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Nazyrov Feruz Gafurovich, academician, doctor of medical sciences, professor director of the Republican Special Scientific and Practical Medical Center of Surgery named after Academician V. Vakhidov, director of the RSS and PMC of Surgery named after Academician V. Vakhidov E-mail: [email protected] Akbarov Mirshavkat Mirolimovich, professor, Republican Specialized Surgery Center named after acad. V. Vahidov, doctor of medical sciences E-mail: [email protected] Kurbaniyazov Zafar Babajanovich, Ph D., in medicine, Department of surgical diseases № 1 Samarkand State Medical Institute E-mail: [email protected] Askarov Pulat Azadovich, Senior Research Fellow - Competitor, Department of surgical diseases№ 1 Samarkand State Medical Institute E-mail: [email protected]
ANALYSIS OF THE RESULTS OF SURGICAL TREATMENT OF "FRESH" DAMAGE TO THE BILE DUCTS
Abstract: Republican Specialized Center of Surgery and the Clinic of Surgical Diseases of Samarkand State Medical Institute has experience in treating 175 patients with "fresh" iatrogenic of hepatico cholehoh injuries from 2000 to 2017 years. The periods for detecting iatrogenic ofbile ducts are divided into those detected intraoperatively (29.1%) or up to 7 days after cholecystectomy (70.9%). Developed algorithms for choosing a method for treating fresh bile ducts damages with an integrated approach to tactical and technical aspects and correction of associated complications reduced the total frequency of postoperative complications from 26.2% to 9.7% and mortality rate from 7.8% to 2.8%.
Keywords: bile ducts, iatrogenic, fresh, injuries, cholangitis, stricture, treatment.
Introduction. According to the World Health Organiza- incidence of intra-abdominal complications "Compared with tion, "among various diseases of the biliary system, gallstone traditional cholecystectomy, the introduction of laparoscopic disease (GD) is 50-65%. There are more than 1 million in the cholecystectomy caused an increase in the frequency of bile world, and in our country about 10,000 cholecystectomies duct damage in 2-4 times, and in percentage, 1-3%" [8; 11]. per year, while 12.6-47.7% of them are accompanied by in- The most complex in the technical execution of surgical interventions on the extrahepatic bile ducts (BD)" [3; 6; 8; 12]. terventions aimed at eliminating the consequences of duct The growth of surgical activity in the treatment of GD led to injury should be performed only in specialized institutions, an increase in the incidence of postoperative complications but despite some success, unsatisfactory results are observed from 5.6% to 15.9% [1; 9; 14]. Despite the long-established on average in even the most experienced surgeons in 10% of and constantly improving technique of cholecystectomy, the cases [5; 10]. Such patients need repeated, sometimes repeat-frequency of damage to the bile ducts has no tendency to de- ed reconstructive operations.
crease [2; 4; 7; 13]. The widespread use of endovideosurgi- Materials and methods. Republican Specialized Center
cal operations in patients with GD and complicated forms of of Surgery named after academician V Vakhidov and the Clin-cholelithiasis did not lead to the expected reduction in the ic of Surgical Diseases of Samarkand State Medical Institute
has experience in treating 175 patients with "fresh" iatrogenic of hepatico cholehoh (HCh) injuries from 2000 to 2017 years. The periods for detecting iatrogenic of BD are divided into those detected intraoperatively (29.1%) or up to 7 days after cholecystectomy (70.9%).
Patients were divided into study groups. The comparison group consisted of 103 (58.8%) patients who, in the period of2000-2010 years, used standard reconstructive-restorative surgeries for fresh injuries of the main BD. The main group of
the study consisted of 72 (41.2%) patients who used the proposed algorithms for choosing the method of surgical treatment of patients with fresh BD injuries in conjunction with the perioperative correction of endogenous intoxication syndrome and prevention of cholangitis in the period from 2011 to 2017 y. In turn the patients were divided by BD iatrogenic revealed during cholecystectomy, i.e. intraoperatively (51 patients) and injuries found in the early postoperative period (124 patients) (table 1).
Table 1. - The distribution of patients in groups for research
Damage type Comparison group Core group
abs % abs %
Fresh damage to the BD Intraoperatively 28 27.2% 23 31.9%
In the early p/o period 75 72.8% 49 68.1%
Total 103 100.0% 72 100.0%
The choice of the method of restoration or reconstructive surgery is affected by the presence of a complication associated with the consequences of damage to the BD. In both groups of the study, the most common pattern of breast cancer in the early postoperative period was in 45 (43.7%) and 30 (41.7%) patients, respectively. The next most common symptom of
patients, and in most cases the pattern of damage to the BD was detected intraoperatively.
In a comparative aspect, in the main group, reconstructive surgery was performed mainly in 69(95.8%) patients, whereas in the comparison group, these interventions were performed in 80% of patients (table 2).
iatrogenic was bile excretion - in 38 (36.9%) and 28 (38.9%)
Table 2.- Type of final interventions performed at the Republican Specialized Center of Surgery and the Samarkand State Medical Institute clinic
Detection of damage to the BD Own damage Damage to other clinics Total
abs % abs % abs %
The control group
External discharge of bile 5 4.9 15 14.6 20 19.4
Recovery 23 22.3 26 25.2 49 47.6
Reconstructive 10 9.7 24 23.3 34 33.0
Total 38 36.9 65 63.1 103 100.0
Core group
External discharge of bile 1 1.4 2 2.8 3 4.2
Recovery 8 11.1 25 34.7 33 45.8
Reconstructive 7 9.7 29 40.3 36 50.0
Total 16 22.2 56 77.8 72 100.0
Results and discussion. Complicated course of the nearest postoperative period in the comparison group occurred in 27 (26.2%) patients, and in the main group - in 7 (9.7%) patients (table 3).
The table below shows that in the comparison group the number of almost all types of complications in the form of insolvency imposed by anastomoses, hemobilia, cholangitis, multiple organ failure and myocardial infarction prevailed. In the comparison group, in 2 cases, relaparotomy was performed in connection with early postoperative complica-
tions and in 8 (7.8%) cases there was a lethal outcome, and in the main group of the study there were no relaparotomy, and the lethal outcome was recorded in 2 (2.8%) sick. In both compared groups, early postoperative complications were more often observed in patients with verified lesions at an early stage after cholecystectomy. The long-term results of surgical treatment of fresh lesions of the gastrointestinal tract were followed up in 92 patients of the comparison group and in 70 patients in the main group.
Table 3.- The frequency of various complications in the early postoperative period
The control group Core group
Compli-cation i/o p/o Total i/o p/o Total
abs % abs % abs % abs % abs % abs %
The failure of the anastomosis - cholelis 2 7.1 4 5.3 6 5.8 1 4.3 2 4.1 3 4.2
The failure of the anastomosis - biloma 0 0.0 2 2.7 2 1.9 0 0.0 0 0.0 0 0.0
The failure of the anastomosis - peritonitis 0 0.0 1 1.3 1 1.0 0 0.0 0 0.0 0 0.0
Hemobilia 1 3.6 2 2.7 3 2.9 0 0.0 1 2.0 1 1.4
Cholangitis 1 3.6 4 5.3 5 4.9 0 0.0 0 0.0 0 0.0
AHRF 0 0.0 6 8.0 6 5.8 0 0.0 2 4.1 2 2.8
Multiple organ failure 0 0.0 3 4.0 3 2.9 0 0.0 1 2.0 1 1.4
Myocardial infarction, acute cardiovascular failure 0 0.0 1 1.3 1 1.0 0 0.0 0 0.0 0 0.0
All compli-cations 4 14.3 23 30.7 27 26.2 one 4.3 6 12.2 7 9.7
Relapara-tomy 0 0.0 2 2.7 2 1.9 0 0.0 0 0.0 0 0.0
Mortality 0 0.0 8 10.7 8 7.8 0 0.0 2 4.1 2 2.8
The frequency of recurrent cholangitis with the use of algorithms for selecting the method of surgical treatment of patients with fresh ZH injuries in conjunction with perioperative correction of endogenous intoxication syndrome and prevention of cholangitis was noted in 8.6% of cases, while in the comparison group, when performing standard reconstructive-restorative operations, this figure was 20.7%. A comparative analysis of the frequency of development of strictures of superimposed biliodigestive and bilobiliary anastomoses in the compared study groups showed that arresting the pattern of recurrent cholangitis influences the development of strictures of BD. So, the frequency of strictures in the comparison group was 33.7%, while in the main group this indicator was 14.3% of cases.
The overall frequency of complications in the comparison group was 56.3% (58), ofwhich 26.2% (27) developed in the near term and in 30.1% (31) of the observations in the distant period. In the immediate postoperative period, anastomotic failure was noted in 9(8.7%), hemobilia in 3(2.9%) cases. The stricture of the anastomosis without cholangitis in the long term occurred in 12(11.7%) patients. The picture of cholangitis with the subsequent formation of a stricture in this group was noted in 5(4.9%) cases in the near term and in the long term in 19(18.4%) cases, respectively. Other complications associated with the severity of the patients in the comparison group were noted only in the nearest postoperative period in 10(9.7%) cases. Mortality associated with tactical and technical aspects in the group was 4.9%(5 patients). Mortality associated with the severity of the condition was 5.8%(6 patients).
In the main group, the overall incidence of complications was 16.5%(17), while in 6.8%(7) they developed in the immediate, and 9.7%(10) in the late postoperative periods.
The frequency of failure of the superimposed anastomosis was 4.2%(3) and was noted in the immediate postoperative period. A stricture of BD without cholangitis was noted in 5.6%(4) cases and was noted in the late postoperative period. The picture of cholangitis with the subsequent formation of a stricture was noted in 8.3%(6) in the separated period after the operation. Other complications associated with the severity of the condition of the patients were in 4.2%(3). All three complications in the main group were noted in the immediate postoperative period. Mortality associated with tactical and technical aspects in the main group and long-term period was 1.4% (1). Mortality associated with the severity of the patients in the immediate postoperative period was 2.8%(2 cases).
Conclusions. Developed algorithms for choosing a method for treating fresh BD damages with an integrated approach to tactical and technical aspects and correction of associated complications reduced the total frequency of postoperative complications from 26.2% (27 patients in the comparison group) to 9.7% (7 patients in the main group) and mortality rate from 7.8% (8 patients) to 2.8% (2 patients). The proposed method allowed us to prevent and arrest attacks of recurrent cholangitis from 20.7% (19 out of 92 patients in the comparison group) to 8.6% (6 out of 70 patients in the main group), thereby reducing the incidence of anastomotic stenosis after reconstructive surgery. about fresh BD damage from 33.7% (31 of 92) to 14.3% (10 of 70). In a comparative aspect, the proposed algorithms for choosing the method of surgical treatment of patients with fresh injuries of the left ventricular, together with perioperative correction of the syndrome of endogenous intoxication and prevention of cholangitis development, allowed to reduce the overall frequency
of postoperative complications in the early and late periods from 56.3%(58 out of 103 patients in the group comparison) to 23.6%(17 of 72 patients in the main group) and mortality from 10.7%(11 patients) to 4.2%(3 patients, respectively).
The proposed comprehensive approach to the treatment of fresh BD injuries reduced the proportion of tactical deficiencies from 26.2% (27 patients in the comparison group)
to 9.7%(7 patients in the main group), technical deficiencies from 20.4%(21) to 9.7% (7) and in general, reduce the incidence of complications with these aspects in mind from 46.6% (48) to 19.4% (14), and mortality from 4.9% (5) to 2, 8% (2). This made it possible to obtain good and satisfactory treatment results in 80.6% (58 out of 72), whereas in the comparison group this figure was 49.5% (51 out of 103 patients).
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