The treatment of patients with major bile duct injuries

The Chair of Faculty and Hospital Surgery of Samarkand

State Medical Institute’s, Uzbekistan

The Republican Specialized Center of Surgery named after Academician V.V. Vahidov, Uzbekistan

It is difficult to determine how often during the operation on the biliary tract injured ducts. The surgeon often does not know about the injury. Approximately 15% of injuries during the operation are identified and immediately repaired. Identified injuries are more, but they do not register if they are not very important to immediately repair.

Obj ective: To investigate the causes of unsatisfactory results of surgical treatment of bile duct injury and to optimize the surgeon's actions depending on the amount of injury.

Subjects: During the period of 2000-2009 years. observed in 72 patients with iatrogenic injuries of MBD. According to our data MBD injury occurred in 28 patients (0,51%) in 5521 cholecystectomy (CE). Of them after laparoscopic cholecystectomy (LCE) – 20, CE through minimal access – 6, CE through laparatomic access – 2. 44 patients came from other hospitals: after LCE – 7, CE through minimal access - 2, CE through laparotomic access – 35. Operation for acute cholecystitis performed in 52 patients for chronic – at 20. In 14 patients (personal observation) revealed injury to the MBD. intraoperatively (the appearance of bile in the surgical wound). In 58 patients (14 of them his own observations, 44 came from other hospitals) revealed damage to the MBD in the early postoperative period (1-8 days).

By the nature of damage – injury to the boundary identified in 11 patients, intersection, resection - 34, excision and ligation – 17, clipping or ligation – 10. Localization of lesions in the terminology of strictures R – "2" in 17 patients, "+1" - 23 patients, "0" – 14 patients, "-1" – 12 patients, "-2 – 6 patients. In the early postoperative period, 27 patients developed clinical increasing jaundice, 15 bile peritonitis in 16 bile outflow plenty of drainage from the peritoneal cavity.

With the boundary wounding hepatico -choledochal (HC) 11 patients underwent reconstructive operations. On the damaged wall of the duct imposed 4.2 suture (break 5/0) on the drainage of Kerala.

Reconstructive surgery first stage holds 15 patients, of whom HepJA on PTCS (percutaneous-transhepatic chol-angiostomy) – 7; HepJA ( transhepatic carcass drainage) THCD no – 3 wide anastomosis was imposed due to dissection of the left hepatic duct after raising it by hilar plate of the liver (Hepp-Couinaud); HepDA – 4 patients. When intrahepatic lesions with destruction of MBD konflyuens in 1 case imposed bihepaticojejunoanastomoz (BiHepJA) by Roo on THCD.

Because of the high, narrow-diameter duct, inflammatory - infiltrative changes in the second stage of reconstructive surgery with 24 patients. Of these 5 patients were admitted with liver failure and severe degree of the first stage of external drainage of biliary tract (2 - PTCS, 3 -THD). Reconstructive surgery performed the second stage: HepJA on Ru in 2 cases Frame drainage of Pradera - Smith, in a 3 - to Seypol - Kurianu. BiHepJA on THCD in 5 cases; Hep-JA by Roo on\THCD - 12; HepDA - 2. 10 patients with excision of the intersection and common hepatic duct (CHD) is imposed BBA ( bilio-biliar anastomosis). 10 patients with ligation and clipping hepatic duct without removing it crosses produced ligatures or clips and drainage of the hepatic duct. In 2 cases at the level of "+1" imposed bilio-biliar anastomosis against peritonitis, they came anastomotic suture failure. These patients were admitted to the clinic running bile peritonitis, they set the THD.

Results and discussion. With the boundary wounding GC in 11 patients after reconstructive surgery strictures in the late postoperative period were not observed. After reconstructive surgery at the intersection and the excision of the hepatic duct satisfactory result was observed in 34 patients: HepJA on Ru (27), BiHepJA on Ru (6) and in one case after HepDA (patient history underwent resection of gastric B-II). Unsatisfactory results were observed in 5 cases, after HepDA developed clinical cholangitis and stricture of the anastomosis. After applying the BBA in all patients and in 5 patients after removal of ligatures and the drainage of the hepatic duct in the period from 6 months to 1.5 years developed stricture of the duct, and they performed reconstructive surgery: HepJA on THCD in 13 cases, without HepJA THCD- 1 HepDA - 1. 2 (2,7%) patients died, which came from other hospitals after attempting to restore the hepatic ducts on a background of peritonitis.

Conclusions: At the intersection, and excision of the MBD performance recovery operations and in which is formed by the damaged duct fistula with the duodenum affects treatment outcomes. In identifying the total damage to the hepatic duct shows HepJA. Reconstructive surgery is indicated only when the boundary is damaged ducts. In identifying damage MBD in the immediate postoperative period, against a background of peritonitis bile outflow useful first step to restrict external drainage of bile ducts. Reconstructive surgery is desirable to perform after decrease in inflammatory - infiltrative process.