ENDOBILIAR LASER LITHOTRIPSY IN SURGICAL TREATMENT OF CHOLEDOCHOLITHIATIC COMPLICATIONS

A.V. MAXIMENKOV, A.R. YAFAROV

State Research and Clinical Center for Laser Medicine, Moscow, RUSSIA

Purpose: In 10% of cases with choledocholithiasis physicians face the problem of “difficult” stones – large size, impacted concrements in the terminal part of choledoch. The main difficulty is this situation is a technical impossibility to put a working part of lithoextractor behind a concrement without a serious risk to damage choledoch walls. Laser lithotripsy can help to solve this problem. The aim of the present work is to develop a technique and to determine indications for laser lithotripsy.

Materials and methods: 72 stones of various size (1.0-3.0 cm) and composition were disintegrated experimentally with YAG:Но laser light. 48 “solid” and 24 “soft” stones were used in the experiment. Results of the experiment have shown that the optimal mode for stone disintegration is energy 2.0 J and frequency 10Hz. Laser choledoch lithotripsy was applied in 11 patients in the clinic- 7 patients had impacted concrements in the terminal part of their choledoch; 4 patients had large stones. In all cases endoscopic papillosphincterotomy with lithoextraction was not effective; the patients were operated on with surgical mini - approach. After cholecystectomy choledochotomy and chledochoscopy were made so as to confirm the diagnosis. Laser lithotripsy was made with YAG:Но laser light- power 1.5-2 J, frequency 10Hz in contact mode under constant visual control. Laser light was delivered via an optic fiber inserted through a working channel of choledochoscope. A constant visual control and contact mode excluded any damage of choledoch walls. Size of disintegrated stones was 0.8-1.5cm. In all cases concrements were disintegrated into 2-3 parts; after that these parts were removed using a Dormia basket. Duration of laser lithotripsy stage including the time of preparation and light delivery to a concrement via a lightguide was from 11 till 18 minutes.

Results: In all cases we could get a one-stage good sanation of biliary tract; there were no complications or deaths.

Conclusion: Thus, laser lithotripsy in patients with difficult stones in the choledoch allows to make a one-stage good sanation of hepaticocholedoch via a little-invasive approach. It also allows to avoid extended traumatic surgical approach such as transduodenal papillosphincterotomy. Laser lithotripsy in patients with impacted concrements in the choledoch is a method of choice.

CHANGES IN HEMODYNAMICS OF THE LIVER IN PATIENTS WITH CIRRHOSIS

V.B.MEHDIZADEH

Central Hospital of Oilworkers, Baku, AZERBAIJAN

With a comprehensive evaluation of the results of this study should be noted that there are a number of changes of ultrasonic parameters that correlate with the class of liver cirrhosis. Qualitative changes in echographic characteristics of liver in patients with cirrhosis are caused by morphological alteration and occur sequentially. Contour irregularities, the heterogeneity of the structure and increased parenchymal echogenicity occurred in 100% of cases. As a prognostic sign they are not critical, as they may be due to focal or diffuse steatosis. More significant are the changes determined by echography of vascular system.

Hemodynamic changes in the portal venous system are already evident in the initial stages of the disease and often ahead of the clinical picture. The diameter of portal vein reduces, pressure in the portal system decreases due to changes in portal blood flow, the formation of portosystemic collaterals and rigidity of the venous wall. Changes in diameters of splenic vein and superior mesenteric vein are also significant. These veins are most sensitive to the change in resistance in the portal system.

However, the most informative was the determination of blood flow velocity in the portal system. The average linear velocity of blood flow in the portal vein is starting to change in the initial stages of cirrhosis and is characterized by slowing of the speed - 17,9 ± 0,9 cm / sec (in the control group -23.6 + 4.2 cm / sec). Further progression of the process leads to irreversible structural reorganization of the hepatic parenchyma, increased intrahepatic resistance, and pronounced hemodynamic instability. Thus, determination of changes in vascular wall stiffness, their ability to dilate gives additional criteria for a reliable assessment of the severity of the patient and can be regarded as a secondary factor in the prognosis of portal hypertension.

Date: 2014-12-28; view: 1039