Objective. To improve the quality of diagnosis and results of treatment in patients, suffering an acute cholecystitis, complicated by formation of perivesicular infiltrate, abscess and Mirizzi’s syndrome. Materials and methods. Results of diagnosis and surgical treatment of 694 patients, suffering an acute cholecystitis, ageing 38 - 87 yrs old, admitted to the clinic in 2010 - 2019 yrs, were analyzed. The examination have included general clinical investigation, biochemical investigations of the blood, ultrasonographic investigation of a gallbladder and extrahepatic biliary ducts, and in accordance to certain indications – computer tomography, papilloscopy and endoscopic retrograde cholangiopancreaticography. Results. Of 694 patients, suffering an acute cholecystitis in 541 (78.0%) perivesical complications were revealed. In 215 (31.0%) patients perivesical infiltrate was formed, while in 76 (11.0%) – perivesical abscess. In 250 (36.0%) patients an acute cholecystitis have developed on background of obturation jaundice, caused by choledocholithiasis in 138 patients, while in 98 patients Mirizzi’s syndrome Type I was diagnosed, and in 14 - Mirizzi’s syndrome Type II. Of 215 patients with an acute cholecystitis and perivesical infiltrate in 84 laparoscopic cholecystectomy was performed after course of antibacterial therapy, while in 131 patients – open cholecystectomy. In all 76 patients with perivesical abscess open cholecystectomy was performed. Of 138 patients, suffering obturation jaundice on background of choledocholithiasis in 82 endoscopic retrograde cholangiopancreaticography with simultaneous lithoextraction and subsequent laparoscopic cholecystectomy was conducted. In 56 patients naso-biliary drainage was installed and was held in place till calculi from common biliary duct have gone away and subsequent laparoscopic cholecystectomy performed. Of 98 patients with an acute cholecystitis and confirmed Mirizzi’s syndrome Type I in 95 laparoscopic cholecystectomy was performed, while in 3 – the open one. Of 14 patients, suffering Mirizzi’s syndrome Type II, in 10 open operation was done with sanation of biliary ducts and plasty of a common biliary duct defect, while in 4 – laparoscopic cholecystocholedocholithotomy with restoration of the bile physiological passage. Conclusion. In 78.0% patients with an acute cholecystitis perivesical complications were diagnosed. Of 531 patients with perivesical infiltrate, choledocholithiasis and Mirizzi’s syndrome in 321 (60.5%) laparoscopic operations on biliary ducts were accomplished. Open laparotomy was performed in 210 (39.5%) patients. In all the patients, suffering Mirizzi’s syndrome of both Types, physiologic passage of bile was preserved.
Мета роботи: поліпшити результати лікування хворих на жовчнокам’яну хворобу, ускладнену синдромом Міріззі, шляхом покращення якості його передопераційної діагностики та удосконалення хірургічного лікування через відновлення фізіологічного пасажу жовчі у дванадцятипалу кишку. Матеріали і методи. Проведено ретроспективний аналіз 898 хворих на гострий холецистит, синдром Міріззі діагностували у 117 хворих, перший тип – у 74, другий тип – у 43 пацієнтів. Комплекс обстеження складався з даних аналізів, клініко-лабораторних методів, променевих методів (ультразвукова діагностика, комп’ютерна томографія), інструментальних методів (фіброгастродуоденоскопія, ендоскопічна ретроградна холангіопанкреатографія). Отримані результати дослідження зіставляли з результатами оперативного лікування. Результати досліджень та їх обговорення. Аналіз 898 історій хвороби пацієнтів із гострим холециститом показав, що синдром Міріззі було виявлено у 117 (13 %) хворих, зокрема перший тип був у 74 (8,3 %), а другий – у 43 (4,7 %). З 74 хворих із першим типом ЛХЕ виконана в 43 (58 %) випадках, а у пацієнтів із другим типом синдрому Міріззі лапароскопічна холецистохоледохолітотомія виконана у 3 (6,9 %) хворих. Зі 117 пацієнтів з обома типами синдрому Міріззі у 46 (39,3 %) були виконані лапароскопічні втручання. У всіх 117 (100 %) хворих було відновлено фізіологічний пасаж жовчі у дванадцятипалу кишку шляхом використання оригінальної техніки оперативних втручань, пріоритетність яких захищена патентами України. Удосконалення діагностичних прийомів для виявлення синдрому Міріззі та визначення його типу, а також використання нових способів виконання оперативних втручань дало змогу уникнути конверсій та ятрогенних ушкоджень жовчних проток.
Summary. Objective — a retrospective analysis of the causes of TEI complications and the results of their treatment. Materials and methods. The long-term results of performed TEI in 2909 patients were analyzed. The most common indication for TEI was choledocholithiasis, which was found in 1873 (65.4 %) patients and stenosis of papilla was detected in 454 (15.6 %) patients. Complications arose in 112 (3.85 %) patients. 4 (0.14 %) patients died. Results. Bleeding occurred in 28 (0.96 %) patients. In 12 of 26 patients, endoscopic hemostatic manipulations were additionally performed. Two patients with profuse bleeding from a papillotomy wound were urgently operated on, one patient died. Acute pancreatitis occurred in 68 (2.33 %) patients, of which 56 (1.92 %) had an edematous form, and 12 (0.41 %) patients had a destructive form. 11 patients were operated on from 2 to 15 days from the onset of the disease. Two patients with pancreatic necrosis died of intoxication, the source of which was progressive retroperitoneal necrosis. In 5 (0.17 %) patients, intervention on the papilla was complicated by perforation of the wall of the duodenum. 4 out of 5 patients were urgently operated on (B-2 antrumectomy, external drainage of the common bile duct and retro duodenal space). All 4 patients recovered. In 1 patient, complication was diagnosed on the 5th day after the intervention, which led to delayed surgery and the death of the patient. In 11 patients (0.38 %), a Dormia basket with a stone in the distal part of the common bile duct wedged when trying to extract it. Only one of 11 patients was operated on as planned; in the remaining 10, the problem was resolved with repeated TEI. Conclusions. Punctual technical implementation of all stages of manipulation, selective cannulation of the bile ducts, careful x-ray control of the position and advancement of the instrument in the ducts helps to reduce the number of complications after TEI.
Abstract. The aim of the study is to improve the treatment results of patients with AP with jaundice syndrome by improving the quality of differential diagnosis of the nature of concomitant jaundice. Materials and methods of research. The treatment results of 52 patients with acute pancreatitis complicated by jaundice syndrome were analyzed, jaundice was mechanical in 42 (80.9 %) cases, parenchy-mal – in 10 (19.1 %). Results and discussion. 28 from 42 patients with acute pancreatitis and mechanical jaundice caused by concretion in the large duodenal papilla, choledocholithiasis and papillitis underwent endoscopic papillosphincterotomy with nasobiliary drainage. In 7 cases open cholecystectomy with choledocholithotomy and retroduodenal space drainage were performed due to the large size of concretions. LChE was performed in 21 case, elective laparoscopic cholecystectomy was performed in 14 patients with compression of the common hepatic duct by inflammatory infiltrate in the gallbladder neck. There were no fatalities in the group of patients with acute pancreatitis and mechanical jaundice. In the group of patients with acute pancreatitis and parenchymal jaundice 4 from 10 patients died, mortality was 40 %. Conclusions. Ultrasound is required for differential diagnosis of mechanical and parenchymal jaundice in acute pancreatitis, which allows the determination of the treatment tactics, type of surgery and the extent of conservative therapy.