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A.O. MONALDI AZIENDA OSPEDALIERA DI RILIEVO NAZIONALE

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.

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A.O. MONALDI AZIENDA OSPEDALIERA DI RILIEVO NAZIONALE

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  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

  2. Pancreatite Subittero Colangite Calcolosi colecisto-coledocica Ittero Dolore Asintomatica

  3. Papillotomia trans duodenale Rendez-vous Open Calcolosi colecisto-coledocica One stage Coledocoscopia Sequenziale inversa Sequenziale Transcistica Transcoledocica

  4. 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 T2002

  5. 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 N2003

  6. Calcolosi colecisto-coledocica Protocolli diagnostici intraoperatori numero e sede dei calcoli deflusso in duodeno Colangiografia peroperatoria: Ecolaparoscopia: numero e sede dei calcoli

  7. 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

  8. 236 patients cholangiography 7 open (grandi calcoli) 16 postop. ERCP (piccoli calcoli) 2 osservazione 25 (11%) choledocholithiasis Duensing RA J Gastrointest Surg. 2000

  9. 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

  10. 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

  11. Calcolosi colecisto-coledocica Protocollo personale: • Pazienti ad alto rischio anestesiologico • Pazienti anziani • Diagnosi dubbia Sequenziale

  12. Calcolosi colecisto-coledocica Protocollo personale: One stage treatment Colangiografia peroperatoria e/o Ecolaparoscopia Coledoco (< 1 cm) Coledoco (> 1 cm) Calcolo unico o multipli con buon deflusso Calcolo papillare Ipertensione da papillite Estrazione transcistica Coledocotomia Rendez-vous Coledocoscopia

  13. 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%)

  14. 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%)

  15. Rendez-vous: 190 casi Vantaggi: Svantaggi: - Disponibilità endoscopista - Tempi ? - Costi - Problemi medico - legali - Buona compliance - Tempi ? - Riduzione complicanze da ERCP

  16. Coledocotomia ideale: 48 casi Vantaggi: Svantaggi: • Tecnologia • Learning curve • One Surgeon • Tempi ? • Costi

  17. Papillotomia transduodenale laparoscopica: 1 caso Calcolosi colecisto-coledocica in gastroresecato

  18. 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%)

  19. Trattamento miniinvasivo della calcolosi colecisto-coledocica Conclusioni: Eclettismo + Tecnologia Tailored treatment

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