Differentiated approach to pancreatic-enteroanastomosis in pancreaticoduodenal resection: a clinical experimental controlled trial

Background. Despite decreasing mortality in pancreaticoduodenal resection, the incidence of postoperative complications in such patients remains high. The choice and formation of “reliable” pancreatic-enteroanastomosis remain relevant.Objectives. The improvement of immediate surgery outcomes in pancreaticoduodenal resection via development of a differentiated algorithm for pancreatic-enteroanastomosis formation.Methods. A prospective non-randomised controlled trial enrolled 90 patients with a pancreaticoduodenal resection surgery. The patients were divided in three cohorts, A (n = 30), B (n = 30) and control C (n = 30). Pancreatic shear wave ultrasound elastography was conducted pre-surgery in main cohorts A and B. Average parenchymal stiffness and intraoperative data decided between the two pancreatico-enteric anastomosis techniques, end-to-side or the original pancreatic-enteroanastomosis. Control cohort C had pancreatico-enteric anastomosis without taking into account the pancreas stiffness and macrocondition.Results. Class A postoperative pancreatic fistula was registered in 2 (6.7%) of 30 patients in cohort B; it was transient, asymptomatic, not requiring additional treatment or a longer postoperative period. No class B and C pancreatic-enteroanastomosis failures or stump pancreonecroses were observed in main cohorts A and B. Clinically significant class B and C postoperative pancreatic fistulae were registered in 5 (16.7%) of 30 patients in control cohort C (inter-cohort comparison statistically significant).Conclusion. The proposed differentiated approach to pancreatic-enteroanastomosis formation associates with a reliably low postoperative complication frequency and lack of clinically significant class B and C postoperative pancreatic fistulae

DIAGNOSTIC FEATURES OF COMPLICATED CHOLELITHIASIS IN PREGNANT WOMEN

The aim is to describe modern approaches used in the diagnostics of cholelithiasis in pregnant women.Results. Cholelithiasis diagnostics in pregnant women is a rather difficult task, frequently taking a long time and significantly worsening the prognosis for both the mother and the fetus. Abdominal ultrasound is the “gold standard” for the diagnosis of cholelithiasis in pregnant women, allowing the diagnosis to be clarified and the treatment tactics to be adjusted. The possibilities of such modern methods as endoscopic ultrasound diagnostics, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and laparoscopic ultrasonography used in difficult diagnostic cases are presented.Conclusion. The use of a maximal range of diagnostic studies in pregnant women makes it possible to establish the diagnosis as soon as possible and to reduce the frequency of surgical and related perinatal complications. As a result, the prolongation of pregnancy and a decrease in maternal and intrauterine mortality can be achieved.Conflict of interest: the authors declare no conflict of interest

Microscopic Colitis. Common Features and Differences

Aim. To study the morpho-molecular mechanisms underlying the formation of microscopic colitis (MC), as well as to identify features of its two forms – collagenous and lymphocytic.Material and methods. We studied biopsy samples from 23 patients exhibiting a clinical picture of irritable bowel syndrome; the material was obtained at the Endoscopic Department of the Region Clinic Hospital No. 2. The material was sampled from the five zones of the large intestine specified in the guidelines (Clinical Guidelines — Diagnosis and treatment of patients with digestive diseases, Appendix No. 3). The material was fixed in 10 % formalin, processed and embedded in paraffin. Sections were stained with hematoxylin and eosin (according to Mallory and Masson), as well as with picrosirius red, followed by the examination of these sections in polarised light. The immunohistochemical study was performed in line with the guidelines using monoclonal antibodies. Abcam antibodies (England) were used to detect type I and type III collagen; Cell Marque antibodies to CD4+ T and CD8+ T-lymphocytes (USA) were used to characterise lymphocytes.Results. It has been established that fi broblasts in the lamina propria play a key role in the pathogenesis of collagenous MC. This cell population synthesises extracellular matrix and forms layers of collagen fibres in the area under the surface epithelium. Pericryptal fibroblasts are also activated. Their differentiation occurs simultaneously with the migration of epithelial cells to the surface of the crypts with a possible change in their cellular composition. Intercryptal fi broblasts provide an increase in the synthesis rate of type III collagen. In the case of lymphocytic colitis, the pathogenetic mechanism is based on the relationship between lymphocytes and the cells in the lamina propria. The outcome is determined by the type of activated lymphocytes. CD8+ lymphocytes infiltrate the epithelial lining, causing a reaction to the luminal component, whereas CD4+ lymphocytes act as helpers and populate the lamina propria in the area under the epithelium.Conclusion. The pathogenesis of collagenous MC is based on the mechanism exhibited by the fibroblasts in the colon lamina propria, whereas the pathogenesis of lymphocytic colitis is determined by the dynamics of CD4+ T and CD8+ T-lymphocyte subpopulations

Electrohydraulic Lithotripsy in the Treatment of the Mirizzi Syndrome. A Clinical Case

Aim. To present an interesting case of treating cholelithiasis in the setting of the Mirizzi syndrome.Materials and methods. This paper presents a clinical case of patient A. (62 years old) who was admitted to hospital with the following diagnosis: cholelithiasis, cholecysto-choledocholithiasis, obstructive jaundice. Drawing on the medical history and complaints of the patient, as well as on the results of physical, laboratory, instrumental and preliminary examination, the patient was diagnosed with choledocholithiasis in the setting of the Mirizzi syndrome. Endoscopic retrograde cholangiopancreatography (ERCP) was prescribed. The ERCP was performed in four stages. The first stage included a typical endoscopic papillotomy, a retrograde cholangiopancreatography, as well as an attempt at endoscopic mechanical lithoextraction; however, the calculus could not be removed. During the second stage, the calculus was visually localized, and its size was determined. The third stage consisted in performing electrohydraulic lithotripsy (EHL) and mechanical lithoextraction of calculus fragments. The final, fourth stage involved follow-up direct cholangioscopy, which revealed that the common bile duct was patent and there were no calculi.Results. EHL constitutes a high-tech method of crushing calculi, which provides an opportunity to carry out minimally invasive treatment in patients with complicated cases of choledocholithiasis, when standard methods of mechanical lithoextraction are not effective