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II. ХИРУРГИЯ
SURGICAL TREATMENT OF MIRISZY SYNDROME IN PATIENTS WITH EXCESS BODY MASS
Aimagambetov M.Zh.1, Auyenov M.A.1, Bulegenov T.A.1, Abdrakhmanov S.T.1, Yoshihiro Noso2, Omarov N.B.1, E.M. Asylbekov N.B.1
Semey Medical University, The Republic of Kazakhstan1.
Medical University of Shimane, Department of Surgery, Department of General Medicine, Faculty of Medicine, Oda Training Center, Japan2
Abstract
The results of treatment of 25 patients with cholelithiasis, complicated by Mirizzi syndrome type III and IV, were studied. There were 6 men (24%) and 19 women (76%), 1:3. The age of the patients ranged from 41 to 78 years. The average age of patients was 63.4±3.4 years. Of these, 14 (56%) patients were overweight: obesity degree I - 7, obesity degree II - 5, the degree of obesity III - 2. All patients were hospitalized as an emergency. All patients were divided into 2 groups depending on the method of elimination of hepatico-holedochus wall defects. The first group - 15 (60%) patients who underwent cholecystectomy, drainage of the common bile duct through the fistula defect by Kerr, hepaticojejunostomy with inter-intestinal anastomosis by Brown (with Shalimov's plug) and Roux (additional drainage by Felker) to the resulting loop. The second group - 10 (40%) patients who underwent cholecystohepaticco-choledochoplasty with P-shaped interrupted sutures on the drainage by Vishnevskiy and hepaticojejunostomy (modelling of Roux technique) using the method of the University Hospital of Semey Medical University. Patients with alimentary obesity -Grades II-III are operated on with the use of "Universal delator Aimagambetov for patients with overweight". Analysis showed us the reduction of postoperative complications in the second group of patients, which allows us to recommend this method as one of the options of choice for the correction in the treatment of Mirizzi syndrome III and IV types.
Артьщ дене cалмаFы бар наукаcтаpдаFы Мириззи синдромыньщ хирургияльщ eMi
Аймагамбетов М.Ж.1, Эуенов М.Э.1, Булегенов Т.А.1, Абдрахманов С.Т.1, Йошихиро Носо2, Омаров Н.Б.1, Асылбеков Е.М.1
Семей каласыньщ мемлекетш медицина университету Казахстан Республикасы1. Шиманэ Медицина Университету Хирургия департаменту жалпы медицина бeлiмi, Ода каласыньщ медицина факультетшщ оку орталы^ы, Жапония2
Ацдатпа
6т -тас ауруыныщ (6ТА)аскынуынан туындаран Мириззи синдромыньщ III жэне IV типндеп 25 наукастыщ емнщ корытындысын талдау. Олардыщ iшiнде ер адамдар 6 (24 %) наукас, эйел адамдар 19 (76 %), ара катынасы 1:3тещ. Наукастардыщжас шамасы 41-ден 78жаска дейн. Наукдстардыц орташа жас шамасы 63,4±3,4.Оныщ шнде 14 (56%) емделушi артык дене салмагына ие болды: I дэрежелi семiздiк - 7, II дэрежелi семiздiк - 5, Ill дэрежелi семiздiк - 2. Барлык наукастар ауруханыа щгыл гурде госпитализацияланды. Барлык наукастар гепатохоледох кабырасынын акауларынжою эдiсiне байланысты 2 топка бвлШщ. Бiрiншi топта - 15 (60%) наукас, оларта келесщей ота жасалынды: холецистэктомия, Кер бойынша холедохтыщ жыланквз акауын дренирлеу, eкелушi iшекте Брауш бойынша (Шалимов беютпеамену) жене Ру бойынша (косымша Фелькер бойынша дренирлеу) шек аралык анастомоз жене гепатикоею-ностомияжасалынды. ЕкШ топта - 10 (40%) наукас, Семей мемлекетткмедицина университетЩ университетк госпиталЩ клиникалы eдiсi бойынша гепатикоеюноанастомия (РУ eдiсi бойынша модельдеу) жене Вишневский дренажында П- тeрiздi тYЙiндi тспен холецистогепатикохоледохопластика жасалынды. Алиментарлык семiздiк -II - III дeрежелi емделушлерге «артык дене салма€ымен ауыратын наукастарта арнал€ан Аймагамбетовкц ембебап жаракат кефкшн» пайдалану аркылы операция жасалды. Талдау кврсеткш бойынша екiншi топта€ы наукастарда операциядан кейшп аскынулар твмендеген. Сотан байланысты Мириззи синдромыныщ III жeне IV титнде емдеу eдiсiн коррекциялау максатында, бул eдiстi нускалардыщ бiрi ре^нде усынуга болады.
UDC:616.36-008.5-616.361-089
МРНТИ 76.29.37
ABOUT THE AUTHORS
M.Zh.Aymagambetov - surgeon, PhD, Associate Professor, Head of the Department of Hospital Surgery at NCJSC «SMU» (meyirbek30@mail.ru +77713693227)
M.A. Auenov - surgeon, PhD doctoral candidate, Department of Hospital Surgery, NCJSC «SMU» (medetaizat15@mail.ru +77751341486)
S.T. Abdrakhmanov - surgeon, PhD doctoral candidate, Department of Hospital Surgery, NCJSC «SMU» (dr.samatbek@mail. ru +77076613278)
T.A. Bulegenov - surgeon, PhD, Associate professor; Vice-rector for scientific and clinical work of NCJSC «SMU» (tolkynbul@ mail.ru +77757563038)
Yoshihiro Noso - surgeon, PhD, MD, Professor, Shimane University, Faculty of Medicine, Izumo city, Shimane, Japan.
E.M. Asylbekov - surgeon, PhD, Doctor of the highest category, Head of the Department of General Surgery of the University Hospital at NCJSC «SMU» (Asylbekov_Yerlan@mail. ru +77076500190)
N.B. Omarov - surgeon, PhD, Head of the educatonal department of Hospital Surgery at NCJSC «SMU» (omarov.n83@mail. ru +77015368081)
Keywords
cholelithiasis, Mirizzi syndrome, hepatico-choledochoujunostomy, cholecystohepaticco-holedocho-plasty
АВТОРЛАР ТУРАЛЫ М.Ж. Аймагамбетов - отташы, м.тд., доцент, госпиталды хирургиясыныц кафедрасыныц мецгерушюг «СМУ» КеАК. (meyirbek30@mail.ru +77713693227) М.Ж. Аймагамбетов - отташы, м.Ед., доцент, госпиталды хирургиясыныц кафедрасыныц мецгерушюг «СМУ» КеАК. (meyirbek30@mail.ru +77713693227) М.Э. Эуенов - отташы, PhD докторант, госпиталды хирургиясыныц кафедрасы. «СМУ» КеАК. (medetaizat15@mail. ru +77751341486) С.Т. Абдрахманов - отташы, PhD докторант, госпиталды хирургиясыныц кафедрасы. «СМУ» КеАК'. (dr.samatbek@ mail.ru +77076613278) Т.А. Булегенов - отташы, м.тд, доцент, проректор, «СМУ» КеАК. (tolkynbul@mail.ru +77757563038) Й. Носо - отташы, д.м.н., доцент, PhD, MD, профессор, Ода к, профессор, Шиманэ университепн^ Медицина Факультет, Жапония. (y.noso@med.shimane-u.ac.jp) Е.М. Асылбеков - отташы, м.тк., жоFарFы санатты хирург Университет госпитальдын жалпы хирургия бeлiмшесiнцi мецгерушсг «СМУ» КеАК. (Asylbekov_Yerlan@mail.ru +77076500190) Н.Б. Омаров - отташы, м.тк., госпиталды хирургиясыньщ кафедрасыныц оку болiмiнiц мецгерушю, «СМУ» КеАК. (omarov.n83@mail.ru +77015368081)
Туйш свздер
вт-тас ауыруы, Мириззи синдрoмы, гепaтикoxoледoxoе-юностомия, xолецистогепатико-xoледoxoплaстикa
Хирургическое лечение синдрома Мириззи у больных с избыточной массой тела
ОБ АВТОРАХ
М.Ж. Аймагамбетов - хирург, д.м.н., доцент, заведующий кафедрой госпитальной хирургии НАО «МУС» (meyirbek30@mail.ru +77713693227) М.А. Ауенов - хирург, PhD докторант, кафедра госпитальной хирургии НАО «МУС».
(medetaizat15@mail.ru +77751341486) С.Т. Абдрахманов - хирург, PhD докторант, кафедра госпитальной хирургии НАО «МУС».
(dr.samatbek@mail.ru +77076613278) T.А. Булегенов - хирург, д.м.н., доцент; проректор по научной и клинической работе НАО«МУС». (tolkynbul@mail.ru +77757563038) Й. Носо - хирург, PhD, MD, профессор, директор образовательного медицинского центра г. Ода, профессор факультета медицины университета Шиманэ, Япония.
(y.noso@med.shimane-u.ac.jp) Е.М. Асылбеков - хирург, к.м.н., врач высшей категории, заведующий отделением общей хирургии Университетского госпиталя НАО «МУС». (Asylbekov_Yerlan@mail.ru +77076500190) Н.Б. Омаров - хирург, к.м.н., завуч кафедры госпитальной хирургии НАО «МУС».
(omarov.n83@mail.ru +77015368081)
Ключевые слова
желчнокаменная болезнь, синдром Мириззи, гепатикохоледо-хоеюностомия, холецистогепати-кохоледохопластика, избыточная масса тела и ожирение.
Аймагамбетов М.Ж.1, Эуенов М.Э.1, Булегенов Т.А.1, Абдрахманов С.Т.1, Йошихиро Носо2, Омаров Н.Б.1, Асылбеков Е.М.1
Государственный медицинский университет города Семей, Республика Казахстан1. Медицинский Университет Шиманэ, Департамент хирургии, отделение общей медицины, Факультет медицины учебный центр г. Ода, Япония2
Аннотация
Изучены результаты лечения 25 больных с желчнокаменной болезнью (ЖКБ), осложнившейся синдромом Мириззи (СМ) III и IV типа. Из них мужчин было 6 (24 %), женщин 19 (76 %). Возраст пациентов варьировал от 41 до 78 лет. Средний возраст больных 63,4±3,4 года. Из них 14 (56%) пациентов имели избыточную массу тела: ожирение I степени - 7, ожирение II степени - 5, ожирение III степени - 2. Все больные госпитализированы в экстренном порядке. Пациенты были разделены на 2 группы в зависимости от способа ликвидации дефекта стенки гепати-кохоледоха. Первая труппа - 15 (60%) больных, которым выполнена холецистэктомия, дренирование холедоха через свищевой дефект по Керу, гепатикоеюностомия с межкишечным анастомозом по Браунус заглушкой по Ша-лимовуи гепатикоеюностомияпо Ру (дополнительным дренированием по Фелькеру) на приводящую петлю. Вторая группа - 10(40%) больных, которым выполнена холецистогепатикохоледохопластика П-образными узловыми швами на дренаже по Вишневскому и гепатикоеюноанастомия (моделирования методики по Ру) по методу клиники университетского госпиталя Государственного медицинского университета г. Семей (УГ ГМУ г. Семей). Пациенты с алиментарным ожирением - II - III степени оперированы с использованием «Универсального ранорасширителя Аймагамбетова для больных с избыточной массой тела». Анализ показал снижение послеоперационных осложнений во второй группе больных, что позволяет рекомендовать этот способ как один из вариантов коррекции выбора при лечении синдрома Мириззи III и IV типа.
Introduction
Currently, there is a parallel progressive increase in the number of patients with complicated forms of cholelithiasis [2,3]. This persistent trend persists over the past years. With an increase in the incidence of gallstones, the number of complications such as choledocholithiasis, obstructive jaundice, cholangitis, and biliary pancreatitis increases [5,9,13]. Among rare complications of gallstones, a special place is occupied by Mirizzi syndrome (SM), which develops with the spread of inflammatory -destructive process from the gallbladder to the bile ducts, resulting in duct compression or cholecysto-biliary fistula formation, through which gallbladder stones migrate into the main bile ducts [1-4].
In connection with the progress of biliary tract surgery and an increase in the incidence of gallstones in recent years, interest in this problem has been increasing. In developed Western countries, SM occurs in less than 1% of patients, and in underdeveloped countries it ranges from 4.7 to 5.7% [1, 10,14].
When type III - IV of the SM, most surgeons hold the position that the choledochojejunostomy is necessary [7,11,16]. But with destructive processes in the gallbladder, cholangitis and infiltration of the hepatoduodenal ligament with the spread of the liver in the gate, as well as overweight of the patient together lead to the technical difficulty of isolating
the hepatic duct and the formation of hepapiko-jejunostomy, thus increasing the risk of damage to the elements of the hepatoduodenal ligament, which requires special approach in the method of performing surgical interventions. Thus, today, SM is one of the complications of gallstone disease, in the diagnosis and surgical tactics of which a number of unresolved issues remain. Despite the wide choice of surgical procedures for this syndrome, the results of treatment today are not quite satisfactory. The presence of SM in a patient during surgery increases the risk of intra- and postoperative complications [15,17]. There is evidence that the higher the degree of destruction of the choledoch wall (type II - IV SM according to A. Csendes 1989), the higher the level of postoperative mortality [12,16]. Postoperative mortality ranges from 4.8 to 23.8%. Hepaticoholedochus and residual choledocholithia-sis strictures in the late postoperative period were noted in 13-14% of patients [8,14,17]. Difficulties in diagnosing SM, the danger of damage to the bile duct, few observations, as well as a fairly wide range of surgical treatment methods determine the relevance of studying this problem. The introduction of modern methods for the diagnosis of SM and the development of rational surgical tactics depending on the type of syndrome will provide an opportunity to improve the treatment of patients with this complication of cholelithiasis.
Purpose of the study
To improve the results of surgical treatment of patients with Mirizzi syndrome III and IV type.
Methods
The results of surgical treatment of 3842 patients with cholelithiasis (CL), treated in the Semey State Medical University in January 2012 are presented to July 2018. Of these, 25 (0.7%) were diagnosed with SM III and IV type. Type III SM was detected in 14 (56%) patients, Type IV SM -11 (44%). There were 6 men (24%), women - 19 (76%). The age of patients ranged from 41 to 83 years, averaged 63.4 years. Of these, 14 (56%) patients were overweight: obesity grade I - 7, obesity grade II -5, obesity grade III - 2. The duration of obstructive jaundice in patients ranged from 3 to 19 days.
All patients with complicated forms of cholelithiasis were admitted with a clinical picture of acute calculous cholecystitis and varying degrees of mechanical jaundice. There were 3 (12%) with mild jaundice, 8 (32%) with moderate, and 14 (56%) with severe.
All operations were performed under endotracheal anesthesia. From the upper middle laparotomy, the operation was performed in 5 (20%) patients, from the mini - access using the apparatus of the mini - assistant "League - 7" M.I. Prudkova - in 4 (16%), the universal retractor M.Zh. Aymagambe-tov, developed in the clinic (patent of the Republic of Kazakhstan No. 90060) - in 9 (36%). Overweight patients 7 (28%) were operated on using the modernized "Universal Retractor Aymagambetov for patients with overweight". The patients were divided into 2 groups depending on the method of the operation.
Results
The control group included 15 (60%) patients who underwent cholecystectomy, intraoperative cholangiography. At the same time, type III SM was diagnosed in 10 (66.7%) patients. In 4 (40%) of them, the operation was completed by dissociating the fistula between the gallbladder and the cho-ledochus, removing the calculus from the common bile duct and draining the choledochus through the fistula defect according to Kerr; 6 (60%) - completed with hepaticojejunostomy with inter-intestinal anastomosis according to Brown and Shalimov stub on the adductor loop. In type IV SM (5 (33.3%) patients), the operation was completed with the formation of hepaticojejunostomy on the isolated loop of the jejunum according to Roux and drainage according to Felker in 3 (60%) and hepaticojeju-nostomy on frame drainage, with an inter-intestinal anastomosis according to Brown, with a plug Shalimov on the adductive loop in 2 (40%) patients. It
should be noted that of these, 9 (60%) patients were hospitalized as planned without acute inflammatory events.
The main group consisted of 10 (40%) patients who underwent cholecystectomy, intraoperative cholangiography (patent of the Republic of Kazakhstan No. 90500), fibrocholedochoscopy using the conductor developed in the clinic through a fistula orifice. All patients were hospitalized on an emergency basis with symptoms of acute inflammatory changes in the gallbladder and ducts. Developed treatment methods were performed for patients of this group. In SM of Type II (only 4 (40%) patients), one patient was treated with hepaticoje-junostomy according to the clinic method (2017 / 0423.1), three performed cholecystohepaticco-choledoplasty with U-shaped interrupted sutures in the Vishnevsky drainage (2017 / 0980.1). In SM IV type (only 6 (60%) patients), four patients received hepaticojejunostomy according to the method of the clinic (2017 / 0423.1), two had cholecystohe-paticco-choledoplasty with U-shaped interrupted sutures in the Vishnevsky drainage (2017 / 0980.1).
In the control group - 15 patients who were operated on with the traditional laparotomy access, the following complications were observed: postoperative wound seroma - in 2 (13.3%), cho-leodynamics (after hepaticojejunostomy and interintestinal anastomosis according to Brown) - in 1 (6.7%) patient. 6 months after the removal of the T-shaped drainage along a Keruu, one patient developed a stricture of the hepaticocholedochus, which a month later a hepaticojejunostomy was applied according to the method of the clinic. 2 (13.3%) patients died. The cause of death in one observation was hepatic-renal failure on the background of severe intoxication and purulent cholangitis (on the 2nd day after surgery), and in the second - DIC (on the 2nd day after surgery).
In the main group, in 6 patients who underwent cholecystohepatico-choledochoplasty, postoperative fistulocolangiography was performed on the 7th day, during which the contrast was freely admitted to the duodenum, there was no insolation of the anastomosis. The Vishnevsky drain pipe from the choledoch was removed on the 9th - 12th day. In the main group of patients who underwent he-paticojejunostomy by the method of the clinic, there were no postoperative complications, no fatal outcomes.
Figures 1-4 show how to eliminate the defect of the wall of the hepaticocholedochus.
The method is as follows: after performing atypical cholecystectomy (Figure 1), a loop of 6080 cm is formed. After the enterotomy, a single-row U-shaped continuous suture is applied to the back lip of the anastomosis (Figure 2). Then, the remain-
ing part of the posterior gallbladder wall intersects at a distance of 2.5-3.0 cm from the edge of the hepaticocholedochus defect, and the crossed edge of the wall adjacent to the defect is mobilized from the bladder bed at a distance of 0.5-0.7 cm, and is superimposed continuous U-shaped suture on the front lip of the anastomosis with 4-0 proleene (Figure 3). The final form of hepaticocholedochae-junostomy is presented in Figure 4.
Discussion
The variety of unresolved problems in bile duct surgery forces the surgical community to discuss issues of biliary duct pathology in the highest surgical forums. The complexity of the surgical intervention for cholecystohepatic-choledochaeal fistulas requires the development of methods for correct-
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Conclusion
Developed and approved methods of surgical treatment of Mirizzi syndrome III and IV types can improve the immediate and long-term results of surgical treatment of patients with this pathology.
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