Postcholecystectomic syndrome

Tashkent Medical Academy

The department of the faculty and hospital surgery

•At first open cholecystectomy was performed in 1882 year by German surgeon Karl Langenbuch

•The first cholecystectomy in Russia – by Yu. F. Kossinskiy in 1886 year

•The first laparoscopik cholecystectomy was performed in 1882 year by German surgeon Erich Muhe

History

•The gall stone disease has every 10 person at our planet

•At 5-40% patients, to which was performed the cholecystectomy, appear or save dyspeptic phenomenas, needing treatment.

EPIDEMIOLOGY

Indications for cholecystectomy

• Chronic calculous cholecystitis

• Acute calculous cholecystitis

• Cholesterosis of the gall bladder

• Polyposis of the gall bladder

Technique of the open cholecystectomy

Technique of the laparoscopic cholecystectomy

Laparoscopic cholecystectomy is “gold standard” method of treatment of the gall stone disease

Postcholecystectomic syndrome-

joined different pathological states and connected with

them clinic manifestations, checked the patients, to which the

cholecystectomy was performed .

Main symptoms of the PChES

Pains in the abdomen (constant

or attacks) with jaundice

External bile fistula

Pains in the abdomen (constant or attacks)

without jaundice

Extended bile ducts

Narrow bile ducts

Steadfast jaundice

Periodically jaundice

- Diseases and pathological atates of the bile-pancreatic system and BDM, not liquidated at the operation (choledocholithiasis, stenosing papillitis, stenosis of the CBD, cysts of the bile ducts and other); .

Classification

- Diseases and pathological atates of the bile-pancreatic system and BDM, directly connected with the operation (defeat of the bile ducts, strictures and deformations of the cult of the bladder’s duct).

- Diseases and pathological atates of the bile-pancreatic system and BDM, connected with the gall stone disease (chronic pancreatitis, hepatitis, gastritis and other).

- Diseases of other organs and systems, not connected with the bile system and cholecystectomy (diaphragmal hernia, USD, psychosteny and other)

- diseases, conducted with the functional defeats of the bile ducts and duodenum, appear as result of absence of the gall bladder: diskynesion of the bile ducts and Oddy’s sphincter.

The reasons of the postcholecystectomic syndrome

•functional (to 60%)

•organically reasons (about 40%)

- changes of the bile ducts - changes of the GIP - defeats not connected with the GIP

Reasons of the residual stones 1. Cholelithiasis wasn’t identified:

- Ignore the indicationts to the choledochotomy;- Hidden currency of the choledocholithiasis-Hard state of the patient; -Technical complications during the operation;- Mistakes in the diagnosis

2. Inferioity revision of the ducts

Reasons of the recidive stones1. Different pathological states, inducting the defect of bile evacuation2. Very big cult of the bladder’s duct or staying the part of gall bladder3. Presence of the alien objects in the ducts (ligatures, drainages, ascarides)

Indications to the ERPChG

Jaundice or cholangitis in anamnesis or at the hospitalization

Increasing of the factors of hepatic testsPancreatitis in anamnesisExpansion of the common bile duct more

than 8 mm or 8 mm or presence cut-in in it by the US datas

Presence of the small concrements in the gall bladder and wide bladder’s duct by US

• Wide bladder’s duct (more than 5 mm)

• Presence of small conrements in the gall bladder and

bladder’s duct

• Intraoperative visualisatiion of expansed bile duct at

the case of divergence with the data of before

operative US

• Impossibility of before operative performing of the

ERPChG and TTChG

Indications to the intraoperative cholangiography

Technique of the intraoperative cholangiography

Technique of the intraoperative cholangiography

Choledocholithotomy

Sewing of the choledotomic aperture and drainage of the choledoch

Lithextraction from the CBD

US

Clinic and diagnostic of the residual choledocholithiasis

Pain in the epigastria, left underrib

Mechanical jaundice

Bile fistulas

Acute cholangitis

X-ray contrasted methods

-ERPChG

-TTChG

- Fistulography

Endoscopic retrograd pancreaticocholangiography

TREATMENT

Not operable Operable

Washing Instrumental deleting

Solution

Miniinvasive Open

ERI TTEBI

Removing the residual stones by the drainage

Removing the residual stones by the endoscopic methods

ERPChG before EPST

ERPChG after EPST

Method of performing of the transcutaneus transhepatical endobiliar interventions

RED of TPCh and descending of the concrements

Reasons and clinic of the strictures of the bile ducts

Mechanical jaundice

Acute cholangitis

Bile fistulas

Surgical reconstruction of the passibility of the bile ducts

At the LChE – conversion (passing to the open operation)

Bile-digestive anastomosis

Transhepatical endobiliar interventions at the strictures of the bile ducts

The tactic of general physician:

1. Collecting the patient’s complaints and

anamnesis

2. Conducting the US

3.Biochemical analysis

4.MRI-cholangiography

5. To refer in time for surgeon’s examination