Endoscopic ultrasound and transpapillary interventions in patients with peripapillary diverticula

Abstract

Aim: to evaluate the possibilities of diagnosed during endoscopic ultrasound (EUS) in clarifying diagnosis of peripapillary diverticula (PD) and optimization of treatment tactics depending on the type of mutual location of the diverticulum and the major duodenal papilla (MDP). Patients and Methods: the study included 304 patients (186 (61.2%) female patients) with peripapillary duodenal diverticulum (PDD). By the criterion of the diverticulum and MDP mutual location, patients were divided into three groups: 195 (64.1%) patients with suprapapillary diverticulum, 59 (19.4%) — with diverticulum of the "butterfly" type, 50 (16.5%) — with intradiverticular MDP. Anatomical features of various diverticula types and associated pathology of periampullary region were studied on the basis of endosonography data, as well as the treatment results of biliary diseases, technical success and complications of transpapillary interventions in various types of diverticula were analyzed. Results and Discussion: patients with intradiverticular MDP were significantly older (69.8±4.4 years). In this group, the size of diverticula (21 mm) and dilatation of choledochus (18 mm) were larger. Patients in this group were significantly more commonly diagnosed with stenosis of the MDP and secondary choledocholithiasis. Indications for endoscopic papillosphincterotomy in patients with PDD were choledocholithiasis — 124 (57.1%), stenosis of the MDP — 44 (20.3%), diverticular compression in terminal choledochus — 49 (22.6%), EUS. The complication rate of transpapillary interventions did not significantly differ and amounted to 2.8%. However, the share of failures during MDP standard biliary cannulation and lithoextraction was higher in the intradiverticular MDP and amounted to 34.5% and 8.8%, respectively, which forced the use of rendezvous procedures that were used in 10 (34.5%) patients of this group. Conclusion: EUS is a highly informative method of diagnostic clarification in PD, providing direct visual inspection of the papillary zone and its echocardiogram. The use of EUS at the initial stage of diagnostics allows to significantly optimize the treatment tactics, determining the indications for transpapillary interventions and ensuring their rational choice. The greatest technical difficulties and failures are expected to occur during manipulations on the intradiverticular MDP, which forces the use of rendezvous procedures, antegrade common bile duct access and laparotomic interventions. KEYWORDS: peripapillary diverticulum, endoscopic ultrasound, transpapillary interventions endoscopic papillosphincterotomy, biliary hypertension. FOR CITATION: Belozerov V.A., Grigoriev N.N., Prokopov V.A., Belozerova D.E. Endoscopic ultrasound and transpapillary interventions in patients with peripapillary diverticula. Russian Medical Inquiry. 2023;7(5):258–263 (in Russ.). DOI: 10.32364/2587-6821-2023-7-5-3.