BILIOUS CHANNELS

From Big Medical Encyclopedia

BILIOUS CHANNELS — system of the channels which are taking away bile from a liver and a gall bladder in a duodenum. Distinguish intra hepatic (see. Liver ) and extrahepatic. items

the Comparative anatomy

, starting with fishes, are available For all vertebrate animals the liver divided into 2 shares, a gall bladder and extrahepatic. item: the general hepatic, vesical and the general bilious, falling into an average gut. Some species of fish, birds and mammals (hoofed animals) in connection with a reduction of a gall bladder have no vesical channel, and the general hepatic is strongly expanded. At other bird species vesical and the general hepatic channels, not forming the general bilious, fall into a gut separately; besides, at them, and also at some hoofed animals bile from the right hepatic lobe comes on a special channel (ductus hepatocysticus) directly to a gall bladder. At mammals in connection with division of a liver into anatomically independent shares the number of the hepatic canals forming the general hepatic channel, variously.

Embryology

Laying of extrahepatic. the item is found in the person on 4 — 5th week of development in the form of epithelial tyazhy, surrounded with a layer of an undifferentiated mesenchyma. At the same time the rudiment of a vesical channel grows from laying of primary gall bladder, and a rudiment hepatic and the general bilious — from a hepatic diverticulum. At the end of the 5th and 6th week of development in laying of canals gleams form.

On the 7th week of development the wall of channels is formed by the mucous membrane covered-: a single-row cylindrical epithelium, and the layer of a mesenchyma containing tsirkulyarno the located cells similar to smooth muscle. To 10 — 11th week of development extrahepatic channels are finally created. Distinctions in intensity of development and in the direction of growth of laying of canals cause considerable variability of anatomic forms of connection Zh. items

Anatomy

Distinguish the following extrahepatic. item: two hepatic channels leaving from liver (see) and draining bile from its shares, the general hepatic, formed as a result of connection hepatic, vesical, taking away bile from gall bladder (see), and the general bilious, forming by connection of the general hepatic and vesical channels.

Hepatic channels are usually presented by two: left and right (ductus hepatici sinister et dexter). Left hepatic channel 1,5 — 2,3 cm long, to dia. 0,3 — 1,1 cm are located in portal fissures over a portal vein behind a square share. It consists of the lateral branch (ramus lat., PNA) going from II and III segments of a liver, a medial branch (ramus med., PNA), going from the IV segment, and the left channel of a share having a tail (ductus lobi caudati sinister, PNA) going from the left part I of a segment. Right hepatic channel 0,5 — 1,3 cm long, to dia. 0,2 — 1,0 cm, taking place in portal fissures over the right branch of a portal vein, form from the front branch (ramus ant., PNA) which is taking away bile from the V—VI segments, a back branch (ramus post., PNA) — from VII, VIII segments and the right channel of a share having a tail (ductus lobi caudati dexter, PNA) waiting from the right part I of a segment. Sometimes the general hepatic channel is formed of several hepatic channels (3 — 5) leaving a liver independently. Occasionally right or left hepatic channel in general is absent, and sectoral or segmented channels fall or in available share (other half of a liver), or into the general hepatic canal.

General hepatic channel (ductus hepaticus communis) usually forms in the right part of portal fissures in front from bifurcation of a portal vein. From the rear edge of a square hepatic lobe the beginning of a channel will be spaced on 1 — 1,5 cm distalny and on 1 cm from its middle to the right. Sometimes this channel is formed in the thickness of a hepatoduodenal sheaf on nek-rum distance (1,5 cm) yut portal fissures. Length of a channel at adults fluctuates from 2 to 10 cm, { 2,5 — 3,5 cm), and to dia are more often. 0,3 — 1,2 cm (0,5 cm are more often). Length of the general hepatic channel at children of 1 — 7 years on average happens apprx. 2 cm, and children have 7 — 14 years of 2,5 cm with an average diameter respectively 0,25 — 0,3 cm and 0,3 — 0,4 cm. Sometimes the general hepatic channel is absent, then the right and left hepatic channels or form together with a vesical channel the general bilious channel near a duodenum, or even fall into it separately. In the latter case the vesical channel falls into the right hepatic. The general hepatic channel throughout in a hepatoduodenal linking of a kpereda from a portal vein is located, crossing it from left to right. Right branch of own hepatic artery (ramus dexter a. hepaticae propriae) crosses behind either the general hepatic, or the left hepatic channel; rather seldom own hepatic artery is located behind from a channel or goes to the left of it.

Fig. 1. Diagrammatic representation of some options of relationship vesical and the general hepatic channels: and — typical interposition (1 — a gall bladder; 2 — a vesical channel; 3 — the general hepatic channel; 4 — the general bilious channel; 5 — a duodenum) — a short vesical channel, in — a short general hepatic channel — the vesical channel crosses the general hepatic in front, d — the vesical channel crosses the general hepatic behind, e — vesical and the general hepatic channels are located on some extent a row, and z — separate falling of the general hepatic and vesical channels into a duodenum (bile gets into a gall bladder through Lushki's courses).

Puzyrny Canal (ductus cysticus) begins from a neck of a gall bladder, passes from right to left, up and kpered before connection with the general hepatic channel. At the beginning of a channel in front of it the cholecystis artery (a. cystica) crosses that serves as a reference point at a gall bladder operations. Here behind a channel the right branch of a hepatic artery is located. To the left of a channel in a hepatoduodenal sheaf there are right hepatic and the general hepatic channels. Interposition of a vesical channel and general hepatic channel can vary considerably (fig. 1) that has practical value at operative measures on the bilious ways. Usually connection vesical and the general hepatic channels happens within a hepatoduodenal sheaf less often behind a duodenum. Length of a vesical channel at adults makes 3 — 7 cm (on average 4,5 cm), and to dia. 0,3 — 0,5 cm (on average 0,35 cm); children of 1 — 7 years on average length of a channel have 2,7 cm, to dia. 0,23 cm, and children have 7 — 14 years length of a channel on average of 3,8 cm at dia. 0,27 cm.

Fig. 2. The diagrammatic representation of some options of falling of the general bilious channel into a duodenum — the back view: and — a typiform of falling of the general bilious channel into average department of the descending part of a duodenum (1 — the general hepatic channel; 2 — a vesical channel; 3 — the general bilious channel; 4 — a pancreat duct) — low falling of a channel into the descending part of a duodenum, in — falling of a channel into the ascending part of a duodenum — falling of a channel into a horizontal part of a duodenum.
Fig. 3. Diagrammatic representation of various forms of connection of the general bilious and pancreatic channels and their falling into a duodenum: and — the general bilious and pancreatic channels connect to formation of a hepatopancreatic ampoule, and in — within a hepatopancreatic ampoule there is a partial or full partition, the guide — the hepatopancreatic ampoule is formed by the general bilious and additional pancreatic channels, e — all three channels fall into a gut independently; 1 — the general bilious channel; 2 — an additional pancreat duct; 3 — a pancreat duct; 4 — a wall of a duodenum.
Fig. 4 — 6. The scheme of some options of relationship of bilious channels, own hepatic artery and a portal vein in portal fissures and in a hepatoduodenal sheaf (in green color bilious channels and a gall bladder, red — own hepatic artery and its branches, blue — a portal vein are shown), fig. 4 — the most frequent form of relationship.

General bilious channel (ductus choledochus), forming by connection vesical and the general hepatic channels, is subdivided into 4 parts: supraduodenalny, located over duodenum (see), the retroduodenal, lying behind an upper part guts, retropancreatic, being behind a head pancreas (see), and intramural where the channel slantwise probodat a back wall of the descending part of a duodenum (fig. 2). Length of the general. the item averages 6 — 8 cm, but also short (to 2 cm) also longer meet (to 12 cm) that depends on the level of its formation; to dia. 0,5 — 1 cm (on average 0,65 cm). Children up to 7 years have average length of the general. the item makes 3 cm at dia. 0,3 cm, and children have 7 — 14 years respectively 5 cm and 0,4 cm of Supraduodenalnaya a part of the general. the item (pars supraduodenalis) 0,3 — 3,2 cm long passes usually in the right edge of a hepatoduodenal sheaf to the right of a portal vein where the channel can be probed at capture of a sheaf big and index by fingers; less often the channel lies in front from a portal vein or in front from a hepatic artery. The anatomic relations between the general hepatic, vesical and the general bilious are presented by channels, a portal vein, own hepatic artery and its branches on tsvetn. fig. 4 — 6. Retroduodenal part of the general. the item (pars retroduodenalis) of average 1,5 — 2 cm passes more to the right of the gatekeeper behind an upper part of a duodenum, being to the right of a portal vein. The retropancreatic part of the canal (pars retropancreatica) 2,5 — 3 cm long is located along a zadnepravy surface of the descending part of a duodenum behind a head of a pancreas; at the left and behind from a channel there is a portal vein. Occasionally this part of the general. the item lies in the thickness of a head of a pancreas. Such features of relationship of the general. items and heads of a pancreas cause a possibility of a prelum of a channel and developing of obturatsionny jaundice at tumors of a head of gland. The intramural part of the general bilious canal (pars intramuralis) the shortest (1,3 — 1,8 cm), it probodat a back wall of the descending part of a duodenum and opens in it on a big nipple of a duodenum (papilla duodeni major, PNA; papilla Vateri), in Krom the hepatopancreatic ampoule (ampulla hepatopancreatica, PNA) — the general mouth of the general bilious and pancreatic channels (fig. 3) is formed. Sometimes the general bilious and pancreatic channels open on a big nipple the general opening, but within it are divided, not forming ampoules, or go separately and open two openings.

Merge of the general is possible. the item with an additional pancreat duct (ductus pancreaticus accessorius). The stated details of the relations of the general bilious and pancreatic channels are of great importance in the analysis of the reasons of disturbances of removal of bile and pancreatic juice in a duodenum.

Innervation Zh.P. it is carried out by branches of hepatic neuroplex (plexus hepaticus).

Blood supply . the item is carried out by the numerous small stipitates originating from own hepatic artery and its branches. Outflow of blood from a wall of channels goes to a portal vein. A lymph drainage from. the item goes on limf, to the vessels which are located along channels to hepatic limf, nodes located along a portal vein. There is close connection between limf, ways. item of a gall bladder, pancreas and liver.

Histology

Wall. the item consists of 3 covers: mucous, muscular and outside. The mucous membrane (tunica mucosa) is covered by a single-layer (high) prismatic epithelium which has properties of pinotsitozny activity. Epithelial cells are rich with lysosomes and mitochondrions which concentrate hl. obr. in their apical part. The epithelium of channels in the functional relation can carry out as secretion (mucous glands of bilious channels), and a resorption. Also scyphoid cells which quantity sharply increases at an inflammation of channels meet. A mucosal surface of a cover of channels on a big extent smooth, but in some sites it forms folds: a spiral fold (plica spiralis) — in a vesical channel, a number of karmanoobrazny folds — in a distal part of the general. the item (these folds extremely complicate or make impossible sounding of a channel from a duodenum). The muscular coat (tunica muscularis) is formed by the bunches of smooth muscle cells located hl. obr. spiralno, and also the elastic and collagenic fibers oriented in circular and in smaller quantity in longitudinal the directions owing to what this cover is called sometimes fibromuscular (tunica fibromuscularis). Generally. the muscular coat is expressed better and presented to the item by two layers — outside and internal; between them the vegetative (autonomous) intermuscular neuroplex containing nervous cells lies. In the place of merge of hepatic channels in the general hepatic concentric accumulations of muscle fibers form similarity of a sphincter — a physiological sphincter of Mirissi. Thickenings of a muscular coat are noted also in other places: in a vesical channel — at an otkhozhdeniya from a neck of a bubble, generally. the item — in its intramural part. The muscular device of an intramural part of the general is most difficult arranged. the item where distinguish two circular sphincters — a sphincter of the general. the item (m. sphincter ductus choledochi, PNA) located in a wall of a channel before an ampoule and a sphincter of a hepatopancreatic ampoule (m. sphincter ampullae hepatopancreaticae, PNA). The specified sphincters in total with a sphincter of a pancreatic channel make the combined sphincter described by R. Oddi. The outside cover (tunica externa) of channels is formed by friable not properly executed connecting fabric. In it the vessels and nerves vascularizing and the innervating channels are located.

Physiology

Movement bile (see) in bilious ways results from the secretory pressure of a liver, motility of a gall bladder and depends on a condition of sphincters of a neck of a gall bladder and a sphincter of a hepatopancreatic ampoule; has value and a tone of walls of bilious channels. Though opinion that. items, peristaltiruya, actively participate in advance of bile in a duodenum, is disputable, many authors [P. L. Mirizzi, Wildegans, etc.] recognize that muscle fibers in walls. items provide their peristaltics. The sphincter of Mirissi undoubtedly plays an active role, interfering with a reversed current of bile at reduction of a gall bladder and to a pelting of intestinal contents in. the item after imposing went. - kish. soustiya.

Methods of a research

In details collected anamnesis and a wedge, a picture often, unfortunately, do not allow to establish completely the reasons of disturbances in zhelchevydelitelny system, and the full diagnosis of a disease. the item is possible only as a result of careful inspection of the patient, a cut sometimes shall proceed also during operation.

Among laboratory methods of a research matters duodenal sounding (see), at Krom signs of an inflammation can be found. item (leukocytes, cells of an epithelium of channels), tumor cells, lyambliya and other parasites. Lack of bilious pigments in Calais can explain the nature of jaundice. Also various functional trials of a liver matter (see. Liver ). However for assessment of a state. items have major importance rentgenol, methods of inspection, including. X-ray cinematography (see), the giving chance of a dynamic research of function Zh. item.

X-ray inspection of bilious channels consists in identification morfol, and funkts, changes in them with a X-ray analysis: holegrafiya (see), holangiografiya (see) and cholecystographies (see). The obtained data estimate, comparing them about a wedge, a picture of a disease.

In the presence of symptoms of biliary hypertensia of one of main goals rentgenol, researches establishment of the reason interfering outflow of bile on is. item. At atresias. items, followed by jaundice, note system osteoporosis, increase in a shadow of a liver and spleen on roentgenograms. The laparoscopic holangiografiya (if the last does not work well, then a holangiografiya on the operating table) allows to differentiate inside - and extrahepatic forms of atresias. the item with inborn hepatitis. Large cyst of the general. the item often gives a distinguishable shadow on the roentgenogram. At a holegrafiya receive an upright image of the general. item and its cysts. Inborn expansion of intra hepatic. the item is recognized by means of a holegrafiya with a tomography. Detection of anomalies of quantity. item, and in particular aberrant. item, and also anomalies of situation and nature of branching. the item is made by means of a holangiografiya.

In recognition of damages. items rentgenol, methods of a research have auxiliary value. Metal foreign bodys give a sharp image on usual roentgenograms. Low-contrast foreign bodys can be found only at a holangiografiya

Hron, the cholangitis leads to uneven expansion and narrowing. the item also creates roughnesses of their outlines on holangiogramma. At primary sclerosing cholangitis the gleam of channels above narrowing is not expanded that it distinguishes a x-ray picture at a sclerosing cholangitis from a stone or a tumor. item.

Fig. 4. Roentgenograms of area of the right hypochondrium at holedokhoduodenalny fistula: and — the bilious channels («an air holangiogramma») filled with gas through fistula are specified by shooters; — at X-ray inspection of a stomach and duodenum the contrast suspension through fistula in a duodenum fills bilious channels and a gall bladder; 1 — a gall bladder; 2 — the fistular course.
Fig. 5. The tomogram of bilious channels at a holegrafiya: two large stones (in the form of defects of filling) in the general bilious channel (are specified by shooters).

The picture of the fistula connecting is indicative. the item with a stomach or intestines, and also artificially created biliodigestivny anastomosis. On roentgenograms against the background of a liver are defined filled with gas Zh. item (fig. 4, a). The contrast suspension from a stomach or a gut through fistula passes in. item (fig. 4, b).

Stones. the item is recognized on the usual roentgenogram if they in them contain in enough salt of calcium carbonate. Diagnosis is facilitated in the presence of several stones which are grouped according to the course vesical hepatic or the general. item. As the leading way of presurgical detection of stones of channels serves the holegrafiya. On holegramma stones cause defects of filling in a shadow. item. These defects (fig. 5) are better visible on tomograms (see. Tomography ).

At a holangiografiya in time and after operation stones determine by direct and indirect symptoms. A direct sign is the image of the stone in the form of defect of filling in a shadow of a channel. If the stone completely corks a channel, then advance of a contrast agent stops; on site a break of a shadow there is a defect in the form of a meniscus or a dome. Carry to indirect symptoms: expansion Zh. the item, the slowed-down transition or lack of transition of a contrast agent to a duodenum, flowing of a contrast agent to intra hepatic channels.

At an ascaridosis the ascarids who got into bilious ways cause obstruction of certain canals or tape-like defects in them on holangiogramma.

Cancer. the item is determined by narrowing or occlusion of a channel on holangiogramma. At arteriography the network of so-called tumoral vessels in a zone of defeat can be revealed.

In diagnosis of diseases. the item plays a part peritoneoskopiya (see) and especially duodenoskopiya (see) with use of various diagnostic receptions, including with retrograde catheterization. the item through duodenoskop. Combination of retrograde catheterization. the item through duodenoskop with introduction to them through a catheter of a contrast agent with a simultaneous X-ray analysis allows to receive very demonstrative pictures reflecting a state. item. Methods the examinations conducted during operation are of great importance for specification of the nature of a disease: intraoperative holangiografiya, holedokhoskopiya (see) and manometriya. the item (see. Holangiomanometriya ).

A radio isotope research

Radiokholegrafiya, a stsintigrafiya play a supporting role in assessment of a state. item. Radio isotope holegrafiya (see) it is based on ability of a liver to catch from blood and to allocate some marked connections with bile (Bilignostum, Bengalese pink, etc.). After intravenous administration on an empty stomach of these drugs 0,3 mkkyur on 1 kg of body weight repeatedly measure by activity a radiation intensity over bilious ways, defining accumulation and removal from them of radioactive bile. For the differential diagnosis important that at a disease of a liver (e.g., at hepatitis) the clearance of blood and accumulation of radio pharmaceutical drug in a liver decrease, but its removal in intestines remains; at defeat. the item (e.g., at mechanical jaundice) sharply falls or there is no intake of drug In intestines, and on the stsintifotogramma received on gamma cameras (see. Stsintigrafiya ), expanded are sometimes visible. item. Use dynamic a stsintigrafiya is very valuable! in diagnosis of an atresia of bilious ways.

A.S. Belousov et al. (1970) suggested to measure the radioactivity of the bile which is coming out in a duodenum by means of the probe entered distalny a big nipple of a duodenum with the gas-discharge counter on the end. After intravenous administration 25 mkkyur Bengalese pink, marked 131 I, impulses count each 2 — 3 min. during the 3rd hour. In patol, conditions various changes of the schedule of bile secretion are observed. Most often the curve has more flat, than normal, the course.

Pathology

the General signs allowing to assume diseases. items, are pains in right hypochondrium and epigastric area; fever, jaundice, a fever, increase in a liver, and it is frequent also spleens, the accelerated ROE, a leukocytosis. Depending on character and weight patol, process, its preferential localization the wedge, a picture of a disease changes, but in case of the organic reason of disturbances by the most Pathognomonic the symptoms connected with stagnation of bile are.

Malformations

make Malformations apprx. 8% of all anomalies. Carry an atresia, an aplasia, a hypoplasia, expansion, diverticulums, doubling, and also shift of the mouth of channels on the unusual place to them.

Fig. 6. The diagrammatic representation of inborn atresias of bilious channels (across Bairov): 1 — an atresia of the general bilious channel (at the left below the norm — is given for comparison); 2 — an atresia of a gall bladder, vesical and the most part of the general bilious channels; 3 — an atresia of a gall bladder, vesical, the general hepatic and the general bilious channels; 4 — an atresia of all extrahepatic channels; 5 — an atresia hepatic and the general hepatic channels; 6 — an atresia of a gall bladder and all extrahepatic channels (the name of pattern units see in fig. 2, a).

Atresia of bilious channels — lack of a gleam in them — meets on 20 — 30 thousand newborns, is for the first time described in 1895 to Giza (Giese) and Vittsel (O. by Witzel). Fetalis occlusion. the item can be caused by disturbance of an embryogenesis of the bilious courses at a stage of a rekanalization. Kirchbaum considers that the reason of an atresia of extrahepatic. the item can be the pre-natal peritonitis which is followed by formation of commissures in subhepatic space. That at an atresia. items constantly are found sharply expressed changes in walls of branches of a hepatic artery, P. Puri and soavt, connect development of an atresia. the item with ischemia of a liver. Different types of atresias (fig. 6) meet. Atresia. the item can be followed by an aplasia and an atresia of a gall bladder. Malformations. items can be combined with malformations of other bodies.

The most characteristic sign of an atresia. the item is expressed jaundice (see) at an akholichny chair. It appears with 2 — the 3rd birthday of the child, is more rare in 1 — 2 week, progressively accrues, and by 2 — 3 months the child becomes saffron-yellow-yellow. The chair at the expressed jaundice can get yellowish coloring owing to allocation of pigments with intestinal juice, but reaction a calla on stercobilin negative. Tears are also painted in yellow color («amber»). Urine from the first days of life is intensively painted, leaves hulls on diapers. Disturbance of coagulability of blood leads to emergence of petekhialny hemorrhages. Body temperature of the child remains normal, he badly puts on weight, the concern owing to a meteorism and a skin itch is noted. In process of increase of jaundice the liver increases; surface its smooth, dense, keen edge. With 2 — the 3rd month children have symptoms portal hypertensia (see): went. - kish. bleedings, expansion of venous network on a front abdominal wall, increase in a spleen, ascites. Due to the disturbance of digestion of fat-soluble vitamins A and D rickets and a keratomalacia develops. From the first days of life increase of bilirubin in blood serum (reaction direct, bystry), moderately expressed anemia, thrombocytopenia is noted. At children is more senior 1 month cholesterol raises, the prothrombin ratio decreases, the sugar curve is perverted. Function of a liver within the first month of life is broken a little, then transaminase becomes more active, Veltmann's tape is extended (see. Veltmanna coagulative test ), there is positive Takat's reaction — the Macaw (see. To oagulyatsionny tests ). In urine bilirubin in the absence of urobilin and urobilinigen is defined. The intravenous holegrafiya helps with diagnosis of an atresia a little. the item since allocation is broken by a liver of a contrast agent. The laparoscopy and a puncture biopsy of a liver matters, however in some cases the final diagnosis of this defect is established only during operation. Differential diagnosis needs to be carried out with fiziol. jaundice, hemolitic disease of newborns (see) and pre-natal hepatitis (see).

Fig. 7. The diagrammatic representation of operations at a partial atresia of outside bilious channels (at the left above black lines gave the diagrammatic representation of an atresia of channels): 1 — a cholecystoduodenostomy at an atresia of the general bilious channel in the presence of a gall bladder; 2 — a hepaticoduodenostomy at an atresia of the general bilious channel, a gall bladder, a distal part of the general hepatic canal.
Fig. 8. The diagrammatic representation of a gepatoduodenostomiya through a bed of a gall bladder at a full atresia of outside bilious channels: and — the first row of seams between a gall bladder and a duodenum is imposed — through a section of a wall of a gall bladder the polyvinyl drainage is entered into tunnels of the left and right half of a liver, in — the anastomosis between a gall bladder and a duodenum is imposed; 1 — a gall bladder; 2 — a liver; 3 — intra hepatic bilious channels; 4 — atrezirovanny bilious channels; 5 — a duodenum; 6 — a polyvinyl drainage.

Treatment of an atresia. the item can be only operational. Life expectancy without operation — 6 — 12 months. In 1927 W. Ladd for the first time successfully operated the child with a partial atresia. item. In 1948 W. P. Longmire for the first time made at 4 children at an atresia of all outside. the item a resection of the left half of a liver also anastomosed its wound surface with a stomach. One of operated recovered. In our country the first successful operation for an atresia. the item it was made by G. A. Bairov in 1956. The age of 4 — 6 weeks is considered the optimum term of an operative measure. Operability fluctuates from 10 to 40%. The technique of operation depends on type of an atresia. At a partial atresia of extrahepatic. the item is imposed an anastomosis between a gall bladder or expanded sites Zh. item and duodenum (fig. 7), stomach or small bowel. In 1959. And. The B of acoruses offered operation of a double hepatostomy: after a regional resection the right and left hepatic lobe makes gepatogastro-also a gepatoduodenostomiya (see. Gepatoduodenostomiya ) or gepatoenterostomiya. Further by G. A. Bairov with soavt, it was offered gepatoduodenoanastomoz through a bed of a gall bladder or through a rudimentary bubble, from to-rogo make tunnels in the right and left half of a liver having an autonomous zhelcheottok (fig. 8). Not satisfactory results of operational treatment of an atresia. items generally are explained by late diagnosis therefore the liver failure develops. At an atresia of intra hepatic. radical treatment is still impossible for the item. According to Fonkaysrud (E. W. Fonkaisrud), the made attempts of transplantation of a liver at this disease give survival on average up to 104 days.

Hypoplasia of bilious channels — defect, at Krom. items represent thin tyazh with the narrow gleam which is not providing evacuation of bile. Extremely rare disease; in literature there are single descriptions of this malformation. It is clinically shown by an akholichny chair. With 5 — the 6th month intensity of jaundice decreases, there is a painted chair, however owing to stagnation of bile biliary cirrhosis can develop and progress.

Inborn expansion of the general bilious channel (cystous expansion, a cyst) arises due to the lack of a muscular layer in a wall of a channel, during the narrowing or an excess of a channel in its distal part. It is described for the first time by A. Vater in 1723. It is characterized by a triad of signs — the pristupoobrazny abdominal pains which are followed by emergence of jaundice and the probed tugoelastichny education in right the hypochondrium, size and a consistence to-rogo can change. During an attack in urine there are bilious pigments, the chair becomes decoloured. Expressiveness of symptoms depends on character of an obstacle for a zhelcheottok and expansion ratio of a channel. Cystous expansion Zh. the item can be complicated by perforation of the thinned wall of a cyst with development of bilious peritonitis or formation of the fistular courses between channels and hollow bodies. Diagnosis of inborn expansion of the general. items confirm data of duodenal sounding (receiving periodically large amount of dark bile), these holangiografiya, a X-ray analysis and a pneumoperitoneum. It is necessary to carry out the differential diagnosis with cysts of a liver and abdominal cavity, cholelithiasis. Treatment is operational, consists in imposing of a holedokhoduodenoanastomoz, partial excision of a wall of an expanded channel is sometimes carried out.

Diverticulums of bilious channels are described in literature in the form of single observations, are clinically shown by the same symptoms, as inborn expansion of the general. item. Presurgical diagnosis is possible by means of a holegrafiya.

Doubling of bilious channels seldom happens true, there is a distal shift of the conjunction right and left hepatic more often than channels which can independently fall into a duodenum or connect in the lower third of a hepatoduodenal sheaf. Shift of the place of a confluence of the bilious courses clinically is not shown, but detection of these anomalies during liver operation. the item and a stomach is of great importance for the prevention of bandaging and crossing of a channel.

Damages

Damages of extrahepatic. items can be closed (at the closed injury of a stomach) and opened (as a result of gunshot or knife wounds or during surgical interventions).

Damages. items at the closed injury of a stomach are connected with considerable discrepancy of a liver and duodenum in different directions at a sharp prelum in right hypochondrium, directed in front back, as a result of strong blow. Also the substantial increase of hydrodynamic pressure in a gall bladder and bilious channels developing in the moment of blow plays a role.

A wedge, a picture of the closed damages. to the item it is similar to clinic of the closed injuries of a gall bladder (see. Gall bladder, damages ) also depends on the nature of damage. the item and amounts of the bile coming to an abdominal cavity.

The diagnosis of the isolated closed damages outside. the item presents great difficulties and usually is established only during a laparotomy.

The isolated fire damages. items meet seldom; during the Great Patriotic War of 1941 — 1945 they were not described. The isolated damages. items at wound cold weapon or other cutting objects also represent an extreme rarity; usually they are combined with injuries of a liver, stomach, intestines.

Accidental wounds of extrahepatic are observed. the item during surgeries; they arise during removal of a gall bladder, a resection of a stomach, especially at low-sited ulcers of a duodenum. In connection with significant increase in quantity of cholecystectomias and resections of a stomach of damage. items during operations are observed more often. H. Kehr, S. P. Fedorov, E. V. Smirnov, S. D. Popov and others note that wound of the main extrahepatic. the item is observed at operations on the bilious ways to 0,5 — 1,5% of cases. V. V. Vinogradov and P. I. Zima on 2800 cholecystectomias wound of the general hepatic and the general. items observed at 35 patients (1,25%). During a resection of a stomach concerning a peptic ulcer D. K. Grechishkin and soavt, noted this complication on 8736 operations in 0,58% of cases.

During removal of a gall bladder damage of the general and right hepatic channels, and also the general is more often observed. the item at the place of a confluence of a vesical channel, is more rare in a supraduodenalny part. At resections of a stomach the general. the item is damaged more often in retroduodenal and supraduodenalny departments.

Damages. items during a cholecystectomia are caused by various reasons: congenital anomalies and variability of an arrangement of a gall bladder and bilious channels; inflammatory and infiltrative or cicatricial changes in area of a neck of a gall bladder, a vesical channel and a hepatoduodenal sheaf, sharply breaking topography; tactical and technical mistakes of surgeons. At a resection of a stomach the contributing moments are: anomalies of an arrangement and confluence. the item, in particular arrangements of a big nipple of a duodenum near the gatekeeper; low arrangement of an ulcer of a duodenum; a penetration of an ulcer in a hepatoduodenal linking, area of portal fissures or a head of a pancreas; extensive commissural process.

The nature of damage of a wall of a channel can be various: a dot or small linear wound, excision of a perednebokovy wall, a partial or full pereresecheniye of a channel, its resection, a pristenochny or full ligature, underrunning or a prelum (e.g., during the closing of a stump of a duodenum), the combined damage of the general bilious and pancreatic channels (at a gastroduodenal resection).

Fig. 9. The diagrammatic representation of some options of possible damages of the general bilious channel at a cholecystectomia: 1 — at a parallel arrangement vesical and the general hepatic channels; 2 — at a parallel arrangement of a gall bladder and the general bilious channel; 3 — at a mobile general bilious channel and an excessive pulling of a gall bladder; 4 — at absence or a short vesical channel; 5 — at simultaneous crossclamping of a vesical artery and the general bilious channel. In all drawings the nature of the arisen damage is shown on the right.

Wound right or the general hepatic channels occurs usually owing to their acceptance for vesical. The general. the item can be accepted for vesical at an arrangement of the last parallel to the general. the item or at an overhang over the general. the item of a neck of a gall bladder, or an arrangement of a gall bladder parallel to the general. item. Damage of the general hepatic and the general. the item can come also at excessive pulling up for a gall bladder, especially at the absent or short vesical channel, and also at a careless stop blindly of suddenly arisen bleeding from vesical or any other artery. It is possible also in attempt of the maximum allocation of a vesical channel for its bandaging at the place of falling into the general. item (fig. 9).

Damage. the item is observed also at a tool research by their metal probes, buzha, spoons, nippers, especially at the forced and rough manipulations on. the items changed as a result of an inflammation.

Prevention of damages. the item during removal of a gall bladder is performance of operation whenever possible out of an acute stage of a disease when inflammatory changes in area of an arrangement. items abate. In especially hard cases it is necessary to be limited cholecystostomy (see). If in connection with technical difficulties it is not possible to allocate a vesical channel completely and to impose a ligature near the place of its falling into the general. the item, it is not necessary to risk; it is necessary to tie up it where it is possible. For detection of anomalies of an arrangement. the item, able to lead to their damage, it is necessary to use widely during operation holangiografiya (see) through a vesical channel or a gall bladder.

At a resection of a stomach the most dangerous moments from the point of view of possible damage. items are allocation back and posterolateral walls of a duodenum, processing of her stump and excision of the penetrating ulcers. In technically difficult cases in order to avoid damage. the item sometimes it is necessary to be limited to a resection of a stomach on switching off (see. Peptic ulcer ).

Damage. the item during operation is determined by the arising expiration of bile in an abdominal cavity. In diagnostically not clear and doubtful cases it is necessary to use sounding. item and holangiografiya. Pointed or small damages. items easily can remain unnoticed. It is difficult to establish accidental bandaging of a channel timely. Usually it is distinguished after operation when obturatsionny jaundice develops. According to various authors, damage. the item during operation is found at once only in 4 — 15% of cases.

Damage. the item during surgical intervention is a serious complication: it demands immediate correction or creation of outside bilious fistula for removal of bile, otherwise diffuse bilious develops peritonitis (see), coming to an end with usually lethal outcome. In more mild cases limited abscesses, outside are formed bilious fistulas (see), strictures. the items demanding difficult repeated operations which should be carried out in unfavorable conditions and with great technical difficulties.

It is necessary to emphasize that damages. items can be not only explicit (wound, crossing, crush of a wall of a channel a styptic clip), but also hidden, shown after operation. The damages arising during the sounding concern to them. the item metal probes or buzha (use of plastic probes is much less traumatic), and also spoons and lithotomy forceps. Unsafe can be also unsuccessfully entered drainages, and also holedokhoskopiya (see), especially during the use of metal (inelastic) tubes. In spite of the fact that these damages usually happen insignificant and limited, further they can lead to cicatricial wrinkling of a thin wall of a channel.

Similar changes can occur also after extended (more than 2 — 3 cm) circular mobilization of the general hepatic and the general. the item because at allocation of the last of surrounding fabrics inevitably there is a damage of the small vessels feeding a wall of a channel. Cicatricial changes of a wall of a channel can arise also after imposing of pristenochny ligatures or after bandaging of a vesical channel very close to the place of its confluence.

Accumulations in subhepatic space and in a circle of the extrahepatic channels of blood and bile arriving from badly taken in bed of a gall bladder, punctures of a liver, not tied up small additional are not indifferent in this respect. the item or from a stump of a vesical channel during the sliding from it badly imposed ligature or eruption of a wall of a channel by it. In all these cases at irrational drainage there is an inflammation of surrounding fabrics from the outcome in fibrosis which can extend also to a wall of a channel.

Cicatricial strictures of the general hepatic and the general. the items arising 4 — 6 months later after a cholecystectomia in most cases are posttraumatic. I. Littmann considers that more than in 90% of cases they arise owing to these or those damages taking place. item.

Cicatricial strictures of the general. items diagnose on existence of recurrent cholangitis (see), obturatsionny jaundices (see) or not healing outside (full or incomplete) bilious fistula, and also on the basis of data of a X-ray contrast research of channels by the intravenous or ascending (endoscopic) holangiografiya or fistulografiya (see). The transdermal intra hepatic holangiografiya is more dangerous and therefore it is applied seldom.

The operative measures applied for the purpose of correction of damages. items, are various, they depend on character and the level of damage, and also anatomic relationship in the field. At small wounds of a wall of channels it is possible to be limited to imposing of single noose sutures (the continuous suture narrows a gleam) synthetic (mylar) thread on an atraumatic needle. It is also reasonable to use MK-6 glue which for the best fixing should be applied by means of a needleless injektor as independently, and in a combination to seams that provides tightness them.

If small damage is located in a hard-to-reach spot, napr, on a back wall of the general. the item, it is necessary to apply Sitenko's method — Nechaya: the additional choledochotomy in convenient for drainage T-shaped the drenazhy place becomes, and damage is not sewn up. The ground mass of bile at the same time comes on a drainage, but not to an abdominal cavity, edges is drained separately drenazhy, brought to the place of defect. At a major defect on a front or side surface defect can be used for outside drainage of a channel, it is better by means of the T-shaped drainage or imposing of one of a biliodigestivny anastomosis: gepatiko-or choledochoduodenostomies, gepatiko-or choledochojejunostomies, gepatiko-or holedokhogastrostomiya. The last way is used seldom since it is less physiologic also an anastomosis of the general. the item with a stomach is subject to scarring. Perhaps also imposing holetsistogastro-, holetsistoduodeno-or a holetsistoyeyunoanastomoza with an interintestinal anastomosis; at the same time both ends of the crossed channel tie up.

At cross crossing of the general bilious channel it is sewed the end in the end thin noose atraumatic sutures on T - or the G-shaped drainage or on a transhepatic drainage across Praderi — to Smith. In order to avoid a cicatricial stricture in the field of a seam the drainage shall be in a gleam of a channel within 4 — 6 months, being a framework for the forming anastomosis. To apply in these cases submersible, or «lost», drainages (see. Drainage ) does not follow: they are not managed and sometimes depart prematurely that leads further to development of a stricture in the field of an anastomosis, and sometimes, on the contrary, are late in a channel, are inlaid with bilious salts and interfere with free outflow of bile that at full obstruction of a channel demands repeated operation for their removal. The transnasal drainage can remain on site no more than several days therefore in similar cases it is also undesirable. Transpapillary drainages are dangerous because of development of acute pancreatitis and a pancreatonecrosis.

At an accidental resection of the general hepatic or the general. the item and impossibility to pull together the crossed ends for sewing together should try to execute it after mobilization of a duodenum on Kokhera. In similar situations also anastamosing of the proximal end of the crossed channel with a duodenum or with the switched-off segment of a jejunum is possible (the end sideways or better a side sideways). The distal end of a channel in these cases is tied up or anastomosed with the same gut.

At accidental bandaging. the ligature shall be immediately removed by the item. If this complication remained unnoticed, and during repeated operation it is not possible to find and remove a ligature, then depending on the level of bandaging of a channel impose or holetsistogastro-, holetsistoduodeno-or holetsistoyeyunoanastomoz, or an anastomosis of the general hepatic or the general. the item with a stomach, duodenal or a jejunum.

The operations undertaken concerning cicatricial strictures or full occlusion. items, have usually recovery or reconstructive character, differ in big complexity and are carried out usually according to vital indications.

At small limited cicatricial strictures of the general, and. for recovery of normal outflow of bile operations which basis is the bilio-biliary anastomosis can be used (e.g., a resection of the narrowed section of the canal with an anastomosis between the rests of a channel). They attract with a possibility of a complete recovery of the lost function, however are applied infrequently because conditions for their performance meet extremely seldom, and also because of danger of development of a recurrence of a stricture.

Also the bougieurage of a channel which almost is not applied as an independent method and also the prosthetics of channels which was not beyond an experiment yet belongs to recovery operations.

Most of surgeons at treatment of extrahepatic. the item gives preference to reconstructive operations, first of all a bypass biliodigestivny anastomosis. For an anastomosis use usually expanded site of the general hepatic or the general. the item proksimalno from the place of narrowing whenever possible where the wall of a channel is not changed. The choice of the anastomosed gut (lean or duodenal) from the point of view of the subsequent function has no basic value, however use a duodenum more often; choledochoduodenostomy (see) it is technically simpler, reliable and takes less time. A contraindication for this operation is existence of a duodenostaz or limited mobility of a duodenum because of existence of commissures.

Fig. 10. The diagrammatic representation of a partial gepatektomiya with an intra hepatic cholangiogastrostomy on a drainage: and — the drainage tube is entered into an intra hepatic bilious channel and removed through a wall of a stomach outside, stitches between a back surface of a liver and a serous cover of a stomach are put; — stitches between a front surface of a liver and a serous cover of a stomach are put, operation is complete; 1 — a liver; 2 — a drainage tube; 3 — the seams connecting a back surface of a section of a liver to a stomach; 4 — a stomach; 5 — the seams connecting a front surface of a section of a liver to a stomach.
Fig. 11. The diagrammatic representation of a partial gepatektomiya with an intra hepatic holangioyeyunostomiya on a drainage: and — the drainage tube is entered into an intra hepatic bilious channel and removed through a gleam of a jejunum outside, stitches between a back surface of a liver and the isolated segment of a jejunum are put; — stitches between a front surface of a liver and the isolated segment of a jejunum are put, operation is complete; 1 — a liver, 2 — a drainage tube, 3 — the isolated segment of a jejunum hemmed to a liver; 4 — a proximal piece of a jejunum; 5 — an interintestinal anastomosis; 6 — the seams connecting a first line of a section of a liver to the mobilized end of a jejunum.

A specific place is held by surgical interventions at high strictures. the item, localized near merge of hepatic channels. The operations undertaken in these cases, technically the most difficult demand special operational receptions, it is much more dangerous to the patient and are followed by a large number of lethal outcomes. They consist in imposing of various anastomosis between proximal department of the general hepatic or share (right and left) hepatic channels, and sometimes and intra hepatic channels with bodies went. - kish. path. Sometimes for imposing of an anastomosis with intra hepatic. the item should do a partial resection of a liver. Depending on character these operations are called: gepatikoyeyunostomiya, hepaticoduodenostomy, gepatokholangiogastrostomiya, gepatokholangioyeyunostomiya (fig. 10 and 11).

Fig. 12. The diagrammatic representation of operation of a hepaticoduodenostomy on a transhepatic drainage (across Praderi — to Smith): 1 — the end of a drainage tube removed on expanded intra hepatic channels through an abdominal wall outside; 2 — an abdominal wall; 3 — a liver; 4 — a stomach; 5 — the general hepatic channel; 6 — a gepatikoduodenalny anastomosis; 7 — a duodenum; 8 — the end of a drainage tube shipped through a gepatoduodenostomichesky opening in a duodenum.
Fig. 13. The diagrammatic representation of drainage of extrahepatic bilious ways at a gepatikoyeyunostomiya with interintestinal an anastomosis (on Felkera): 1 — the general hepatic channel; 2 — gepatikoyeyunoanastomoz; 3 — enteroenteroanastomoz; 4 — an enterostoma; 5 — an abdominal wall; 6 — the drainage tube entered into the general hepatic canal and other end removed through a gleam of a jejunum outside.

The greatest difficulties consist in detection and allocation from powerful hems of the channels which are quite often located highly in the field of portal fissures and also in creation of good adaptation of a mucous membrane. the item and anastomosed body (a stomach, a gut); success of all operation quite often depends on care of their contact. When the technical reasons of accurate connection of mucous membranes throughout an anastomosis do not manage to receive no, the anastomosis is created on the drainage which is carrying out function of a framework. The drainage is left for 4 — 6 months and more, removing its second end outside through a liver across Praderi — to Smith (fig. 12) or through a gut on Felkera (fig. 13); sometimes use the hidden drainage (see. Drainage ). There are several modifications of the similar operations offered by B. S. Rozanov, E. V. Smirnov and S. D. Popov, I. Littmann, A. A. Shalimov, H. Haberer, H. Peiper, etc.

At impossibility to carry out a biliodigestivny anastomosis with extrahepatic. the item (powerful hems, danger of damage of large vessels, etc.) it can be imposed with usually considerably expanded intra hepatic channels which find by means of a puncture. Then on mandrin the polyethylene drainage is entered into the canal, on Krom the channel is anastomosed with a gut (gepatokholangioenteroanastomoz).

When no of the listed operative measures for one reason or another can be executed, A. Dolyotti and W. P. Longmire for removal of bile suggested to use an intra hepatic channel of the left hepatic lobe (after its resection), anastomosing it with a stomach or a small bowel. This operation received the name of a partial gepatektomiya from an intra hepatic holangiogastro-or - a jejunostomy (fig. 10 and 11).

At outside bilious fistulas make connection of channels with a gut through the formed fistular course — a holefistuloenterostomiya. The anastomosis is imposed both in an abdominal cavity, and out of it — a hypodermic fistuloenterostomy according to E. V. Smirnov (see. Bilious fistulas ).

It is long the existing stenosis of extrahepatic. the item can be complicated by biliary cirrhosis with portal hypertensia and bleeding from varicose expanded veins of a gullet that considerably worsens the forecast. In these cases at first make splenorenalny shunting, and in the second stage — elimination or correction of a stricture. In nearby come cases perhaps single-step combined intervention — arterioliz and denervation of the general and own hepatic arteries and a biliodigestivny anastomosis.

Diseases

Fig. 14. The diagrammatic representation of dyskinesia of bilious channels (on Theuer): and — atonic dyskinesia — hypertensive - hyperkinetic dyskinesia; 1 — the general bilious channel (it is given in a section); 2 — a duodenum (it is given in a section).

Functional disturbances (dyskinesia) of bilious channels disturbances of neurohumoral regulatory mechanisms of relaxation and reduction of their muscles result. At the same time in one cases the atony of the general prevails. the item and a spasm of a sphincter of a hepatopancreatic ampoule because of increase in a tone of a sympathetic nervous system, in others — a hypertension and a hyperkinesia of the general. the item at relaxation of this sphincter (fig. 14) that is connected usually with excitement of a vagus nerve. Dyskinesia. items are quite often combined with diskinetichesky frustration gall bladder (see) are also caused by the same reasons. Clinically dyskinesia. items are characterized stupid or acute, usually short-term, by pains in an upper part of a stomach with irradiation in a back, a right shoulder-blade, usually without temperature increase, a fever, fever, gepato-and splenomegalies. Diagnosis of dyskinesia. the item is established at an exception of the organic reasons of suffering (stones. item, inflammatory changes, etc.).

Inflammatory diseases bilious channels most often develop as a result of similar processes in a gall bladder (see. Cholecystitis ) or the ascending infection from intestines. Depending on preferential localization of inflammatory process distinguish a cholangiolitis (defeat of the intra hepatic bilious courses and small channels) and in not hepatic cholangitis (see), defeat hepatic, the general hepatic and the general. item. Clinic of a purulent inflammation. the item is characterized by fever, gepato-and a splenomegaly, recurrent jaundice, the progressing liver failure. Acute inflammatory diseases. items often are complicated by emergence pancreatitis (see). The result of inflammatory processes in. items often happen Obliterating sclerous changes in them which owing to disturbance of outflow of bile lead to development of secondary biliary cirrhosis or sometimes to abscesses of a liver.

Parasitic invasion also can be the cause of defeat. item. In bile protozoa (lyambliya, trichomonads, amoebas), helminths can be found: roundworms — ascarids, a threadworm, an intestinal ugritsa, ankylostomas; flukes — flukes cat's, Chinese or hepatic; tape-worms — a tapeworm a bull, pork, dwarfish, wide tape-worm and many other Klin, manifestations of a parasitic invasion hesitate over a wide range — from an asymptomatic parasitosis to heavy intoxication.

Stones — the most frequent pathology. the item (see. Cholelithiasis ).

Tumors

Benign and malignant tumors. items meet seldom.

To benign tumors. items belong fibromas, adenomas, neurofibromas, lipomas, myxomas, papillomas, myomas, etc. In the beginning they do not cause any disturbances, however in process of the growth, usually slow, lead to narrowing of a gleam of a channel up to full obstruction it. At the same time there are pains in right hypochondrium, sometimes as hepatic colic, and obturatsionny jaundice. Klien, a picture very much reminds cholelithiasis. Diagnosis of a benign tumor is difficult even during operation. It should be differentiated with a concrement and with a malignant new growth. Sometimes the nature of a tumor manages to be found out only after urgent or even full gistol, researches.

Benign tumors. items are subject to removal in connection with danger of development of obturatsionny jaundice and a possibility of a malignancy. In some cases this operation should be combined with a resection of a small segment of a channel or with imposing of a biliodigestivny anastomosis.

Malignant tumors. the item, as a rule, epithelial, is more often columnar-celled crayfish of a skirrozny or papillary structure (see. Cancer ). They meet still less than primary cancer of a gall bladder.

Cancer of extrahepatic. the item considerably meets at men more often 50 years are aged more senior. The combination it with cholelithiasis is noted less than at cancer of a gall bladder.

Favourite places of localization of cancer. items are an ampullar part of the general. item and place of merge vesical, the general hepatic and the general. the items which are the narrowest departments.

Malignant tumors. items differ in big tendency to fibrosis. Macroscopically they represent small (1,5 — 2,5 cm) the tumors of whitish color growing in a gleam of a channel and infiltriruyushchy its wall. At palpation of a channel the dense node is defined or all channel represents a rigid tube; the tumor is difficult to be distinguished from a cicatricial stricture of a channel. Strictures speak well inflammatory changes in surrounding fabrics, however in some cases the issue can be resolved only after gistol, researches.

Cancer. the item grows rather slowly, late metastasizes, usually in a liver and regional limf. nodes. In a late stage of a disease germination of a tumor in the next bodies and fabrics, ascites owing to a prelum of a portal vein is observed.

The most often found and earliest symptom at malignant tumors. the item is obturatsionny jaundice. Content of bilirubin in blood serum exceeds 10 and even 20 mg of %. The amount of cholesterol and an alkaline phosphatase in blood increases. Jaundice often is followed - a painful itch, sometimes it precedes emergence of jaundice. Decrease in a prothrombin ratio (to 30%) and albuminoglobulinovy coefficient is observed (lower than 1,0). At cholemias (see) hypodermic and intestinal bleedings develop. The emaciation, the general weakness, loss of appetite appearing sometimes before developing of jaundice progress. Abdominal pains are absent more often or they are insignificant, stupid character, are localized in right hypochondrium, epigastric area, in spin.

Development is in some cases observed cholangitis (see).

The liver is a little increased, painful at a palpation. Functional trials of a liver during 2 — 3 weeks of a disease, unlike an acute hepatitis, do not change. At long obturation of a channel a tumor in a liver cirrhotic changes develop and it becomes dense, sometimes hilly.

If the malignant tumor is localized distalny places of a confluence of a vesical channel, then at obstruction by it of the general. items develop the stagnation of bile and bilious hypertensia promoting stretching of a gall bladder; in these cases it is well probed, being considerable increased in sizes, intense, painless (Courvoisier's symptom). Eventually also overlying extend. the items containing not bile, but muciform white liquid («white bile»).

At localization of a tumor in the place of merge vesical and the general. the item develops an edema or an empyema of a gall bladder, and at obturation a tumor of an overlying general hepatic channel the gall bladder deprived of bile is in the fallen-down state. It is necessary to consider that at defeat of one of share hepatic channels (right or left) jaundice can be absent even after full occlusion its new growth and atrophies of the corresponding hepatic lobe.

Diagnosis of malignant tumors. for the item it is difficult, it is frequent even during operation. A wedge, manifestations allow to suspect cancer. the item, especially in the presence of Courvoisier's symptom. However even much the increased gall bladder can be covered with the increased right hepatic lobe and not be probed. Great diagnostic difficulties arise in the presence of a cholangitis and the expressed pain syndrome simulating cholelithiasis. Usual methods of a X-ray contrast research Zh. and. are not shown because of early the arising intensive jaundice. The diagnosis is facilitated a peritoneoskopiya with a simultaneous X-ray contrast research of bilious ways (a laparoscopic holetsistokholangiografiya or a laparoscopic holegrafiya) and transdermal transhepatic holangiografiya (see). However the last is dangerous in connection with the possible biliation and bleeding from a puncture opening in a liver sometimes resulting in need of a laparotomy.

Treatment of malignant tumors. the item only surgical, however operability at this disease low. By data I. F. Linchenko, from 800 observations radical operations are made only in 14,8% of cases.

At operative measures concerning tumors. the item is carried out a resection of a channel with sewing together (if it works well) its ends on a drainage or with imposing of a biliodigestivny anastomosis, and at defeat of an intramural part of the general. the item — a pankreatoduodenalny resection (see. Pancreatoduodenectomy ). At palliative interventions for the purpose of recovery of outflow of bile impose holetsistoduodeno-or holetsistoenteroanastomoz.

At localization of a tumor in the field of the general hepatic channel resort to palliative operations: rekanalization and intubations of a channel or to outside transhepatic drainage. Also operation of removal of a channel with imposing of an anastomosis between an intra hepatic channel and a gut is possible (gepatokholangioenteroanastomoz).

By data A. A. Shalimova, a lethality after radical operations makes apprx. 30%. Palliative operations, liquidating jaundice and intoxication and normalizing chemism of digestion, improve a condition of patients and prolong their life.

Preoperative preparation, the postoperative period

At operations on. the item is used a set of probes for check of passability. the item (see. Probes ), special spoons and nippers for removal of concrements from them. The equipment of the operating room shall provide carrying out during operation of a holangiografiya and holangiomanometriya (see). Audit. the item is considerably facilitated in the presence of a holedokhoskop (see. Holedokhoskopiya ).

Preoperative training of patients with an uncomplicated hron, a disease. the item comes down generally to regulation of function of a liver, increase in protective forces of an organism, the prevention of postoperative complications from cardiovascular system and a respiratory organs. For creation fiziol, rest of bile-excreting system the molochnorastitelny diet is appointed the patient. For normalization of function of a liver appoint glucose, a complex of polyneuramins, ascorbic to - that, phthiocol, seripar, glutaminic to - that, methionine, orotovy to - that, edges stimulates activity of a liver. Constant control behind electrolytic balance of blood (especially behind a ratio of K:Ca), studying of a condition of coagulant and anticoagulative system of blood is necessary. At patients with jaundice, a cholangitis, pancreatitis, in addition to the specified actions, it is necessary to normalize protein metabolism and to fill proteinaceous insufficiency (a diet, transfusion of proteinaceous drugs, plasmas), to reduce intoxication, to normalize electrolytic balance (Haemodesum, ringerovsky solution), to apply small doses of a hydrocortisone or Prednisolonum, just before, in time and immediately after operation. For fight against hepatonephric insufficiency it is necessary to pour 1% solution glutaminic to - you. In the presence of an acute cholangitis use antibiotics of a broad spectrum of activity; in the presence of pancreatitis appoint antienzymes (Trasylolum, Contrykal).

By the main method of anesthesia at operations on. the item is an endotracheal anesthesia using muscle relaxants of short action. Anesthesia shall provide stability of a hemodynamics during operation in order to avoid development of a hypoxia of a liver, very dangerous to this category of patients. In the presence of contraindications to an endotracheal anesthesia of operation on. items can be made under local or spinal anesthesia.

For access to outside. many cuts are offered to the item, but all of them can be divided into four basic groups: slanting cuts in the field of a costal arch, longitudinal (including a verkhnesredinny section), the cross and angular or combined sections. Slanting cuts in right hypochondrium are the most widespread.

Operations on. items are made for removal from them of concrements, concerning tumors. the item, in case of damages. the item, and also for recovery of the zhelcheottok broken owing to various reasons.

Fig. 15. Holangiogramma (received at a holangiografiya on the operating table): 1 — a reflux of contrast weight in a pancreat duct; 2 — two stones in a terminal part of the expanded general bilious canal; 3 — contrast weight in a duodenum; 4 — a cannula for introduction of contrast weight to channels, on the right in the drawing shadows of surgical instruments are visible.
Fig. 16. The diagrammatic representation of operation of removal of a stone from the general bilious channel by means of Fogarti's probe: 1 — Fogarti's probe entered into the general bilious canal (2); 3 — a stone; 4 — the inflated cuff of the probe; 5 — a duodenum.
Fig. 17. Plastic probes for sounding of bilious ways.
Fig. 18. The postoperative holangiogramma (received at administration of contrast medium through a drainage tube), allowing to reveal the operations which remained later stones in the general bilious channel: 1 — a drainage tube through which a contrast agent is entered; 2 — deformation of the general hepatic channel; 3 — deformation of the general bilious channel; 4 — stones in a channel; 5 — a spasm of a sphincter of the general bilious channel.

The tool research of channels during operation shall begin with the holangiografiya which is carried out through a vesical channel (fig. 15) by means of special cannulas. At suspicion on existence of small concrements it is reasonable to use a method transilluminations (see) — raying of channels by means of fiber glass lighting tips: on a red background of a channel concrements are allocated in the form of black points. In the presence of stones generally. items and in all doubtful cases make opening of the general. the item — a choledochotomy (see). For removal of small stones use Fogarti's probe with a razduvny cuff on the end (fig. 16) and washing of the general. the item a strong stream fiziol, solution from the syringe. At doubt in a full removing calculus from. items apply a holedokhoskopiya. At suspicion on a stricture of terminal department of the general bilious channel or a big nipple of a duodenum carry out sounding of channels by elastic plastic probes of different diameter — from 2 to 6 mm (fig. 17). After removal of concrements the opening in the general bilious channel is taken in a deaf seam, sometimes with leaving of the drainage entered through a vesical channel or with drainage of a gleam of the general. item. T-shaped drenazhy.

In the presence of an unremovable obstacle to outflow of bile on channels resort to imposing of a biliodigestivny anastomosis (see. Hepaticoduodenostomy , Gepatoduodenostomiya , Choledochoduodenostomy ). The majority of operations on. the item comes to an end with outside drainage of channels with various methods: a rubber catheter according to Vishnevsky, the T-shaped tube according to Kerr; with removal of a drainage through tissue of a liver. An exception are an internal biliodigestivny anastomosis and those cases, when there is no contraindications to imposing of deaf seams on a wound. item. As a rule, operations on. items come to an end with introduction of drainages to an abdominal cavity. Before extubation at the patient if during operation the holedokhoskopiya was made, it is necessary to suck away contents of a stomach (irrigational liquid). Postoperative maintaining patients essentially does not differ from training of the patient for operation. A main objective in the postoperative period is prevention of development of hepatonephric insufficiency. Therefore it is necessary to care for bystry recovery of normal function of a liver: enter 1% solution glutaminic to - you, appoint vitamins, Sireparum, corticosteroid hormones, carry out fight against paresis of intestines (prozerin, Pituitrinum, continuous aspiration of contents of a stomach by a stylet etc.), monitor normalization of a diuresis. When operation is finished with drainage. the item, a drainage delete in 12 — 14 days after operation, previously beginning (with 7 — the 9th days) periodic crossclamping of a drainage for increase in intake of bile in a duodenum. Before removal of a drainage through it surely make a holangiografiya, edges it is important for assessment of a state and passability. item; with its help it is possible to reveal postoperative strictures. the items left in canals stones (fig. 18). At purulent cholangites a drainage from. items delete in 3 — 4 weeks, and at not constructive operations when the managed drainages across Praderi — to Smith or Felker are used, delete them in several months.

The description of anatomy, physiology and pathology of intra hepatic bilious channels — see. Liver .

See also Drainage , Bilious fistulas , Gall bladder .



Bibliography:

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L. D. Lindenbraten (rents., I am glad.), O. B. Milonov (damages, PMC., hir.), S. S. Mikhaylov (An.), A. M. Nogaller (mt. issl., diseases), A. P. Shapkina (malformations).

Яндекс.Метрика