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INTRODUCTION: Experience in the use of diagnostic and/or therapy of endoscopic retrograde cholangiopancreatography (ERCP) in children is limited. This is due to the underdiagnosis of pancreaticobiliary disease in the pediatric population and specialist personnel in this procedure. OBJECTIVE: To determine the safety and success rate of ERCP in children at Hospital Fundación Santa Fe de Bogotá between January 2007 and June 2015. METHODOLOGY: This was an observational, descriptive, retrospective case series study of patients under 18 years, who underwent ERCP between January 2007 and June 2015. The following variables were analyzed: indication, duration, type of procedure, rate of success, and complications. RESULTS: A total of 30 patients were included, in whom 65 ERCP procedures were performed. Successful cannulation was achieved in 52 of the 65 procedures (80%). Among the complications that occurred, there were four cases of pancreatitis (6.2%), two cases of bleeding (3.1%), and one case of bacteremia (1.5%), and in most cases (58 in total, 89.2%), there were no complications. DISCUSSION: The pediatric gastroenterology group of the Fundación Santa Fe de Bogotá has obtained good results in performing ERCP in the pediatric population with a success rate of 80% associated with a null mortality rate. There is enough literature available to conclude that performing ERCP in the pediatric population maintains an adequate success rate and a low complication rate. In all the studies evaluated, a null mortality rate was found, so it is considered that this procedure is safe in patients under 18 years of age.

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Resumen La presencia conjunta y masiva de cálculos biliares de la vía biliar, tanto intra como extra hepática, es una rara entidad dentro de la población occidental. A continuación, se presentan 2 casos, los cuales debutan con cuadro clínico de dolor en hipocondrio derecho y con datos clínicos y de laboratorio de obstrucción de la vía biliar, y que mediante estudio de colangio resonancia, se evidencian múltiples litos endoluminales de la vía biliar de manera global, además se muestra del tratamiento de uno de los casos mediante CPRE con evacuación exitosa de los cálculos biliares.

Abstract The joint and massive presence of gallstones from the bile duct, both intra and extra hepatic, is a rare entity within the western population. Two cases are presented below, which debuted with a clinical picture of pain in the right hypo chondrium and with a clinical picture of pain in the right hypochondrium and with clinical and laboratory data of bile duct obstruction, and that by means of a resonance cholangiography study, multiple endoluminal stones of the bile duct are evidenced. Overall, it also shows the treatment of one of the cases by ERCP with successful evacuation of the gallstones.

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BACKGROUND: Acute pancreatitis is an important complication of endoscopic retrograde cholangiography (ERC), occurring between 1-10% of patients. Several randomized controlled trials and meta-analyses have demonstrated the effectiveness of nonsteroidal anti-inflammatories (NSAIDs) such as diclofenac and indomethacin as a post-ERC pancreatitis (PEP) prophylaxis. The aim is to determine if the rectal diclofenac use reduces the PEP rate. METHODS: Retrospective cohort study. Subjects were included who underwent ERC for different indications in a tertiary center between January 2015 and June 2016. Two groups were analyzed: group A (without diclofenac use) and group B (with use of diclofenac as PEP prophylaxis). Biodemographic, technical and mortality variables were measured. RESULTS: The total cohort was 116 patients, 67 in group A and 49 in group B. The average age was 61.9±17.8 and 58.3±15.8 years, respectively (P=0.2606). Gender distribution showed a women predominance in both groups (P=0.933). Of the technical variables measured, the precut showed a statistically significant relationship to PEP (P=0.013). Of the total cohort, 8.6% developed acute pancreatitis after an ERC: four in group A and six in group B (P=0.196). In those who developed PEP (n=10), six patients developed severe acute pancreatitis (SAP). The average hospitalization for PEP was 32.2±34 days (P=0.881). No patients died, not were there any adverse reactions to the drug. CONCLUSIONS: Rectal diclofenac administered at the beginning of the ERC did not reduce the PEP rate in this patients cohort.

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Introducción: La estenosis de la vía biliar es una afección poco frecuente, pero con serias repercusiones en la morbilidad de los pacientes. La gran mayoría ocurre después de la cirugía hepatobiliar: la colecistectomía es la más común de estas cirugías. El reconocimiento temprano y el enfoque multidisciplinario adecuado es la piedra angular para lograr obtener resultados finales óptimos. Objetivo: Describir el tratamiento endoscópico de los pacientes con estenosis poscolescistectomía atendidos en el Instituto de Gastroenterología (Cuba). Métodos: Se realizó un estudio retrospectivo descriptivo de los pacientes con diagnóstico de estenosis biliar poscolescitectomía. Se determinaron variables sociodemográficas, clínicas y endoscópicas de interés. Resultados: Se estudiaron 16 pacientes. Predominaron las mujeres menores de 50 años. El 75 % de los pacientes tenían antecedente de colecistectomía laparoscópica. Las estenosis biliares tipo I y III, según la clasificación de Bismuth, fueron las más usuales. El tratamiento endoscópico mediante colangiografía retrógrada endoscópica (CPRE) con colocación de múltiples prótesis plásticas fue la conducta terapéutica más empleada. Conclusiones: En las estenosis poscolescitectomía los procedimientos endoscópicos se han convertido en el tratamiento de elección, como un procedimiento menos invasivo, con baja morbilidad y mortalidad, con evidentes resultados comparables a los logrados con procedimientos quirúrgicos no endoscópicos(AU)

Introduction: Bile duct stenosis is an infrequent condition, but it seriously affects patient morbidity. The vast majority of cases occur after hepatobiliary surgery, cholecystectomy being the most common of such surgeries. Early recognition and an appropriate multidisciplinary approach are the cornerstones to achieve optimal final results. Objective: Describe the endoscopic treatment of patients with postcholecystectomy stenosis cared for at the Institute of Gastroenterology in Cuba. Methods: A retrospective descriptive study was conducted of the patients diagnosed with postcholecystectomy bile duct stenosis. Determination was made of sociodemographic, clinical and endoscopic variables of interest. Results: A total 16 patients were studied. There was a predominance of women aged under 50 years. 75% of the patients had a history of laparoscopic cholecystectomy. The most common bile duct stenoses were types I and III by Bismuth's classification. The most frequent therapeutic management was endoscopic treatment by endoscopic retrograde cholangiography (ERCP) with placement of multiple plastic prostheses. Conclusions: Endoscopic procedures have become the treatment of choice in postcholecystectomy stenosis. They are less invasive, their morbidity and mortality are low, and their results are comparable to those of non-endoscopic surgical procedures(AU)

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Introducción: La estenosis de la vía biliar es una afección poco frecuente, pero con serias repercusiones en la morbilidad de los pacientes. La gran mayoría ocurre después de la cirugía hepatobiliar: la colecistectomía es la más común de estas cirugías. El reconocimiento temprano y el enfoque multidisciplinario adecuado es la piedra angular para lograr obtener resultados finales óptimos. Objetivo: Describir el tratamiento endoscópico de los pacientes con estenosis poscolescistectomía atendidos en el Instituto de Gastroenterología (Cuba). Métodos: Se realizó un estudio retrospectivo descriptivo de los pacientes con diagnóstico de estenosis biliar poscolescitectomía. Se determinaron variables sociodemográficas, clínicas y endoscópicas de interés. Resultados: Se estudiaron 16 pacientes. Predominaron las mujeres menores de 50 años. El 75 por ciento de los pacientes tenían antecedente de colecistectomía laparoscópica. Las estenosis biliares tipo I y III, según la clasificación de Bismuth, fueron las más usuales. El tratamiento endoscópico mediante colangiografía retrógrada endoscópica (CPRE) con colocación de múltiples prótesis plásticas fue la conducta terapéutica más empleada. Conclusiones: En las estenosis poscolescitectomía los procedimientos endoscópicos se han convertido en el tratamiento de elección, como un procedimiento menos invasivo, con baja morbilidad y mortalidad, con evidentes resultados comparables a los logrados con procedimientos quirúrgicos no endoscópicos(AU)

Introduction: Bile duct stenosis is an infrequent condition, but it seriously affects patient morbidity. The vast majority of cases occur after hepatobiliary surgery, cholecystectomy being the most common of such surgeries. Early recognition and an appropriate multidisciplinary approach are the cornerstones to achieve optimal final results. Objective: Describe the endoscopic treatment of patients with postcholecystectomy stenosis cared for at the Institute of Gastroenterology in Cuba. Methods: A retrospective descriptive study was conducted of the patients diagnosed with postcholecystectomy bile duct stenosis. Determination was made of sociodemographic, clinical and endoscopic variables of interest. Results: A total 16 patients were studied. There was a predominance of women aged under 50 years. 75 percent of the patients had a history of laparoscopic cholecystectomy. The most common bile duct stenoses were types I and III by Bismuth's classification. The most frequent therapeutic management was endoscopic treatment by endoscopic retrograde cholangiography (ERCP) with placement of multiple plastic prostheses. Conclusions: Endoscopic procedures have become the treatment of choice in postcholecystectomy stenosis. They are less invasive, their morbidity and mortality are low, and their results are comparable to those of non-endoscopic surgical procedures(AU)

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Se describe la primera experiencia con la utilización del método laparoendoscópico rendez-vous en el manejo de pacientes con litiasis vesicular y alta sospecha de coledocolitiasis en el servicio de Cirugía I del Hospital Universitario de Caracas. Método: Se aplicó el método rendez-vous a 8 pacientes que ingresaron con los diagnósticos de litiasis vesicular y alta sospecha de coledocolitiasis de forma electiva. Resultados: Se realizó la colangiografía intraoperatoria en 7 de 8 pacientes, se confirmó la presencia de coledocolitiasis en cuatro pacientes (57%) y se logró la extracción exitosa de cálculos de la vía biliar en 3 (75%) a través de colangiografía retrógrada endoscópica selectiva sobre guía biliar previa-mente colocada por el cirujano vía transcística. No se reportaron casos de pancreatitis post procedimiento ni casos de litiasis residual en 3 meses de seguimiento. La media de estadía hospitalaria fue de 9,75 días (2 ­ 25 días) y de estadía postoperatoria 2,87 días (1 ­ 7 días). Conclusión: El método rendez-vous se presenta como alternativa terapéutica mínimamente invasiva segura y exitosa para el manejo de pacientes con alta sospecha de coledocolitiasis y litiasis vesicular, trayendo como beneficios la resolución en un tiempo anestésico de ambas patologías, la disminución de las complicaciones de la CPRE y una estancia hospitalaria corta(AU)

We describe the first experience using laparoendoscopic "ren-dez-vous" approach in the management of patients diagnosed with simultaneous cholecystolithiasis and choledocholithiasis at General Surgery Department of "Hospital Universitario de Caracas". Method: Eight patients diagnosed with simultaneous cholecystolithiasis and choledocholithiasis underwent elective laparoendoscopic "rendez-vous" approach. Results: Intraoperative cholangiography confirmed choledocholithiasis in four patients (57%), lithiasis were successfully extracted on three of them (75%) using intraoperative endoscopic retrograde cholangiography after transcystic insertion of a guide wire to reach Vater's papilla. No post endoscopic retrograde cholangiography pacreatitis or residual common ductal stones were reported after a 3 months follow. Mean hospital stay was 9.75 days (2-25 days), and mean post operatory stay was 2.87 days (1-7 days). Conclusion: Rendez-vous approach isa minimal invasive, safe and effective choice available to the management of patients diagnosed with simultaneous cholecystolithiasis and choledocholithiasis, which is performed in a single anesthesia, needs a short hospital stay and lowers ERC complications(AU)

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The presence of cholestasis in both mild and severe forms of acute biliary pancreatitis (ABP) does not justify, of itself, early endoscopic retrograde cholangiography (ERC) or endoscopic sphincterotomy (ES). Clinical support treatment of acute pancreatitis for one to two weeks is usually accompanied by regression of pancreatic edema, of cholestasis and by stone migration to the duodenum in 60%-88% of cases. On the other hand, in cases with both cholestasis and fever, a condition usually characterized as ABP associated with cholangitis, early ES is normally indicated. However, in daily clinical practice, it is practically impossible to guarantee the coexistence of cholangitis and mild or severe acute pancreatitis. Pain, fever and cholestasis, as well as mental confusion and hypotension, may be attributed to inflammatory and necrotic events related to ABP. Under these circumstances, evaluation of the bile duct by endo-ultrasonography (EUS) or magnetic resonance cholangiography (MRC) before performing ERC and ES seems reasonable. Thus, it is necessary to assess the effects of the association between early and opportune access to the treatment of local and systemic inflammatory/infectious effects of ABP with cholestasis and fever, and to characterize the possible scenarios and the subsequent approaches to the common bile duct, directed by less invasive examinations such as MRC or EUS.

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Se revisa el caso clínico de un paciente de 71 años que cursa con una lesión obstructiva del hilio hepático, la evolución clínica, los estudios imagenológicos y los paraclínicos sugieren un tumor de Klatskin, el cual fue manejado por derivación biliar percutánea aliviando la ictericia. En la presente revisión se consideran los factores etiopatogénicos de estos tumores, su nueva clasificación anatómica así como las diversas alternativas del estudio por imágenes, enfatizando en la clasificación de Bismuth-Corlette. Se confrontan las alternativas de paliación, como los diferentes tipos de stents endoscópicos o el abordaje percutáneo, la extensión del drenaje (uni o bilateral). Por último, se revisan los aspectos quirúrgicos y las posibilidades de quimio y radioterapia en estos tumores.

This is a clinical case of a 71-year-old man with an obstructive lesion of the hepatic hilum, the clinical, imaging studies and the lab tests suggest a Klatskin tumor, which was managed by percutaneous biliary drainage to relieve the jaundice. In this review we consider the pathogenetic factors of these tumors, a new anatomic classification and the various alternative imaging studies, emphasizing the Bismuth-Corlette classification. Confront palliative alternatives, such as different types of endoscopic stents or percutaneous approach, drainage extension (uni or bilateral). Finally, we review the surgical aspects and possibilities of chemotherapy and radiotherapy in these tumors.

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