SURGICAL TACTICS IN EXTRAHEPATIC BILE DUCT INJURIES

Abstract

Aim. To optimize the tactics of surgical treatment of iatrogenic extrahepatic bile ducts (EBD) injuries in conditions of specialized clinic. Materials and methods. The nearest and long-term results of treatment of 118 patients who had been treated at Perm Regional Clinical Hospital depending on the type of injuries, terms of their diagnosis, techniques of operative intervention were studied. Results. In case of iatrogenic injuries of extrahepatic ducts, the following techniques were used: hepaticocholedochoanastomoses, hepaticojejunoanastomoses on the defunctionalized by Roux loop with exchangable transhepatic, “lost” drainages and without “frame” drainages, end-to-side choledochoduodenoanastomoses, anastomosis of the major duodenal papilla with the posterior wall of the duodenal stump. After restorative surgeries, complications were diagnosed in 19 % of cases, after reconstructive ones - in 20-28 %, after choledochoduodenoanastomoses - 50 % that was significantly higher than in other groups of patients ( r =0,32; p =0,02). Lethality after restorative operations was 19 %, after reconstructive ones ranged from 0 to 7 %, after choledochoduodenoanastomoses - 13 %, however, the difference was statistically insignificant ( r =0,00; p =0,93). Absence of surgeon's experience in surgical hepatology, formation of choledochoduodenoanastomoses, presence of cicatrically changed tissues in the region of hepatoduodenal ligament while applying biliary-enteric anastomosis contributed to development of strictures in the remote period ( r =0,29; p =0,006, r =0,35; p =0,01 and r =0,35; p =0,001, respectively). Use of frame drainages did not influence development of failures ( r =0,00; p =0,95) and cicatrical strictures of biliary-enteric fistulas ( r =0,1; p =0,41). Conclusions. 1. Application of choledochoduodenoanastomosis for restoration of bile passage after iatrogenic bile duct injuries gives unsatisfactory results. 2. Use of "frame drainages" in case of pathology of hepaticojejunoanastomoses does not decrease the number of failures and strictures of biliary-enteric fistulas. 3. In case of terminal biliary tract injury, anastomosis between the major duodenal papilla and the posterior duodenal wall or the defunctionalized by Roux loop can serve as a variant for reconstruction.

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