In the real work results of various transpapillary interventions at patients suffering from biliary stones complicated with choledocholythiasis, the existence of small concrements in the choledochus are presented. One of the most dangerous complications of biliary surgery is the development of acute pancreatitis after the transpapillary interventions both in the laparoscopic and endoscopic surgery. The analysis of materials at our clinic for the past 5 years revealed that acute pancreatitis occurs after transpapillary intervention development. The reasons for this are various complications but according to most authors, this is due primarily to the injuries of ampullar and periampular area as well as large duodenal papilla and Virsung’s duct injury which leads to inflammation of the pancreatic head parenchyma with the development of further complications.
The aim of our study was to reduce the risk of postoperative pancreatitis using balloon dilatation.
Materials and methods. During 2014 at theSumy Regional Hospital there was conducted a comparative study of laparoscopic interventions for choledocholithiasis, which included 94 patients. The age of patients was 35–75 years, mean age was (52.0±5.4) years. Urgently there were admitted (29.8%) with an attack of acute calculous cholecystitis, other patients were hospitalized in a planned manner with the presence of chronic calculous cholecystitis. The presence of jaundice with increased total bilirubin blood from 45 to 200 mmol/l was noted in 57 patients (60.6%). In the preoperative stage choledocholithiasis was diagnosed in 61 (64.8%) patients, and 26 (27.6%) patients anticipated with more probability, and 7 (7.4%) patients with choledocholithiasis diagnosis was established intraoperatively. All patients were operated laparoscopically by the standard method.
In the first group of patients that were 35 (37.2%) patients, common bile duct revision was carried out without transpapillaric interventions, and in the second group, 59 (62.7%) patients with common bile duct revision were carried out transpapillaric intervention (balloon dilatation — 28 patients, bouginage — 18 patients, pushing calculus end with the fybrocholedoscope into the lumen of the duodenum — 8 patients, ERCP and partial papillosphinctrotomia followed with lytoextraction — 5 patients). Laparoscopic intervention was ended by Pykovski drainage in 74 patients, and Kerry’s — 20 patients.
Results. In the first group there were no complications but in 4 patients of this group during the first 3–4 days after surgery there was observed a small (20–30 ml) bile leakage from catching drainages, 6 patients of this group were observed transient increase blood amylase 1–2 days after surgery that did not require significant medical correction. The second group — 47 (79.6%) patients were noted transient increase in blood amylase to 80–100 IU/l in the first 3 days after surgery. In 26 patients who performed bouginage and pushing calculus with end of the fibrocholedochoscope there was registered transient increase in blood amylase accompanied by steady increase in pressure in the ductal system of the liver, leading to increased external loss of bile from 7–14 days.
The increase in pressure in the ductal system of the liver was observed in 14 patients who were performed balloon dilatation. The pressure in the ductal system of the liver stabilized within 2–3 days. The development of acute pancreatitis with increased blood amylase 120 U/L in the second group of patients was observed in 9 cases: in two cases after partial papilotomy and ERCP followed by removal of concrements herniation, in 4 patients who were performed balloon dilatation, and in 3 patients with bouginage of distal choledochus and VDS. It should be noted that removal of calculus in the lumen of the duodenum is greatly facilitated in patients who underwent balloon dilatation, and these patients were not detected residual choledocholithiasis and unselected cases of acute pancreatitis in the postoperative period.