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13
II. ХИРУРГИЯ
SURGICAL TACTICS IN COMBINED PATHOLOGIES OF THE BILIARY SYSTEM
МРНТИ 76.29.34
Farajli V.F.
Azerbaijan Medical University, III Department of surgical diseases, Baku, Azerbaijan
ABOUT THEАUTHORS
Faradjli V.F. - researcher of the Azerbaijan Medical University
Abstract
For creation of system of the correct and timely choice of tactics at the combined pathologies of biliary system within 5 years researches on 80 patients were carried out. Cholecystectomy was performed in 20 patients on the background of chronic pancreatitis with a concomitant exacerbation of chronic stone cholecystitis,after which the developed pancreatitis in 40% of patients became the cause of death.For a thorough solution of the problem in the combined pathologies of the biliary system, the authors created an algorithm table due to the fact that the results of examinations and anamnestic data exceed the figure 35 and difficulties are created in the differential evaluation of such a number of indicators.The data is processed on the computer according to the created algorithm table. The use of 60 patients divided into 3 groups provides timely thorough diagnosis, adequate preventive measures corresponding to the detected pathological changes both before and during the operation, drainage of the bile ducts along with cholecys-tectomy provides early and persistent treatment of acute pancreatitis.Mortality among these patients is 5%.
Also, the diagnosis of the algorithm program allows you to timely recognize the developed pathological and functional changes(in most cases, left aside) not only in the biliary system, but also in other parts of the digestive tract, as well as the implementation of the necessary measures during the operation. This in turn leaves no room for the development of pathological syndromes after surgery. The accuracy of the program in the diagnosis is 92.7%, the prognosis of the disease is 86.2%. The proposed surgical tactics are confidently offered to practitioners.
Билиарлы ЖYЙeнщ косарланган патологиялардьщ барысындагы оталык T9cmi
Keywords
biliary system, the concomitant pathology, the algorithm of surgical tactics
Фараджли В.Ф.
Эзiрбайжан Медициналык, Университету хирургиялык, аурулар кафедрасы, Баку к,., Эзiрбайжан
АВТОРЛАР ТУРАЛЫ
Фараджи В.Ф. - ЭМУ - дьщ Fылыми кызметкеpi
Ацдатпа
Билиарлы жYЙенiн косарламан патологиялары барысында колданылатын тэслд1 ез уакытында тацдау жэне дурыс жYЙенi калыптастыру Yшiн 5 жыл бойы 80 наукаска зерттеулер журпзш^. Созылмалы панкреатиттц ая-сында косарлан€ан аскынан созылмалы тасты холецистит бар 20 наукаска холецистектомия жасалды. Содан кейiн наукастардыц 40% -ы аскыюан панкреатитц себебнен кез жумгды. БилиарлыжYЙенiц косарлаюан патологиялары барысында туындаган мэселелерд1ц жYЙелi шеш1м1н табу Yшiн авторлар алгоритм кестеан дайында-ды, ейткен зерттеулердiц жэне анамнестикалык мдлiметтердiц нэтижелерi 35-тен асады, ал мундай керсетюш мелшерi дифференциалдык багалау кез1нде киындыктар тудырады. Мдлiметтер алгоритмдер кестес бойынша компьютерде ецделедi. 60 наукасты 3 топка белу аркылы диагноз уакытында койылады, операцияга дейiн жэне операция уакытында аныктал€ан патологиялык езгерстерге сэйкес алдын алу шараларын жYргiзе алады, холеци-стэктомиямен катар ет тYтiгiн дренаждау аркылы жедел панкреатин ерте жэне туракты емдеудi камтамасыз етедi. Мундай наукастардыц арасында€ы елiм 5%-ды курайды.
Сондай-ак алгоритм баедарламасы бойынша диагностика жасау билиарлыкжYЙедегi €ана емес ас корыту жолыныц баска да белiмдерiндегi (кеп жардайда назардан тыс калатын) функционалдыкжэне патологиялык езгерiстердi ез уакытында аныктауга, сонымен катар операция уакытында кажет шараларды орындауга мYмкiндiк берещ. Бул ез кезепнде операциядан кейiнгi патологиялык синдромдардыц аскынуына жол бермейдi. Диагностика жасауда€ы бардарламаныц дэлдг 92,7%-ды, ал ауру а€ымын болжауда€ы дэлдк 86,2%-ды курайды. Жорарыда атал€ан хирургиялык тэсл тджiрибешi дэргерлерге сенiмдi турде усынылады.
Туйш свздер
билиapлы жуйе, жaнaмaлac пaтoлoгиялap, aлгopитм, xиpypгиялык тэсл
Хирургическая тактика при сочетанных патологиях билиарной системы
ОБ АВТОРАХ
Фараджи В.Ф. -
Научный сотрудник АМУ
Фараджли В.Ф.
Азербайджанский Медицинский Университет, кафедра хирургических болезней, Баку, Азербайджан
Ключевые слова
билиарная система, сочетанные патологии, алгоритм, хирургическая тактика
Аннотация
Для создания системы правильного и своевременного выбора тактики при сочетанных патологиях билиарной системы в течении 5 лет были проведены исследования на 80 больных. У 20 больных на фоне хронического панкреатита при сочетанно развившемся обострении хронического каменного холецистита была проведена холецистектомия,после которой развившийся панкреатит у 40% больных стал причиной смерти. Для основательного решения создавшейся проблемы при сочетанных патологиях билиарной системы авторы создали таблицу алгоритма по причине того, что результаты обследований и анамнестические данные превышают цифру 35 и создаются трудности в дифференциальном оценивании такого количествапоказателей. Данные обрабатываются на компьютере по созданной таблице алгоритма. Применение у разделённых на 3 группы 60 больных обеспечивает своевременную основательную постановку диагноза, адекватное проведение профилактическихмероприятий соответствующих обнаруженным патологическим изменениям как до так и во время операции, дренирование жёлчных протоков наряду с холецистэктомией обеспечивает раннее и стойкое лечение острого панкреатита. Смертность среди этих больных составляет 5%.
Также диагностика по программе алгоритма позволяет своевременно распознать развившиеся патологические и функиональные изменения(в большинстве случаев оставшиеся в стороне) не только в билиарной системе, но и в других отделах пищеварительного тракта, а также выполнение нужных мероприятий во время операции. Это в свою очередь не оставляет места для развития после операции патологических синдромов. Точность программы в диагностике составляет 92,7%, прогнозирование течения болезни составляет 86,2%. Предложенная хирургическая тактика с уверенностью предлагается практическим врачам.
Complications caused by pathologies of individual members of the biliary system still create undesirable problems for clinicians (2,3,5,10).Despite the fact that with the help of modern laboratory and instrumental research methods, it is possible to identify changes in the liver, intra-and extrahepatic bile ducts, gallbladder and common bile duct, Vir-sung duct, fater papilla and 12-duodenum. There are still unresolved problems (1,12,13). The combined description of the pathologies of these zones requires careful differential diagnosis (6,8,9,10,11). With this approach, it is clear that the aspects that are the main and auxiliary in the combined development of pathologies, their relationship, i.e., the pathogenesis and mechanism of the development of the combination still remains unresolved (1,2,4).
This analysis of the problem allows you to reveal many points. Any pathology that has developed in any Department of the biliary system brings with it other changes and the timely detection and correct assessment of these changes ensures the timely conduct of operations, as well as along with the operation of preventive measures (3,7,11).
Until now, the document of a single program reflecting the pathogenetic basis of the types of operations selected with combined changes in the hepatobiliary system and duodenum remains undeveloped (7,14).
The aim of the study is to improve the results of surgical treatment taking into account the dis-
closure of pathogenetic aspects reflecting the development of combined pathologies of the biliary system.
Materials and methods: the Research was carried out for 5 years at the clinical bases of the Department of surgical diseases. Examinations were carried out on 80 patients admitted to the clinic with a diagnosis of acute cholecystitis, which developed on the background of chronic pancreatitis. Despite the confirmation of the diagnosis of exacerbation of chronic pancreatitis after cholecystectomy, the detection of existing combined pathologies, possibly covering the hepatobiliary region and the 12th duodenum and taking into account the possible need for preventive measures before surgery. Patients along with traditional methods of research were carried out contrast radiography of the stomach, 12-duodenum, RPH And CT.
A transnasal probe is inserted into the patient together with a thin catheter prior to RPHG. During endoscopy, a catheter with a probe is inserted into the lower horizontal part of the duodenum and stored there for decompression. After the end of RPHG, a catheter with a diameter of 0.3 cm passing through the Vater nipple, which plays the role of a stent, is stored there for the purpose of decompression - the outflow of bile and pancreatic fluid; the other end is located outside, so it allows you to observe the outflow of bile. These are preventive measures. All patients underwent cholecystectomy,
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 3-2019
34
including 60 patients with laparoscopic, 20-and laparotomy. The 80 patients involved in the study were divided into 4 groups.
Group I: 20 patients developed acute cholecystitis on the background of pancreatitis. These patients had no interventions before and during surgery for pancreatitis. In 12 of them, cholecystectomy was performed laparoscopically, in 8 patients-by the open method. In this group of patients, the mortality rate was 40%.
Group II: in this group, consisting of 20 patients before surgery due to chronic pancreatitis, endo-scopic drainage was performed with a probe to ensure the outflow of bile and pancreatic juice (a catheter with a diameter of 0.3 cm passing through the Vater nipple) and decompression of the 12-duo-denum.
Only then were cholecystectomy and strong's surgery performed to prevent chronic 12-duodenal obstruction. 12 patients underwent laparoscopic surgery, 8 patients underwent open surgery.
Chronic pancreatitis and chronic obstruction of the duodenum 12 were found in 20 patients of group III before surgery. Before the operation for the developed acute stone cholecystitis, drainage through the Vater nipple and decompression of the 12-duodenum was performed. Along with open cholecystectomy in these patients, strong's surgery was also performed and this eliminated chronic duodenal obstruction.
Group II: in this group, consisting of 20 patients before surgery due to chronic pancreatitis, endoscopic drainage was performed with a probe to ensure the outflow of bile and pancreatic juice (a catheter with a diameter of 0.3 cm passing through the Vater nipple) and decompression of the 12-duo-denum.
Only then were cholecystectomy and strong's surgery performed to prevent chronic 12-duodenal obstruction. 12 patients underwent laparoscopic surgery, 8 patients underwent open surgery.
Chronic pancreatitis and chronic obstruction of the duodenum 12 were found in 20 patients of group III before surgery. Before the operation for the developed acute stone cholecystitis, drainage through the Vater nipple and decompression of the 12-duodenum was performed. Along with open cholecystectomy in these patients, strong's surgery was also performed and this eliminated chronic duodenal obstruction.
In 20 patients of group IV, along with acute cholecystitis, which developed against the background of chronic pancreatitis, structural changes and a decrease in the conductivity of the biliary tract and the Virsung duct were found during the examination. The sealing of the Fater's nipple and its circumference was also found, as well as the
impossibility of preserving the inserted catheter in the lumen of the duct. These patients underwent open surgery. After cholecystectomy, 14 patients underwent drainage of the common bile duct by the Pikovsky method.; internal drainage and strong's surgery were performed in 6 patients by the Monastery method. The development of acute pancreatitis in combined pathologies confirms the operation in an open way. Developing in acute pancreatitis diseases of intraperitoneal hypertension syndrome further exacerbate acute pancreatitis (4). With laparoscopic operations, there is inevitably an even greater increase in intra-abdominal pressure. The use of numerous laboratory and instrumental methods of examination indicates that none of them individually or in a systematic form is completely satisfied with clinicians.
Also, the collected anamnesis, the results of laboratory, instrumental and special methods of examination are scattered. They cannot play a role in the primary early diagnosis of acute pancreatitis, acute acute stone cholecystitis, developed against the background of chronic pancreatitis. When multiple organ failure in patients is overlooked a large number of indicators, or remains hidden in the background. Therefore, we considered it important to create an algorithm table, which is the guarantor of the correct design of treatment tactics, as well as early diagnosis and prevention of these combined pathologies and their complications, combined under one system (table.1).
It is important to use a computer program for the full functioning of the new and newly created algorithm table. Thus, all the data received are processed on a computer and a single system is created. A comparative analysis of the data obtained in this system with the normal indicators of markers is carried out, after that these data are recorded. In the end, conditions are created for the disclosure of ways to improve the results of cholecystectomy operations and prevention of chronic pancreatitis; acute stone cholecystitis. We conduct our research on the basis of this program. Practically, carrying out research work on the created program led to obtaining good results and getting rid of complications in the postoperative period. Mortality decreased from 40% to 5 %.
Thus, we can say that the created program of the algorithm fully reflects the goal and the tasks emanating from it. It is an excellent document that plays the role of a beacon in revealing hidden moments. Certainly and with confidence can be offered for use by practitioners.
The results of personal experience and analysis the study of local and foreign authors gives grounds to come to the conclusion that the combined pathology of the biliary system may develop
Table 1.
Table of algorithm of treatment and prevention of exacerbation of chronic pancreatitis after cholecystectomy
pronounced pathological changes in other areas of the digestive tract.
Therefore, for the full formulation of the diagnosis and plan of surgery, it is necessary to find out the following points (table. 2).
Adequate creation of preventive and therapeutic measures selected as a result of the analysis of diagnostic examinations provides the basis for the identification and simultaneous elimination of hidden pathologies; in parallel, gives the basis for the systematic use of data on a computer program in accordance with the prepared algorithm table.
Results and discussion: Based on the data of
instrumental examinations and clinical and laboratory indicators obtained on the first day after admission to the hospital, up to 35 clinical and laboratory symptoms were detected for the correct assessment of pathological changes, allowing for differential diagnosis.
In the current situation, the method leading to the correct solution of the tasks - can be considered an algorithm table and a computer program.
So, on the first day after admission of patients differential diagnosis of numerous indicators, the degree of development of chronic pancreatitis, forecasting its exacerbation after cholecystectomy
№ Detect changes Number Selectable operations Number
1 SHH,RE 16 Hernioplasty 16
2 AS, GP 12 Surgical treatment 12
3 DS, DGR 24 Duodenography, Strong's operation 4+20
4 GD, DD 4+4 Elimination of diverticulum by crimping seam 8
5 CL, CP 80 Cholecystectomy 80
6 BD, HPBD 14+12 Biliary drainage 60
7 XK 10 Colopexy 10
Table 2.
Detected changes corresponding to the operation.
Qeyd:
1) SHH - sliding Hiatal hernia Re-reflux-esophagitis
2) AS - atony of the stomach, GP - gastropod
3) DS-duodenostasis; DGR-duodenogastric reflux
4) GD-gastric diverticulum; DD-duodenal diverticulum; BD-biliary dyskinesia; HPBD-hepatopancreatobi-liary disorders
CI - cholelithiasis; CP-chronic pancreatitis; CC-chronic colostasis.
makes it possible to make the right choice, the planned operation and other activities.
The developed algorithm and the effectiveness of the computer program was proved by the use of 60 patients. In this case, the accuracy of the program in the diagnosis is 92.7%, the prognosis during the disease is 86.2%. Also, the advantage of the proposed program is that the graphical drawing of the results allows doctors to adjust the appropriate treatment tactics and freely assess the expected results and diagnosis
The application of the program in the clinic showed that the belonging of patients to a particular group determines the tactics of treatment. Thus, the treatment was carried out according to the group, but in patients from the group the postoperative period proceeded unfavorably, 8 of 20 patients died, of which 5 patients were operated laparoscopically, 3-e by laparotomy. In this group of patients, the algorithm program was not applied. Other 3 groups (60 patients) were examined according to the developed program, they were performed preventive and therapeutic measures in the order specified in the program. In these groups, only 3 patients died due to multiple organ failure.
2 of them were operated laparoscopies, 1 patient surgery was carried out by laparoscopy. As can be seen on the table (Tab. 2) combined pathologies of the hepatopancreatobiliary system can develop
simultaneously with diseases of individual areas of the digestive tract and in this case, the operations used are aimed at eliminating them as a whole.
This solution does not leave room for the development of any syndromes in the postoperative period. The results of examination of patients in different periods after surgery confirms the above.
Thus, it can be noted that the combined pathology of the biliary system is also combined with pathologies of other parts of the digestive system. In the initial examination of patients, as noted in the program, these points should be taken into account. It can be concluded that the problems associated with the pancreas, arising after cholecystectomy for combined pathologies of the biliary system not only remain, but they are even more aggravated lead to high mortality (40%). In patients who make up the main group, preventive measures drainage of the biliary tract before and during surgery-not only prevents exacerbation of the pathology, it also plays the role of pathogenetic treatment and prevents chronic changes in the hepatobiliary system, developed before surgery. Mortality among such patients was reduced to 5%. This gives reason to say that when detecting pathologies of the biliary system and along with developed other pathologies of the digestive tract. The developed program can become a normative document for practicing physicians.
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