CLINICA DE CHIRURGIECARITAS
CLINICA DE CHIRURGIECLINICA DE CHIRURGIECARITASCARITAS COLEDOCUL CHIRURGICAL CLASIC
ŞI COLEDOCUL ENDOSCOPICCOLEDOCUL CHIRURGICAL CLASIC
ŞI COLEDOCUL ENDOSCOPIC
Prof. Dr. Eugen BrătucuClinica Chirurgie, Spital Caritas
Universitatea de Medicină şi Farmacie Bucureşti
Prof. Dr. Eugen BrătucuClinica Chirurgie, Spital Caritas
Universitatea de Medicină şi Farmacie Bucureşti
SURGICAL VERSUS ENDOSCOPIC CHOLEDOCUS –INDICATION, TECHNIQUES, RESULTS (Abstract): The treatmentof lithiasis of the main biliary duct is still controversial. There are different criterias for the types of treatment: endoscopic, surgicalminimally invasive techniques or open surgery. Based to the experienceof Caritas Department of Surgery, this paper reviews the indicationsand the results of the treatment of lithiasis of main biliary duct. Conclusion: Open surgery was performed in 50% of cases. Thisapproach is also indicated after failure of laparoscopic technique, but the gold standard of the treatment of the lithiasis of main biliary duct isthe minimally invasive procedures (laparoscopic techniques andERCP).
KEY WORDS: BILIARY LITHIASIS, ERCP, LAPAROSCOPY
SURGICAL VERSUS ENDOSCOPIC CHOLEDOCUS –INDICATION, TECHNIQUES, RESULTS (Abstract): The treatmentof lithiasis of the main biliary duct is still controversial. There are different criterias for the types of treatment: endoscopic, surgicalminimally invasive techniques or open surgery. Based to the experienceof Caritas Department of Surgery, this paper reviews the indicationsand the results of the treatment of lithiasis of main biliary duct. Conclusion: Open surgery was performed in 50% of cases. Thisapproach is also indicated after failure of laparoscopic technique, but the gold standard of the treatment of the lithiasis of main biliary duct isthe minimally invasive procedures (laparoscopic techniques andERCP).
KEY WORDS: BILIARY LITHIASIS, ERCP, LAPAROSCOPY
Litiaza coledocianaLitiaza coledociana“LAUDATIO” - CHIRURGIA MINIINVAZIVA“LAUDATIO” - CHIRURGIA MINIINVAZIVA
“SILENCE” - CHIRURGIA CLASICA“SILENCE” - CHIRURGIA CLASICA
CENUSAREASA?CENUSAREASA?
1. O IGNORAM?
2. CE PERFORMANTE MAI ARE?
3. CE FEL DE SERVICII MAI ADUCE?
1. O IGNORAM?
2. CE PERFORMANTE MAI ARE?
3. CE FEL DE SERVICII MAI ADUCE?
NU ESTE UN ELOGIU AL CHIRURGIEI CLASICE
LOCUL CHIRURGIEI CLASICE
NU ESTE UN ELOGIU AL CHIRURGIEI CLASICE
LOCUL CHIRURGIEI CLASICE
Coledocul litiazic = chirurgie clasica
Coledocul litiazic = chirurgie clasica
1970 - OGOSHI -> ERCP1970 - OGOSHI -> ERCP
1974 - CLASSEN -> SE1974 - CLASSEN -> SE
1976 - COTTON -> Clearance endoscopic1976 - COTTON -> Clearance endoscopic
COLEDOC ENDOSCOPICCOLEDOC ENDOSCOPIC
Chirurgia laparoscopicaChirurgia laparoscopica
DezobstructiatranscisticaDezobstructiatranscistica ColedocolitotomieColedocolitotomie
Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]
185
Litiaza coledocianaLitiaza coledociana
“PRIMADONNA”
CHIRURGIE CLASICA
’’CENUSAREASA’’
“PRIMADONNA”
CHIRURGIE CLASICA
’’CENUSAREASA’’
Litiaza coledocianaLitiaza coledociana
CHIRURGIE - LAPAROSCOPICA SI CLASICA
ENDOSCOPIE
RADIOLOGIE
CHIRURGIE - LAPAROSCOPICA SI CLASICA
ENDOSCOPIE
RADIOLOGIE
LAPAROSCOPIALAPAROSCOPIA
COLEDOC
CHIRURGICAL
COLEDOC
CHIRURGICAL
COLEDOC ENDOSCOPIC
COLEDOC ENDOSCOPIC
RADIOLOGIA INTERVENTIONALA
RADIOLOGIA INTERVENTIONALA
COLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICACOLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICA
EVITAREA COLEDOCOTOMIEI
EVITAREA COLEDOCOTOMIEI
LAPAROSCOPIALAPAROSCOPIA
COLEDOC
CHIRURGICAL
COLEDOC
CHIRURGICAL
COLEDOC ENDOSCOPIC
COLEDOC ENDOSCOPIC
RADIOLOGIA INTERVENTIONALA
RADIOLOGIA INTERVENTIONALA
COLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICACOLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICA
EVITAREA COLEDOCOTOMIEI
EVITAREA COLEDOCOTOMIEI
LAPAROSCOPIALAPAROSCOPIA
COLEDOC
CHIRURGICAL
COLEDOC
CHIRURGICAL
COLEDOC ENDOSCOPIC
COLEDOC ENDOSCOPIC
RADIOLOGIA INTERVENTIONALA
RADIOLOGIA INTERVENTIONALA
COLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICACOLECISTECTOMIA CLASICA + DEZOBSTRUCTIE ENDOSCOPICA
EVITAREA COLEDOCOTOMIEI
EVITAREA COLEDOCOTOMIEI
CHIRURGIE CLASICA
30%
CHIRURGIE CLASICA
30%
• COLECISTECTOMIE LAPARO
• DEZOBSTRUCTIE LAPARO-ENDOSCOPICA
• COLECISTECTOMIE LAPARO
• DEZOBSTRUCTIE LAPARO-ENDOSCOPICA
LAPARO - ENDOSCOPIELAPARO - ENDOSCOPIE
GOLDSTANDARDGOLDSTANDARD
’’HOLLY PLAN’’’’HOLLY PLAN’’
Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]
186
CHIRURGIA LAPARO SI CLASICA
CHIRURGIA LAPARO SI CLASICA
MIJLOACE PROPRII DE ENDOSCOPIE INTRAOPERATORIE
ColangiografieUltrasonografieColedocoscopie
MIJLOACE PROPRII DE ENDOSCOPIE MIJLOACE PROPRII DE ENDOSCOPIE INTRAOPERATORIEINTRAOPERATORIE
ColangiografieColangiografieUltrasonografieUltrasonografieColedocoscopieColedocoscopie
TRATAMENTUL LITIAZEI COLEDOCIENETRATAMENTUL LITIAZEI COLEDOCIENE
TIMP VEZICULAR -> COLECISTECTOMIATIMP VEZICULAR -> COLECISTECTOMIA
TIMP COLEDOCIAN -> DEZOBSTRUCTIATIMP COLEDOCIAN -> DEZOBSTRUCTIA
MORTALITATE 1987MORTALITATE 1987
AUTORI CHIRURGIE CLASICA
DEZOBSTRUCTIE ENDOSCOPICA
J. L. DUPAS 9% 3,4%
K. H. SCHRIEFFERS
3,1% 3.8%
J. P. NEOPTOLEMOS
4,3% 5,8%
AUTORI CHIRURGIE CLASICA
DEZOBSTRUCTIE ENDOSCOPICA
J. L. DUPAS 9% 3,4%
K. H. SCHRIEFFERS
3,1% 3.8%
J. P. NEOPTOLEMOS
4,3% 5,8%
CHIRURGIA COLEDOCIANA CLASICA
“AB INITIO”COLECISTECTOMIE CONVERTITA 5-7%LITIAZE COMPLEXE
DE SECUNDA INTENTIEESEC ENDOSCOPICESEC LAPAROSCOPIC
“AB INITIO”COLECISTECTOMIE CONVERTITA 5-7%LITIAZE COMPLEXE
DE SECUNDA INTENTIEESEC ENDOSCOPICESEC LAPAROSCOPIC
TIMP VEZICULARTIMP VEZICULAR TIMP COLEDOCIANTIMP COLEDOCIAN
95%95% COLECISTECTOMIE LAPAROSCOPICA
COLECISTECTOMIE LAPAROSCOPICA
DEZOBSTRUCTIE ENDOSCOPICADEZOBSTRUCTIE ENDOSCOPICADEZOBSTRUCTIE LAPAROSCOPICADEZOBSTRUCTIE LAPAROSCOPICA
TRANSCISTIC - 23% esecTRANSCISTIC - 23% esec
COLEDOCOTOMIE – 7,3% esecCOLEDOCOTOMIE – 7,3% esec
5%5% COLECISTECTOMIE CLASICACOLECISTECTOMIE CLASICA
DEZOBSTRUCTIE CLASICADEZOBSTRUCTIE CLASICA
DEZOBSTRUCTIE ENDOSCOPICADEZOBSTRUCTIE ENDOSCOPICA
8% esec8% esec
7 BRISBANE METROPOLITANHOSPITALS
7 BRISBANE METROPOLITANHOSPITALS
LITIAZA COLEDOCIANALITIAZA COLEDOCIANA
LITIAZA SIMPLALITIAZA SIMPLA
LITIAZA COMPLEXALITIAZA COMPLEXA
LITIAZA MIGRATACALCULI RESTANTSTENOZA ODDI
LITIAZA MIGRATACALCULI RESTANTSTENOZA ODDI
LITIAZA AUTOHTONAPANLITIAZALITIAZA INTRAHEPATICALITIAZA DUPA ABD
LITIAZA AUTOHTONAPANLITIAZALITIAZA INTRAHEPATICALITIAZA DUPA ABD
STENOZE CBPPANCREATITA CR. COMPRESIVAFISTULE BILIOBILIARE SI BILIODIGESTIVEDILATATII CHISTICE CONGENITALEDIVERTICULI VATERIENI?
STENOZE CBPPANCREATITA CR. COMPRESIVAFISTULE BILIOBILIARE SI BILIODIGESTIVEDILATATII CHISTICE CONGENITALEDIVERTICULI VATERIENI?
Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]
187
DEZOBSTRUCTIA COLEDOCIANA
DEZOBSTRUCTIA COLEDOCIANA
LAPAROSCOPIALAPAROSCOPIA ASOCIATASOCIAT ENDOSCOPIAENDOSCOPIA
SECVENTIALSECVENTIAL RENDEZ - VOUSRENDEZ - VOUS
ESECESEC
DEZOBSTRUCTIE CLASICADEZOBSTRUCTIE CLASICA
40%40%
SOLUTII TERAPEUTICESOLUTII TERAPEUTICE
ESECESEC 30%30%
COLEDOCOTOMIE LAPARO
COLEDOCOTOMIE LAPARO
DEZOBSTRUCTIE ENDOSCOPICA
DEZOBSTRUCTIE ENDOSCOPICA
7,3% ESEC
17% MORBIDITATE
7,3% ESEC
17% MORBIDITATE
8% ESEC
13% MORBIDITATE
8% ESEC
13% MORBIDITATE
ESECESEC
CHIRURGIE CLASICACHIRURGIE CLASICAREZOLVA ESECURILE LAPARO-ENDOSCOPICEREZOLVA ESECURILE LAPARO-ENDOSCOPICE
COLECIST LAPAROCOLECIST LAPARO ++ DEZOBSTRUCTIE TRANSCISTICADEZOBSTRUCTIE TRANSCISTICA
7%7%
DEZOBSTRUCTIE ENDOSCOPICA PRE CL
30% ESEC
DEZOBSTRUCTIE ENDOSCOPICA PRE CL
30% ESEC
37% ESEC37% ESEC 45% ESEC45% ESEC
DEZOBSTRUCTIE TRANSCISTICADEZOBSTRUCTIE TRANSCISTICA
DEZOBSTRUCTIE ENDOSCOPICADEZOBSTRUCTIE ENDOSCOPICA17%17% 13%13%
BILIRAGIEBILIRAGIE 14,6%14,6% 0%0%
PANCREATITAPANCREATITA 7,3%7,3% 8,8%8,8%
CALCULI RESTANTICALCULI RESTANTI 2,4%2,4% 4,4%4,4%
REOPERATIREOPERATI 7,3%7,3% 6,6%6,6%
ESEC = 33%ESEC = 33% ESEC = 30%ESEC = 30%
CHIRURGIE CLASICA DE SECUNDA INTENTIE = 30% CHIRURGIE CLASICA DE SECUNDA INTENTIE = 30%
CHIRURGIE CLASICA DE PRIMA INTENTIE = 10%CHIRURGIE CLASICA DE PRIMA INTENTIE = 10%50%50%
MORBIDITATE MORBIDITATE
BRISBANE2006
1959 - 1998 - 40 DE ANI1959 - 1998 - 40 DE ANI10015 INTERVENTII PE CAI BILIARE10015 INTERVENTII PE CAI BILIARE
2127 INTERVENTII CBP (21,2%) 2127 INTERVENTII CBP (21,2%) BENIGN 66.7%BENIGN 66.7%
MALIGN 33,3%MALIGN 33,3%1420 LEZIUNI BENIGNE CBP1420 LEZIUNI BENIGNE CBP
• 982 LITIAZE CBP – 69%
• 438 ALTE LEZIUNI CBP – 31%
• 982 LITIAZE CBP – 69%
• 438 ALTE LEZIUNI CBP – 31%
7 REINTERVENTII DUPA S O - 0,7%
4 DECESE SPECIFICE S O - 0,85%
7 REINTERVENTII DUPA S O - 0,7%
4 DECESE SPECIFICE S O - 0,85%
42 REINTERVENTII DUPA DEZOBSTRUCTIE + DRENAJ / DEZOBSTRUCTIE + ABD
4,2%
42 REINTERVENTII DUPA DEZOBSTRUCTIE + DRENAJ / DEZOBSTRUCTIE + ABD
4,2%
CLINICA CHIRURGIE CARITASIAN 1997 - SEPT 2006
CLINICA CHIRURGIE CARITASIAN 1997 - SEPT 2006
LITIAZE CBP = 347 CAZURILITIAZE CBP = 347 CAZURI
LITIAZA MIGRATA = 282 CAZURI -> 81,2%LITIAZA MIGRATA = 282 CAZURI -> 81,2%
• MIGRATA - 204 CAZURI - 58,7%
• RESTANTA - 78 CAZURI - 22,4%
• MIGRATA - 204 CAZURI - 58,7%
• RESTANTA - 78 CAZURI - 22,4%
LITIAZA AUTOHTONA = 42 CAZURI -> 12,1%LITIAZA AUTOHTONA = 42 CAZURI -> 12,1%
LITIAZA MIGRATA SI AUTOHTONA = 23 CAZURI -> 6,6%LITIAZA MIGRATA SI AUTOHTONA = 23 CAZURI -> 6,6%
DEZOBSTRUCTIE COLEDOCIANA
ABORD TERAPEUTIC
MIGRATA RESTANTA AUTOHTONA AUTOHTONA + RESTANTA
CLEARENCE ENDOSCOPIC
49,5% 89,7% 73,8% X CLEARENCE CHIRURGICAL CLASIC
50,5% 10,3% 26,2% 6,62%
CLEARENCE ENDOSCOPIC = 49,3%
CLEARENCE CHIR CLASIC = 50,7%AB INITIO = 36,3%
ESEC ENDOSCOPIC = 22,6%
Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]
188
ESEC ENDOSCOPICESEC ENDOSCOPIC22,6%22,6%
LITIAZA MIGRATA - 30,6%LITIAZA MIGRATA - 30,6%
LITIAZA RESTANTA - 10,2%LITIAZA RESTANTA - 10,2%
LITIAZA AUTOHTONA - 26,2%LITIAZA AUTOHTONA - 26,2%
• CLEARENCE ENDOSCOPIC 49,3%
• CLEARENCE CHIRURGICAL CLASIC 50,7%
• CLEARENCE ENDOSCOPIC 49,3%
• CLEARENCE CHIRURGICAL CLASIC 50,7%
CRITERII DE SELECTIEPE GRUPE DE INDICATIE
TERAPEUTICA
CRITERII DE SELECTIEPE GRUPE DE INDICATIE
TERAPEUTICA
COLEDOC ENDOSCOPIC
COLEDOC ENDOSCOPIC
GRUP IGRUP I
INDICATIE TERAPEUTICA
INDICATIE TERAPEUTICA
CRITERII DE SELECTIE
CRITERII DE SELECTIE
- Litiaza coledociana migrata
- Calculi coledocieni restanti
- I-a recidiva dupa dezobstructielaparo-endoscopica
- Litiaza coledociana migrata
- Calculi coledocieni restanti
- I-a recidiva dupa dezobstructielaparo-endoscopica
LITIAZA SIMPLALITIAZA SIMPLA
COLEDOC CHIRURGICAL
COLEDOC CHIRURGICAL
GRUP IIGRUP II
INDICATIE TERAPEUTICA
INDICATIE TERAPEUTICA
CRITERII DE SELECTIE
CRITERII DE SELECTIE
- Tentative nereusite de dezobstructie laparo-endoscopicela pacientii din GRUP I- Duoden exclus chirurgical
- Tentative nereusite de dezobstructie laparo-endoscopicela pacientii din GRUP I- Duoden exclus chirurgical
LITIAZA SIMPLALITIAZA SIMPLA
- Fistule bilio-biliare- Fistule coledoco – digestive- Alte situatii complexe
- Fistule bilio-biliare- Fistule coledoco – digestive- Alte situatii complexe
LITIAZA COMPLEX
A
LITIAZA COMPLEX
A
COLEDOC CHIRURGICAL
LITOGEN
COLEDOC CHIRURGICAL
LITOGEN
GRUP IIIGRUP III
INDICATIE TERAPEUTICA
INDICATIE TERAPEUTICA
CRITERII DE SELECTIE
CRITERII DE SELECTIE
- Litiaza coledociana recidivanta ( > 1 recidiva)
- Litiaze intrahepatice primitive sausecundare
- Panlitiaza
- Stenoze iatrogene asociate cu litiaza
- Stenoze sclero-inflamatorii asociatecu litiaza
- Coexistenta dilatatiilor chisticecongenitale intra si/sau extrahepatice
- Diverticuli juxtavaterieni asociatilitiazei CBP
- Litiaza coledociana recidivanta ( > 1 recidiva)
- Litiaze intrahepatice primitive sausecundare
- Panlitiaza
- Stenoze iatrogene asociate cu litiaza
- Stenoze sclero-inflamatorii asociatecu litiaza
- Coexistenta dilatatiilor chisticecongenitale intra si/sau extrahepatice
- Diverticuli juxtavaterieni asociatilitiazei CBP
LITIAZA COMPLEXALITIAZA COMPLEXA
Grup I
Coledoc endoscopic
Grup I
Coledoc endoscopic
Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]
189
Litiaza CBP migrataLitiaza CBP migrata Litiaza CBP migrataLitiaza CBP migrata
Litiaza CBP migrataDiverticul de fereastra duodenala
Litiaza CBP migrataDiverticul de fereastra duodenala
Litiaza CBP migrataDiverticul de fereastra duodenala
Litiaza CBP migrataDiverticul de fereastra duodenala
Litiaza CBP restantaDiverticul de fereastra duodenala
Litiaza CBP restantaDiverticul de fereastra duodenala
Litiaza CBP restantaDiverticul de fereastra duodenala
Litiaza CBP restantaDiverticul de fereastra duodenala
Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]
190
Litiaza CBP restantaautohtonizata
Litiaza CBP restantaautohtonizata
Grup II
Coledoc chirurgical
Grup II
Coledoc chirurgical
Litiaza CBP migrataDiverticul de fereastra duodenala
Fistula colecisto-coledociana
Litiaza CBP migrataDiverticul de fereastra duodenala
Fistula colecisto-coledocianaLitiaza CBP migrata
Fistula colecisto-duodenalaLitiaza CBP migrata
Fistula colecisto-duodenala
Grup III
Coledoc chirurgical litogen
Grup III
Coledoc chirurgical litogen
Litiaza CBP dublu recidivataLitiaza CBP dublu recidivata
Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]
191
Litiaza autohtona CBPDiverticul de fereastra duodenala
Status post PSE
Litiaza autohtona CBPDiverticul de fereastra duodenala
Status post PSEStenoza CBP postoperatorie
Litiaza autohtonaStenoza CBP postoperatorie
Litiaza autohtona
Stenoza CBP postoperatorieLitiaza autohtona
Stenoza CBP postoperatorieLitiaza autohtona
Colangita sclero-inflamatorieLitiaza intra si extrahepaticaColangita sclero-inflamatorieLitiaza intra si extrahepatica
Megacoledoc litiazicMegacoledoc litiazic Diverticul de fereastra duodenalaDilatatie congenitala CBP
Diverticul de fereastra duodenalaDilatatie congenitala CBP
Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]
192
Diverticul de fereastra duodenalaDilatatie congenitala CBP
Control postop
Diverticul de fereastra duodenalaDilatatie congenitala CBP
Control postopAlgoritm terapeutic in
litiaza coledocianaAlgoritm terapeutic in
litiaza coledociana
GRUP IGRUP I
COLEDOC ENDOSCOPIC
COLEDOC ENDOSCOPIC
REZOLVARE ENDOSCOPICA
REZOLVARE ENDOSCOPICA 1-a RECIDIVA1-a RECIDIVA
ESECESEC
CHIRURGIE DESCHISA
CHIRURGIE DESCHISA
GRUP IIGRUP II
GRUP IIGRUP II
COLEDOC CHIRURGICAL
COLEDOC CHIRURGICAL
CHIRURGIE DESCHISA
CHIRURGIE DESCHISA
LITIAZA MIGRATALITIAZA
MIGRATA
DEZOBSTRUCTIE+
DRENAJ EXTERN
DEZOBSTRUCTIE+
DRENAJ EXTERNRECIDIVARECIDIVA
LITIAZA AUTOHTONA
LITIAZA AUTOHTONA
ACDACD
RECIDIVARECIDIVA
ESECESEC
GRUP IIIGRUP III
COLEDOC CHIRURGICAL LITOGEN
COLEDOC CHIRURGICAL LITOGEN
RECIDIVARECIDIVA
A 2-a RECIDIVA
A 2-a RECIDIVAHJS”Y”HJS”Y”
CHIRURGIE DESCHISAHJS DE VIZITARE
CHIRURGIE DESCHISAHJS DE VIZITARE
LITIAZA INTRAHEPATICA
LITIAZA INTRAHEPATICA
A 3-a RECIDIVA
A 3-a RECIDIVA
CONCLUZIIChirurgiaChirurgia clasicaclasica pentrupentru dezobstructiedezobstructie coledocianacoledociana se se aplicaaplica in in aproximativaproximativ 50% din 50% din litiazelelitiazele coledocienecoledociene: de prima : de prima intentieintentie (10%), de (10%), de secundasecunda intentieintentie (40%).(40%).
Ea Ea corecteazacorecteaza esecurileesecurile, , accidenteleaccidentele sisi incidenteleincidentele chirurgieichirurgieiminiinvaziveminiinvazive. . TotodataTotodata ea ea esteeste folositafolosita ““abab initioinitio”” in in cazurilecazurile celecele maimaidificiledificile: : litiazelelitiazele complexecomplexe..
CalitatileCalitatile dezobstructieidezobstructiei miniinvaziveminiinvazive conferaconfera acesteiaacesteia aureolaaureola de de ““gold gold standardstandard”” in in chirurgiachirurgia litiazeilitiazei coledocienecoledociene..
AtunciAtunci candcand nunu se se obtineobtine efectulefectul scontatscontat -- dezobstructiadezobstructia -- prinprin““strategiastrategia fericitafericita”” ((miniinvazivaminiinvaziva), ), ramaneramane ultimaultima intentieintentie: : chirurgiachirurgiaclasicaclasica..
ChirurgiaChirurgia miniinvazivaminiinvaziva sisi ceacea clasicaclasica se se deruleazaderuleaza in mod in mod secventialsecvential, , fiecarefiecare cu cu compartimentulcompartimentul eiei..
ChirurgiaChirurgia clasicaclasica nunu maimai esteeste astaziastazi o o ““primadonnaprimadonna”” dardar ramaneramane o o ““solutiesolutie salvatoaresalvatoare”” careiacareia trebuietrebuie sasa--ii iertamiertam dezavantajeledezavantajele..
Articole multimedia Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 – 9341]
193
Top Related