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24РАСПРОСТРАНЕННОСТЬ ЖЕЛЧНОКАМЕННОЙ БОЛЕЗНИ И СОВРЕМЕННЫЕ МЕТОДЫ ЛЕЧЕНИЯ
Юлдашева Гулнора Бахтияровна
Андижанский государственный медицинский институт
Желчнокаменная болезнь - это твердые вещества (желчные камни), которые могут возникать в желчном пузыре. Желчнокаменная болезнь распространена во всех штатах. Причины заболевания до конца не изучены, но предполагается, что факторов много. Жидкость желчного пузыря хранится в желчном пузыре и выделяется в тонкую кишку, когда это необходимо для пищеварения. Если желчь содержит слишком много холестерина или слишком много билирубина (одного из компонентов желчи) или желчный пузырь не может удалить желчь, могут развиться камни в желчном пузыре. При желчнокаменной болезни образуются разные виды камней. Наиболее распространенный тип, связанный с холестерином, связан с наличием слишком большого количества холестерина в желчи. Другой вид камня, называемый пигментным камнем, образуется из избытка билирубина, который образуется в результате распада эритроцитов в печени. В данной статье рассматриваются современные методы лечения желчнокаменной болезни и ее распространенность среди населения.
Ключевые слова: Желчнокаменная болезнь, желчный пузырь, желчные камни, желчная жидкость, холестерин, пигмент, печень, эритроциты, билирубин.
XOLELITIAZNING TARQALISHI VA ZAMONAVIY DAVOLASH USULLARI
Xolelitiaz bu o't pufagida paydo bo'lishi mumkin bo'lgan qattiq substansiya (o't toshlari). Xolelitiaz barcha davlatlarda keng tarqalgan. Kasallikning sabablari to'liq tushunilmagan, ammo uning ko'plab omillari borligi taxmin qilinadi. O't pufagida o't suyuqligi saqlanadi va ovqat hazm qilish uchun kerak bo'lganda uni ingichka ichakka chiqaradi. Agar safro tarkibida juda ko'p xolesterin yoki juda ko'p bilirubin bo'lsa (o'tning tarkibiy qismlaridan biri) yoki o't pufagi ishlamay qolsa va o'tni chiqara olmasa, o't toshlari rivojlanishi mumkin. Xolelitiyozda har xil turdagi toshlar hosil bo'ladi. Xolesterin bilan bog'liq eng keng tarqalgan turi safroda juda ko'p xolesterin mavjudligidan kelib chiqadi. Pigment tosh deb ataladigan toshning yana bir turi jigardagi qizil qon hujayralarining parchalanishi natijasida hosil bo'lgan ortiqcha bilirubindan hosil bo'ladi. Ushbu maqolada xolelitiazni zamonaviy davolash usullari va uning aholi orasida tarqalishi muhokama qilinadi.
Kalit so'zlar: Xolelitiaz, o't pufagi, o't toshlari, o't suyuqligi, xolesterin, pigment, jigar, qizil qon hujayralari, bilirubin.
PREVALENCE OF CHOLELITHIASIS AND MODERN TREATMENTS
Cholelithiasis is a solid substance (gallstones) that can occur in the gallbladder. Cholelithiasis is common in all states. The causes of the disease are not fully understood, but it is assumed that there are many factors. Gallbladder fluid is stored in the gallbladder and excreted into the small intestine when needed for digestion. If the bile contains too much cholesterol or too much bilirubin (one of the components of the bile) or the gallbladder fails and cannot remove the bile, gallstones can develop. In cholelithiasis, different types of stones are formed. The most common type associated with cholesterol is due to the presence of too much cholesterol in the bile. Another type of stone, called pigment stone, is formed from
excess bilirubin, which is formed as a result of the breakdown of red blood cells in the liver. This article discusses modern treatments for cholelithiasis and its prevalence among the population.
Keywords: Cholelithiasis, gallbladder, gallstones, bile, cholesterol, pigment, liver, red blood cells, bilirubin.
Introduction: Gallstones are a very common condition among the general population. Generally, this situation does not cause symptoms, but 10%-25% of affected people may have specific symptoms, such as biliary pain and acute cholecystitis, and 1%-2% of these may have major complications. In most cases, symptoms and major complications occur due to the migration of stones into the common bile duct (CBD) and this circumstance can cause obstruction of the bile flow in the small intestine, resulting in pain, jaundice, and sometimes cholangitis. Primary choledocholithiasis refers to stones formed directly within the biliary tree, while secondary choledocholithiasis refers to stones migrated from the gallbladder. Primary stones are generally brown in colour and composed mainly of calcium bilirubinate; these stones are rare in Western populations and more common in Asia, but the exact aetiology and overall prevalence remain unclear. Secondary choledocholithiasis stone composition parallels that of cholelithiasis, with cholesterol as the most common type. Of the total of cholecystectomies performed every year for cholelithiasis, the presence of CBD stones (CBDSs) is 5%-15%; another small percentage of these will develop CBDS after intervention. The management of CBDSs represents an important clinical problem. In symptomatic patients, the primary goal is to obtain complete clearance of the CBD and cholecystectomy; on the contrary, in asymptomatic patients, there is still no shared diagnostic and therapeutic path. In the last 20 years, the development of new technologies has allowed new diagnostic and therapeutic scenarios, with a consequent critical evaluation of management options. All these have led to a more cautious and patient-tailored preoperative workup based on the patient's risk and ultimately to a multidisciplinary approach. However, if on the one hand multidisciplinarity has improved the management of patients with symptomatic cholelithiasis, on the other hand it has shown non-unanimous consent in the choice of treatment for choledocholithiasis: Endoscopic or surgical? Since the early 1990s, laparoscopic cholecystectomy (LC) has been considered the gold standard of treatment for cholelithiasis, while endoscopic retrograde cholangio-pancreatography (ERCP) was chosen for isolated CBDSs; no consensus exists to address choledocholithiasis. To date, many therapeutic options are available, including laparoscopic, endoscopic, percutaneous, and traditional open techniques, applied both as a combination in a simultaneous way or as a gradual sequence. The most followed therapeutic options are preoperative ERCP followed by LC; LC plus intraoperative laparoscopic CBD exploration (LCBDE); LC plus intraoperative ERCP (rendezvous technique); and, finally, LC plus postoperative ERCP. The preference between one technique and the other is, most of the time, guided by the presence of professional resources and local skills rather than by its verified effectiveness.
Choledocholithiasis refers to the presence of one or more gallstones in the common bile duct (CBD). Treatment of gallstones depends on the stage of disease. This is associated with the increasing consumption of fatty food. With advances in radiological services, more patients are diagnosed with Gallstones. It is unique disease as it involves 3 organs namely the liver, gallbladder and pancreas. The clinical presentation varies depending on whether the bile flow is obstructed. Laparoscopic surgery offers a faster recovery and return to daily activities. The gallbladder is an organ located under the liver It functions as a store for bile
produced by the liver. Bile is essential for the absorption and digestion of fat. When the semi-digested food passes the upper part of the small intestine called duodenum, a hormone called Cholecystokinin is released which stimulates bile release. This is associated with the increasing consumption of fatty food. With advances in radiological services, more patients are diagnosed with Gallstones. It is unique disease as it involves 3 organs namely the liver, gallbladder and pancreas. The clinical presentation varies depending on whether the bile flow is obstructed. Laparoscopic surgery offers a faster recovery and return to daily activities. Gallstone disease is a very common condition in the general population. Prevalence of gallstones increases with age, from 8% in people younger than 40years old to more than 50% in people older than 70. In this last group, the incidence of symptomatic gallstone disease is around 30%, representing the most common cause of acute abdominal pain in elderly population. Elderly patients have been found to have higher risk of developing gallstone-related complications. Furthermore, early recurrence of symptomatic disease in elderly population has been estimated around a third of patients on follow-up, being these episodes related with increasing morbidity rates for each new episode. Current guidelines recommend early cholecystectomy (EC) in order to prevent gallstone-related complications and recurrence in the absence of contraindication for the surgical procedure. Although cholecystectomy has been described to be effective and safe for elderly patients, the treatment of symptomatic cholelithiasis with EC still remains a debatable issue. Elderly patients are less likely to undergo a surgical treatment, due to patient's preference, surgeon reticence, and related comorbidities. Finally, they present a higher risk of surgeryrelated complications with an increase in morbidity, mortality, costs, and recurrence rate (RR). Gallstone disease presents a high incidence and morbidity in elderly population. Although cholecystectomy is the most accepted treatment, a high proportion of elderly patients still undergo an NOM. Only a few studies have analyzed the RR after NOM of symptomatic gallstone disease in the elderly patients. Previous retrospective analyses notified RR around one-third of patients after a 1-year follow-up , increasing up to 40% in the long term. A group of scientists came to the following conclusion from their research: NOM of the first episode for symptomatic gallstone disease showed an RR of 39% after a 2-year follow-up. RR was related to the specific diagnosis and severity of the first episode at H1. If there are no contraindications for surgery, cholecystectomy should be considered during the initial admission in order to prevent relapses.
Management of cholelithiasis with choledocholithiasis must be conducted appropriately. A delay in the diagnosis of this pathological condition can increase morbidity and mortality. Unlike other diseases that have a certain diagnosis, the presence of stones in the CBD is sometimes only suspicious. Historically, diagnosis was achieved through a careful association between clinical symptoms, serology, and radiological images. Today, the development of new radiological imaging, interventional endoscopy, and laparoscopy techniques has allowed us to arrive at a faster and more accurate diagnosis. The management of cholelithiasis with choledocholithiasis has become multidisciplinary, and more professional figures are involved (radiologists, gastroenterologists, endoscopists, and surgeons), and will be increasingly adapted not only to a specific patient but also to the available resources of a specific environment in order to have the best possible management. However, endoscopy and surgery always retain a central diagnostic and therapeutic role. Many studies and meta-analyses have been conducted by various authors regarding the comparison between one-session and two-session treatments for patients with concomitant gallbladder and CBD stones. The findings have shown equivalent success rates, postoperative
morbidity, stone clearance, mortality, conversion to other procedures, total operation time, and failure rate, but one-session treatment is characterized by a shorter hospital stay and more cost benefits. Consequently, the latter option, when local resources and expertise are available, should be offered as a treatment of choice. However, in cases of incomplete or difficult removal of CBDSs, other additional techniques can also be used, which can be of valuable help in selected patients [1-12].
All endoscopic procedures are invasive for the patient. They are also diagnostic and therapeutic procedures. ERCP involves cannulation of the ampulla of Vater and then of the CBD; through the injection of contrast medium under fluoroscopy, defects in filling are observed. This method is often used as a procedure of choice for evaluating the presence of choledocholithiasis, but complications can occur in as many as 8% to 12% of patients, usually manifesting as pancreatitis. Due to its invasiveness and possible complications, ERCP is recommended for patients with a high probability of choledocholithiasis; this endoscopic examination conducted by expert operators can also be an adequate treatment. Although most endoscopists routinely reach the second portion of the duodenum, there are some situations that can make this manoeuvre difficult. Sometimes, the papilla major is difficult to identify and cannulate; this then represents a time of stress and danger for the operator as well as for the patient, such as when the cannula is placed in a duodenal diverticulum. Previous surgical procedures on the stomach are another frequent cause of ERCP failure. The second duodenal portion is difficult to reach after a Roux-en-Y reconstruction, omega anastomosis, and gastric by-pass, and after gastrectomy with duodenal stump closure and Billroth II reconstruction. In those cases, diagnosis and treatment must be conducted surgically. In the past decades, ERCP has been widely used for the diagnosis of CBDS; today, this procedure is being abandoned, especially in those patients who have a low or moderate risk of disease. ERCP accuracy is lower than that of EUS and MRC, especially in cases of dilation of the CBDS and presence of small stones. Furthermore, this procedure has a non-negligible morbidity and exposes the patient to X-rays and complications such as pancreatitis. The use of sphincterotomy during ERCP is therapeutic and mandatory in high-risk patients, but this procedure in untrained hands can increase morbidity and mortality, possibly causing duodenal perforation or haemobilia. Therefore, the use of ERCP is recommended in those patients with strong suspicion of choledocholiasis; in other cases, the use of EUS or MRC is preferable. The increase of the laparoscopic approach for the treatment of patients with cholelithiasis, which has completely replaced open surgery, has revived the therapeutic role of ERCP. To date, for the management and treatment of cholecysto-choledocholithiasis, the most used approaches are in two sessions or in a single session, and in both cases the ERCP retains a fundamental role. A further refinement of the classic endoscopic procedures is represented by the endoscopic US, which uses an US probe mounted on the tip of an endoscope. EUS does not use ionizing radiation. In comparison to ERCP, it is more useful for stones smaller than 5 mm and has a complication rate between 0.1% and 0.3%. EUS may not be adequate in patients undergoing gastric surgery, as the anatomical situation would be altered. Like transabdominal US, EUS is not limited by bowel gas, but it is always an operator-dependent procedure. Giljaca et al in 2015 published the results of a systematic review, reporting high rates of diagnostic accuracy for both EUS and MRC for choledocholithiasis. The authors found a sensitivity of 95% and specificity of 97% for EUS, and a sensitivity of 93% and specificity of 96% for MRC. The choice between EUS and MRCP, for intermediate probability choledocholithiasis, is based on the resource availability, personal experience, and costs [1320].
LC is confirmed as the gold standard for the treatment of symptomatic cholelithiasis, but the therapeutic choice for CBDS is not clear. For the latter situation, the available strategies, conducted in a minimally invasive way, can be divided into two-session treatments and single-session treatments. The first category includes preoperative ERCP followed by LC, and LC followed by postoperative ERCP; the second category includes LC with LCBDE, and LC with intraoperative ERCP, also called the rendezvous technique.
Through an endoscopic biliary sphincterotomy or a laparoscopic procedure, the extraction of ductal stones may not be completed or be difficult; in these cases, the open surgical approach still retains an important role, like other additional techniques.
Four decades ago, cholelithiasis was treated exclusively by open cholecystectomy and similarly, choledocholithiasis was managed by open CBD exploration, which was performed by duodenotomy and sphincterotomy or bilioenteric anastomosis. Open surgery is now considered obsolete, but the recent literature has shown its superiority over ERCP in the clearance of CBDS, with lower morbidity and mortality rates (20% vs 19% and 1% vs 3%, respectively). Open exploration of the CBD can be conducted through a coledochoenterostomy or a sphincterotomy; the choice depends on the surgeon's experience. Some authors prefer coledochoenterostomy for CBD with a diameter greater than 2 cm, in order to create a large opening between the bile duct and intestine. An emerging problem is that open biliary surgery is performed increasingly less outside specialized centres in hepato-bilio-pancreatic surgery; this raises new questions regarding the most appropriate management of those patients. Their number is scarce but not negligible, and their complex cases often need conversion or revision using an open approach by skilled surgeons.
During the sphincterotomy, an incision of approximately 1 cm is made in the distal part of the sphincter musculature. A catheter or dilator is passed distally and a Kocher manoeuvre is performed, followed by duodenotomy at the level of the ampulla. The dilator exposes the ampulla in the operating field, where it is sufficiently incised along its anterosuperior border with subsequent removal of the impacted stone. Choledocoenterostomy is commonly performed as a side-to-side choledochoduodenostomy for dilated CBD with multiple stones. These patients require drainage for good long-term results without recurrence of jaundice or cholangitis. The most used technique is that of a side-to-side hand-sutured anastomosis between the supraduodenal CBD and the duodenum. Kocher's manoeuvre is performed to expose the distal CBD. Choledochotomy is performed for 2-3 cm to the lateral border of the duodenum. Anastomosis is performed with interrupted absorbable sutures. The biggest complication that can occur is sump syndrome caused by food or other debris trapped in the distal part of CBD; its management is endoscopic with ERCP/ES. Another option may be choledochidjejunostomy with a roux-en-Y loop, but performed by expert hands [21-24].
Lithotripsy could be considered the ideal management of CBDS, as it resolves the disease without interruption of the CBD wall and without performing a sphincterotomy. However, this technique cannot be considered definitive in the treatment of cholecysto-choledocholithiasis since the genesis of the stones is secondary to the lithogenic bile in the gallbladder, and for this reason the recurrence rate would be very high. Fragmentation of gallbladder stones would increase the percentage of their migration into the choledochus. Another advantage of this technique is certainly that of being performed in a single application. Lithotripsy is not able to avoid cholecystectomy but it can be a valid therapeutic alternative in those patients already cholecystectomized or for whom it is not indicated. However, it cannot be overlooked that lithotripsy requires dedicated instrumentation and skilled personnel, which are not always available, thus limiting its diffusion. There are
various approaches described for stone fragmentation: Mechanical, electrohydraulic, laser, and extracorporeal shock wave. Endoscopic mechanical lithotripsy is usually performed after failed endoscopic sphincterotomy for CBDS through a Dormia basket or balloon catheter. CBD clearance is reached in about 80%-90% of cases. Failure may be due to CBDS size exceeding 3 cm, since stones could not be captured, and stone impaction in the CBD. Endoscopic electrohydraulic lithotripsy may be used in cases of difficult CBDS. A large operating channel accommodates a 4.5 Fr calibre probe with an electrohydraulic shock wave generator sending high-frequency hydraulic pressure waves. In order not to cause damage to the surrounding tissue, the probe must be positioned as close as possible to the stone. The stone removal rate ranges from 74% to 98%. This procedure requires costly and fragile instrumentation and good coordination of two skilled endoscopists. Endoscopic laser lithotripsy has been used to fragment large stones under fluoroscopic visualization, because of the risk of heat-induced biliary damage. Today, single-operator steerable cholangioscopy allows the safer use of laser lithotripsy with direct vision. A removal rate of CBDS has been reported of about 93%-97%, with a complications rate of 4%-13%. The holmium laser is the newest one, but its use is very expensive. Laser lithotripsy has recently been proposed with laparoscopic, open surgery, or percutaneously approaches. Extracorporeal shock-wave lithotripsy is also used in cases of difficult CBDS with US or fluoroscopic guidance. Modern lithotriptors employ water-filled compressible bags; because of the discomfort experienced by the patient, general anaesthesia is often required. Contraindications to this technique are portal thrombosis and varices of the umbilical plexus, and it can also cause adverse events, such as transient biliary colic, subcutaneous ecchymosis, cardiac arrhythmia, self-limited haemobilia, cholangitis, ileus, and pancreatitis. More sessions are typically required. The recurrence rate during a 1-2 year follow-up period is about 14%. Currently, extracorporeal shock-wave lithotripsy is not considered the first-line treatment for difficult bile duct stones [25-39].
Another group of scientists conducted research on the treatment of elderly gallstone patients [40]. The aim of this study was to evaluate the differences in clinical outcomes of endoscopic retrograde cholangiopancreatography (ERCP), ERCP followed by cholecystectomy (EC) and percutaneous aspiration (PA) in the elderly population with choledocholithiasis. The results showed that, a patient's age negatively affects the treatment outcomes of cholelithiasis with associated complications. The EC procedure appears to be the method of choice for the management of complicated gallstones in patients of all ages. Annually, 1.3 million procedures are performed and an overall complication rate is 5-10% . Patients undergoing either ERCP or cholecystectomy have a 70% lower risk of biliary disease recurrence within 1 year. In another study, ERCP alone was shown to reduce the recurrence by 37%. These data are consistent with the conclusion that ERCP only is not sufficient to reach an optimal treatment outcome and that ERCP should be combined with cholecystectomy for adequate stone clearance. In comparison with ERCP alone, a smaller number of stones remain in the CBD after cholecystectomy. However, cholecystectomy after ERCP appears not to be necessary for patients with acalculous cholecystitis. With the increase in the age of the population, the number of elderly patients undergoing treatment for symptomatic gallstones is expected to increase. In fact, the proportion of emergency and elective surgical cases involving older patients is on the rise. Of relevance, elderly surgical patients are characterized by higher indices of comorbidities than younger subjects, posing an additional challenge in the management of gallbladder stones. Although the mortality rate after cholecystectomy remains low (0.2-0.3%), this fraction is increased in the older
population and with increasing comorbidities. In fact, elderly patients were 7-10 times more likely to die post-operatively. Additionally, approximately 1% of patients who undergo laparoscopic cholecystectomy suffer from a procedure-related CBD injury. This adverse event is more common in the elderly and results more often in death in this age group. Patients affected by diseases of the heart, lungs and kidneys, as well as type 2 diabetes— conditions more frequent in the older population—are more likely to die following cholecystectomy. In order to lessen the risk of morbidity and mortality associated with cholecystectomy, elderly patients are recommended to undergo laparoscopic instead of open cholecystectomy.
Conclusion. Cholelithiasis is a real disease that is more common in the elderly and women, which we discussed in detail in the article. In addition, modern methods of treatment of this disease were also mentioned. Modern research has been studied by several scientists. Hopefully, this article will be the impetus for more in-depth research on cholelithiasis.
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