[Mirizzi syndrome management (in Russian only)]. / Lechenie sindroma Mirizzi.

AIM: To assess an effectiveness of complex preoperative diagnosis, conservative treatment, minimally invasive biliary decompression for Mirizzi syndrome and to analyze surgical outcomes depending on the effectiveness of minimally invasive biliary decompression. MATERIAL AND METHODS: There were 67 patients with Mirizzi syndrome aged 27-96 years (mean age -64.8 years). The diagnosis was established on the basis of complaints, objective data, laboratory survey, abdominal X-ray, ultrasound (US), endoscopic gastroduodenoscopy (EGDS), computed tomography (CT) and magnetic resonance imaging (MRI). Extrahepatic bile duct visualization in case of suspected biliodigestive fistula was achieved by using of percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, cholecystocholangiography, intraoperative cholangiography. RESULTS: The analysis of the diagnosis and treatment of patients with Mirizzi syndrome and mechanical jaundice with and without symptoms of cholangitis was carried out. It should be noted that percutaneous transhepatic cholangiography and cholecystocholangiography with antegrade contrasting were able to confirm Mirizzi syndrome type 1 without complications. Retrograde cholangiopancreatography in patients with Mirizzi syndrome type 2 reduced the diagnostic value of contrast-enhancement with complications in every fifth patient. Percutaneous drainage for Mirizzi syndrome type 1 was effective in all patients. There was low effectiveness of medication for Mirizzi syndrome. Medication combined with antegrade biliary decompression was 7 times more effective than retrograde decompression. All patients underwent surgery. Mortality depended on surgical emergency and effectiveness of biliary decompression. So, emergency interventions were followed by mortality rate near 60% while there were no deaths after elective procedures. Overall mortality was 11.9%.

[Influence of biliary decompression technique on the outcomes of reconstructive surgery]. / Vliianie sposoba dekompressii zhelchnykh protokov posle ikh povrezhdeniia na rezul'taty vosstanovitel'nykh operatsii.

AIM: To evaluate bile ducts injuries and effect of biliary decompression technique on the outcomes of reconstructive surgery. MATERIAL AND METHODS: There were 21 patients with biliary injury during cholecystectomy, 20 patients with cholelithiasis, and 1 patient after surgery for perforated duodenal ulcer. Their age was 22-81 years (mean 54.3 years). Primary surgery through median laparotomy was followed by biliary injury in 12 patients, laparoscopic cholecystectomy - in 6 patients, open laparoscopy - in 3 patients. Patients were divided into 2 groups. In group 1 (n=11) biliary injury was diagnosed intraoperatively, in group 2 (n=10) - in 2-11 days after primary procedure. According to European Association for Endoscopic Surgery (EAES) 2013 classification biliary injury type 1 was found in 5 patients, type 2 - in 9 cases, high damage involving confluence (type 3) - in 1 patient, type 4 - in 1 patient, and type 6 - in 5 patients. Endoscopic retrograde cholangiopancreatography in 3 patients revealed that biliary drainage output after laparoscopic cholecystectomy was caused by cystic duct clipping failure, endoscopic papillosphincterotomy was successfully used for biliary drainage output (type 6). In 3 patients operated through median laparotomy biliary excretion cessation was observed after 2-3 days that indicated damage of aberrant bile ducts. RESULTS: Bile outflow into gastrointestinal tract was restored in 11 out of 16 patients with iatrogenic biliary injury types 1-4, external biliary drainage was used in 4 patients due to their severe condition and abdominal inflammatory changes. Biliary fistulae occurred in 5 out of 8 patients in both groups after primary reconstructive surgery. Biliary stricture was observed in 3 cases due to external biliary drainage failure followed by peritonitis. 7 patients underwent reconstructive surgery with positive result. Mortality was absent. In 1 patient with biliary fistula outcome is unknown. CONCLUSION: Transumbilical biliary drainage is optimal during reconstructive surgery.

[MORPHOLOGICAL CHANGES IN THE SMALL INTESTINE ASSOCIATED WITH STRANGULATION OF MECHANICALLY OBSTRUCTED BOWEL].

AIM: To estimate the degree and prevalence of pathomorphological changes in the small intestine at different distances from the visible necrosis boundary depending on acute mechanical obstruction for the choice of the optimal extent of resection. MATERIALS AND METHODS: Small intestine fragments for morphological study were obtained from 52 patients aged 17-83 (mean 47 ± 17) years after emergency resection of mechanically obstructed necrotic bowel. Strangulation caused by obstructive adhesion was diagnosed in 48%, constricted hernia in 38.5%, torsion in 13.5% of the cases. Tissue morphology was studied by histological staining and light microscopy at 5 cm intervals between the sections. RESULTS: The degree and prevalence of pathomorphological changes in the small intestine depended on the severity of obstruction and increased with its decompensation. CONCLUSION: The extent of resection in proximal and distal directions from the visible boundary of necrosis must be chosen on an individual basis depending on the degree of compensation of mechanical intestinal obstruction. The absence of extensive resection especially in the proximal direction allows to reduce the frequency of short bowel syndrome with malabsorption in the late postoperative period.

[Enteral nutrition as a method of correction of protein energetic insufficiency in patients with perforating gastric and duodenal ulcer].

The results of examinations and treatment of 338 patients operated by reason of perforated gastric and duodenal ulcer (PGDU). It was established, that parenteral and oral nutrition in PGDU patients after traditional surgical operation did not improve patients' trophic state. Performance of early enteral nutrition with Pevzner's diet and nutritive maintenance during all postoperative period in patients, operated by low-invasive methods, has favorable influence on patients' trophic state.

[Enteral nutrition in the complex treatment of patients with mechanical jaundice in gallstone disease].

The article summarizes the results of the examination and treatment of 99 patients with mechanical jaundice (MJ) related to gallstone disease (GSD). The patients were distributed into three groups according to three degrees of the dysfunction of the greater duodenal papilla (GDP) sphincter. Group 1 consisted of 52 patients with transitory MJ (degree I), Group 2 consisted of 32 patients with stable MJ remaining after coping with the pain attack (degree II), and Group 3 consisted of 15 patients with MJ and cholangitis (degree III). Trophic status disturbances and the effects of balanced clinical nutrition on the results of surgical treatment were assessed in all the patients. The severity and duration of jaundice were found to influence the severity of trophic changes. Clinical nutrition (sipping and enteral tube feeding) favored survival after papilla-sparing surgery in patients with MJ related to gallstone disease.