Харьковская медицинская академия последипломного образования, г. Харьков, Украина Постхолецистэктомический синдром с позиции хирурга и гастроэнтеролога Резюме. Представлены результаты лечения 173 больных с постхолецистэктомическим синдромом (ПХЭС) с органическими изменениями сфинктера Одди и 140 больных с функциональными изменениями сфинктера Одди. Основным направлением лечебной тактики при органических причинах ПХЭС было максимальное использование эндоскопических методов лечения и эндохирургии в сочетании с современными терапевтическими средствами. При выявлении функциональных изменений сфинктера Одди применялась медикаментозная терапия с дифференцированным подходом к выбору препаратов в зависимости от преобладания гипертонуса или недостаточности сфинктера Одди (мебеверина гидрохлорид (дуспаталин), итоприд, тримебутина малеат (тримспа)). Для нормализации физико-химических свойств желчи и профилактики повторного холедохолитиаза использовались производные урсодезоксихолевой кислоты (Урсофальк).

Chronic pancreatitis is a recurrent progressive disease accompanied by fibrosis and fibrocystic degeneration of the pancreatic parenchyma. There are remained the unexplored issues of progression of fibrosis in the pancreas parenchyma, which lead to a rapid enlargement of the head, the development of complications that require a resection surgery. To develop a differentiated approach to the choice of surgical treatments and indications for pancreatoduodenal resection in complicated forms of chronic pancreatitis, a study was performed in 137 patients underwent resection and drainage surgery. Pancreatoduodenal resection was accomplished in 12 patients. Instrumental research methods were used: multidetector (64−slice) computed tomography with 3D reconstruction, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography. Two clinical examples are given. Indications for pancreatoduodenal resection in patients with chronic pancreatitis were expressed fibro−inflammatory process in the area of the pancreas head, suspected development of oncological pathology. Progressive fibrotic changes in the pancreas parenchyma, mainly in the head, occurring in some patients, associated with stellate cell activation and fibrogenesis, they lead to the development of biliary and portal hypertension, stimulation of oncogenesis. It is concluded that with the progression of fibro−inflammatory process in the pancreas head with the development of complications (pancreatic, biliary and portal hypertension), as well as in case of impossibility to exclude the tumor, the surgery of choice is pancreatoduodenal resection. The presence of severe fibrosis in the pancreas parenchyma reduces the risk of developing pancreatic fistula when performing pancreatoduodenal resection. Key words: complicated forms of chronic pancreatitis, pancreatoduodenal resection, fibro−inflammatory process, pancreatic fistula

Summary. Objective. Development of an algorithm for choosing the method of pancreatojejunoanastomosis in pancreatoduodenal resection, taking into account the degree of change in the pancreatic parenchyma. Materials and methods. Pancreatoduodenal resection was performed on 291 patients with obstructive diseases of the pancreatoduodenal zone. Three options were used for pancreatojejunoanastomos: invagination ductopancreatojejunal — in 210 (72.4 %), invagination pancreatojejunal — in 68 (23.4 %), pancreatojejunal with bandage repair of the crescent ligament of the liver — in 13 (4.4 %) patients. Results. The pancreatic parenchyma was assessed by the following factors: puffiness, infiltration, obesity, degree of pancreatic parenchyma fibrosis, location and diameter of the Wirsung duct. High and low risk factors for the development of pancreatic fistula were identified. Diagnosis of pancreatic fistula was carried out according to the classification of ISGPF (2016). A differentiated approach was applied to the choice of pancreatojejunoanastomosis depending on the degree of changes in the pancreatic parenchyma, the diameter and location of the Wirsung duct. Conclusion. Evaluation of the degree of pancreatic parenchyma changes, the diameter and location of the Wirsung duct allows you to choose the optimal technique for pancreatojejunoanastomosis in pancreatoduodenal resection. The use of a differentiated approach to the choice of pancreatojejunoanastomosis technique for pancreatoduodenal resection, taking into account the degree of change in the pancreatic parenchyma, can reduce the incidence of PF (type B, C).

The aim of the research. To develop an algorithm for the two-stage treatment of patients with tumors pancreatoduodenal zone complicated by obstructive jaundice using biliary decompression techniques at the first stage and conducting pancreatoduodenal resection at the second stage of treatment. Materials and methods. Preliminary biliary decompression was conducted in 51 patients with prolonged obstructive jaundice and high bilirubin numbers (above 250 μmol/l). The following minimally invasive options were used for biliary decompression: percutaneous transhepatic cholangio-drainage in 21 (41.2 %), endoscopic stenting in 18 (35.3 %), various cholecystostomy (percutaneous transhepatic, contact, video laparoscopic) in 12 (25, 8 %) patients. A two-stage method has been developed for the treatment of pancreatic tumors complicated by obstructive jaundice. Results. Percutaneous transhepatic cholangio-drainage was performed under ultrasound-X-ray navigation — in 11 (52.4 %), under angiographic control — in 10 (47.6 %) patients. Endoscopic stenting was performed in 18 (35.3 %) patients; plastic stents were used. Three options were used for pancreatojejunoanastomos: invagination ductopancreatojejunal — in 31 (60.8 %), invagination pancreatojejunal — in 16 (31.4 %), pancreatojejunal with bandage plasty of the crescent ligament of the liver — in 4 (7.8 %) patients. Diagnosis of pancreatic fistula was carried out according to the classification of ISGPF (2016). Biochemical leak was observed in 3 (5.9 %), pancreatic fistula (type B) in 2 (3.9 %) patients. Post-operative gastrostasis was detected in 3 (5.9 %) patients. Conclusions. Percutaneous transhepatic cholangio-drainage and endoscopic stenting are the most effective methods of biliary decompression. The use of biliary decompression in patients with pancreatic tumors complicated by the development of obstructive jaundice allows patients to prepare for the execution of PDR with reduced perioperative risk.

The aim. Improving the algorithm for diagnosing patients with postcholecystectomy syndrome (PCS), taking into account functional and organic changes in the major duodenal papilla (MDP). Materials and methods. 208 patients with PCS were examined. Laparoscopic cholecystectomy (CE) was performed in 172 patients in history, open CE was performed in 36 patients. 47 patients had obstructive jaundice, 84 had signs of biliary hypertension without an increase in bilirubin, 77 had no signs of biliary hypertension and an increase in bilirubin. The following instrumental research methods were used: abdominal organs ultrasound examination (AO USE), duodenoscopy, endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT). In the main group, to study the morphofunctional changes in MDP, duodenoscopy with parietal impedancemetry, ultrasound of the hepatobiliary zone with a choleretic load were used. Results. In the main group, 34 patients underwent ultrasound of the hepatobiliary zone and Vater's nipple area with a choleretic breakfast according to Boyden according to the method of Grigoriev P.Ya. in our modification, 21 patients had an expansion of the choledochus by 2 mm. At the same time, taking meverin led to a decrease in the diameter of the choledochus, which indicated functional changes in the MDP. In 13 patients, the expansion of the choledochus, observed when taking a choleretic breakfast, persisted with the use of antispasmodics, which indicated the presence of an organic pathology of MDP. Duodenoscopy with impedancemetry was performed in 41 patients: 20 patients had 760–820 Ohm, which indicated the presence of functional changes, 12 patients had inflammatory changes in the MDP and 703–760 Ohm were detected, 9 patients with cicatricial fibrous changes had indicators impedance measurement 640–703 Ohm. The use of ultrasound with a choleretic breakfast and duodenoscopy with parietal impedancemetry in patients of the main group made it possible to identify functional and organic (inflammatory, fibrous) changes in the MDP, which made it possible to develop a therapeutic algorithm using both conservative therapy and the use of various options for transpapillary endoscopic interventions. Conclusions. Conducting an in-depth diagnosis of morpho-functional changes in MDP using parietal impedancemetry of MDP and ultrasound of the hepatobiliary zone with choleretic load allows us to identify both functional and morphological changes in MDP, which makes it possible to develop a therapeutic algorithm using drug therapy and transpapillary endoscopic techniques.