Трансдуоденальная лапароскопическая папиллэктомия при аденоме большого дуоденального сосочка

A 60-year-old man admitted to the clinical center due to weakness, episodes of jaundice. The laboratory date revealed elevated levels of total bilirubin—112.5 μmol/l (range 8,5–20,5 μmol/l) and direct bilirubin—60.8 μmol/l (range 4,3–4,6 μmol/l), elevated hepatic enzymes (aspartate aminotransferase [AST]: 95 U/l (range ≤ 40 U/L), alanine aminotransferase [ALT]: 301 U/l (range ≤ 30 U/L). When performing esophagogastroduodenoscopy, a polyp of the large duodenal papilla with a spread to the terminal parts of the bile and pancreatic ducts was revealed, and a biopsy was taken. Histological examination detected tubulovillous adenoma with epithelial dysplasia II–III stage. DS: “Tubulovillous adenoma of the major duodenal papilla with epithelial dysplasia II–III”. Complications: “Multiple choledocholithiasis. Mechanical jaundice. Liver failure.” Considering the inability to carry out endoscopic treatment, recurrent nature of the jaundice it was decided to perform surgery: laparoscopic duodenotomy, papillectomy, choledocholithotomy, performing of choledochoduodenal anastomosis, duodenoplasty and abdominal drainage. The postoperative period was taking its normal course. Duration of staying in the intensive care unit—4 days. Enteral fluid intake started on the 2-nd postoperative day. Enteral feeding was restored in a 3 days. Polyps of the large duodenal papilla are relatively rare form of tumors of the gastrointestinal tract, which may not manifest clinically, or, as the above case, lead to severe pathological conditions. Currently, there is no single approach to the treatment of this group of diseases. Some authors propose a pancreatoduodenal resection, but the risks of this operation associated with high postoperative morbidity and mortality are not always justified. The case is unique because the described procedure is less invasive and affects the minimum number of organs. Laparoscopic approach has significant advantages in the treatment of this infrequent pathology.