A critical analysis of the ten-year experience of using endoscopic transpapillary interventions in an urgent surgical hospital

The aim of this work was to provide a critical analysis of the ten-year experience of using transpapillary interventions in an urgent surgical hospital with a detailed study of all groups of registered complications.Material and methods. In the period from 2008 to 2018, 1188 retrograde endoscopic transpapillary grafts were performed on the bile ducts with dissection of the major duodenal papilla in a typical and atypical way on the basis of our clinic. The group of observed patients included 1188 patients with endoscopic papillosphincterotomy, including 839 women (70.6%) and 349 men (29.4%). The average age was 63.2 ± 1.25.Results. During the period, 25 complications (2.1%) were revealed when performing transpapillary interventions with dissection of the major duodenal papilla: acute pancreatitis — 10 patients (0.8%); bleeding from the opening of the major duodenal papilla — 4 (0.33%), perforation 12p. intestines — 4 (0.33%), breakage of the basket cable with wedging — 1 (0.08%), cholangitis — 1 (0.08%), overlapping with a stent of the lobar duct — 1 (0.08%). The overall mortality associated with complications is 0.25%. Based on the analyzed material, the iatrogenic index was calculated. It was 0.044. After the analysis of complications, on the basis of the data obtained, we proposed an algorithm of actions when performing transpapillary interventions.Conclusion. Based on the study, we come to the conclusion that it will not be possible to completely level the risk and avoid possible papillotomic-induced complications. In this regard, the early, preferably intraoperative diagnosis of the latter and the prompt implementation of correlating therapeutic measures are of great importance, which will undoubtedly improve the treatment results and have a positive eff ect on the outcome of the disease.

New Surgical Technique to Induce Reversible Liver Fibrosis by Surgical Closure of Major Duodenal Orifice in Dogs

This study was conducted to induce and evaluate reversible liver fibrosis in dogs by surgical closure of the major duodenal orifice. The study was performed on six healthy local adult dogs. Reversible liver fibrosis was surgically induced in all animals by surgical closure of major duodenal papilla using absorbable suture material for 60 days. Induced liver fibrosis was assessed by clinical, ultrasonographical examination, laboratory and histological methods. The clinical manifestation of the jaundiced dogs showed reduced food intake, pale-yellowish mucus membrane, inflammatory signs of the wound site and severe postoperative pain. Biochemically, there was significantly increased values of the aspartate aminotransferase, alkaline phosphatase, alanine aminotransferase, indirect bilirubin, direct bilirubin and total bilirubin especially during the first two days after surgery followed by a gradual decrease of these values until the end of the but still higher than normal values. Ultrasonographic examinations showed abnormal changes in the liver tissue such as an increase in both size and wall thickness of the gall bladder and mottled heterogeneous appearance of the liver during the first two weeks following the surgical induction of the hepatic fibrosis. Histological evaluation of liver samples revealed showed necrosis of hepatocytes and deposition of eosinophilic material, infiltration of inflammatory cells, recent thrombus in the hepatic vein, fatty change. Slight clinical, biochemical, ultrasonographic improvement was observed at 30th post-operative day. In conclusion, surgical induction of reversible liver fibrosis in dogs was an easy technique by surgical closure of major duodenal papilla and the results were confirmed by the clinical, ultrasonographical, laboratory and histological examination.

Laser papillosphincterotomy in choledocholithiasis and acute biliary pancreatitis

Objective. The radical elimination of extrahepatic biliary tract pathology in choledocholithiasis and acute biliary pancreatitis (ABP) reduces the risk of infection and eliminates the source of endogenous intoxication; so, the search of safe and effective techniques for endoscopic papillosphincterotomy (EPT) is important.Purpose: to assess outcomes of laser-assisted endoscopic papillosphincterotomy.Material and methods. 288 patients with “wedged” (n = 111) and “valve” (n = 177) choledocholithiasis and acute biliary pancreatitis were divided into two groups depending on EPT technique: in the control group, a papillotome with electrocoagulation cord was used (n = 195); in the main group, laser scalpel was used (n = 93).Results. 87 patients with “wedged” choledocholithiasis were treated with EPT and an end electrode on the wedged stone. 16 patients out of them had mild bleeding which was stopped by irrigation with epinephrine solution (1 : 10 000) followed by the targeted coagulation. The average surgical time was 38 ± 16 min. In 24 patients with rigid and edematous medial wall of the duodenum due to acute biliary pancreatitis, the proposed device plus laser technique for papillosphincterotomy were used (patent of the Russian Federation No. 2614891). There was no bleeding, the average surgical time was 24 ± 12 min. In “valve” choledocholithiasis, laparoscopic cholecystectomy (LCE) was performed; calculi from the common bile duct were removed. In 108 patients during LCE, EPT was made via an antegrade catheter. In 69 patients with anatomical and physiological obstacles caused by the major duodenal papilla, we performed LCE and EPT with laser light via an antegrade guide light made of fluoroplastics (patent of the Russian Federation No. 41594). Concrements from the common bile duct were removed with the Dormia basket.Conclusions. Laser light causes less damage, reliably provides hemostasis along the incision line on the anterior wall of the major duodenal papilla; in addition, a wedged calculus in “wedged” choledocholithiasis and a fluoroplastic light guide in “valve” choledocholithiasis reliably protect the posterior wall of the major duodenal papilla from laser light damage. Laser techniques used in EPT make the treatment of choledocholithiasis in patients with ABP having anatomical and physiological problems due to the major duodenal papilla safe and effective.

Initial experience with a homemade “hybrid-tome” for needle-knife precut in patients with difficult biliary cannulation

Background and study aims Current clinical guidelines recommend needle-knife precut (NKP) as the primary and best method for performing a biliary cannulation (BC) when simple techniques fail and the criteria are met for difficult BC (DBC). However, many endoscopists avoid or defer early NKP in favor of alternative, simpler techniques that have not been shown to be either safer or more effective. Our goal is to test a device that provides the needle-knife papillotome (NKPT) with traction capability and which can facilitate the learning and execution of NKP. Patients and methods This was a descriptive bicentric observational study of a personal cohort of patients undergoing early NKP to analyse the efficacy and safety of the technique with a “hybrid-tome” (HT) built using the isolated core of a NKPT and a conventional canulotome. Results Over a 4-year period, we performed 43 NKPs with the HT, achieving BC in one or two steps in all cases. The 100 % technical success was matched by a 95 % clinical success rate. We recorded 11 adverse events (23 %): five hemorrhages, four pancreatitis, and two cholangitis. In addition to the objective data, we confirmed that HT facilitates alignment with the duodenal papilla and the execution of pre-cutting, especially if the papilla is intradiverticular or hidden by folds. Conclusions The HT tested seems to help trained endoscopists to perform NKP, especially in some anatomic situations, which can improve compliance with the guidelines recommended for early NKP in patients with DBC.

Challenging diagnostic work-up of a massive fluid-filled structure in the cranial abdomen of a cat

A 9-year-old female, neutered European shorthair cat was presented with acute vomiting, obvious jaundice and painful enlargement of the abdomen. Icteric skin and mucous membranes in addition to severe bilirubinaemia (mainly direct bilirubin) and a large increase in liver enzyme activities were the main findings at the initial examination. Radio- and ultrasonographic evaluation revealed a massive fluid-filled structure caudal to the liver displacing abdominal organs, in particular the stomach. As this structure with a diameter of 8–10 cm occupied considerable space in the cranioventral abdomen, a detailed ultrasonographic examination of the liver and the gallbladder, and determination of the structure’s association with a particular abdominal organ was initially impossible. Via ultrasound-assisted puncture under general anaesthesia 300 ml of an almost clear fluid could be aspirated. Cytological examination revealed a cyst content-like fluid with cell detritus.Further ultrasonographic and computed tomographic diagnostics followed by abdominal laparotomy finally enabled diagnosis of a cystic dilatation of the entire common bile duct and accumulation of white bile. Histopathological examination after euthanasia (requested by the owner) identified lymphoplasmacytic cholangitis and necrosis of the duodenal papilla. The massive dilatation of the common bile duct complicated its definite diagnosis by diagnostic imaging methods. It was most likely caused by a longer-standing obstruction of the bile flow by lymphoplasmacytic cholangitis with necrosis and granulation tissue formation in the area of the duodenal papilla. An interesting but initially misleading feature was the presence of white bile. The etiology of this extremely rare condition remains obscure but in the described case a manifestation of impaired hepatocyte function secondary to biliary stasis is suspected to be the cause.

The Efficacy and Safety of Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiography in Pediatric Patients with Surgically Altered Gastrointestinal Anatomy

Balloon enteroscopy-assisted endoscopic retrograde cholangiography (BEA-ERC) is useful and feasible in adults with pancreatobiliary diseases, but its efficacy and safety have not been established in pediatric patients. We compared the success rate and safety of BEA-ERC between adults and pediatric patients. This single-center retrospective study reviewed 348 patients (pediatric: 57, adult: 291) with surgically altered gastrointestinal anatomies who underwent BEA-ERC for biliary disorders from January 2007 to December 2019. The success rate of reaching the anastomosis or duodenal papilla was significantly lower in pediatric patients than in adult patients (66.7% vs. 88.0%, p < 0.01). The clinical success rate was also significantly lower in pediatric patients (64.9% vs. 80.4%, p = 0.014). The rate of adverse events was significantly higher in pediatric patients than in adults (14.2% vs. 7.7%, p = 0.037). However, if the anastomotic sites were reached in pediatric patients, the treatment was highly successful (97.3%). The time of reaching target site was significantly longer in pediatric patients than in adult patients. This study shows that BEA-ERC in pediatric patients is more difficult than that in adult patients. However, in patients where the balloon enteroscope was advanced to the anastomosis, clinical outcomes comparable to those in adults can be achieved.