







































Volume 04 Issue 01-2024 76 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

Servi 

 

 

 

 

 

 

 

 

 

 

ABSTRACT 

The results of surgical treatment of 103 patients with “fresh” IVS injuries were analyzed. The main operation for 

complete transection and excision of the IVS is HepEA according to Roux-en-Y, which was performed in 67 patients 

with good long-term results in 97.01%. The formation of the BBA with complete intersection of the duct in all cases 

resulted in a stricture. Restorative surgery is indicated only for partial damage to the duct. HepDA also had a negative 

effect on treatment outcomes. Complications in the immediate postoperative period17.5%, in the remote – 33.9%. 

Repeated surgical interventions were performed in 32.03% of patients, mortality rate was 5.8%. 

KEYWORDS 

Bile ducts, iatrogenic damage, restorative and reconstructive operations. 

INTRODUCTION

Over the past two decades, the incidence of biliary 

tract diseases has increased in many countries of the 

world, including Uzbekistan. Accordingly, the number 

of operations on them. Thus, about 700,000 

cholecystectomies (CE) are performed annually in the 

  Research Article 

 

FEATURES OF SURGICAL TACTICS FOR “FRESH” DAMAGES OF THE MAIN 

BILY DUCTS 
 

Submission Date: January 21, 2024, Accepted Date:  January 26, 2024,  

Published Date: January 31, 2024  

Crossref doi: https://doi.org/10.37547/ajbspi/Volume04Issue01-12 

 

 

Rakhmanov K.E. 
Samarkand State Medical University, Uzbekistan, Samarkand 

 

Nasimov A.M. 
Samarkand State Medical University, Uzbekistan, Samarkand 

 

Journal Website: 

https://theusajournals.

com/index.php/ajbspi 

Copyright: Original 

content from this work 

may be used under the 

terms of the creative 

commons attributes 

4.0 licence. 

 

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Volume 04 Issue 01-2024 77 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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USA, more than 100,000 in Russia, and about 10,000 in 

Uzbekistan [5, 7, 13]. 

At the same time, the frequency and severity of bile 

duct injuries have noticeably increased and amount to 

0.2 - 1.9% [2, 4, 7, 8, 9, 11, 14, 16]. Authors dealing with 

this problem note that the introduction of laparoscopic 

cholecystectomy has led to a noticeable increase in the 

frequency and severity of bile duct injuries. Taking the 

average frequency of injuries to the main bile ducts 

(MBD) as 0.5 - 1% in Uzbekistan, from 50 to 100 people 

suffer from such a complication per year. 

Treatment of bile duct injury is extremely difficult, 

requires expensive therapeutic and diagnostic 

procedures, and leads to serious disability in patients. 

Mortality is 8-17%, complications during operations 

occur in up to 47% of cases, the development of post-

traumatic strictures of the bile ducts - up to 35-55% [1, 

3, 6, 10, 12, 15, 17]. 

The timing of detection of IVS damage is important in 

the outcome of treatment. There are “fresh” injuries 

and post-traumatic scar strictures of the bile ducts and 

biliodigestive anastomoses. “Fresh” injuries are 

divided into those diagnosed on the operating table 

and those detected in the early postoperative period. 

The results of studies, including in Uzbekistan, show 

that only in 30% of cases iatrogenic damage to the bile 

ducts is recognized during surgery, up to 50% of 

damage is diagnosed in the postoperative period 

against the background of the development of 

peritonitis, rapidly increasing obstructive jaundice or 

bile leakage through the drainage. More than 15% of 

patients die from progressive peritonitis, increasing 

jaundice or other postoperative complications that are 

not recognized in a timely manner. 

For the healthcare of our Republic, analysis of the 

frequency and causes of unsatisfactory results of 

surgical interventions on the biliary tract is extremely 

relevant. In addition, it is extremely important for 

practical surgeons to develop an algorithm of actions 

for “fresh” injuries of the bile ducts. 

Purpose of the study: optimization of surgical 

treatment of “fresh” injuries of the main bile ducts. 

METHOD 

An analysis of the results of surgical treatment of 103 

patients with “fresh” IVS injuries in the period 2014 – 

2023 was carried out. In our own observations, IVS 

injuries were noted in 38 (0.58%) patients in 6521 

cholecystectomies; 65 patients were admitted from 

other hospitals with “fresh” IVS injuries. 

In 78 patients there was intersection (9), excision (38) 

and excision with ligation of the proximal stump of the 

hepaticocholedochus (31), in 11 - a parietal edge wound, 

in 14 - alipation or ligation without crossing the 

duct.Localization of damage: common bile duct (CBD) 

- in 14 patients, common hepatic duct (CHD) - in 48, AHF 

and bifurcation area - in 31, AHF with destruction of 

confluence - in 10. The nature and location of damage 

are presented in Table. 1.  

 

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Volume 04 Issue 01-2024 78 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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Table 1. 

Nature and location of damage MZhP. 
 

Character 

 

 

 

 

 

Localization 

Edge damage 

Intersection Excision 

Excision and 

ligation 
Clipping or 

ligation 

without 

crossing 

Total 

+2 8 5 1 4 6 24 

+1 2 4 12 17 3 38 

0 1 - 8 4 5 18 

-1 - - 10 3 - 13 

-2 - - 7 3 - 10 

Total eleven 9 38 31 14 103 

 

In 28 (27.2%) patients, IVS damage was detected 

intraoperatively. In the vast majority - 75 (72.8%) 

patients, damage was detected in the early 

postoperative period: increasing obstructive jaundice 

was observed in 34 patients, biliary peritonitis - in 20, 

bile leakage - in 10, and a combination of two or more 

complications was observed in 11 patients. 

When intraoperative damage to the IVS was detected, 

out of 28 patients, 17 patients underwent restorative 

surgery and 11 patients underwent reconstructive 

surgery. 

Crossing and excision of the bile ducts. 

This type of damage was observed in 18 of 28 patients 

(64.3%), with transection in 6 (21.4%) and excision in 12 

(42.8%) patients. According to the terminology of bile 

duct strictures, damage “+2” (the length of the 

preserved proximal part of the AKI is more than 2 cm) 

was in 3 patients, “+1” (the length of the AKI is 1 cm) – 

in 6 patients, “0” - bifurcation injury - in 2 patients, “-1” 

(preservation of the arch of AKI confluence) – in 3 

patients and “-2” (AKI confluence is destroyed) – in 4 

patients. Thus, most patients had high damage. 

Damage was identified intraoperatively by the 

appearance of bile in the surgical wound and additional 

tubular structures in the removed gallbladder. 

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Volume 04 Issue 01-2024 79 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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11 patients from this group underwent reconstructive 

surgery: 9 of them had hepaticojejunostomy 

(Hepaticojejunostomy) with a loop of small intestine 

disconnected according to Roux, and 2 patients had 

HepDA applied. 

For injuries at the “+1”, “0” level, the site for 

anastomosis was created by dissecting the left hepatic 

duct, exposing it under the chiliary plate (Hepp-

Couinaud method). 

In 4 cases, when the damage occurred with the 

destruction of confluence (level “-2”), in order to form 

a single anastomosis with the jejunum, the platform 

was created by parallel suturing of the remnants of the 

lobar ducts along their medial walls, cutting the 

septum between them (Cattell method). After the 

neoconfluence was formed, both lobar ducts were 

additionally dissected, which significantly increased 

the diameter of the future anastomosis. 

Despite the small diameter of the ducts, it was possible 

to create a platform for anastomosis ranging in size 

from 10 to 25 mm (≤ 15 mm - 3; 16-25 mm - 7; ≥25 mm - 

1). In 2 patients, HepEA was placed on transhepatic 

frame drainage (TPCD) according to Seipol-Kurian due 

to the narrow diameter of the duct. 

Thus, the use of techniques developed during 

operations for IVS strictures made it possible to 

perform relatively wide precision anastomoses. 

 Reconstructive surgery (RBS) with transection 

(4) and excision (3) of the CBD and AKI was performed 

in 7 patients. 

Regional wound of the hepaticocholedochus. 

A marginal wound was observed in 10 (35.7%) patients. 

In 2, the AKI was damaged and in 8, the CBD was 

damaged. All patients underwent reconstructive 

surgery: 2-3 sutures (Prolene 5/0) were placed on the 

wall of the duct using a Kera drainage. 

The types of operations for patients with “fresh” IVS 

injuries detected intraoperatively are presented in 

Table 2. 

Table 2.  

Types of operations for patients with IVS injuries identified intraoperatively. 
Type of operation Quantity 

Suturing a duct defect on a Kera drainage 10 

BBA 7 

HepDA 2 

HepEA 9 

 

In the early postoperative period, IVS injuries were 

detected in 75(72.8%)patients, with intersection and 

excision in 60 (80%) patients, clipping or ligation 

without intersection in 14 (18.7%) and marginal damage 

in 1 (1.3%) patient. Damage “+2” was in 13 patients, “+1” 

– in 31, “0” – in 15, “-1” – in 9 and “-2” – in 7 patients. 

When injuries were detected without inflammatory-

infiltrative changes in the subhepatic space and 

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Volume 04 Issue 01-2024 80 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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hepatorenal failure (HRF), 35 patients underwent one-

stage surgery. 

Of the 14 patients with clipping or ligation of the duct, 

12 patients had the clips or ligature removed and 2 

patients had a BBA applied. During excision of HC, 

HepEA was applied to 8 patients, HepDA was applied 

to 2 patients, and BBA was applied to 10 patients 

simultaneously. In case of a marginal wound, 1 patient 

underwent suturing of the duct defect on the Kera 

drainage. 

In the presence of peritonitis, an inflammatory-

infiltrative process and PPN due to obstructive 

jaundice and cholangitis, the bile ducts of 40 patients 

were externally drained in the first stage, 

reconstruction was performed in the second stage. 

In this group, 3 patients died after the first operation 

due to advanced peritonitis and multiple organ failure. 

1 patient refused the second stage of the operation. 

After correction of the inflammatory-infiltrative 

process in the abdominal cavity and the clinic of PPN, 6 

patients were given HepDA and 30 patients were given 

HepEA, of which 27 anastomosis was applied to TPCD: 

according to Praderi-Smith (2), Seipol-Kurian (21) and 

Galperin (4 ). The indications for TPCD were high 

damage to the bile ducts and a narrow diameter of the 

duct. The types of operations for patients with “fresh” 

IVS injuries identified in the early postoperative period 

are presented in Table 3. 

Table 3. 

Types of operations for patients with IVS injuries identified in the early postoperative period. 
Type of operation Quantity 

Removing ligatures or clips 12 

BBA 12 

Suturing a duct defect on a Kera drainage 1 

HepDA 8 

HepEA 38 

External drainage of the bile duct 4 

 

RESULTS 

After correction of intraoperatively detected IVS 

injuries, no specific complications were observed in the 

immediate postoperative period. In the long-term 

postoperative period, cicatricial strictures of the bile 

ducts and BDA were detected in 35% (Table 4). 

In 7 patients, after the application of a BBA, a cicatricial 

stricture of the bile ducts was detected. In contrast to 

the marginal wound, with complete transection and 

excision of the bile duct, the axillary blood supply to 

the bile duct is disrupted, which leads to a cicatricial 

stricture, and the anastomosis in these cases is 

performed with tension. These patients required 

repeated interventions: HepEA was applied to 5 

patients; 1 – HepDA (had a history of gastric resection 

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Volume 04 Issue 01-2024 81 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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according to B-II); 1 – bile duct stenting with a 

satisfactory treatment result. 

In patients after the application of HepDA, attacks of 

cholangitis and BDA stricture were periodically 

observed in the long-term postoperative period. 1 

patient had HepEA applied and 1 patient periodically 

received sessions of balloon dilatation and diathermic 

expansion of the anastomotic area. 

After applying HepEA, out of 9 patients, an 

anastomotic stricture was observed in 1 patient. He 

underwent antegrade bougienage with a satisfactory 

treatment result. 

Table 4. 

Long-term results and types of re-interventions in the first group of patients. 

Types of operations Qty 

Stricture of 

the 

gallbladder 

and BDA 

Repeated intervention 

Suturing the defect on the Kera 

drainage 
10 - - 

BBA 7 7 
5-HepEA, 1-HepDA, 1-duct 

stenting 
HepDA 2 2 1-HepEA, 1-REBV 
HepEA 9 1 REBV 

 

In patients with IVS injuries detected in the early 

postoperative period after surgical interventions, 

specific complications were observed in 8% and 33% of 

cases, respectively, in the immediate and late 

postoperative periods. Death was observed in 6 (8%) 

cases: in 2 patients due to acute renal failure, 1 due to 

acute cardiovascular failure, 3 due to advanced 

peritonitis and multiple organ failure. 

In the immediate postoperative period, in 5 patients 

after the application of HepEA and HepDA, partial 

failure of the BDA was observed, which in 4 cases was 

manifested by bile leakage and 1 biloma of the 

subhepatic region. Bile leakage stopped 

spontaneously on days 11-15 after surgery, and the 

biloma was drained under ultrasound guidance. In 1 

patient, after the application of HepEA, hemobilia was 

observed in the immediate postoperative period, 

which was treated conservatively (Table 5). 

Table 5. 

Types of complications in the immediate postoperative period in the second group of patients. 
 

Type of complication Qty % 

Peritonitis 3 (3 deaths) 4 

Liver failure 4 (2 deaths) 5.33 

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Volume 04 Issue 01-2024 82 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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Cardiovascular failure 1 (fatal) 1.33 

Hemobilia 1 1.33 

Wound suppuration 4 5.33 

Partial failure of BDA 
Of these, external bile leakage 

biloma 

5 

4 

1 

6.67 

Total 18 24 

Of these, deaths 6 8 

 

In 15 patients, after reconstructive operations in the 

late postoperative period, a cicatricial stricture of the 

bile duct developed and they required repeated 

interventions: 12 patients were treated with HepEA; 1 

patient with HepDA, 2 patients with bile duct stenting. 

From this group, the patient, after applying HepDA, 

periodically takes courses of X-ray endobiliary 

intervention (REI) due to recurrent cholangitis and 

HepDA stenosis. 

All 7 patients with HepDA underwent repeated 

interventions: 2 patients had HepDA uncoupled and 

HepEA was applied, 5 patients received periodic REBV 

sessions. 

In 3 patients, after application of HepEA, stenosis of 

the MDA was observed. 1 patient underwent repeated 

HepEA and 2 patients periodically received 

conservative therapy (Table 6). 

Table 6. 

Long-term results and types of re-interventions in the second group of patients. 

Types of operations Qty 

Stricture of the 

gallbladder and 

BDA 

Repeated interventions 

Removing ligatures or clips 12 5 HepEA 

BBA 12 10 
7-HepEA, 2 – stent, 1-HepDA 

(REBV) 
Suturing the defect on the Kera 

drainage 
1 - - 

HepDA 8 7 2 – HepEA, 5 – REBV 

HepEA 38 3 
1 – HepEA, 2 – conservative 

therapy 
External drainage of the bile duct 4 - - 

Total 75 25 

15- HepEA, 2 – stent, 1-HepDA 

(REBV), 5 – REBV, 2 – 

conservative therapy 

 

In total, complications developed in 18 (17.5%) patients 

in the immediate postoperative period. In the long-

term period, an unsatisfactory result (development of 

stenosis) was observed in 35 (33.9%) patients: in 13 

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Volume 04 Issue 01-2024 83 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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(37.14%) and 22 (62.86%), respectively, after 

reconstructive and restorative operations. Repeated 

surgical interventions were required in 33 (32.03%) 

patients. 

CONCLUSION 

In recent years, the number of cholecystectomies has 

increased markedly and most of them are performed 

laparoscopically (according to our data - more than 

80%). The number of IVS injuries has also increased, and 

these injuries are particularly severe, since in addition 

to the high bifurcation mechanical trauma, the thermal 

effect on the duct wall is added. 

The best results were obtained in patients where 

operations were performed upon intraoperative 

detection of IVS injuries (in 84.3% of patients). But 

unfortunately, intraoperative detection of IVS injuries 

occurred in 27.2% of cases. In a significant proportion of 

patients, bile duct injuries are diagnosed late 

(according to our data - in 72.8%), after the 

development of bile peritonitis or obstructive jaundice. 

Because of this, most patients had to undergo external 

drainage of the bile ducts at the first stage, missing the 

opportunity to normalize bile flow immediately after 

injury. 

We believe that if damage to the IVS is detected in the 

immediate postoperative period against the 

background of peritonitis, subhepatic abscess, or bile 

leakage, at the first stage it is advisable to limit 

ourselves to external drainage of the biliary tract. It is 

advisable to perform reconstructive surgery after the 

inflammatory-infiltrative process subsides in 2-3 

months. This tactic was justified in 30 (73.1%) patients 

in this group. 

Our experience has shown that the main operation for 

complete transection and excision of the IVS is HepEA 

according to Roux-en-Y: a good long-term result was 

obtained in 97.01% of patients. HepEA without frame 

drainage significantly reduces the treatment time for 

patients, however, we were able to use the Hepp–

Couinaud method only in 11 patients in this group. The 

peculiarity of this operation is the isolation of the left 

hepatic duct at its confluence with the right duct under 

the portal plate. This makes it possible to isolate the 

ducts outside the scar tissue and apply an anastomosis 

up to 2-3 cm wide, mainly due to the left hepatic duct, 

avoiding long-term (up to 1.5-2 years) drainage of the 

anastomosis zone, which is burdensome for the 

patient. 

Restorative surgery is indicated only for partial 

marginal damage to the duct. In 11 patients of this 

group, by suturing the duct defect on the Kera 

drainage, we achieved a satisfactory result. When the 

duct is injured, in contrast to its complete intersection, 

good results are explained by the fact that the integrity 

of the narrow posterior wall of the duct ensures 

sufficient blood supply. 

The formation of the BBA during the intersection and 

excision of the duct in all 17 cases resulted in the 

formation of a scar stricture: 14 patients underwent 

reconstructive surgery, 3 - endoscopic stenting. Our, 

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Volume 04 Issue 01-2024 84 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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still small, experience with endobiliary stenting allows 

us to positively evaluate this method. 

Operations during which an anastomosis of the 

damaged duct with the duodenum was formed had a 

negative impact on the results of treatment. These 

patients developed chronic cholangitis and stenosis of 

the BDA, which required repeated reconstructive 

operations in 2 cases and endoscopic intervention in 9 

cases. 

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(ISSN – 2771-2753) 
VOLUME 04 ISSUE 01 PAGES: 76-85 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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