Hepatobiliary and Pancreatic: Bile duct stricture after cholecystectomy
Notice bibliographique
Résumé
There are three common patterns of bile duct injury during cholecystectomy. The first is complete obstruction of the bile duct by a suture or clip that results in post-operative jaundice. The second is damage to the bile duct that results in a localized bile collection or biliary peritonitis. The third is the development of a bile duct stricture that presents as pain, jaundice or cholangitis, usually within 2 years of cholecystectomy. Complete obstruction of the bile duct is managed by further surgery, usually an hepaticojejunostomy. Bile duct leaks are usually managed by endoscopic therapy but there has been debate about the relative merits of endoscopic and operative management for bile duct strictures. Although endoscopic dilatation and endoscopic stents are of temporary benefit, many of these patients have developed recurrent strictures and on-going symptoms. Because of this, surgical management has been recommended for most patients, usually a choledochojejunostomy or hepaticojejunostomy. However, additional endoscopic options include the use of multiple stents over a prolonged period of time or covered metallic stents that can be left in situ for several months and then removed. Unfortunately, these options have not been tested in randomized controlled trials. In the patient illustrated below, a good long-term outcome was achieved with multiple plastic stents. A 48-year-old woman was investigated because of the development of upper abdominal pain and fever, 1 month after laparoscopic cholecystectomy. Liver function tests were abnormal and an abdominal ultrasound study showed mild dilatation of the common hepatic duct and intrahepatic ducts. Endoscopic retrograde cholangiopancreatography showed a stricture, 2 cm in length, in the mid-bile duct (Figure 1). Over a 7 month period, a total of eight plastic stents were sequentially inserted to achieve continuous and progressive dilatation of the stricture. Eight stents have a diameter of approximately 77 F (2.6 cm). The stents were left in situ for 15 months to allow for complete remodelling of the area. There was no apparent stricture after removal of the stents and a repeat ERCP after 10 years showed a normal bile duct (Figure 2). The patient remains asymptomatic. The use of multiple stents for 12-24 months is an option for patients with post-operative biliary strictures and appears to be associated with lower recurrence rates than stenting for shorter periods with one or two stents. Contributed by
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Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,000 |
| Bibliométrie | 0,000 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».