Republican Specialized Center of Surgery after academician Vakhidov, Tashkent, UZBEKISTAN
Introduction: In modern hepatology portosystemic shunting remains in a number of foreground trends for the prevention of bleeding from esophageal and qastral varices in patients with liver cirrhosis (LC) with portal hypertension (PH).
Materials and methods: Summarizing the results of more than 35 years of experience in implementing of DSRA, we present the results of these interventions in different periods of PH surgery in our country. The analysis is performed in three study groups: first group - the stage of implementation of portosystemic shunting (PSSh) (1976-1992), the second group - the stage of formation of a specialized unit of PH in the RSCS (1992-1998) and the third group - the stage of perfection of DSRA imposition and expantion of indications for this type of shunting (precisional technique, the restriction of reset by the original method in patients with severe expansion of splenic vein; 1998-2010). The study included 285 patients with PH. The average age was 28,9 ± 12,5 years.
Results: At the stage of implementation of PSSh the share of DSRA was only 19.2% (24 out of 125), in the remained cases central types of anastomoses were imposed. In the second period, the percentage of DSRA rose to 24.0 % (35 of 146). The present period is characterized by the dominance of selective anastomosis, whose share reached to 48.5% (231 of 476), and over the past five years has increased to 54.0%. Against the background of the type of selective shunting rate of liver failure and encephalopathy was lower than in central vatiants. Moreover, if during the implementation of PSSh the frequency of these complications reached 25% and 33.3%, respectively, later their frequency decreased to 14.3% and 17.1%, and at the present time due to opportunities of conservative therapy and strictly individualized approach to this type of bypass surgery the frequency has diminished to 8.2% and 10.4% of cases. Lethality at this stage of implementation reached 33.3%, in the second period - 8.6%, at present the frequency of fatal outcomes has lowered to 4.8%.
Conclusions: Today DSRA is performed in more than 50% of cases, and for the older age group or in low compensatory reserve of hepatocytes against the background of LC, this type of shunting remains the only foreground way to decompress the portal basin. Relative contraindications such as high residual portal pressure and consequently the risk of bleeding even against the background of functioning shunt, as well as growing ascitic syndrome inherent to the next period after selective decompression, may be offset by the inclusion of specific therapeutic measures into the complex treatment.
TACTICS OF SURGICAL TREATMENT OF PATIENTS WITH MIRIZZI'S SYNDROME
F.G. NAZİROV, M.M. AKBAROV, M.SH. NISHANOV
Republican Specialized Centre of Surgery named after acad. V. Vakhidov, Tashkent,
Mirizzi’s syndrome is a rather rare pathology of biliary system and according to the literature is diagnosed in 0.5-5% of patients with various forms of cholelithiasis. Diagnosis and surgical treatment of Mirizzi’s syndrome is a complex and unresolved challenge, and the results of operations remain unsatisfactory, characterized by a high level of fatal outcomes - 17%. Long-term results also remain unsatisfactory - proximal hepaticocholedochal strictures develop in 20% of patients.
Materials and methods: We have experience of surgical treatment of 107 patients with Mirizzi’s syndrome. Age of patients ranged between 39 to 78 years (average age 55.5+7.86), 81 –women, 26 - men (ratio 3,1:1). Patients were divided according to Csendes classification: I type of the syndrome was diagnosed in 38 patients; II type - in 34 patients; III type - in 28 patients and IV type - in 7 patients.
Results: Cholecystectomy was performed in 15 patients with type I syndrome; choles-cystectomy with choledochal drainage by Keruen was performed in 36 patients with II type of the syndrome, cholecystectomy and drainage with hepaticocholedochal plasty by Keruen was performed in 26 patients with III and IV types of the syndrome; cholecystectomy with drainage of the choledoch by Hallstead Pikovsky - 7 patients with I type of the syndrome and 5 patients with IV type of the syndrome were inserted hepaticojejunostomy in view of complete destruction of the hepaticocholedochal wall. Laparoscopic cholecystectomy was performed in 15 patients with I type of Mirizzi’s syndrome, and in 3 patients with II type laparoscopic cholecystectomy was completed by drainage of the choledoch by Keruen. In the nearest postoperative period the following complications were encountered: lack of seams of varying severity in 5 (4.6%) patients, the progression of liver failure in 6 (5.6%) patients and other complications in 8 (7.5%) patients. In the postoperative period 4 (3.7%) patients died of the progression of hepato-renal failure. Long-term results were studied in 38 patients, of them 5 patients had hepatococholedochal strictures, which led to repeated reconstructive interventions.
Conclusion: Surgical treatment of patients with Mirizzi’s the syndrome shall be built subject to the type of the syndrome. Open methods of surgical correction of Mirizzi’s syndrome, which include a subtotal cholecystectomy insertion of sutures on the fistulous orifice and choledochal drainage by T-tube, plasty of the bile duct by the remaining part of the gallbladder, hepaticojejunostomy by Roux, have advantages over laparoscopic methods.