Open Access Research Journal Medical and Health Science Journal, MHSJ www.academicpublishingplatforms.com ISSN: 1804-1884 (Print) 1805-5014 (Online) Volume 6, 2011, pp. 118-123 ENDOSCOPIC PAPILLOSPHINCTEROTOMY AND CHOLECYSTECTOMY IN THE TREATMENT OF THE COMPLICATED FORMS OF CHOLELITHIASIS Acute cholecystitis (AC) appears as the basic complication of cholelithiasis. However, the leading place in the mortality structure belongs to choledocholithiasis, cholangitis obstructive, jaundice, and especially to infected biliary pancreatic necrosis. Retrospective analysis of the results of investigations and surgical treatment of 1023 patients with complicated forms of cholelithiasis included 314 men and 709 women at the age between 15 and 91 years. Such complications of cholelithiasis as AC, choledocholithiasis, cholangitis and stricture of papilla major are not the contra-indication to laparoscopic cholecystectomy. The treating possibilities of laparoscopic and endoscopic technique in 96.2% cases allowed successfully performing cholecystectomy and the correction of bile outflow without doing the wide laparotomy. Offered technical improvements of laparoscopic cholecystectomy promoted lowering of conversions number (from 8.8% to 3.8%) and the quantity of intra- and postoperative complications contained in the changes of trocat inserting points, using modified instruments for tissue dissection, mobilizing of gall-bladder and hemostasis. ABDUKHAKIM KHADJIBAEV, SHUKHRAT ATADJANOV, MIRKAMAL KHASHIMOV, KHIKMAT ANVAROV Republic Research Centre of Emergency Medicine Uzbekistan Keywords: Cholelithiasis, endoscopic papillosphincterotomy, laparoscopic cholecystectomy. UDC: 616.366-003.7:089 Introduction Cholecystitis, cholelithiasis are registered in each 6th citizen of Uzbekistan elder than 20 years (Aripov, 1987; Khadjibaev, 2009). It is noticed by numerous epidemiological researches that the quantity of persons suffering from cholelithiasis increases upon the age: if at the age interval from 31 to 40 this the ratio is 1:32 then at the age interval from 81 to 90 years it becomes as 1:3. At the age of 55-64 each 10th man and each 5th woman has the gal-stones in the gall-bladder (Khojiboev, 2007; Lau, 2006). The main complication of this diseases is the acute cholecystitis (AC); but in the mortality structure the topping point belongs to choledocholithiasis, cholangitis, obstructive jaundice and infected biliary pancreatonecrosis. So, if at the acute cholecystitis the mortality amounts 0.1-7% (Aripov, 1987; Lau, 2006) then at choledocholithiasis, cholangitis, obstructive jaundice it is 10% (Briskine, 2008; Mosygine, 2000); and at infected biliary pancreatonecrosis it reaches 15-66% (Emelyanov, 1996; Sheyko, 2009). Such outcomes of the illness cannot satisfy the surgeons and that is why it is necessary to work-out the treating tactics of the complicated forms of cholelithiasis depending from primary affection of the system gal-bladder - bile-ducts - pancreas. Searching the ways of the improving the early diagnostics results and the surgical treating of AC and its complications led to the universal widening of the indexes to the usage of video-laparoscopic and endoscopic technologies (Vazquez-Iglesias, 2006; Himal, 2002). Emergency laparoscopy at AC differs by little traumatism and low frequency of complications in the nearest post-operative period (Nikolopoulos, 2009). However, there is the point of view that some forms of the acute inflammation of the gall-bladder are contra-indication to the laparoscopic cholecystectomy (LCE). Such cases can include the destructive forms of cholecystitis complicated by paravesical infiltration or abscess and the presence of the violent inflammatory changes in the part of gallbladder neck (Sharma, 2003). The limited possibilities of laparoscopic manipulations in the acute destructive - 118 -
cholecystitis followed by inflammatory changes of gallbladder neck and hepatoduodenal ligament show the necessity of the revision of the surgical tactics for AC. The above-mentioned situation is complicated by that the majority of such patients are the people with the high operational risk determined by the basic and concomitant illnesses and the old age. Material and methods 1023 patients with the complicated forms of cholelithiasis and treated in the Department of Emergency Surgery (Uzbekistan) from 2002 to 2009 were retrospectively studied. There were totally 314 men (30.8%) and 709 women (69.2%) at the age of 15 to 91 years old (average age - 55.5±0.5 years.) The false guiding diagnosis was in 84 (8.2%) patients. It should be noted that the most difficulties in the diagnostics of AC both in pre-admission level and in admission occurred in patients of elderly and senile age. So, the diagnosis of AC in some cases had certain complications both in pre-admission and in admission levels. The average duration of the disease from the time of appearing the first symptoms till the admission to RRCEM made 2.4±0.75 years; 504 (49.3%) patients (about half of operated) had the duration of the illness from 1 till 3 years. The leading part in clinical presentations of the illness belongs to the pain syndrome and 328 (32.1%) patients had the acute cholecystitis attack for the first time. Another patients had the pain attacks typical for the cholelithiasis at the age of 2 months till 28 years; 45% of them were treated in the hospital once, 28.3% - 2-3 times and others - more than 3 times. So, 67.9% of patients were in-patient with AC and were performed the conservative treatment but then the disease had an acute condition required more active treating tactics. 627 (61.3%) patients had disease advantage due to the presence of concomitant disease and that increased the risk of operative intervention. In the group elder than 60 years the persons with the high surgical risk level made 313 (88.1%). Of 1023 patients with the complicated forms of cholelithiasis the 295 were performed LCE, 238 were made traditional cholecystectomy (TCE), 138 - endoscopic papillosphincterotomy (EPST) + LCE, 119- EPST + TCE, and 233 - only EPST with unblocking of bile-duct. Laparoscopic or traditional surgical interventions were performed in different durations after the admission: emergency ones were made in 32.5%, urgent - in 56.4%, and postponed ones - in 11.1% cases. The duration of laparoscopic operations was from 20 minutes to 300 minutes (59.0±17.6 min.). The half of the all interventions had duration of 50-65 min. (quartile measure Q25%-Q75% and median was 55 min.). The diagnostics of AC and its complications was based on the laboratory data and the instrumental investigations (US, endoscopy, CT, MRI, ERCP). For the analysis of clinical-morphologic forms of calculous cholecystitis and its complications the tabulation of multi-measured comments was done. As it is known, the structure of any clinical patient s diagnosis includes the basic one (the simple grouping variable) and the complication of the basic diagnosis. Indeed, the complication is the variable with multi-measured comments (includes in itself several possible types of the meanings). In our case the basic diagnosis divided the patients into 5 groups corresponding to one of cholelithiasis forms. The Table 1 is two-ported: there are clinical-morphologic forms of cholelithiasis and the quantity of complications for the each mentioned type. As it is shown from the table, in 135 cases cholelithiasis occurred as the basic disease and in 239 cases - as the complication of calculous cholecystitis. - 119 -
The frequency of the occurrence of each complication to the total quantity of all complications is given in the column % of comments in Table 1; percentage of the complications from the total quantity of patients - in the column % of observations. Such difference in the percentage measure is explained by the fact that some patients had 1, 2 and more complications, while 35 patients had no one complication. ТABLE 1. TWO-PORTED TABLE OF CLINICAL-MORPHOLOGIC FORMS OF CHOLELITHIASIS AND ITS COMPLICATIONS Complications of basic diagnosis Acute catarrhalcholecystitis1 18 (11.5%) Forms of cholelithiasis (n=1023) Acutephlegmonous cholecystitis 534(54.2%) Acutegangrenous cholecystitis 147(14.4%) Acute gangrenousperforated cholecystitis 89 (8.7%) Choledocholithiasis 135(13.2%) Frequincy Percentage of comments,% Percentage of observations% Gallbladder empyema 0 152 63 0 0 215 11.96 21.76 Paravesical infiltration 0 392 112 52 4 560 31.15 56.68 Paravesical abscess 0 0 21 37 0 58 3.23 5.87 Choledocholithiasis 69 156 14 0 0 239 13.29 24.19 Cholangitis 21 66 0 0 38 125 6.95 12.65 Obstructive Jaundice 74 156 14 0 128 372 20.36 37.65 Stenosis 56 33 0 0 88 177 9.84 17.91 Acute biliary pancreatitis 8 8 3 0 12 31 1.72 3.14 Mirizzi syndrome 1 4 6 0 10 21 1.17 2.13 Sum of comments 1798 100 181.98 Paravesical infiltrations had occurred more often among 1023 patients: they made 56.7%. They were widely spread among the group of patients with phlegmonous forms of cholecystitis. And in 4 cases paravesical infiltrations occurred in patients with choledocholithiasis; state of these patients was estimated as the migration of the only concrement from the gall-bladder into the choledoch. Mirizzi syndrome was revealed in all these patients. All results are expressed as mean ± standard error of the mean (SEM). The results were statistically analyzed by SPSS 13.0 for Windows. A p value less than 0.05 was considered significant. Results and discussion On the base of the disease clinical course and considering the laboratory and ultrasound diagnostic data of 508 patients suspected on the pathology of hepatic bile-ducts there were determined the necessity to perform endoscopic and x-ray investigations and operations (Table 2). According to our observations the patients after EPST with bile-ducts sanations, LC was performed in 138 (13.5%) cases and open operations were made in 119 (11.6%) cases. In 233 (22.8%) patients according to their refuse from the cholecystectomy or to contraindications, the second treatment level was not performed. The types of operative interventions performed after the sanation of bile-ducts are shown in Table 3. - 120 -
TABLE 2. TYPES OF ENDOSCOPIC INVESTIGATIONS AND OPERATIONS Interventions Total % Endoscopic retrograde cholangiopan creatography (ERCP) 508 49.7 Endoscopic papillosphincterotomy (EPST) 490 47.9 Mechanical lithoextraction (MLE) 110 10.8 Mechanical lithotripsy (МLT) 84 8.2 Nazobiliar drainage (NBD) 34 3.3 TABLE 3. ALLOCATION OF PATIENTS ACCORDING TO THE TYPES OF CHOLELITHIASIS COMPLICATIONS AND OPERATIONS Complications of cholelithiasis Cared cure EPST EPST+LCE EPST+TCE n % n % n % Choledocholithiasis 136 13.3 114 11.1 103 10.1 Stenosis 83 8.1 16 1.6 10 0.98 Choledocholithiasis 14 1.4 8 0.78 6 0.59 +Stenosis Total 233 22.8 138 13.5 119 11.6 χ2=47.826, df=4, P =<0.001. α test with sensitivity 0.05 = 1.000, higher than necessary level 0.8 Laparoscopic cholecystectomy was performed in 433 patients, including 138 ones by the second level after endoscopic interventions and 295 with without pathology of hepatic bile-ducts. The technique aspects of laparoscopic cholecystectomy in non-complicated calculous cholecystitis are rather well studied and developed. However, the operation in acute destructive cholecystitis has its peculiarities and difficulties. Gaining the experience we settled and offered some techniques which allow avoiding the narrow places appeared during the intervention. In some cases the infiltration, thickening of gall-bladder wall size reaches such stage that it becomes impossible its holding even by strong clip; and the attempt to fix the organ leads to tear and possible perforation its destructive-changed wall. In such cases we recommend to sew widely the wall of the bottom by П-typed suture. Subsequently, the ligature is coughed by the clip and used for the organ s traction. In the part of gall-bladder cervix it is often managed to catch and keep the wall with traumatic the 5th clip but in difficult cases the way of sewing can be used here too. Substantial technique difficulties occurred at gangrenous form of cholecystitis when the necrotized and molten gall-bladder wall is easily torn. The imperative moment in such cases is the mobilization and clipping of non-necrotized part of cystic duct. In the cases when before the operation it was managed to get reliable information about bile-duct status or at having the suspicion on choledocholithiasis during the laparoscopic operation, it was performed the intra-operational cholangiography (totally 12 cases, 2.8%). Indications to such procedure besides the widening of the general bile-duct more than 9 mm. we consider non-clear topography in the area of gall-bladder cervix which occurs as a rule due to inflammatory and infiltrated changes. For performing the investigation the cystic duct was clipped, dissection of the duct with micro-scissors was made lower the clips to enter into the aperture the 6 Fr cholangiographic catheter. It was previously conducted through Olsen clip for cholangiography. In 127 patients with AC we have used the modified type of LCE with using 10 mm. of trocar. The inserting points of trocar into abdominal cavity were the following: 1. The 1st trocar paraumbilically for the optic system; - 121 -
2. The 2nd trocar epigastrically for using the instruments; 3. The 3rd trocar for 5 sm. Below of the right costal margin in the point between the middle- subclavian and the front underarm lines. Through this trocar the hard 10 mm Babcock s clip is inserted. After the punction and evacuation of the contents of gall-bladder, it is caught with Babcock s clip in the gall-bladder cervix area and the traction is done up and medially. Then, with the help of clip-dissector the lateral gall-bladder wall and Hartman pocket are subserously released. Gradually moving Babcock s clip to the pointed area of Hartman pocket the preparation of cystic duct is performed in the direction from the gall-bladder wall to the side of confluence with the common hepatic duct. Then the medial wall of gallbladder is mobilized. The cyst artery is prepared, clipped and crossed. Then the gallbladder is mobilized from the cervix subserously and extracted. The main advantage of the original method is the widening of the capacity of safety dissection of tissues. It allowed to reliably reducing the quantity of contra-indications for the operations. By using our method it was managed to reduce the percentage of conversions from 8.8% to 3.8%. The attempt of laparoscopic division of paracystic infiltration and scar tissues performed in all patients from the basic group. Convinced in failure of endoscopic manipulations in 38 (8.8%) patients we switched to laparotomic access. In 1 (0.23%) case the reason for this access was the injury at the coagulation of the hepatic corner of the large intestine at its inserting from the union with gall-bladder. In 3 (0.7%) cases we switched to laparotomic access after dividing of paracystic infiltration and common bile-duct injuring. Considering the low percentage of failures while dividing scar-infiltrated unions with using endoscopic technologies (3.8%), we suggest that the attempt of laparoscopic cholecystectomy can be done in all cases. However, it should be switched to laparoscopy when discovering rough scar changes in such anatomic area, badly accessible to endoscopic preparation in order to avoid reliable increase of operation duration and casual injury of included organs. The most serious intra-operational complications (common bile-duct injury (3) and the perforation of the hepatic corner of the large intestine (1)) occurred in patients operated later than the 5th days from the starting of the diseases. Cyst artery also was often injured at the laparoscopic cholecystectomy in patients from the second group. The frequency of such complications as suppuration of operational perforations approximately the same in all patients being laparoscopic operated due to AC. TABLE 4. POST-OPERATIVE COMPLICATIONS IN LCE AND TCE GROUPS Indications LCE n=295 TCE n=238 n % n % Intro-abdominal bleedings 2 0.68 - - Bile-bleeding through drainage 6 2.0 4 1.7 Bile peritonitis 3 1.0 1 0.42 Subhepatic abscess 1 0.34 1 0.42 Wound suppuration 16 5.4 30 12.6 Pneumonia 2 0.68 5 2.1 Cardiac infarction - - 2 0.84 Post-operative mortality 0 0 0 0 Total 30 10.1 43 18.1 Among the operated patients in 21 (4.8%) cases we noted the suppuration of the setting place of epigastric trocar. It is probably connected with that this perforation was widen and the sutures were done on aponeurosis and also by the infection at the extraction of the gall-bladder. - 122 -
In the comparative aspect (LCE and TCE) the post-operative complications are given in the Table 4. The percentage of the post-operative complications in LCE group is lower than in TCE (10.1% and 18.1%). Thus, as the complications of AC start to develop at the 4th days of the diseases we come to conclusion that LCE is better to perform before the appearance of AC complications - in first 72 hours of the diseases starting. At a later date this issue should be treated differentially and estimated not only the type of local changes but own experience and technical equipment. Regardless of the inflammation type in all cases we perform the single-stage radical operation. In our observations in no case we found indications to the multistage operations. Not being absolute opponents of two-stage treating method at the destructive cholecystitis we think, however, that indications for it should be limited. Two-stage treating method can be recommended to the inoperable patients. Conclusion Such complications of cholelithiasis as AC, choledocholithiasis, cholangitis and stricture of papilla major are not the contra-indication to LCE. The treating possibilities of laparoscopic and endoscopic technique in 96.2% cases allowed successful performing cholecystectomy and the correction of bile outflow without doing the wide laparotomy. Offered technical improvements of laparoscopic cholecystectomy promoted the lowering of conversions number (from 8.8% to 3.8%) and the quantity of intra- and post-operative complications contained in the changes of trocat inserting points, using modified instruments from tissue dissection, mobilizing of gall-bladder and hemostasis. References Aripov, U., 1987. The complications of gallstone disease: classification and tactics choice, Uzb. Med. J. [Medecinskiy Jurnal Uzbekistana], in Russian, Vol.10, p.55-58. Briskine, B. et al., 2008 Surgical tactics in acute cholicystitis and choledocholithiasis complicated with jaundice in Elderly, J Ann. Surg. Hepatology [Jurgal Annali Hirurgicheskoy Gepatologii], in Russian. Vol.13, pp.15-19. Emelyanov, S. et al., 1996. Methodic aspects of endosurgery of bile ducts, J Ann. Surg. Hepatology [Jurgal Annali Hirurgicheskoy Gepatologii], in Russian, Vol.1, pp.115-120. Himal, H., 2002. Minimally invasive (laparoscopic) surgery. The future of generale surgery, Surg. Endosc., Vol.20, pp.1647-652. Khojiboev, A. et al., 2007. Small-invasive treatment of acute cholecystitis complicated by jaundice in Elderly patients. J Grekov s Bulletin of Surg. [Vestnik Hirurgii im. I. Grekova], in Russian, Vol.166, p.66-69. Khadjibaev, A. et al., 2009. Endoscopic surgery of gallstone disease in association with out-hepatic bile ducts tumors, Pirogov s J of Surg, [Hirurgiya. Jurnal imeni N.I.Pirogova] in Russian. Vol.2., pp.40-43. Lau, J., Leow, C., Fung, T. et al., 2006. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients, Gastroenterology, Lauol.130, pp.96-103. Nikolopoulos, I., Thakur, K., 2009. Comment on: urgent cholecystectomy for acute cholecystitis, Ann R Coll. Surg Endl., Vol.91(6), p.537. Sharma, S., Larson, K., Adler, Z., Goldfarb, M., 2003. Role of Endoscopic retrograde cholangiopancreatography in the management of suspected choledocholithiasis, Surg.Endosc., Vol.17, pp.868-71. Sheyko, S. et al., 2009. The evolution of surgical tactics in management of acute cholecystitis, Abstracts of 12th All-Russian Congress of Endoscopic Surgery, J End. Surg. [Jurnal Endoskopicheskaya Hirurgiya], in Russian, Vol.1, pp.59-60. Vázquez-lglesias, J., González-Conde, B., López-Rosés, L., Estévez-Prieto, E., Alonso-Aguirre, P., Lancho, A., Suárez, F., and Nunes, R., 2004. Endoscopic sphincterotomy for prevention of the recurrence of acute biliary pancreatitis in patients with gallbladder in situ: long-term follow-up of 88 patients, Surg. Endoscopy, Vol.18, рр.1442-446. - 123 -