below than 30 g/l, a decrease in the prothrombin index below than 82%. We rated the patient’s condition as a
second class according to the Child-Pugh scheme. The severity of patient’s condition besides the obstructive
jaundice, in 63.3% of cases was stipulated by purulent cholangitis, hepatic failure. A partial stricture of
hepaticocholedoch was revealed in all cases.
In 19 cases the obstruction was located in the fusion zone of the bile duct with the bladder duct. Such
position of the defect, in our opinion, is most typical, especially at the stage of the laparoscopic method
mastering. All patients in this group were diagnosed promptly and appropriate interventions were performed. In
18 cases an obstruction to the bile outflow was located in the distal part of the choledoch. Exactly in such cases
doctors of general surgical departments encounter the problem of recurring interventions. The content of direct
bilirubin in these patients was from 300 to 390 μm. They were timely hospitalized to our hospital before the
development of liver failure. The endoscopic method including the probing of the stenotic segment in
combination with local diathermocoagulation of the hard-bouging cicatricial segment we managed to restore
the patency of the hepaticocholedoch and to perform stenting of the stenotic segment and it led to patients’
recovery and their discharge after 6-8 days.
The efficiency of drainage was estimated by endoscopic criteria, clinical condition of patients and also by
laboratory indicators. Improvement of general condition, appearance of appetite, staining of feces and reduction
or disappearance of skin itching were clinical signs of an effective drainage.
During the first three days the activation of patients, a decrease or complete termination of the bile
secretion from the external fistula, normalization of the temperature, a decrease in the intensity of icteric
staining of the skin and urine were objectively noted. There was a decrease in the level of total and direct
bilirubin, normalization of alkaline phosphatase levels, enzymes in laboratory indicators.
Our observations showed that endoscopic treatment was effective almost in all patients with distal stenosis
of the bile duct, in 19 from 21 patients with stenosis of the hepaticocholedoch middle part, the effectiveness of
endoscopic treatment had been almost the same for these 2 groups of patients. In the treatment of proximal
stenosis the success has been achieved in 6 from 8 cases and it differs both from the results of distal stenosis
treatment and from the results of middle third stenosis drainage. Thus, the prospect of endoscopic treatment are
determined by the localization of the cicatrical process and are less effective in patients with proximal strictures
of common bile ducts.
In order to prevent the incrustation of the drainage tube a constant intake of deoxycholic acid drugs was
prescribed. It should be noted that complications associated with stents of external bile ducts were not observed.
The stents were extracted during duodenoscopy at different periods (from 6 to 10 months). It must also be
remembered that endoscopic manipulations can cause a number of complications: duodenal injury, hemorrhage,
exacerbation of cholangitis, pain syndrome and pancreatitis. Acute pancreatitis was developed in 18.4% of
patients and it was stopped by conservative drugs and in 10.2% - hemorrhage from the EPST zone after
endoscopic interventions. Hemorrhage was stopped by the electrocoagulation method [10]. There were no
mortality outcomes in this group. Two months after the discharge 12 patients addressed with the signs of
restenosis and they were performed a repeated endoscopic dilation. In 7 patients the biliostents independently
emerged into the lumen of the intestine after 3 months, but the bile passage remained satisfactory. There is a
stable remission at a small extent of stricture and with a greater extent of stricture and the CBD restriction had
been noted by the 6th month which required recurring interventions. In 9 patients with a stricture length more
than 0.5 cm endoscopic manipulations were ineffective and they were performed reconstructive surgeries. Only
1 from 13 patients who were undergone balloon dilatation without biliostents had a relatively stable
improvement, the rest of them were performed double or triple repeated dilation without any effect. They were
performed reconstructive surgeries six months later.
CONCLUSION
Thus, the surgery of the external biliary fistula presents great difficulties. The choice of reconstructive and
restorative surgeries depends on many factors. The level of fistula, its shape and direction, the cause, the nature
of concomitant pathology are distinguished among them. Complex preoperative diagnostic results based on
which the surgeon can carefully weighs indications or contraindications to some method of intervention are
considerably significant. The use of transduodenal biliostenting makes it an alternative to the complex
reconstructive interventions and creates the prospects for improving the treatment results of such complicated
pathology as external biliary fistulas. The efficiency analysis of endoscopic treatment of anhepatic bile ducts
Turakulov UN. 2018. Endoscopic Interventions in Patients with External Biliary Fistulas Caused by Iatrogenic Injuries of Biliary Tracts. J. Life