CC BY
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III. ХИРУРГИЯ
UDC 616.366-003.7-007.272
About the authors:
Aueskhan T. Djumabekov - head of the Department of Surgery with the course of Thoracic Surgery and Coloproctology of the KazMUCE;
Sapar M. Abuov - Associate Professor of Surgery Department with the course of Thoracic Surgery and Coloproctology of the KazMUCE;
Rakhmanberdi B. Kalymbetov -Associate Professor of Surgery Department with the course of Thoracic Surgery and Coloproctology of the KazMUCE; Samat M. Zharmenov - Associate Professor of Surgery Department with the course of Thoracic Surgery and Coloproctology of the KazMUCE; Tagabai S. Zhoraev - Associate Professor of Surgery Department with the course of Thoracic Surgery and Coloproctology of the KazMUCE;
Adilbek J. Artykbaev - assistant of Surgery Department with the course of Thoracic Surgery and Coloproctology of the KazMUCE.
Key words:
obstructive gallstone, small bowel obstruction, fistula biliodigestive.
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SURGICAL TREATMENT OF OBSTRUCTIVE GALLSTONE INTESTINAL OBSTRUCTION
Djumabekov A.T., Abuov S.M., Kalymbetov R.B., Zharmenov S.M., Zhoraev T.S., Artykbaev A.J.
Kazakh medical university of continuing education, Almaty, Kazakhstan, Abstract
The analysis of the results of treatment of 5 patients with gallstone obstructive intestinal obstruction was carried out. All patients, women aged 62 to 83 years, were conducted surgical treatment: two patients were operated with the diagnosis of acute cholecystitis, 2 - mesenteric thrombosis, 1 - peritonitis of unknown etiology, and only 1 of these observations before the operation there was an assumption about the true nature of the disease. In all cases, enterolithotomy with suturing of wounds with double-row stitching was carried out. Relapse of obstructive gallstone obstruction was observed in one patient in 6 months after surgery. The possibility of enterothomy and simultaneous operations on the gall bladder and biliodigestive fistula is regarded.
бттеп тас ¡шек куысыньщ б1тел1нген жука ¡шект ете алмайтындык хирургиялык емдеу
Жумабеков Э.Т., Абуов С.М., Калымбетов Р.Б., Жэрменов С.М., Жораев Т.С., Артьщбаев А.Ж.
Казак медициналык уздшз бшм беру университет!, Алматы, Казакстан
Ацдатпа
Аш ¡шектщ ет куысында™ таспен 6iTeëyi анык1талfан 5 наукасты емдеу нэтижелерше сарапта-ма журпзшген. Барлык наукастар 62 мен 83 жас аралы^ында™ эйелдер. Oларfа хирургиялык ем журпзшген: 2 наукас жедел холецистит диагнозыммен,, 2 - мезентериалды тромбоз диагнозымен, 1 - белпаз этиологиялы перитонит диагнозымен опeрацияfа алынfан. Осы жаедайлардыщ тек б!реушде fана опeрацияfа дешн аурудыщ шынайы табиfаты туралы жорамал болды. Барлык наукастарда энтеро-литотомия жасалып, ота шекке ек катарлы тИс салу аркылы аякталfан. Б!р наукаста 6 айдан кешн аш шектщ ет жолдарында™ таспен кайта б!телу! байкалfан. Б!р мезетте энтеротомия мен ет кабы™ жэне билидигестивт жыланкезге ота жасау мумюндИ к1арастырылfан.
Об авторах:
Джумабеков Ауесхан Толегенович -заведующий кафедрой хирургии с курсами торакальной хирургии и колопроктологии КазМУНО, e-mail: Jumabekov@nur.kz, т. 87017414437;
Абуов Сапар Махамбетович - доцент кафедры хирургии с курсами торакальной хирургии и колопроктологии КазМУНО, e-mail: hirurgia.agiuv@mail.ru, т. 87013720109; Жарменов Самат Мадиханович - доцент кафедры хирургии с курсами торакальной хирургии и колопроктологии КазМУНО, e-mail: szharmenov@mail.ru, т. 87017393635; Калымбетов Рахманберды Бегалиевич - доцент кафедры хирургии с курсами торакальной хирургии и колопроктологии КазМУНО, e-mail: hirurgia.agiuv@mail.ru, т. 87076835072; Жораев Тагабай Сапарханович - доцент кафедры хирургии с курсами торакальной хирургии и колопроктологии КазМУНО, e-mail: hirurgia.agiuv@mail.ru, т. 87014732215; Артыкбаев Адилбек Жанибекович - ассистент кафедры хирургии с курсами торакальной хирургии и колопроктологии КазМУНО, e-mail: _Artykbaeff@mail.ru, т 87026902995.
Ключевые слова
Ключевые слова: сочетанный эхинококкоз, торакоскопиче-ская эхинококкэктомия
Хирургическое лечение обструктивной желчнокаменной тонкокишечной непроходимости
Джумабеков А.Т., Абуов С.М., Калымбетов Р.Б., Жарменов С.М., Жораев Т.С., Артыкбаев А.Ж.
Казахский медицинский университет непрерывного образования, Алматы, Казахстан Аннотация
Проведен анализ результатов лечения 5 больных с желчнокаменной обтурационной тонкокишечной непроходимостью. Всем пациентам, женщинам в возрасте от 62 до 83 лет, проведено оперативное лечение: 2 пациенток были оперированы с диагнозом острый холецистит, 2 - мезентериальный тромбоз, 1 - перитонит неясной этиологии и лишь в 1 из этих наблюдений до операции возникло предположение об истинной природе заболевания. Во всех случаях произведена энтеролитотомия с ушиванием раны двухрядными швами. Рецидив обтурационной желчнокаменной непроходимости отмечен у одной пациентки через 6 месяцев после операции. Рассматривается возможность проведения энтеротомии и одномоментных операций на желчном пузыре и билиодигестивном свище.
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2(43)*2015
Gallstone obstructive small bowel obstruction is a rare disease whose frequency is 0.3 - 2.1% in relation to all other types of intestinal obstruction observed at 0.2 - 0.6 % of patients with cholelithiasis [1, 2]. As a result of the formation of internal biliodigestive fistula and migration of gallstones in the lumen of the small intestine the obstructive small bowel obstruction is formed. Prolonged exposure to large calculus in the gallbladder leads to the formation of internal biliodigestive fistula often - between the gallbladder and the duodenum. Large stone fills the cavity of the gallbladder, thereby mucosa, and then all of the bottom wall of the gallbladder necrotic. Because of the resulting inflammation and adhesions in the paravesical space, the duodenal wall is soldered to the bottom wall of the gallbladder. Mechanical pressure on the wall of the duodenum results in formation of pressure sores occurs inner vesico-intestinal fistula, concretion and migrates into the duodenum and further through the small intestine.
Biliary ileus is not characterized by a typical clinical course and the presence of specific symptoms that causes the majority of cases of late diagnosis and belated action. Hence the low awareness of a wide range of practitioners about the disease. In this regard, an important role for carefully collected history and modern methods of radiological and ultrasound diagnosis [ 3 , 4, 5 ] .
Materials and methods. From 2007 to 2014, on the basis of the surgical department (CCCH, Almaty) there were 5 patients with gallstone obstructive intestinal obstruction. These were women elderly, from 62 to 83 years. All they have done on an emergency basis: in the period from 6 hours to 7 days from the onset of the disease. On admission and observation of the clinical manifestations of fuzziness it was put the following diagnosis: acute cholecystitis (2), acute pancreatitis (1). Only 2 were immediately diagnosed with intestinal obstruction.
If you receive 2 patients reported they have gallstones, and 1 patient had a history indicate episodes of abdominal pain, seizures resembling biliary colic, 2 patients in the anamnesis there were no information about possible diseases of biliary system and small bowel obstruction served as the first manifestation of gallstone disease.
In 3 patients stone migration through the intestines was accompanied by a temporary improvement, cessation of abdominal pain for 1026 hours. Then the pain again resumed, joined bloating and vomiting. Periods of imaginary well-being characteristic of intestinal obstruction caused by gallstones, especially dangerous in terms of prognosis, since dulled the vigilance of the doctor, lengthened the period of diagnosis. Such cyclical flow features are associated with both promotion of the small intestine gall stones, and with the passing spasm of the bowel. The ending is a complete obstruction of the lumen of the small intestine
concretions became an indication for surgery.
X-ray examination at the primary and control abdominal radiographs in all 5 patients found intestinal symptoms such as arcade, horizontal fluid levels. Typical signs of biliodigestive fistula - the presence of gas in the bile ducts (aeroholia) - X-ray diffraction revealed only one patient.
More informative was abdominal ultrasonography, which was performed in all patients. This method allowed to detect the presence of gallstones in 4 patients, the gas in the bladder and ducts - at 1, gastrostasis - at 3, pneumatosis small intestine - in 3, pendulum peristalsis - at 3, free fluid in the abdominal cavity - in 3 patients.
At US 1 patient in the lumen of the small intestine marked by persistent acoustic shadow, do not change their size and shape in different projections of polypositional scan. This suggested the presence of a stone in the projection of the small intestine and to determine the level of obstruction.
Based on these data it can be argued that the dynamic abdominal ultrasound is a highly informative diagnostic and screening method that contributes to the solution of the question of the advisability of surgical treatment in the clinical picture unclear.
Results. The assumption of the presence of obstructive gallstone intestinal obstruction occurred in 1 case with a diagnosis of "acute intestinal obstruction", in other cases it has been set a preliminary diagnosis "acute cholecystitis" - 2 patients, "mesenteric thrombosis" - 1, "peritonitis of unknown etiology" - 1.
The operation is performed under endotracheal anesthesia, using a median laparotomy. In all patients during surgery autocholecystoduodenostomy was detected, occlusive stone located on different levels of the small intestine, at a distance of 1 - 1.5 m from the ligament Traits. Gallstones reached 3 - 5 cm in diameter. In subhepatic space in all patients the adhesions or dense infiltration were marked.
To eliminate obstructive gallstone intestinal obstruction the enterolithotomy was applied. All observations were made over a fixed stone enterotomy followed suturing holes with double-row suture hub vicryl №3 laterally and drainage of the abdominal cavity. In 2 cases, further performs nasogastrointestinal intubation probe in 3 cases - to express the contents of the small intestine in a distal direction to the cecum.
Simultaneous interventions on the bile ducts in the obstructive ileus gallstone consider aggravating the patient's condition, so they never performed. We justify the position advanced age patients are often burdened with serious comorbidities, the severity of their condition is due to late hospitalization and delay the timing of surgical interventions, the technical complexity of co-operation in the presence of dense infiltrate expressed or scar adhesions, lack of diagnostic information about the nature of the
BULLETIN OF SURGERY IN KAZAKHSTAN № 2(43)-2015
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fistula and its with respect to adjacent anatomical structures. However, the separation of biliodigestive fistula is justified in situations where there is a risk of recurrence of gallstone ileus.
Here we are observing, analyzing which one can assume that the underestimation of the states in the biliodigestive fistula properly - in the late postoperative period led to a relapse of gallstone ileus.
Patient K., 82 years old, was hospitalized urgently 16/11/2013, after 23 hours from the onset of the disease: acute cholecystitis. US: the gallbladder with stones. FEGDS: duodenal spasm, deformed. Survey abdominal radiography: pneumatosis intestinal. The patient's condition is of moderate severity. Abdomen moderately swollen, painful on palpation in the right upper quadrant. Spend antispasmodic, infusion therapy. The patient's condition improved temporarily.
17.11.2013 there were pains in the umbilical region, vomiting. In the survey abdominal radiography to study the passage of barium - barium delay, single "Kloiber's cups".
18.11.2013 - operation. Median laparotomy was carried out. In subhepatic space dense infiltration in which the gallbladder, greater omentum, stomach, duodenum, transverse colon division. At a distance of 1.5 m from the bunch in the small intestine Traits discovered calculus size of 5x4 cm. Above calculus gut stretched distal portion of the small intestine - sleeping. Intraoperative diagnosis: cholelithiasis, chronic calculous cholecystitis, autocholecystoduodenostomy, acute small bowel obstruction obstructive gallstones.
Longitudinal enterolithotomy stumbling over a fixed orifice double-row suturing seam in the transverse direction and nasogastrointestinal intubation probe, abdominal drainage. The postoperative period - without complications, was discharged home.
After 6 months of re-entry with a similar clinical picture. On US - concretions in the gallbladder, gallbladder sleeping. In the survey abdominal radiography - multiple "Kloiber's cups". Suspect gallstone small bowel obstruction. After preliminary preoperative preparation - upper middle laparotomy. In the abdominal cavity there were planar adhesions that are cut. In the small intestine at a distance of 130 cm from the ligament Traits diagnosed gallstone the size of 3x5 cm, occlusive its lumen. Above obstacle clearance jejunum significantly expanded, it contains a liquid and a gas, less - sleeping. In subhepatic space had expressed adhesive process and palpation of the gallbladder calculus 4x3 cm.
There was conducted enterolithotomy contents expressed into the small intestine distal direction.
Because of the risk of recurrence of gallstone intestinal obstruction it was decided to divide biliodigestive fistula. During the operation -raising adhesions subhepatic space, performed cholecystectomy, closure of duodenal wall two-row suture. There was a recovery.
The remaining 4 patients were operated on the gallstone obstructive intestinal obstruction, cholecystectomy was not made in the late postoperative period, and appeals were not repeated.
Repeated observations of gallstone obstructive intestinal obstruction relate to casuistry. In emergency situations, the amount of the operation should be minimal - enterolithotomy. Performing simultaneous co-operation is a big risk for the life of the sick elderly who are in serious condition. However, radical surgery for gallstone intestinal obstruction is acceptable if it is carried out by highly qualified surgeon who owns technology operations on the biliary tract, subject to timely diagnosis of the disease, the satisfactory condition of the patient, adequate preoperative preparation, adequate anesthetic management, with the ability of the operating surgeon to properly assess anatomical situation in hepatobiliary zone.
Thus, the features of obstructive gallstone intestinal obstruction lie in its fluctuating course, with periods of slow progression of an imaginary being. The diagnosis of gallstone ileus is placed on the basis of history of a cholelithiasis, dynamic clinical observation, X-ray contrast study of the abdominal cavity, and especially on the results of dynamic ultrasound.
Gallstone surgery of choice for obstructive intestinal obstruction is enterolithotomy. Immediate elimination of intestinal obstruction and fistula uncoupling are performed under strict indications.
References
1. Dobrovolsky S.R., Ivanov M.P., Nagai I.V. Gallstone ileus obstructive. Surgery, 2004; 3: 5155. (in Russ.).
2. Subbotin V.M., Busyrev Y.B., David M. Radical surgery for gallstone ileus. Annals of Surgery, 2000; 4: 31-33.
3. Kurguzov O.P. Gallstone small bowel obstruction. Surgery, 2007; 6: 13-19. (in Russ.).
4. Dibirov M.D., Fedorov V.P., Martirosyan N. Surgery , 2007; 5 : 17-21. (in Russ.).
5. Khasanov A.G., Nurtdinov M.A., Ibraev V.A. Surgical treatment of obstructive gallstone ileus. Medical bulletin of Bashkortostan, 2007; 5: 2: 1922. (in Russ.).
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2(43)-2015
