Endoscopic Papillotomy Research Articles

Difficult choledocholithiasis. Literature review

The incidence of stones in the common bile duct in patients with symptomatic gallstone disease varies significantly and depends on age, ranging from 5% to 33%. In 85—90% of cases, choledocholithiasis is effectively treated with endoscopic papillotomy (EPT) and lithoextraction, which is currently considered the standard method for managing this pathology. However, in 10—15% of cases, choledocholithiasis is technically challenging for endoscopic treatment, requiring alternative methods and specialized equipment. This research examines the epidemiological aspects related to the increasing detection rate of choledocholithiasis, which is attributed to advancements in modern diagnostic techniques. Particular emphasis is placed on etiological factors such as genetics, obesity, and dietary habits that enhance bile lithogenicity. The pathogenesis section elucidates the mechanisms underlying primary and secondary stone formation in the bile ducts and their physiological impacts, including such complications as acute cholangitis, biliary sepsis, cholestatic hepatitis, and biliary cirrhosis of the liver. Distinct focus is placed on the criteria for difficult choledocholithiasis, encompassing stone characteristics, location, altered biliary anatomy, and the patient’s general condition. Diagnostic techniques include laboratory and instrumental investigations, particularly ultrasound, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound. The treatment section emphasizes the importance of timely stone removal to prevent complications. Modern treatment options are discussed, including both conservative and surgical methods such as endoscopic procedures and laparoscopic surgeries. The significance of an interdisciplinary approach to the diagnosis and treatment of choledocholithiasis and its many manifestations is emphasized. Difficult choledocholithiasis remains a relevant issue in hepatobiliary surgery, and its effective treatment requires an individualized and multidisciplinary approach, involving endoscopic and laparoscopic technologies.

Improvement of laparoscopic interventions on the bile ducts in choledocholithiasis

Objective. To improve the technique of laparoscopic choledocholithotomy to improve the results of choledocholithiasis treatment. Materials and methods. The study covers the period from 2012 to 2022, during which 144 patients with choledocholithiasis were treated. In 120 patients, the surgical intervention was successfully performed using a fully laparoscopic approach: in 48 patients (group 1), the common bile duct was drained with a T-shaped drainage; in 34 patients (group 2), the intervention on the common bile duct was completed with a primary suture of the duct; in 38 patients (group 3), a biliary stent was inserted integrally with subsequent suturing of the choledochotomy opening. Results. In group 1, 5 (10.4%) patients had serious complications that required repeated surgical interventions: dislocation of the T-shaped drainage in 1 (2.1%) patient, development of biliary peritonitis in 4 (8.3%) patients. In the treatment of patients in group 2, a number of advantages were noted compared to the treatment of patients with T-shaped drains. The majority of patients with primary common bile duct suture were discharged on the 3rd day after surgery, and they returned to active work in 2 to 3 weeks. At the same time, 3 (8.8%) patients in this group had complications that required repeated surgical interventions: in 1 patient with multiple choledocholithiasis, bile leakage into the abdominal cavity was caused by a residual stone, in 2 patients - by papillitis and partial inflammatory stenosis of the large duodenal papilla. They underwent endoscopic papillotomy. Of the 38 patients in group 3, 32 had biliary stents that migrated to the intestine on their own. These patients had no complaints in the long term. In 6 patients, the stents remained in the ducts for 30 days after surgery. In 5 of them, endoscopic dosed papillotomy with a needle papillotome was performed, after which the stents were easily removed from the ducts. In 1 patient, a stone up to 6 mm in diameter fell out of the common bile duct along with the stent. None of the patients had signs of pancreatitis or elevated blood amylase levels. Conclusions. Laparoscopic interventions on the common bile duct allow successful removal of large and numerous calculi in one stage. Primary suturing of the common bile duct has significant advantages over the installation of T-shaped drains and allows to reduce the treatment time. In case of multiple choledocholithiasis and suspected stenosis of the duodenal papilla, it is advisable to combine primary common bile duct suture with antegrade stenting of the bile ducts.

Retrograde cholangioscopy in differential diagnosis of parasitic invasion

The authors present differential diagnosis of parasitic invasion of the common bile duct. A 52-year-old patient admitted with malignant bile duct obstruction, mechanical jaundice, cholestatic hepatitis and cholangitis. Bile duct tumor was preliminary diagnosed according to anamnesis, complaints, physical, laboratory and instrumental data. Retrograde cholangiopancreatography, endoscopic papillotomy and revision of the common bile duct were performed. There was occlusion at the level of the upper third of the common bile duct. Retrograde cholangioscopy was performed to clarify the nature of obstruction and tumor. Cholangioscopy revealed parasites in the common bile duct that required extraction. The patient was sent to the infectious disease hospital.

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.

Echinococcal Cyst Blockade — the Rare Cause of Acute Pancreatitis and Obstructive Jaundice

Aim: demonstrate an algorithm for the diagnosis and treatment of acute pancreatitis and obstructive jaundice caused by obstruction of the terminal part of the common bile duct by daughter echinococcal cyst.Key points. The article presents a clinical case of acute echinococcal obstruction of the terminal part of the common bile duct in a patient with a complicated course of liver echinococcosis. A 33-year-old man was hospitalized with epigastrium and right hypochondrium pains and jaundice. In 2019 the patient underwent the removal of a cyst in the 7th liver segment and cholecystectomy for liver and gallbladder echinococcal lesions. Laboratory research revealed leukocytosis, hyperbilirubinemia and an increase in the transaminases level. Transabdominal ultrasound showed signs of dilatation throughout bile ducts. Duodenoscopy revealed a fixed yellowish-white oval formation with transluent capsule, completely blocking bile and pancreatic juice outflow at the major duodenal papilla. After non-annulation endoscopic papillotomy, migration of the substrate (echinococcal cyst) into the duodenum was noted, active flow of bile and pancreatic secretions was restored. Oral transpapillary cholangioscopy was performed for a detailed bile ducts examination. It revealed no echinococcal cysts, residual parasitic structures or biliary tree lesions. The treatment was completed with pancreatic stenting. After complex treatment in the intensive care and surgery unit with complete condition stabilization, the patient was discharged with recommendations for further treatment in a specialized clinic.Conclusion. Migration of a daughter cyst from the echinococcal liver focus can cause acute blockade of the terminal part of the common bile duct and acute obstructive pancreatitis. The combination of clinical, radiological and endoscopic methods allows to diagnose and eliminate this rare complication of liver echinococcosis with subsequent successful treatment.

Outcome of the Endoscopic Biliary Stenting for Irretrievable Common Bile Duct Stones in an Academic Hospital – A Prospective Study

Background: Choledocholithiasis is characterized by the existence of a stone in the common bile duct. Based on findings published in the Medical Clinics of North America, around 10-15% of individuals with gallstones experience the development of choledocholithiasis. Presently, the established approach for addressing common bile duct stones involves the implementation of endoscopic papillotomy and stone extraction. The combined utilization of Dormia basket, balloon catheter, and lithotripsy achieves a success rate of approximately 90%. In cases where traditional endoscopic removal methods prove ineffective, biliary stenting plays a crucial role in the conservative management of CBD stones. Objectives: The main goal of the study was to evaluate the outcome of biliary stenting in irretrievable common bile duct stones. Materials and Methods: This observational study took place at the Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, from January 2018 to December 2018. The study included consecutive patients who were 18 years or older and diagnosed with common bile duct stones. These patients underwent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The study specifically focused on patients who received biliary stenting for irretrievable common bile duct stones, and they were enrolled as participants in the study. Results: Out of the 83 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction, 29 patients (35%) were deemed as having irretrievable stones, necessitating the implementation of stenting. Among these irretrievable stone cases, the average age was 46.69, and there was a predominance of females with 17 patients (58.6%). Of the 29 cases, 22 patients completed the follow-up. During the follow-up ERCP, a significant reduction was observed in both the average number of stones (3.14 vs. 1.9; P=0.002) and their size (16.32 vs. 12.4; P=0.005). Successful stone extraction was achieved in 14 patients (63.64%) during the second ERCP. In one patient (4.55%), spontaneous clearance of the stone occurred, while in 7 patients (31.81%), stone extraction was not possible during the second ERCP. The reduction in mean stone size was the only significant factor affecting the success of the second ERCP. However, there was no correlation found between the duration of stenting and the reduction in stone size (r=-0.193, p=0.401). Conclusion: Our study shows that repeat ERCP can successfully extract stones regardless of stenting duration. Unlike Western data, we emphasize the effectiveness of endoscopic biliary stenting in a context with limited access to advanced techniques, where initial stone extraction rates are lower. This approach is particularly beneficial for patients with stone sizes over 15 mm, avoiding the need for complex surgical procedures.

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.

Migration of biliary endoprosthesis - case report and literature review

Introduction. The most common indications for placing a biliary stent are benign and malignant diseases that interfere with the normal flow of bile through the extrahepatic bile ducts. This procedure carries the risk of developing early and late complications. Case outline. We present a case of a 63-year-old female patient admitted to our hospital for additional diagnostics and treatment. At admission the patient reported the onset of the following symptoms several days prior to hospitalization: severe abdominal pain, predominantly in the upper quadrants, nausea, vomiting, and icterus. With the initial idea of carrying out non-surgical treatment of this condition, the patient was referred for endoscopic retrograde cholangiopancreatography for the purpose of endoscopic calculi extraction. However, due to technical difficulties, the aforementioned procedure was not carried out. Instead, upon endoscopic papillotomy, a plastic biliary stent was placed. The second day after the procedure, the patient reported passing dark stools. After that, an esophagogastroduodenoscopy was performed, which revealed a biliary stent in the duodenum, but without active bleeding. As part of the same procedure, the biliary stent was removed, and the next day the patient underwent surgical treatment. Conclusion. In order to prevent and reduce the incidence of adverse effects and complications, special caution should be applied when performing the procedure. It is even more important to timely recognize the occurrence of complications and to treat them promptly, in order to achieve the best treatment outcomes possible.

Cholecystectomy before, simultaneously, or after ERCP in patients with acute cholecystitis: A protocol for systematic review and/or meta analysis.

Introduction:Cholecystectomy is the intervention of choice for treating acute cholecystitis; when conservative management does not work, it operates on the patient outside the critical condition. It can be performed together with or after endoscopic papillotomy through endoscopic retrograde cholangiopancreatography (ERCP) when it is concurrent with a situation of cholechodocolithiasis or when there is compression and consequent increase in pressure in the bile duct caused by a calculus jammed in the vesicular infundibulum (Mirizzi’s syndrome), with or without jaundice, fever, and pain in the right hypochondrium (Charcot’s Triad), which can progress to sepsis of biliary origin. This review aims to assess whether the timing of cholecystectomy (before or after ERCP) interferes with the postoperative period and clinical outcome in patients with acute cholecystitis.Methods and Analysis:By searching the MEDLINE/PubMed, Embase, Web of Science, ScienceDirect, ClinicalTrials.gov, CINAHAL, Latin American and Caribbean Literature in Health Sciences, Scopus and Cochrane Central databases, Controlled Trials Registry Randomized clinical trials will be searched to analyze whether ERCP performed before or after open or laparoscopic cholecystectomy (LC) in patients with acute cholecystitis is beneficial or not, through the analysis of postoperative complications. No language or publication period restrictions will be imposed. The primary outcome will be postoperative complications (postoperative morbidity and mortality). Four independent reviewers will select the studies and extract data from the original publications, with a fifth reviewer in case of disagreement regarding the inclusion or not of particular research in the present review. The risk of bias will be assessed using The Risk of Bias 2 (RoB 2.0) tool, and the certainty of evidence will be evaluated using the grading of recommendations assessment, development, and evaluation. Data synthesis will be performed using the Review Manager software (RevMan V.5.2.3). To assess heterogeneity, we will calculate the I2 statistics. Additionally, a quantitative synthesis will be performed if the included studies are sufficiently homogeneous.Ethics and Disclosure:Since the present study will review secondary data, previously published and scientifically validated, it will not be necessary to obtain ethical approval. The results of this systematic review will be published in a peer-reviewed journal.Prospero registration number:International Prospective Registry of Systematic Reviews (PROSPERO) CRD42021290726.

X-ray Surgery for Iatrogenic Bile Duct Injury After Laparoscopic Cholecystectomy (Single Center Experience)

IM OF STUDY To show the possibilities of antegrade X-ray surgical techniques in the treatment of iatrogenic bile duct injuries after videolaparoscopic cholecystectomy.MATERIAL AND METHODS The study included 24 patients with “minor” and 20 patients with “major” (according to Strasberg) iatrogenic injuries of the extrahepatic biliary tract. Antegrade endobiliary intervention was performed in 26 patients, including the “bridge-procedure” variant preceding the reconstructive surgery. Endobiliary drains were maintained during the reconstructive surgery and in the early postoperative period to control the viability of the anastomosis.When a stricture of the biliodigestive anastomosis (BDA) was detected, balloon dilatation of the anastomotic area was performed. In the subgroup of “minor” injuries, external drainage of the subhepatic biloma in 18 people were supplemented with endoscopic papillotomy in 12 cases.RESULTS In all patients with “minor” injuries of the biliary tree, X-ray surgical techniques were effective. In 11 patients with “major” bile duct injuries, cholangiostomy drainage was gradually transformed into external-internal drainage. In 2 trauma cases of classes D and E temporary antegrade stenting of the duct injury area with a coated self-expanding endobiliary stent was performed. The follow-up period after removal of the antegrade frame drainage ranged from 8 months to 14 years. There were no stricture or failure of BDA.CONCLUSION Short-term external biliary drainage, including the use of rendezvous techniques, may be suffi cient to eliminate the failure of the cystic duct stump. Cholangiostomy drainage, temporary endobiliary stent allow preparing the patient for reconstructive intervention. Drainage marking of the damaged area facilitates the verifi cation of tubular structures in the reconstruction area. Preservation of drainage after reconstructive intervention is the prevention of failure of the biliodigestive anastomosis in the early postoperative period, the development of its stricture in the long term.

Surgical Treatment of Patients with Acute Pancreatitis in Sterile Stage 
 and in Biliary Etiology of the Disease

The main indication for surgical treatment in acute pancreatitis (AP) is infected necrosis in the late phase of the disease. However, some patients require surgery in the sterile stage including the earliest period. In sterile necrosis interventions are associated with the risk of infection and increased mortality, being the responsibility of a surgeon. Patients with biliary AP often require early interventions and specific tactic regarding the pathology of the biliary tract. The review analyses recent studies and modern practical recommendations on the surgical treatment of patients with AP in the sterile stage and in biliary etiology. Obstruction of bile duct and cholangitis, enzymatic peritonitis, abdominal compartment syndrome caused by ineffective conservative measures, massive pancreatogenic accumulations with the threat of a rupture into the abdominal cavity, pain syndrome, compression of the adjacent organs often resulted from the disconnected pancreatic duct syndrome require invasive interventions to prevent the development of infectious necrosis. A number of questions have an ambiguous solution. The threshold level of intra-abdominal pressure, the rate of its increase, or other apparent criteria for the implementation of surgical decompression and the choice of decompression technique for abdominal compartment syndrome have not been stated. The optimal timing and the priority method of drainage in the disconnected pancreatic duct syndrome remain uncertain. The management of patients with biliary acute pancreatitis regarding prophylactic endoscopic papillotomy is controversial. Further, well-designed research studies involving surgical treatment of patients with acute pancreatitis are needed.

Using air cholangiography to reduce postendoscopic retrograde cholangiopancreatography cholangitis in patients with malignant hilar obstruction.

Cholangitis after endoscopic retrograde cholangiopancreatography (ERCP) is a major problem for patients with hilar biliary obstruction. To date, it remains unclear whether air-contrast cholangiography (ACC) can reduce cholangitis in these patients. For this reason, our study assesses the efficacy of reducing cholangitis through ACC. This paper presents a retrospective study conducted at a tertiary university hospital. We enrolled patients who were diagnosed with hilar structures and underwent ERCP between January 2012 and December 2018. From 2015 onwards, ACC was performed following the successful selective cannulation into the dilated intrahepatic bile duct of these patients. The primary aim was to assess patients with cholangitis in both an ACC group and iodine contrast cholangiography (ICC) group. This study included 80 patients, 35 of whom received ACC and 45 who received ICC. There were no differences between the 2 groups in terms of the number of patients who underwent endoscopic papillotomy, endoscopic nasobiliary drainage, endoscopic biliary stent placement, or other technical procedures or complications. A total of 19 patients (23.8%) presented with fever (cholangitis) after the ERCP procedure (4 ACC, 15 ICC; 11.4% vs. 33.3%, respectively; P=0.03). One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP. Among the other 18 cholangitis patients, 8 (1 ACC, 7 ICC) were treated with additional ERCP or percutaneous transhepatic biliary drainage (PTBD), while the remaining 10 only received antibiotics. One patient in the ICC group who obtained a plastic stent for palliative drainage died 2 weeks post-ERCP. We found that ACC significantly reduced the incidence of cholangitis in patients with hilar obstruction.

Management of Choledocholithiasis - Should We Remove the Bile Duct?

Retrieval of stone by endoscopic papillotomy, laparoscopic choledochotomy or open choledochotomy is the treatment of choice for choledocholithiasis. Published literature shows that the recurrence rate is 4% to 24% with existing method of treatment. We have treated 8 patients who admitted with recurrent choledocholithiasis in the department of Hepato-Biliary-Pancreatic and Liver Transplant Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh in the period of January 2016 to December 2019. None had intrahepatic duct abnormality or stones. All patients underwent either ERCP stenting, open choledocholithotomy or both 16 to 84 months back. Management policy is designed and outcome is observed on these patients. There were 3 males and 5 females; age ranges 18 to 60 years. The common bile duct (CBD) diameter of all patient ranges from 15 to 24mm. The shape of CBD is different from normal variant; S shaped, saculated, grossly dilated with terminal narrowing. Considering the anatomical abnormality and recurrence of disease we have removed the abnormal part of common bile duct along with stones and the operation was completed by Roux-en-Y hepaticojejunostomy. All patients were completely symptom free for 6 to 48 months after surgery. Removal of abnormal part of common bile duct with reconstruction in the form of Roux-en-Y hepatico-jejunostomy may be considered for treating choledocholithiasis with abnormal CBD (abnormally dilated, abnormally shaped, angulated or sacculated) however, long-term follow up is required for final comment.

ИЗМЕНЕНИЕ ФИЗИКО-ХИМИЧЕСКИХ СВОЙСТВ ЖЕЛЧИ В ПРОЦЕССЕ ВОЗНИКНОВЕНИЯ И МАНИФЕСТАЦИИ ХОЛАНГИТА. ОСТРЫЙ ХОЛАНГИТ: ВОЗМОЖНЫЕ МЕХАНИЗМЫ ЗАПУСКА

Objective. To determine the possible triggering mechanism for the development and manifestation of acute suppurative cholangitis based on the study of the rheological, physical and chemical properties of bile. Methods. The bile of choledoch was studied inpatients (n=41) with calculous obstruction of the biliary tract, 25 of them had clinical picture of cholangitis. For comparison, 32 patients with asymptomatic choledocholithiasis were examined. Bile sampling was performed in each patient twice: the first bile intake was obtained during duodenoscopy and cannulation of the major papilla of the duodenum and endoscopic papillosphincterotomy and the second portion - during a follow-up examination three days after the endoscopic papillotomy. The biliary pH, viscosity, the amount of solids in it, the concentration of primary bile acids, microbial contamination and the intraductal pressure were studied. Results. For the first time, it has been hypothesized that a reduced concentration of bile acids in the bile causes a subsequent chain of triggering and manifestation of acute cholangitis. In the first bile intake the concentration of bile acids is three fold decreased in patients with acute cholangitis in comparison with the patients of control group, and in the second case it reliable increased but was lower than in the control group. It was a small amount of bile acids caused sedimentation of a colloidal bile solution, increased its viscosity and amount of dry sediment, caused precipitation and sludge. This chain process caused the instantaneous inclusion of concretion in sludge and acute obstruction of the choledoch. As a result of bacterial contamination, the microbial dissemination of bile increases by 10<sup>3</sup>-10<sup>4</sup> times, the choledoch becomes like an abscess. Endoscopic papillosphincterotomy breaks this chain and surgical management is the definitive mode of treatment for decompression and biliary track sanitation. Conclusion. A decrease of bile acids in the content of the bile causes a chain process of sedimentation, the formation of sludge and a complete block of the choledoch, which is the primary trigger for cholangitis. What this paper adds Scientific and theoretical principles which in their essencedetermine the possible mechanism of the development of cholangitis due to choledocholithiasis have been developed. The physicochemical properties of bile play a decisive role in the triggering mechanism of cholangitis. Reduction of the synthesis of bile acids in the liver or their resorption in the intestine starts an avalanche-like process of sedimentation in the micellar solution of bile in the choledoch, sludge with the stones appears, the pH decreases, intraductal pressure rises, as a result of bacterial infection microbial contamination the microbal dissemination increases by 10<sup>3</sup>-10<sup>4</sup> fold.

Bile Duct Injury: Surgical Use of Endobiliary Stents for the Management in Emergency Situations

This study reviews bile duct injuries (BDI) most commonly found in our setup and a novel technique of endobiliary stent usage for management in emergency situations leading to significantly less morbidity and mortality. A total of 211 patients were analyzed out of 214 BDI. All the data regarding demographic details, time of injury, time to referral, surgeons’ perception of anatomy, anatomical variance, and the type of presentation were collected. We propose a new technique and management guideline in the current era of endoscopy and surgery together for the treatment of BDI and benign biliary stricture. We have observed that the mean age was 45.5 years. Out of 211 cases, 175 were after laparoscopic cholecystectomy. Exploration and external drainage of bile was done in initial 12 patients, out of which 3 patients had a combined endobiliary surgical internal stent and T tube. Later on, all patients (38) were internally drained with endobiliary stents. All patients of minor bile duct injury were managed with endoscopic retrograde cholangiography and papillotomy, and endobiliary plastic stenting. Overall, 76% of patients with biliary laceration and segmental injury (less than 1 cm) were managed with endoscopic stent techniques, without definitive surgery. Only 24% of the patient with minor or less than 1-cm laceration group of patients needed hepatico jejunostomy (HJ) along with all major-type bile duct injuries. We propose the use of an endobiliary plastic stents for internal drainage and repair of BDI in emergency and intraoperative situations in order to avoid long-term external drains as well as nutritional and electrolytes issues following high-output biliary fistula. Furthermore, it prevents the progression of biliary stricture.

Endoscopic Biliary Large Balloon Dilation Lithotripsy for Giant and Impacted Stones Removal: A Western Series

Background: Endoscopic removal of packed, large, or impacted stones, in which a basket cannot be deployed or is unable to grasp the stone(s), is challenging and inevitably leads to repeated procedures such as stent insertion and extra- or intracorporal lithotripsy. In this study, we describe the results of an alternative stone disintegration technique in a considerable series of patients using an esophageal/pyloric balloon for stone fragmentation or making working space in the bile duct to allow the deployment of the basket, a technique we call endoscopic biliary large balloon lithotripsy. Methods: We retrieved data from 1,429 endoscopic retrograde cholangiopancreatographies (ERCPs) from 2 prospective trials performed between 2014 and 2019. Patients with difficult bile duct stones, in which a balloon dilator up to 15 mm was used to crush or increase the working space parallel to the stones in the common or hepatic duct, were included in the study. Results: From the 1,429 ERCPs, 299 had difficult stones (>1 cm, impacted or multiple stones). Large balloon lithotripsy was employed in 46 cases after endoscopic papillotomy and endoscopic biliary large balloon dilation with failed attempted balloon or basket stone(s) extraction. Failure to clear the bile duct at first ERCP occurred in 4 cases (91.3% of success). Complications were observed in 5 patients (10.8%; 1 perforation, 1 pancreatitis, and 3 bleedings), who were treated conservatively. Conclusions: Large balloon lithotripsy, in order to crush the stones or make working room for baskets or balloons in the bile duct, is an effective, safe, and low cost technique for impacted, packed, or giant bile duct stones.

Minimally invasive surgical interventions in the treatment of severe acute pancreatitis

To improve the outcomes in patients with severe destructive pancreatitis undergoing minimally invasive surgery. There were 482 patients with acute destructive pancreatitis for the period from 2007 to 2016. Non-infected acute destructive pancreatitis was diagnosed in 58% (n=280) of patients, infected pancreatic necrosis - in 42% (n=202) of patients. Minimally invasive technologies were used in the treatment of purulent complications of destructive pancreatitis: endoscopic papillotomy, percutaneous puncture of fluid accumulations, ultrasound- and X-ray-assisted drainage of abscesses and retroperitoneal phlegmon. There were 688 drainage surgeries in 92 patients with infected pancreatic necrosis: US-assisted Seldinger drainage - 599 (87%), single-stage drainage - 89 (13%) cases. Percutaneous transfistular retroperitoneal interventions were made in 72 patients (one intervention - 29 patients, redo procedures - 43 patients). Complications associated with minimally invasive procedures developed in 2.7% (19) of cases. Six patients required laparotomy. Mean length of hospital-stay was 36.5 days. Mean rate of restitution of post-necrotic areas was 37.7 days. Minimally invasive procedures reduce overall mortality up to 6% in patients with acute pancreatitis and up to 14% in those with destructive forms of inflammation.

Endoscopic service specifics in the Filatov’s State Clinical Hospital 15 of the Moscow Health Care Department for new coronavirus COVID-19 epidemic and the re-profiling of the regular hospital into an infectious hospital. First results

<h3></h3> В статье описаны сложности, с которыми столкнулась эндоскопическая служба ГКБ №15 им. О.М. Филатова во время перепрофилирования под «ковидный» госпиталь: нехватка кадров, сложности работы в средствах индивидуальной защиты. Подробно указаны меры, которые были предприняты в отношении эндоскопической службы: прекращение плановых эндоскопических исследований, усиление эндоскопических бригад дополнительными сотрудниками во время проведения сложных манипуляций, исключение из пользования фиброволоконных аппаратов. Описаны результаты проведенных эндоскопических папиллотомий, литоэкстракций, эндоскопического гемостаза при кровотечениях. Сделан вывод, что в результате проведенных реформ эндоскопическая служба смогла в полном объеме выполнять поставленные задачи.

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.

Cholecystectomy after Endoscopic Papillotomy for Choledocholithiasis in the Elderly—Is It Necessary?

Although elective laparoscopic cholecystectomy is the accepted strategy after endoscopic retrograde cholangiopancreatography (ERCP), papillotomy, and common bile duct (CBD) clearance, the decision to perform a cholecystectomy in high-risk elderly comorbid patients remains subjective and is controversial. The aim of this study was to examine the outcome of elderly patients with cholecystectomy deferral after successful initial endoscopic removal of CBD stones. The study examined a retrospective patient database, which included all patients aged &gt;60 years who underwent an ERCP for CBD stones at the Chaim Sheba Medical Center. The study cohort was divided according to whether a subsequent cholecystectomy was performed and also by age 60 to 80 or &gt;80 years. All biliary-related complications were recorded. The primary outcome measures were biliary complications, perioperative and periprocedural mortality, CBD stone recurrence, and the need for future surgical intervention. There were 111 patients (mean age 79.4 ± 9.1 years) who underwent ERCP with follow-up. After excluding 11 patients, 100 patients were left for analysis, 46 of whom underwent a cholecystectomy and 54 were observed without operation. There were significant longer term biliary complications in five of the operated patients (10.9%) and in four of the unoperated cases (7.4%). All biliary-related complications were managed successfully by conservative means except for one fatality in the nonoperated group. Biliary-related complications after successful ERCP for CBD stones were unaffected by surgery but were more commonly observed in older cases. A watch and wait policy may be justified in elderly comorbid patients.