Endoscopic Papillosphincterotomy Research Articles

Double Postbulbar Block in the Prevention of Postmanipulation Pancreatitis

Abstract The problems of preventing postmanipulation pancreatitis (PMP) remain the subject of debate and a lot of research from leading scientific clinics around the world. The article is devoted to the assessment of prevention methods of PMP in patients with lesion of the pancreaticobiliary zone who underwent transpapillary interventions. Aim of the study Evaluation of the effectiveness of the author’s method of preventing PMP.Material and methods A prospective two-center randomized study included 545 patients treated in the Department of Liver Surgery and General Surgery in 2020–2022, who underwent ERCP and endoscopic papillosphincterotomy. There were 146 (26.8%) male patients, and 399 (73.2%) female patients, aged from 18 to 92 years, the mean age 62.7±7.4 years. Patients were divided into 3 groups according to the method of preventing PMP: in the 1st group, standard drug premedication was supplemented with two postbulbar blocks with a solution of lidocaine 0.5% 10 ml before and after the intervention (RF Patent No. 2779221, 09/05/2022), in the 2nd group standard premedication was combined with placebo was used, and in the comparison group 3 no submucosal injections were performed. The monitoring of clinical manifestations of PMP and the level of amylase was carried out every 12 hours until the parameters normalized. Statistical processing was carried out using program STATISTICA 6.1 for Windows.Results The frequency of mild pancreatitis, corresponding to the criteria for PMP, did not exceed 18% in groups 1 and 3 (p=0.3408), but was lower with pseudo postbulbar block, 9% (χ2=2.83, р=0.0926), the difference was not statistically significant. The incidence of severe pancreatitis was significantly lower in group 1 with double postbulbar block where there were no cases of pancreatic necrosis among 143 patients (χ2=6.19, р=0.0129). The mortality did not differ significantly among groups (χ2=0.15, р=0.7004). The duration of the hospital period had significant differences between groups (Student’s t-test 1.973, p=0.001). The hospital period with double postbulbar block turned out to be significantly shorter.Conclusion 1. Double postbulbar blockade significantly reduces the risk of developing severe postmanipulation pancreatitis, regardless of existing risk factors. 2. Double postbulbar block significantly reduces the duration of the hospital period after endoscopic papillosphincterotomy. 3. Pseudo postbulbar block using saline requires further evaluation as a possible way to prevent mild pancreatitis.

Laser lithotripsy for pancreatic duct stones

Aim. To confirm the possibility of minimally-invasive laser procedure for fragmentation of stones in the pancreatic duct following the results of laboratory experiments and medical practice. Materials and methods. A fully functional hardware complex consisting of a pulsed laser unit, video endoscopic system and cooling system was created for experimental stone fragmentation in laboratory. The experiments involved microscopic video registration of the fragmentation process, pressure and temperature measurement in the stone area. Pancreatic stones, human and artificial gallstones as well as porcine pancreas were used in the experiments; the gastrointestinal tract was made of silicone, the pancreas was made of gelatin aqueous solution jelly. In clinical practice, a patient with lithiasis of Wirsung's duct was assigned to ultrasound and CT, then endoscopic papillosphincterotomy, endoscopic pancreatoscopy, laser lithotripsy and lithoextraction, pancreatic duct stenting. The procedures involved a laser unit, videoduodenoscope, catheter and their video systems. Results. The laboratory experiments established that effective and safe laser fragmentation of stones from 4 × 7 mm into 0.1–2 mm occurs in the flowing fluid in front of the stone at 1 μs laser pulse duration, 5–15 Hz frequency and 120–150 mJ laser energy. After laser fragmentation of the stone in a patient with virsungolithiasis and removal of fragments from the duct, the patient was discharged from the hospital on the 12th day due to improvement of healthcondition. Conclusion. The possibility of minimally-invasive fragmentation of stones in the pancreatic duct by laser lithotripsy has been proved.

Peculiarities of pharmacological prevention strategy of pancreatic complications after endoscopic papillosphincterotomy for choledocholithiasis

The most frequent complication of endoscopic papillosphincterotomy (EPST) is acute pancreatitis. This complication is supposed to be based on mechanical, chemical, hydrostatic, enzymatic and thermal impact on pancreatic ducts and parenchyma. According to different literature data, the incidence of post-EPST pancreatitis (PEP) varies from 30 to 40%, and the mortality rate is 2-10%. The aim of the investigation was to expand information about peculiarities of early diagnostics and prevention of post-EST pancreatitis at the present stage. To reach the set goal we analyzed 559 case histories of patients with diagnosed cholelithiasis, 319 of them underwent EPST. During the study it was found out, that elevated neutrophils/lymphocytes ratio over 4,96 (p=0,001), high LDH level over 250 IU/ml (p=0,01), as well as C-reactive to albumin index over 0,180 (p=0,001) are reliable markers of early diagnosis. Also, indirect diagnostic markers of PEEP are biochemical signs of cholestasis and cytolysis of hepatocytes, as well as hyperglycemia combined with glucosuria. We consider the inclusion of intraoperative injections of papillotomy wound margins with Epinephrine in combination with subsequent Somatostatin administration in combination with rectal Diclofenac and intravenous hydration with Reamberin to be the most effective strategy for PEP prevention. Thus, we can conclude that despite the ongoing research and the search for effective algorithms for the prevention and early diagnosis of PEP, their data often contradict each other or simply do not confirm their effectiveness. The problem of prevention and diagnosis of PEP remains complex and requires further study. There are discrepancies, sometimes significant ones, in the current literature, which provides grounds for the development and research of new methods of early diagnosis and prevention.

Obstructive jaundice: routing, diagnostics, treatment tactics

Aim. To analyze three-level system of medical care for different categories of patients with obstructive jaundice on the example of Pavlov University.Materials and methods. The paper presents a retrospective analysis of treating patients with obstructive jaundice. The analysis covered the period from January 2015 to April 2023 and involved an etiology of obstructive jaundice, range of performed surgical interventions, postoperative complication rate, and mortality.Results. The study involved 2494 patients, including 1569 (62.9%) with cholelithiasis. The total mortality accounted for 7.2%, the incidence of postoperative complications – 13.9%. A choice of decompression procedure in patients with malignant tumors depended on the block level. Interventions included percutaneous transhepatic drainage, cholecystostomy, stenting of common bile duct. Hybrid surgery was performed in patients with calculous cholecystitis and choledocholithiasis. A number and size of concrements, a diameter of common bile duct influenced the choice of interventions and their volume. Two-stage tactics for stricture of biliodigestive anastomosis included percutaneous transhepatic drainage and reconstructive surgery. Endoscopic intervention was performed for choledocholithiasis. Procedures for stricture of biliary anastomoses after orthotopic liver transplantation involved endoscopic papillosphincterotomy, balloon dilatation of stricture and stenting of bile duct. Management of obstructive jaundice against the background of gestation included endoscopic papillosphincterotomy, lithoextraction, and, if necessary, treating the pregnancy termination threat.Conclusion. The routing of patients with obstructive jaundice to the 2nd and 3rd level of healthcare units is found necessary to be differentiated, depending on the etiology and severity of their condition. Obstructive jaundice in pregnant women requires the patient to be referred to the hospital of the 3rd level. Creation of a shared dispatch service responsible for a certain territory can reduce a number of routing stages.

Peculiarities of pharmacological prevention strategy of pancreatic complications after endoscopic papillosphincterotomy for choledocholithiasis

The most frequent complication of endoscopic papillosphincterotomy (EPST) is acute pancreatitis. This complication is supposed to be based on mechanical, chemical, hydrostatic, enzymatic and thermal impact on pancreatic ducts and parenchyma. According to different literature data, the incidence of post-EPST pancreatitis (PEP) varies from 30 to 40%, and the mortality rate is 2–10%. The aim of the investigation was to expand information about peculiarities of early diagnostics and prevention of post-EST pancreatitis at the present stage. To reach the set goal we analyzed 559 case histories of patients with diagnosed cholelithiasis, 319 of them underwent EPST. During the study it was found out, that elevated neutrophils/ lymphocytes ratio over 4.96 (p = 0.001), high LDH level over 250 IU/ml (p = 0,010), as well as C-reactive to albumin index over 0,180 (p = 0.001) are reliable markers of early diagnosis. Also, indirect diagnostic markers of PEEP are biochemical signs of cholestasis and cytolysis of hepatocytes, as well as hyperglycemia combined with glucosuria. We consider the inclusion of intraoperative injections of papillotomy wound margins with epinephrine in combination with subsequent Somatostatin administration in combination with rectal diclofenac and intravenous hydration with Reamberin to be the most effective strategy for PEP prevention. Thus, we can conclude that despite the ongoing research and the search for effective algorithms for the prevention and early diagnosis of PEP, their data often contradict each other or simply do not confirm their effectiveness. The problem of prevention and diagnosis of PEP remains complex and requires further study. There are discrepancies, sometimes significant ones, in the current literature, which provides grounds for the development and research of new methods of early diagnosis and prevention.

Endoscopic stenting of bile ducts for preventing mechanical jaundice recurrence in gallstone migration

Aim. To study the reasons for stone migration from the gallbladder into the main bile ducts after endoscopic lithoextraction and to develop methods for preventing recurrent mechanical jaundice before performing the cholecystectomy.Material and methods. Delayed cholecystectomy was recommended for 328 patients with calculous cholecystitis and mechanical jaundice after endoscopic papillosphincterotomy, lithoextraction and restoration of adequate bile outflow. 23 patients were readmitted to hospital with recurrent mechanical jaundice caused by recurrent choledocholithiasis. All patients underwent duodenoscopy, endoscopic retrograde cholangiography and lithoextraction within 12 hours after admission. The size of the gallstones, the diameter of the cystic duct, the level of its insertion into the common hepatic duct, and the length of the previously performed papillotomy were considered as possible causes of recurrent choledocholithiasis.Results. Multiple gallstones of 2–4 mm and low cystic duct insertion into the common hepatic duct were detected in all 23 patients. An increase in the diameter of the cystic duct >5 mm was revealed in 18 patients. In 10 patients, the initial papillotomy was <8 mm.Conclusion. The factors predisposing to recurrent mechanical jaundice due to migration of gallstones into the bile duct and indications for its stenting after lithoextraction before cholecystectomy are ultrasound signs of multiple small gallstones, low insertion the dilated cystic duct into the bile duct, and partial, non-extended papillotomy.

Methods of early diagnosis and pharmacological prevention of pancreatitis after endoscopic papillosphincterotomy

Introduction. The most frequent complication of endoscopic papillosphincterotomy (EPST) is acute pancreatitis. This complication is supposed to be based on mechanical, chemical, hydrostatic, enzymatic and thermal impact on pancreatic ducts and parenchyma. According to different literature data, the incidence of post-EPST pancreatitis (PEP) varies from 30 to 40 %, and the mortality rate is 2–10 %.The aim of the investigation was to expand information about peculiarities of early diagnostics and prevention of post-EST pancreatitis at the present stage.Materials and methods. To reach the set goal we analyzed 559 case histories of patients with diagnosed cholelithiasis, 319 of them underwent EPST.Results. During the study it was found out, that elevated neutrophils/lymphocytes ratio over 4,96 (p = 0,001), high LDH level over 250 IU/ml (p = 0,01), as well as Creactive to albumin index over 0,180 (p = 0,001) are reliable markers of early diagnosis. Also, indirect diagnostic markers of PEEP are biochemical signs of cholestasis and cytolysis of hepatocytes, as well as hyperglycemia combined with glucosuria. We consider the inclusion of intraoperative injections of papillotomy wound margins with Epinephrine in combination with subsequent Somatostatin administration in combination with rectal Diclofenac and intravenous hydration with Reamberin to be the most effective strategy for PEP prevention.Conclusions. Thus, we can conclude that despite the ongoing research and the search for effective algorithms for the prevention and early diagnosis of PEP, their data often contradict each other or simply do not confirm their effectiveness. The problem of prevention and diagnosis of PEP remains complex and requires further study. There are discrepancies, sometimes significant ones, in the current literature, which provides grounds for the development and research of new methods of early diagnosis and prevention.

Risk factors for post-endoscopic retrograde pancreatography pancreatitis in malignant extrahepatic biliary obstruction: a retrospective single-center study

Background. Decompression interventions under the endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice in malignant extrahepatic biliary obstruction (MEHBO). Acute pancreatitis is the most common complication of ERCP. Many studies have been performed to identify the risk factors for post-ERCP pancreatitis (PEP). However, these works in general include the analysis of ERCP in patients with various causes of biliary obstruction without subdividing patients with malignant obstruction.
 Purpose.The aim of this study was to determine the risk factors for PEP in patients with MEHBO.
 Materials and Methods. A retrospective analysis of 100 cases of ERCP in MEHBO was done. PEP was in 2 patients, and 14 patients had hyperamylasemia (HA). The following factors were analyzed: gender, age, level of MEHBO, obstruction of the main pancreatic duct (MPD), total bilirubin level, history of endoscopic papillosphincterotomy (EPST), periampullary diverticulum, successful ERCP, primary selective biliary cannulation, catheterization and/or contrast injection into MPD, Precut EPST, successful decompression.
 Results and discussion. Univariate analysis showed that PEP is associated with an obstruction at the level of the proximal and middle third of the hepaticocholedochus (p = 0.004) and with absence of MPD obstruction (p = 0.022); female gender (p = 0.012), obstruction at the level of the proximal and middle third of the hepaticocholedochus (p < 0.001), absence of MPD obstruction (p < 0.001), catheterization and/or contrast injection into MPD (p = 0.040) are associated with PEP or hyperamylasemia (HA); female gender (p = 0.024), obstruction at the level of the proximal and middle third of the hepaticocholedochus (p < 0.001), absence of MPD obstruction (p=0.006), catheterization and/or contrast injection into MPD (p = 0.035), successful decompression (p = 0.004) are associated with HA. Multivariate regression analysis showed that, for PEP and for PEP or HA as well as for HA, the risk factors are obstruction at the level of the proximal and middle third of the hepaticocholedochus (p = 0.005; p < 0.001; p < 0.001, respectively) and absence of MPD obstruction (p = 0.022; p < 0.001; p = 0.008, respectively). Female gender is a risk factor for PEP or HA and HA (p = 0.011; p = 0.028, respectively), and catheterization and/or contrast injection into MPD are risk factors for PEP or HA (p = 0.04). Conclusion. Development of PEP in MEHBO depends on the localization of a tumor and involvement of the pancreas. The risk factors for PEP in MEHBO are tumor localization at the level of the middle and proximal third of the hepaticocholedochus and absence of MPD obstruction.

On the degree of effectiveness of surgical aids for mechanical jaundice

Relevance. The problem of mechanical jaundice is the most urgent in abdominal surgery. This is primarily because the frequency of this pathology is steadily increasing, and the mortality rate does not have a distinct downward trend. Surgical tactics in case of mechanical jaundice remains multivariate, and a differentiated approach is needed for treating this contingent of patients, which is decisive in improving the results of surgical aids.The aim of the study. To improve the results of treatment of patients with mechanical jaundice of calculous etiology.Materials and methods. The analysis of the results of treatment and specially conducted studies in 554 patients with mechanical jaundice of calculous etiology was carried out. The patients underwent ultrasound, CT, and MRI. The concentration of adrenaline, norepinephrine, dopamine, 11-oxycorticosteroids, histamine, and serotonin, as well as toxic metabolic products were determined. The state of the autonomic nervous system was assessed by determining the autonomic index and mathematical analysis of the heart rate using variational pulsometry.Results. All the patients were operated on. Priority was given to stage-by-stage surgical tactics combining endoscopic decompression of the biliary tract with endoscopic papillosphincterotomy in the early stages of hospitalization and open surgical treatment after cupping the clinic of mechanical jaundice. There was a 3-fold increase in the number of endoscopic interventions. The mortality rate for the entire period decreased by 2.1 times. The reason for the results obtained is the degree of trauma of the operation. The parameters of the musculoskeletal, autonomic nervous, and sympathoadrenal systems were determined in patients divided into three groups. In the first group, primary open surgery on the biliary tract was performed, in the second — endoscopic papillosphincterotomy and abdominal surgery on the biliary tract, in the third — only endoscopic papillosphincterotomy. Endoscopic papillosphincterotomy had the most sparing effect on the functioning of the cardiovascular system and normalization of vegetative homeostasis. The volume of the surgical aid for mechanical jaundice affects the content of the sympathoadrenal system and biologically active substances in the blood plasma. When performing abdominal operations, compared with minimally invasive ones, the concentration of adrenaline, norepinephrine, serotonin, histamine, and 11-oxycorticosteroids in the blood increased by 1.5–2.5 times.Conclusion. The effectiveness and priority of minimally invasive operations for treating mechanical jaundice have been confirmed. The use of endoscopic resolution of biliary hypertension makes it possible to reduce the mortality rate against the background of a steady trend toward normalization of the indicators of the sympathoadrenal system and variational pulsometry.

Successful endoscopic treatment of giant multiple choledocholithiasis using oral transpapillary cholangioscopy and intraductal contact lithotripsy

The paper presents a clinical case of successful staged endoscopic treatment for giant multiple choledocholithiasis . Conventional surgery was contraindicated in the patient due to significant comorbidities and high anaesthetic risk . Contact lithotripsy was the basic minimally invasive treatment method . It was combined with balloon dilatation of the endoscopic papillosphincterotomy area and mechanical intraductal lithotripsy . Contact lithotripsy in oral transpapillary cholangioscopy , in combination with other modern methods for endoscopic treatment of choledocholithiasis , has a good technical and clinical effect even with giant calculi .

The role of endoscopic draining in the treatment of mechanical jaundice of different etiology on the background of chronic opistorchiasis

Purpose of the study: to conduct a comparative analysis of endoscopic retrograde transpapillary interventions in patients with chronic opisthorchiasis and obstructive jaundice of various etiologies.Material and Methods. The results of treatment of 129 patients with chronic opisthorchiasis and obstructive jaundice of various etiologies who underwent transpapillary interventions to correct bile duct, were analyzed. In order to assess the condition of patients, general clinical methods and a set of laboratory and instrumental methods were used. The study was carried out in two groups, in the first endoscopic drainage of the bile ducts was carried out, in the second – either endoscopic papillosphincterotomy with choledocholitholite extraction, or endoscopic papillosphincterotomy with bougienage of the ducts. Each group of patients was divided into subgroups according to nosology: 1 – diseases of the biliary tract; 2 – oncological diseases of the hepatopancreatic zone; 3 – pancreatitis. Laboratory indicators before and after the application of minimally invasive interventions were compared.Results. The use of various methods of transpapillary interventions normalizes indicators of bilirubin, and aminotransferases in patients by 5–10 days. Endoscopic stenting of the ducts was the method of choice with cancers of the parasitic organs. With concomitant choledocholithiasis, the endoscopic papillosphincterotomy technique with subsequent lithotripsy and lithoextraction were used. Draining operations showed a good efficacy in the treatment of jaundice in the case of impossibility of removing the calculus. Endoscopic papillosphincterotomy with ductal bougienage was the operation of choice for streak tours of the common bile duct. With purulent cholangitis, endoscopic papillotomy with the installation of nasobiliary drainage and subsequent sanitation of the bile ducts was used.Conclusion. The use of endoscopic drainage has proven itself well in patients with obstructive jaundice of tumor etiology, as well as in patients with choledocholithiasis when it is impossible to remove the calculus. This surgery allows for quick normalization of the bilirubin level.

ENDOSCOPIC TREATMENT OF BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION TAKEN FROM A LIVING DONOR

The results of our study show the efficacy and safety of the stepwise endoscopic treatment of strictures and lack of biliobiliary anastomoses in most patients. Diagnostic and therapeutic transpapillary interventions after orthotopic liver transplantation include endoscopic retrograde cholangiopancreatography, endoscopic papillosphincterotomy and, in case of necessity, balloon dilatation of the biliobiliary anastomosis along with prosthetics with plastic stents, replacing them with fully covered self-expanding metallic stents 3-6 months later. After analyzing the results of the obtained data, we may draw the following important conclusion that endoscopic retrograde cholangiopancreatography remains a highly effective method of diagnosis and treatment of all biliary complications arising from orthotopic liver transplantation from a living donor.

Эндоскопическая ультрасонография и транспапиллярные вмешательства у пациентов с парапапиллярными дивертикулами

Aim: to evaluate the possibilities of diagnosed during endoscopic ultrasound (EUS) in clarifying diagnosis of peripapillary diverticula (PD) and optimization of treatment tactics depending on the type of mutual location of the diverticulum and the major duodenal papilla (MDP). Patients and Methods: the study included 304 patients (186 (61.2%) female patients) with peripapillary duodenal diverticulum (PDD). By the criterion of the diverticulum and MDP mutual location, patients were divided into three groups: 195 (64.1%) patients with suprapapillary diverticulum, 59 (19.4%) — with diverticulum of the "butterfly" type, 50 (16.5%) — with intradiverticular MDP. Anatomical features of various diverticula types and associated pathology of periampullary region were studied on the basis of endosonography data, as well as the treatment results of biliary diseases, technical success and complications of transpapillary interventions in various types of diverticula were analyzed. Results and Discussion: patients with intradiverticular MDP were significantly older (69.8±4.4 years). In this group, the size of diverticula (21 mm) and dilatation of choledochus (18 mm) were larger. Patients in this group were significantly more commonly diagnosed with stenosis of the MDP and secondary choledocholithiasis. Indications for endoscopic papillosphincterotomy in patients with PDD were choledocholithiasis — 124 (57.1%), stenosis of the MDP — 44 (20.3%), diverticular compression in terminal choledochus — 49 (22.6%), EUS. The complication rate of transpapillary interventions did not significantly differ and amounted to 2.8%. However, the share of failures during MDP standard biliary cannulation and lithoextraction was higher in the intradiverticular MDP and amounted to 34.5% and 8.8%, respectively, which forced the use of rendezvous procedures that were used in 10 (34.5%) patients of this group. Conclusion: EUS is a highly informative method of diagnostic clarification in PD, providing direct visual inspection of the papillary zone and its echocardiogram. The use of EUS at the initial stage of diagnostics allows to significantly optimize the treatment tactics, determining the indications for transpapillary interventions and ensuring their rational choice. The greatest technical difficulties and failures are expected to occur during manipulations on the intradiverticular MDP, which forces the use of rendezvous procedures, antegrade common bile duct access and laparotomic interventions. KEYWORDS: peripapillary diverticulum, endoscopic ultrasound, transpapillary interventions endoscopic papillosphincterotomy, biliary hypertension. FOR CITATION: Belozerov V.A., Grigoriev N.N., Prokopov V.A., Belozerova D.E. Endoscopic ultrasound and transpapillary interventions in patients with peripapillary diverticula. Russian Medical Inquiry. 2023;7(5):258–263 (in Russ.). DOI: 10.32364/2587-6821-2023-7-5-3.

Modern minimally invasive technologies for the treatment of cholelithiasis

Surgical community has not yet reached any consensus on the adequate treatment of gallstone disease with combined stones of the gallbladder and bile ducts. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic papillosphincterotomy (EPST) followed by laparoscopic cholecystectomy (LCE) have been considered the optimal treatment method for the past thirty years. Thanks to improvement of technologies and experience in laparoscopic surgery, many centers in the world offer simultaneous treatment of cholecystocholedocholithiasis, i.e. LCE and laparoscopic choledocholithotomy. Transcystical and transcholedochal extraction of calculi from the common bile duct is the most common. Intraoperative cholangiography and choledochoscopy are used to assess extraction of calculi while T-shaped drainage, biliary stent and primary suture of common bile duct are used to complete choledocholithotomy. Laparoscopic choledocholithotomy is associated with certain difficulties, requires some experience in choledochoscopy and intracorporeal suturing of common bile duct. There are many unresolved issues regarding the choice of laparoscopic choledocholithotomy technique depending on the number and dimensions of stones, diameter of cystic duct and common bile duct. The authors analyze literature data on the role of modern minimally invasive interventions in the treatment of gallstone disease.

ЭНДОСКОПИЧЕСКАЯ ДИАГНОСТИКА И ЛЕЧЕНИЕ ПРОРЫВА ЭХИНОКОККОВОЙ КИСТЫ ПЕЧЕНИ В ЖЁЛЧНЫЕ ХОДЫ

Hepatic echinococcosis (HE), also known as hydatid disease in humans, is a parasitic disease prevalent in countries with a developed animal husbandry industry. The parasite mainly impacts the liver and lungs of an individual and presents itself as a cyst. Severe complications of HE are suppuration, communicating rupture of hepatic hydatid cysts (HHC) into the abdominal or pleural (through the diaphragm) cavities, adjacent hollow organs, and bile ducts. In the latter case, the ducts are blocked by HHC elements with the development of obstructive jaundice (OJ). The article presents a rare clinical case of successful treatment of a patient with HHC, complicated by a communicating rupture of hepatic hydatid cysts into the biliary tract and the development of OJ. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), endoscopic papillosphincterotomy (EPST), chitin coat extraction, and mechanical block elimination with biliary tract lavage. Keywords: Hepatic echinococcosis, communicating rupture into the bile ducts, obstructive jaundice, endoscopic retrograde cholangiopancreatography, papillosphincterotomy, chitin coat extraction.

A Case of Zipper Effect in Endoscopic Papillosphincterotomy

This article discusses a rare complication that occurred during endoscopic papillosphincterotomy for choledocholithiasis - electrosurgical effect or zipper effect. The experience of early surgical treatment of complications of endoscopic papillosphincterotomy with zipper effect is given.

Bleeding after endoscopic intervention for the major duodenal papilla (a literature review)

Endoscopic biliary sphincterotomy (EST) is the cornerstone of endoscopic retrograde cholangiopancreatography (ERCP), and bleeding is one of the most common complications after performing EST. The frequency of bleeding after EST varies greatly from 1.0 % to 48.0 %. Clinically, bleeding can range from minor to life-threatening. The aim of the work was to find out the frequency and risk factors for immediate, delayed and recurrent bleeding after EST, ways of prevention and the most effective methods of treatment for this complication based on the meta-analysis results of recent years. Conclusions. Bleeding after endoscopic papillosphincterotomy is a common complication with a mortality rate of 1.2–9.0 %. Independent risk factors are liver cirrhosis, duodenal ulcer, end-stage renal failure, hemodialysis, duration of the procedure, prior use of antiplatelet drugs, especially in patients with a low level of platelets (<100,000/μL), and elderly individuals (>80 years). The risk of bleeding after EST does not depend on the size of papillectomy, and the preventive use of proton pump inhibitors does not reduce the risk of bleeding after EST. The advantages of endoscopic papillary balloon dilatation in reducing the risk of bleeding in patients with liver cirrhosis and in individuals on hemodialysis have been proven. The use of stents (FC-SEMS) is recognized as an effective hemostatic approach to refractory bleeding after EST but is limited in using due to the high cost and additional stent removal procedure. Endoscopic application of peptide hemostatic gel is considered as a third-line hemostatic strategy for bleeding after performing EST.

Evaluation of the influence of methods of sanitation of the common bile duct on the course of the postoperative period of endoscopic papillosphincterotomy

Gallstone disease continues to occupy a leading position in terms of the number of surgical interventions in modern emergency surgery. The purpose of our study is to determine the risks of developing post-manipulation pancreatitis depending on the method of sanitation of the choledochus, to determine the dynamics of regression of hyperamylasemia and hyperbilirubinemia in patients after endoscopic papillosphincterotomy (EPST), to assess long-term results—the frequency of repeated hospitalizations and the need to perform surgical interventions for restenosis of the papilla. Materials and methods : a prospective analysis of 60 clinical cases of patients after EPST was performed. Patients were divided into 2 groups depending on the method of sanation of the common choledochus. The frequency of development of an increase in the level of blood amylase and bilirubin and the timing of regression of these indicators were assessed. An analysis was also made of repeated cases of hospitalizations and the need for interventions on the papilla. Results : the development of hyperamylasemia in the group of revision of the choledochus occurred in 23% of cases, in the group without mechanical sanitation — in 13%. Hyperbilirubinemia in the immediate postoperative period developed in 27 and 23% of cases, respectively. The terms of regression of elevated biochemical parameters were higher in the group of patients with a mechanical method of sanation of the common choledochus. Conclusion : mechanical methods of sanation of the common choledochus can increase the incidence of post-manipulation complications after EPST and increase the recovery time for normal values of biochemical parameters. To assess the longterm results of the development of papillary restonosis after EPST, it is necessary to form larger groups of patients with the possibility of conducting a multicenter study.

Application of one-stage surgical tactics treatment of acute cholecystitis in combination with choledocholithiasis

Introduction: Concrements of the common bile duct (choledocholithiasis) occur from 8% to 20% in patients with acute cholecystitis. This pathology requires simultaneous correction of the pathology of the gallbladder and the common bile duct. Methods: We retrospectively analyzed the case histories of 135 patients who underwent endoscopic retrograde cholangio pancreatography, endoscopic papillosphincterotomy, choledocholithoextraction followed by laparoscopic cholecystectomy + CHEST + LCE) for acute cholecystitis in combination with choledocholithiasis in the period from January 2016 to March 2021. Patients who underwent simultaneous treatment (ERCP + EPST + CLE + LCE under one anesthesia) were assigned to the OS group (n = 63), patients who underwent two-stage treatment (ERCP + EPST + CLE and LCE on the 3-4th day during one hospitalization) were assigned to the TS group (n = 72). All endoscopic procedures in both groups were performed by the same endoscopist using the same technique. Result: There were significant differences between the groups in terms of the duration of anesthesia, the dynamics of the decrease in the blood serum of the total bilirubin and the leukocytes range at the postoperative period, the frequency of postoperative complications and the duration of the average hospitalization in favor of one-stage treatment. 

Opportunities of using oral intraluminal laser lithotripsy for a large calculus of the common bile duct (clinical report)

There is a clinical report of successful oral intraluminal laser lithotripsy with subsequent lithoextraction of a large concretion of the common bile duct in a patient with choledocholithiasis and mechanical jaundice. For the intraluminar lithotripsy a tulium laser "Urolaz" was used with energy modes 0,025-0,05-0,1 J, up to a maximum of 0.5 J. The average power is 6-10 W. Laser exposure was carried out by pulses in an aqueous medium in order to prevent carbonation of the light guide and smoke. The effect of exposure to the concretion was manifested in its fragmentation and the formation of small particles without damage of the mucous membrane of the common bile duct. The total duration of the intervention was 45 minutes. The method is effective and safe, thus it avoids the need of endoscopic papillosphincterotomy and violation of the anatomical integrity and physiological function of the Oddi sphincter.