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.

Upper digestive hemorrhage secondary to major duodenal papilla Dieulafoy’s lesion: Case report

Introduction: Dieulafoy’s lesion (DL) is occasioned by a tortuous, persistent and large caliber artery that emerges the mucosa from the submucosa of an organ, eventually triggering gastrointestinal bleeding in the presence of eroding factors of the mucosa and arterial wall. The presence of DL has been described in many anatomic topographies and although it predominates in the upper digestive tract, the presence of this lesion exactly in the major duodenal papilla is a rare event. Objective: to report a case of upper gastrointestinal bleeding secondary to a major duodenal papilla DL. Case report: a 72 year-old female, admitted to hospital care with a clinical history of two months continuous, painless melena, multiple previous blood transfusions and symptomatic anemia. She was referred by another health service with the diagnostic hypothesis of hemobilia, suggested by two previous esophagogastroduodenoscopies. Her abdominal ultrasound and arteriography were normal. A third esophagogastroduodenoscopy evidenced active bleeding in the duodenal major papilla, and after a carefully analysis a papillar DL was diagnosed. It was treated by endoscopy with adrenaline 1:10000 injection and thermocoagulation. Following this procedure she evolved with severe acute pancreatitis due to papillitis and need of intensive care unit admission. No rebleeding was detected and hospitalar discharge occurred twenty days after hospitalization. Conclusion: The localization of a DL at the major papilla is a rare event and acute pancreatitis is a complication related to its endoscopic treatment.

Ultrasonography in diagnosis of the common bile duct pathology and pathology of the major duodenal papilla, complicated by mechanical jaundice

Mechanical jaundice is a clinical syndrome that develops due to the bile flow impairment along the bile ducts to the duodenum, remains one of the urgent problems of medicine. Of great importance among the causes of mechanical jaundice are diseases of the common bile duct and the major duodenal papilla, the diagnosis of which to this day remains a rather difficult task. The use of MRCP, ERСP, endo-ultrasonography and other highly informative bile tract imaging methods, despite great diagnostic capabilities, is associated with a number of limitations. In this regard, an important place, especially in the primary examination of patients, is occupied by transabdominal ultrasound, the advantages of which are non-invasiveness, portability, accessibility, safety, the possibility of multiple reiteration. A review of the literature presents domestic and foreign data of researchers regarding the possibility of ultrasonography in diagnostics of the common bile duct pathology and the pathology of the major duodenal papilla that are complicated by mechanical jaundice, as well as the greatest difficulties in diagnosing this pathology.

A RARE HISTOLOGICAL FINDING AFTER PANCREATICODUODENECTOMY

In this paper, we describe the case of successful surgical treatment of a rare combination of three malignant tumors of the major duodenal papilla in one patient. A 59-year-old woman presented with abdominal pain, fever, nausea, vomiting, weight loss and obstructive jaundice. After routine examination, the patient with suspected cancer of the major duodenal papilla underwent pylorus-sparing pancreatoduodenal resection. Final histology revealed a rare collision of three types of cancer in the major duodenal papilla invading the pancreatic head: moderately-differentiated adenocarcinoma (30 %), moderately differentiated squamous cell carcinoma (20 %) and poorly differentiated small cell neuroendocrine cancer (50 %), surgical resection margins were intact. Immunohistochemical analysis revealed positivity for synaptophysin, chromogranin A and cytokeratin 5/6. The tumor diameter of 2 cm and the absence of signs of locoregional spread allowed the process to be staged as T2N0M0, so the patient did not receive any adjuvant treatment. Follow-up CT performed 6 months later showed two lesions in the liver, and biopsy of one of them was performed. Metastasis of neuroendocrine cancer was histologically and immunohistochemically verified. She started first-line chemotherapy with etoposide + cisplatin.

Possibilities of CT perfusion in diagnostics of periampullary tumors

Purpose. To study the possibilities of CT perfusion (CTP) in detecting periampullary tumors depending on the anatomical localization, to compare the diagnostic efficiency with the standard CT protocol. Materials and methods. CT scan of the abdominal organs according to the standard protocol and CTP were performed in 229 patients with periampullary tumors. Results. In adenocarcinoma of the pancreas, compared with adenocarcinoma of the major duodenal papilla, BF, BV, MSI (p<0,005) were statistically significantly lower, there were no differences in MTT, TTP, and PS (p>0,005). In distal cholangiocarcinoma, compared with adenocarcinomas of the pancreas and the major duodenal papilla (MDP), the BF, BV and MSI values were statistically significantly higher, the TTP values were lower (p<0,005), there were no differences in the MTT and PS values (p>0,005). Conclusion. CT perfusion is a highly informative method for detecting and determining the anatomical affiliation of periampullary tumors with a sensitivity of 98,7%, a specificity of 98%, and a diagnostic accuracy of 98,4%.

EVOLUTION OF TREATMENT OF CANCER OF THE MAJOR DUODENAL PAPILLA

Cancer of the major duodenal papilla is a rare disease with a reported population incidence of 6 per million. Endoscopic ultrasonography and intraductal ultrasonography are useful for diagnosing tumor extension of the major duodenal papilla. However, there are no specific biochemical studies or tumor markers, and an algorithm for early diagnosis of cancer of the major duodenal papilla has not been developed. Pancreatoduodenal resection remains the main treatment method for patients with a resectable tumor. However, long-term outcomes of radical surgeries are not satisfactory, with the median survival rate of 52–113 months, and the 5-year survival rate of 30–78.8 %. The study of prognostic factors will allow the development of the effective schemes of radical treatment, a therapeutic algorithm that will inevitably increase life expectancy. Radical surgery should be integrated into multi-modal treatment. Of all the variety of prognostic factors, the morphological differentiation of the tumor is of interest. According to our data, the overall 5-year survival rate, the average life expectancy for pancreatobiliary and intestinal subtypes of cancer of the major duodenal papilla after expanded pancreatoduodenal resection, respectively, was 0 % versus 38.05 % and 9.3 ± 1.79 months versus 48.0 ± 7.69 months. An accurate morphological diagnosis is of paramount prognostic importance, since it can have therapeutic consequences; that is, morphologically oriented and specific (neo)adjuvant treatment corresponding to subtypes of cancer of the major duodenal papilla. Currently, a multi-modal approach in the treatment of cancer of the major duodenal papilla is under development. Data on the use of adjuvant therapy in the radical treatment regimen are contradictory. There are no randomized controlled trials for neoadjuvant treatment. Little attention is paid to complications of chemotherapy and radiation therapy in the neoadjuvant treatment option. According to our data, chemoembolization of the gastro-duodenal artery resulted in complications in 21.4 %, and external beam radiation therapy resulted in radiation-induced injuries in 25 %. NCC N and ESMO currently do not provide recommendations for (neo)adjuvant treatment of cancer of the major duodenal papilla.

WAYS TO IMPROVE DIAGNOSIS OF PATIENTS WITH POSTCHOLECYSTECTOMY SYNDROME

Postcholecystectomy syndrome is a symptom complex that occurs or worsens after cholecystectomy and is a functional and / or organic disorder. It often complicates the post−surgery course of gallstone disease. The presence of symptoms of the disease indicates a deterioration in the quality of life of patients, but the diagnostic examination is not always possible to detect morphological or functional changes. Thus, at present the syndrome is an urgent problem of gastroenterology and biliary surgery. Diagnostic issues with a differentiated approach to the functional or organic nature of postcholecystectomy syndrome are important for the choice of further treatment tactics. In order to improve the diagnostic algorithm taking into account the changes in the area of the major duodenal papilla, a study was conducted in 137 patients. To determine the functional disorders of the sphincter of Oddi there was used the method of ultrasound investigation of hepatobiliary area and Vater's papilla with choleretic loading on Boyden as well as the Grigoriev's methods in the absence of organic obstruction of the terminal choledochus at previous stages of examination. Morphological changes in the major duodenal papilla area were evaluated using the technique of parietal ph−impedancemetry, which was performed on the background of benign mechanical jaundice in the patients after cholecystectomy during endoscopic retrograde cholangiopancreatography prior to endoscopic papillosphincterotomy. The obtained results help to perform a differentiated approach to the patients who underwent cholecystectomy, taking into account morphofunctional changes in the area of the major duodenal papilla and allow the implementation of the selected methods to the research algorithm of patients with postcholecystectomy syndrome. Key words: postcholecystectomy syndrome, functional and organic changes of major duodenal papilla, patency of the terminal choledochus, treatment tactics.