Роль и место эндобилиарных вмешательств в хирургическом лечении механической желтухи доброкачественного генеза

Аннотация

Topicality and demand of the subject of dissertation. Obstructive jaundice (OJ) and its complications remain one of the most essential issues in modem surgery. According WHO data, about 10% of adult population worldwide suffer from gall-stone disease (GSD), and this ratio duplicates each decade. It is more significant in the age over 40, when morbidity risk rises 4-10 times more. Moreover, with the aging of patients the number of exacerbations of the disease increases, patients are significantly more likely to develop complications, primarily c ho ledo c ho lithias is. The rates are much worse, if OJ is associated with suppurative cholangitis or acute pancreatitis, as well as in elderly or old age patients. Postoperative mortality consists 5.6-6.3%, in patients with purulent cholangitis this rate reaches 33%. Two-stage treatment method is the key to solving the problems associated with OJ in the existing variety of therapeutic tactics. However, performing endoscopic papillosphincterotomy (EPST) at the first stage is not always possible, and microcholecystostomy has several disadvantages. Recently, the use of percutaneous pcrhepatic therapeutic and diagnostic procedures in patients with OJ is of growing interest. Percutaneous perhepatic cholangiography (PPCG) not only solves diagnostic tasks, but also helps to conduct external drainage of bile that, in some cases, allows avoiding urgent open surgical intervention, eliminating clinical and inflammatory manifestations of the disease, preparing the patient and performing the second main stage of surgical treatment in a safe period. However, to date such treatment issues for OJ as stages, sequence of application of minimally invasive and traditional open methods, as well as effectiveness in case of their combination therefore continue to be contentious. Therefore, the topic of dissertation is relevant and requires further investigation. According the Decree of the President of the Republic of Uzbekistan reg. No 2107 from 10 Nov 1998, the new Republican Service of Emergency medicine has been created. Taking this to account, current research devoted to optimizing of one of the most essential problems in Emergency medicine. The purpose of the study: was to improve results of surgical treatment of patients with obstructive jaundice of benign genesis through optimization approaches to staged use of minimally invasive and reconstructive interventions. The scientific novelty of the dissertation is as follows: it was scientifically assessed the informativeness of modem methods of X-ray non-invasive imaging and minimally invasive methods of direct contrasting of BD to clarify the etiological causes, nature and level of lesion in OJ of BG. The characteristic sonographic, magnetic-resonance, endoscopy, X-ray cholangiographic semiotics of OJ ofBG. the algorithm of therapeutic measures in various variants of OJ of BG, based on wide use of minimally invasive diagnostic and therapeutic endobiliary interventions and staged performing of open surgeries. for the first time were offered the original classification of paravattcral diverticula and appropriate technical solutions for overcoming the difficulties of conducting endobiliary transpapillary interventions arising from anatomical abnormalities of the structure of LDP zone. indications for antegrade endobiliary interventions were precised, diagnostic and therapeutic capabilities were greatly expanded and methods of minimally invasive decompression of the biliary system in cholcdocholithiasis and scar strictures of extrahepatic biliary ducts were improved. it was proposed and introduced into clinical practice the original method of plasty of vesico-cholcdochal fistula in Mirizzi syndrome by forming the cystic duct with flap from the wall of gallbladder that helps to eliminate defect of choledochus; pathognomic cholangiographic symptoms characteristic for Mirizzi syndrome were identified. for the first time was developed and introduced into clinical practice a fundamentally new way of forming bilio-biliary and bilio-digestive anastomoses with the use of external metal carcass that allows to prevent the development of stenosis of anastomosis at late postoperative period. for the first time was developed a universal tool for transhepatic drainage of the common bile duct by Pradcry-Smith that allows to quickly impose cholangioscopy and to minimize injury of liver parenchyma. Conclusions 1. On the modem stage of the development of biliary surgery, we can consider endoscopic transpapillar and antegrade percutaneous endobiliary procedures are methods of choice for decompression of bile ducts decompression in patients with OJ of BO. They are obligatory to provide adequate urgent aid for these patients. 2. The number of patients hospitalized with acute forms of GSD has been continued to increase (on 37.5%) for over a 10-year observation period. The number of patients with choledocholithiasis during this period increased more than 4.5-fold, its frequency among patients with acute forms of GSD increased from 7.2% to 20.1%. 3. Cholcdocholithiasis (in 67.5% of cases) and LDPstenosis (21.2%) are the dominating reasons of OJ of BG. 34.5% of patients with mechanical jaundice of benign genesis refer to clinic with complicated course of disease (suppurative cholangitis, liver abscesses, hepatic failure, acute ulcers of stomach and duodenum and their combination). There is a direct correlation between complication rate and jaundice duration (%2=667.95; p<0.0001). 4. Among X-ray non-invasive imaging techniques, ultrasound examination shows high sensitivity and informativeness in assessing the diameter of intra- and extrahepatic bile ducts. Together with availability and ease of its use, this allows using it as a primary screening diagnostic method. Opportunities of MSCT in patients with mechanical jaundice of benign genesis are limited by expansion of intra- and/or extrahepatic bile ducts and visualization of proximal level of stricture. In good sensitivity of MSCT in detecting CTS and LDP stenosis (88.0%), the specificity and overall accuracy of this method remain very low (46.2% and 69.7%, respectively). 5. By diagnostic value, MRCPG is not inferior methods of direct roentgenocholangiography. Use it at choosing the method of endobiliary diagnostic and therapeutic interventions in patients with mechanical jaundice allows reducing the number of «vain» RPCG and EPST. Diagnostic values of methods of BD direct contrasting (RPCG and PPCG) in mechanical jaundice of benign origin are 98.2% and 99.1%, respectively. 6. The presence of paravattcral diverticula is not a contraindication for performing diagnostic and therapeutic transpapillary interventions. Compliance with the technical protocols of performing papillosphincterotomy with regard to our proposed classification of diverticula provides higher efficiency (89.1% vs. 75.0%) and safety (the frequency of complications is reduced from 16.7% to 6.5%) of endoscopic endobiliary procedures. 7. Active and combined use of endoscopic methods of staged wide dissection of the Vater papilla, LDP balloon dilatation, mechanical lithotripsy, nasobiliary drainage with spiral probe in patients with large stones of choledochus three-fold reduces the frequency of inefficient procedures. 8. Use of PPCS (authors inventory certificates # 1572562 and # 1454400, invention # IDP 2001 0255|DF), expansion of indications for additional roentgenoendovascular therapeutic procedures could improve BD external drainage in 100% of cases, significantly improve indicators of successful externalinternal drainage of bile ducts, according to the method of our clinic from 45.8% to 82.2%, excrete stones into duodenum from 18.3% to 61.1%, and balloon dilation of narrowing parts from 16.6% to 72.8%. Proposed approaches to PPCS technique could reduce the overall frequency of complications from 53.3% to 40.4%. The increase of intervention of therapeutic procedures has no effect in terms of mortality (6.7-6.6%). 9. Characteristic X-ray signs of Mirizzi syndrome are localization of blocking stone at the level of the middle third of hepaticocholcdochus, absence of CTS extension, absence of shadow of cystic duct at contrasting gallbladder, «disappearance» of catheter retrogradely introduced into gallbladder. 10. In Mirizzi syndrome the proposed method of plasty of fistulous opening with formation of cystic duct (optimizing invention # 00004 from 20.12.2012) allows to drain the common bile duct by Pikovsky that contributes to decrease in the frequency of failure of cholcdochus sutures from 12.5% to 7.7%. In patients with Mirizzi syndrome, who had operated without prior endobiliary BD decompression, postoperative mortality reached 30.8%, and after two-stage surgical treatment this rate reduced to 5.9%. 11. When performing reconstructive-restoration interventions in patients with iatrogenic injuries of BD, the formation of bilio-biliary and bilio-digestive anastomoses on metal carcass (patent # IAP 04332 from 13.04.2011) reduce the invasiveness and complexity of operation, increase the reliability of anastomosis, contribute to significantly reduction of the frequency of early and late postoperative complications (from 20.0% to 9.5% and from 25.0% to 14.3%, respectively). 12. In performing of transhepatic bile duct draining by Pradery-Smith for decompression of bile tree, the usage of original device can reduce surgical injury, diminish the time for CBD draining in 7-8 times.