Colecistitis aguda en vesícula biliar izquierda. Presentación de un caso resuelto en forma segura por vía laparoscópica

Left-sided gallbladder (LSGB) is a rare bile duct abnormality, usually found during a cholecystectomy. Symptoms usually do not differ from those of a normally positioned gallbladder, making the preoperative diagnosis extremely uncommon. We report the case of an acute cholecystitis in a patient whit LSGB, safely managed with laparoscopic surgery. A 24-year-old male patient was admitted to our institution with clinical and radiological signs of acute cholecystitis. The intraoperative finding of an acute cholecystitis in a LSGB made us modify ports positioning and a cholangiograhy was done by direct puncture of the gallbladder before hilum dissection. After the cystic duct was identified, a transcystic cholangiography was performed which confirmed a complete and clear bile duct anatomy and laparoscopic cholecystectomy was safely completed. The intraoperative finding of a LSGB makes the surgeon change some aspects of the usual technique to perform a safe cholecystectomy as LSGB significantly increases the risk of common bile duct injuries. Meticulous dissection of the gallbladder hilum to achieve a critical view of safety and the systematic use of intraoperative cholangiography are extremely important to perform a safe laparoscopic cholecystectomy.

The Best Approach for Laparoscopic Fluorescence Cholangiography: Overview of the Literature and Optimization of Dose and Dosing Time

Background: Fluorescence cholangiography using indocyanine green (ICG) can enhance orientation of bile duct anatomy during laparoscopic cholecystectomy. To ensure clear discrimination between bile ducts and liver, the fluorescence ratio between both should be sufficient. This ratio is influenced by the ICG dose and timing of fluorescence imaging. We first systematically identified all strategies for fluorescence cholangiography. Second, we aimed to optimize the dose of ICG and dosing time in a prospective clinical trial. Methods: PubMed was searched for clinical trials studying fluorescence cholangiography. Furthermore, 28 patients planned to undergo laparoscopic cholecystectomy were divided into 7 groups, receiving different intravenous doses (5 or 10 mg ICG) at different time points (0.5, 2, 4, 6, or 24 hours prior to surgery). Results: The systematic review revealed 27 trials including 1057 patients. The majority of studies used 2.5 mg administered within 1 hour before imaging. Imaging 3 to 24 hours after ICG administration was never studied. The clinical trial demonstrated that the highest bile duct-to-liver ratio was achieved 3 to 7 hours after administration of 5 mg and 5 to 25 hours after administration of 10 mg ICG. Up to 3 hours after administration of 5 mg and up to 5 hours after administration of 10 mg ICG, the liver was equally or more fluorescent than the cystic duct, resulting in a ratio ≤1.0. Conclusion: This study shows for the first time that the interval between ICG administration and intraoperative fluorescence cholangiography should be extended. Administering 5 mg ICG at least 3 hours before imaging is easy to implement in everyday clinical practice and results in bile duct-to-liver ratios >1.0.

The Prevalence of Hjortsjo Crook Sign of Right Posterior Sectional Bile Duct and Bile Duct Anatomy in ERCP

Aim. The frequency of the Right Posterior Sectional Bile Duct (RPSBD) hump sign in cholangiogram when it crosses over the right portal vein known as Hjortsjo Crook Sign and the bile duct anatomy are studied. Knowledge of the implication of positive sign can facilitate safe resection for both bile duct and portal vein. Methods. Prospectively, we included 237 patients with indicated ERCP during a period from March 2010 to January 2015. Results. The mean age (±SD) and male to female ratio were 38.8 (±19.20) and 1 : 1.28, respectively. All patients are Arab from Middle Eastern origin, had biliary stone disease, and underwent diagnostic and therapeutic ERCP. Positive Hjortsjo Crook Sign was found in 17.7% (42) of patients. The sign was found to be equally more frequent in Nakamura’s RPSBD anatomical variant types I, II, and IV in 8.4% (20), 6.8% (16), and 2.1% (5), respectively, while rare anatomical variant type III showed no positive sign. Conclusion. Hjortsjo Crook Sign frequently presents in RPSBD variation types I, II, and IV in our patients.

Repair of a Post-Hepatectomy Posterior Sectoral Duct Injury Secondary to Anomalous Bile Duct Anatomy Using a Novel Combined Surgical-Interventional Radiologic Approach

A 64-year-old woman with a completely transected posterior sectoral duct following extended hepatectomy underwent a combined operative procedure with interventional radiology and surgery to restore biliary-enteric drainage. The anterior and posterior sectoral ducts were identified, and catheters were inserted into both systems. The posterior sectoral catheter was placed intraoperatively through a preoperatively placed sheath, and a new tunnel was created through the regenerated liver surface. Biliary-enteric anastomoses were created over the stents.