In this study, the analysis of morphological changes of the gallbladder was carried in patients with acute cholecystitis of four age groups: young (25-44), middle (45-59), old (60-74) and senile (75-89) age. In patients older than 50 years the more pronounced growth of dense connective tissue (p=0,028) and a higher degree of lymphocytic infiltration (p=0,045) was observed in the adventitia as compared to women younger than 50 years. In patients of the elderly and senile age in the mucosa the number of macrophages was higher than in women of the young and middle age (p= 0,03). In the old age group, the cross-sectional area of the nuclei of the surface epithelium was significantly higher than young women (p=0,018). These changes point to chronic protracted course of gallstone disease in women of older age groups and acute inflammation in patients of the younger age.
The ratio of the prevalence of the gallstone disease (GSD) in the elderly and senile age groups compared with young and middle-aged patients can reach 3:4. The main complication of the GSD is acute cholecystitis, which is observed in more than 90% of patients. However, the most dangerous complication is considered to be obstructive choledocholithiasis, which leads to the development of mechanical jaundice and cholangitis in 10 - 35% of cases. The aim of the researchwas to propose an algorithm for the treatment of the GSD complicated by acute cholecystitis and obstructive choledocholithiasis in elderly and senile patients with severe concomitant pathology. Methods.The study is based on the analysis of the results of examination and treatment of 47 patients with GSD complicated by acute calculous cholecystitis and obstructive choledocholithiasis. All patients were divided into 3 groups. The first group included 17 patients in whom, in addition to acute cholecystitis, choledocholithiasis with concretion infringement in the BSDK was detected. The second group included 24 patients in whom, in addition to acute cholecystitis, obstructive choledocholithiasis and cholangitis were diagnosed. The third group included 6 patients in whom for some reason choledocholithiasis was not diagnosed at the first stage or it occurred later as a complication of cholecystostomy. Results.For patients of the first group the endoscopic papillosphincterotomy on stone was performed followed by cholangiography to find out the status of the bile ducts. Patients of the second underwent percutaneous transhepatic choledochostomy at the first stage. Patients of the third group were injected a Foley catheter into the cavity of the gallbladder through the cholecystostomy opening and the cavity of the gallbladder was sealed. Saline solution was injected into the lumen of the gallbladder and its ducts under the pressure of 250 mm. aq. art. This led to the dilatation of the lumen of the bile ducts. Conclusions.The proposed algorithm allows radical treatment of the GSD complicated by choledocholithiasis and cholangitis. The differentiated approach to the transpapillary solution of choledocholithiasis allows to minimize the risk of post-manipulation pancreatitis. AAPST allows to cure choledocholithiasis when endoscopic papillosphincterotomy is dangerous or not feasible.
Relevance. The prevalence of cholelithiasis increases with age and reaches 25-30% in elderly and senile patients [1]. The "golden standard" of surgical intervention for acute cholecystitis, by right, is considered to be video-laparoscopic cholecystectomy, but with severe concomitant pathology, video-laparoscopic cholecystectomy is limited. Even with the "open" cholecystectomy in patients older than 60 years, lethality is 5-10 times higher than in young people [4]. In connection with this, an alternative method of treatment of OX in patients of older age groups was proposed - thermal mucoclasiа of the gallbladder. Aim. To carry out complex analysis of the results of laboratory and ultrasound methods of clinical examination in elderly patients with acute cholecystitis (AC) depending on two main types of surgical treatment: video laparoscopic cholecystectomia or thermal mucoclasia of a gall bladder. Materials and methods. The results of the red and white blood counts, the assessment of biochemical blood parameters, immune markers and the outcomes of ultrasound examination of the gall bladder before operation and after different periods following this treatment were analyzed in elderly patients who were admitted urgently to the surgical units of the Kursk city hospitals. Results and its discussion. In patients who underwent traditional cholecystostomy with the thermal mucoclasia lower values of erythrocytes, hemoglobin and general protein levels were detected demonstrating the presence of anemia. In this group the secondary immunodeficiency with alterations of the T-cell immunity was noted. These changes are most probably related to aging since the average age of these patients was about 10 years more than in the VLHE group. Patients who were operated by VLHE were admitted to hospitals with more pronounced changes of biochemical blood parameters, i.e. with higher levels of bilirubin, ACT, ALT and amylase. Conclusions. The results of the present study can be used for the choice of the surgical operation and for the pre-operatory treatment of elderly patients with acute cholecystitis.
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