POSTCHOLECYSTECTOMY SYNDROME

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POSTCHOLECYSTECTOMY SYNDROME (Latin post after + grech, chole bile + kystis a bubble + ektome excision, removal; syndrome; synonym: holetsistektomichesky syndrome, postcholecystectomy disease, the residual phenomena after a cholecystectomia) — the collective concept combining a complex of the morbid conditions observed after removal of a gall bladder is more often in the form of pains, various on intensity, dispeptic frustration, symptoms of defeat of the general bilious channel (the alternating obturatsionny jaundice, the cholangitis) coming at once or through a nek-swarm time after operation.

The term «Postcholecystectomy Syndrome» is low-successful as contains wrong idea of possibility patol, the states connected directly with removal patholologically of the changed gall bladder. A lack of this name is as well the fact that it combines all extremely various reasons patol, states which can develop after removal of a gall bladder, including and not having relations to biliary system, napr, atypically proceeding diseases of other abdominal organs. Besides, it does not disclose essence of a disease and therefore it has to be deciphered or is even replaced with the name more accurately reflecting this symptom complex, napr, «residual a choledocholithiasis «a terminal cholangitis», etc. Nevertheless the term «Postcholecystectomy Syndrome» was widely adopted in a wedge, the practician, and V. M. Sitenko and A. I. Nechay, Malle-Gui and Kestens (P. Mallet-Guy, P. J. Kestens), etc., understanding all shortcomings of this name, consider it convenient for designation of the general group patol, the states which developed at patients later cholecystectomias (see).

The number of patients, at to-rykh later removal of a gall bladder did not come improvements, is rather great; the percent of unsatisfactory results after a cholecystectomia, on summary statistics of O. B. Milonov, averages 11,9%. Among sick P. of page the women at the age of 40 — 60 years suffering from it prevail is 7 times more often than men; it, probably, is connected with the fact that they have cholelithiasis more often.

P.'s reasons for page can be divided into two groups: 1) connected with the made operation; 2) not connected with an operative measure. Treat the first: the gepatiko-choledocholithiasis unliquidated which is not eliminated during operation or again arisen cicatricial stenosis of a faterov of a nipple (a big nipple of a duodenum, T.); effects of technical errors — a posttraumatic cicatricial stricture of the general bilious channel, the left part of a gall bladder or patholologically the changed stump of a vesical channel; diseases of bodies of a biliopankreatoduodenalny zone, hron, recurrent or indurative (sclerosing) pancreatitis (see) with a prelum of the general bilious channel, the interventions which are not eliminated during operation or developed later; postoperative complications — an obliteration of a biliodigestivny anastomosis, terminal cholangitis (see) at formation of «cul-de-sac» below an anastomosis, a postoperative cholangiohepatitis, perikholedokhealny lymphadenitis, commissural process of an abdominal cavity (see. Adhesive desease ). P.'s reasons for page which are not connected with a cholecystectomia are caused in most cases by the diseases of other abdominal organs proceeding sometimes is atypical: hron, gastritis, peptic ulcer of a stomach and duodenum, hron, duodenal impassability (duodenostazy), hernia of an esophageal opening of a diaphragm, hron, appendicitis, enteritis, colitis, urolithiasis, nephroptosis, spondylarthrosis, etc.

According to O. B. Milonov, P. of page having a feedforward with a cholecystectomia can be caused: 1) the diseases which resulted from defeats of the general bilious channel (37,1%), not eliminated or not korrigirovanny during operation — a choledocholithiasis, a cicatricial stenosis of a big nipple of a duodenum; 2) the technical or tactical mistakes made during intervention (18,6%) — leaving of a part of a gall bladder or patholologically the changed stump of a vesical channel, the wounds of the general bilious channel which remained unnoticed or demanded stitching of a channel which led to formation of cicatricial strictures of the last; 3) diseases of bodies biliopankreatoduodenal-ache zones (32,6%) — hron, hepatitis, hron, pancreatitis, a duodenitis, duodeno-staz; 4) diseases of other bodies (11,7%).

The reasons of leaving of concrements, and also undetected and не-корригированных of strictures of terminal department of the general bilious channel in most cases serve a defective research of extrahepatic channels during operation or failure from it for one reason or another (difficulties of an intubation of a channel, widespread inflammatory process, etc.). The reasons of damage hepatic and the general bilious channels and leaving of a part of a gall bladder at most of the operated patients are the difficulties of a technical order which were found during operation which were caused extensive inflammatory infiltra-tivnymi by changes in a zone of intervention, anatomic features of a confluence of a vesical channel, insufficient experience and qualification of the operating surgeon.

The clinical picture P. of page is extremely various and is characterized by symptoms of one of the listed above diseases.

P.'s diagnosis by the village quite often can be difficult. In recognition of actual reasons of a disease, in addition to laboratory researches (definition of bilirubin, an alkaline phosphatase, transaminases, amylases of blood, urine, functional trials of a liver, etc.), big, and at times and decisive, the X-ray contrast research of bilious and hepatic channels matters. At the same time use intravenous holegrafiya (see); transdermal transhepatic holangiografiya (see), and also an endoscopic retrograde holangiopankreatografiya (see. Pankreatokholangiografiya retrograde ), being the most informative. Quite often final diagnosis manages to be made only during operation at an intraoperative holangiografiya and by means of a tool research hepatic, the general bilious channels and bodies of a pankreatoduodenalny zone.

Treatment usually depends on the reasons which caused P. of page. If they are not connected directly with the made cholecystectomia and caused by diseases of other abdominal organs, it is necessary to carry out the corresponding treatment. If the reasons of unsatisfactory result of a cholecystectomia are caused by defeat of bodies of a bilio-pankreatoduodenalny zone, in most cases it is necessary to make repeated operative measures on the bilious ways.

A. I. Krakovsky and Yu. K. Dunayev indications to operations at P. divide page on absolute and relative. They carry to the first: the cases of a cholestasia and a zhelchepotera caused gepatikokholedokholi-tiazy, the stenosing process hepatic and the general bilious channels or a big nipple of a duodenum, hron, indurative pancreatitis, full outside bilious fistulas. Relative indications: a persistent pain syndrome in the absence of strong indications of disturbance of passability of bile-excreting channels; serious associated diseases at partial or passing disturbance of a passage of bile in a duodenum.

Repeated operations at P. of page are, as a rule, difficult, technically difficult, traumatic and demand profound knowledge of this pathology, wide experience of the surgeon, equipment by the special equipment and tools. Their indispensable condition is performance during intervention of a X-ray contrast research hepatic both the general bilious channels and use transilluminations (see), balloon catheters (Fogarti's catheter), the elastic calibrated probes, holedokhoskopiya (see), etc. Value of a kokhmpleksny intraoperative research is so big that at impossibility of its running in of communication with lack of conditions or the necessary equipment at all repeated operation should not undertake.

Optimum access at the operations made at P. by page is the section in right hypochondrium with excision of an old postoperative hem. Allocation from hems of the general hepatic and the general bilious channels quite often presents great difficulties. As reference points can serve a box of a gall bladder on a lower surface of a liver and a stump of a vesical channel. It can be used for a holangiografiya, the plan and the nature of further surgery depend on data a cut.

If find the left part of a gall bladder or patholologically them delete the changed stump of a vesical channel containing concrements. Residual stones are also subject to removal what after allocation of the general bilious channel from hems it is necessary to make for choledochotomy (see). Operation in these cases is finished with drainage of the general bilious T-obraznym Canal drenazhy (see. Drainage ), imposing of a deaf seam on a holedo-hotomichesky opening and drainage through a stump of a vesical channel, and in the presence in the general bilious channel of small concrements and «putties» — imposing of a biliodigestivny anastomosis. Sometimes the pas-pillosfinkterotomii is possible to remove concrements from terminal department of the general bilious channel in the way endoscopic (see. Faterov of pacifiers ) or by means of special tools (the basket probe of Dormi and, Fogarti's probe, the managed Buren's probe) through outside bilious fistula.

At a cicatricial stricture of terminal department of the general bilious channel, and also stenoses of a big nipple of a duodenum at patients of advanced and senile age impose a biliodiges-tivny anastomosis, usually holedokhoduodenoanastomoz (see. Choledochoduodenostomy ). At strictures of a big nipple of a duodenum at younger age the papillosfinkteroto-miya (plastics) providing adequate outflow of bile from all departments of the general hepatic and the general bilious channels, and also a pancreatic secret is reasonable. In cases of sharp narrowing of the nipple which is followed by an atony and considerable expansion of the general bilious channel (to 20 mm and more) and existence in it of concrements, it is necessary to make so-called double internal drainage of the general bilious channel — a papillosfpnkterotomiya and choledochoduodenostomy.

At high posttraumatic strictures of the general hepatic channel operation is carried out in the field of portal fissures in the conditions of the cicatricial changed walls of a channel and surrounding fabrics. The gepatiko-digestivny anastomosis imposed in these cases often is exposed to repeated scarring and an obliteration. For the prevention of it the anastomosis should be created on the plastic drainage which is carried out chrespe-chenochno outside across Praderi — to Smith (see. Bilious channels, operations ). Remaining on site a long time (12 — 14 months and more), it carries out function of a framework, preventing development of cicatricial impassability of an anastomosis.

At full outside bilious fistulas (see) the last exsect and impose an anastomosis between the general bilious channel and intestines. If because of cicatricial processes it is not possible to allocate fistula completely, the anastomosis can be created between duodenal or a jejunum and the rest of fistula, and it is obligatory on the drainage removed transpechenochno. Results of these operations are more favorable, than after the hypodermic fistuloenterostomy according to Smirnov which is easily cicatrizing.

The forecast depends on the reasons which caused P. of page. If a repeated operative measure removes completely P.'s cause for page, the forecast, as a rule, favorable.

P.'s prevention by the village is carrying out complex to - and especially intraoperative research of bodies of a gepatopankreatoduo-denalny zone, first of all hepatic and the general bilious channels. Prevention of the surgical defects of operation which are one of the reasons of P. of page consists in careful attitude to fabrics, good knowledge of topography hepatic and the general bilious channels taking into account options and anomalies of their arrangement, and also carrying out operation by the qualified surgeon, it is desirable in specialized department, at the time of remission of inflammatory process and, whenever possible, in the earliest, uncomplicated period of a disease.



Bibliography: Krakow A. I. and Dunayev Yu. K. Repeated operations on the bilious ways, Tomsk, 1978, bibliogr.; Malle-Gui P. and Kestens P. Zh. Sindr after a cholecystectomia, the lane with fr., M., 1973; Milonov O. B. and Timoshin A. D. A complex research during operations on the bilious ways, M., 1981; Petrovsky B. V., etc. Reconstructive surgery at defeats of extrahepatic bilious channels, M., 1980 Sitenko V. M. and A. I Nechay the Postcholecystectomy syndrome and on vtorny operations on the bilious ways, JI. 1972, bibliogr.; M and 1 1 e t - G u at P. Der Platz der Choledochoduodenostomie in der Behandlung des Postcholecystektomie syndroms, Langenbecks Arch. klin. Chir. Bd 325, S. 400, 1969; S with h e i n C. J. Po^ stcholecystectomy Syndromes, Hagerstown 1978, bibliogr.; Soehendra N. u. an Aktuelle Aspekte des sog. Postcholezystekto-mie-Syndroms, Chir. Praxis, Bd 25, S. 469 1979.


O. B. Milonov,

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