No abstract
Background. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic biliary decompression are of the highest priority among minimally invasive procedures for the correction of the malignant obstruction of the extrahepatic biliary tracts. For this purpose, nasobiliary drainage and plastic or metal stents are used. However, it is not always possible to perform the endoscopic drainage of biliary ducts when there is a malignant obstruction. Purpose – to assess the immediate results of the use of the ERCP and endoscopic biliary decompression in malignant obstruction of the extrahepatic biliary tracts depending on the degree of obstruction. Materials and methods. A retrospective analysis of 106 cases of the malignant obstruction of the extrahepatic biliary tracts was performed. Out of 106 patients, 43 (40,6%) were males, and 63 (59,4%) were females. The age range of the patients was from 42 to 90 (68,4±11,1) years. Obstruction at the level of the major duodenal papilla was in 18 (17%) patients; at the level of the distal third of the common bile duct – in 66 (62,3%) patients; at the level of the middle third of the common bile duct – in 11 (10,4%) patients; at the level of the proximal third of the common bile duct – in 11 (10,4%) patients. Results. Out of 106 patients we managed to perform the ERCP in 94 (88,7%), and in 79 (84%) of them endoscopic drainage was successful. The complications after the ERCP were observed in 9 (8,5%) patients. In the malignant obstruction of the extrahepatic biliary tracts at the level of the major duodenal papilla we managed to perform the ERCP and restore the bile outflow in 17 out of 18 patients. In the malignant obstruction of the common bile duct, we managed to perform the ERCP in 77 (87,5%) out of 88 patients. In the obstruction at the level of the distal third, the endoscopic drainage was successful in 50 (87,7%) out of 57 patients who had undergone the ERCP. In the obstruction of the middle and proximal thirds of the common bile duct, the endoscopic drainage was successful in 12 (60%) out of 20 patients in which we managed to perform the ERCP. In the tumoral obstruction of the common bile duct, decompression at the level of the distal third was more successful (p = 0,027). Taking into consideration the obstruction of the major duodenal papilla, endoscopic biliary decompression was much more effective in the obstruction at the level of the major duodenal papilla and the distal third of the common bile duct compared to the obstruction of more proximal regions of the common bile duct (p = 0,002). In the tumoral obstruction of the extrahepatic biliary tracts at the level of the middle and proximal thirds of the common bile duct, the development of acute pancreatitis was characteristic of this process (p = 0,027). Conclusions. The performed retrospective analysis of the use of the ERCP in the malignant obstruction of the extrahepatic biliary tracts showed higher effectiveness of the endoscopic decompression in the obstruction of the distal regions of the extrahepatic biliary tracts compared with the obstruction at the level of the middle and proximal thirds of the common bile duct. Acute pancreatitis as a complication of the ERCP and endoscopic surgeries was significantly more often observed in the obstruction at the level of the middle and proximal thirds of the common bile duct.
Background. Decompression interventions under the endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice in malignant extrahepatic biliary obstruction (MEHBO). Acute pancreatitis is the most common complication of ERCP. Many studies have been performed to identify the risk factors for post-ERCP pancreatitis (PEP). However, these works in general include the analysis of ERCP in patients with various causes of biliary obstruction without subdividing patients with malignant obstruction. Purpose.The aim of this study was to determine the risk factors for PEP in patients with MEHBO. Materials and Methods. A retrospective analysis of 100 cases of ERCP in MEHBO was done. PEP was in 2 patients, and 14 patients had hyperamylasemia (HA). The following factors were analyzed: gender, age, level of MEHBO, obstruction of the main pancreatic duct (MPD), total bilirubin level, history of endoscopic papillosphincterotomy (EPST), periampullary diverticulum, successful ERCP, primary selective biliary cannulation, catheterization and/or contrast injection into MPD, Precut EPST, successful decompression. Results and discussion. Univariate analysis showed that PEP is associated with an obstruction at the level of the proximal and middle third of the hepaticocholedochus (p = 0.004) and with absence of MPD obstruction (p = 0.022); female gender (p = 0.012), obstruction at the level of the proximal and middle third of the hepaticocholedochus (p < 0.001), absence of MPD obstruction (p < 0.001), catheterization and/or contrast injection into MPD (p = 0.040) are associated with PEP or hyperamylasemia (HA); female gender (p = 0.024), obstruction at the level of the proximal and middle third of the hepaticocholedochus (p < 0.001), absence of MPD obstruction (p=0.006), catheterization and/or contrast injection into MPD (p = 0.035), successful decompression (p = 0.004) are associated with HA. Multivariate regression analysis showed that, for PEP and for PEP or HA as well as for HA, the risk factors are obstruction at the level of the proximal and middle third of the hepaticocholedochus (p = 0.005; p < 0.001; p < 0.001, respectively) and absence of MPD obstruction (p = 0.022; p < 0.001; p = 0.008, respectively). Female gender is a risk factor for PEP or HA and HA (p = 0.011; p = 0.028, respectively), and catheterization and/or contrast injection into MPD are risk factors for PEP or HA (p = 0.04). Conclusion. Development of PEP in MEHBO depends on the localization of a tumor and involvement of the pancreas. The risk factors for PEP in MEHBO are tumor localization at the level of the middle and proximal third of the hepaticocholedochus and absence of MPD obstruction.
Objective. To improve quality of diagnosis of paravesical complications in patients, suffering an acute cholecystitis, using demonstration of interrelationship of changes in the gallbladder wall histostructure and its echogram data. Materials and methods. Comparative analysis of the gallbladder wall echogram and results of the gallbladder wall morphological investigation was conducted in 520 patients with an acute cholecystitis to determine the kind of paravesical complications. Results. Morphological investigation of the gallbladder wall have shown that the gallbladder dimensions and the wall thickness enhancement are not universal characteristic features for an acute cholecystitis. To determine the kind of its inflammation (phlegmonous, gangrenous or catarral) is also impossible. In accordance to ultrasonographic criteria an acute cholecystitis diagnosis is established, аnd patho-morphologist determines the inflammation form. Sclerotic processes with overgrowth of dense connective tissue were revealed in the gallbladder wall while presence of a long-term inflammatory process. That's why in the patients, suffering an acute cholecystitis, the gallbladder wall echograms may show excessively white signal with delineated contours, but at the same time the gallbladder volume may be not changed or even reduced. This data may impact the choice of operative procedure. Ultrasonographic signs of presence of paravesical infiltrate and abscess were established as well. Conclusion. Echographic changes of the gallbladder wall indicates its inflammation, but do not give possibility to find which form it has. The gallbladder volume may be reduced in an acute cholecystitis, if inflammation occurs on background of recurrent process. The gallbladder wall demonstrates excessively white positive echographic signal, if in its structure connective tissue and collagen fibers prevail.
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