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Section 7. Medical science
Yakubov Erkin Amongeldievich, Tashkent Pediatric Medical Institute, Uzbekistan E-mail: yakubov. [email protected] Ergashev Nasriddin Shamsiddinovich, PhD, Professor Tashkent Pediatric Medical Institute, Republic of Uzbekistan
Mistakes, dangers and complications in surgery of the cysts of biliary ducts in children
Abstract: From 74 children operated in our institution due to cyst anomalies of the biliary ducts of them in 12 children there were performed erroneous operations in the other clinics. This is explained by diagnostic and tactic mistakes by physicians of the medical institutions without experience in treatment of children with anomalies of the biliary ducts. In two patients there were observe complications of the iatrogenic character in the complex anatomo-topographic variants of anomalies. In 33 children there were found various complications in the postoperative period. In the article there were presented the most frequent complications, their causes and characteristic features of the therapeutic tactics.
Keywords: cysts biliary ducts, treatment, complications, children.
Introduction
The diagnostic and tactical mistakes and complications, connected to them, at the cystic anomalies of the biliary ducts (CABD) are observed rather frequent. The abnormal introduction of the segmental ducts into the common biliary duct (CBD) and anatomic variations of the formation of the gallbladder and biliary tract complicate performance of the open and laparoscopic surgeries may be cause of iatrogenic injuries or technical mistakes. The danger sharply occurs under the conditions of marked adhesive process due to developed biliary peritonitis at the rupture of the cyst or complications of the inadequate primary surgery [2; 3]. In the literature there is described a case of iatrogenic injury of the portal vein at the removal of the cyst of the common biliary duct [1].
The purpose of research was to analyze errors, dangers and complications at the stage of diagnosis and operative introduction and to develop adequate surgical tactics in the cystic anomalies of the biliary ducts on the basis of the material of our clinic.
Material and methods of research
On the clinical bases at the chair of hospital children surgery, children oncology of Tashkent Pediatric Medical Institute in 1979-2016 there were observed and treated 76 patients with CABD (60 girls and 16 boys) at the age of the neonatal period to 16 years old. Of them 74 children underwent operative interventions.
Results and discussion
The primary and repeated surgeries were per in our clinic in 62 (83.8%) from 74 children; 12 (16,2%) children the primary palliative surgeries were carried out in the other hospitals. Two out of 12 patients admitted from the other hospitals were operated with wrong diagnosis of anomaly of the gallbladder development. The cyst of the common biliary duct remained to be unrecognized. In one case the cholecystectomy was made wrongly without intervention into the cystic-changed common biliary duct; in the secondary case the surgery consisted in "elimination of the adhesion of the gallbladder". Some times ago in these children the former clinical attributes of disease have renewed. At repeated inspection the correct diagnosis was established: the cyst of the common biliary duct. The patients were performed repeated surgical correction. One girl underwent erroneous appendectomy at admission to the hospital with pains in the abdominal cavity at the place of residence. Two years later at hospitalization with suggestion of hepatic echinococcosis the diagnosis was not confirmed, and in this case the cyst of
the common biliary duct remained also to be unrecognized. In the further in our clinic the child was studied and operated with real diagnosis — the cyst of the CBD. The similar tactic mistake was observed in the girl in the age of 1 year and 1 month with the diagnosis ofprimary peritonitis. The operation was completed by drainage of the peritoneal cavity. In 6 days with continuous peritonitis the patient was repeatedly operated. There was found perforation of the cyst of CBD, and the drainage cystostoma was applied. In the girl of 2,5 month old operated with suspicion on intestinal invagination, there was revealed rupture of the common biliary duct; there was performed suture of the rupture without drainage of the common biliary duct. The child has died. The autopsy showed that the cause of the biliary peritonitis was the tear of the cyst of the CBD. In the lumen of the gallbladder there were found con-crements. The histological investigation showed presence of the ectopic tissue of the pancreatic gland in the wall of the CBD. The rest 7 patients of this group, being underwent surgery with wrong diagnosis the liver echinococcosis (6) and intestinal invagination (1), due to confusion and absence of experience in the surgeon in relation to radical treatment of the cysts of the common biliary duct, the operation was finished by external bile deviation. In 3 of them there were occurred complications, required repeated operation at the early postoperative period. The child being operated because of suspicion on intestinal invagination required relaparotomy on the 5th day due to adhesive intestinal obstruction. In two patients in the postoperative period there were noted signs of the continuing biliary peritonitis connected with incomplete hermetization of the drainage tube in the cyst (1) and it's falling down from the cyst cavity because of insufficient fixation (1). In two patients there were observed complications of the iatrogenic character. In one of the there had happened injury of the portal vein wall during surgery under the conditions of the massive adhesive process in the hepatoduodenal zone and inflammatory signs around the cyst at the stage of mobilization. The wound was sutured and hemorrhage stopped. The surgery was finished by cholecystectomy, partial dissection with reconstruction of the cyst of the common biliary duct and formation of the hepaticoduodenal anastomosis. In the postoperative period there were developed clinical-laboratory indicators of the portal hypertension, stopping with intensive conservative measures on the 7th day after surgery. The second child required repeated operative intervention in the nearest postoperative period
Mistakes, dangers and complications in surgery of the cysts of biliary ducts in children
after cholecystectomy, partial resection of the cyst with application of the hepaticoduodenoanastomosis in connection with increasing signs of mechanic jaundice. The development of this complication was connected with ligation of the segmental duct independently running into the cystic dilated common biliary duct at application of hepaticoduodnoanastomosis. It was confirmed by the retrospective analysis of intraoperative cholangiography. At the relaparotomy on the 3d day after operation there was loosened the second layer of sutures along the right edge of the created anastomosis. In the postoperative period the signs of mechanical jaundice were quickly stopped, its intensity attenuated. The biliation from drainage tube stopped on the 7 day. The patient was discharged at the satisfactory state.
Out of 74 primary and repeated operations which have been carried out in clinic, in 41 (55,4%) patients the postoperative period proceeded smoothly, in 33 (44,6%) there were observed 63 complications; in 20 cases they were more than two in one patients. The lethal outcomes in the early postoperative period there were observed in 4 (5,4%) cases. The patients with the lethal outcomes were from group of these 33 patients with postoperative complication.
Early postoperative complications were divided into general surgical (paresis of the intestine, adhesive intestinal obstruction, suppurative-inflammatory complications, intestinal eventration, hemorrhage (in the gastric-intestinal tract or in the abdominal cavity) — 11; specific (bile secretion, progressing or addition of the pancreatitis, mechanic jaundice, progressing of the damaged liver function, DBC) — 49; somatic (acute respiratory and renal insufficiency, sepsis, polyorgan failure, generalization of the intrauter-ine infection) — 3.
Clinical signs of acute pancreatitis with characteristic pain attack and dyspeptic expressions increase in amylase level in the analysis of blood and urine appeared on the 2-3 days after application of the hepaticoenterostomy (9) hepaticoduodenostomy (1) and external cyst drainage (1). The development of this complication, probably, is caused by reactive pancreatitis due to traumatization of the head of pancreatic gland in the cyst mobilization. In 2 patients the shown factors promoted an aggravation of the available before operation pancreatitis. On a background of complex conservative treatment with inclusion of contrical the signs of pancreatitis were stopped, amylase indicators normalized.
The bile secretion in the postoperative period was noted in 14 (20%) patients. The volume of bile secreted through drainage tube inserted into the abdominal cavity accounted for 50-400 ml a day. This hermetic external drainage of the cyst (3) and drawing (erroneous removal) of the cystomic tube in 3 patients. This became the cause of peritonitis development, eventration of the intestine required of repeated surgeries. In 8 cases after operation of the internal drainage independently on their type the excretion of bile, evidently, was connected with non hermetic biliodigestive anastomosis. Absences of the signs of peritonitis and gradual decrease in volume of the bile excreted have become the indicators for waiting tactics. On the 5-12 day the bile excretion has stopped independently.
Progressing of liver insufficiency was in 5 children at the age to 6 months who had external cyst drainage with liver biopsy. In all these patients prognosis at discharge was determined as unfavorable. They dead during 30-40 days after discharge from hospital due to increasing liver insufficiency induced by progress of biliary liver cirrhosis.
In one patient on the 3d day after operation cholecystectomy, the cystectomy with application of hepaticoduodenostomy there was noted intestinal hemorrhage, worsening of the state, vomiting with blood trace, tarry stool, increase in anemia expressions (atonia, paleness, reduction of the erythrocyte quantity and hemoglobin features). In the fibrogastroduodenoscopy the source of hemorrhage was not defined. The hemostatic therapy appeared to be effective, on the 6 day the hemorrhage stopped. In the other patient on the 2 day after operation of cholecystectomy, cystectomy with application of the hepaticoenterostomy by Roux there was noted worsening of the health state, increase in abdomen cavity volume, reduction in hemoglobin level. The child was performed repeated surgery with hemoperitonitis. The cause of hemorrhage was removal of ligature from one branch a. cystica.
The analysis of intraoperative and postoperative complications showed that the main causes of their occurrence appeared to be severe initial state of the patients, complex anatomo-topographic variants of anomalies, inflammatory processes in the hepatoduodenal zone, tactic and technique mistakes at the stages of diagnosis and operative treatment. The optimization of the diagnosis and surgical treatment of CABD on the basis of differential approach taking into account anatomic peculiarities of the cysts, established by preoperative studies and intraoperative cholangiography, allowed decrease in number of diagnostic mistakes, complications and lethal outcomes during the last years. From 25 operated children in the period 19792004 the complications and lethal outcomes were 16 (64%) and 2 (8%) cases. Among 49 operated children in 2005-2016 years the complications and lethal outcomes accounted for 17 (34,7%) and 2 (4%) cases.
Conclusions
The mistakes at the preoperative period were cause by absence of clear symptomatic, characterized by dynamic clinical signs, low awareness and alertness of the physicians of various specialties in relation to cystic anomalies of the biliary ducts that in total appeared to be main cause of the delayed diagnosis and occurrence ofvarious complications.
The tactical and technical mistakes of the doctors at the peripheral level during surgery complicate realization of repeated interventions, increase risk of occurrence of intraoperative complications and confirm expediency of realization of operative treatment under conditions of the specialized departments.
In newborns and young children of early breast age CABD mainly proceed on a background of decompensated disorders of the liver function, induced by congenital causes, negatively influencing on the results of treatment, outcome of disease, that requires differential surgical approach.
References:
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2. Dong Q, Jiang BX, Jiang Z, et al. Management of congenital choledochal cyst complicated by biliary anomalies and aberrant bile duct//World J Pediatr. 2006 May;2 (2): 133-138.
3. Liuming H., Hongwu Z, Gang L, et al. The effect of laparoscopic excision in children with choledochal cyst: a midterm follow-up study//Journal of Pediatric Surgery - 2011; 46: 662-665.
