Correction of bile outflow in complicated calculous cholecystitis

The method of low-traumatic atypical endoscopic papillosphincterotomy (EPST) with an antegradely inserted probe which permits to correct simultaneously bile outflow in choledocholithiasis and strictures of the terminal part of the common bile duct was used in 26 patients with cholelithiasis. Advantage of this surgical policy in complicated forms of calculous cholecystitis is possibility of one-stage treatment. Comparative analysis of one-stage and routine two-stage treatment policies was carried out in 52 patients. EPST permits to avoid stage of retrograde pancreatocholangiography and papillosphincterotomy. Absence of technical difficulties due to EPST and a protective role of the probe which minimizes risk of acute pancreatitis are demonstrated.     

Surgical policy in patients with chronic calculous cholecystitis complicated by choledocholithiasis

Results of surgical treatment in 116 patients with chronic calculous cholecystitis complicated by choledocholithiasis were studied. Introduction in clinical practice of endoscopic papillosphincterotomy (EPST) and laparoscopic cholecystectomy changed surgical policy for benign combined lesions of gall bladder and extrahepatic bile ducts. Complex endoscopic treatment is preferable if contraindications are absent. Complex endoscopic treatment was used in 26.7% cases, combined surgical and endoscopic (trans-papillar surgeries) - in 30.2%, conventional surgical - in 33.6%. Isolated EPST and endo-biliary procedures were performed in 9.5% patients. Complex endoscopic treatment is preferable for chronic calculous cholecystitis complicated with choledocholithiasis. Combined and conventional surgical policy is indicated when appliance of endoscopic technologies is not possible.     

Endoscopic papillosphincterotomy in patients with acute cholecystitis and lesions of the common bile duct

The authors analyse treatment of 115 patients who were admitted for acute cholecystitis with involvement of the bile ducts which manifested itself as a rule, as obstructive jaundice and cholangitis. Endoscopic papillosphincterotomy (EPST) was conducted as the first stage of treatment in 83 patients, as the second stage after cholecystectomy or laparoscopic cholecystotomy in 30, and during the surgical intervention in 2 patients. Experience shows that treatment of this contingent of patients in two stages is advisable. In emergency operations for acute cholecystitis, when the revealed abnormalities in the hepaticocholedochus cannot be corrected adequately due to the patient's severe condition or marked inflammatory changes in the region of the hepatoduodenal ligament, the operation should be completed by drainage of the common bile duct and antegrade or retrograde EPST should be performed in the post-operative period. In the presence of obstructive jaundice and acute suppurative cholangitis, when there is a high operative risk, EPST should be undertaken as an emergency intervention ensuring timely decompression and cleansing of the bile ducts. In 37.3% of patients EPST was conducted by an atypical method due to the high operative risk, as a result the efficacy of the endoscopic operation increased to 93.3%.     

Risk assessment of the acute pancreatitis development after papilla Fateri balloon dilatation

Data of 241 patients with acute cholecystitis, complicated with obstructive jaundice are analyzed. The risk of the acute pancreatitis development after choledocholithotomy, endoscopic papillosphincterotomy (EPST) and balloon dilatation of the papilla Fateri is assessed. Thus, choledocholithotomy and EPST, combined with the simultaneous manipulations on the terminal part of the common bile duct, are more often followed by the acute pancreatitis. Whereas the balloon dilatation of the papilla Fateri is more often followed by an asymptomatic hyperamylasuria. Demonstrated, that difficulties by papilla Fateri cannulation during EPST furthers the pancreatonecrosis development. The authors suggested a marked balloon catheter, which allows safely and effectively dilate papilla duodeni. The optimal diameter of the balloon is showed to be 1 sm wide.     

Diagnostics of stenosis of the major duodenal papilla in patients with choledocholithiasis

The article presents results of treatment of 63 patients with cholecystocholedocholithiasis from a minilaparotomic access without a preliminary endoscopic papillosphincterotomy (EPST). The method of revision of the common bile duct is described and the diagnostic algorithm after the detection of impaired patency of its terminal part. Stenosis of the major duodenal papilla (MDP) was diagnosed in 7 patients (11.1%) in whom the operation was followed by successful EPST. Based on the data of personal investigations and analysis of literature the authors made a conclusion that preoperative diagnostics of stenosis of MDP was problematical. This diagnosis must be made using a complex of intraoperative diagnostic methods among which the probe of MDP is of main significance.     

Late results of endoscopic papillosphincterotomy treatment in patients with acute cholecystitis

The authors examined 81 patients who were subjected to endoscopic papillosphincterotomy (EPST) in the management of acute cholecystitis attended by total or partial obstruction of the choledochus. Cholestomy was carried out before or after EPST in 68 patients but not in 13 patients. The duration of the follow-up period after treatment ranges from 12 months to 6 years. All patients who were examined felt well and had no complaints caused by cholelithiasis. It was found that destruction of the sphincter apparatus of the major duodenal papilla and terminal choledochus led to the development of reflux from the duodenum into the choledochus in 25% of cases. In 18 patients ultrasonic examination revealed signs of chronic pancreatitis which was not manifested clinically. Among 13 patients with a preserved gallbladder containing concrements only 3 were operated on during the follow-up period. Residual choledocholithiasis was found in 5 patients in whom during good bile drainage after EPST it was not manifested clinically. The authors come to the conclusion that EPST shows a high clinical efficacy in the treatment of acute cholecystitis complicated by obstruction of the terminal choledochus.     

Diagnosis and differential treatment of acute pancreatitis of biliary etiology

The experience in examination and treatment of 208 patients with acute pancreatitis of biliary etiology was analyzed. Complex endoscopic treatment was carried out in 88% patients. If there are indications, it is reasonable to perform retrograde pancreatocholangiography (RPCG) and endoscopic papillosphincterotomy (EPST) during surgery in patients with concomitant enzymatic ascites-peritonitis. In the others patients RPCG and EPST must be regarded as the first stage of treatment. Surgical procedure of choice at the second stage of treatment is laparoscopic cholecystectomy.     

Laparoscopic cholecystectomy in choledocholithiasis and stricture of the terminal part of the common bile duct

The authors offer the treatment and diagnostic algorithm in choledocholithiasis, stricture of a terminal portion of the common hepatic duct and papilla stenosis revealed in laparoscopic cholecystectomy (LCE). With the purpose of intraoperative assessment of bile ducts states during LCE, the diagnostic system including laparoscopic and ultrasonic examinations, cholangiography and choledochoscopy was developed and applied. In intraoperative revealing of choledocholithiasis without bile outflow disorders and wide cystic duct the authors prefer to remove the concrements during choledochoscopy through cystic duct without intervention on Vater's papilla (VP). In combination of choledocholithiasis with bile outflow disorders and also in isolated papilla stenosis and stricture of a terminal portion of the common hepatic duct, one-stage laparoscopic cholecystectomy, intraoperative antegrade papillosphincterotomy and retrograde calculus extraction is optimal. In cases when complete endoscopic calculus extraction is impossible, the drainage of the common hepatic duct by Cholsted's with subsequent delayed endoscopic papillosphincterotomy (EPST) is acceptable. During intraoperative examination in 49 patients (57.6%) the concrements in choledochus, not diagnosed earlier, were revealed, in 21--stricture of terminal choledochus portion and in 19 patients--papilla stenosis. In 12 cases the concrements were removed during choledochoscopy through the cystic duct stump, 4 patients with big concrements required laparoscopic choledocholithotomy. In 16 cases LCE with various variants of choledochus drainage was performed as the first stage, as the second stage--EPST and lithoextraction. Antegrade papillosphincterotomy was performed in 15 patients during LCE. In 12 cases intraoperatively revealed choledocholithiasis combined with papilla stenosis (7) and choledochus stricture (5) was the indications to intraoperative papillosphincterotomy. Papilla stenosis was the indication to antegrade papillosphincterotomy in 3 patients.     

Minimally invasive two-stage treatment of cholecystocholedocholithiasis

Two groups of patients in whom two-stage treatment of cholecystocholedocholithiasis was performed with different succession of using endoscopic papillosphincterotomy (EPST) and laparoscopic cholecystectomy (LCE) were compared. In 59 patients (1st group) EPST was used as the first stage, in 67 patients (2nd group) LCE and drainage of choledochus preceded the endoscopic intervention. The effectiveness of EPST was 93.3 and 95.5% correspondingly in the first and second groups. There were no considerable differences in the frequency of complications, period of treatment at the hospital in the two groups. Lythextraction was obtained considerably more often at the first attempt in the second group of patients (79.1% versus 59.9%, p < 0.05). Due to inefficiency of EPST in three cases in the second group of patients reoperations were required. Thus, EPST should be performed before LCE for the rationally planned further treatment in case of its inefficiency.     

Minimally invasive methods for treatment of cholelithiasis, complicated by choledocholithiasis

Disease of the common bile duct (choledochal duct) was revealed in 18 from 531 patients with bile tract lithiasis (3.4%), who underwent laparoscopic cholecystectomy and in 3 of 72 patients (5.4%), who underwent cholecystectomy through minilaparotomy approach. Stenosis of the large duodenal papilla was observed in 14 patients, choledocholithiasis in 9 patients. Endoscopic papillosphincterotomy (EPST) was performed in all cases. There were no complications. In 2 cases moderate amylasemia was detected. Laparoscopic cholecystectomy was performed 5 days after the procedure on the large duodenal papilla (5.1 days mean). Intervention with the use of mini-approach after EPST was carried out in patient with concrement of gall bladder duct stump, which was revealed 3 months after laparoscopic cholecystectomy. Mini-approach made it possible to perform reconstructive operations on bile ducts in combination with cholecystectomy in 3 patients. At present there are many tools which enable combined treatment of the bile tract lithiasis complicated by bile ducts pathology with low-invasive technique.     

Possibilities of transpapillary and laparoscopic methods of choledocholithiasis treatment

The results of surgical treatment of patients, suffering choledocholithiasis, were adduced. In 493 patients laparoscopic exploration of common biliary duct was accomplished, in 297 of them the choledocholithiasis diagnosis was definitely established while performing laparoscopic cholecystectomy (LCHE); in 136--endoscopic papillosphincterotomy (EPST) was done preoperatively, but the attempts to perform transpapillary lithoextraction and lithotripsy have failed; in 60--a residual choledocholithiasis was noted. In 930 patients EPST and lithoextraction were performed preoperatively and as a second stage--LCHE.     

Surgical tactics in cholangitis in middle-aged and elderly patients]

The authors analysed the results of examination and treatment of 399 elderly and old-aged patients in the period between 1971 and 1981. At that time cholangitis was managed in 146 (36.6%) patients mainly by surgical intracavitary operations, in 21.2% with a fatal outcome. The results showed the high risk of surgical methods for treatment of cholangitis. Since 1982 the authors have introduced into every-day practice endoscopic methods for the management of this disease. It was found that endoscopic papillosphincterotomy (EPST) is the most physiological and safe method for the treatment of choledocholithiasis, stenosis of the major duodenal papilla, and acute cholangitis. EPST undertaken in 253 (63.4%) patients ensured adequate decompression of the bile ducts in 187 (73.9%) of them and facilitated removal of cholangitis and recovery. With the use of EPST in the treatment of acute cholangitis not only was the number of surgical operations on patients of the older age group reduced, but the mortality decreased to 5.5% (which was 3.9 times lower than the mortality in management of cholangitis by surgical operations).     

Surgical interventions for obstruction of the extrahepatic bile ducts]

The results of surgical correction of obstruction of the extrahepatic bile ducts in 279 patients are presented. The operation of choice was choledocholithotomy, which was added by papillosphincterotomy and external drainage of the common bile duct in indications. In obstruction of bile ducts of the tumor genesis, the different biliodigestive anastomoses were created. The postoperative lethality was 4.6%.     

Surgical tactics in duodenal trauma

Results of surgical treatment of 61 patients with injuries of the duodenum are analyzed. The causes of injuries were stab-incised wounds in 24 patients, missile wound -- in 7, closed abdominal trauma -- in 26, trauma of the duodenum during endoscopic papillosphincterotomy -- in 4. All the patients underwent surgery. Complications were seen in 32 (52.5%) patients, 21 patients died, lethality was 34.4%. Within the first 24 hours since the trauma 7 patients died due to severe combined trauma, blood loss, 54 patients survived acute period of trauma, including 28 patients after open trauma, 26 -- after closed and 4 -- after trauma of the duodenum during endoscopic papillosphincterotomy. Diagnostic and surgical policies are discussed. Results of treatment depending on kind and time of surgery are regarded. It is demonstrated that purulent complications due to retroperitoneal phlegmona, traumatic pancreatitis, pneumonia are the causes of significant number of unfavorable outcomes. Therefore, it is important to adequately incise and drainage infected parts of retroperitoneal fat tissue with two-lumen drainages. Decompression through duodenal tube is the effective procedure for prophylaxis of suture insufficiency and traumatic pancreatitis. Suppression of pancreatic and duodenal secretion with octreotid improves significantly surgical treatment results.     

Antegrade papillosphincterotomy in laparoscopic cholecystectomy

Stenotic lesions of the distal part of the common bile duct are often revealed in laparoscopic cholecystectomy. From 1997 intraoperative antegrade papillosphincterotomy (APST) has been introduced in clinical practice of the endoscopic department of the A.V. Vishnevsky Institute of Surgery as the method able both to treat choledocholithiasis and restore adequate bile outflow. Indications to APST were stenosis of Vater's papilla (13 patients), stricture of a terminal part of the common bile duct (6 patients), choledocholithiasis in combination with distal bile duct stenosis (20 patients), isolated choledocholithiasis (4 patients). APST was successful in 36 patients and in 35 ones it was a final procedure for correction of ducts lesions. There were no complications of APST. It is an effective method in the treatment of intraoperatively defected stenotic lesions of the biliary tracts and choledocholithiasis. It makes the base of one-stage surgical policy in line with cholangioscope-assisted lithoextraction, intraoperative retrograde papillosphincterotomy and balloon dilatation of Vater's papilla. Antegrade papilloshincterotomy in patients with cholelithiasis and lesions of the ducts revealed during surgery permits one to reduce number of complications, time of hospital stay and increase comfort of surgical care.     

Treatment of calculous cholecystitis and its complications

Results of treatment of 10,724 patients with different forms of acute and chronic cholecystitis are analyzed. Surgical treatment was performed in 7819 (72.9%) patients. Variants of treatment of acute and chronic cholecystitis are presented. Typical cholecystectomy is the basic surgery in patients with acute calculous cholecystitis (63% procedures). Laparoscopic cholecystectomy (LCE) was performed in 37% patients. Two-stage surgeries with previous microcholecystostomy (MCS) and endoscopic papilloshincterotomy (EPST) are indicated in late hospitalization of patients with intoxication and severe concomitant diseases. They permit to prepare patients for cholecystectomy and to decrease scope of surgery. In cholelithiasis and jaundice EPST and MCS are indicated for almost all patients as a preliminary procedure before surgery on the biliary tract and cholecystectomy. This two-stage variant permitted to reduce postoperative lethality from 9.7 to 1.6%. In chronic cholecystitis LCE is the main type of surgery with minimal postoperative lethality. For patients with recurrent calculous cholecystitis, frequent exacerbations, severe concomitant diseases EPST in choledocholithiasis and sanation of gall bladder through fistula are indicated.     

Cholecystic-choledochal calculi. Endolaparoscopic treatment]

BACKGROUND AND AIM: Common bile duct calculosis is a pathology which has always been treated using traditional laparotomic surgery. The introduction of endoscopic papillosphincterotomy and mini-invasive and videolaparoscopic methods has drawn attention to the fact that these methods may be able to replace conventional surgery. METHODS: The authors examine the epidemiological and clinical aspects of common bile duct calculosis, reporting their experience in ten female patients treated during the period from 1992 to 1997, all of whom presented jaundice, pain and fever. Of these, eight underwent papillosphincterotomy using an endoscopic approach, followed by laparoscopic removal of common bile duct calculi within 24 hours. In two cases it was necessary to resort to conventional methods owing to difficulty in cannulating the papilla caused by a diverticulum in one patient and stenosis in the other, and the tenacious synechiae between the common bile duct and the gallbladder. RESULTS: The postoperative period was free of complications. CONCLUSIONS: The associated treatment, namely endoscopic papillosphincterotomy and endoscopic cholecystectomy proved a valid alternative to traditional laparotomic treatment, demonstrating a good level of reliability and safety for patients and reductions in terms of resources and hospitalisation time.     

Duodenoscopic interventions on the terminal part of the choledochus]

The results of various methods of duodenoscopic interventions on the terminal choledochus in 261 patients with papilla stenosis and choledocholithiasis were analysed. Endoscopic papillosphincterotomy by the cannulation method was performed in 107 patients, endoscopic papillosphincterotomy with preincision of the major duodenal papilla in 31, and endoscopic suprapapillary choledochoduodenostomy in 123 patients. The performance of various methods of duodenoscopic interventions according to indications made it possible to increase the possibility of conducting the operation to 98% and its efficacy to 95%. Complications after duodenoscopic interventions occurred in 10% of cases with 1.2% lethality. The late results of duodenoscopic interventions were good in 85.5% of cases irrespective of the mode of the operation.     

The ways for reduction of complication rate after laparoscopic cholecystectomy at acute cholecystitis

Results of 1831 laparoscopic cholecystectomies (LCE) are analyzed. Symptoms of obstructive jaundice were at 170 (9.3%) patients. All these patients underwent endoscopic papillosphincterotomy before LCE for removal of bile hypertension. Conversion to open surgery was necessary in 44 (2.4%) cases. Intraoperative injuries of extrahepatic bile ducts occurred at 5 (0.27%), bleeding--at 10 (0.6%) patients. Postoperative complications were seen at 36 (2.0%) patients including intraabdominal bleeding (4), drainage bile less (8), subhepatic abscess (4), epigastric wound infection (16). There were 2 (0.1%) lethal outcomes. Accurate surgical technique and timely conversion to open surgery prevent complications of LCE.     

Principles of treating the postcholecystectomy syndrome

The experience with treatment in the Institute of Clinical and Experimental Surgery of 3572 patients with postcholecystectomy syndrome in the period from 1971 to 1987 is summarized. Two-dimension ultrasonography, intravenous infusion, retrograde endoscopic, percutaneous transhepatic cholangiography and fistulocholangiography were the main diagnostic procedures. In choledocholithiasis, the endoscopic papillosphincterotomy was performed. Tubular stenosis of the common bile duct was considered an indication for choledochoduodenoanastomosis formation. In bile duct strictures, biliobiliary and biliodigestive anastomoses were created. With the aim of prophylaxis of anastomotic stenoses, the active dilatation of anastomoses was employed. In duodenostasis, surgical correction was accomplished with regard for its causes and degree of pronouncement, character and severity of the related complications.