SURGICAL APPROACH FOR TREATMENT OF OBSTRUCTIVE JAUNDICE IN PATIENTS OF DIFFERENT AGE GROUPS.

OBJECTIVE: The aim: Assessment of the effectiveness of using minimally invasive and open methods of bile duct decompression for treatment of obstructive jaundice (OJ) by comparing complications in patients of di!erent age groups. PATIENTS AND METHODS: Materials and methods: We analyzed the results of surgical treatment of 250 patients with OJ. The patients were assigned to two groups: Group I (n = 100) consisting of young and middle-age patients, and Group II (n = 150) consisting of elderly, senile and long-living patients. The average age was 52 ± 6.0 years. RESULTS: Results: 62 (24.8%) Group I patients and 74 (29.6%) Group II patients were submitted to minimally invasive surgical interventions. 38 (15.2%) Group I patients and 76 (30.4%) Group II patients were submitted to open surgical interventions. Complications after minimally invasive surgery (n = 62) in Group I patients were observed in 2 (3.2%) cases, and in 4 (10.5%) cases after open surgeries (n = 38). Complications following minimally invasive interventions (n = 74) in Group II patients were registered in 5 (6.8%) cases, and in 9 (11.8%) cases following open operations (n = 76). 2 (2.6%) Group II patients died for transmural myocardial infarction. CONCLUSION: Conclusions: The use of minimally invasive surgical interventions for treatment of young and middle-aged OJ patients compared to patients of older age groups makes it possible to reduce the frequency of complications by 2.1 times, which is a statistically signi"cant (p <0.05). The frequency of complications after open surgical interventions of bile ducts in patients of di!erent age groups is not statistically signi"cant (p >0.05).

CHARACTERIZATION OF STRUCTURAL DISORDERS OF THE LIVER DEPENDING ON THE DURATION OF SUBHEPATIC CHOLESTASIS IN PATIENTS OF DIFFERENT AGE GROUPS.

OBJECTIVE: The aim: To study structural disorders of the liver depending on the duration of subhepatic cholestasis in patients of different age groups. PATIENTS AND METHODS: Materials and methods: 50 obstructive jaundice patients were subdivided into two groups. Group I (n = 25) consisted of young (18-44-year-old) and middle-aged patients (45-59-year-old), while the Group II (n = 25) included elderly (60-74-year-old) and senile patients (75-90-year-old). RESULTS: Results: We performed morphological and morphometric studies of 50 liver biopsy specimens taken from patients of different age groups with different duration of obstructive jaundice: less than 7 days, 7-14 days, 14-21 days, 21-28 days, and over 28 days. CONCLUSION: Conclusions: In patients of the Groups I and II, pathological hepatic changes in the early stages of mechanical jaundice were manifested in the form of he-patocyte dystrophy and hepatitis development. In the Group I patients, manifestations of steatohepatitis, fibrosis and initial signs of liver cirrhosis were noted in the late stages of subhepatic cholestasis. In addition to the above-mentioned changes, Group II patients, in the late stages of mechanical jaundice, presented signs of severe fibrosis and well-shaped liver cirrhosis. Taking into account the above morphological changes in the liver with different duration of subhepatic cholestasis, we consider reasonable to decompress bile ducts in patients of older age groups at earlier stages of mechanical jaundice compared to young and middle-aged patients, thus preventing post-decompression liver dysfunction and the subsequent development of biliary cirrhosis.

Comparative assessment of bile duct decompression methods in patients with obstructive jaundice of non-tumor genesis.

OBJECTIVE: Introduction: Obstructive jaundice is one of the most common diseases of the digestive system observed in 10-15% of the world's population. The question of making a choice among methods of bile duct decompression is still under discussion, since both single-stage and two-stage methods of biliary decompression lead to progression of hepatic insufficiency after restoration of bile passage. The aim: To determine a tempo of biliary decompression after external and internal drainage of bile ducts, endoscopic transpapillary interventions in patients with obstructive jaundice of non-tumor genesis. PATIENTS AND METHODS: Materials and methods: We analyzed the outcomes of surgical treatment of 180 patients with obstructive jaundice of the non-tumor genesis. The patients were divided into three groups: group I (n = 86), where endoscopic methods of biliary decompression were used; group II (n = 48), where biliodigestive anastomoses were formed; and group III (n = 46), where the external drainage of bile ducts was conducted. The average age was 62 ± 6.0 years. The average duration of obstructive jaundice was 20 ± 3.7 days. RESULTS: Results: The patients of the group I demonstrated a gradual decrease of bilirubin and alkaline phosphatase levels, which reached the normal readings on Day 7. The patients of the group II demonstrated normal levels of bilirubin and alkaline phosphatase on Day 14. The patients of the group III demonstrated rapid decrease of bilirubin and alkaline phosphatase levels, which reached the normal readings on Day 28. The transaminase level in each group of patients had reached the norm earlier. CONCLUSION: Conclusions: No significant disturbances of the functional state of the liver after endoscopic transpapillary interventions were observed. Formation of areflux biliodigestive anastomoses was accompanied by a moderate rate of biliary duct decompression. The external drainage of biliary ducts was characterized by a rapid rate of biliary decompression, leading to a post-compression syndrome.

Improving the results of the laparoscopic cholecystectomy in patients with complicated course of the calculous cholecystitis.

OBJECTIVE: Introduction: The laparoscopic cholecystectomy (LCE) has become "gold standard" in treatment of the gallstone disease (GSD). However, introduction of LCE is accompanied by increase in the frequency of the bile duct injuries by 2-5 times, and transfer to the conversion offsets main advantages of the laparoscopic access. The aim:Тo improve the results of treatment of the patients with complicated course of the calculous cholecystitis by developing new methods of the laparoscopic cholecystectomy. PATIENTS AND METHODS: Materials and methods: The results of surgical treatment of 420 patients with complicated course of the calculous cholecystitis were analyzed. The patients were divided intwo groups: group I (n = 210) where the standard four-trocar LCE was used and the group II (n = 210) where the developed methods of LCE were used. The average age made up 62 ± 6.0 years. Duration of disease made up from 1 month to 35 years. RESULTS: Results: The patients in group I LCE with complicated course of the acute cholecystitis was performed in 108 (25.7%) cases, chronic - in 102 (24.3%) cases. The patients in group II surgical intervention with complicated course of the acute cholecystitis was performed in 112 (26.7%) cases, chronic - in 98 (23.3%) cases. The patients of group I intraoperative injuries were observed in 12 (5.7%) cases and patients of group II - in 4 (1.9%) cases. The conversion was applied in 13 (6.2%) and in 4 (1.9%) cases, respectively. 2 (0.9%) patients died. CONCLUSION: Conclusions: Introduction of the developed methods of LCE with complicated course of the calculous cholecystitis allows to reduce the frequency of intraoperative injuries by 3,8% and conversion rate - by 4,3% (p <0,001).

Experience in treatment of patients with esophageal achalasia.

OBJECTIVE: Introduction: Esophageal achalasia is a neuromuscular disease, which is characterized by persistent impaired reflex opening of esophageal sphincter. Disease incidence is 0.6-2.0 per 100 000 population with no tendency to decrease. The aim of the study was to improve the results of treatment in patients with achalasia of cardia by differentiated approach in the choice of therapy method. PATIENTS AND METHODS: Materials and methods:148 patients with esophageal achalasia aged 18 - 67 were studied between 2003 and 2018. The following degrees of the disease were determined (by Petrovskyi's classification): first - in 8, second - in 59, third - in 70, fourth - in 11 patients. Drug therapy was administered in achalasia of first degree, and cardiodilatation courses - in second and third degree of the disease. Indications for surgical treatment were: impossibility to perform cardiodilatation, S-shaped esophageal deformation (stage IV), complications associated with cardiodilatation, achalasia combined with other surgical pathology, recurrence of disease. RESULTS: Review: Cardiodilatation therapy resulted in sustained clinical effect in stages I and II of the disease. In case of unsatisfactory results of cardiodilatation patients underwent elective operations. 18 patients underwent Heller-Dor plastic surgery, 4 - Heller-Petrovskiy operation, 1 - Besley plastic repair, 2 - Nissen fundoplication. In early postoperative period no failure or perforation of the esophagus occurred. The following complications developed: seroma - in 3 patients, postoperative wound infection - in 1 case. In one patient (4%) the recurrence of disease was due to scar deformation of esophagogastric junction after Heller-Petrovskiy operation on the cardia. CONCLUSION: Conclusions: Cardiodilatation is an effective method of conservative therapy in stages I and II of the disease, while in stages III and IV it is warranted as preoperative preparation measure. We think Heller-Dor operation to be the best method of plastic repair in esophageal achalasia.

Selection of biliary decompression method for treatment of obstructive jaundice in patients of older age groups.

OBJECTIVE: Introduction: The development of minimally invasive techniques allowed to expand the indications and possibility of performing surgeries in patients of elderly and old age with obstructive jaundice (OJ). However, the criteria for the selection of minimally invasive and open surgeries in patients with OJ remain undefined. The aim: To study the efficacy of single or multiple-stage methods of biliary decompression for treatment of OJ in patients of older age groups. PATIENTS AND METHODS: Materials and methods: We have analyzed the results of surgical treatment in 140 patients with OJ of benign origin. The patients were divided in two groups: group I (n = 70) where two-stage minimally invasive methods were used and group II (n = 70) where single-stage minimally invasive and open surgeries were used. The average age was 75 ± 6.0 years. The average duration of OJ was 22 ± 3.7 days. RESULTS: Results: The patients in group I were subjected to two-stage minimally invasive surgeries in 70 (50.0%) cases. The patients in group II were subjected to single-stage minimally invasive surgeries in 16 (11.4%) cases and to open surgeries in 54 (38.6%) cases. The average duration of hospital stay in patients of group I made 7.1 ± 1.5 days, and 11.2 ± 1.2 days in patients of group II. The patients of group I experienced complications in 5 (7.1%) cases and patients of group II experienced complications in 10 (14.3%) cases. 1 (1.4%) patient died. CONCLUSION: Conclusions: Stepwise approach to minimally invasive surgeries in patients of elderly and old age with bile duct obstructions allows to reduce the frequency of postoperative complications down to 7.2% (p< 0.05). Single-stage correction is recommended for patients with hyperbilirubinemia of less than 100 mcmol/l and the duration of OJ of less than 14 days, with presence of compensated or subcompensated co-occurring pathology as well as in the absence of purulent cholangitis and biliary pancreatitis.