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Focus on Hybrid Endoscopic and Percutaneous Image-Guided Surgery

Epublication, Sep 2017;17(09). URL: http://websurg.com/doi/fc01en29
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Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
Ivo Boškoski, Roxana Adelina Ciurezu, Iulia Crisan, Ludovica Guerriero, François Habersetzer, Mourad Bouhadjar, Didier Mutter, Jacques Marescaux
Хирургические операции
1 год назад
1458 просмотров
68 лайков
0 комментариев
09:31
Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
Ivo Boškoski, Roxana Adelina Ciurezu, Marian Morar, Ludovica Guerriero, François Habersetzer, Mourad Bouhadjar, Didier Mutter, Jacques Marescaux
Хирургические операции
1 год назад
1008 просмотров
66 лайков
0 комментариев
11:04
Postoperative CBD stenosis
Benign biliary strictures are often a consequence of iatrogenic injury during laparoscopic cholecystectomy or they may arise after liver transplantation or hepatic resection with duct-to-duct biliary anastomosis. Other etiologies of benign biliary strictures are primary sclerosing cholangitis, chronic pancreatitis, and autoimmune cholangitis. In the past, surgical repair was the treatment of choice. Today, ERCP has a pivotal role in the treatment of the vast majority of these lesions. Up to 80% of postoperative benign biliary strictures develop within 6 to 12 months after surgery with symptoms as pruritus, jaundice, abdominal pain, alterations of liver function tests and recurrent cholangitis. Prompt identification of these lesions is essential because long-standing cholestasis can lead to secondary biliary cirrhosis. MRCP with cholangiographic sequences is the preferred non-invasive method for diagnostic cholangiography. In particular, this imaging method can be useful in hilar strictures and in patients with suspected anastomotic biliary stricture after liver transplantation.
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
Ivo Boškoski, Marian Morar, Iulia Crisan, Ludovica Guerriero, François Habersetzer, Mourad Bouhadjar, Didier Mutter, Jacques Marescaux
Хирургические операции
1 год назад
855 просмотров
83 лайков
0 комментариев
18:14
Common bile duct stricture due to an inoperable pancreatic head cancer: metal stent placement
There are several major indications for the endoscopic drainage of malignant common bile duct obstruction. There are several types of drainage: a preoperative biliary drainage, which is performed in selected cases (delayed surgery, high bilirubin levels, itching, cholangitis), a biliary drainage before neo-adjuvant therapies, and a biliary drainage for palliation. According to the ESGE guidelines, palliative biliary drainage should be performed according to life expectancy. If less than 4 months, plastic stent placement is recommended; if longer than 4 months, a self-expandable metal stent should be placed. In any case, every single patient should be evaluated for the best treatment. In particular, since uncovered self-expandable metal stents are impossible to remove, malignancy must be evidenced before placement of these stents.
ERCP: acute cholangitis in a patient with antiplatelet (clopidogrel) therapy
Acute cholangitis is a clinical emergency. Urgent biliary drainage and bile ducts disobstruction represent the only effective therapy. Acute cholangitis is a result of bile flow obstruction and bile infection. Both ERCP and percutaneous biliary drainage are valid therapeutic options associated with antibiotics. ERCP with biliary sphincterotomy and stones clearance is less invasive and generates less discomfort as compared to percutaneous biliary drainage. Percutaneous biliary drainage is reserved for patients in poor or bad clinical conditions and co-morbidities, unavailability of ERCP or surgically altered anatomy unsuitable for ERCP. We present a case of an 81-year-old female patient with antiplatelet therapy (Plavix®/clopidogrel) and cholangitis. During ERCP, there was evidence of previously unreported small biliary sphincterotomy. Consequently, biliary balloon dilation followed by stones extraction were performed. A nasobiliary drainage was also placed to flush the bile ducts with saline over 24 hours.
Ivo Boškoski, Iulia Crisan, Roxana Adelina Ciurezu, Ludovica Guerriero, François Habersetzer, Mourad Bouhadjar, Didier Mutter, Jacques Marescaux
Хирургические операции
1 год назад
504 просмотров
92 лайков
0 комментариев
09:17
ERCP: acute cholangitis in a patient with antiplatelet (clopidogrel) therapy
Acute cholangitis is a clinical emergency. Urgent biliary drainage and bile ducts disobstruction represent the only effective therapy. Acute cholangitis is a result of bile flow obstruction and bile infection. Both ERCP and percutaneous biliary drainage are valid therapeutic options associated with antibiotics. ERCP with biliary sphincterotomy and stones clearance is less invasive and generates less discomfort as compared to percutaneous biliary drainage. Percutaneous biliary drainage is reserved for patients in poor or bad clinical conditions and co-morbidities, unavailability of ERCP or surgically altered anatomy unsuitable for ERCP. We present a case of an 81-year-old female patient with antiplatelet therapy (Plavix®/clopidogrel) and cholangitis. During ERCP, there was evidence of previously unreported small biliary sphincterotomy. Consequently, biliary balloon dilation followed by stones extraction were performed. A nasobiliary drainage was also placed to flush the bile ducts with saline over 24 hours.
Double wire biliary cannulation, biliary stone removal and pancreatic stent placement
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure in digestive endoscopy. Cannulation in ERCP requires optimal training, understanding of papillary anatomy, and especially understanding cholangiography and pancreatography imaging. The choice of cannulation technique (contrast vs. wire) depends on the expertise of local teams, even if the injection of a small amount of contrast can better show the way and direction of the ducts. It is essential to choose the appropriate accessories according to the case that's being dealt with. Here, we present the case of a hemophilic 71-year-old male patient with elevated liver enzymes, and magnetic resonance cholangiopancreatography (MRCP) was performed to detect common bile duct stones. The patient has also a left lobe liver hematoma which originated from mild trauma. Endoscopically, the papilla of this patient presented with an ectropion and long infundibulum. Biliary cannulation was performed with the double wire technique, first cannulating Wirsung’s duct which straightened the siphon. After a large biliary sphincterotomy, the stone was removed with a Dormia basket. A small pancreatic stent was placed to prevent pancreatitis.
Ivo Boškoski, Iulia Crisan, Marian Morar, François Habersetzer, Mourad Bouhadjar, Didier Mutter, Jacques Marescaux
Хирургические операции
1 год назад
656 просмотров
54 лайков
0 комментариев
18:35
Double wire biliary cannulation, biliary stone removal and pancreatic stent placement
Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure in digestive endoscopy. Cannulation in ERCP requires optimal training, understanding of papillary anatomy, and especially understanding cholangiography and pancreatography imaging. The choice of cannulation technique (contrast vs. wire) depends on the expertise of local teams, even if the injection of a small amount of contrast can better show the way and direction of the ducts. It is essential to choose the appropriate accessories according to the case that's being dealt with. Here, we present the case of a hemophilic 71-year-old male patient with elevated liver enzymes, and magnetic resonance cholangiopancreatography (MRCP) was performed to detect common bile duct stones. The patient has also a left lobe liver hematoma which originated from mild trauma. Endoscopically, the papilla of this patient presented with an ectropion and long infundibulum. Biliary cannulation was performed with the double wire technique, first cannulating Wirsung’s duct which straightened the siphon. After a large biliary sphincterotomy, the stone was removed with a Dormia basket. A small pancreatic stent was placed to prevent pancreatitis.
Percutaneous nephrolithotomy
This is the case of a 60-year-old man with a large left kidney stone (>3cm) taking up the entire renal pelvis and lower calyceal cavities. Under general anesthesia, the patient is placed in a supine modified lithotomy position, with a 3L water bag underneath the left lumbar fossa to raise it. The left leg is straight whereas the right leg is put on a leg brace flexed.
A cystoscopy is performed in order to identify the left ureteral orifice and introduce a 7 French beveled ureteral stent. This stent is connected to a Foley catheter. A contrast agent is injected into the ureteral stent.
The kidney’s lower pole is punctured with an 18 Gauge hypodermic needle, making sure to stay in contact with the stone. A rigid Lunderquist® guidewire is passed into the needle. The pathway is dilated using metallic coaxial dilators and with a dilation balloon until an Amplatz® renal sheath is placed. The sheath will then be extended.
A nephroscopy is performed to identify the stone, fragment and aspirate it partially with the LithoClast Master® intracorporeal lithotripter. Some large fragments will be withdrawn with crocodile forceps. The lithotripter system fails to remove the residual stone. A Malecot®-type nephrostomy tube is used and the ureteral stent is replaced by means of a double J catheter.
Christian Saussine
Хирургические операции
1 год назад
1908 просмотров
88 лайков
0 комментариев
34:10
Percutaneous nephrolithotomy
This is the case of a 60-year-old man with a large left kidney stone (>3cm) taking up the entire renal pelvis and lower calyceal cavities. Under general anesthesia, the patient is placed in a supine modified lithotomy position, with a 3L water bag underneath the left lumbar fossa to raise it. The left leg is straight whereas the right leg is put on a leg brace flexed.
A cystoscopy is performed in order to identify the left ureteral orifice and introduce a 7 French beveled ureteral stent. This stent is connected to a Foley catheter. A contrast agent is injected into the ureteral stent.
The kidney’s lower pole is punctured with an 18 Gauge hypodermic needle, making sure to stay in contact with the stone. A rigid Lunderquist® guidewire is passed into the needle. The pathway is dilated using metallic coaxial dilators and with a dilation balloon until an Amplatz® renal sheath is placed. The sheath will then be extended.
A nephroscopy is performed to identify the stone, fragment and aspirate it partially with the LithoClast Master® intracorporeal lithotripter. Some large fragments will be withdrawn with crocodile forceps. The lithotripter system fails to remove the residual stone. A Malecot®-type nephrostomy tube is used and the ureteral stent is replaced by means of a double J catheter.