Modern aspects of surgical treatment of iatrogenic injury and benign strictures of the bile ducts
Science Articles / / August 12, 2017
Romanov VE, Chernyshov VN
Clinic Surgery Institute of Postgraduate Education of the Samara State Medical University and the Regional Clinical Hospital named after Kalinin.
Surgical treatment of iatrogenic injuries and scar strictures of extrahepatic bile duct is one of the most difficult problems in biliary surgery.This contributes to an increase in the number of patients with biliary tract disorders, and, respectively, and the increase in the number of operations performed.Another circumstance that affects the rate of iatrogenic damage hepaticocholedochus is the widespread adoption of the practice of laparoscopic techniques.According to reports the frequency of injuries hepaticocholedochus the classical "open" cholecystectomy varies from 0.1-0.5%, at least shows the higher its frequency.At the same time, the frequency of damages of the bile ducts during laparoscopic cholecystectomy significantly higher than in the classic "open" surgery and observed at 0.2-0.8% operations, and, according to some s
Despite the large number of publications, remain controversial issues of treatment of iatrogenic injury hepaticocholedochus.We give different numbers of frequency of damage of the bile ducts with cholecystectomy.There is no clear opinion on the timing of operations with established complications, contradictory data on the results of interventions hepaticocholedochus (frameless techniques gepatikoeyunoanastomii type Hepp-Couinaud anastomosis and drainage on the frame-by Getz et al.), Remain relevant issues of technical equipment operation.Most publications began to appear about endobiliary interventions with lesions and strictures of extrahepatic bile ducts, but not all with clear indications for their use.
purpose of research - to work out the best options for operations and the timing of their implementation when diagnosed lesions of the bile ducts;try to find techniques that simplify the technique of operations for injuries and benign strictures hepaticocholedochus.
Materials and methods. The treatment analysis of 118 patients with iatrogenic injuries bile duct extrahepatic cholecystectomy during the period from 1986 to 2002.In 12 of these ducts are damaged during operations in our clinic.6 (0.11%) people they happened at "open" cholecystectomy (5380 operations), even in 6 (0.25%) - in laparoscopic cholecystectomy (2376 operations).
Women were 89 men - 29. The average age of patients was 44.5 years.To determine the version of damages and restrictions of the bile duct was used E.I.Galperina classification with the classification of the elements of S. Strasberg and H. Bismuth.
Depending on the manifestations of bile duct damage, patients were divided into three groups:
-1 - I group - the damage hepaticocholedochus ascertained when performing the first surgery (21 patients);
- Group 2 - Patients with manifestations of bile peritonitis (18 patients);
- 3- group - patients with symptoms of obstructive jaundice, cholangitis, partial or total external biliary fistula (79 people).Prior to joining the clinic in 26 (31.6%) patients of the troupe performed unsuccessful operation (1 to 6) in the aftermath of hepaticocholedochus injuries.In 7 patients in this group identified a "mini-trauma" of the bile ducts.
Patients in Group 1.Of the 21 patients in 3 were performed reconstructive operations on hepaticocholedochus: one patient - suturing lateral defect hepaticocholedochus length of about 1.5 cm on the T-shaped drainage, another two - stapling excised duct on the T-shaped drainage.In 18 patients after detection of iatrogenic injury gepatikoholsdoha was performed Hepaticojejunostomy removable transhepatic drendzhe.In accordance with the above classification of 17 patients were damaged II, III and IV types and only 4 - 1 type.
All patients crossed bile ducts were not dilated, their diameter is less than 4-5 mm.The small diameter of the bile ducts excluded the possibility of creating a wide tubeless biliodigestive anastomosis.The optimal solution in this situation was considered by the restoration zhelchetoka Hepaticojejunostomy removable traspechenochnom drainage.
Postoperatively, the patient died 1 by hemobilia.In the late postoperative periods of the three patients who underwent reconstruction surgery, two patients developed strictures hepaticocholedochus (after biliobiliarnogo anastomosis on the T-shaped drainage).A good result was observed in one - after closure of the regional gepatikoholsdoha defect in the T-shaped drainage.Of the 18 patients undergoing hepaticojejunostomy on removable drainage trapepechenochnom good results were observed in 17 (94.4%) persons.
Patients 2 groups.In 18 patients the injury of the bile ducts found in the postoperative period on the background of bile peritonitis (all operated out of our clinic).In these patients performed just rehabilitation of the abdominal cavity with external drainage of the bile ducts.Further treatment was aimed at the elimination of peritonitis.Necessarily considered a return to the intestine seceding from the abdomen bile, preferably at conducted at gastroduodenoscopy nanointestinalnomu thin catheter.
8 patients with external biliary drainage reconstructive surgeries were performed after decrease in peritonitis phenomena in terms of 3 to 6 weeks after drainage - "early" surgery, all patients were performed hepaticojejunostomy removable transhepatic drainages.Serious problems with the release of injured bile duct, the imposition gepatikoeyunoanastomoza due to scar-adhesions during the operation in these terms we have not mentioned.Complications after surgery were operated on in 3 (subdiaphragmatic abscess, cholangitis, inconsistency in place enterostomy removal transhepatic drainage), postoperative mortality was not.In the late postoperative periods (over 5 years) gepatikoanastomozov strictures were observed in 1 patient out of 8 operated.
10 patients Hepaticojejunostomy removable trans-hepatic drainage performed by 2.5-3.5 months after surgery, external drainage of the gall - "later" operation.In all cases, the transaction is marked rough scar-adhesions, difficult to isolate injured bile duct and the imposition gepatikoeyunoanastomoza.In the immediate postoperative complications were observed in 33% of operated (6 people), postoperative mortality was not.In the long-term period after surgery scar contraction gepatikoeyunoanastomoza occurred in 3 out of 10 operated patients.
Group 3 patients.79 people with external biliary fistula, obstructive jaundice, cholangitis included in this group.Before entering the clinic, 26 patients were operated on between 1 and 6 times in other surgical hospitals in an attempt to restore zhelchetoka.
To restore zhelchetoka 18 patients failed hepaticojejunostomy with disabled Roux loop of intestine without long transhepatic drainage anastomosis.In 12 of them carried out drainage of the anastomosis zone on Prader-Smith for 8 weeks.Avoid prolonged drainage failed in the presence of stricture type 1 in 16 patients and the possibility of imposing biliodigestive anastomosis at least 2-3 cm with a thorough comparison of the mucous duct and serous-muscular edge of the ulcer.In 2 patients a wide anastomosis could impose by dissection, mainly the left hepatic duct after its mobilization under the plate of liver portal.Tional postoperative mortality was no complications in the postoperative period occurred in 3 (16.6%) persons.In the long-term period in all 18 patients good results recorded transactions.
in 40 patients in this group had made transactions with the carcass transhepatic drainage of the anastomosis.Of these, 16 patients had been previously operated in other surgical hospitals: hepaticoduodenostomy was performed in 9 patients, biliobiliarny anastomosis - in 4, suturing the edge of the defect in the common bile duct 3, Hepaticojejunostomy - in 10 patients.Of these 26 patients at 18 is Hepaticojejunostomy, while 8- indobiliarnye intervention (in 3 narrowed stented duct), in 5 - temporary drainage skeleton for Prader-Smith.In 11 of these 40 patients gepaptikoeyunostomiya was performed in the "early" timing - 2 weeks - 1.5 months after hepaticocholedochus injury.All 11 patients had good long-term results of operations.29 patients were performed "later" operation through 2.5 6 months after injury hepaticocholedochus - gepatikoeyunoaiastomoza stricture developed in the long-term period in 4 patients,
In 10 patients with stricture previously imposed gepatikoeyunoanastomoza dissection hepatic duct was performed mainly.by the left, through the lumen of the opened jejunum.At the same time as in the intestine it has been opened by Finney pyloroplasty.In 2 patients zone expanded fistula drained by Prader-Smith 8-9 weeks, the rest performed transhepatic drainage for Getz.
7 In Group 3 patients were diagnosed extended strictures hepaticocholedochus.In 4 of them - after laparoscopic cholecystectomy (probably post-burn), in 2 - after open (wound edge), and 1 - after the restoration of flow in the T-shaped drainage.In these 7 patients was performed endobiliary stricture stented area.In stenting long-term period (up to 5 years) stricture recurrence was observed in 4 people.All were operated on again.
endobiliary stent with good results performed in 2 patients admitted to the clinic with the strictures gepatikoduodenoanastomozov.In 5 patients with restenosis gepatikoduodenoanastomozov was conducted skeleton drainage constriction with a temporary external-internal drainage Prader-Smith.Drains were removed after the elimination of jaundice and cholangitis (2-2.5 months), and patients are under observation,
Of the 74 patients operated on 3 groups after surgery died 9 (12.2%) persons.Of the 65 survivors of complications in the postoperative period were observed in 21.6% of operated.In the long-term period after surgery good results were observed in 57 (87.7%) were operated, stricture recurrence occurred in 8 (12.3%).
Overall, 118 patients with iatrogenic bile duct injuries, 113 were operated, 10 died (8.5%) patients.Postoperative complications (suppuration of postoperative wounds, abscesses of the abdominal cavity, liver abscesses, and others.) Were observed in 26 (23%) were operated.In the late postoperative periods (up to 16 years), 2 patients died of detected tumors of the bile ducts, an additional 2 patients - from comorbidities.
stricture relapses in late after our operation were noted in 14 (11.9%) patients.In 2 patients restenosis developed after the imposition of hepaticocholedochus biliobiliarnogo anastomosis at the T-drain.Both patients underwent Hepaticojejunostomy removable transhepatic drainages Getz with good long-term results (time of observation 13 and 10 years).Relapses strictures diagnosed in the period from 2 to 4 months in 4 patients out of 7 endobiliary after stenting.One - performed a laparotomy with removal of the stent and applying gepatikoeyunoanastomoza (now drainage is removed, a good result is stored 2 years), the rest taken endobiliary treatments: probing and "disclosure" to the initial stent diameter (patients are observed).
8 patients was stenotic gepatikoeyunoanastomoza.In 5 of them managed to remove the stricture by en dobiliarnogo stenting narrowed anastomosis.After CHCHH specified location and extent of contraction, dilation accompanied him Billon with time (5-7 days) externally-internal drainage of the biliary tract with the establishment of the end of the perforated drainage in the gut.After the elimination of high bilirubinemia and cholangitis conducted narrowed stented duct using the chosen stent (Wallstent, Palmaz et al.).ductal stenting results were good in all patients.The remaining 3 patients were performed relaparo tomiyu, cut the stricture with transhepatic draining aniem anastomosis with good results in the area up to 2 years.
Thus, of the 118 patients with different types of iatrogenic bile duct injury, postoperative mortality was 8.5%.Of the 108 survivors in separated periods after surgery, 94 (87.03%) patients were able to restore patency of the bile duct at the timing observations from 2 to 16 years.Operations and treatment proven effective in 14 (12.96%) patients who were growing phenomenon zhelchestaza.All of them carried out various structural interventions (endobiliary including) with x irrigating immediate results, patients are under observation, but to judge the long-term results from them yet.
1. Basic operation of iatrogenic lesions of the bile ducts is Hepaticojejunostomy with long carcass drainage replaceable transpechenym drainage.The use of tubeless Hepaticojejunostomy method requires certain conditions.
2. With respect to the timing of reconstructive surgery seems appropriate in the presence of external biliary fistula reconstructive surgery to perform early as possible after the elimination of the phenomena bile peritonitis (3-4 weeks after external drainage of biliary tract).
3. A promising area of treatment of patients with benign strictures is to use endobiliary technologies (external-internal skeleton drainage, dilatation and agency service ducts).Our while small, experience endobiliary stent (14 patients) allows positively evaluate this method stenoses gepatikoёyuno - and gepatikoduodeioanastomozov.