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II. ХИРУРГИЯ
RETROGRADE ENDOSCOPIC TREATMENT OF MECHANICAL JAUNDICE SYNDROME
Abdirashev Y.B., Abdiyev N.M., Izmagambetova Sh.S., Isbambetov A.S.
JSC "National scientific center of surgery named by A.N. Syzganov", Almaty, Kazakhstan
Abstract
Despite the development of medical technologies, the elaboration of international clinical guidelines and the improvement of surgical technique for biliary tree, the management of mechanical jaundice is still relevant. The causes of this syndrome are bile duct and gallbladder stones, tumor compression and strictures of the biliary tract, developed as a result of surgery (cholecystectomy, liver transplantation) and radiation therapy. Unrelieved compression of the biliary system leads to severe disruption of coagulation system and internal organs which can quickly lead to mortality. This article reflects the analysis of the results of treatment of jaundice.
МРНТИ 76.29.34
ABOUT THEАUTHORS
Yerlan Abdirashev - M.D., head of functional diagnostic and endoscopy department.
Nurken Abdiyev- endoscopy doctor, functional diagnostic and endoscopy department
Sholpan Izmagambetova - endoscopy doctor, functional diagnostic and endoscopy department
Askhat Isbambetov - M.D., head of surgery department. e-mail: abdiyev_n_m@bk.ru. Mobile: +77755577746
Keywords
ERCP, PTBD, SEMS, common bile duct, endoprothesis, mechanical jaundice.
Мeханикалык cаpFаю cиндpомындаFы эндоскопиялык peтpогpадты eмдiк шаралар
Aбдpашeв Е.Б., Aбдиeв Н.М., Измагамбeтова Ш.С., Иcбамбeтов A.C.
AK «А.Н. Сызганов атында?ы Улттык ?ылыми хирургия орталь™», Алматы, Казакстан
Ацдатпа
Медицина теxнологиясынын дамуы, xалыкаpалык клиникалык нускаулардыц дамытуына жeне xиpypгиялык оталарды жетiлдipyiне карамастан, меxаникалык сартаю синдромынын клиникалык менеджмент eлi актyальдi болып саналады. Бул синдромныц непзп себептеpi вт жолдарыныц кез-келген меxаникалык eсеpден (тас, от-алардан кейiнгi тыртыктар, обыр eсеpiнен кысылу) тузшген кедерп болып табылады. Емделмеген меxаникалалык сартаю ауыр коагулопатията жeне iшкi агзалардыц жеткiлiсiздiгiне eкелiп, тез арада наукастарды влiмге eкелiп соктырады. Бул макалада меxаникалык сартаю синдромындагы емшщ нeтижелеpi кврсетлген.
АВТОРЛАР ТУРАЛЫ
Эбдт'рашев Ерлан Байтереулы - функ-ционалды диагностика жэне эндоскопия б6лiмiнiц мецгерушю.
Абдиев Нуркен Махамашулы -
дэргер-эндоскопист, функционалды диагностика жэне эндоскопия б6лiмi.
Измагамбетова Шолпан Сертккызы
- дэргер-эндоскопист, функционалды диагностика жэне эндоскопия б6лiмi.
Исбамбетов Асхат Сагимбекулы -
ацылыхирургия б6лiмшесiнiц мецгерушс. e-mail: abdiyev_n_m@bk.ru. Mobile: +77755577746
Туйш ce3Aep
РХПГ, ЧЧХС, еАМС, жалпы вт жолы, эндопротез, меxаникалык саргаю.
Ретроградное эндоскопическое лечение при синдроме механической желтухи
Абдрашев Е.Б., Абдиев Н.М., Измагамбетова Ш.С., Исбамбетов А.С.
АО «Национальный научный центр хирургии имени А.Н. Сызганова», Алматы, Казахстан
Аннотация
Несмотря на развитие медицинских технологий, разработки международных клинических руководств и совершенствование хирургических вмешательств на билиарную систему, проблема лечения синдрома механической желтухи остается актуальной. Причинами данного синдрома являются камни желчных протоков и желчного пузыря, опухолевые сдавления и рубцовые стриктуры желчных путей, развившиеся в результате хирургических вмешательств (холецистэктомия, трансплантация печени) и лучевой терапии. Неразрешенная обтурация желчных протоков приводит к выраженной коагулопатии и полиорганной недостаточности, и без оказания своевременной медицинской помощи приводит больных к смерти в краткие сроки. В данной статье отражен анализ результатов лечения при синдроме механической желтухи.
ОБ АВТОРАХ
Абдрашев Ерлан Байтереулы - врач высшей категории, заведующий отделением функциональной диагностики и эндоскопии.
Абдиев Нуркен Махамашович - врач -эндоскопист, отделение функциональной диагностики и эндоскопии.
Измагамбетова Шолпан Сериковна
- врач-эндоскопист, отделение функциональной диагностики и эндоскопии.
Исбамбетов Асхат Сагимбекович -
заведующий отделением платной хирургии. e-mail: abdiyev_n_m@bk.ru. Mobile: +77755577746
Ключевые слова
РХПГ, ЧЧХС, СРМС, общий желчный проток, эндопротез, меxаническая желтyxа.
Introduction
The mechanical jaundice is one of the leading diseases in surgical and oncological practice. The causes of this syndrome may be caused by benign etiology (bile duct stones, stricture of the biliary tract), and malignant etiology (tumor of pancreato-biliary system). Unresolved obstruction of the bile duct leads to severe disorders of the hepatorenal system and hepatic en-cephalopathy. Without providing treatment in time, the patient's death occurs in the short time.
At the same time, the frequency of development of mechanical jaundice according to different authors is from 12,0 to 45,2%. And with benign diseases this level varies from 4,8 to 22,5%, and for malignant lesions - from 36,6 to 47,0%.
Objective. Analysis of the outcome of endo-scopic retrograde intervention of patients with mechanical jaundice.
Material and methods
In the Department of Endoscopy and Functional Diagnostics of the NSCS named after A.N. Syz-ganov for the period from 2014-2018, retrograde interventions were performed in 809 patients with jaundice of different etiology. Women were 688 (85%), men 134 (15%). The age of patients was from 18 to 75 years, more than 60% of patients were over 60 years old. Benign genesis: 512 (63,3%) patients, while jauindice associated with choledo-cholithiasis - 196 (24,2%) patients and postcholecystectomy syndrome with choledocholithiasis was in 191 (23,6%) patients. At the same time, in 146 (76,4%) patients the size of stones was more than 1.0 cm. Benign strictures of common bile duct (CBD) after previously operations were 44 (5,4%) patients. Among which, anastomotic strictures of CBD after liver transplantation were in 17 (38,6%) patients, and high strictures after cholecystectomy in 27 (62,4%) patients. The stricture of the terminal part of CBD was in 79 (9,8%) patients. Malignant etiology was present in 297 (36,7%) patients. Of these, 67 (22,5%) have a proximal block and 230 (77,5%) have a distal tumor block.
Endoscopic treatment of obstruction of the biliary tract depended on the genesis of jaundice. Out of 397 patients with choledocholithiasis, 376 (97,2%) patients underwent EST with stone extraction and in the case of technical difficulties associated with extraction of large stones from CBD, 11 (2,8%) patients underwent temporary plastic stent placement to resolve jaundice. Later, the patients went for surgery. In cases of detection of benign strictures of the terminal part of CBD, EST was performed by all 79 (100%) patients, and to 15 (19%) patients was supplemented by stenting of the CBD in the long strictures. With benign anas-
tomotic strictures of CBD after liver transplantation, 15 (88,2%) patients underwent stenting of the bile duct with plastic stents. Of these, 7 (41,2%) patients underwent stenting in several time every 3 months. 2 (11,8%) patients underwent percutaneous external bile withdrawal.
In 27 (100%) patients with proximal benign strictures, endoprothesis of the biliary tract with plastic stents was performed to 22 (81,5%) patients. 5 (18,5%) patients underwent an open reconstruction surgery of bile dict.
297 (36,7%) patients has a proximal and distal blocks due to tumor growth. To 213 (71,7%) plastic and SEMS 84 (28,3%) were placed. In proximal block (Klatskin tumor, lymph node shrinkage of the lymph nodes or HCC), 67 (82%) stenting were performed in 67 patients, of which 4 (6%) patients underwent bilateral endoprothesis. Technical success was 82%. The remaining 12 (18%) patients underwent PTBD. Of 230 (28,4%) patients with distal block: 184 (80%) patients had pancreatic head formation and 46 (20%) jaundice patients were caused by tumor of main papillae. At the same time, endoprosthesis of CBD to 225 (75,7%) patients with distal block had succeeded in, thus the technical success was 97,8%. In some cases, a combined method (antegrade and retrograde methods) of drainage was performed. In cases of development of cholangitis, patients primarily performed external decompression of infected bile. After the inflammatory subsided, the second stage of the patient was carried out the final retrograde stenting of the CBD for palliative purposes.
Results and their discussions
The complications in the early postoperative period: bleeding - 29 (3,6%) patients, post-cath-eterization pancreatitis - 38 (4,7%) patients, cholangitis - 13 (1,6%) patients, stent disposition - 70 (8,6 %) patients. Bleeding was noted from the zone of the main duodenal papilla after EST. The dislocation of stents in the early periods (up to 2 weeks) often occurred when using plastic prostheses. In these cases, we carried out the restenting. Chol-angitis was resolved by additional external removal of the infected bile to the outside via an antegrade method, or through a nasobiliary stent. In the early postoperative period, 9 (1,1%) patients died. Death occurred as a result of cholangitis with the development of sepsis in 5 (0,6%) patients, of pancreonecrosis in 2 (0,2%) cases and 3 (0,4%) of the patient died due to hepatico-renal failure. It should be noted that all patients were taken to the operation with the initial severe condition due to the underlying disease and coagulopathy. In the late postoperative period, complications were observed such as:
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2-2018
cholangitis - 24 (2,9%) patients, migration or occlusion of stent - 32 (3,9%) patients. The bed-stay from 2 to 14 days, the average stay of the patient in the hospital was 3.8 days. The average term of functioning of plastic prosthesis ranged from 2 to 7 months. Therefore, plastic stents were used as a temporary treatment before radical surgical treatment. The most effective and long-term drainage of the bile ducts is provided by the metal nitinol stents. It showed a good results in the case of inoperable tumors of the biliopancreatoduodenal zone. SEMS patency is more than a year and a half years.
Conclusions
The effectiveness of retrograde decompression of the biliary tract reached almost 100% of all cases. When the lithoextraction of large stones was unsuccessful, we recommend installation of a plastic stent to reduce the jaundice. What it says, is that endoscopic methods should be the first line of treatment.
References
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As our experience shows, the overwhelming number of patients with post-cholecystectomy syndrome, complicated by choledocholithiasis, the size of the stones was more than 1,0 cm. This circumstance may indicate that the stones in the CBD already presense before the cholecystectomy. In this connection, we recommend patients with stone of gallbladder to carry out advanced diagnostic measures, including MRI in M-RCP mode.
It should be noted that the choice of treatment and the method of drainage of the bile should be determined strictly according to the indications. If the patient has signs of a high block on the M-RCP, accompanied by the cholangitis, it is necessary to conduct an external tap of the infected bile as a first stage. After the inflammatory process subsides, a planning retrograde endoprosthesis should be performed. As we see, both decompression methods are complementary. Patients with mechanical jaundice require a multidisciplinary approach.
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