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ОРИГИНАЛЬНЫЕ СТАТЬИ
Абдурахманов Диёр Шукуруллаевич,
Ассистент кафедры хирургических болезньей №1
Самаркандский Государственный медицинский институт
Самарканд, Узбекистан
Анарбоев Санжар Алишерович,
Ассистент кафедры хирургических болезньей №1
Самаркандский Государственный медицинский институт
Самарканд, Узбекистан
Рахманов Косим Эрданович,
Доцент кафедры хирургических болезньей №1
Самаркандский Государственный медицинский институт
Самарканд, Узбекистан
ВЫБОР ХИРУРГИЧЕСКОЙ ТАКТИКИ ПРИ МЕХАНИЧЕСКОЙ ЖЕЛТУХЕ
АННОТАЦИЯ
Проанализирован опыт лечения 247 пациентов с механической желтухой, поступивших в клинику №1
СамГМИ в сроки с 2010 по 2020 годы. Для дифференциальной диагностики механической желтухи применяли
неинвазивные и инвазивные методы исследования. Эффективность механической литотрипсии достигла 86%.
Основным методом завершения чрескожных чреспеченочных эндобилиарных вмешательств, в случае
невозможности выполнения традиционного хирургического вмешательства, является эндопротезирование
желчевыводящих протоков. При выборе метода желчеотведения необходимо учитывать уровень обтурации
желчевыводящих путьей, распространение патологического процесса и состояние пациента. Двухэтапный
метод лечения синдрома механической желтухи, позволил уменьшить количество послеоперационных
осложнений на 17%, а летальность снизить до 2,8%.
Ключевые слова:
Миниинвазивные хирургические пособия, механическая литотрипсия, чрескожные
чреспеченочные эндобилиарные вмешательства.
Абдурахманов Диёр Шукуруллаевич,
1-сон хирургик касалликлар кафедраси ассистенти
Самарқанд Давлат тиббиёт институти, Ўзбекистон
Анарбоев Санжар Алишерович,
1-сон хирургик касалликлар кафедраси ассистенти
Самарқанд Давлат тиббиёт институти, Ўзбекистон
Рахмонов Косим Эрданович,
1-сон хирургик касалликлар кафедраси доценти
Самарқанд Давлат тиббиёт институти, Ўзбекистон
МЕХАНИК САРИҚЛИК УЧУН ЖАРРОҲЛИК ТАКТИКАСИНИ ТАНЛАШ
АННОТАЦИЯ
СамДТИ 1-клиникасига 2010-йилдан 2020-йилгача бўлган даврда қабул қилинган 247 нафар механик
сариқлик билан оғриган беморларни даволаш тажрибаси таҳлил қилинди. Механик сариқликнинг
дифференциал диагностикаси учун инвазив бўлмаган ва инвазив текширув усуллари қўлланилди. Механик
литотрипсиянинг самарадорлиги 86% га етди. Анъанавий жарроҳлик аралашувини амалга ошириш мумкин
бўлмаган тақдирда перкутор траншепатик эндобилиар аралашувларни якунлашнинг асосий усули ўт
йўлларининг ндопростетикасидир. Сафро олиб ташлаш усулини танлашда ўт йўлларининг обструкция
даражасини, патологик жараённинг тарқалишини ва беморнинг аҳволини ҳисобга олиш керак. Механик
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сариқлик синдромини даволашнинг икки босқичли усули операциядан кейинги асоратлар сонини 17% га
камайтириш ва ўлимни 2,8% га камайтириш имконини берди.
Калит сўзлар:
минимал инвазив жарроҳлик, механик литотрипсия, жигар орқали эндобилиар аралашув.
Abdurakhmanov Diyor Shukurullaevich,
Assistant of the Department of Surgical Diseases No. 1
Samarkand State Medical Institute
Samarkand, Uzbekistan
Anarboev Sanjar Alisherovich,
Assistant of the Department of Surgical Diseases No. 1
Samarkand State Medical Institute
Samarkand, Uzbekistan
Rakhmanov Kosim Erdanovich,
Associate Professor of the Department of Surgical Diseases No. 1
Samarkand State Medical Institute
Samarkand, Uzbekistan
CHOICE OF SURGICAL TACTICS FOR MECHANICAL JAICULAR
ANNOTATION
The experience of treating 247 patients with obstructive jaundice admitted to the 1st clinic of SamMI in the
period from 2010 to 2020 was analyzed. For the differential diagnosis of obstructive jaundice, non-invasive and
invasive research methods were used. The efficiency of mechanical lithotripsy reached 86%. The main method for
completing percutaneous transhepatic endobiliary interventions, if it is impossible to perform traditional surgical
intervention, is endoprosthetics of the bile ducts. When choosing a method of bile removal, it is necessary to take into
account the level of obstruction of the biliary tract, the spread of the pathological process and the patient's condition.
The two-stage method of treating obstructive jaundice syndrome allowed to reduce the number of postoperative
complications by 17%, and the mortality rate to 2.8%.
Keywords:
Minimally invasive surgical techniques, mechanical lithotripsy, percutaneous transhepatic
endobiliary interventions.
Introduction
.The problem of treating jaundice
of
mechanical
etiology
(obstructive,
obstructive,
subhepatic) remains one of the most intractable problems
of clinical surgery so far [2, 3, 4, 13, 15]. Despite the vast
arsenal of modern research methods, differential
diagnosis of obstructive jaundice is difficult, and late
identification of its true cause leads to a significant delay
in performing the necessary surgical intervention. Certain
achievements in the treatment of this severe category of
patients are associated, first of all, with the introduction
of modern (laparoscopic, endoscopic, ultrasound, X-ray
television) minimally invasive technologies into clinical
practice in medical institutions [1, 3, 4, 10, 17, 18].
Materials and methods
.The experience of
diagnostics and treatment of 247 patients with obstructive
jaundice, admitted to the 1st clinic of SamMI in the
period from 2010 to 2020, was analyzed. The patients
were between 17 and 81 years old, including 114 women
and 133 men.
Traditional surgical treatment of patients with
obstructive jaundice complicated by purulent cholangitis,
hepatic failure, thrombohemorrhagic syndrome, etc., is
very risky and is accompanied by high mortality [5, 8, 9].
Postoperative mortality in patients with non-neoplastic
jaundice is 10.4–25.2%, and in patients with neoplastic
jaundice it can reach 40% [3, 6, 12]. The high mortality
rate after traditional operations performed against the
background of prolonged obstructive jaundice required to
divide the treatment process in this severe category of
patients into two main stages: at the first stage,
decompression of the biliary tract using minimally
invasive technologies (percutaneous, endoscopic). After a
slow
elimination
of
biliary
hypertension
(rapid
decompression is undesirable, as it can lead to worsening
liver failure, hemobilia), elimination of endogenous
intoxication
(by
infusion
therapy,
hemodilution,
according to plasmapheresis indications), improvement of
the functional state of the liver proceeded to the final
second stage of treatment. In recent years, this two-stage
approach to the treatment of this severe category of
patients has found an increasing number of supporters [7,
9, 11, 14, 16]. In recent years, our widespread
introduction into clinical practice of new tactical and
technological schemes for treating patients with
obstructive jaundice through the use of sparing methods
of decompression of the biliary tract and methods of
sanitation of the ducts has significantly improved the
results of treatment. Indications for the use of one or
another method of decompression of the biliary tract
using
modern
minimally
invasive
technologies
(endoscopic, laparoscopic operations, operations from a
mini-access,
The most appropriate was the use of endoscopic
methods of biliary excretion in cholangiolithiasis
(especially choledocholithiasis), lesions of the terminal
section of the common bile duct (non-extended strictures,
stenosis of BSDK, papillitis, etc.)
Results.
The high diagnostic efficacy of ERCP
in 192 (77.73%) patients was favorably combined with
the possibility of performing therapeutic procedures
(papillosphincterotomy, litextraction and lithotripsy,
nasobiliary
drainage,
sanitation
of
bile
ducts,
implantation of endoprostheses, etc.) (Table 1).
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Tab. 1.
Kind of minimally invasive technologies in the treatment of obstructive jaundice (stage I - decompression of the bile
ducts)
See operations
Number of patients
abc.
%
I. Endoscopic methods
RCPH with temporary retrograde nasobiliary drainage
66
23.4
RCPG with endoscopic dosed papillosphincterotomy
47
16.67
RCPG with stenting
21
7.45
RCPG with mechanical litextraction
58
20.57
II. Puncture methods
External cholecystostomy under ultrasound control
41
14.54
Percutaneous transhepatic anterograde cholangiostomy (PTS) under the control
of ultrasound and X-ray EOP (electro-optical converter on the X-ray
endovascular complex "Integris V-3000") with stent arthroplasty
29
10.28
III. Laparoscopic methods
Laparoscopic cholecystostomy with drainage of the abdominal cavity and
omental bursa
14
4.96
Laparoscopic cholecystectomy with external drainage of the common bile duct
6
2.13
Total
282
100
Therapeutic tactics for choledocholithiasis has
now become more active in connection with the
development of various methods of litextraction and
lithotripsy. Litextraction is indicated for patients with a
burdened anamnesis, when it is undesirable to conduct
repeated X-ray contrast studies, with the danger of
concretions in the terminal section of the CBD, with
multiple small stones. The procedure is contraindicated
when the diameter of the calculus exceeds the diameter of
the CBD and the size of the papillotomy opening. The
need for literacy arose in 20.57% of patients. The
efficiency of mechanical lithotripsy reached 86%.
Nasobiliary drainage with a thin catheter, as a rule,
became the final stage of endoscopic interventions. The
wide possibilities of nasobiliary drainage have made it
possible to increase the efficiency of endoscopic
treatment methods and reduce the number of possible
complications. Nasobiliary drainage in 66 (23.4%)
patients was of great importance for endoprosthesis in 21,
treatment of external biliary fistula in 3, cholangiogenic
abscesses in 7, aspiration of bile for biochemical,
cytological and bacteriological studies, temporary
drainage of bile ducts in case of impossibility of
arthroplasty in 45 patients. In 47 patients with tumor
obstruction of the biliary tract, after a contrast study, PST
was performed, and in 21 patients - nasobiliary drainage
with endoprosthetics (stenting) of the extrahepatic ducts
and separate endoprosthetics of the hepatic ducts.
Endoscopic retrograde drainage greatly facilitated patient
preparation, without worsening their condition, to
subsequent operations on the biliary tract, and
arthroplasty was the final stage of treatment in 16
inoperable patients. If it was impossible to use or
inexpedient endoscopic methods of decompression and
drainage of the bile ducts (“high block” of the bile ducts),
percutaneous transhepatic cholangiostomy (PTS) was
used in 29 patients under the control of ultrasound and X-
ray television. External-internal drainage is the most
physiological. The intervention was ended with dosed
decompression of the biliary tract under conditions of
CChS, followed by the final restoration of the outflow of
bile in an operative manner. Dosed decompression of the
bile ducts was carried out by adjusting the lumen of the
draining catheter. The high level of occlusion in all
patients was due to the oncological process and dictated
the only possible method of decompression - CChS. In all
cases, the aim was to recanalize the tumor with external-
internal drainage for subsequent prosthetics or stenting of
the CBD. When the lobar hepatic ducts were
disconnected, their separate drainage was performed,
which was performed in 8 patients. In conditions of
purulent cholangitis, preference was given to external
drainage until complete sanitation of the bile ducts and
antibacterial therapy, taking into account the association
of aerobic and anaerobic microbial flora in 70.1% of
cases. In 5 cases of unresectable tumors, external
drainage was transferred to external-internal drainage,
followed by endoprosthetics. External cholecystostomy is
most acceptable in the complex therapy of acute
pancreatitis, complicated by obstructive jaundice.
Laparoscopic cholecystostomy was performed in 14
patients, percutaneous transhepatic cholecystostomy
under ultrasound control - 29. Bile excretion through
cholecystostomy with tumor lesion is limited due to
possible tumor stenosis of the cystic duct orifice. The
main method for completing percutaneous transhepatic
endobiliary interventions, if it is impossible to perform
traditional surgical intervention, is endoprosthetics of the
bile ducts. Endoprosthetics was performed, as a rule, at
the second stage (after stabilization of the patient's
condition), and in uncomplicated cases it was performed
simultaneously with drainage of the bile ducts.
Transhepatic endoprosthetics of the bile ducts in 29
patients with obstructive jaundice, caused by unresectable
tumors of the hepatopancreatoduodenal zone, was an
effective method of internal drainage, representing one of
the options for modern minimally invasive technologies,
and was considered by us as an alternative to surgical
operations in 12 patients. Out of 164 (66.40%) patients
with diseases causing acute obstruction of the bile ducts,
with the syndrome of painful obstructive jaundice, after
stage I - decompression of the biliary system, 137
(83.54%) were subsequently operated on. Treatment of 27
(16.46%) patients was limited to stage I endoscopic
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surgical interventions (PST - 20 (14.6%), temporary
stenting - 7 (5.11%). Stage II operations (radical - 124
(90.51%) ), palliative - 13 (9.49%) in this group of
patients (Table 2) representing one of the options for
modern minimally invasive technologies, and was
considered by us as an alternative to surgical operations
in 12 patients. Out of 164 (66.40%) patients with diseases
causing acute obstruction of the bile ducts, with the
syndrome of painful obstructive jaundice, after stage I -
decompression of the biliary system, 137 (83.54%) were
subsequently operated on. Treatment of 27 (16.46%)
patients was limited to stage I endoscopic surgical
interventions (PST - 20 (14.6%), temporary stenting - 7
(5.11%). Stage II operations (radical - 124 (90.51%) ),
palliative - 13 (9.49%) in this group of patients (Table 2)
representing one of the options for modern minimally
invasive technologies, and was considered by us as an
alternative to surgical operations in 12 patients. Out of
164 (66.40%) patients with diseases causing acute
obstruction of the bile ducts, with the syndrome of
painful obstructive jaundice, after stage I - decompression
of the biliary system, 137 (83.54%) were subsequently
operated on. Treatment of 27 (16.46%) patients was
limited to stage I endoscopic surgical interventions (PST -
20 (14.6%), temporary stenting - 7 (5.11%). Stage II
operations (radical - 124 (90.51%) ), palliative - 13
(9.49%) in this group of patients (Table 2) with the
syndrome of painful obstructive jaundice, after stage I -
decompression of the biliary system, 137 (83.54%) were
subsequently operated on. Treatment of 27 (16.46%)
patients was limited to stage I endoscopic surgical
interventions (PST - 20 (14.6%), temporary stenting - 7
(5.11%). Stage II operations (radical - 124 (90.51%) ),
palliative - 13 (9.49%) in this group of patients (Table 2)
with the syndrome of painful obstructive jaundice, after
stage I - decompression of the biliary system, 137
(83.54%) were subsequently operated on. Treatment of 27
(16.46%) patients was limited to stage I endoscopic
surgical interventions (PST - 20 (14.6%), temporary
stenting - 7 (5.11%). Stage II operations (radical - 124
(90.51%) ), palliative - 13 (9.49%) in this group of
patients (Table 2)
Tab. 2.
The nature of surgical interventions for diseases of the pancreatobiliary zone, complicated by obstructive jaundice, after
decompression of the bile ducts and relief of jaundice (stage II - radical and palliative traditional surgical operations)
The nature of the operation
Number of patients
%
%
I. Radical surgery for cholelithiasis
Laparoscopic cholecystomy after PST, cholelite extraction
63
28.64
Traditional
cholecystectomy,
choledocholithotomy,
external
choledochostomy (according to Keru, Vishnevsky, Halstead)
17
7.72
Traditional cholecystectomy, supraduodenal choledochoduodenostomy
(according to Yurash)
27
12.27
II. Radical surgical interventions for tumor and non-tumor diseases of the bile ducts
Resection of the common bile duct with the formation of
hepaticoenteroanastamosis
3
1.36
Pancreatoduodenal resection
4
1.82
Dissection of the stricture of the common bile duct with the formation
of choledochojejunostomy
III. Radical surgical interventions for other diseases of the pancreatobiliary zone
Pancreatoduodenal resection
14
6.36
Longitudinal pancreatojejunostomy with choledochoduodenostomy
(according to Yurash)
2
0.91
Cystoduodeno-, cystojejunostomy on the off loop (Ru)
13
5.91
Extended cholecystectomy with resection of the IV liver segment
2
0.91
IV. Palliative operations
Cholecystojejunostomy with entero-enteroanastomosis (according to
Monastyrsky Shalimov)
17
7.73
Choledochojejunostomy with enteroenteroanastomosis (according to
Herzen-Ru)
12
5.46
Cholecystojejunostomy,
gastrojejunostomy
with
entero-
enteroanastomosis
14
6.36
Diagnostic laparoscopy (removal of ascites, tissue biopsy)
9
4.1
Total
220
100
was performed after stopping the phenomena of liver
failure and normalizing the level of bilirubin in the blood
(mean 4.8 days). Laparoscopic cholecystectomies were
performed in 63 (28.64%) patients after performing PST,
cholelitoextraction. After unsuccessful attempts at
endoscopic
cholelithotripsy
and
"fixed"
large
concrements of the CBD, 44 (32.12%) patients underwent
traditional
cholecystectomy
with
intraoperative
choledochoscopy, cholelithotomy, and drainage of the
CBD
in
17
(12.41%),
with
choledochoduodenoanastomosis in 27 (19.71%) %) of
patients. This group of patients was characterized by the
largest
number
of
performed
radical
surgical
interventions, of which more than 50% - by the
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endovideosurgical method. It should be noted that
jaundice in these patients quickly gave in to relief as a
result of stage I surgical procedures, and the phenomena
of hepatic-renal failure were noted only in 17.4% of cases
with SVR syndrome (acute pancreatitis, cholangitis,
biliary sepsis). Out of 83 (33.60%) patients with diseases
causing chronic (tumor) obstruction of the spruce ducts,
with the syndrome of painless obstructive jaundice, 63
(75.90%)
were
operated
on
after
the
first
"decompression" stage. Treatment of 20 (24.10%)
patients with locally advanced tumors and the fourth
stage of the oncological process was limited to
performing stage I operations (endoscopic permanent
stenting - 19 (22.89%), internal intrahepatic stenting after
PChS - 8 (9.64%). causing chronic (tumor) obstruction of
the spruce ducts, with a syndrome of painless obstructive
jaundice, after the first "decompression" stage 63
(75.90%) were operated on. Treatment of 20 (24.10%)
patients with locally advanced tumors and the fourth
stage of the oncological process was limited to
performing stage I operations (endoscopic permanent
stenting - 19 (22.89%), internal intrahepatic stenting after
PChS - 8 (9.64%). causing chronic (tumor) obstruction of
the spruce ducts, with a syndrome of painless obstructive
jaundice, after the first "decompression" stage 63
(75.90%) were operated on. Treatment of 20 (24.10%)
patients with locally advanced tumors and the fourth
stage of the oncological process was limited to
performing stage I operations (endoscopic permanent
stenting - 19 (22.89%), internal intrahepatic stenting after
PChS - 8 (9.64%).
Purulent septic complications (suppuration of
postoperative wounds - 28 (11.34%), pneumonia - 7
(2.83%), biliary sepsis - 6 (2.43%) ) were most often
manifested in the postoperative period in patients with
tumors
of
the
CBD,
OBD,
choledocholithiasis,
accompanied by purulent cholangitis, cholangiogenic
abscesses of the liver. Insolvency of pancreatojejuno-,
biliodigestive anastomoses, accompanied by bile leakage
and pancreatic fistulas - 7 (2.83%), progression of hepatic
renal failure and hemorrhagic disorders - 13 (5.26%),
myocardial infarction - 2 (0.81%) - developed in a group
of patients over 60 years of age with malignant genesis of
obstructive jaundice (after PDD for cancer of the
pancreatic head, CBD resection for adenocarcinoma,
extended cholecystectomy for signet ring cancer,
Conclusion. When choosing bile duct, it is
necessary to take into account the level of obstruction of
the biliary tract (proximal or distal), the spread of the
pathological process to the surrounding organs and
tissues and the patient's condition (is it planned to
perform radical surgery after drainage of the bile ducts
and decompression), the projected life time after
minimally invasive intervention, if radical the operation
is not indicated, the likelihood of possible complications,
material and technical support and the level of
preparedness of the surgeon for one or another type of
operation.
Tab. 3.
Postoperative complications and causes of death patients with obstructive jaundice
The nature of postoperative complications complications
Number of
complications
Deaths
abc.
%
abc.
%
Insolvency of pancreatojejun-, biliodhistivny anastomoses, bile
leakage, pancreatic fistulas
7
2.83
1
0,4
Early acute postoperative pancreatitis
20
8.1
1
0,4
Intra-abdominal bleeding (arrosive)
3
1.21
1
0,4
Acute gastrointestinal ulcers complicated by bleeding
24
9.72
Progression of hepatic renal failure and hemorrhagic disorders
13
5.26
2
0.81
Biliary sepsis
6
2.43
2
0.81
Hemobilia
1
0,4
Suppuration of a postoperative wound
28
11.34
Pneumonia
7
2.83
Acute myocardial infarction
2
0.81
Total
111
44.93
7
2.82
A two-stage method of treating obstructive
jaundice syndrome, complicating the course of benign
and malignant diseases of the biliary-pancreatoduodenal
zone (the first stage is decompression of the bile ducts,
the
second stage is the implementation of radical and
palliative traditional surgical interventions), made it
possible to reduce the number of postoperative
complications by 17%, and the mortality rate to 2, 8%.
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