Purulent Cholangitis Research Articles

Endoscopic retrograde contact electro-impulse lithotripsy and lithotomy

The paper presents clinical observation of a patient with cholelithiasis and so-called “difficult” choledocholithiasis. Considering the developed complications – mechanical jaundice and purulent cholangitis, as well as large operative risk, it was decided to refrain from open surgical intervention. Traditionally-performed endoscopic stone extraction did not provide any success. Contact electro-impulse lithotripsy and lithotomy were performed. This enabled choledocholithiasis and cholangitis to be eliminated, bile ducts patency to be restored, and ensured the possibility of safe elective surgical intervention for chronic calculous cholecystitis.

The tumoral immunity state in purulent cholangitis

Objective. Complex estimation of state of the immune system tumoral chain in patients, suffering purulent cholangitis was done to determine diagnostic and prognostic immunological markers in different course of the disease.
 Materials and methods. Depending on pathological changes in biliary system of the investigated patients, they were distributed into three groups: I –cholangitis, caused by choledocholithiasis, ІІ – cholangitis in environment of cicatricial strictures, ІІІ – cholangitis in environment of performed reconstruction of ductal system. The levels of immunoglobulins A, M, G, and cytotoxical tumoral factors were investigated.
 Results. In acute course of inflammation the changes in immunoreactivity were determined, showing high levels of immunoglobulins of early immune response. In chronic cholangitis the enhanced raising of the blood serum cytotoxicity was noted, and its level connection with the disease clinical severity. Statistically significant high level of the middle molecular mass polypeptides have constituted the result of accumulation of secondary endogenic toxins with their insufficient elimination.
 Conclusion. The summarized amplitude in the immunoreactivity changes was maximally pronounced in patients with an acute course of cholangitis, demonstrating high levels of the early immune response immunoglobulins. In chronic course the signs of the immune response exhaustion dominated.

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.

Long-term observation of complex treatment of cicatricial stricture of the terminal section of the common bile duct

Corrosive stricture of the common bile duct complicated by obstructive jaundice, is a serious life-threatening disease. The stricture associated with chronic pancreatitis is difficult to treat due to fibrosis, scarring of the bile duct wall in the distal region. Preference is given to minimally invasive methods of eliminating stricture to restore the bile outflow. The presented rare long-term clinical observation of the complex treatment of corrosive stricture of the common bile duct terminal section complicated by obstructive jaundice, purulent cholangitis, coagulopathy, hemobilia, demonstrates the complexity of managing such patients, the effectiveness of the use of minimally invasive technologies.

Сlinical case of acute opsthorchiasis in endoscopy

A clinical case of one of the most common parasitic diseases in the Russian Federation, opisthorchiasis, is presented. Today, opisthorchiasis and its associated complications are an urgent problem in medicine. Parasitic invasions are in fourth place in terms of damage to public health. There is no specific clinical picture, and the predominance of latent forms makes it difficult to diagnose opisthorchiasis. Particular attention is paid to the issue of complications, the most significant of which are acute pancreatitis, purulent cholangitis, liver abscesses, perforation of the bile ducts with the development of bile peritonitis. In the chronic course of invasion, parasitism occurs in the host‘s hepatobiliary tract, production of toxic and immunogenic waste products, and disruption of cell metabolism, which is one of the factors contributing to the development of cancer of the bile ducts and pancreas. The relevance of the problem of opisthorchiasis and its complications, combined with the complex and vulnerable diagnosis of this disease (clinical, laboratory, instrumental), demonstrate the importance of finding effective methods for its detection.

CONJUGATED TREATMENT OF ACUTE PURULENT CHOLANGITIS IN ADULTS FROM 26 TO 80

Relevance. Acute purulent cholangitis is one of the severe and life threatening complications of bile tract diseases, which is an acute inflammation of the bile ducts, formed against the background of a persistent violation of bile outflow function. One of the most important causes of bile outflow failures is bile stone disease.

Transpapillary nanoelectroimpulse choledocholithotripsy under the visualization of SpyGlass imaging

The clinical case of treatment of the patient with gallstone disease complicated by phlegmonous calculous cholecystitis, choledocholithiasis, obstructive jaundice and purulent cholangitis is presented. The combination of such dangerous complications requires urgent surgical treatment, the minimum amount of which is cholecystectomy and bile duct external drainage at the first stage of treatment. In this case, the simultaneous elimination of choledocholithiasis was considered unjustifiably traumatic and not rational due to the large size of the concretion (13 mm). We also decided to refuse the wide endoscopic papillosphincterotomy. At the second stage of treatment, under the control of transpapillary choledochoscopy, nanoelectroimpulse choledocholithotripsy was performed with the destruction of a dense concretion of choledochus without damaging the surrounding tissues and the sphincter apparatus of the large papilla of the duodenum, which eliminates the likelihood of complications arising after papillosphincterotomy.

Паллиативное хирургическое лечение с применением локальной и системной фотодинамической терапии злокачественных новообразований панкреатобилиарной зоны, осложненных механической желтухой

The paper analyses the tactics of managing patients with malignant neoplasms in the pancreatobiliary area complicated by obstructive jaundice in two nosologically and clinically comparable groups of patients. The aim of the research. To evaluate the effectiveness of complex palliative treatment with the use of photodynamic therapy in patients with malignant neoplasms in the pancreatobiliary area complicated by obstructive jaundice. Material and methods. In the main group, which consisted of 41 patients, palliative complex treatment was carried out using local and systemic photodynamic therapy of neoplasms in the pancreatobiliary area complicated by obstructive jaundice, purulent cholangitis. In the comparison group, which consisted of 165 patients, palliative complex treatment of complications was carried out without the use of photodynamic therapy. Complex palliative treatment in both groups included the following surgical interventions: percutaneous transhepatic mono- and bilobar drainage of the bile ducts, stenting of the bile ducts under ultrasound and X-ray control as well as bypass biliodigestive anastomoses. Symptomatic conservative treatment included infusion, detoxification, analgesic, hepatoprotective and antibacterial therapy. Results. Against the background of local and systemic photodynamic therapy in the main group, a decrease in the largest size of the neoplasm in patients with malignant neoplasms of the pancreas from 42.5 mm to 38 mm within a week after treatment was established according to the data of multispiral computed tomography of abdominal organs with intravenous bolus contrast. The largest neoplasm size decreased from 40.5 mm to 31 mm within a month after treatment according to the ultrasound examination of the abdominal cavities. Restoration of bile excretion into the intestine in 100% of patients with malignant neoplasms of the bile ducts and the head of the pancreas was registered, as well as an increase in life expectancy of patients by more than 1 year, a decrease in the risk of complications due to a slowdown in the growth of neoplasms associated with a decrease in the concentration of the cytokine TNF-α. Conclusion. Complex treatment with the use of photodynamic therapy of malignant neoplasms of the pancreatobiliary area allows reducing the largest size and rate of neoplasm invasion and to increase the survival rate of patients.

Radical surgery for complicated cholelithiasis in elderly patients: three clinical cases

Management of complicated cholelithiasis (gallstone disease) in elderly patients is often limited to the use of only minimally invasive interventions.Case report. We report three clinical cases of gallstone disease complications in patients over 75 years old who had previously undergone minimally invasive surgery and who was refused radical surgical treatment due to comorbidity. In two patients, this led to the development of purulent cholangitis and multiple organ failure, which required emergency hospitalization. At the first stage, biliary drainage was performed; then the multidisciplinary team managed to stabilize the condition of the patient; at the second stage, biliodigestive anastomoses were formed through laparotomic access on a loop turned off by the Ru. Complete relief of symptoms was achieved and no relapse was observed.In another case, cholecystoduodenal fistula with stone migration and complete obstruction of the small intestine was found during laparotomy in an asymptomatic patient hospitalized for elective surgery.Discussion. Comorbidity should not be considered as an absolute contraindication to radical surgery of complicated cholelithiasis in elderly patients: gallstone disease complications in most cases exceed the risks of surgical intervention. Radical surgery of complicated gallstone disease in patients over 75 years old is possible in condition of patient management by a multidisciplinary team.

Minimally-invasive technologies in the treatment of choledocholithiasis complicated by biliary pancreatitis

Minimal invasive endoscopic technologies are used in the treatment of patients with biliary pancreatitis with complicated cholangitis and biliary sepsis. 56 patients were treated for the period 2014 - 2018, aged 65.5 ± 15.18 years. ERCP was performed in 31 (55,3%) patients, in 13 (23,2%) - surgical intervention was performed without contrast of extrahepatic bile ducts. Papillotomy in 52 cases (96,4%) was performed by string papilloma and in 4 (7,1%) - by needle. In all cases, subtotal papilloprotectomy was performed [1], supplemented by balloon sphincteroplasty. In the I group, the patients included patients with biliary pancreatitis clinic, in group II patients with clinic of biliary sepsis, in the III group patients with purulent cholangitis clinic, biliary sepsis and septic shock. In the 1st and 2nd groups of patients, mortality was not observed. In the 3rd group, 3 patients died (37,5%). The rest of the patients are discharged from the hospital in a satisfactory condition. A decrease in the level of markers of hepatitis cytolysis (AlAT, AsAT, GGTP, L-FABP) was observed during surgical procedures without ERCP, indicating the toxic effect of contrast on the liver parenchyma. L-FABP is a highly informative marker for hepatocyte cytolysis and can be used as a criterion for hepatic insufficiency and prognosis of biliary sepsis. The high efficiency of transpacillary endoscopic surgical techniques in the treatment of biliary pancreatitis and biliary sepsis was noted.

Minimally-invasive technologies in the treatment of choledocholithiasis complicated by purulent cholangitis

Minimal invasive endoscopic technologies are used in the treatment of patients with choledocholithiasis with complicated cholangitis and biliary sepsis. 56 patients were treated for the period 2014 - 2018, aged 65.5 ± 15.18 years. ERCP was performed in 31 (55,3%) patients, in 13 (23,2%) - surgical intervention was performed without contrast of extrahepatic bile ducts. Papillotomy in 52 cases (96,4%) was performed by string papilloma and in 4 (7,1%) - by needle. In all cases, subtotal papilloprotectomy was performed [1], supplemented by balloon sphincteroplasty. In the I group, the patients included patients with acute cholangitis clinic, in group II patients with clinic of biliary sepsis, in the III group patients with purulent cholangitis clinic, biliary sepsis and septic shock. In the 1st and 2nd groups of patients, mortality was not observed. In the 3rd group, 3 patients died (37,5%). The rest of the patients are discharged from the hospital in a satisfactory condition. A decrease in the level of markers of hepatitis cytolysis (AlAT, AsAT, GGTP, L-FABP) was observed during surgical procedures without ERCP, indicating the toxic effect of contrast on the liver parenchyma. L-FABP is a highly informative marker for hepatocyte cytolysis and can be used as a criterion for hepatic insufficiency and prognosis of biliary sepsis. The high efficiency of transpacillary endoscopic surgical techniques in the treatment of cholangitis and biliary sepsis was noted.

The Usage of Endobiliary Stents with Antiseptic Coating in the Treatment of Choledocholithiasis

Introduction: Choledocholithiasis is still an actual problem of treatment of complicated forms of cholelithiasis. The difficulties in treatment of this pathology are caused by the predominance of elderly and senile aged patients whom biliary stenting in most cases can be used as the only method of treatment. The purpose of the study is to justify the usage of endobiliary prostheses with antiseptic coating in the treatment of patients with choledocholithiasis. Material and methods: We analyzed the results of 95 patients’ treatment with “difficult” choledocholithiasis and in these casesbiliary endoprostheses were used at the first stage of curing. In 56 cases (group 1–58.4%), stenting was performed with “traditional” plastic prostheses without special coating, 39 stentings (group 2–41.6%) were performed with plastic stents, the surfaces of which were modified with 10% betadin solution. Results: The frequency of patient’s postoperative complications of the 1st group was 19.64% and 7.69% in the 2nd group. The decrease of specific complications such as early stent obturation and the development of purulent cholangitis was identified. The rate of complications in cases of endobiliary uncoated stenting using was 7.14% and 5.36% and these complications occurred in 2.56% and 2.56% in the group where Betadine coating was used. The term of serving of the biliary stents in the 2nd group (182.3±37.1 days) was significantly higher than the term of the uncoated stents (125.8±33.9 days). Conclusion: The usage of the antiseptic coating reduces the risk of developing of purulent-septic complications and increases the duration of functioning of biliary stents in patients with “difficult” choledocholithiasis.

RESULTS OF ACUTE PURULENT CHOLANGITIS TREATMENT WITH GENETIC ENGINEERING ANALOGUE OF DORNAZE-ALPHA NATURAL ENZYME

The aim: To evaluate the effectiveness of the proposed method of surgical treatment of patients with acute purulent cholangitis. Materials and methods: The research is based on the analysis of the treatment results in 104 patients with acute purulent cholangitis. The volume of surgical interventions on the biliary tract in patients was as follows: endoscopic papillosphincterotomy (EPST) + naso-biliary drainage; EPST + laparoscopic cholecystectomy; cholecystectomy + choledocholithotomy + drainage of the common bile duct. Results: The APACHE-2 scale assessment for patients in the control group was 12,80 ± 1,73, with the SOFA scale - 4,32 ± 0,31 points. Accordingly, the assessment for patients in the main group with the APACHE-2 scale is 11.76 ± 0.81, with the SOFA scale - 4.33 ± 0.79 points. The results obtained in both the control and the main group indicate that the physiological reactions of the organism to the disease, treatment, development of organ dysfunction are reflected in the integrated severity assessment scales. Conclusion: The performed analysis of clinical and laboratory results of treatment in both groups established the high efficiency of the proposed treatment method in patients with acute purulent cholangitis, which promotes the more rapid medical and social rehabilitation in this category of patients.

Possibilities of endobiliary stenting with complex choledocholithiasis

Objective: To increase the effectiveness and safety of endosurgical treatment of choledocholithiasis. Methods: The set goal is achieved by studying the causes of unsatisfactory results of lithoextractions, improving its tactics and technology. Patients with known predictors of the futility of lithoextraction were excluded from the study. Based on the study of other causes of inefficiency namely strangulation of calculi with a basket, progression of obstructive jaundice, the addition of purulent cholangitis or postpapillotomy bleeding some new tactical rules and endosurgical techniques were formulated. Their effectiveness was tested in group of patients. Results: When comparing the research and control groups, a decrease in the frequency of endosurgical treatment of choledocholithiasis was revealed. Conclusion: The effectiveness of the proposed tactical principles and technological techniques has been proved. Key words: endoscopic papillosphinctertomy, endoscopic lithoextraction, obstructive jaundice, purulent cholangitis, postpapillotomy bleeding.

Epidemiological features of the course of non-tumor mechanical jaundice (comparative clinical and statistical review)

The epidemiology of mechanical jaundice (MJ) caused by complications of cholelithiasis has its own specific historical characteristic: the first successes before the period associated with the accumulation of primary material, then – the development of additional methods of diagnosis of cholecystitis and its complications. The modern stage is connected with the introduction and development of high-tech minimally invasive technologies. The average rate of this disease is gradually increasing. This is primarily due to the introduction to the work of the surgeon, ultrasound and endoscopic diagnostics, allowing to separate a mechanical jaundice at the stage of the pathological process: extrahepatic cholestasis, stones in the bile ducts with hepatocytes and purulent cholangitis with septic manifestations. The percentages of frequency of each stage began to differ depending on the sex, age and severity of the syndrome of mutual aggravation of concomitant diseases. Complications in the form of MJ began to occur more often in men, although previously they prevailed in women. Patients with MJ in old age and old age often began to be hospitalized in surgical hospitals for operations. This led to a sharp increase in the number of patients with severe comorbidities or a combination of one or more decompensated diseases. At high figures remain indicators of complications and mortality, which do not tend to decrease.

Minimally-invasive technologies in the treatment of choledocholithiasis complicated by cholangitis and biliary sepsis

Minimally-invasive endoscopic technologies are used in the treatment of patients with choledocholithiasis with complicated cholangitis and biliary sepsis. 56 patients were treated for the period 2014–2018, aged 65,5 ± 15,18 years. ERCP was performed in 31 (55,3%) patients, in 13 (23,2%) – surgical intervention was performed without contrast of extrahepatic bile ducts. Papillotomy in 52 cases (96,4%) was performed by string papilloma and in 4 (7,1%) – by needle. In all cases, subtotal papilloprotectomy was performed, supplemented by balloon sphincteroplasty. In the I group, the patients included patients with acute cholangitis clinic, in group II patients with clinic of biliary sepsis, in the III group patients with purulent cholangitis clinic, biliary sepsis and septic shock.
 In the 1st and 2nd groups of patients, mortality was not observed. In the 3rd group, 3 patients died (37,5%). The rest of the patients are discharged from the hospital in a satisfactory condition. A decrease in the level of markers of hepatitis cytolysis (AlAT, AsAT, GGTP, L-FABP) was observe during surgical procedures without ERCP, indicating the toxic effect of contrast on the liver parenchyma. L-FABP is a highly informative marker for hepatocyte cytolysis and can be used as a criterion for hepatic insufficiency and prognosis of biliary sepsis. The high efficiency of transpacillary endoscopic surgical techniques in the treatment of cholangitis and biliary sepsis was noted.

Problematic issues of endoscopic biliary stenting

Objective. To study the results of endoscopic biliary stenting (EBS) for biliary obstruction of various genesis to determine the problematic issues of the procedure and possibility of its efficacy raising.
 Materials and methods. Experience of conduction of 5748 endoscopic transpapillary interventions in 2010 - 2017 yrs was analyzed: endoscopic papillosphincterotomy was performed in 2919 (50.8%) observations, stenting of biliary ducts - in 379 (6.6%). In 296 (78.1%) observations plastic stents (PS) were introduced, while in 83 (21.9%) – the self-expanding metallic stents.
 Results. Of 208 patients, in whom primary temporary EBS was performed for tumoral biliary obstruction, using PS, in 153 (73.6%) the next stage of treatment have constituted elective operation in 10 - 14 days after elimination of hyperbilirubinemia, signs of cholangitis, additional examination and determination of the intervention volume. Among these patients in 56 (36.6%) radical operations were performed, and in 97 (63.4%) – palliative operations. In 47 patients PS for closure of external biliary fistula (EBS) PS was introduced: in 13 (27.7%) – for tubular stenosis of distal part of common biliary duct, in 7 (14.9%) – for insufficiency of sutures of common biliary duct (after choledocholithotomy), in 14 (29.8%) – for intraoperative damages of extrahepatic biliary ducts, in 5 (10.6%) – for presence of Luschka channels, in 8 (17.0%) – for a state after hepatic resection, echinococectomy. Presence of concrements, which due to some reasons were not removed endocopically, in environment of purulent cholangitis have constituted the indication for performance of EBS in 24 (8.1%) observations, chronic pancreatitis, complicated by obturation jaundice – in 9 (3.0%). Correction of iatrogenic damages of biliary ducts with development of their partial strictures, EBF, using EBS with introduction of PS, were performed in 8 (2.7%) patients.
 Conclusion. The necessity exists to study the treatment results in patients, suffering biliary obstruction of various genesis, to determine problematic issues of the main procedures and possibilities of their efficacy raising.

MANAGEMENT OF PATIENTS WITH PURULENT CHOLANGITIS AND MECHANICAL JAUNDICE OF TUMOR GENESIS IN EMERGENCY HOSPITAL

There were analyzed results of treatment of 246 patients with purulent cholangitis and obstructive jaundice with designing and implementation of original algorithm for management in an emergency hospital with usage of minimally invasive interventions and sepsis treatment. The article is illustrated with self-findings.

The Comparative Analysis of the Effectiveness of Endoscopic Transpapillary Interventions (Literature Review)

This article presents a comparative analysis of the effectiveness of endoscopic transpapillary management in patients with choledocholithiasis. The minimal complications are achieved using classical endoscopic papillosphincterotomy. However, in some cases, cannulation can be extremely difficult (stenosis, tumor of the major duodenal papilla, the anatomical features of the major duodenal papilla) or even impossible (wedged stone), and the introduction of a guidewire into the pancreatic duct significantly increases the risk of developing postoperative pancreatitis. The desire to increase the success when performing endoscopic papillosphincterotomy with diagnostic purpose (to perform endoscopic retrograde cholangiopancreatography after failure of traditional cannulation) and for the purpose of performing transpapillary operations has naturally led to the development of new non-standard methods of endoscopic papillotomy, the introduction of new instruments – wire guides and guided cannulas. Further increase in the frequency of successful endoscopic papillotomy can be facilitated by using atypical methods of surgery. Some authors show that classical papillosphincterotomy is comparable to the method of endoscopic papillosphincterotomy with balloon dilatation in effectiveness of extracting stones from the common bile duct. However, balloon dilatation in the extraction of choledocholithiasis is preferable due to fewer postoperative complications.The authors of this article note that endoscopic management do not always solve the problem of choledocholithiasis, but still have undeniable advantages compared with the laparotomy, in which choledocholithotomy sometimes has to be expanded, and duodenotomy with transduodenal papillosphincterotomy is conducted. Literature shows that main mortality causes after endoscopic interventions in patients with choledocholithiasis were progression of purulent cholangitis, biliary sepsis, acute postoperative pancreatitis, “discharge” syndrome.

Взаимосвязь маркеров эндотелиальной дисфункции при гнойном холангите у больных с хроническим гепатитом и без хронического гепатита на фоне обтурационной желтухи

Цель. Изучение взаимосвязи маркеров эндотелиальной дисфункции при гнойном холангите у больных с хроническим гепатитом и без хронического гепатита на фоне обтурационной желтухи, выявление его раннего перехода в цирроз печени и оптимизация тактики лечения в до- и послеоперационном периоде с оценкой показателей исследуемых лабораторных тестов. Материалы и методы. Исследование проведено в отношении 15 больных с гнойным холангитом, из них у 9 больных был хронический гепатит, у 6 больных хронического гепатита не было. Из 9 больных с хроническим гепатитом 4 больным противовирусную терапию не проводили, 5 - проводили. Результаты. Непосредственные результаты проведенного лечебно-диагностического исследования свидетельствуют о сходных проявлениях эндотелиальной дисфункции при гнойном холангите у больных с хроническим гепатитом и без хронического гепатита. Всем больным с гнойным холангитом выполняли декомпрессию желчных протоков, устраняли причины обтурации, проводили дезинтоксикационную терапию. По данным корреляционного анализа показателей функционального состояния эндотелия у больных с хроническим гепатитом, получавших противовирусную терапию, улучшение отметили на 10-е сут, через 1 мес оно было более выраженным, чем у больных, не получавших противовирусную терапию. У 6 больных с гнойным холангитом без хронического гепатита своевременное хирургическое, дезинтоксикационное лечение совместно с озонотерапией привело к улучшению показателей функционального состояния эндотелия на 10-е сут, через 1 мес они приблизились к норме. Выводы. Своевременное выявление эндотелиальной дисфункции при гнойном холангите у больных с хроническим гепатитом и без хронического гепатита способствует раннему прогнозированию его перехода в стадию цирроза печени и правильному выбору тактики лечения в до- и послеоперационном периоде. Подытожив полученные данные, можно сделать вывод о том, что при гнойном холангите у больных с хроническим гепатитом целесообразно проведение противовирусной терапии до и после операции.