BACKGROUND

The frequency of choledocholithiasis among patients with cholelithiasis reaches 30%. Currently, in the treatment of choledocholithiasis, endoscopic transpapillary interventions are highly effective and have a relatively low risk of complications (4—9.8%). A limitation to the successful use of standard lithoextraction may be “complex” choledocholithiasis. If simultaneous lithoextraction is not possible, in order to level out possible complications and quickly relieve obstructive jaundice and cholangitis, they often resort to temporary stenting or nasobiliary drainage of the common bile duct.

OBJECTIVE

To substantiate the optimal staging of endoscopic interventions in «complex» choledocholithiasis in various categories of patients.

MATERIAL AND METHODS

The experience of treating 197 patients (19.8%) who were diagnosed with «complex» choledocholithiasis was analyzed. One-stage (in 114 patients) or two-stage (in 83 patients) approaches were used for treatment. The one-stage approach assumed the desire to extract the concretion without fail during the primary endoscopic transpapillary intervention. The two-stage approach involved the installation of a plastic biliary stent (in 80 people) or the establishment of nasobiliary drainage (in 3 people) during the initial intervention. The second stage, after 1.5—3 months, was performed, if necessary, mechanical lithotripsy and / or balloon dilation of the EPST area and lithoextraction. According to the type and type of EPST, the patients of the one-stage and two-stage approaches were comparable.

RESULTS

Risk factors were identified that could have an additional adverse effect on the possibility of performing transapillary intervention and during the postoperative period: blood bilirubin level of 201 mmol/l or more, age 65 years and older, presence of acute cholangitis clinic, presence of concretion wedged into the lumen of choledochus. These factors were the basis for determining the therapeutic approach in patients with «complex» choledocholithiasis. With a one-step approach, transpapillary interventions for «complex» choledocholithiasis proved effective in 99 people (86.8%). The failures of the one-stage approach were due to the increased density of the concretion (in 3 patients — destruction of the Dormia basket), in 12 patients it was not possible to remove the concretions due to their dense position in the lumen of the choledochus. Complications were detected in 5 (4.39%) clinical cases with a one-step approach: 2 bleeding from the EPST area after balloon dilation, which was stopped endoscopically; 2 post-manipulation pancreatitis, one patient had herniation of the Dormia basket with a stone. There were no deaths.

With a two-stage approach, treatment was successful in 80 of 83 patients (96.4%). Failures of the two-stage approach occurred in 3 patients: destruction of the Dormia basket was noted in 2 people, in 1 person the stone could not be captured. When performing a two-stage intervention, there were 2 complications (2.4%). There were no procedure-related deaths.

CONCLUSION

In patients with «complex» choledocholithiasis with severe mechanical jaundice and cholangitis, preference should be given to two-stage tactics, which first involves decompression of the biliary tract by stenting or nasobiliary drainage in order to minimize the risk of complications during primary intervention. The effectiveness of two-stage tactics in clinical situations associated with high bilirubin levels, cholangitis and a significant risk of postoperative complications is 96.4%. Factors that have an unfavorable effect on the outcome of transpapillary intervention may also be age over 65 years and a con-the flint. A two-stage tactic for «complex» choledocholithiasis is indicated in the presence of two or more adverse factors. One-stage tactics can be applied in the presence of no more than 1 unfavorable factor. The effectiveness of this approach is 96.8%.