TRATAMENTUL COLECISTITEI CRONICE ALITIAZICE

TRATAMENTUL COLECISTITEI CRONICE ALITIAZICE

Tratamentul chirurgical

Solutia preferata este realizarea colecistectomiei pentru toti pacientii, exceptand cazurile care au contraindicatii pentru interventia chirurgicala.

Colecistectomia laparoscopica

Laparoscopic surgery requires a space for visualization and instrument manipulation, and this space is usually created by establishing a pneumoperitoneum with carbon dioxide. Both open and closed methods have been used to establish a pneumoperitoneum. With the open technique, a small incision is made above the umbilicus into the peritoneal cavity. A special blunt-tipped cannula (Hasson) with a gas tight sleeve is inserted into the peritoneal cavity and anchored to the fascia. This technique is often used after previous abdominal surgery and should avoid infrequent, but potentially life-threatening, trocar injuries. In the closed technique a special hollow insufflation needle (Veress) with a retractable cutting sheath is inserted into the peritoneal cavity through a supraumbilical incision and used for insufflation. Once an adequate pneumoperitoneum has been established, a 10-mm trocar is inserted through the supraumbilical incision. The laparoscope with attached video camera is then inserted through the umbilical port, and an examination of the peritoneal cavity is performed. Both forward viewing (0-degree) and angled (30-degree) laparoscopes are available. With either the open or the closed techniques, additional trocars are inserted under direct vision. Most surgeons use a second 10-mm trocar placed subxiphoid and two additional 5-mm trocars positioned subcostally in the right upper quadrant in the midclavicular and anterior axillary lines. Five-millimeter cameras and 3-mm instruments are also available.

The two smaller ports are used for grasping the gallbladder and placing it in the ideal position for an antegrade cholecystectomy. The lateral port is used to retract the gallbladder cephalad, elevating the inferior edge of the liver and exposing the gallbladder and the cystic duct. The medial 5-mm cannula is used to grasp the gallbladder infundibulum and to retract it laterally to further expose the triangle of Calot. This maneuver may require bluntly taking down any adhesions between the omentum or duodenum and the gallbladder. The junction of the gallbladder and cystic duct is identified by stripping the peritoneum off the gallbladder neck and removing any tissue surrounding the gallbladder neck and the proximal cystic duct. Once the cystic duct is identified, an intraoperative cholangiogram may be performed by placing a hemoclip proximally on the cystic duct, incising the anterior surface of the duct, and passing a cholangiogram catheter into the cystic duct. Once the cholangiogram is completed, two clips are placed distally on the cystic duct, and it is divided (see Fig. 50-11 B). A large cystic duct may require placement of a pretied loop ligature to provide a secure closure. ^{[10] [18]}

The next step is the identification and division of the cystic artery. The artery is usually encountered running parallel to and behind the cystic duct. Once the artery is identified and isolated, clips are placed proximally and distally on the artery, and it is divided. Once the artery and any branches are controlled, the gallbladder is dissected out of the gallbladder fossa by use of either a hook or spatula cautery (Fig. 50-12) . The peritoneum overlying the gallbladder is placed on tension by use of the two grasping forceps, and the peritoneum and adventitia between the gallbladder and liver are divided with the cautery. Just before the gallbladder is removed from the liver, the operative field is carefully searched for hemostasis, and adequate placement of the cystic duct and artery clips is confirmed. The gallbladder is then dissected off the liver and is usually removed through the umbilical port. The fascial defect and skin incision may need to be enlarged to remove the gallbladder and contained gallstones. If the gallbladder has been entered during the dissection or if it is acutely inflamed or gangrenous, the gallbladder may be placed in a plastic specimen retrieval bag before it is removed from the peritoneal cavity.

Open Cholecystectomy

Open cholecystectomy can be performed through either an upper midline or a right subcostal (Kocher) incision. Identification and division of the cystic duct and artery initially limit bleeding from the gallbladder for the remainder of the dissection. With lateral traction on the gallbladder neck, the peritoneum overlying the triangle of Calot is incised, and the cystic duct is identified and ligated. Cholangiography is performed at this time if indicated. The cystic duct is then ligated both proximally and distally and divided. Similarly, the cystic artery is ligated and divided after it is carefully traced onto the gallbladder. If the anatomy cannot be clearly identified, the gallbladder

should be dissected from the fundus downward toward the gallbladder neck, making the ductal and vascular anatomy easier to identify. The gallbladder is dissected out of the gallbladder bed by incising the overlying peritoneum with cautery At this point, cystic duct cholangiography is performed. Rarely, a small duct entering the gallbladder from the liver is encountered and should be ligated. A closed suction drain is placed if there is concern about the security of the cystic duct closure (e.g., as in gangrenous cholecystitis).

Sindromul postcolecistectomie

Acest termen este utilizat pentru a incadra grupul heterogen de pacienti care continua sa acuze dureri in hipocondrul drept dupa colecistectomie. Principalul motiv pentru remisia incompleta a simptomatologiei anterioare interventiei ar fi stabilirea incorecta a diagnosticului de colecistita cronica.

Cele mai comune cauze ale acestui sindrom sunt: disfunctia sfincterului Oddi si sindromul de intestin iritabil.

Sphincter of Oddi Dysfunction

The sphincter of Oddi is a complex muscular structure surrounding the distal common bile duct, pancreatic duct, and ampulla of Vater. Pain characteristic of biliary colic and episodes of recurrent acute pancreatitis have been attributed to a poorly defined clinical syndrome described as dysfunction of the sphincter of Oddi. Sphincter of Oddi dysfunction may be caused by either a structural or functional abnormality involving the sphincter. Fibrosis of the sphincter from gallstone migration, operative or endoscopic trauma, pancreatitis, or other nonspecific inflammatory processes can lead to elevated sphincter pressures. Elevated sphincter pressures may also present in the absence of a structural abnormality, and these cases of sphincter of Oddi dyskinesia or spasm are often associated with more diffuse abnormalities of gastrointestinal motility. ^[61]

Sphincter of Oddi dysfunction should be suspected in patients with typical episodic biliary-type pain without an obvious organic cause. Approximately 1% of patients undergoing cholecystectomy are estimated to have sphincter of Oddi dysfunction. Numerous diagnostic tests have been used to diagnose sphincter of Oddi dysfunction, but none is sensitive or specific. Elevated serum amylase or transaminases may be present in patients with sphincter of Oddi dysfunction. Ultrasound evidence of sphincter of Oddi dysfunction includes a dilated (>12 mm) common bile duct, an increase in common bile duct diameter in response to cholecystokinin, and an increase in pancreatic duct diameter in response to secretin. Delayed emptying of contrast from the common bile duct after endoscopic retrograde cholangiopancreatography is also indicative of abnormal sphincter function. Endoscopic manometry has also been used to evaluate the sphincter of Oddi, and an elevated basal sphincter pressure (>40 mm Hg) has been correlated with a successful response to sphincter ablation.

Both endoscopic sphincterotomy and transduodenal sphincteroplasty with transampullary septectomy have been used to manage patients with sphincter of Oddi dysfunction. Results of both treatments appear to be similar and are more dependent on the presence of objective signs of sphincter dysfunction than on the procedure performed. The surgical approach (transduodenal sphincteroplasty with transampullary septectomy) has the advantage of including division of the transampullary septum, which can impede pancreatic duct drainage when chronically inflamed and fibrotic. A further advantage is that mucosa to mucosa apposition can be achieved minimizing the risk of scarring and restenosis. When objective evidence of sphincter dysfunction is present (elevated transaminases, delayed biliary emptying, dilated common bile duct, elevated basal sphincter pressure), 60 to 80% of patients are pain-free or improved after sphincterotomy or sphincteroplasty.

Sindromul de intestin iritabil se caracterizeaza prin durerea de tip biliar in lipsa semnelor imagistice de boala biliara, ceea ce face ca tratamentul sa fie dificil. Managamentul in cazul acestor pacienti consta in: recomdandarea unei diete fara grasimi, administrarea de antispastice si blocanti ai canalului de calciu. Cea mai importanta componenta a tratamentului este probabil comunicarea cu pacientul, in incercarea de clarifica natura cronica si benigna a acestei afectiuni.

Alte cauze de sindrom postcolecistectomie sunt reprezentate de: esofagita de reflux, ulceratii peptice, sindrom postgastrectomie, stricturile biliare si sindromul de bont al ductului cistic.