Attitude towards preoperative biliary drainage for malignant obstructive jaundice have recently changed twice. This is due certain factors including complications of minimally invasive biliary drainage, level of bile duct block, cholangitis, need for neoadjuvant chemotherapy, time to scheduled surgery, severe general condition of patient, future liver remnant volume. We comprehensively searched PUBMED, MD Consult and National Library of Medicine using the following keywords: “obstructive jaundice (OJ)”, “cellular immunity”, “preoperative biliary drainage”, “selective biliary drainage”, “distal and proximal bile duct block”, “complications”. Randomized clinical trials and meta-analyzes, opinions of reputable specialists in hepatopancreatobiliary surgery and our own experimental and clinical studies were foreground. The analysis showed that preoperative biliary drainage is not a safe procedure and results an increased number of complications. Absolute indications for preoperative biliary drainage are cholangitis, need for neoadjuvant chemotherapy, increased risk of radical surgery and unresectable tumor. Future liver remnant volume should be considered in patients with portal cholangiocarcinoma followed by proximal block to determine indications for preoperative biliary drainage.

Objective. To determine the role bile duct stenting with self-expandable metallic stents in the treatment of malignant obstructive jaundice.
Material and methods. Eight-year experience of palliative antegrade stenting with self-expandable metallic stents was analyzed. There were 218 patients with malignant obstructive jaundice. Distal and proximal obstruction was diagnosed in 118 (54%) and 100 (46%) patients, respectively. We have used self-expandable metallic covered, partially covered and bare-metal stents with diameter of 10, 8 and 6 mm and length of 40, 60 and 80 mm.
Results. Technical success in antegrade two-stage installation of self-expandable stents have been achieved in 208 (99%) patients. There were 230 deployed self-expandable metallic stents. Seven (3%) patients underwent simultaneous stenting of right and left hepatic ducts and confluence area with bare-metal stents. Stenting of right or left hepatic ducts and confluence area with partially covered stents was carried out in 34 (16%) patients. Other 59 (27%) patients with proximal biliary obstruction and no separation of lobar bile ducts underwent stenting with 27 partially covered and 31 covered stents. Distal obstruction was managed by using of covered stents as a rule (63%). Complications after antegrade biliary stenting occurred in 29 (13%) patients.
Conclusion. Antegrade biliary stenting with metallic self-expandable stents is effective and minimally invasive approach. Moreover, it is comparable with conventional palliative interventions aimed at bile outflow recovery.

Modern approaches to surgical treatment of malignant obstructive jaundice are reviewed in the article. The advantages and disadvantages of various types of minimally invasive biliary decompression are emphasized.

Objective. To analyze safety and efficacy of X-ray surgical treatment of choledocholithiasis in case of failed endoscopic procedures.
Material and methods. A retrospective analysis included 195 patients with choledocholithiasis who underwent X-ray surgical treatment. Primary X-ray surgical intervention was antegrade cholangiostomy. Data of antegrade cholangiography were used to determine type of endobiliary intervention. Antegrade mechanical and pneumatic choledocholithotripsy and lithoextraction, balloon dislocation of stones of the common bile duct into duodenum or jejunum, lithoextraction using rendezvous technique after endoscopic papillotomy through transpapillary drainage tube or a wire were applied.
Results. Puncture and drainage of non-dilated bile ducts were successfully performed in 30 (15.4%) patients. There were 212 procedires of cholangiostomy in 195 patients including redo interventions. Complications after cholangiostomy were absent in 92.9% of cases. Minor complications occurred in 7.1% of cases. Antegrade mechanical and pneumatic choledocholithotripsy and lithoextraction was performed in 118 (98.3%) patients. Balloon dislocation of stones of the common bile duct into duodenum was applied in 52 (81.3%) patients. Lithoextraction using rendezvous technique after previous endoscopic papillosphincterotomy was performed in 12 (60%) patients. Six patients underwent transpapillary external-internal drainage of common bile duct. Five patients had stricture of biliodigestive anastomosis complicated by cholelithiasis. Lithotripsy and lithoextraction through antegrade approach or dislocation of stones into jejunum after previous balloon dilatation were performed in these patients. Postoperative mortality was 1.5%. Minimally invasive techniques were absolutely effective for choledocholithiasis in 187 (98.9%) patients.
Conclusion. Antegrade X-ray surgical management is effective and safe in patients with choledocholithiasis and unsuccessful previous endoscopic procedures. Integral efficiency of antegrade management of cholelithiasis was 88.8%.

Approaches and results of endoscopic transpapillary procedures in the treatment of patients with obstructive jaundice of various origins are analyzed. Modern trends in the development of endobiliary surgery and recommendations devoted to various endoscopic techniques and methods of biliary decompression depending on etiology and severity of obstructive jaundice, management of patients and dates of interventions are described. Leading specialized centers are characterized by quite high effectiveness of endoscopic transpapillary interventions in patients with cholelithiasis complicated by obstructive jaundice (95.2–97.5%), benign biliary strictures (63.7–92.8%) and biliopancreatoduodenal malignancies (70–96.8%). Analysis of modern tactical and technical approaches and international guidelines for transpapillary interventions allowed us to determine the current capabilities of retrograde minimally invasive curative technologies, systematize and optimize the basic algorithms for endoscopic care in patients with obstructive jaundice, and outline the prospects for the introduction and improvement of the effectiveness of new techniques.

Objective. Retrospective analysis of the treatment of complications after endoscopic retrograde transpapillary interventions.
Material and methods. There were 5701 endoscopic retrograde interventions for the period from 01.01.2008 to 01.01.2019. Overall incidence of complications was 1.5%, mortality rate – 0.24%. Bleeding after endoscopic papillosphincterotomy developed in 13 (0.22%) cases, acute postoperative pancreatitis in 49 (10.85%) cases, ERCPassociated perforation in 24 (0.42%) patients.
Results. Endoscopic approach (epinephrine injection into the edges of major duodenal papilla and cautery) was usually effective for bleeding after endoscopic retrograde cholangiopancreatography. Massive intraoperative bleeding required surgical treatment in one case with favorable outcome. There were no cases of recurrent bleeding. One patient died due to severe bleeding in 3 days after surgery. ERСP-associated (“retroduodenal”) perforation occurred in 24 (0.42%) patients. Endoscopic treatment was undertaken in 16 cases and was effective in 15 (93.75%) cases. Overall mortality among patients with ERCP-induced perforation was 20.8%. An attempt of pancreatic duct stenting for postoperative pancreatitis was made in 30 cases; successful procedure was in 28 (93.3%) cases. Surgery resulted recovery in 26 (86.7%) patients. Progression of acute postoperative pancreatitis followed by death occurred in 2 cases despite successful pancreatic duct stenting. Mortality rate was 25%.
Conclusion. Treatment of ERCP-associated complication is lengthy, time-consuming and expensive. Timely diagnosis and assessment of severity of complications is essential. It is necessary to determine an adequate surgical approach. Everyone should keep in mind all possible risk factors, clearly define the indications for ERCP and follow the technique of the procedure strictly in order to reduce complication rate. In our opinion, endoscopic approach is advisable for post-ERCP complications, because conventional surgery results higher postoperative mortality, increased duration and cost of treatment.

Objective. To improve the outcomes of percutaneous endobiliary interventions through prediction of postoperative complications and searching for minimally invasive methods of their treatment.
Material and methods. Percutaneous en dobiliary interventions have been performed in 2458 patients for the period from 2006 to 2018 including bile duct stenting in 1895 patients.
Results. Early postoperative complications included hemobilia (2.1%), abdominal bleeding (0.2%), duodenal bleeding (0.1%), pleuritis (0.9%), abdominal bile leakage (1.5%) and peritonitis (0.8%), liver hematoma (0.7%), right-sided pleuritis (0.9%), pancreatitis (13.8%). In our opinion, these complications are serious and require immediate intensive care and invasive repair. Mortality rate was 8.4% among all patients with early complications and 0.9% among those after endobiliary interventions. Delayed complications of percutaneous transhepatic interventions are migration of stent or drainage tube, drain incrustation, malignant invasion of stent, recurrent cholangitis, cholangiogenic liver abscesses, abdominal abscesses, sepsis, fragmentation of drain or stent, portal vein thrombosis. The most severe late complications (sepsis and portal vein thrombosis) resulted mortality rate 50–60%.
Conclusion. Combined dual (ante- and retrograde) biliary approach and control throughout minimally invasive surgery eliminate disadvantages of individual accesses, reduce invasiveness, postoperative morbidity and mortality.

Successful combined minimally invasive intervention (antegrade and retrograde) in a patient with choledocholithiasis and previous pancreatoduodenectomy is described in the article.

Objective. To evaluate possibilities and advantages of SpyGlass DS system (Boston Scientific) in the diagnosis and treatment of pancreato-biliary diseases.
Material and methods. SpyGlass DS has been applied in 24 interventions in 22 patients for the period from December 6, 2017 to July 6, 2018. There were 21 cholangioscopies, 2 pancreaticoscopies and one cholangiopancreaticoscopy. The indications for cholangioscopy were undifferentiated strictures (n = 14), suspected Mirizzi syndrome (n = 2), large choledocholithiasis and need for laser lithotripsy (n = 1). There was a need to pass a guidewire under visual control (n = 2) and to control bile duct stones extraction (n = 1). Scheduled removal of ligature after laparoscopic cholecystectomy was in 1 case. Indication for pancreaticoscopy was suspected malignancy within the strictures associated with chronic pancreatitis, for cholangiopancreaticoscopy – assessment of spread of major duodenal papilla tumor into common bile and pancreatic ducts.
Results. Overall technical success rate was 95.8% (23/24). Intraductal biopsy was successfully performed in 13 out of 14 (92.9%) cases. Cholangiocarcinoma was histologically confirmed in 6 cases. Curative interventions were performed in all 4 cases. There were no complications and mortality.
Conclusion. The main indications for endoscopic peroral intraductal interventions are various types of undifferentiated and complicated biliary and pancreatic strictures, as well as “difficult” bile and pancreatic duct stones. The technology of diagnostic and curative endoscopic interventions using the SpyGlass DS system is relatively simple while morbidity and mortality rates are similar to those after conventional transpapillary interventions.