MANAGEMENT OF MINIMALLY INVASIVE SURGERY IN THE TREATMENT OF PROXIMAL BILE DUCT TUMOR OBSTRUCTION

Аннотация

Obstructive jaundice induces catastrophic homeostatic disturbances that threaten the patient’s life. The material of the study consisted from 42 patients with proximal biliary obstruction tumor treated in the Unit of Endoscopy and Miniinvasive Surgery of the Republican Government Hospital and MSPI Oncologic Institute, gastrology department, in the period between 2010–2018 years. There was carried out percutanattranshepatic decompression (PTHD) in 32 cases (76.2%) The success of the percutanattranshepatic approach in hilar tumors is in the limits of 90%. Keywords: tumoral obstructive jaundice, percutanattranshepatic external decompression. Background. Obstructive jaundice is a result of the serious complication of the biliary tract or pancreatic pathology, that during it’s evolution modifyes natural biliary flow from liver to the duoden. The obstructive jaundice is manifested by skin and mucous jaudice, skin prurit, modifications of urine and stool color. The pain and fever are also caracteristic for this syndrome [1; 2; 5; 6]. The main causes of the obstructive jaundice in patients after 50 years are malignant tumors. (67.3% cases) [5; 6]. The proximal extrahepatic bile duct tumors make 10–26% from whole malignant lesions of the bile duct [2; 3; 9; 10]. About 54.4% from these patients consists males. The metabolic disturbances induced by obstructive jaundice, threaten the patient’s life if the obstruction isn’t rezolved as quickly as posible. From surgical point of view these patients present a serious problem, because of low degree rezectibility of these tumors, while the obstruction has to be solved in a short time [2; 5; 6; 11]. As a solution, percutaneous biliary drainage for obstructive jaundice was introduced in 1970. It may be helpful in relieving obstructive symptoms, in special, those due to unresectable malignant tumors [3; 4; 7; 8; 9; 12; 13]. 53 THEORETICAL ASPECTS IN THE FORMATION OF PEDAGOGICAL SCIENCES International scientific-online conference Implemented endoscopic ultrasonography-guided biliary interventions are of great and increasing interest in patients with unresectable biliary malignant obstruction [3; 7; 9; 12; 13]. Percutaneous biliary drainage starts with the performance of percutaneous transhepatic cholangiography for the delineation of obstruction level. When the obstruction is high-degree, the external drainage is recomended [12; 13]. As a contraindication for percutaneous biliary drainage are mentioned presence of bleeging disorders and massive ascities [3; 4; 10]. Endoscopic ultrasound-guided biliary drainage is an effective alternative for rezolvation of a biliary obstructive jaundice in cases of unresectable tumor lesions [1; 3; 9]. The aim of our study was to decrease the severity of metabolic manifestations in obstructive jaundice syndrome in patients with proximal bile duct tumor obstruction by minimal invasive methods for the patients life quality improving in unresectable tumors or as a first step for surgical radical treatment. Materials and methods. The study is based on data of 42 patients with proximal bile duct tumor obstruction treated in our institutions from 2010 to 2018. Data on obstructive jaundice causes are presented in (table 1). Resulting from table, the patient’s age varies from 50 till 78 years old, middle age being 61.5 ±1.4 years. Male/female ratio being 1.2:1.0, excepting the gall bladder tumors with ratio 1.0: 5.0. All the patients have fulfilled the following main steps: 1. Clinical-analytic step – determination of metabolic disturbances; 2. Noninvasive step: ultrasound investigation, CT, MNR in cholangiography rejim; 3. Invasive step: endoscopic cholangiopancreatography (ECPG), percutaneotranshepatic punction (PTHP). In about 80% cases there was an opportunity to make an accurate diagnosis of malign tumor as a cause of obstructive jaundice by fulfilled diagnostic methods. The extra- and intrahepatic ducts enlarging have been observed by echography investigation in all cases. The maximum attension during the investigation has been attended to hepatic sizes, the biliary duct obstruction level, comon biliary duct implication, presence of ascities and metastatic lesions. Fig. 1 demonstrates enlargement of comon biliary duct (CBD), lack of ascities and hepatic metastatic lesions. These data presented the direct indications for biliary duct percutaneotranshepatic decompression. 54 THEORETICAL ASPECTS IN THE FORMATION OF PEDAGOGICAL SCIENCES International scientific-online conference To estimate the possibility of endoscopic drainage the retrograde endoscopy cholangiopancreatography (RECPG) has been fulfilled. The endoscopic bile ducts drainage is more physiological and comfortable for patients, producing good quality of life. Unfortunately, in 95% of our cases the RECPG results have been demonstrated a full common bile duct obstruction, that didn’t permit to make an endoscopic stent introducing. There is a case of principal bile duct obstruction demonstr