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Commento all’articolo a cura del Dott. Antonio Pesce

Nonostante i notevoli progressi nella tecnologia e nelle tecniche chirurgiche, le lesioni iatrogene delle vie  biliari rappresentano ancora oggi un problema di salute pubblica sia in termini medico-legali che di costi sanitari.
Allo stato attuale la percentuale di lesioni iatrogene maggiori oscilla tra lo 0.3-0.8%, percentuale che si è notevolmente ridotta negli ultimi anni, rispetto agli inizi della laparoscopia. In letteratura scientifica sono stati proposti e descritti diversi metodi per prevenire le lesioni iatrogene delle vie biliari: dalla valutazione della cosiddetta “Critical View of Safety (CVS)” alla colangiografia intra-operatoria. Nonostante i vari dibattiti ed opinioni non esiste allo stato attuale un metodo che può essere considerato “gold standard”.

Sono state proposte varie soluzioni per ovviare a questo inconveniente: varianti tecniche di dissezione (es. colecistectomia infundibolare, anterograda) o il riconoscimento di dettagli anatomici come “landmarks”/reperi (es. solco di Rouvière e lindonodo cistico di Mascagni), la colangiografia intra-operatoria solo in casi selezionati. Risulta altrettanto vero che il solco di Rouvière può mancare nel 20% dei casi e presenta varianti anatomiche morfo-strutturali; il linfonodo cistico non sempre si visualizza e spesso risulta incostante. Una tecnica innovativa è rappresentata dalla colangiografia fluorescente, introdotta recentemente da Ishizawa et al. nel 2010 e che consiste nella visualizzazione “real-time” dell’albero biliare extraepatico mediante fluorescenza. L’utilizzo del colorante vitale verde indocianina (IGC), a dosaggio e tempo di somministrazione prestabiliti, permette la visualizzazione delle strutture biliari intra-operatoriamente con chiari vantaggi rispetto alla colangiografia convenzionale (visualizzazione “real-time” e dinamica, costi ridotti, “learning curve” rapida, sicurezza e rapidità della metodica, mancata esposizione a radiazioni ionizzanti, dissezione più sicura del Calot). Il titolo dell’editoriale risulta davvero molto accattivante: sarà possibile nell’immediato futuro raggiungere lo 0% di lesioni iatrogene biliari durante interventi di colecistectomia laparoscopica? Ritengo sia una sfida per ciascun chirurgo addominale. La possibilità di azzerare la percentuale di lesioni iatrogene penso sia difficile, però tutti quanti dobbiamo lavorare con l’obiettivo di ridurre al minimo il rischio di lesioni, soprattutto i giovani che vivono pienamente in una realtà chirurgica sempre più “mini-invasiva”. L’intervento di colecistectomia videolaparoscopica è senza dubbio l’intervento chirurgico più eseguito in chirurgia generale però ricordiamo tutti che non tutte le colecistectomie sono uguali e ogni colecistectomia nasconde delle insidie. Già agli inizi degli anni ’90 il Prof. Strasberg diceva che le lesioni iatrogene biliari non dipendono dal numero totale di colecistectomie eseguite ma dalla tecnica con cui vengono eseguite, sottolineando l’importanza della critical view of safety. Oggi alla “critical view” si affianca la tecnologia. L’editoriale nella parte finale cita così: “The technique is here; we need to work on it.” Il vantaggio di una chirurgia sempre più innovativa va sfruttato al massimo: lavoriamoci insieme. Un perfetto binomio tra anatomia chirurgica e innovazione tecnologica.




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