Surgical treatment of cholelithiasis complications

Abstract

The aim of the work was to provide the analysis of surgical treatment for patients with cholelithiasis complications. Materials and methods. 184 patients were included. Men – 68 (37 %), women 116 (63 %). The male to female ratio 1: 1.7. The average age was 64,1 + 1,0 years, ranged from 31 to 88. Results. Endoscopic sphincterotomy was performed in 105 patients with choledocholithiasis and obstructive jaundice. In 89 (84.7 %) patients primary EPST was successful, 9 (8.6 %) patients underwent successful second intervention. In 7 (6.7 %) patients an open surgery was performed. Recovery of bile flow leads to normalization of bilirubin levels, AST and ALT remains increased. Acute cholangitis diagnosed in 62 (33,7 %) patients. All patients underwent surgical treatment. All patients classified according Tokyo Guidelines 2013 – acute cholangitis of first – 53.3 %, second – 41.9 % and third (severe) – 4.8 %. Recovery of bile duct leads to normalization of bilirubin levels, but the activity of cytolytic enzymes (AST and ALT) remains high. Postoperative complications were observed in 16 (15,2%) patients: Grade 1–2 (Clavien-Dindo) – in 13 (12,38 %) patients, Grade 3b – in 3 (2,85 %). Acute pancreatitis and bleeding from the papillotomy incision were the most common complications. E. coli, P. aeruginosa, K. pneumoniae isolated from bile in patients with mild or severe cholangitis. EPST was performed in 29 patients, was successful in 22 (75.9 %) patients. Open surgery was performed in 40 patients: 10 (25 %) patients – cholecystectomy with choledochotomy for stone extraction; in 20 (50 %) patients– external drainage of CBD. In 10 (25 %) patients internal drainage performed: in 5 cases, choleldochoduodenostomy, in 5 – hepaticojejunostomy in our modification. Mirizzi syndrome (Beltran and Csendes,2008) diagnosed in 34 patients (third group). The analysis of the results of diagnostics and surgical treatment of Mirizzi syndrome showed that of 34 patients with Mirizzi syndrome, 14 came with signs of acute cholecystitis, 5 – complicated by the formation of subhepatic or subdiphragmic abscesses, 1 – abscess of the liver. 18 came with dominant simptoms of obstructive jaundice and cholecystitis, and 2 – with an obstruction of the small intestine. All patients noticed recurrent pain attacts during longgoing disease. Conclusion. Acute cholangitis developed in 33,7 % of patients with obstructive jaundice caused by choledocholithiasis. Severity (according to Tokyo Guidelines 2013 criteria) – first degree – 53.3 %, second – 41.9 %, the third (severe) – 4.8 %. Subcompensation or decompensation of at least one body system occurs in 46.7 % of patients. Cholangitis leads to significant changes in peripheral blood, disturbances of the liver function, which persist after the bile flow reparation. The degree of local morphological changes increases from the first type of Mirizzi syndrome to the fifth, obliteration of the Calot’s triangle occurs. Such changes lead to the development of cholecystobiliary or cholecystoenteric fistula.