numero e sede dei

calcoli

numero e sede dei calcoli

deflusso in duodeno

Calcolosi colecisto-coledocica

Protocolli diagnostici intraoperatori

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

25 (11%) choledocholithiasis

7 open(grandi calcoli)

16 postop. ERCP (piccoli calcoli)

2 osservazione

Duensing RA J Gastrointest Surg. 2000

Surg. Endosc 1999

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”

Terapia chirurgica miniinvasiva calcolosi colecisto-coledocicaTecnologia:

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-coledocicaProtocollo personale:

Coledoco (< 1 cm)

One stage treatment

Colangiografia peroperatoria e/o Ecolaparoscopia

Calcolo papillare

Ipertensione da papillite

Rendez-vous

Coledoco (> 1 cm)

Calcolo unico o multipli con buon deflusso

Coledocotomia

Coledocoscopia

Estrazione

transcistica

Calcolosi colecisto-coledocicaEsperienza 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

Tempi operatori 150 min (range 90 - 320 min)

Degenza post-op 6 gg (range 4 -25 gg)

Conversioni 3 (1,07%)

M/F: 112/168 età: 16-89

Vantaggi:

- Buona compliance

- Tempi ?

- Riduzione complicanze da

ERCP

Rendez-vous: 190 casi

Svantaggi:

- Disponibilità endoscopista

- Tempi ?

- Costi

- Problemi medico - legali

Vantaggi:

- One Surgeon

- Tempi ?

- Costi

Coledocotomia ideale: 48 casi

Svantaggi:

-Tecnologia

- Learning curve

Papillotomia transduodenale laparoscopica: 1 caso

Calcolosi colecisto-coledocica in gastroresecato

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%)

Calcolosi colecisto-coledocica

Esperienza personale:

Complicanze:

Trattamento miniinvasivo della calcolosi colecisto-

coledocica

Conclusioni:

Eclettismo + Tecnologia

Tailored treatment