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Background: Periampullary duodenal diverticula are rare and pancreaticobiliary complications infrequent, however, when they are diagnosed and associated with symptoms, they warrant urgent intervention. The aim of this article is to present a clinical case of severe cholangitis secondary to the presence of a periampullary diverticulum successfully treated endoscopically. Clinical case: A 68-year-old man with a history of diabetes and hypertension, was admitted to the emergency room with symptoms of abdominal pain, fever, and tachycardia. With acute kidney injury and alterations in liver function tests, ultrasound with dilated common bile duct and gallstones. Magnetic resonance cholangiography is performed, showing duodenal diverticulum and choledocholithiasis. Antibiotic management is given, and endoscopic retrograde cholangiopancreatography is decided, finding a duodenal diverticulum with stones and pus inside, sphincterotomy, transpapillary dilation and multiple sweeps are performed. Cholecystectomy was performed 7 days later, and the patient was discharged without complications. Conclusions: In patients with signs of severe cholangitis, it is important not to delay endoscopic retrograde cholangiopancreatography, even when infrequent associated pathologies are evidenced, such as a periampullary duodenal diverticulum, since this represents the diagnostic and therapeutic method of choice with high rates of resolution in the case of an obstructive pathology of the bile duct.

Introducción: los divertículos duodenales periampulares son raros y las complicaciones pancreaticobiliares infrecuentes; sin embargo, cuando se diagnostican y se asocian a sintomatología ameritan intervención urgente. El objetivo de este trabajo es presentar un caso clínico de colangitis severa secundaria a la presencia de un divertículo periampular tratado de manera exitosa por vía endoscópica. Caso clínico: hombre de 68 años con antecedentes de diabetes e hipertensión, quien acude al área de Urgencias con cuadro de dolor abdominal, fiebre y taquicardia. Se identifica lesión renal aguda y alteraciones en las pruebas de función hepática, ultrasonido con colédoco dilatado y litiasis vesicular. Se realiza colangioresonancia magnética que evidencia divertículo duodenal y coledocolitiasis. Se otorga manejo antibiótico y se decide colangiopancreatografía retrógrada endoscópica, encontrándose divertículo duodenal con litos y pus en su interior, se realiza esfinterotomía, dilatación transpapilar y múltiples barridos. Se realiza colecistectomía a los siete días y se egresa a domicilio por mejoría sin complicaciones. Conclusiones: en pacientes con datos de colangitis grave es importante no retrasar la colangiopancreatografia retrógrada endoscópica, aun cuando se evidencien patologías asociadas infrecuentes como un divertículo duodenal periampular, ya que esta representa el método diagnóstico y terapéutico de elección con tasas altas de resolución ante una patología obstructiva de la vía biliar.

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La Sociedad Europea de Endoscopia Gastrointestinal (ESGE) define "canulación difícil" como aquella en la que se realizan más de 5 intentos, se exceden 5 minutos, o se produce canulación inadvertida del conducto pancreático 2 o más veces (criterios 5-5-2), recomendando estos puntos de corte para realizar técnicas avanzadas de canulación y disminuir la tasa de eventos adversos post CPRE. Nuestro objetivo fue evaluar el rendimiento de los criterios 5-5-2 y su asociación con complicaciones post CPRE en un hospital de referencia de Perú. Realizamos un estudio analítico prospectivo de casos y controles en el que se incluyó 120 pacientes a los que se realizó CPRE. El grupo casos estuvo formado por 30 pacientes que cumplieron al menos uno de los criterios 5-5-2 y el grupo controles por 90 pacientes sin ninguno de estos criterios. Se comparó el desarrollo de complicaciones en cada grupo y su asociación con cada uno de los criterios 5-5-2. Las complicaciones presentadas fueron: pancreatitis post CPRE (6,6% en el grupo casos vs 3,3% en el grupo controles), sangrado (3,3% controles vs 0% casos) y perforación (1,1% controles vs 0 % casos); sin observar diferencia estadísticamente significativa. El criterio de 2 o más ingresos inadvertidos al conducto pancreático presentó asociación significativa (OR= 10,29, IC: 1,47-71,98; p= 0,005) con el desarrollo de pancreatitis post CPRE. Los criterios 5 minutos y 5 intentos no se asociaron a complicaciones post CPRE. En conclusión, el más relevante de los criterios 5-5-2 fue el ingreso inadvertido al conducto pancreático en 2 o más ocasiones, mostrando asociación por sí solo con pancreatitis post CPRE. Los criterios tiempo y número de intentos podrían ampliarse con cautela sin aumentar la tasa de complicaciones post CPRE.

The European Society for Gastrointestinal Endoscopy (ESGE) defines "difficult biliary cannulation" by the presence of one or more of the following: more than 5 contacts with the papilla, more than 5 minutes attempting to cannulate, or inadvertent cannulation of the pancreatic duct in 2 or more times (5-5-2 criteria), recommending these cut-off points to perform advanced cannulation techniques in order to reduce the rate of post-ERCP adverse events. Our objective was to evaluate the performance of the 5-5-2 criteria and their association with post-ERCP complications in a reference hospital in Peru. We performed a prospective analytical case-control study and 120 patients who underwent ERCP were enrolled. The case group included 30 patients who met at least one of the 5-5-2 criteria and the control group included 90 patients without any of these criteria. The ERCP- related complications in both groups and their association with each of the 5-5-2 criteria were compared. The ERCP-related complications that occurred were post-ERCP pancreatitis (6.6% in the case group vs. 3.3% in the control group), bleeding (3.3% controls vs. 0% cases) and perforation (1.1% controls vs. 0% cases); no statistically significant differences were observed. The criterion of 2 or more unintended cannulations to the pancreatic duct showed a significant association (OR= 10.29, CI: 1.47-71.98; p= 0.005) with the incidence of post-ERCP pancreatitis. The criteria 5 minutes and 5 attempts were not associated with post-ERCP complications. In conclusion, among 5-5-2 criteria only the unintended cannulation of 2 or more times into the pancreatic duct was associated with an increased risk of post-ERC pancreatitis. The time and number of attempts criteria could be cautiously expanded without increasing the rate of post-ERCP complications.

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La disfunción del esfínter de Oddi (DEO) es una patología poco frecuente que debe ser considerada en el diagnóstico diferencial de pacientes con episodios de dolor biliar o pancreatitis aguda recurrente y antecedente de colecistectomía. Generalmente son pacientes con múltiples consultas, en los cuales la patología ha afectado considerablemente su calidad de vida. El diagnóstico se sustenta en la clínica, los marcadores serológicos y los medios diagnósticos de soporte, que se solicitan según el componente esfinteriano sospechado. El tratamiento con mayor eficacia es la esfinterotomía endoscópica. El uso de prótesis es aceptado, pero discutido. Se presenta el caso de un paciente masculino en la cuarta década de la vida que consultó por múltiples episodios de pancreatitis aguda recurrente con estudios de etiología que sospecharon disfunción del esfínter de Oddi pancreático y quien fue llevado a manejo endoscópico, con mejoría de su cuadro clínico.

Sphincter of Oddi Dysfunction (SOD) is a rare pathology that should be considered in the differential diagnosis of patients with biliary pain episodes or recurrent acute pancreatitis and a background of cholecystectomy. Generally, these are patients with multiple consultations where this pathology has considerably affected their quality of life. Diagnosis is based on clinical findings, serological markers and supporting diagnostic tests requested according to the suspected sphincteric component. The most effective treatment is endoscopic sphincterotomy. The use of prosthesis is accepted but debated. We present the case of a male patient in his forties who consulted for multiple episodes of recurrent acute pancreatitis with etiology studies suspecting dysfunction of the pancreatic sphincter of Oddi and who was taken to endoscopic management with improvement of his clinical picture.

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Los abscesos hepáticos son colecciones supurativas encapsuladas dentro del parénquima hepático, las cuales generalmente se encuentran infectadas por bacterias. Se forman por diferentes mecanismos, una de ellas es la secundaria a la infección de las vías biliares, colangitis aguda, la misma que en su evolución natural puede progresar a una infección severa e incluso a sepsis o choque séptico y es por ello que requiere un diagnóstico y tratamiento adecuados. La litiasis biliar puede complicarse con colangitis aguda tras la obstrucción al flujo de salida de la bilis con posterior infección, generalmente bacteriana, no solo del árbol biliar sino también del parénquima hepático. Se presenta el caso clínico de una paciente mujer joven que cursó con microabscesos hepáticos colangiolares tras un evento de coledocolitiasis no tratado oportunamente.

Hepatic abscesses are suppurative collections encapsulated within the liver parenchyma, which are generally infected by bacteria. They are formed by different mechanisms, one of them is secondary to bile duct infection, acute cholangitis, which in its natural history can progress to severe infection and even sepsis or septic shock and that is why it requires a proper diagnosis and treatment. Gallstones can be complicated by acute cholangitis after bile outflow obstruction with subsequent infection, usually bacterial, not only of the biliary tree but also of the liver parenchyma. We present the clinical case of a young female patient who presented with cholangiolar hepatic microabscesses after an event of choledocholithiasis not treated in a timely manner.

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Cholecystocholedocholithiasis is a common disease worldwide; however, there is still no consensus regarding a gold standard therapy for its management. Nowadays, the preferred method is a "two-step" process, starting with an endoscopic common bile duct (CBD) stone extraction (endoscopic retrograde cholangiopancreatography [ERCP]) followed by a laparoscopic cholecystectomy (LC). Nevertheless, this "two-step" approach has shown some difficulties over time (i.e., need for two hospital admissions, need of at least two anesthesia inductions, higher rate of post-procedural pancreatitis, longer hospitalizations and thus, increased costs). On the other hand, the laparo-endoscopic rendezvous (LER), which is a simultaneous combined procedure for removing the gallbladder laparoscopically and clearing the CBD endoscopically, is another valid treatment modality that involves a "single-step" resolution of cholecystocholedocholithiasis applying a multidisciplinary approach of the patient. The aim of this study was to present our initial outcomes. We retrospectively analyzed eleven patients who consecutively underwent LER at our institution from May 2017 to March 2022. The patients' mean age was 50.6 years old (range, 34 - 68) and most were male 54.5% (6/11). LER successfully achieved CBD stone clearance in 90.9% (10/11) of the cases. Post-LER pancreatitis was not recorded in any case. Post-operative complications included one reoperation (1/11; 9.1%) due to bleeding from one of the laparoscopic trocar sites. Our group concluded that LER can be effectively applied in Perú with good mid-term results and confirmed its effectiveness in accomplishing CBD stone clearance. Based on our results, we recommend the use of LER as a safe and valid therapeutic option for our patients.

La colecistocoledocolitiasis es una enfermedad común a nivel mundial; sin embargo, aún no hay ningún consenso sólido acerca de una sola "terapia ideal" para su manejo. Hoy en día, el método mas utilizado es un procedimiento que involucra "dos estadios", el cual comienza con la extracción endoscópica de cálculos del conducto biliar común (CBD) (colangiopancreatografía retrógrada endoscópica [CPRE]) seguida de una colecistectomía laparoscópica (CL). Sin embargo, este enfoque de "dos estadios" ha mostrado algunas desventajas con el tiempo (necesidad de dos ingresos hospitalarios, necesidad de al menos dos inducciones anestésicas, mayor tasa de pancreatitis post-procedimiento, hospitalizaciones más prolongadas y, por lo tanto, mayores costos). Por otra parte, el rendezvous laparo-endoscópico (RLE), es otra modalidad de tratamiento que implica la resolución en "un solo paso" de la colecistocoledocolitiasis, aplicando un enfoque multidisciplinario hacia el paciente. El RLE es un procedimiento en el cual simultáneamente se realizan la CL y la extracción de cálculos coledocianos por vía endoscópica. El objetivo de este estudio fue presentar nuestros resultados iniciales. Analizamos retrospectivamente once pacientes que fueron intervenidos quirúrgicamente mediante la técnica de RLE en nuestra institución desde mayo de 2017 hasta marzo de 2022. La edad media de los pacientes fue de 50,6 años (rango de edad, 34 - 68) y la mayoría fueron varones 54,.5% (6/11). RLE logró eliminar con éxito los cálculos de CBD en el 90,9 % (10/11) de los casos. En ningún caso se registró pancreatitis post-RLE. Las complicaciones postoperatorias incluyeron una reintervención (1/11; 9,1%) por sangrado de uno de los trócares laparoscópicos. Nuestro grupo concluyó que la técnica RLE se puede aplicar de manera efectiva en Perú con buenos resultados a mediano plazo y confirmó su efectividad para lograr la eliminación de cálculos de CBD. En base a nuestros resultados, recomendamos el uso de RLE como una opción terapéutica segura y válida para nuestros pacientes.

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SpyGlass DS es un sistema de colangioscopia peroral, asociado a mejor calidad de imagen y conFiguración. Actualmente, existe diversidad en su uso y escasa información sobre su implementación, incluyendo resultados clínicos y eventos adversos. Describir la experiencia de uso del SpyGlass DS en varios centros de referencia en gastroenterología en Colombia, mencionando eficacia y posibles eventos adversos. Este es un estudio observacional (serie de casos). La principal indicación fue coledocolitiasis (n:204), seguida de estenosis biliar (n:40) y pancreatolitiasis (n:16). 49,2% fueron hombres, edad media de 58,6 años, clínicamente con predominio de dolor abdominal (80,5%) e ictericia (86,1%). Todos los casos presentaron diagnóstico por imagen previo (tomografía computarizada, resonancia magnética o ecografía), 98,07% colangiopancreatografía retrógrada endoscópica previa (n:255) y 75% stent plástico biliar. Se utilizó láser en 78/220 pacientes y litotricia electrohidráulica en 142/220 pacientes, con tasas de resolución en una sola sesión 96,15% y 95,07%, respectivamente. Siete casos requirieron segunda sesión de litotricia y 3 pacientes requirieron manejo quirúrgico, uno por pancreatolitiasis con páncreas divisum de base y 2 por hepatolitiasis. 40/260 pacientes presentaron estenosis biliar, 32/40 con hallazgos malignos (colangiocarcinoma) y 8/40 con patología benigna (colangitis esclerosante primaria, cambios inflamatorios inespecíficos) tras estudios histopatológicos. Como complicaciones, se registraron 6 casos de bacteriemia (2,5%), siendo más frecuentes en casos de estenosis. La estancia media postoperatoria fue 2,04 días. Concluimos que el uso del SpyGlass DS es factible en nuestro medio, siendo eficaz para diagnóstico y tratamiento de lesiones biliares, y con bajo riesgo de eventos adversos.

SpyGlass DS is a peroral cholangioscopy system, associated with improved image quality and conFiguration. Currently, there is diversity in its use and little information on its implementation, including clinical outcomes and adverse events. To describe the experience of using SpyGlass DS in several gastroenterology reference centres in Colombia, mentioning efficacy and possible adverse events. This is an observational study (case series). The main indication was choledocholithiasis (n:204), followed by biliary stricture (n:40) and pancreatolithiasis (n:16). 49.2% were male, mean age 58.6 years, clinically with predominance of abdominal pain (80.5%) and jaundice (86.1%). All cases had previous imaging (CT scan, MRI or ultrasound), 98.07% previous endoscopic retrograde cholangiopancreatography (n:255) and 75% biliary plastic stent. Laser was used in 78/220 patients and electrohydraulic lithotripsy in 142/220 patients, with single-session resolution rates of 96.15% and 95.07%, respectively. Seven cases required a second lithotripsy session and 3 patients required surgical management, one for pancreatolithiasis with basal pancreas divisum and 2 for hepatolithiasis. 40/260 patients presented with biliary stricture, 32/40 with malignant findings (cholangiocarcinoma) and 8/40 with benign pathology (primary sclerosing cholangitis, non-specific inflammatory changes) after histopathological studies. As complications, 6 cases of bacteraemia (2.5%) were recorded, being more frequent in cases of stenosis. The mean postoperative stay was 2.04 days. We concluded that the use of SpyGlass DS is feasible in our setting, being effective for diagnosis and treatment of biliary lesions, and with low risk of adverse events.

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RESUMEN La colangiopancreatografía retrógrada endoscópica (CPRE) es considerado actualmente un procedimiento diagnóstico y terapéutico en lesiones obstructivas del tracto biliar sobretodo coledocolitiasis y estenosis, así como en enfermedades pancreáticas en general. Sin embargo, es conocido el desarrollo de ciertas complicaciones tales como pancreatitis aguda, colangitis aguda, colecistitis entre otras de menor incidencia dentro de las cuales el hematoma subcapsular hepático toma relevancia por su elevada mortalidad. Presentamos el caso de un paciente varón de 52 años que luego de tres horas de ser sometido a CPRE desarrolla dolor abdominal de inicio repentino con reducción importante del hematocrito, y mediante estudio de imágenes se evidencia un hematoma subcapsular hepático. Es manejado inicialmente de forma conservadora y luego se procede a un drenaje percutáneo, evidenciándose posteriormente contenidos residuales en descenso mediante seguimiento radiológico.

ABSTRACT Endoscopic retrograde cholangiopancreatography (ERCP) is currently considered a diagnostic and therapeutic procedure in obstructive lesions of the biliary tract, especially choledocholithiasis and stenosis, as well as in pancreatic diseases in general. However, it is known the development of certain complications such as acute pancreatitis, acute cholangitis, cholecystitis among others of lower incidence within which the hepatic subcapsular hematoma takes relevance due to its high mortality. We present the case of a 52-year-old male patient who three hours after undergoing ERCP develops abdominal pain of sudden onset with significant reduction of hematocrit, and imaging study shows a hepatic subcapsular hematoma. He was initially managed conservatively and then proceeded to a percutaneous drainage, subsequently showing residual descending contents by radiological follow-up.

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ABSTRACT - BACKGROUND: Biliary fistulas typically occur as surgical complications after laparoscopic cholecystectomy, liver transplantation, or partial liver resection. AIMS: This study aimed to evaluate the efficacy of the endoscopic treatment of biliary fistulae secondary to liver transplantation compared to that of other etiologies. METHODS: A retrospective study of 25 patients undergoing endoscopic retrograde cholangiopancreatography for biliary fistula from 2015 to 2021 was conducted at the Endoscospy Unit of Walter Cantídio University Hospital. Clinical characteristics and endoscopic success rates of the post-liver transplantation group were analyzed in comparison with those of other etiologies. RESULTS: The main causes of biliary fistula were liver transplantation (44%) and cholecystectomy complications (44%). The post-liver transplantation group had a significantly higher proportion of male sex (liver transplantation=81.8%, others=28.6%) and older age (liver transplantation=54.1 years, others=42.0 years) and a higher incidence of biliary stenosis (liver transplantation=90.9%, others=14.3%) than those of the group with other etiologies (p<0.05). The two groups received similar treatment types, among which sphincterotomy associated with biliary stent placement was most commonly used. Endoscopic therapeutic success rates showed no significant difference between the post-liver transplantation group (63.6%) and the group with other etiologies (71.4%). CONCLUSIONS: The endoscopic treatment of biliary fistulae secondary to liver transplantation presented a recovery rate similar to that of other etiologies despite the patients older age and the presence of biliary stenosis

RESUMO - RACIONAL: As fístulas biliares geralmente ocorrem como complicações cirúrgicas, especialmente após colecistectomia laparoscópica, transplante hepático ou ressecção hepática parcial. OBJETIVOS: Avaliar a eficácia do tratamento endoscópico das fístulas biliares secundária ao transplante hepático em comparação com outras etiologias. MÉTODOS: Estudo retrospectivo de 25 pacientes submetidos a Colangiopancreatografia Retrógada Endoscópica por fístula biliar entre 2015 e 2021 no Serviço de Endoscopia do Hospital Universitário Walter Cantídeo. As características clínicas e as taxas de sucesso endoscópico do grupo pós-transplante hepático foram analisadas em comparação com as de outras etiologias. RESULTADOS: As principais causas de fístula biliar foram pós-transplante hepático (44%) e complicações da pós-colecistectomia (44%). O grupo pós-transplante hepático apresentou proporção significativamente maior de sexo masculino (pós-transplante hepático=81,8%, outros=28,6%) e idade mais avançada (pós-transplante hepático=54,1 anos, outros=42,0 anos) e maior incidência de estenose biliar (pós-transplante hepático=90,9%, outros=14,3%) do que o grupo com outras etiologias (p<0,05). Os dois grupos receberam tipos de tratamento semelhantes, dentre os quais a esfincterotomia associada à aposição de prótese biliar foi a mais utilizada. As taxas de sucesso terapêutico endoscópico não mostraram diferença significativa entre o grupo pós-transplante hepático (63,6%) e o grupo com outras etiologias (71,4%). CONCLUSÕES: O tratamento endoscópico das fístulas biliares secundária ao transplante hepático apresentou taxa de recuperação semelhante à de outras etiologias, apesar da idade avançada dos pacientes e da presença de estenose biliar.

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RESUMEN Introducción : La canulación difícil en casos de colangiopancreatografía retrógrada endoscópica (CPRE) podría asociarse a diversos factores incluyendo el tipo de papila mayor, sin embargo, existen datos limitados con respecto a esta posible asociación. Objetivos : Determinar la asociación entre el tipo de papila y la canulación biliar difícil. Materiales y métodos : Se realizó un estudio retrospectivo transversal analítico en pacientes mayores de 18 años en quienes se realizó CPRE en papila virgen, de julio 2019 a abril 2021, en una institución privada. Se excluyeron las canulaciones frustras. La papila fue clasificada en base a la clasificación de Haraldsson. Se evaluó la asociación cruda y ajustada a posibles confusores entre el tipo de papila y canulación difícil. Se calcularon los riesgos relativo (RR) e intervalos de confianza al 95%. Resultados : Se incluyeron 188 pacientes. La edad media fue 55 años, el 66% de sexo femenino. La indicación más frecuente fue coledocolitiasis con 88,5%. El tipo de papila duodenal mayor más frecuente fue el tipo 1 (32%), seguido de tipo 3 (27%), tipo 2 (25%) y tipo 4 (16%). Las papilas tipo 2, 3, 4 presentaron una relación significativa con canulación difícil comparadas con la tipo 1 (p<0,001, p<0,001 y p=0,008 respectivamente). La indicación diferente a coledocolitiasis también mostró una relación significativa con canulación difícil (p<0,001). En el análisis ajustado, El RR para canulación difícil en comparación con la papila tipo 1 fue: de 2,51 (IC 95% 1,23-5,94) para la papila tipo 2, 3,72 (IC 95% 1,79-7,71) para la papila tipo 3 y 3,41 (IC 95% 1,54-7,71) para la tipo 4. La indicación distinta a la coledocolitiasis también se asoció a un mayor riesgo de canulación difícil con un RR de 2.36 (IC95% 1,57-3,56). El precorte tipo fistulotomía fue usado con mayor frecuencia en la papila tipo 3 (46%) mientras que el uso de canulótomo fue más frecuente en la papila tipo 4 (29,6%). Conclusiones : Los tipos de papila 2, 3 y 4, están asociados a mayor riesgo de canulación difícil. Ello debe ser considerado al momento de realizar la CPRE a fin de reducir el riesgo de complicaciones.

ABSTRACT Introduction : Difficult cannulation in cases of endoscopic retrograde cholangiopancreatography (ERCP) could be associated with several factors, including: type of major papilla, however, there are limited data regarding this possible association. Objectives : To determine the association between the type of papilla and difficult biliary cannulation. Materials and methods : A retrospective cross-sectional analytical study was conducted in patients over 18 years old who underwent ERCP on papilla naive, from July 2019 to April 2021, in a private institution. Unsuccessful cannulations were excluded. The papilla was classified based on Haraldsson classification. The crude association and adjusted for possible confounders between the type of papilla and difficult cannulation was evaluated. Relative risks (RR) and 95% confidence intervals were calculated. Results : 188 patients were included. The mean age was 55 years, 66% female. The most frequent indication was choledocholithiasis with 88.5%. The most frequent type of major duodenal papilla was type 1 (32%), followed by type 3 (27%), type 2 (25%) and type 4 (16%). Type 2, 3, 4 papillae showed a significant relationship with difficult cannulation compared to type 1 (p<0.001, p<0.001 and p=0.008 respectively). The indication other than choledocholithiasis also showed a significant relationship with difficult cannulation (p<0.001). In the adjusted analysis, the RR for difficult cannulation compared to type 1 papilla was: 2.51 (95% CI 1.23-5.94) for type 2 papilla, 3.72 (95% CI 1.79-7.71) for papilla type 3 and 3.41 (95% CI 1.54-7.71) for type 4. The indication other than choledocholithiasis was also associated with a higher risk of difficult cannulation with a RR of 2.36 (95% CI 1.57-3.56). The fistulotomy type precut was used more frequently in the type 3 papilla (46%), while the use of cannula was more frequent in the type 4 papilla (29.6%). Conclusions : Papilla types 2, 3 and 4 are associated with a higher risk of difficult cannulation. This should be considered when performing ERCP in order to reduce the risk of complications.

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RESUMEN Introducción: La evidencia de simulación en colangiopancreatografía retrograda endoscópica es limitada. Objetivo: El objetivo de este estudio es revisar la efectividad de la simulación en entrenamiento de endoscopistas en colangiopancreatografía retrograda endoscópica con énfasis en la canulación exitosa de la vía biliar, así como en el tiempo de canulación y evaluación del desempeño. Materiales y métodos: Se realizó una revisión sistemática en MEDLINE, EMBASE y Web of Science, desde 1970 hasta junio 2021. Se incluyeron estudios clínicos aleatorizados que compararan el entrenamiento simulado de colangiopancreatografía retrograda endoscópica versus el entrenamiento tradicional. Resultados: Se incluyeron 4 estudios, con un total de 80 participantes y 1 475 procedimientos. El odds ratio (OR) para canulación exitosa de la vía biliar con el uso de simulación fue de 2,12 (95% IC, 1,60-2,81) y el tiempo medio de canulación fue menor con respecto al entrenamiento tradicional (p<0,001). Dos estudios encontraron mejor calificación en el desempeño global de los endoscopistas con el entrenamiento simulado (OR: 1,86 (95% IC 1,29-2,7)) y (OR 2,98 (95% IC, 1,38-6,43). Conclusiones: La simulación en colangiopancreatografía retrograda endoscópica puede mejorar el desempeño de los endoscopistas en cuanto al tiempo y la canulación exitosa de la vía biliar.

ABSTRACT Introduction: The evidence for simulation in endoscopic retrograde cholangiopancreatography is limited. Objective: The objective of this study is to review the effectiveness of simulation in endoscopist training in endoscopic retrograde cholangiopancreatography with emphasis on the successful cannulation of the bile duct, as well as on the cannulation time and performance evaluation. Materials and methods: A systematic review was conducted in MEDLINE, EMBASE, and Web of Science, from 1970 to June 2021. Randomized clinical studies comparing endoscopic retrograde cholangiopancreatography simulated training versus traditional training were included. Results: 4 studies were included, with a total of 80 participants and 1,475 procedures. The odds ratio (OR) for successful bile duct cannulation with the use of simulation was 2.12 (95% CI, 1.60-2.81) and the mean time to cannulation was shorter compared to traditional training (p<0.001). Two studies found a better score in the global performance of endoscopists with simulated training (OR: 1.86 (95% CI 1.29-2.7)) and (OR 2.98 (95% CI, 1.38-6.43). Conclusions: Endoscopic retrograde cholangiopancreatography simulation can improve the performance of endoscopists in terms of time and successful bile duct cannulation.

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Introducción : La coledocolitiasis sigue estando presente hasta en 20% de la enfermedad vesicular calculosa sintomática y los cálculos complejos o difíciles son un tercio de estos. La dilatación papilar con balones de gran diámetro (DPBGD) con o sin esfinterotomía endoscópica (EE) previa proporciona excelentes resultados en el tratamiento de dichos cálculos y además complementada con variantes como litotricia mecánica (LM) y prótesis temporales y/o definitivas metálicas. Objetivos : mostrar tasas de éxito, complicaciones y eventos adversos. Demostrar que se obtiene mayor tasa de éxito con técnicas combinadas o variantes. Materiales y métodos : Evaluamos la seguridad y éxito de la DPBGD con o sin EE y otras combinaciones para el manejo de cálculos complejos. Describimos nuestros casos de una década y los comparamos con la anterior donde no realizábamos dilataciones. De 865 CPRE's por coledocolitiasis, 223 (25,78%) fueron cálculos complejos. Los tratamientos EE+DPBGD (n=183) y DPBGD solamente (n=40). Se requirieron modalidades adicionales en 15,25% (n=34). Estos dos grupos se compararon con respecto a eventos adversos, éxito de extracción, número de sesiones, duración de procedimientos y necesidad de LM y colocación de prótesis plásticas. Resultados: Se logró tratamiento completo y extracción en primera sesión en 84,74% sin diferencia significativa entre EE o sin/EE (p=0,2). Los eventos adversos no fueron significativamente diferentes en los grupos (DPBGD sóla vs. DPBGD c/EE p=0,1): eventos adversos 12,5% vs. 10,38% (incluyendo dolor sin pancreatitis); pancreatitis 2,7% vs. 2,5%). Éxito inicial y con métodos adicionales similares. El tiempo promedio de procedimiento fue mayor en el grupo de DPBGD sin/EE (20,5 minutos) contra el de DPBGD c/EE. Conclusiones : La DPBGD en CPRE permite extraer cálculos hasta en 99,65% de casos (90% en series previas sin dilatación) cifras similares a lo descrito en la literatura. Los eventos adversos de la DPBGD con/sin EE son similares entre sí y con los de CPRE clásica y no hay diferencia estadística, guardando similitud con otras series nacionales y mundiales.

Introduction : Bile duct stones constitutes 20% of symptomatic gallbladder disease and difficult stones are one third of this. Endoscopic papillary large balloon dilation (EPLBD) with or without prior endoscopic sphincterotomy (EST) produces excellent outcomes for the treatment of complex or difficult common bile duct (CBD) stones, alone or combined with previous therapeutic options as mechanical lithotripsy (ML) and temporary or definitive stenting. Objectives : Show success rate, complications and adverse events. Show that higher success rates are obtained combining ERCP techniques with no increase in complications. Materials and methods: We evaluated the safety and therapeutic outcomes of EPLBD with vs. without EST and other combinations for the removal of difficult bile duct stones. We described our procedures for a decade and compare them with the previous decade without balloon dilation. Of 865 patients and procedures, 223 (25.78%) had difficult stones. Treatments where EPLBD with EST (n=183), EPLBD alone group (n=40). Additional modalities where required in 15.25% (n=34). These two groups were compared with respect to overall procedure-related adverse events, overall stone removal success rate, number of sessions required for complete stone removal, need for mechanical lithotripsy, temporal or definite stenting and total procedure time. Results Safety removal of stones was achieved in one session on 84.75% of cases with EPLBD. The incidence of adverse events was not significantly different between the groups (EPLBD alone vs. EPLBD with EST: overall adverse events 12.5% vs. 10.38% (including pain); pancreatitis 2.7% vs. 2.5%, p=0.62). Overall success similar, initial success similar, and the need for additional techniques were also similar between groups. Median total procedure time tended to be greater in the EPLBD alone group (20.5 minutes) than in the EPLBD with EST group. Conclusion DPBGD in ERCP allows bile duct stone extraction rates close to 99.65% (90% in previous decade) according to other reports of literature. Adverse events of EPLBD alone or with EST are similar between them and with classic ERCP without statistical difference and similar to other world series.

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Introducción. La coledocolitiasis es la presencia de cálculos en las vías biliares. En la mayoría de los casos se trata mediante la colangio pancreatografía retrógrada endoscópica y menos comúnmente por intervención quirúrgica laparoscópica. El objetivo de este estudio fue describir una cohorte retrospectiva de pacientes sometidos a exploración laparoscópica de la vía biliar. Métodos. Se incluyeron pacientes intervenidos entre los años 2014 y 2018, en dos instituciones de nivel III en Cali, Colombia, referidos para valoración por cirugía hepatobiliar, por dificultad para la extracción de los cálculos por colangio pancreatografia retrograda endoscópica, debido al tamaño, la cantidad, o la dificultad para identificar o canular la papila duodenal. Resultados. De los 100 pacientes incluidos, se encontró que el 72 % fueron mujeres, con rango de edad entre 14 y 92 años. Al 39 % de los pacientes se les extrajo un solo cálculo y al 16 % 10 cálculos. Un 12 % presentaron cálculos gigantes (mayores de 2,5 cm de ancho) y un 44 % presentaron litiasis múltiple. Al 69 % de los pacientes se les realizó colecistectomía. El porcentaje de éxito de limpieza de la vía biliar por laparoscopia fue del 95 %.Discusión. La exploración laparoscópica de la vía biliar es una técnica posible, reproducible, segura y con excelentes resultados para el manejo de la coledocolitiasis

Introduction. Choledocholithiasis is the presence of stones in the bile ducts. In most cases it is treated by endoscopic retrograde cholangio pancreatography and less commonly by laparoscopic surgery. The objective of this study was to describe a retrospective cohort of patients who underwent laparoscopic exploration of the bile duct.Methods. The study included patients operated between 2014 and 2018, in two level III institutions in Cali, Colombia, referred for evaluation for hepato-biliary surgery, due to difficulty in removing stones by endoscopic retrograde pancreatography cholangiography, due to the size, quantity, or difficulty of identifying or cannulating the duodenal papilla. Results. Out of the 100 patients included, it was found that 72% were women, with an age range between 14 and 92 years. A single stone was removed from 39% of patients and 10 stones from 16%; 12% had giant stones (greater than 2.5 cm wide), and 44% had multiple stones; 69% of the patients underwent cholecystectomy. Laparoscopic bile duct cleaning success rate was 95%. Discussion. Laparoscopic exploration of the bile duct is a possible, reproducible, and a safe technique with excellent results for the management of choledocholithiasis

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La colangitis esclerosante primaria (CEP) se define por la inflamación, fibrosis y estenosis de los conductos biliares intra o extrahepáticos que no pueden ser explicadas por otras causas. La prevalencia de CEP está estimada entre 0 a 16,2 por 100.000 habitantes, mientras que la incidencia está entre 0 y 1,3 casos por cada 100.000 personas por año. Las causas siguen siendo difíciles de dilucidar y en muchos casos se establece como de origen idiopático. Sin embargo, se han propuesto factores genéticos, ambientales e isquémicos asociados, además de un componente autoinmune. Existe además una fuerte asociación entre la enfermedad inflamatoria intestinal y la CEP. Los síntomas suelen ser inespecíficos, 50% de los pacientes son asintomáticos, presentando únicamente alteración en el perfil hepático de patrón colestásico, con predominio de elevación de la fosfatasa alcalina. La ictericia es un signo de mal pronóstico que con frecuencia se asocia a colangiocarcinoma. La confirmación diagnóstica se hace por colangiopancreatografía retrógrada endoscópica (CPRE) e imágenes por resonancia magnética. Aún no existe un tratamiento establecido, y en la mayoría de los casos coexiste con otras patologías. El tratamiento es multimodal con fármacos, terapia endoscópica y trasplante hepático.

Primary sclerosing cholangitis (PSC) is defined by inflammation, fibrosis, and stenosis of the intra or extrahepatic bile ducts that cannot be explained by other causes. The prevalence of PSC is estimated between 0 to 16.2 per 100,000 inhabitants, while the incidence is between 0 and 1.3 cases per 100,000 persons-year. The causes remain elusive and, in many cases, it is established as idiopathic in origin. However, genetic, environmental and ischemic factors have been proposed in addition to an autoimmune component. There is also a strong association between inflammatory bowel disease and PSC. Symptoms are usually nonspecific, 50% of the patients are asymptomatic, presenting only an alteration in the liver profile with a cholestatic pattern, and predominance of elevated alkaline phosphatase. Jaundice is a poor prognostic sign and is frequently associated with cholangiocarcinoma. Diagnostic confirmation is made by endoscopic retrograde cholangiopancreatography and magnetic resonance imaging. There is still no established treatment, and in most cases, the disease coexists with other pathologies. Treatment is multimodal with drugs, endoscopic therapy and liver transplantation.

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RESUMEN La colangiopancreatografía retrógrada endoscópica (CPRE) representa el tratamiento de primera línea para el drenaje biliar en pacientes con obstrucción biliar maligna avanzada. Sin embargo, este procedimiento representa un desafío en pacientes con anatomía alterada quirúrgicamente. El ultrasonido endoscópico (USE) permite la toma de muestras de tejido mediante punción aspiración con aguja fina y también representa una alternativa de drenaje biliar al abordaje percutáneo o quirúrgico. Nuestro objetivo es comunicar un caso en el que la ecoendoscopia permitió el diagnóstico definitivo de la recurrencia de la enfermedad oncológica de base y el alivio de la obstrucción biliar en un paciente con anatomía alterada quirúrgicamente.

ABSTRACT Endoscopic retrograde cholangiography with biliary stenting is the generally recognized optimal treatment of malignant biliary obstruction. This procedure, though, is challenging in patients with surgically altered anatomy. Endoscopic ultrasound (EUS) enables tissue sampling by means of fine-needle aspiration and also represents an alternative recourse for biliary drainage in preference to a percutaneous approach. We aimed to report a case in which EUS enabled a definitive diagnosis of the recurrence of oncologic disease and the relief of biliary obstruction in a patient with a surgically altered anatomy.

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RESUMEN El tratamiento de las lesiones quirúrgicas de las vías biliares (LQVB), empleando procedimientos quirúrgicos de mínimo acceso en forma conjunta, a pesar de sus beneficios, ha sido escasamente reportado. Describimos el tratamiento combinado láparoendoscópico, en una paciente con fístula biliar y estenosis postoperatoria del conducto hepático derecho (CHD). Con base en la descripción de un caso clínico, ilustramos la técnica quirúrgica y evaluamos su aplicabilidad y resultados. Empleando colangiografía laparoscópica, identificamos la fistula biliar y demostramos la oclusión del CHD por un clip metálico, el cual fue retirado mediante guía fluoroscópica. Realizamos maniobra de "rendezvous" biliar y colocamos de prótesis plástica endoscópica. La fístula biliar resolvió en 12 días y a 40 meses de seguimiento, la paciente permanece sin alteraciones. El abordaje láparo-endoscópico, aunque técnicamente demandante, resultó efectivo para el tratamiento de esta paciente. Su seguimiento es fundamental y de especial interés, a fin de evaluar los resultados a largo plazo.

ABSTRACT Treatment of bile ducts injuries (BDI) treatment, combining minimally access surgical techniques, although their benefits, has been scarcely reported. We described a combined laparoscopic-endoscopic procedure, carried out in a patient with postoperative right hepatic duct (RHD) injury associated to laparoscopic cholecystectomy. Based on a clinical case description, we illustrate the surgical technique and assess their applicability and results. A biliary fistula was identified employing laparoscopic cholangiography and a metallic clip applied, producing RHD occlusion, was retrieved under fluoroscopic guidance. A biliary "rendezvous" maneuver was done for positioning an endoscopic biliary stent. The biliary fistula disappeared within two weeks and during 40-months of follow-up the patient remains asymptomatic. Laparoscopic-endoscopic approach, although technically demanding, resulted effective to treat this patient. A Continuous follow-up is essential for evaluating the long-term results.

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ABSTRACT Objective: To determine the period during which we should avoid cholecystectomy after endoscopic retrograde cholangiopancreatography. Methods: A retrospective analysis of electronic medical charts of 532 patients undergoing endoscopic retrograde cholangiopancreatography, between March 2013 and December 2017. Results: Approximately one-third of patients underwent the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography. The conversion rate was 3.8%. The need for abdominal drainage and the finding of biliary tract injury after surgery were observed in 15.1% and 1.9% of patients, respectively. The length of stay was significantly shorter among patients undergoing surgery more than 30 days after endoscopic retrograde cholangiopancreatography. These patients had a median length of stay of one day, whereas the median length of stay in the group undergoing the procedure between 4 and 30 days after endoscopic retrograde cholangiopancreatography was 2 days. Conclusion: The period during which we should avoid cholecystectomy is between 4 and 30 days after endoscopic retrograde cholangiopancreatography.

RESUMO Objetivo: Analisar o período durante o qual devemos evitar a colecistectomia após a colangiopancreatografia retrógrada endoscópica. Métodos: Foi realizada análise retrospectiva dos prontuários eletrônicos de 532 pacientes submetidos à colangiopancreatografia retrógrada endoscópica, no período de março de 2013 a dezembro de 2017. Resultados: Cerca de um terço dos pacientes realizaram o procedimento entre 4 e 30 dias após a colangiopancreatografia retrógrada endoscópica. A frequência de conversão do procedimento foi de 3,8%. A necessidade de dreno abdominal e o achado de lesão de via biliar após a cirurgia atingiram 15,1% e 1,9% dos pacientes, respectivamente. O tempo de internação foi significativamente menor entre os pacientes com tempo de colangiopancreatografia retrógrada endoscópica superior a 30 dias. Estes pacientes apresentaram, em mediana, um dia de internação hospitalar, enquanto o tempo mediano de internação no grupo que realizou o procedimento entre 4 e 30 dias foi de 2 dias. Conclusão: O período durante o qual devemos evitar realizar a colecistectomia após a colangiopancreatografia retrógrada endoscópica é do 4° ao 30° dia.

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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.

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.

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ABSTRACT Background: Obesity can be treated with bariatric surgery; but, excessive weight loss may lead to diseases of the bile duct such as cholelithiasis and choledocholithiasis. Endoscopic retrograde cholangiopancreatography is a diagnostic and therapeutic procedure for these conditions, and may be hampered by the anatomical changes after surgery. Aim: Report the efficacy and the safety of videolaparoscopy-assisted endoscopic retrograde cholangiopancreatography technique in patients after bariatric surgery with Roux-en-Y gastric bypass. Method: Retrospective study performed between 2007 and 2017. Data collected were: age, gender, surgical indication, length of hospital stay, etiological diagnosis, rate of therapeutic success, intra and postoperative complications. Results: Seven patients had choledocholithiasis confirmed by image exam, mainly in women. The interval between gastric bypass and endoscopic procedure ranged from 1 to 144 months. There were no intraoperative complications. The rate of duodenal papillary cannulation was 100%. Regarding complications, the majority of cases were related to gastrostomy, and rarely to endoscopic procedure. There were two postoperative complications, a case of chest-abdominal pain refractory to high doses of morphine on the same day of the procedure, and a laboratory diagnosis of acute pancreatitis after the procedure in an asymptomatic patient. The maximum hospital stay was four days. Conclusion: The experience with endoscopic retrograde cholangiopancreatography through laparoscopic gastrostomy is a safe and effective procedure, since most complications are related to the it and did not altered the sequence to perform the conventional cholangiopancreatography.

RESUMO Racional: A obesidade pode ser tratada com a cirurgia bariátrica; porém, doenças da via biliar como colelitíase e coledocolitíase podem surgir, principalmente devido à grande perda de peso. A colangiopancreatografia retrógrada é procedimento diagnóstico e terapêutico dessas afecções, e pode ser dificultada pela alteração anatômica após a operação. Objetivos: Relatar a eficácia e a segurança da colangiopancreatografia endoscópica retrógrada assistida por videolaparoscopia nos pacientes pós-cirurgia bariátrica com derivação gástrica em Y-de-Roux. Método: Estudo retrospectivo entre 2007 e 2017. Foram coletados: idade, gênero, indicação cirúrgica, tempo de internamento, diagnóstico etiológico, taxa de sucesso terapêutico, intercorrências intra e pós-operatórias. Resultados: Sete pacientes tiveram coledocolitíase confirmada por exame de imagem, principalmente em mulheres. O intervalo entre a derivação gástrica e o procedimento endoscópico variou de 1 a 144 meses. Não houve intercorrências intraoperatórias. A canulação da papila duodenal foi obtida em 100% dos casos. A maioria dos casos de complicações foi relacionada à gastrostomia, e raramente ao procedimento endoscópico. Houve duas intercorrências pós-operatórias, um caso de dor toracoabdominal refratária às doses elevadas de morfina no mesmo dia do procedimento, além de um diagnóstico laboratorial de pancreatite aguda pós-procedimento em paciente assintomático. A permanência hospitalar máxima foi de quatro dias. Conclusão: A colangiopancreatografia retrógrada endoscópica pela gastrostomia laparoscópica é método eficaz, seguro, visto que a maioria das complicações foi relacionada à gastrostomia; ela não altera a sequência de realização da colangiopancreatografia convencional.

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SUMMARY OBJECTIVE: We conducted this study to investigate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP) on elder choledocholithiasis and its effects on the levels of TNF-α, IL-1, and IL-6. METHODS: Elder patients with choledocholithiasis were enrolled in this study, and according to the surgical methods, they were divided into the ERCP group and the surgical group. After treatment, we compared the efficacy of these two methods on patients, inflammatory responses indicated by the levels of TNF-α, IL-1, and IL-6, and the complications. RESULTS: No statistical significance was identified in the difference of the success rate in removal between the two groups (98% vs. 94%), but indicators of the ERCP group, including the surgical duration (28.5±12.8) min, remission duration of abdominal pain (1.2±0.2) d, recession time of jaundice (2.0±0.3) d, postoperative bedridden time (1.4±0.2) d, treatment time of the anti-infection (1.5±0.2) d, length of stay in hospital (6.5±0.3) d, levels of TNF-α (2.1±0.2) μg/L, IL-1 (6.3±0.8) μg/L, IL-6 (2.8±0.3) μg/L, and the incidence rate of complications (1.8%), were all significantly lower than those in the surgical group (p<0.05). CONCLUSION: In the treatment of choledocholithiasis, ERCP is excellent in controlling the trauma, accelerating the recovery duration, reducing the occurrence of complications and ameliorating the inflammatory responses. Thus, it is an ideal choice for choledocholithiasis.

RESUMO OBJETIVO: Realizamos este estudo para investigar a eficácia clínica da colangiopancreatografia retrógrada endoscópica (ERCP) na coledocolitíase idosa e seus efeitos nos níveis de TNF-α, IL-1 e IL-6. MÉTODOS: Pacientes idosos com coledocolitíase foram matriculados neste estudo. De acordo com os métodos cirúrgicos, eles foram divididos em grupo ERCP e grupo cirúrgico. Após o tratamento, comparamos a eficácia desses dois métodos em pacientes, respostas inflamatórias indicadas pelos níveis de TNF-α, IL-1 e IL-6 e as complicações. RESULTADOS: Não houve significância estatística na diferença da taxa de sucesso na remoção entre os dois grupos (98% versus 94%), mas indicadores do grupo ERCP, incluindo a duração cirúrgica (28,5 ± 12,8) min, duração da remissão da dor abdominal (1,2 ± 0,2) d, tempo de recessão de icterícia (2,0 ± 0,3) d, tempo pós-operatório (1,4 ± 0,2) d, tempo de tratamento da infecção (1,5 ± 0,2) d, duração da internação (6,5 ± 0,3) d, níveis de TNF-α (2,1 ± 0,2) μg / L, IL-1 (6,3 ± 0,8) μg / L, IL-6 (2,8 ± 0,3) μg / L e a taxa de incidência de complicações (1,8 %) foram todos significativamente inferiores aos do grupo cirúrgico (p<0,05). CONCLUSÃO: No tratamento da coledocolitíase, a ERCP é excelente no controle do trauma, acelerando a duração da recuperação, reduzindo a ocorrência de complicações e melhorando as respostas inflamatórias. Assim, é uma escolha ideal para a coledocolitíase.

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Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice in patients with choledocholithiasis. However, despite its high success rate, in some cases it is not successful, requiring alternative therapy. Billroth II partial gastrectomy is a condition associated with an important failure rate of ERCP. When endoscopic treatment fails, surgical exploration of the bile duct is the most common approach. However, the surgery is related to a greater complexity of execution and morbimortality. We describe the case of a patient with choledocholithiasis and Billroth II partial gastrectomy, submitted to the combined treatment called rendez-vous laparoendoscopic, after failure of ERCP, which unites in a single stage the endoscopic treatment of choledocholithiasis and laparoscopic removal of the gallbladder. We conclude that this therapeutic approach was effective, safe, with low cost and without complications.

La colangiopancreatografía endoscópica retrógrada (CPRE) es el tratamiento de elección en pacientes portadores de coledocolitiasis. Sin embargo, a pesar de su elevada tasa de éxito, en algunos casos no es exitosa, exigiendo terapia alternativa. La gastrectomía parcial con reconstrucción a Billroth II es una condición asociada a la importante tasa de fracaso de la CPRE. Cuando el tratamiento endoscópico falla, la exploración quirúrgica de la vía biliar es un enfoque más común. Sin embargo, la cirugía se relaciona con una mayor complejidad de ejecución y morbimortalidad. Describimos el caso de un paciente con coledocolitiasis y gastrectomía parcial con reconstrucción a Billroth II, sometido al tratamiento combinado denominado rendez-vous laparoendoscópico tras fallo de la CPRE, que une en una sola etapa el tratamiento endoscópico de la coledocolitiasis y la retirada laparoscópica de la vesícula biliar. Llegamos a la conclusión de que este enfoque terapéutico fue eficaz, seguro, de bajo costo y sin complicaciones.

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