Pathological syndromes of the biliary tract decompression

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Abstract

Background: The increased incidence of cholelithiasis and tumoral lesions of the hepatopancreatoduodenal zone leads to an increase in the number of patients with obstructive cholestasis.

Aims: To identify the spectrum of pathological conditions developing after decompression of the biliary tract in obstructive cholestasis and to develop an effective pathogenetically determined algorithm for treating patients.

Methods: The results of the examination and treatment of 216 patients with obstructive cholestasis, who underwent various options for decompression of the biliary tract, were analyzed. Obstructive cholestasis of a tumor genesis was present in 112 (51.8%) patients, benign cholestasis in 104 (48.2%). The main group included 112 patients, the comparison group included 104 patients. A two-stage tactics was applied in 133 (61.6%) cases, 83 patients (38.4%) were operated in one stage. The treatment results were compared for the experimental group (n=112) in which a pathogenetically based algorithm was applied and for the control group (n=104) receiving a standard therapy.

Results: Accelerated decompression syndrome developed in 31 (14.3%) cases, of those 26 in the comparison group, 5 in the main group. Disorders of the water and electrolyte balance occurred in 32 (46.4%) patients with complete external bile diversion. Digestion remodeling syndrome was present in 44 patients from 117 patients with external bile diversion.

Conclusions: It has been shown that the pathogenetically based therapy after biliary decompression significantly reduces the number of complications in the postoperative period.

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The purpose of the study. To define the range of abnormalities that develop in postcompression phase of BT OH, and if you develop effective pathognomonic due to the algorithm of treatment of patients with this pathology.

Material and methods. This scientific study included 216 patients with OX who underwent various options for BT decompression at the General Surgery Clinic with Radiation Diagnostics FSBEI HE "DGMU" of the Ministry of Health of the Russian Federation. OX of tumor genesis was observed in 112 (51.8%) cases, benign genesis - in 104 (48.2%).
Patients with both cholestasis of tumor and benign origin were divided into 2 groups: the main group, where we developed the algorithm for treating patients with jaundice after BT decompression, and the control, with treatment in this phase in the traditional version.
The main group of patients with tumor occlusion of BT included 58 (51.7%) patients, and the control group - 54 (48.1%). Among patients with cholestasis of benign origin, the main group included 54 (52.0%) patients and the control group - 50 (48.0%).

Age composition of patients varies from 28 to 89 years of age, elderly and senile age was 64, 8%. Comorbidities were present in 50.5% of cases. OH, mild in the main group of patients there were 13(6,0 %) cases in the control in 14 (6,4%); moderate in 38(34,0%) and 34(32,7%), respectively; severe - 61(60,0 %) and 56(60,9%) respectively.
Decompression of BT as the first stage of surgical treatment, patients with OH tumor Genesis conducted in 79(36.6 per cent) cases, of which the main group of patients in 39(18,0%) cases, control 40(18.6 per cent). All of these patients with jaundice moderate and severe degree. In the case of OH benign origin moderate and severe, decompression of BT performed in 54(25,0%) cases. Of them in the main group of patients included 26(12,0%) patients in the control -28(13.0 per cent). The rest 83(38,4%) patients surgical treatment of OH carried out in one step. Among patients with tumor occlusion of the BT, it is conducted in 33(15.4%) cases, and benign occlusion – 50(23.0 percent). Of them in the main group included 17(7,8%) patients OH tumor Genesis (mild – 4, moderate -13) and 26(12,0%) benign (mild-9, moderate -17), in the control -16(7,4%) and 24(11,1%), respectively. In a two-stage surgical tactics of treatment of patients with OH tumor Genesis, in the resolution stage cholestasis were used different variants of access to the biliary system. Cholecystostomy of the mini-access laparoscopic assisted performed in 34(41,7%) patients (main group 18, for controlling -16), cholecystostomy under ULTRASOUND navigation in 11(13,9%) cases (main group -6, -5 control), CCHS with external biliary diversion is 18(22,7%) patients (main group 10, the control -8) and CCHS with the external-internal biliary diversion -16(21,7%) cases (main group -7, -8 control). OH benign origins for decompression BT, we used the following approaches: cholecystectomy from mini access -13(24,1%) patients (main group -7, -6 control), cholecystostomy under ULTRASOUND-navigation - 5(93%) cases (main group -3, -2 control); CCHS with external drainage of BT - 25(46,2%) observations (main - on 14, control 11); CCHS, balloon dilatation of BDS with the location of stones in the duodenum, external drainage of BT – 11(20,4%) cases (main - 5, test 6).
In a one-step surgical treatment of benign OH Genesis patients with mild cholestasis carried out the following interventions: cholecystectomy (HE)+ choledocholithotomy (x LT) + choledochoduodenostomy (submitted by) from a wide laparotomy (SL) – 4(8,0%), HO + CRT + external drainage (ND) BT from SHL -6(12,0%), CRT+ submitted by from SHL - 4(8,0%), CRT + choledochojejunoanastomosis (GEA) of SHL -3(6.0 percent). In the subgroup with moderate cholestasis HO + CRT + submitted by from SHL conducted in 8(16%) cases, HO + CRT + ND of SH – 10 (20,0%), CRT + submitted by from SHL - 2 (4,0%), CRT + GEA from SHL - 3(6,0%) endoscopic retrograde papillotomy – 5(10.0%) and with lithoextraction -5(10.0 per cent).
If you use a one-stage surgical approach in the treatment of OH in cancer patients mild jaundice performed the following operations: resection of the bile duct (RIP) + left hemihepatectomy (LGE) + hepaticojejunostomies (GHEA) with isolated PY loop of jejunum -2; REP + resection of segment IV of the liver + retrievedocuments (THEA) with isolated PY loop of jejunum -2; HO + RIP + wedge resection of the liver (if) + bihepaticojejunostomies (BGEA) with isolated jejunal loop - 3; da - 2; operation of the Monastery - 1.
Patients with benign OH Genesis, which was taken by a two-stage tactics of treatment in the second stage after resolution of cholestasis and cholangitis surgery following lines: HAE + CRT + submitted by from SHL - 3; HO + CRT + GEA from SHL - 2; HO + CRT + ND BT mini access -7; HO + CRT + ND BT from SHL - 6; CRT + submitted by SHL from CCHS removed after 7-8 days – 3; CRT + GEA from SHL with the elimination CCHS after 7-8 days – 8; CRT + seam choledoch with the elimination CCHS after 2 weeks - 9; CRT + seam choledoch from mini access with the elimination CCHS in 2 weeks – 5.
For strictures of the proximal BT held: GHEE from SHL with the elimination CCHS 7 - 8 days – 3 patients, of BGEA disabled by Roux loop of jejunum with the elimination CCHS on the 7 - 8th day - 3.
The OH observations with tumor Genesis in the second stage of treatment was carried out following surgery. REP + of LGE+ of GHEE disabled by Roux loop of jejunum – 2; REP + resection of segment IV of the liver + TEA with isolated Roux loop of jejunum - 2; stenting of bile ducts – 2.
Cancer of the gallbladder operated on 5 patients: HAE + RIP + KRP + of BGEA disabled jejunal loop – 3, HO + RIP + KRP + of GHEE disabled loop – 2. Transhepatic drainage was removed for 10 – 12 hours.
In 4 cases with cancer of the gall bladder during the second stage stenting of the bile ducts, and 11 – the external-internal drainage of BT.
Patients with periampullary tumors during the second stage: da – 23, the operation of the Monastery – 9, stenting of the terminal part of choledoch – 3, external-internal drainage of BT -14. The external-internal drainage of BT the second stage held in the case of metastases in the lymph nodes pericholedochal.
The results are subjected to statsremote program using Microsoff Excel 2010, Statistica 6.1, Stat Soff.
Results and their discussion.
In the majority of cases after decompression of BT patients reported reduction of pain, absence of pruritus, decrease in weakness, lethargy.
Rapid elimination of breast, especially during prolonged her existence, leads to an increase in hepatic insufficiency and there arises a second problem in the treatment of OH - prevention and treatment of the syndrome of "accelerated" decompression BT. The creation of the slow pace of galeotto after decompression using minimally invasive techniques is also essential in the prevention of the syndrome of "accelerated" decompression BT. This is in most cases achieved with the use of catheters with smaller diameter, creating a longer path Galeotti, cholecystoenterostomy extracorporeal shunt etc.
117 (54,2%) cases of 216 patients with OH was performed external drainage of BT (cholecystostomy-63, CCHS – 54). They were discharged from hospital with a functioning external biliary fistula again in the clinic received 32 (46.4%) patients with significant violations of water-electrolyte balance. 

The main syndrome that develops in the post-decompression period of BT and due to which, mainly, depletion of patients with external bile drainage is “remodeling” of digestion. This condition, expressed to varying degrees in our patients, was noted in 44 (33.1%) cases. In the postoperative period, 8 (3.7%) patients died, of which in the control group 6 (2.7%), in the main - 2.
Conclusion
After BT decompression due to OX, various pathological conditions often occur that can worsen the condition of patients. these include: BT rapid decompression syndrome, water-electrolyte disturbance syndrome, drainage-associated inflammatory BT disorders, digestive remodeling syndrome.

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About the authors

Rasul T. Mejidov

State Budget Educational Institution “Dagestan State Medical University”

Email: okhirurgiya@bk.ru
ORCID iD: 0000-0002-9662-6520

MD, Dr. Sci. (Med.), Professor

Russian Federation, 1, Lenin Square, 367000, Makhachkala, Dagestan Republic

Saadat Magomedova

Clinic for General Surgery FSBEI HE "DGMU" Ministry of Health of the Russian Federation, Makhachkala.

Author for correspondence.
Email: saadat_leon@mail.ru
ORCID iD: 0000-0002-0156-679X

сandidate of medical siences, assistant of the department of general surgery, FSBEI HРE "DGMU" of the ministry of health of the Russian Federation.

Russian Federation, Makhachkala st. Lenina 1

Elmira P. Mamedova

State Budget Educational Institution “Dagestan State Medical University”

Email: elma.1973@mail.ru
ORCID iD: 0000-0002-7649-1702

Senior Laboratory Assistant

Russian Federation, 1, Lenin Square, 367000, Makhachkala, Dagestan Republic

Asli Z. Abdullaeva

State Budget Educational Institution “Dagestan State Medical University”

Email: doct.asli@mail.ru
ORCID iD: 0000-0002-8888-4861
SPIN-code: 3985-9176

MD, Cand. Sci. (Med.)

Russian Federation, 1, Lenin Square, 367000, Makhachkala, Dagestan Republic

Umukusum A. Nasibova

State Budget Educational Institution “Dagestan State Medical University”

Email: Uma4kaa1985@mail.ru
ORCID iD: 0000-0002-5705-3918

Assistant

Russian Federation, 1, Lenin Square, 367000, Makhachkala, Dagestan Republic

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Supplementary files

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2. Fig. 1. Magnetic resonance cholangiogram, 3D-reconstruction: а — periampular tumor (arrow); б — a concretion in the bile duct (arrow).

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3. Fig. 2. Multispiral computed tomography with contrast: distal block of the biliary tract (arrow).

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Copyright (c) 2021 Mejidov R.T., Magomedova S., Mamedova E.P., Abdullaeva A.Z., Nasibova U.A.

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