TREATMENT TACTICS OF IATROGENIC BILE DUCT INJURIS IN CHOLECYSTECTOMY
Scientific Surgical Center named after M.A. Topchubashev, Baku, AZERBAIJAN
Iatrogenic bile duct injury is one of the most difficult complications of hepatobiliary surgery. We studied characteristics of bile duct injuries during traditional cholecystectomy in 54 patients. More than in 80% of observations there was revealed a high level of damage (III-V types acc. to H. Bismuth). Patients observed by us, in addition to mechanical (intersection, resection) injuries has occurred thermal effects on the wall of the duct (6 or 11.1% of patients). In 21 (37.7%) of cases the damage was revealed during surgery, in 30 (56.6%) - 2-30 days after surgery, in 3 patients (5.7%) - 6 months after cholecystectomy. Surgical tactics depended on the level, terms of injury, the condition of the walls of the ducts, and complications. In 39 (72.2%) patients, preference was given to the biliodigestive anastomosis on the loop of the small intestine turned off by Roux, of which in 79.4% of the observations there were used interchangeable transhepatic drainage (on Saypol Kurian). In the remaining patients there were performed sutures of defects or end-to-end bili-bilioanastomoses (5 or 9.3% of patients) or hepaticoduodenal anastomoses (2 or 3.7% of patients). 6 (11.1%) patients with duct injuries with sizes not more than half the diameter were inserted sutures of the wound with the installation of a frame T-shaped drainage the knee of which was installed above or below the level of injury. In the postoperative period in all cases there was carried out the correction of fluid and electrolyte balance, treatment and prevention of liver-kidney failure, control of anaerobic infection. In the closest postoperative period 9 (16.7%) patients were found variety of specific complications. 3 (5.6%) patients in the immediate postoperative period had extrabiliary fistula, which within 20-60 days were successfully treated by conservative methods. 1 (1.9%) patient underwent relaparotomy due to the development of bile peritonitis associated with failure of anastomosis. In the immediate postoperative period of hepatic and renal failure 2 (3.7%) patients died. Observations carried out in the period of 2-4 years showed the development of strictures of anastomosis in 4 (7.4%) cases. The mentioned patients were performed repeated restructurization operation. Thus, the results show that, for the prevention and treatment of iatrogenic bile duct injury during cholecystectomy well-developed program of actions, including evaluation of the causes or factors of risk of the development of complications and application of substantiated tactics in the selection of a method of surgical correction are required.
APPLICATION OF FIBROELASTOMETRY FOR THE DIAGNOSIS OF LIVER FIBROSIS
Dagestan State Medical Academy, Makhachkala, RUSSIA
Introduction. The main method of progression of chronic diffuse liver diseases - with fibrosing with the ultimate formation of liver cirrhosis or hepato-cellular carcinoma is one of the most urgent challenges of hepatology.
Gained experience served as an incitement for the creation of methods, allowing to conduction non-invasive diagnostics of liver fibrosis. One of such high-tech non-invasive methods for assessing of the degree of liver fibrosis is fibroelastometry – determination of fibrosis by means of elastic waves ("Fibroscan», Echosens, France).
Study of liver fibrosis in patients with chronic diffuse liver diseases by the method of fibroelastometry by METAVIR scale (F0 - no fibrosis, F4 - cirrhosis of the liver) was held in the Republic of Dagestan for the first time.
Materials and methods of study: We studied 218 patients with chronic diffuse liver diseases of different etiologies at the age from 19 to 62 years (average age 35,6 ± 10,5 years), of them - 134 (36,6 ± 9,9 years) men and - 84 (37,2 ± 11,3 years) – women. Stage of liver fibrosis was determined on “Fibroscan” device (Echosens, France).
Results of the study: In the study of the stage of fibrosis in the common group it was determined that F0 according to Metavir scale was detected in 104 (47,7%), F1 – in 50 (22,9%), F2 – in 21 (9.6%) F3 – in 15 (6.9%) and F4 - in 28 (12.9%) patients. Subject to the sex, there was revealed prevalence of the I and II stages of fibrosis in the female group (common group - 8,8 ± 6,6 kPa; male- 8,2 ± 5,8 kPa; female - 9,7 ± 7,8 kPa).
In the comparative assessment of average age, depending on the stage of fibrosis, the following results were found: the average age in the group F0 (4,8 ± 0,9 kPa) constituted 32,5 ± 9,0 years, F1 - stage (7,3 ± 0 7kPa) - 34,1 ± 9,5 years, F2 - stage (9,8 ± 0,7 kPa) - 39,3 ± 9,6 years, F3 - stage (11,9 ± 0,5 kPa) - 40.2 ± 12,8 years and F4 - stage (23,7 ± 6,9 kPa) - 44,9 ± 10,3 years.
In the study the average values of fibrosis in different age groups it was revealed that in the group patients at the age of 19-29 years, mean value of fibrosis constituted 6,6 ± 2,8 kPa, 30-39 years - 7,8 ± 6,2 kPa, 40-49 - 9 4 ± 5,9 kPa, 50-62 years - 15,1 ± 9,8 kPa.
Conclusion: The obtained preliminary results of non-invasive diagnostics of fibrosis show that the older the patients are the higher is the stage of liver fibrosis. Modern diagnosis of fibrosis and early causal treatment of chronic diffuse liver diseases should reduce the rate of the progression of liver fibrosis.