Aim. To evaluate information content of confocal laser endomicroscopy with targeted biopsy in verifying etiology of extrahepatic bile duct strictures.

Material and methods. There were 28 patients with extrahepatic bile duct strictures who underwent retrograde intervention with confocal laser endomicroscopy and targeted biopsy. Data of confocal laser endomicroscopy and biopsy were compared with final postoperative and histological diagnosis. Follow-up within 1–4 years after endoscopic treatment was also considered.

Results. Diagnostic sensitivity, specificity and overall accuracy of the method in differential diagnosis of common bile duct strictures were 91.7%, 93.7% and 92.8%, respectively. Complication (acute edematous pancreatitis) occurred in 1 (3.6%) case.

Conclusion. Confocal laser endomicroscopy is new effective method for in vivo microscopic assessment of mucous membrane. Despite technical complexity, the method is not associated with advanced morbidity and, accordingly, has no additional contraindications in comparison with ERCP.

Aim. To study the possibilities of endoscopic ultrasonography with contrast enhancement and fine-needle biopsy in the diagnosis of metastatic lesions of the pancreas.

Materials and methods. 299 patients with solid pancreatic neoplasms were examined in the period from 2016 to 2018. Among them, adenocarcinoma of pancreas was diagnosed in 96.3% (n= 288), in 3.7% of cases (n= 11) a secondary lesion of the pancreas was suspected due to the presence of a tumor of another localization. Endosonography with contrast enhancement and fine-needle biopsy was performed for all these patients.

Results. In 7 of 11 patients, there was a primary lesion of the pancreas (ductal adenocarcinoma), confirmed by morphological research data from a fine-needle biopsy. Of the 11 cases, the metastatic lesion of the gland was morphologically verified in 4 (36.4%) cases. In 2 cases, metastases of renal cell carcinoma were diagnosed, 1 was metastasis of small cell lung cancer, and 1 was metastases of colorectal cancer. Patients with secondary lesions of the pancreas accounted for 1.3% of the total number of patients.

Conclusion. In the presented clinical observations, the possibilities of endo-ultrasound with contrast enhancement were analyzed, as well as the prospect of cytological and immunocytochemical studies in situations where the material obtained during fine-needle puncture is insufficient for histological examination. Such an approach is fully justified and helps to clarify the nature of the neoplasm in difficult situations.

Aim. To assess the role of endoscopic ultrasonography (EUS) in bile duct drainage for malignant mechanical jaundice followed by abnormal anatomy of upper gastrointestinal tract.

Material and methods. There were 43 attempts to form EUS-assisted biliodigestive anastomoses in 43 patients for the period 2014–2018. Procedure was successful in 33 (76.74%) patients.

Results. Two periods were identified to analyze the results. The first period (2014–2015) included 21 patients who underwent surgery, the second period (2016–2018) – 22 patients. In the first period, the effectiveness of EUS-assisted procedures was 57%, in the second one – 96%.

Conclusion. EUS-assisted biliodigestive anastomoses are useful for biliary decompression in various anatomical situations including switching off the duodenum from food passage. These operation is safe alternative to other types of decompression with accumulation of experience.

Aim. To evaluate an effectiveness of endoscopic papillectomy (EA) for benign ampullary tumors.

Material and methods. There were 45 patients with ampullary tumors who underwent endoscopic papillectomy in 2014–2018. Mean dimension of tumor was 2.25 ± 1.75 cm.

Results. Papillectomy was successfully performed in all cases. En-bloc resection was completed in 24 cases (53%), while 21 (47%) patients had a piecemeal resection. Pancreatic duct stenting was carried out in 30 (67%) cases. Postoperative complication rate was 31%. Postoperative bleeding occurred in 8 (18%) cases, perforation in 4 (8.9%) cases, acute pancreatitis in 2 (4.4%) cases. Mortality was 4.4 % (n= 2). Local recurrence rate within 4-year period was 2.2% (n= 1). Mean length of hospital-stay was 13 days (13 ± 11) considering prolonged treatment of patients with complicated postoperative period.

Conclusion. Endoscopic papillectomy is effective minimally invasive treatment of benign ampullary tumors. Regardless considerable morbidity rate, all of them may be effectively managed by medication or endoscopic procedure. EP can be considered as a first-line treatment of benign ampullary tumors.

Aim. To compare immediate and long-term results of internal drainage of pancreatic pseudocyst by using of endosonography-assisted and open surgical approaches.

Material and methods. EUS-assisted internal drainage of pancreatic pseudocyst was performed in 32 patients in 2011–2016. Open drainage procedures were carried out on the other 32 patients.

Results. In the group of endoscopic drainage, technical success rate, clinical success rate and complication rate were 97%, 85% and 26%, respectively. There were no recurrent pseudocysts in long-term period. Comparison with open surgery confirmed advantages of endoscopic technique regarding time of operation (p< 0.01), intraoperative blood loss (p< 0.01) and length of hospital-stay (p< 0.01).

Conclusion. EUS-assisted internal drainage of pancreatic pseudocysts in the treatment of chronic pancreatitis is characterized by high rate of technical and clinical success, small postoperative morbidity and low incidence of longterm recurrences.

Aim. To identify diagnostic value of hepatocholescintigraphy for evaluation of functional state of biliodigestive anastomoses (BDA).

Material and methods. ^99mTc-IDA hepatocholescintigraphy was applied in 52 patients to evaluate function of biliodigestive anastomoses.

Results. Scintigraphic signs of “bowel-anastomosis” and/or “BDA-intrahepatic bile ducts” reflux were revealed in 14 (27%) cases. Obstruction of biliodigestive anastomosis occurred in 3 (5.7%) patients. Normal bile flow through BDA was observed in 10 (19.2%) patients, impaired passage – in 21 (40.3%) cases. Tracer delay in intrahepatic bile ducts was noted in 21 (25.0%) cases, signs of adhesive process near deferent bowel – in 3 (3.8%) cases.

Conclusion. Hepatocholescintigraphy is highly effective method to assess biliary tract in patients after Roux-en-Y biliodigestive anastomoses formation.

Aim. To evaluate the immediate results of endoscopic retrograde stenting of bile ducts in benign hepatopancreatoduodenal diseases and to justify enlargement of indications for surgery.

Material and methods. There were 341 patients with various benign hepatopancreatoduodenal diseases for the period 2007–2017. Plastic stents were installed in 326 (95.6%) patients, metal self-expanding stents – in 15 (4.4%) patients.

Results. There was a tendency to increase of the number of stenting procedures in patients with benign hepatopancreatoduodenal diseases that was primarily due to expansion of indications for this intervention. Therapeutic and prophylactic purposes of biliary stenting were determined. The main objectives of therapeutic stenting were bile drainage restoration in obstructive jaundice, reduction of extra- and intrahepatic biliary pressure, as well as drainage of cavities in liver communicating with biliary system. The main prophylactic goal was to prevent violation of bile outflow after endoscopic manipulations on the major duodenal papilla at high risk of migration of stones from gallbladder and reflux cholangitis. Severe complications of endoscopic transpapillary procedures were not observed.

Conclusion. The indications for endoscopic transpapillary stenting of the bile ducts in case of benign hepatopancreatoduodenal diseases were systematized and reasonably expanded. Immediate results of biliary stenting confirm high efficacy of the method.

Aim. Present a program of examination and treatment of patients with biliary duct injury, corresponding to the level of the international protocol and modern requirements for the quality of medical care.

Material and methods. The results of examination and treatment of 77 patients with bile ducts injuries are analyzed. The analysis of the main surgical interventions for the elimination of bile ducts injuries is given: reconstructive operations in 44.3% of patients, recovery operations – in 36.7% and external drainage – in 19%.

Results. A program approach has been developed to assist patients with bile duct injuries in civil health care at various levels of surgical care.

Conclusions. The implementation of this program provides timely diagnosis of damage to the bile duct and minimizing the number of postoperative complications at the second and third levels of surgical care. It was determined that a rational approach to reduce the number of injuries of the bile ducts is their prevention by perfect adherence to the technique of surgical intervention on the organs of the upper floor of the abdominal cavity, and to reduce the number of negative consequences, the proposed algorithm for diagnosis and treatment.

Aim. To determine the role of antegrade X-ray surgical interventions in the treatment of benign postoperative biliary strictures.

Material and methods. A retrospective analysis of treatment of 36 patients with benign biliary strictures was performed. Isolated stricture of biliodigestive anastomosis was diagnosed in 25 cases, partial clipping of common hepatic duct proximal to biliodigestive anastomosis – in 3 cases, partial clipping of bile duct – in 3 patients, isolated biliary strictures – in 5 patients including 4 of them with stricture within previously deployed T-shaped drainage. At the first stage, percutaneous transhepatic cholangiostomy was performed. According to antegrade cholangiography data, structure type “+1, +2” by H. Bismuth classification in modification of E. I. Galperin was diagnosed in 16 (55.2%) patients, proximal biliary strictures (“0”–“−2”) in 13 patients. Three patients with partial clipping of common bile duct and 4 patients with benign biliary stricture in the area of previously deployed T-shaped drainage were not classified. Recanalization of strictures by “catheter-guide” system was followed by antegrade dilatation of the stricture. Final stage was frame external-internal drainage for 6–12 months with stepwise redo balloon dilatation every 3 months (35 patients). The criterion for the end of minimally invasive treatment was the absence of balloon waist in the stricture zone observed during the next procedure but not earlier than in 6 months from primary balloon dilatation. Surgical correction was indicated for recurrent stricture.

Results. Direct technical success was achieved in 35 patients. There was 1 case of recurrent strictures within 1 year among 3 cases of primary repair of biliary strictures in the area of previously installed T-shaped drainage. Resection of common bile duct stricture was followed by Roux-en-Y hepaticojejunostomy. Recurrence-free period among 36 patients ranged from 1 to 10 years, median – 56 months. There were no mortality and complications after X-ray surgery.

Conclusion. Antegrade recanalization and balloon dilatation of the stricture followed by long-term external-internal biliodigestive frame drainage are effective for both stricture of biliodigestive anastomosis and partial clipping of bile duct. Conventional surgical procedures should be preferred for cicatricial strictures of extrahepatic bile ducts after previous T-shaped drainage deployment.

Pancreatoduodenectomy is the most common surgery for benign tumors of the pancreatic head and chronic pancreatitis. However, advanced resection and unsatisfactory quality of life in long-term period call into question the propriety of this procedure for benign tumors of the pancreatic head and chronic pancreatitis. Duodenum-sparing proximal pancreatectomy is the current approach. The review is devoted to the main techniques of duodenum-sparing pancreatectomy, outcomes of these procedures and their role in pancreatic surgery.

It is presented care report of the patient with liver alveococcosis. Survey confirmed parasitic invasion of both liver lobes. Radical alveococcectomy was impossible under these conditions since remnant liver volume was less than 30%. Treatment was divided into two stages. Moreover, it was decided to perform cryodestruction of parasitic tumor besides surgical intervention per se. Liver resection combined with cryodestruction of remnant parasitic tumor may be considered as radical treatment especially in redo surgery. Diagnosis, treatment, outcomes and literature review are comprehensively described in the article.

It is presented case report of a 52-year-old patient with necrosis of pancreatic body and tail complicated by massive arrosive bleeding. Complications occurred after pancreatoduodenectomy. Pancreatic stump extirpation allowed to optimize postoperative period and to discharge the patient in a satisfactory condition.