Violation of Choledoch Distant Patency: Reasons, Principles of Diagnostics and Treatment

The diagnostics and treatment of the patients with violation of distant part of the general bile duct patency remain until now urgent and insufficiently explored problem. Choledocholithiasis, stenosis and the dysfunction of the large duodenal papilla, papillitis, strictures and choledoch tubular stenosis should be considered most common causes of choledoch distal patency syndrome of non-neoplastic genesis. Until present time approaches in optimal diagnostic and treatment tactics are not standardized. Criteria of priority order, phasing and volume of surgical intrusions are not defined especially in patients with benign diseases of the large duodenal papilla and parapapillary zone. Aim of the research. Creation of the complex program of diagnostics and treatment of the patients with violations of choledoch distal patency of non-neoplastic genesis directed on the improvement of the treatment results. Materials and methods. The work is based on the retrospective study and treatment of 60 patients with violations of choledoch distal patency. The program of examination included standard clinic-laboratory diagnostics, instrumental diagnostics with the use of ultrasound research, duodenoplasty, endoscopic retrograde cholangiopancreatography. Results. Discussion. Violation of choledoch distant patency was found in 60 (100%) patients under ultrasound research. Width of the choledoch varied from 0,6 to 2,4 sm in diameter. The stenosis of the large duodenal papilla was found in 26 (43,3 %) patients under duodenoplasty and endoscopic retrograde cholangiopancreatography. In isolation this pathology was found in 10 (16,7 %) cases and in 16 (26,7 %) patients – together with choledocholithiasis. Choledocholithiasis appeared to be the second main cause of choledoch patency violation which was found in 24 (40 %) patients. In 5 (8,3%) patients the stone of LPD ampulla became the cause of cholestasis. Solitary concernments of the distant part of the general bile duct were found in 14 (23,3%), and numerous - in 10 (16,7%) patients. Choledoch microlites from 1 to 3mm found in 3 (5,4 %) patients were in all cases accompanied by acute papillitis. Concernments from 0,2 to 1,2 sm were endoscopically extracted in 20 (83,3 %) cases, and concrements from 1,7 to 2,4 sm were considered endoscopically non-extracted in 4 (16,7%) cases, these patients were performed “open” choledocholithotomy. In 33 (55%) cases endoscopic retrograde cholangiopancreatography was successful after papillae cannulation and in 19 (31,7%) cases it was performed after diagnostic or therapeutic endoscopic papillosphyncterotomy. One-phase therapy with the use of minimally invasive intrusions became final in treatment of 46 (76,7%) patients with the stenosis of the large duodenal papilla and choledocholithiasis. Two-phase treatment: endobiliary intrusion (the 1st phase) and laparoscopic cholecystectomy (the 2nd phase) were performed in 34 (56,7%) patients with calculose cholecystitis. Surgical therapy was not performed in 7 (11,6%) patients with indicators of Oddi sphincter dysfunction. Conlusions. The method of ultrasound research is the most informative screening method of violations of choledoch patency diagnostics making possible to determine the level of obstruction and often the cause of obstruction in 100% of cases. The data received under duodenopapilloscopy and endoscopic retrograde cholangiopancretohraphy make possible to interpret and specify correctly the cause of violation of choledoch distal patency in up to 98 % cases. The priority methods of surgical correction of choledoch terminal section and zone of the large duodenal papilla organic pathology are minimally invasive trans-papillary intrusions and only in case of their inefficiency performance of traditional “open” surgical intrusions is possible.