Tratamento laparoscópico de coledocolitíase

Paciente com história de 18 meses de emagrecimento e icterícia foi encaminhado ao Serviço de Cirurgia Abdominal do Hospital do Câncer, São Paulo, SP., com hipótese diagnóstica de câncer de cabeça de pâncreas. Exames laboratoriais mostraram elevação de bilirrubinas e de enzimas canaliculares. Ultra-sonografia abdominal revelou dilatação de via biliar intra e extra-hepática. Tomografia computadorizada mostrou árvore biliar dilatada com presença de cálculo de cerca de 3 cm em colédoco distal. O paciente foi submetido a colecistectomia com coledocotomia, retirada do cálculo e anastomose colédoco-duodenal por laparoscopia. Evoluiu sem intercorrências, recebendo alta no sexto dia de pós-operatório. Conclui-se que o tratamento laparoscópico da coledocolitíase é factível em alguns pacientes, especialmente naqueles com dilatação de via biliar. A retirada de cálculos deve ser seguida de procedimento de drenagem da via biliar com dreno de Kehr. Em alguns pacientes com colédoco cronicamente dilatado, como o do presente caso, a anastomose colédoco-duodenal é o procedimento de escolha. With the advances of videolaparoscopic surgery, this approach had become the treatment of choice for cholelithiasis. However, about 5% to 10% may present common bile duct lithiasis. Most surgeons have still difficulties to deal with this situation and do prefer resolve with open surgery or with further endoscopic approach. We present a case of a 60-year-old man, with 18 months history of right upper quadrant pain, weight loss and jaundice. He was referred with diagnostic of pancreatic cancer. Laboratory investigation showed increased bilirrubin (10 mg/dL), alkaline phosphatase and GGT. Abdominal ultrasound showed atrophic gallbladder with dilated intra and extrahepatic biliary tree. Computerized tomography scan disclosed enlarged biliary tree with 3 cm stone in the distal common bile duct. The patient underwent a laparoscopic cholecystectomy followed by choledochotomy and retrieval of the large stone. A latero-lateral choledochoduodenum anastomosis was then performed to decompress the biliary tree. The patient had an uneventful recovery being discharged at the 6th postoperative day. Laparoscopic management of choledocholithiasis is feasible in many patients, specially those with dilated biliary tree. The retrieval of stones may be followed by biliary drainage with T-tube. In some elderly patients with chronically dilated common bile duct, as in the present case, a choledochoduodenal anast