Kurbaniyazov Z.B.², Akbarov M.M.¹, Nishanov M.Sh.¹, Rahmanov K.E.², Davlatov S.S.²

IMPROVEMENT OF SURGICAL TREATMENT OF INTRAOPERATIVE INJURIES OF MAGISTRAL BILE DUCTS

Republican specialized surgical Centre named after academician V.Vahidov¹.

Samarkand State medical institute².

Material of investigation. The results of surgical treatment of 103 patients with intraoperative magistral bile ducts (MBD) injuries during the period of 2000 – 2010 have been analysed.

65 patient were admitted from the other in – patient departments with intraoperative MBD injuries, of them 12 after LChE, 52 – TchE and 1 – MLChE.

In 28 (27,2%) patients MBD injuries were revealed intraoperatively, in most of them – 75 (72,8%) patients the injuries were revealed in early postoperative period. There were 81 operated females (78,6%), 22 males (21,4%). The age of the patients was 19 – 80 years.

Results. In intraoperative revealing of bile ducts injuries of 28 patients, 18 patients had complete duct transaction, 10 – marginal injury. In 25 patients the operations for rehabilitation of bile ducts anatomy were performed at once and in 3 patients during two stages.

In revealing bile ducts injuries in early postoperative period (n=75) one or two stages interventions were performed, depending on presence of infiltrative – inflammatory changes in subhepatic area.

Discussion. In most patients bile ducts injuries are diagnosed lately (in 72,8% according to our findings) after development of peritonitis or mechanical jaundice. So in most patients external drainage of bile ducts is performed instead of bile outflow normalization immediately after getting trauma.

In revealing MBD injuries in the nearest postoperative period on the background of peritonitis, subhepatic abscess, bile excreting, it is reasonable to perform only external drainage of the bile tracts. It is desirable to perform reconstructive operation after remission of inflammatory – infiltrative process in 2-3 months as a second stage of treatment. This tactics proved to be correct in 30 (73,1%) patients of this group.

In 7 (17,1%) patients rehabilitation – reconstructive operations on the background of peritonitis resulted in insolvency of anastomosis sutures.

The main operation in complete MBD transaction and excision is HepJA according to Roux that was only performed in 64 patients with good follow – up result in 95,3%. HepJA without carcass drainage shortens considerably the terms of patients treatment, however this method (Hepp-Couinaud) was only performed in 11 patients of this group. According to E.Itala (2006) the main feature of this operation is in isolation of the left hepatic duct in the place of its confluence with the right duct under the portal lamina. It gives opportunity to isolate the ducts out of cicatricial tissues and to apply anastomosis 2-3 sm wide, mainly on the account of the left hepatic duct, escaping burdensome, long (1,5 – 2 years) drainage of anastomosis area.

BBA formation in transaction and excision in all 19 observation was completed by development of cicatricial stricture. Of them 16 patients underwent reconstructive operations, 3 – endoscopic stentation. Some experience in endobiliar stentation permits us to estimate positively this method. Performance of operations for formation of anastomosis of the injured duct and duodenum had unfavourable results. These patients had chronic cholangitis and biliodigestivanastomosis stenosis that required repeated reconstructive operations in 2 and endoscopic interventions in 9 patients.

The cause of failure in treatment of intraoperative MBD injuries are unpunctual diagnosis and performance of inadequate in volume operations directed to restoration of bile outflow by formation of biliobiliary and bilioduodenal anastomoses.