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 >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 >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.

Timing of the termination of mechanical jaundice after antegrade and retrograde decompressive surgeries in mechanical jaundice of various genesis

Aim: to determine in a comparative aspect the effectiveness of various minimally invasive decompressive operations in mechanical jaundice of different genesis. Materials and methods. In 135 patients with mechanical jaundice, the rate of bile duct resolution after cholecystostomy and percutaneous cholangiostomy was studied on the background of pancreatic head tumor. In 643 patients with obstructive bile duct disease in cholelithiasis, timing of the termination of jaundice after minimally invasive retrograde (endoscopic papillosphincterotomy (EPT) and EPT with transpapillary drainage) and percutaneous antegrade (cholecystostomy and cholangiostomy) of decompressive operations was studied. Result. Upon cholelithiasis and hyperbilirubinemia less than 100 μmol/l, jaundice is terminated after both variants of retrograde decompression within 3–5 days, antegrade interventions increase these terms by half. Comparison of retrograde and antegrade decompressive surgeries in mechanical jaundice of medium and severe degree on the background of cholelithiasis indicates that the rate of termination of bile stasis is the highest after EPT with transpapillary drainage. Isolated EPT and percutaneous cholangiostoma with medium-grade gallstones increase the duration of jaundice termination by an average of one week. Upon hyperbilirubinemia more than 200 μmol/l, cholangiostomy is not worse than transpapillary drainage. The longest termination period of obstructive jaundice (28–30 days) is observed after superimposition of microcholecystostoma. In patients with jaundice of a mild degree of tumor genesis, no differences in the results were revealed after both variants of percutaneous decompression. Upon hyperbilirubinemia above 100 μmol/l, when cholangio- and cholecystostomy were compared, a higher rate of decrease in serum bilirubin was observed after percutaneous interventions with a cholecystostomy. Conclusion. At all severity levels of mechanical jaundice on the background of cholelithiasis, the best way of decompression is endoscopic papillotomy with transpapillary drainage. In obturation bile stasis upon the pancreatic head tumor, the best decompressive effect is observed after percutaneous cholecystoostomy.

Early or delayed laparoscopic cholecystectomy after endoscopic cholangiopancreatography and papillotomy- does it make a difference?

Background Endoscopic retrograde cholangiopancreatography with endoscopic papillotomy (ERCP/EPT) followed by a cholecystectomy is a standard treatment of common biliary duct stones. It is unclear, however, what is the optimal time interval between ERCP/EPT and cholecystectomy. The primary aim of our study was to evaluate our current practice where patients are mostly operated one to three months after ERCP/EPT. The secondary aim was to determine the optimal timing for the cholecystectomy after ERCP/EPT.Methods A retrospective analysis of 117 patients who underwent a preoperative ERCP/EPT followed by a cholecystectomy was performed. Associations between demographic characteristics, type and duration of operation, conversion rate, postoperative complications and interval time were tested using multiple linear regression. The optimal interval was studied by drawing receiver operating curve (ROC) and studying the area under curve (AUC).Results The time interval between cholecystectomy and ERCP/EPT was not associated with the number of conversions to open surgery, duration of the operation or postoperative complications. There was no statistically significant association between any independent variable and time interval. No threshold interval could be found that would discriminate whether a patient had either operation conversion or complications or not.Conclusion No statistically significant associations between the timing of cholecystectomy after ERCP/EPT and the rate of conversions, complications or operation duration are seen in the group. Our current practice is safe, as the time interval in our study does not affect the rate of conversions, postoperative complications or operation duration. Based on the results of our study, no recommendations regarding the optimal time for the surgery can be given. Larger prospective randomized trials are needed.

Antegrade X-ray surgical interventions in patients with choledocholithiasis in case of failed endoscopic procedures

Objective. To analyze safety and efficacy of X-ray surgical treatment of choledocholithiasis in case of failed endoscopic procedures. Material and methods. A retrospective analysis included 195 patients with choledocholithiasis who underwent X-ray surgical treatment. Primary X-ray surgical intervention was antegrade cholangiostomy. Data of antegrade cholangiography were used to determine type of endobiliary intervention. Antegrade mechanical and pneumatic choledocholithotripsy and lithoextraction, balloon dislocation of stones of the common bile duct into duodenum or jejunum, lithoextraction using rendezvous technique after endoscopic papillotomy through transpapillary drainage tube or a wire were applied. Results. Puncture and drainage of non-dilated bile ducts were successfully performed in 30 (15.4%) patients. There were 212 procedires of cholangiostomy in 195 patients including redo interventions. Complications after cholangiostomy were absent in 92.9% of cases. Minor complications occurred in 7.1% of cases. Antegrade mechanical and pneumatic choledocholithotripsy and lithoextraction was performed in 118 (98.3%) patients. Balloon dislocation of stones of the common bile duct into duodenum was applied in 52 (81.3%) patients. Lithoextraction using rendezvous technique after previous endoscopic papillosphincterotomy was performed in 12 (60%) patients. Six patients underwent transpapillary external-internal drainage of common bile duct. Five patients had stricture of biliodigestive anastomosis complicated by cholelithiasis. Lithotripsy and lithoextraction through antegrade approach or dislocation of stones into jejunum after previous balloon dilatation were performed in these patients. Postoperative mortality was 1.5%. Minimally invasive techniques were absolutely effective for choledocholithiasis in 187 (98.9%) patients. Conclusion. Antegrade X-ray surgical management is effective and safe in patients with choledocholithiasis and unsuccessful previous endoscopic procedures. Integral efficiency of antegrade management of cholelithiasis was 88.8%.

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.

SOME FEATURES OF CHOLESTASIS IN CANCER PATIENTS DURING THE REDUCTION OF LIVER FUNCTIONAL RESERVES

Purpose. To determine the indications for the supra - and transpapillary externally-internal drainaging of the biliary tree in case of jaundice syndrome. Material and methods. The results of minimally invasive treatment of 246 patients with external-internal drainage of the biliary tree were analyzed. Among patients with proximal tumor block the external-internal drainage is made in 92 cases, in 42 (45,7%) out of them in suprapapillary embodiment and in 50 (54,3%) - via transpapillary approach. In 154 cases with distal tumor (obstruction peripapillary cancer) transpapillary drainage was performed. Results. The technical success of the external-internal drainaging was achieved in 242 patients (98,4%). It was failed to pass the duodenum in 4 patients with the cancer of common bile duct (3) and cancer of papilla of Vater (1). There was no complications related to the technique of external-internal drainage. In 18 patients (8,8%) out of 204 with transpapillary location of the drainage, we were forced to temporarily return to full outer bile outflow because of acute cholangitis. The syndrome of an acute blockade of the papilla of Vater arising after transpapillary external-internal drainaging required endoscopic papillosphincterotomy in 42 (84%) out of 50 patients with proximal tumor block bile outflow and in 7 (4.5%) out of 154 patients with peripapillary cancer. Conclusion. Suprapapillary and transpapillary embodiment of the drainage are equivalent in terms of the efficacy of cholestasis elimination. Syndrome of an acute blockade of papilla of Vater is the most often complication of the transpapillary external-internal drainage requiring the carrying out of endoscopic papillotomy «on drainage». This syndrome arises very frequently in a case of transpapillary external-internal drainage due to the proximal tumor obstruction of the biliary tree. The risk of acute cholangitis due to regurgitation after manipulation is absent in the suprapapillary location of the external-internal drainage, and with its transpapillary position is realized only with a concomitant violation of the outflow of bile.

The history and clinical value of intraluminal endoscopy of digestive tract

The article presents periods of development of intraluminal endoscopy in general. Especially, the input of national specialists is considered since their works yield not to works of foreign specialists. The intraluminal endoscopy, prior to becoming independent clinical direction as effective technique of diagnostic and treatment of various diseases, - passed long and thorny path from the first invention of P. Bozzini in 1807 to our time of digital endoscopy. The modern arsenal of endoscopic methods includes biopsy, radiopaque endoscopic through-papillary interventions (endoscopic retrograde pancreocholangiography, endoscopic papillotomy), endoscopic electroexcisio of neoplasms of gastrointestinal tract, techniques of hemostasia, fistuloscopy, chromoendoscopy, endoscopic ultrasonography, narrow band endoscopy, balloon-assisted and capsular enteroscopy, etc. The intraluminal endoscopic surgery under certain diseases became alternative to common surgical operations though its active development as a new direction was apprehended negatively by many doctors and heads of clinics.