Koledokolityazis ve Kolanjit
Özet
Safra kesesi taşlarının en sık ve ciddi komplikasyonlarından olan koledokolityazis ve akut kolanjit, acil müdahale gerektiren inflamatuar süreçleri kapsamaktadır. Safra yollarındaki mekanik tıkanıklık, artan intraduktal basınç ve bakteriyel kolonizasyon nedeniyle gelişen akut kolanjit; ateş, sarılık ve karın ağrısından oluşan Charcot triadı veya septik şoka ilerleyen Reynolds pentadı ile klinik bulgu verir. Hastalığın yönetiminde hemodinamik destek, geniş spektrumlu antibiyoterapi ve biliyer tıkanıklığın açılması temel prensiplerdir. Tokyo Kılavuzu (TG18) standartlarına göre şiddet derecesi belirlenen vakalarda, cerrahi olmayan ve düşük komplikasyon oranına sahip endoskopik transpapiller drenaj (EBS veya ENBD) birinci basamak tedavi yöntemi olarak öne çıkmaktadır. Endoskopik işlemlerin başarısız olduğu durumlarda EUS rehberliğinde drenaj, perkütan transhepatik biliyer drenaj (PTBD) veya cerrahi alternatifler devreye girer. Akut enfeksiyon tablosu kontrol altına alındıktan sonra, nüksleri önlemek amacıyla erken dönemde elektif kolesistektomi uygulanmalıdır. Günümüzde iki aşamalı ERCP+LK protokolü yaygın olarak uygulansa da, son çalışmalar tek seansta gerçekleştirilen laparoskopik ana safra kanalı eksplorasyonu ve laparoskopik kolesistektomi kombinasyonunun (LKD+LK), daha düşük maliyet, daha kısa yatış süresi ve azalan pankreatit komplikasyonları ile hafif ve orta vakalarda daha üstün olduğunu ortaya koymaktadır.
Choledocholithiasis and acute cholangitis, representing severe complications of gallstone disease, involve critical inflammatory processes requiring prompt clinical intervention. Acute cholangitis, driven by biliary obstruction, increased intraductal pressure, and bacterial colonization, typically presents with Charcot's triad (fever, jaundice, and abdominal pain) or can rapidly progress to Reynolds' pentad, leading to septic shock. The cornerstone of initial management involves hemodynamic stabilization, broad-spectrum antibiotic therapy, and urgent biliary decompression. According to the Tokyo Guidelines (TG18), endoscopic transpapillary drainage (EBS or ENBD) is recommended as the first-line intervention due to its minimally invasive nature. When transpapillary routes fail, alternative techniques such as EUS-guided drainage, percutaneous transhepatic biliary drainage (PTBD), or surgical options are utilized. Following successful clearance and stabilization, early elective cholecystectomy is recommended to prevent recurrent biliary events. While the two-stage ERCP plus laparoscopic cholecystectomy (ERCP+LC) remains widely practiced, recent clinical data demonstrate that single-stage laparoscopic common bile duct exploration combined with laparoscopic cholecystectomy (LCBDE+LC) offers distinct advantages for mild-to-moderate cases, including lower hospital costs, shorter stays, preservation of the sphincter of Oddi, and reduced postoperative pancreatitis risks.
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