Differentiated approach to the choice of treatment of patients with obstructive jaundice due to choledocholithiasis

I.YA. Dzyubanovsky, O.I. Dzyubanovsky, M.M. Galei

Abstract


Diagnosis and treatment of choledocholithiasis surgery is an urgent problem. Despite the progress made in the diagnosis and treatment of choledocholithiasis in this surgical problem are many unresolved issues relating to methods of diagnosis and rational treatments that could help improve outcomes.
Purpose. Improved results of surgical treatment of patients with choledocholithiasis.
Materials and methods. Analysis of surgical treatment of 177 patients with choledocholithiasis. For higher informativeness of biliary obstruction and choledocholithiasis verification was used endoscopic retrograde pankreatoholanhiohrafy and magnetic resonance cholangiopancreatography. Based on the level of bilirubin at admission, the patients were divided according to the severity of obstructive jaundice. Laparoscopic surgery was performed by laparoscopic equipment of «Olympus» (Japan) «KarlStorz» (Germany). Conducted biochemical studies to determine the functional state of the liver.
Results and discussion. Of 177 patients with choledocholithiasis, chronic calculous cholecystitis occurred in 162 patients (95.2 %) and only 15 patients (4.8 %) — acute calculous cholecystitis.
In 139 (78.53 %) of 177 patients seen comorbidities. Of these, 95 patients of 139 were present two or more comorbidities. Noteworthy that, at the age of 60-74 years without comorbidities were identified 9 (12.67 %) patients aged 75-89 years were related in all patients polimorbidnosti index in these patients was 4.05.
Open surgeries recognized as a one-stage, were performed in 52 patients (29.4 %). In 46 (88.46 %) of them were made with choledochoduodenostomy cholecystectomy in 6 (11.54 %) — cholecystectomy with mini laparotomy access with holedoholitotomia and external drainage of choledochal.
Mini-invasive endoscopic surgeries were performed in 125 patients out of 177 (70.6 %). One-stage surgical tactics of mini-invasive, endoscopic surgeries was used in 18 patients (14.4 %), of which 10 performed with endoscopic papillosphincterotomia nazobiliarnym drainage, followed by choledochal arthroplasty and 8 patients — with endoscopic papillosphincterotomia with removal of calculus.
Two-stage surgical tactic was developed in 86 patients (68.8 %), while the first phase was carried out miniinvasive papillosphincterotomia endoscopic extraction of calculus and the second phase of laparoscopic cholecystectomy.
Comparative analysis of mini-invasive and traditional methods of surgical treatment of patients with choledocholithiasis showed that mini-invasive treatments were 70.6 % of patients compared to traditional on laparatomy access surgery. Frequency of complications after surgery for mini-invasive interventions in 2.9 times less than the traditional and the level of mortality decreased by 4.7 times.
Conclusion. Go to the mini-invasive endoscopic and laparoscopic surgical methods of treatment in patients with choledocholithiasis in case of low and moderate operational and anesthetic risk and the absence of local intraoperative anatomical and inflammation changes in gallbladder and elements hepatoduodenal ties, significantly improves the quality of patient care.


Keywords


choledocholithiasis; surgical treatment; diagnosis

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DOI: https://doi.org/10.22141/1997-2938.3-4.26-27.2014.83211

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