Modern options of endoscopic retrograde stenting of bile ducts in treatment of obstructive jaundice at malignant pancreatobiliary tumors

Aim of investigation. Acute obstructive jaundice developed on background of malignant pancreatobiliary neoplasms is one of the most complex and dramatic problems of modern abdominal surgery. At surgical interventions at the climax of obstructive jaundice and/ or cholangitis, postoperative period of these patients is characterized by high severity and is accompanied by high postoperative mortality. Due to this in the last decades the increasing number of researchers prefer endoscopic retrograde approach of biliary drainage for treatment of obstructive jaundice.Material and methods. From January, 2007 to July, 2013 overall 3269 endoscopic retrograde interventions on major duodenal papilla (MDP) have been executed in the Scientific-educational center of abdominal surgery and endoscopy, Moscow city clinical hospital #31. Endoscopic stenting of biliary tract have been carried out in 523 cases, of them 418 (79,9%) procedures were carried out in 287 patients with jaundice of neoplastic origin (148 women, 139 men). Patients were in the age of 32 to 94 years (mean 68,2±9,3 year). With the help of the comprehensive diagnostic program providing ultrasound investigation, computer tomography, endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography, it was possible to determine in 207 (72,1%) cases the distal block of biliary tract due to tumors of MDP, terminal CBD portion, distal part of common bile duct and pancreatic head, and the proximal block in 80 (27,9%) cases at lesions of gallbladder, hepatico-choledochal duct, lobar hepatic ducts or compression of proximal biliary tree by lymph nodes of hepatoduodenal ligament.Results. Bilioduodenal stents at 272 (94,8%) patients were installed after preliminarily endoscopic papillosphincterotomy (EPST). Adequate drainage of biliary tracts after biliary stenting was achieved in all patients. At the same time in 48 cases stenting of biliary tract failed. The reasons of failure were mainly due to duodenal stenosis caused by malignant involvement and extended and convoluted neoplastic deformation of the bile duct. Complications after endoscopic interventions, including acute pancreatitis, cholangitis, bleeding from EPST zone, perforation of wall of duodenum and stent migration, occurred in 22 cases (5,3%). Postoperative mortality was 3,5%. Thus almost in all cases death occurred after achievement of endoscopic biliary decompression. After bilioduodenal stenting in all patients jaundice was resolved or has essentially decreased. In 230 (80,1%) of them endoscopic aid was final treatment method of late-stage neoplastic process in inoperable patients. At relapse of jaundice endoscopic sanitation or stent replacement was performed. In other patients (19,9%) after resolution of jaundice surgical decompression interventions have been carried out.Conclusion. According to authors data, at malignant pancreatobiliary tumors in 85,7% of cases endoscopic retrograde drainage of the biliary tracts is possible and effective in treatment of obstructive jaundice. This method allows to prepare patients with obstructive jaundice for surgical interventions, including radical treatment, or may be a final method of treatment in inoperable patients. Morbidity rate after endoscopic retrograde interventions on MDP for acute obstructive jaundice of neoplastic origin is almost same as at those after standard retrograde interventions and according to our results equals to 5,3%

Difficult choledocholithiasis – result of overdue surgical treatment of gallstone disease

Aim of investigation. To analyze results of diagnostics and treatment of difficult forms of choledocholithiasis.Material and methods. Difficult forms of choledocholithiasis (large size, atypical improper shape and localization of stones, alteration of anatomy of pancreatobiliary area) were revealed in 275 patients. At admission obstructive jaundice was present in 202 (73,5%) of them, cholangitis – in 67 (24,4%), acute biliary pancreatitis – in 8 (2,9%). Surgical treatment was started with transpapillary operations.Results. In 12 (4,4%) patients transpapillary procedures appeared to be impossible, all of them have been operated by surgically. Endoscopic operations were carried out for remainder 263 patients (95,6%) that allowed to resolve obstructive jaundice, and only at 65,8% of patients – to sanify bile ducts completely. Complications of endoscopic treatment developed in 22 (8,4%) cases. The surgical choledocholititomy was executed in 57 patients, complications develop in 21 (36,8%). The mortality in group with difficult choledocholithiasis was 5,1%. At analysis of the causes of neglect of disease in difficult choledocholithiasis patients it was revealed, that the majority of them (217 – 78,9%) had a long history of gallstone disease (GSD). Various surgical interventions for biliary tracts were carried out to 27 patients. Part of patients (84) received conservative therapy for biliary colic and complications of GSD, abandoning of operative treatment resulted in, first, development of severe complication – choledocholithiasis, second, development of unfavorable anatomical conditions for its noninvasive resolution.Conclusion. Complex anatomical conditions in patients with choledocholithiasis basically develop as a result of overdue surgical treatment of gallstone disease. The main cause of delay in cholecystectomy is unjustified long-term and ineffective conservative treatment

Efficacy of parenteral rabeprazole at acute ulcer gastroduodenal bleeding in patients with high risk of relapse after endoscopic hemostasis

Aim of investigation. To determine efficacy of ulcer bleeding treatment at high risk of relapse after endoscopic hemostasis: the baseline intensive therapy including antisecretory treatment including parenteral form of rabeloc (rabeprazole) was applied.Material and methods. Original study included overall 25 patients with acute ulcer gastroduodenal bleeding. Past history was complicated for peptic ulcer in 14 patients. Ongoing ulcer bleeding (Forrest Ia, b) was found in 5 patients. Hemostasis has been effectively carried out by combined approach (injection of epinephrine solution and argon plasma coagulation). In the other 20 patients with stopped bleeding by the time of examination preventive endoscopic hemostasis was implemented.Results. Patients received rabeloc (rabeprazole 20 mg) bolus intravenous injections every 6 hs for 3 days until high risk of bleeding relapse disappeared, followed by single-dose 20 mg intravenously for 10 days. Dynamic endoscopy on the 2, 4, 7, 14 day have been carried out in 25 patients, of them 4 patients required additional endoscopic hemostasis and continued of parenteral injection of rabeloc 20 mg every 6 hs for three days more. In all studied patients it was possible to avoid bleeding relapse. By the 4-th day of treatment in 21 (84%) patient signs of high risk of a bleeding were absent. For relatively short 2-week treatment term stomach ulcer size reduced by 54%, duodenal ulcers — by 47%, and in 24% complete healing was achieved.Conclusions. Parenteral form of second generation proton pump inhibitor rabeloc (rabeprazole) meets requirements for treatment active gastric or duodenal ulcers complicated by acute bleeding

First Use of Superpulsed Fibre Thulium Laser-Based Contact Stone Ablation in Common Bile and Main Pancreatic Ducts

Aim. A clinical demonstration of the feasibility of novel superpulsed thulium fibre laser in contact intraductal lithotripsy in patients with choledocholithiasis and pancreatic lithiasis.Key points. We describe two clinically successful ablations of large biliary and pancreatic calculi using a FiberLase U2 superpulse fibre thulium laser appliance (IRE-Polus, Russia) during oral transpapillary cholangiopancreaticoscopy in patients with technically unfeasible conventional minimally invasive treatment for choledocho- and pancreatic lithiasis. A 72-yo patient was urgently admitted with acute mechanical jaundice, cholangitis and a history of endoscopic papillosphincterotomy (EPST) and bilioduodenal stenting with a plastic implant for technically impractical lithotripsy and lithoextraction. An ineffective extracorporeal lithotripsy attempt was followed on day 3 by a second retrograde intervention and endoscopic contact laser lithotripsy controlled in oral transpapillary cholangioscopy with FiberLase U2. A 50-yo patient was admitted with clinical signs of chronic calculous pancreatitis and a history of EPST, pancreatic ductotomy and plastic pancreatic stenting. The first endoscopy stage comprised the encrusted pancreatic stent removal, retrograde pancreaticography, pancreatic ductotomy, narrowed terminal Wirsung’s duct bougienage with mechanical dilators and additional balloon-assisted dilation of the excision area and pancreatic stricture. Mechanical intraductal lithotripsy was unsuccessful. Contact lithotripsy with a novel superpulsed fibre thulium laser has been rendered. The technique presented ensures a complete sanation of the duct at no mucosal damage.Conclusion. We present the fully successful first national and world experience of the superpulsed fibre thulium laser application in contact lithotripsy of large calculi in common bile and main pancreatic ducts

Ischemic Changes in the Mucous Membrane of the Transverse Colon as a Complication of Acute Pancreatitis

Aim: to present a clinical case of a patient with a complicated course of acute pancreatitis.Key points. A 31-year-old patient was admitted to the surgical department with a clinical picture of acute alcoholic pancreatitis. Signs of anemia were regarded as a consequence of gastrointestinal bleeding. Computed tomography with contrast enhancement, along with an increase in the size of the pancreas, the presence of foci of pancreatic necrosis with multiple fluid accumulations in the parapancreatic space, revealed smoothed gaustration and thickening of the walls of the predominantly transverse colon. During colonoscopy, ischemic changes of the colon mucosa were detected in a timely manner. Negative results of analysis for toxins A and B of Clostridioides difficile and pathogenic intestinal flora were obtained. By the means of intensive care, it was possible to achieve complete stabilization of the patient's condition, normalization of laboratory blood parameters and relief of ischemic processes in the colon wall.Conclusion. Ischemic changes of the colon can serve as a complication of acute pancreatitis. A thorough analysis of the results of computed tomography at the first signs of colon lesion and colonoscopy contributed to the rapid detection of complications and prevention of irreversible colon ischemia

The Use of L-Menthol in Endoscopic Transpapillary Interventions. Prospective Randomized Dual-Center Study

Aim: to study the effect of L-menthol on duodenal peristalsis, the results of cannulation of the papilla, the effectiveness and safety of endoscopic retrograde transpapillary interventions (ERTI).Materials and methods. A prospective two-center randomized placebo-controlled trial was carried out from January to November 2022 in two centers. The study included 126 patients, 69 (54.8 %) men and 57 (45.2 %) women, mean age — 62.1 ± 1.8 years. The inclusion criteria were age 18–75 years, indications for ERTI, absence of previous endoscopic papillotomy, absence of allergy to menthol, consent to participate in the study. After randomization, the main group (“L”) included 70 patients, the control group — 56. Patients in group “L” were irrigated with 25 mL (160 mg) of L-menthol (Spectavium), patients in the control group — with 25 mL of saline solution. Peristaltic activity was studied before and three minutes after administration of the drug. The intensity of peristalsis was assessed according to a modified Hiki scale: 0 points — complete absence of peristalsis; 1 point — single peristaltic waves; 2 points — intense peristalsis, little amenable to straightening at maximum insufflation; 3 points — pronounced peristalsis.Results. Three minutes post-irrigation, the suppression of peristaltic waves was noted in the experimental group “L”: 0 points — 63 (90 %) patients, 1 point — 6 (8.6 %) patients, compared to the control, with no change in peristalsis (p < 0.05). Successful selective cannulation was achieved in 64 (91.4 %) patients of group “L” and in 41 (73.2 %) — of the control group (p < 0.05). Non-cannulation endoscopic papillotomy had to be used in 6 (8.5 %) cases in group “L” and in 14 (25 %) cases in the control group. In general, successful cannulation was achieved in 100 % of patients in group “L”, and in 94.5 % — in the control group (p < 0.05). The duration of the intervention was significantly reduced in group “L” — 40 ± 2.5 vs. 50.3 ± 3.6 min. Among the complications, only intraoperative bleeding was registered (2 (2.9 %) — group “L”, 5 (8.9 %) — the control group), which was eliminated endoscopically in all cases.Conclusion. The use of L-menthol during ERTI helps to achieve noticeable inhibition of peristalsis, promotes successful cannulation, reduces the intervention time, minimizes the risk of intraoperative complications. Thus, L-menthol has demonstrated its effectiveness and safety, which makes it possible to use it in the arsenal of combating enhanced peristalsis during ERTI

ВОЗМОЖНОСТИ ЭНДОСКОПИЧЕСКОГО РЕТРОГРАДНОГО СТЕНТИРОВАНИЯ ЖЕЛЧНЫХ ПРОТОКОВ ПРИ ЗЛОКАЧЕСТВЕННЫХ ОПУХОЛЯХ ОРГАНОВ ПАНКРЕАТОБИЛИАРНОЙ ЗОНЫ, ОСЛОЖНЕННЫХ МЕХАНИЧЕСКОЙ ЖЕЛТУХОЙ

Purpose. In the last 10 years in the treatment of acute jaundice, developed on a background of malignant tumors of the pancreatobiliary zone (PBZ), more preferred method is endoscopic retrograde biliary drainage.Material and methods. From January 2007 to July 2012 in the clinic of hospital surgery N. 2 PRNMU endoscopic biliary stenting was performed in 441 patients. Of these, 324 (73.5%) stenting fell to 234 patients with a tumor of the extrahepatic bile ducts. The diagnostic program included ultrasonography, computed tomography, endoscopic ultrasonography and endoscopic retrograde cholangiopancreaticography.Results. Installing of bilioduodenal stent in 223 patients (95.3%) was generated after the pre-endoscopic papillosphincterotomy (EPST). The adequacy of the biliary drainage after produced in the required amount of biliary stent placement was achieved in all patients. In 46 cases, execute the biliary tract prosthesis failed. Complications of endoscopic interventions presented with acute pancreatitis, cholangitis, bleeding from the area of EPST, perforated duodenal wall and migration of the stent were in 19 cases (5?9%). Postoperative mortality was 3?8%. 7 patients (3%) died after the endoscopic decompression of the biliary tract. After stenting in all patients with jaundice it was resolved or significantly reduced. In 185 of them (79%) was the definitive guide endoscopic treatment because of severity of tumor process. In cases of jaundice reccurence endoscopic stent recanalizing or replacement were performed. In the remaining cases (21%) patients after the resolution of jaundice decompressive surgical intervention were done.Conclusion. The method of endoscopic retrograde biliary drainage allows you to prepare patients with obstructive jaundice for surgical intervention, including the radical. The frequency of complications after endoscopic retrograde operations on the major duodenal papilla for acute jaundice blastomatous origin did not differ from that after the standard retrograde interventions and was 6%. Актуальность. В последнее десятилетие в лечении острой механической желтухи, развившейся на фоне злокачественных новообразований органов панкреатобилиарной зоны (ПБЗ), все больше отдают предпочтение эндоскопическому ретроградному способу дренирования желчных протоков.Материал и методы. С января 2007 по июль 2012 г. в клинике госпитальной хирургии № 2 РНИМУ им. Н.И. Пирогова было выполнено эндоскопическое протезирование билиарного тракта у 441 больного. Из них 324 (73,5%) стентирования пришлись на долю 234 пациентов с опухолью внепеченочных желчных протоков. Диагностическая программа включала в себя ультразвуковое исследование, компьютерную томографию, эндоскопическую ультрасонографию и эндоскопическую ретроградную панкреатикохолангиографию.Результаты. Установка билиодуоденального стента у 223 больных (95,3%) производилась после предварительно выполненной эндоскопической папиллосфинктеротомии (ЭПСТ). Адекватность дренирования желчных протоков после произведенного в необходимом объеме билиарного стентирования была достигнута у всех пациентов. В 46 случаях выполнить стентирование билиарного тракта не удалось. Осложнения после эндоскопических вмешательств, представленные острым панкреатитом, холангитом, кровотечением из области ЭПСТ, перфорацией стенки двенадцатиперстной кишки и миграцией стента встретились в 19 случаях (5,9%). Послеоперационная летальность составила 3,8%. В 7 случаях (3%) пациенты умерли после достижения эндоскопической декомпрессии билиарного тракта. После билиодуоденального стентирования у всех пациентов желтуха разрешилась или существенно снизилась. У 185 из них (79%) эндоскопическое пособие явилось окончательным методом лечения вследствие запущенного опухолевого процесса. При рецидиве желтухи выполняли эндоскопическую санацию стента либо его замену. В остальных случаях (21%) после разрешения желтухи больным были произведены хирургические декомпрессивные вмешательства.Заключение. Метод эндоскопического ретроградного дренирования желчных протоков позволяет подготовить больных с механической желтухой к оперативным вмешательствам, в том числе и радикальным (либо является окончательным методом лечения опухолей органов ПБЗ, осложненных механической желтухой у неоперабельных больных). Частота осложнений после эндоскопических ретроградных вмешательств на большом сосочке двенадцатиперстной кишки по поводу ост- рой механической желтухи бластоматозного генеза практически не отличалась от таковой после стандартных ретроградных вмешательств и составляла 6%.

Clinical Guidelines of the Russian Society of Surgeons, the Russian Gastroenterological Association, the Association of Surgeons-Hepatologists and the Endoscopic Society “REndO” on Diagnostics and Treatment of Chronic Pancreatitis

Aim: to present modern methods of diagnosis and treatment of chronic pancreatitis for gastroenterologists, general practitioners and physicians.Chronic pancreatitis (CP) is a long-term inflammatory disease of the pancreas, manifested by irreversible morphological changes in the parenchyma and pancreatic ducts, which cause pain and/or persistent impairment of function. Current concept on the etiology of CP is reflected by the TIGAR-O classification. The criteria for establishing the diagnosis of CP include typical attacks of abdominal pain and/or clinical and laboratory signs of exocrine, endocrine insufficiency with the mandatory detection of characteristic morphological changes (calcifications in the parenchyma and pancreatic ductal stones, dilatation of the main pancreatic duct and its branches). CT, MRCP, and pancreatobiliary endosonography are recommended as the methods of choice to verify the diagnosis of CP. Conservative treatment of patients with CP is provided for symptom relief and prevention of complications. Individual cases with severe non-interactable abdominal pain, as well as a complicated course of the disease (development of ductal hypertension due to main pancreatic duct stones or strictures, obstructive jaundice caused by compression of the common bile duct, symptomatic postnecrotic cysts, portal hypertension due to compression of the portal vein or thrombosis of the splenic vein, persistent duodenal obstruction, pseudoaneurysm of the celiac trunk basin and the superior mesenteric artery) serve as an indication for endoscopic or surgical treatment. The Guidelines set out modern approaches to the diagnosis, conservative, endoscopic and surgical treatment of CP, and the prevention of its complications.Conclusion. The implementation of clinical guidelines can contribute to the timely diagnosis and improve the quality of medical care for patients with chronic pancreatitis

VIDEO-LAPAROSCOPIC INTERVENTIONS IN DIAGNOSTICS AND TREATMENT OF TORSION AND NECROSIS OF APPENDICES EPIPLOICA

A retrospective analysis of treatment of 82 patients with torsion and necrosis of appendices epiploica was made. The video-laparoscopic surgery of these patients was performed. When the diagnosis is unclear, the differential diagnostics should be made between the appendices epiploica disease and other abdominal diseases using the video-laparoscopy. This method allowed the establishment of the correct diagnosis of torsion and necrosis of appendices epiploica in 95,1% of patients. The laparoscopic treatment was made in 87,8% of cases with minimal quantity of postoperative complications. The video-laparoscopy allowed the detection of accompanying pathology of abdominal organs and performance of the correction by low-invasive method. The need of conversion occurred in 12,2% of patients. Postoperative period was characterized by uneventful recovery, minimal usage of analgesics and antibiotics, early stages of rehabilitation, perfect cosmetic effect in majority of patients