Abstract
Objective. The radical elimination of extrahepatic biliary tract pathology in choledocholithiasis and acute biliary pancreatitis (ABP) reduces the risk of infection and eliminates the source of endogenous intoxication; so, the search of safe and effective techniques for endoscopic papillosphincterotomy (EPT) is important.Purpose: to assess outcomes of laser-assisted endoscopic papillosphincterotomy.Material and methods. 288 patients with “wedged” (n = 111) and “valve” (n = 177) choledocholithiasis and acute biliary pancreatitis were divided into two groups depending on EPT technique: in the control group, a papillotome with electrocoagulation cord was used (n = 195); in the main group, laser scalpel was used (n = 93).Results. 87 patients with “wedged” choledocholithiasis were treated with EPT and an end electrode on the wedged stone. 16 patients out of them had mild bleeding which was stopped by irrigation with epinephrine solution (1 : 10 000) followed by the targeted coagulation. The average surgical time was 38 ± 16 min. In 24 patients with rigid and edematous medial wall of the duodenum due to acute biliary pancreatitis, the proposed device plus laser technique for papillosphincterotomy were used (patent of the Russian Federation No. 2614891). There was no bleeding, the average surgical time was 24 ± 12 min. In “valve” choledocholithiasis, laparoscopic cholecystectomy (LCE) was performed; calculi from the common bile duct were removed. In 108 patients during LCE, EPT was made via an antegrade catheter. In 69 patients with anatomical and physiological obstacles caused by the major duodenal papilla, we performed LCE and EPT with laser light via an antegrade guide light made of fluoroplastics (patent of the Russian Federation No. 41594). Concrements from the common bile duct were removed with the Dormia basket.Conclusions. Laser light causes less damage, reliably provides hemostasis along the incision line on the anterior wall of the major duodenal papilla; in addition, a wedged calculus in “wedged” choledocholithiasis and a fluoroplastic light guide in “valve” choledocholithiasis reliably protect the posterior wall of the major duodenal papilla from laser light damage. Laser techniques used in EPT make the treatment of choledocholithiasis in patients with ABP having anatomical and physiological problems due to the major duodenal papilla safe and effective.
Highlights
Экстренная ликвидация острой блокады оттока желчи и панкреатического секрета, радикальное устранение патологии внепеченочных желчных путей (ВПЖП) в преобладающем большинстве случаев приводит к «абортированию» острым билиарным панкреатитом (ОБП), снижает вероятность его инфицирования, устраняет существенный источник эндогенной интоксикации, связанный с острым холециститом, холангитом, а также экономически оправдано, так как исключает повторную госпитализацию больных для удаления желчного пузыря в связи с наличием в нем конкрементов [2,3,4,5]
Material and methods. 288 patients with “wedged” (n = 111) and “valve” (n = 177) choledocholithiasis and acute biliary pancreatitis were divided into two groups depending on endoscopic papillosphincterotomy (EPT) technique: in the control group, a papillotome with electrocoagulation cord was used (n = 195); in the main group, laser scalpel was used (n = 93)
87 patients with “wedged” choledocholithiasis were treated with EPT and an end electrode on the wedged stone. 16 patients out of them had mild bleeding which was stopped by irrigation with epinephrine solution (1 : 10 000) followed by the targeted coagulation
Summary
Laser light causes less damage, reliably provides hemostasis along the incision line on the anterior wall of the major duodenal papilla; in addition, a wedged calculus in “wedged” choledocholithiasis and a fluoroplastic light guide in “valve” choledocholithiasis reliably protect the posterior wall of the major duodenal papilla from laser light damage. Причиной ОБП является миграция конкрементов по желчным протокам с развитием протоковой гипертензии в протоке поджелудочной железы (ППЖ) и желчных путях. Экстренная ликвидация острой блокады оттока желчи и панкреатического секрета, радикальное устранение патологии внепеченочных желчных путей (ВПЖП) в преобладающем большинстве случаев приводит к «абортированию» ОБП, снижает вероятность его инфицирования, устраняет существенный источник эндогенной интоксикации, связанный с острым холециститом, холангитом, а также экономически оправдано, так как исключает повторную госпитализацию больных для удаления желчного пузыря в связи с наличием в нем конкрементов [2,3,4,5]. При ликвидации внутрипротоковой гипертензии особенно часто эта опасность возникает при наличии некоторых анатомических особенностей строения БСДК и патологических изменений в его зоне (перипапиллярный дивертикул, папиллит, стриктура, аденома, стеноз или точечное устье БСДК), отек и деформация, ригидность стенки ДПК, вызванная ОБП. Цель – оценить результаты эндоскопической папиллосфинктеротомии с применением лазера при холедохолитиазе и остром билиарном панкреатите
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