Cerca del 10% de los pacientes a nivel mundial que presentan un cuadro de colecistitis sufren también de coledocolitiasis. Esta aparición de cálculos en el conducto biliar común, a pesar de su relativamente baja incidencia, no debería de ser pasada por alto por la comunidad gastroenterológica, ya que puede tener como consecuencia la aparición de problemas mayores como obstrucción biliar, colangitis o incluso una pancreatitis.
A la fecha, la forma más común de lidiar con la coledocolitiasis es a través de una Coliangopancreatografía Retrógada Endoscópica (CPRE), pre o posoperatoria. Sin embargo, existe evidencia científica consistente que apunta a la opción que el manejo laparoscópico de este padecimiento podría ser más efectivo y menos riesgoso del paciente.
Las estadísticas indican que entre el 40 y 60% de las CPRE que tienen como motivo detectar cálculos en la vía biliar son negativas. Esto debe de plantear la duda sobre qué tan realmente es beneficiosa esta práctica para los pacientes. Al ser procedimiento separado de la colecistetomía, una CPRE puede sumar costos económicos, riesgos y uso de anestesia para el paciente y, si prestamos atención al porcentaje anterior, podemos argumentar que cerca de la mitad de estos procedimientos no tienen un efecto positivo en su estado de salud. Además, se sabe que en uno de cada diez casos, una CPRE puede tener consecuencias desfavorables, desde sangrados hasta pancreatitis.
¿Por qué se mantiene esta norma? En realidad, una de las causas que han hecho a que este procedimiento sea el más recurrente para tratar la coledocolitiasis se debe a que la mayor parte de los cirujanos prefieren efectuar una colecistectomía sin enfrentarse a los cálculos en la vía biliar.
No obstante, los avances tecnológicos y educativos en cirugía de mínima invasión que se han tenido a lo largo de los últimos años han permitido que la comunidad gastroenterológica haya podido desarrollar las destrezas necesarias para limpiar la vías biliares después de la colecistectomía.
Realizar una exploración del conducto biliar común (CBC) laparoscópica es algo que debería de estar al alcance de todo practicante de cirugía general. Los aspectos báscos a dominar de manera previa son la capacidad de realizar una colecistectomía laparoscópica con coliangograma, colocar una via venosa y manejar el endoscopio.
Además, se han hecho innovaciones que permiten realizar el coliangrograma de forma menos invasivas, como el ultrasonido laparoscópico, con el que se permite visualizar el coledoco sin necesidad de hacer incisiones.
Dependiendo del resultado de este examen, se puede tomar la decisión de expulsar los cálculos mediante un lavado, lo cual es generalmente efectivo al momento de enfrentarse a cálculos de entre 3 y 4 mm. La acción a tomar en los demás casos es recurrir a un cateter Fogarty 4-Fr. Al efectuar este procedimiento de forma adecuada, se remueven los cálculos, dejando el CBC libre. Tras esto, se podrá seguir procediendo con la colecistectomía hasta la extirpación de la vesícula.
Es momento de que se optimicen los procedimientos para este tipo de padecimientos en la comunidad gastroenterológica. Establecer un buen juicio quirúrgico tomando decisiones sensatas, estandarizas y metodológicamente más seguras es la base para que tengamos los mejores resultados para nuestros pacientes.
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