[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.

[Diagnostics and surgical treatment of the tumor obturative intestinal obstruction].

The study summarize the results of diagnostics and treatment of 536 patients aged 37-97 years with colon cancer stage II-IV, complicated by bowel obstruction. Patients with subcompensated and decompensated bowel obstruction prevailed. The dependence of the clinical picture from the tumor localization and the severity of the obstruction were identified. The authors pose that the decision about the median laparotomy needs the preoperative diagnosis of the obturative obstruction without verification of its causes. Decision about the delayed radical operation and minimizing the treatment to colon decompression should be based on additional diagnostic data (X-ray, irrigoscopy and colonoscopy). Surgical interventions with the median laparotomy showed the mortality rate of 30.7% and morbidity of 57.5%. The miniinvasive decompression of the colon reduces these rates to 1.8 and 7.1%, respectively.

[Extended, combined, and concurrent surgery in patients with neoplastic obturation large bowel obstruction].

The study included 552 patients (mean age 68.9 +/- 1.0 years) with neoplastic obturation large bowel obstruction (NOLBO). They were allocated to 3 groups depending on the character of surgical intervention. Group 1 comprised 172 patients (31.2%) operated under endotracheal anesthesia (ETA) through a medial approach for the resection of the segmented intestine and its tumours with colostomy or ileostomy (n = 154) and primary interintestinal anastomoses (n = 18). Group 2 of 56 patients (10.1%) with neglected NOLBO in very severe condition underwent medial laparotomy under ETA with internal or external colonic decompression without tumour resection. Minimally invasive decompressive ileotsomy or colostomy depending on localization of the tumor was performed under local anesthesia after premedication in 324 (58.7%) patients of group 3. The grave clinical condition of the patients was due to polyorgan insufficiency (POI). Postoperative lethality in groups 1, 2, and 3 following surgery in the acute phase of NOLBO was 26.9, 39.3, and 1.8% respectively. The condition of patients of group 1 and 2 with indications for urgent extended, combined or concurrent surgery was too serious to allow for an adequate intervention; it was possible only in 7 (14.6%) of the 48 patients. Diminution of POI manifestations by restoration of segmented intestine patency by low-invasive intervention in patients of group 3 and their preoperative preparation by balanced diet during 3-4 weeks made possible extended combined surgery in all 50 patients of this group without a fatal outcome.