В настоящее время стратегия предоперационного лечения пациентов с механической желтухой опухолевого генеза не определена. Продолжаются дискуссии о показаниях к желчеотведению, выборе метода билиарного дренирования и его продолжительности. Анализ международных исследований показал, что рутинное предоперационное дренирование "по умолчанию" не рекомендовано. Показания к билиарному дренированию при резектабельном процессе определяют по тяжести механической желтухи, холангиту, срокам предстоящей операции, а при проксимальном уровне билиарного блока-по типу опухоли по Bismuth-Corlette. Выбор антеградного или ретроградного способа предоперационного желчеотведения зависит от уровня билиарного блока и возможностей лечебного учреждения. В большинстве исследований показано, что предпочтительными являются ретроградные (эндоскопические) способы при дистальном блоке и антеградные (чреспеченочные)-при проксимальном. Сроки предоперационного дренирования зависят от нормализации показателей биохимического анализа крови. Увеличение продолжительности дренирования может способствовать развитию ранних послеоперационных осложнений. Оптимальным сроком считают 2 нед. Для успешного лечения больных механической желтухой опухолевого генеза необходимо максимально достоверно определить причину ее развития, что позволяет выработать стратегию и тактику в конкретной клинической ситуации. Целесообразность и способ билиарной декомпрессии следует рассматривать в соответствии с выбранной стратегией лечения пациента.
Aim. To analyze complications of percutaneous transhepatic cholangiostomy depending on biliary obstruction level and drainage type.Material and methods. Percutaneous transhepatic biliary drainage was carried out in 974 patients with mechanical jaundice of different genesis. External drainage was predominantly performed for distal obstruction, external-internal suprapapillary – for proximal obstruction. Strictures of biliodigestive anastomosis were managed using percutaneous balloon dilatation and long-term external-internal drainage.Results. Overall morbility was 19.1%. Significant relationship between morbidity and obstruction level, drainage type and tubes quantity was detected. Drainage tube dislocation was the most common drainage-related complication both in proximal and distal obstruction. External-internal transpapillary drainage was followed by suppurative cholangitis and acute pancreatitis in 81.5% of cases. External-internal suprapapillary drainage was accompanied by acute cholangitis in 17.1% of patients and was determined by disconnection of subsegmental ducts that required additional drainage tubes placement. In most cases, complications were corrected by minimally invasive surgery and nonsurgical treatment. Overall mortality was 1.3% (0.3% in cases of distal obstruction and 1.8% in cases of proximal obstruction).Conclusion. Percutaneous transhepatic biliary drainage is a routine non-traumatic method of biliary decompression that may be successfully used irrespective to obstruction level and cause of jaundice. External-internal suprapapillary drainage is preferable for proximal biliary obstruction while external-internal transpapillary drainage should be avoided.
The management of biliary decompression in malignant hilar carcinoma remains controversial. This review shows the most relevant aspects of endoprosthetics for proximal biliary obstruction, including necessity of stenting and morphological verification before radical surgery, selection of approach to drain etc. The main contradictions and ways to solve them are presented in this article, based on evidence researches, international and expert consensus conferences.
Aim. To evaluate the effectiveness of percutaneous ALPPS as a method for preventing post-resection liver failure.Materials and methods. The methodology involved a retrospective study of the results of portovenous embolization and percutaneous radiofrequency assisted liver partition with portal vein embolization (PRALLPS), in case of the future liver volume <40% . The degree of hypertrophy of the future liver remnant and its rate were assessed in two groups. Complications of manipulation and frequency of postresection hepatic failure were studied.Results. In the first stage, portenous embolization was successfully performed in 38 patients and PRALLPS was successfully performed in 47 patients. In the second stage, liver resection was performed in 27 (71.1%) and 33 (70%) patients. The most frequent complication of PRALLPS was bile accumulation in the radiofrequency ablation area (13.1%). The incidence of other complications of the first stage did not differ between groups. No differences in blood loss or incidence of liver failure were reported after the second stage. No fatal outcomes reported. The mean degree of hypertrophy and growth did not differ between the groups. The mean time of hypertrophy of the future liver remnant after percutaneous radiofrequency assisted partition of the parenchyma with portal vein embolization and portenous embolization was 13 ± 5 and 18 ± 7 days (p = 0.008).Conclusion. The results of percutaneous radiofrequency assisted liver partition with portal vein embolization are comparable in terms of safety with those of portenous embolization. Radiofrequency partition of the parenchyma with portal vein embolization enables optimal hypertrophy of the future liver remnant to be achieved faster.
Aim. To analyze radiofrequency ablation per se and in combination with other X-ray surgical procedures in patients with liver and bile ducts malignancies. Material and methods. Radiofrequency ablation was used in three groups: percutaneous intervention or in combination with liver resection – group 1 (n = 111); ablation combined with intra-arterial chemoembolization (n = 3) – group 2; RFA followed by right portal vein embolization (RALPPES) in order to induce liver hypertrophy to enable liver resection – group 3 (n = 20). Results. There were no recurrences after radiofrequency ablation. Two-year survival was 55% in patients with hepatocellular carcinoma and liver cirrhosis.Colorectal cancer metastases were followed by 4-year survival near 55%. RFA combined with intra-arterial chemoembolization were associated with complete tumor destruction in patients with hepatocellular carcinoma over 4–5 cm and stabilization in patients with progressive intrahepatic cholangiocarcinoma. Liver hypertrophy was over 50% in two weeks after RALPPES that enables liver resection in 95% of patients. Symptoms of liver failure after hemihepatectomy were not observed in any patients. Conclusion. Combination of interventional methods is able to improve outcomes in patients with liver and bile ducts malignancies.
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