“La calcolosi incidentale del coledoco: tailored treatment” 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

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

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

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 T 2002

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 N 2003

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

Lorimer JW, Lauzon J Am J Surg. 1997 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

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

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

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

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

Estrazione transcistica 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

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%)

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%)

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

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

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

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%)

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