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PREVENTION OF THE LIVER FAILURE DEVELOPMENT BY DECOMPENSATION OF THE BILIARY SYSTEM IN PATIENTS WITH OBSTRUCTIVE JAUNDICE BY PERFORMING MINIMALLY INVASIVE LAPAROSCOPIC CHOLECYSTECTOMY

PREVENTION OF THE LIVER FAILURE DEVELOPMENT BY DECOMPENSATION OF THE BILIARY SYSTEM IN PATIENTS WITH OBSTRUCTIVE JAUNDICE BY PERFORMING MINIMALLY INVASIVE LAPAROSCOPIC CHOLECYSTECTOMY
Дзыгал Александр, кандидат медицинских наук, доцент

Грубник Юрий Владимирович, заведующий кафедрой, доктор медицинских наук, профессор

Одесский национальный медицинский университет, Украина

Участник первенства: Национальное первенство по научной аналитике - "Украина";

For over the 25-year period that has elapsed since the first laparoscopic cholecystectomy (LCE) performed by the French surgeon F. Dubois, its indications continue to expand [1, 2]. In this regard, it is important that endovideosurgical technologies and, in particular, laparoscopy have currently occupied positions in the choice of treatment tactics of surgical patients as well as spread to the related specialties, giving them a new impetus to development [1, 3-6]. Surgery of the organs of the hepatopancreatoduodenal area served as a source of evolutionary development of laparoscopic techniques, and LCE is officially recognized as the "gold standard" in the surgical treatment of gallstone disease (GSD) [7, 8].

When analyzing the results of many years of clinical follow-ups and surgical treatment of patients with hepatic insufficiency (PI), we came to the conclusion that a certain percentage of this disease develops due to ineffective treatment (objective or subjective causes) of patients with obstructive jaundice (OJ). We refer patients with OJ to those with acute surgical diseases, but we believe that urgent surgery is risky in obturation of the extrahepatic biliary tract, cholangitis and others with a prospect of a significant number of complications up to the formation of multiple organ failure and substantial (3.5 - 4-fold) increase in mortality, comparable with the corresponding figures in the conservative treatment of OJ [9-11].

The question of choice of surgical treatment in this group of patients is controversial, but most experts believe that two-stage method of treating such patients is the best. In the first stage, simultaneous or prolonged decompression, sanation of the gallbladder or bile ducts are usually carried out that allows to eliminate clinical manifestations of the disease mainly of the inflammatory origin, as well as to prepare the patient for performing the second, main stage of surgical treatment, aimed at eliminating the causes of OJ - performing LCE.

This tactic of treatment allows to decrease the number of postoperative complications, reducing the overall mortality as well as having a prophylactic effect preventing the destructive changes in the liver parenchyma, the toxic effect of accumulation of bile acids in the hepatocytes and their necrosis.

Issues directly determining treatment strategies of this category of patients by the surgeon are debatable. There are different views  as to what kind of pathology associated with the presence of OJ is to be considered essential in each case; what treatment should be started with; whether the clinical course of the disease allows to perform one-stage surgery, or it must be  performed in sequence in several stages and what stages they should be; what surgical approach should be used in the treatment of patients with dysfunction of the cardiovascular and respiratory systems; what kind of surgery - laparoscopic or traditional [open] - should be performed for better postoperative course and for preventing the development of multiple organ failure - this is a list of the most important questions, the answers to which should be fast, specific and individual in each case determining tactics, scope and timeliness of surgery.

Objective. Assessment of the effectiveness of the two-stage method of treatment of OJ patients, with a focus on improving the functional state of the liver in the postoperative period.

Materials and methods.

For the last 3 years we have treated 164 patients with OJ aged 32 to 72. There were 121 (73.8%) women and 43 (26.2%) men. The age 85 patients (51.8%) was over 50, 56 patients (34.1%) were over 60 years old.

The diagnosis of OJ is based on clinical examination of the patients, biochemical blood analysis, and ultrasound examination of the organs of the hepatopancreatoduodenal area, computed tomography, endoscopic retrograde cholangiopancreatography and percutaneous-transhepatic cholangiography.

Specific manifestations of the OJ syndrome including yellowness of the skin and sclera, were found in 138 (84.1%) patients, dark urine and feces acholia - in 69 (42.1%) patients, pain and feeling of heaviness in the right upper quadrant and in the upper abdomen - in 143 (87.2%) patients. 98 patients (59.8%) were identified a dyspeptic syndrome (nausea, dryness or bitterness in the mouth, heartburn, belching, loss of appetite, changes in the stool character, etc.). Itchy skin with typical scratching on the body was noted in 32 (19%) patients and elevated body temperature - in 19 (11.6%).

As a result of the treatment, all patients were retrospectively divided into 2 groups: patients in the group 1 (n = 101, 61.6%) were performed a two-stage surgery with endoscopic papillosphincterotomy (EPST) at the first and LCE –at the second stage. 63 patients (38.4%) whom we had to perform a full open surgery for choledocholithiasis at the first stage and/or open cholecystectomy (OHE) at the second stage, constituted the group 2 for the investigation.

Monitoring of patients treated was made during the first 7-10 days after surgery and 3 months after discharge.

The results obtained were processed statistically using One Wasy Analysis Of Variance Criteria. Differences were considered significant in p < 0.5.

Results and discussion.

Of the total number of patients with OJ the cause of obturation of the extrahepatic biliary tract was cholelithiasis and associated choledocholithiasis in 131 patients (79.9%), 17 patients (10.4%) had acute pancreatitis, the edematous form, 6 (3.7%) patients - a benign stricture against the background of the common bile duct cholelithiasis, 5 (3.0%) patients - postcholecystectomical syndrome, choledocholithiasis, 3 patients (1.8%) - acute calculous cholecystitis, 2 patients (1.2%) - stenosis of the bile papilla.

98 (59.8%) patients were performed EPST, of whom 88 (53.7%) patients were operated on for choledocholithiasis. We are active supporters of medical tactics in choledocholithiasis, despite the development of various methods of lithoextraction and lithotripsy. The arsenal of advanced tools for lithotripsy consists of hard and soft Dormia baskets and balloon catheters. We believe that it is advisable to apply hard baskets in cases when the diameter of the stone is comparable to the diameter of the terminal part of the common bile duct. Balloon catheters and soft baskets are useful for small stones, especially in floating calculi.

EPST was completed with lithoextraction in 59 patients (66.0%). Lithoextraction is indicated in patients with a burdened history when conduction of repeated control studies is undesirable, in high probability of stone impaction in the terminal part of the common bile duct in their spontaneous passage, and in multitude of small stones. Lithoextraction is contraindicated in case when the calculus diameter is greater than the diameter of the terminal part of the common bile duct and size of the papillotomic orifice. Removal of stones was performed by Dormia basket Olympus, their number ranged from 1 to 11, the maximum diameter of the stone removed was 15 mm.

29 patients (17.7%) were performed EPST with mechanical lithotripsy. Mechanical lithotripsy was used in single calculi of over 10 mm in diameter in the narrow terminal part of the common bile duct, multiple stones in the hepaticocholedochus that fit tightly to each other, and in maintaining the sphincter apparatus of the big duodenal papilla in young patients.

7 (4.3%) patients were performed nasobiliary drainage for biliary decompression, 3 patients (1.8%) - balloon dilatation and stenting.

A choice of the preoperative biliary decompression method was determined by the level of localization of the bile flow obturation; hence minimally invasive procedures are performed only for making an accurate diagnosis. We believe that effective treatment of this group of patients is possible only in case of the integrated use of the above mentioned minimally invasive techniques.

We consider it appropriate to note here that a diagnostic search in patients with cholelithiasis complicated with choledocholithiasis, especially in the presence of OJ and cholangitis, is very limited in time. The surgeon has a few hours to make a decision. A choice of surgical tactics in these patients is decisive, namely, what patients should be solved the problem of elimination of bile hypertension and cholangitis at the first stage, who should be carried out staged treatment, and who should be performed a direct surgery. We believe EPST to be effective operation aimed at correcting the disturbed bile outflow that allows us to recommend it as the operation of choice for patients with OJ in the obturation of the bile duct due to choledocholithiasis, and consider it the main method of surgical treatment of patients with OJ having a high degree of the operational risk.

All 98 patients after EPST and all patients in the group 1 were performed LCE in 1-5 days. Surgery started laparoscopically. 25 patients had to be resorted to conversion. The cause for conversion in 12 of them was the presence of multiple stones of different diameters, which failed to be removed laparoscopically. 5 patients had cirrhosis of the liver; thereby significant blood loss developed while performing LCE. In 5 patients, the cause of conversion was intraoperative detection of Mirizzi syndrome with severe inflammation and presence of stones in the common bile duct, and in 3 cases there were indications to the formation of biliodigestive anastomosis - choledohjejunoanastomosis

All patients were clinically determined to have phlegmanous gallbladder, which was confirmed by morphological examination. Bile hypertension and intervention on the major duodenal papilla is likely to cause inflammation of the bile duct, and especially of the gallbladder wall. It once again confirms our opinion of an individual approach to operations in the biliary system, especially in elderly patients.

6 cases of complications (5.9%) were observed among the patients in the group 1, which were eliminated during the postoperative period, before discharge of the patients. All patients were still alive after 3 month follow-up after surgery. At this time, clinical and laboratory indices confirmed a satisfactory degree of the liver functioning, which was confirmed by its ultrasonography. Only 2 patients had transient hyperamylasemia.

Significantly more postoperative complications - in 12 patients (19.0%) were observed among patients in the group 2 compared to the index in the patients of the group 1 (p < 0.1). At the time of examination in 3 months after the operation 3 patients died because of liver failure. According to medical history and clinical and laboratory examination methods, the development of liver failure in patients in the group 2 was observed in 9 patients (14.3%), which significantly exceeded this figure in the patients in the group 1 (p < 0.1).

Thus, the data obtained allow us to formulate the main conceptual approaches to the tactics of minimally invasive surgical treatment of patients if they have OJ syndrome due to bile duct obturation.

We consider it important to recommend not perform surgical interventions at the "height" of the inflammatory period, in a maximum clinical severity of jaundice. Secondly, we note the necessity to operate on such patients in the so-called "cold" period. Third, an individual approach must be an obligatory factor in choosing the tactics of the surgeon who should take into account the medical history of patients, clinical peculiarities of the disease, data from laboratory blood tests, results of preoperative diagnostic procedures, presence of concomitant medical conditions, possible high operational risk, the functional state of the cardiovascular and respiratory systems, and others.

Fourth, in the presence of biliary decompression a question should be solved of one-, two- or three-stage tactics of treatment of such patients. According to our data, two-stage treatment of patients with OJ is successful in the presence of choledocholithiasis, when EPST is performed at the first stage to reduce hypertension and biliary elimination of biliary decompression, and LCE performance – at the second stage.

Separately we want to single out the aspect of the liver functioning in the postoperative period, because our data convince that in OJ patients LCE, but not OCE is a prophylactic measure that prevents the development of liver failure. It is also important that patients with obstructive jaundice and choledocholithiasis in the presence of pathology of the cardiovascular and respiratory systems as well as in patients over 60 years are advisable to perform a three-stage surgery.

 

References:

  • 1. 10 year experience of laparoscopic cholecystectomy: conversion rates & complications treatment., K. Christodoulou, L. Koulouridis, E. Christodoulou [et al.]., Abstr. 16th World Congress of Endoscop. Surgery. – Stockholm., 2008., P. 167.
  • 2. Dubois F. Laparoscopic cholecystectomy: historical perspective and personal experience.,. Dubois, G. Berthelot, H. Levard.,Surg. Lapararosc. Endosc. -1991.,Vol. 1, No.1.,pp. 52­60.
  • 3. Pavlovsky M.P., Kolomiytsev V.I., Shakhova T.I. Modern diagnostic-curing algorithm in case of complicated acute calculous cholecystitis., Military Health Problems. – 2007., 20: pp. 56-62 (In Ukrainian).
  • 4. Sherlock Sh. Zabolevaniya pecheni i zhelchnyih putey [Diseases of the liver and biliary tract]. – Moscow., GEOTAR-MED, 2002. - 676 p (In Russian).
  • 5. Grubnik V.V., Koval’chuk A.L., Zagorodnyuk O.N., Grubnik Yu.V. Endovascular surgery in the complex treatment of patients with cholelithiasis with concomitant liver cirrhosis., Ukr. J. Surg. 2009; 5: 58-60(In Russian).
  • 6. Sipos P. Increased cholecystectomy rate in the laparoscopic era: a study of the potential causative factors., P. Sipos // Surg. Endoscop. – 2007., Vol. 21., No. 7., pp. 1241-1244.
  • 7. Koperna Th. Laparoscopic versus Open Treatment of Patients with Acute Cholecystitis., Th. Koperna, M. Kisser, F. Schulz., Hepato–Gastroenter. – 1999., Vol. 46., pp. 753–757.
  • 8. Laparoscopic cholecystectomy – the new “gold standard”., N.J. Soper, P.T. Stockmann, D.L. Dunnegan [et al.] ., Arch. Surg. – 1992., Vol. 127., pp. 917–921.
  • 9. Zakharash M.P., Zaverny L.G., Stel’makh A.I., Zakharash Yu.M., Bekmuradov A.R., Kalashnikov A.A., Butenko D.I. Surgical tactics in acute cholecystitis and its complications in patients with increased operational and anesthetic risk., Kharkiv Surg. School. – 2007., No. 4(27)., pp. 92-96 (In Russian).
  • 10. A comparative study of early vs. delayed laparoscopic cholecystectomy in acute cholecystitis., R.P. Yadav, S. Adhikary, C.S. Agrawal [et al.]., Kathmandu Univ. Med. J. (KUMJ). – 2009., Vol. 7, No. 25., pp. 16–20.
  • 11. Surgical outcomes of open cholecystectomy in the laparoscopic era., A.S. Wolf, B.A. Nijsse, S.M. Sokal [et al.]., Am. J. Surg. – 2009., Vol. 197., No. 6., pp. 781–874
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Ваша оценка: Нет Средняя: 5.4 (7 голосов)
Комментарии: 3

Рудень Василь Володимирович

Шановні доповідачі! Ви задекларували мету дослідження наступним чином: "Оцінка ефективності методу двоступеневої лікування хворих OJ, з акцентом на поліпшення функціонального стану печінки в післяопераційному періоді". У контексті цього хочу запитати - де результати ефективності у Вашій доповіді? Творчих подальших успіхів!

Лахтин Юрий Владимирович

Dear authors! The topic of your research relevant. The goal is set. Research methods are adequate. Results and conclusions relevant to the purpose. Looking for an active implementation of the results of your research into practice. Good luck to the authors. Sincerely, Lakhtin Yu.

Григоренко Любовь Викторовна

Dear authors Yuriy Vladimirovich and Alexandr Dzyhal! To my opinion your scientific research is highly professional experience in the field of surgery. How should you explain your own data that the average age of majority of the patients was over 60 y.o. and 73% against 26% were women. Why in Odessa and I think in the whole country primary prevention of cholecystit is absent at all, acording to your statistical database. Unfortunately majority of the patients didn't abide healthy diet low cholesterol, low carbon diet. Best wishes and professional success from Hryhorenko Luibov
Комментарии: 3

Рудень Василь Володимирович

Шановні доповідачі! Ви задекларували мету дослідження наступним чином: "Оцінка ефективності методу двоступеневої лікування хворих OJ, з акцентом на поліпшення функціонального стану печінки в післяопераційному періоді". У контексті цього хочу запитати - де результати ефективності у Вашій доповіді? Творчих подальших успіхів!

Лахтин Юрий Владимирович

Dear authors! The topic of your research relevant. The goal is set. Research methods are adequate. Results and conclusions relevant to the purpose. Looking for an active implementation of the results of your research into practice. Good luck to the authors. Sincerely, Lakhtin Yu.

Григоренко Любовь Викторовна

Dear authors Yuriy Vladimirovich and Alexandr Dzyhal! To my opinion your scientific research is highly professional experience in the field of surgery. How should you explain your own data that the average age of majority of the patients was over 60 y.o. and 73% against 26% were women. Why in Odessa and I think in the whole country primary prevention of cholecystit is absent at all, acording to your statistical database. Unfortunately majority of the patients didn't abide healthy diet low cholesterol, low carbon diet. Best wishes and professional success from Hryhorenko Luibov
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