The place of transpapillary endoscopic interventions in complicated acute cholecystitis

Objective. To determine the need and role of transpapillary endoscopic interventions in acute cholecystitis complicated by the main bile ducts pathology based on refined diagnostics using modern radiology examination methods.

Materials and methods. The experience of treatment of 1137 patients operated on for acute cholecystitis during the last three years was analyzed. A differentiated approach for the use of highly informative methods of radiology diagnostics was based on clinical, anamnestic, laboratory and ultrasound data. In the selected groups of increased risk of bile duct pathology, endoscopic ultrasonography and magnetic resonance cholapgiopancreatography were used to clarify the diagnosis. The need for these studies was substantiated in 23.4% of cases. Based on the data obtained, indications for minimally invasive interventions aimed at decompression and correction of pathological changes in the biliary tract were formulated. They were performed in 182 (16%) patients, mainly by the endoscopic transpapillary route. Results. The need for a detailed assessment of clinical, laboratory, and ultrasound data is shown, indicating a possible biliary tract pathology and justifying the use of high-tech methods of radiology diagnosis. The options of decompression interventions, their rational sequence and combinations in acute cholecystitis complicated by bile ducts pathology are considered. Attention is focused on the need for careful monitoring of the effectiveness of interventions with a view to timely correction. Using the proposed diagnostic and treatment algorithm, the mortality rate was 0.26%.

Conclusion. In acute cholecystitis, a detailed assessment of clinical, laboratory, and ultrasound data allows us to identify the “alarming” symptoms of a possible bile ducts pathology. These patients require an in-depth assessment of the state of the biliary tract using high-tech non-invasive diagnostic methods — endoscopic ultrasonography or magnetic resonance cholangiopancreatography. The detected changes (choledocholithiasis, stenosis of large papilla of the duodenum) should be eliminated by endoscopic transpapillary interventions as the first stage of treatment before removal of the gallbladder.

1. Galperin E.I., Vetshev P.S. Rukovodstvo po khirurgii zhelchnyh putej [Guidelines for biliary surgery]. Moscow: VIDAR-M, 2006. 365 р. (In Russian)

2. Ermolov A.S., Ivanov P.A., Blagovestnov D.A., Demchenko S.S., Novosel S.N., Almakaev M.R. Treatment policies for acute cholecystitis complicated by choledocholithiasis. Pirogov Russian Journal of Surgery / Khirurgiya. Zhurnal imeni N.I. Pirogova. 2014; 1: 10-14. (In Russian)

3. 2016 WSES Guidelines on Acute Calculous Cholecystitis. Endoscopic surgery = Endoskopicheskaya khirurgiya. 2017; 6: 25-71. https://doi.org/https://doi.org/10.17116/endoskop201723625-71 (In Russian)

4. Fedorov V.E., Gusev K.A. Patients with obstructive jaundice inacute calculous colecystitis treatment tactics individualization. Fundamental research. 2015; 1-3: 618-622. (In Russian)

5. Yokoe M., NoguchiY., Hata J., Takada T., Miura F., Strasberg S.M., Asbunh.J., Wakabayashi G., Kozaka K., Endo I., Deziel D.J., Okamoto K., Hwang T.L., Chen M.F., Huang W.S.W., Ker C.G., Jonas E., HanH.S., Yoon Y.S., Choi I.S, Yoon D.S., Shikata S., Ukai T., Higuchi R, Yamamoto M., Gabata T., Mori Y., Iwasita Y., Hibi T., Jagannath P., Liau K.H., Dervenis C., Gouma D.J., Cheiqui D., Belli G., Garden O.J., Gemenez M.E., Esantibanes E., Suzuki K., Umezava A., Supe A.N., Pitt H.A., Singh H., Chan A.C.W., Lau W.Y., Teoh A.Y.B., Honda G., Sugioka A., Asai K., Gomi H., Itoi T., Kiriyama S., Yoshida M., Maymi T., Matsumura N., Tokumura H., Kitano S., Hirata K., Inui K., Sumiyama Y. Tokyo guidelines 2018: Diagnostic criteria and severity grading of acute cholicystitis (with videos). J. Hepatobiliary Pancreat. Sci. 2013; 25 (1): 41-54. https://doi.org/10.1002/jhbp.515

6. Kokhanenko Yu.N., Lataria E.L., Danilov S.A. Choice of the surgical treatment method in cholecysto-choledocholithiasis. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2011; 16 (4): 56-60. (In Russian)

7. Khrupkin V.I., Afanasyev A.N., Glagolev N.S. Decompression methods in treatment of high surgical risk patients with acute obstructive cholecystitis. Journal of Experimental and Clinical Surgery. 2014; 7 (4): 424-430. (In Russian)

8. Campanile F.C., Pisano M., Coccolini F., Catena F., Agresta F. Acute cholecystitis: WSES position statement. World J. Emerg. Surg. 2014; 9(1): 58. https://doi.org/10.1186/1749-7922-9-58.

9. Boys J.A., Doorly M.G., Zehetner J., Dhanireddy K.K., Senagore A.J. Can ultrasound common bile duct diameter predict common bile duct stones in the setting of acute cholecystitis? Am. J. Surg. 2014; 207 (3): 432-435. https://doi.org/10.1016/j.amjsurg.2013.10.014.

10. Maple J.T., Ben-Menachem T., Anderson M., Appalaneni V. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest. Endosc. 2010; 71 (1): 1-9. https://doi.org/10.1016/j.gie.2009.09.041.

11. Shcherbatykh A.V., Bakhtairova V.I., Egorova I.E., Shmakov D.A. The changes in the activity of alkaline phosphatase and gamma glutamyltransferase in the blood serum of patients with acute and chronic calculouscholecystitis. Sibirskij Medicinskij Zurnal (Irkutsk) = Siberian Medical Journal (Irkutsk). 2015; 6: 68-71. (In Russian)

12. Shapovalyants S.G., Mylnikov A.G., Pankov A.G., Orlov S.Yu., Freidovich D.A., Ardasenov T.B. Diagnostics of choledocho-lithiasis and papillostenosis in patients with acute calculous cholecystitis. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2004; 9 (2): 33-39. (In Russian)

13. Sartelli M., Allegri A., Bertoli P., Campanati L., Campanile F.C., Catena F., Ceresoli M., Coccolini F., Colaianni N., Di Saverio S., Capponi Michela G., Lotti M., Magnone S., Manfredi R., Montori G., Gabriela N., Piazzalunga D., Pisano M., Poiasina E., Poletti E., Ansaloni L., Khokha V. Acute calculous cholecystitis: evidences and guidelines. Emergency medicine. 2015; 13 (1): 24-38. (In Russian)