RESUMO
Choledocholithiasis is one of the more common benign disorders of the biliary tract with multiple features of presentation and several alternatives for its diagnosis and treatment. Our aim was to perform a based-evidence revision to propose a diagnostic and therapeutic algorithm. The raised values of gamma glutamiltranspeptidase, alkaline phosphatase and total bilirubin, are well predictors for a choledocholithiasis. The image evidence for a pre-operative detection with higher sensibility, specificity and better cost-effectiveness is the cholangioresonance. For its intraoperative detection, the cholangiography is the method most frequently used, though cholangioscopy is likewise useful. In the case of a post-operative suspicious, the cholangiography through the T tube is the gold standard. With regard to the treatment of the choledocholithiasis, the different stages are analyzed. depending if the detection was performed pre, intra or postoperatively. As a conclusion, the approach of the choledocholithiasis in one step seems to be better that to perform it in two steps, being the laparoscopic exploration for bile ducts stones more safety than the use of the intraoperative ERCP (endoscopic retrograde cholangiopancreatography) .The postoperative ERCP is not recommended excepting in very selected cases, and the biliodigestive derivations should be reserved only for the primary lithiasis of the common bile duc
Assuntos
Humanos , Ductos Biliares/cirurgia , Colangiografia , Cálculos da Bexiga Urinária/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Coledocolitíase/patologia , Síndrome de Mirizzi/terapiaRESUMO
Chronic complications of symptomatic gallstone disease, such as Mirizzi syndrome, are rare in Western developed countries with an incidence of less than 1% a year. The importance and implications of this condition are related to their associated and potentially serious surgical complications such as bile duct injury, and to its modern management when encountered during laparoscopic cholecystectomy. The pathophysiological process leading to the subtypes of Mirizzi syndrome has been explained by means of a pressure ulcer caused by an impacted gallstone at the gallbladder infundibulum, leading to an inflammatory response causing first external obstruction of the bile duct, and eventually eroding into the bile duct and evolving to a cholecystocholedochal or cholecystohepatic fistula. This article reviews the life of Pablo Luis Mirizzi, describes the earlier and later descriptions of Mirizzi syndrome, discusses the pathophysiological process leading to the development of these uncommon fistulas, reviews the current diagnostic modalities and surgical approaches and finally proposes a simplified classification for Mirizzi syndrome intended to standardize the reports on this condition and to eventually develop a consensual surgical approach to this unexpected and seriously dangerous condition.