Хірургічна тактика при лікуванні ускладнених форм жовчнокам’яної хвороби у хворих похилого і старечого віку

Abstract

Research objective. Study of efficiency of one-stage and two-stage operative interventions during treatment of complicated forms of gallstone disease in elderly and senile patients. Materials and methods. 320 patients ill with complicated forms of gallstone disease were treated at the surgical clinic during 2002-2013. The patients' age ranged from 70 to 89 years. The patients aged 70-79 years (125 persons) formed the largest group. The disease anamnesis made up from 1 month to 25 years. A complicated clinical course of acute calculous cholecystitis was diagnosed in 123 (38,4%) patients, of chronic cholecystitis in 107 (33,4%) cases. Pathology of biliary ducts was observed in 90 (28,1%) patients. Associated pathology was diagnosed in 228 (71,2%) cases.Results. For diagnosis of choledocholithiasis the instrumental examination methods were applied: ultrasound examination of all the patients, endocscopic retrograde cholangiopancreatography in 42 (13,1%) patients, intraoperative cholangiography – in 32 (10,0%), magnetic resonance tomography in 7 (2,2%) and fibrogastroduodenoscopy in 11 (3,4%) cases. In case of a complicated clinical course of acute calculous cholecystitis minimally invasive interventions were performed in 112 (35,0%) cases and in case of a chronic clinical course – in 158 (49,4%) patients. Open biliary duct interventions were performed in 50 (15,6%) cases. One-stage biliary duct operative interventions (laparoscopic cholecystectomy (LCE) with further biliary duct intervention) were performed in 68 (21,2%) patients. Two-stage interventions (endoscopic papillosphincterotomy (EPSE) with further LCE in case of chronic cholecystitis and LCE with further EPSE during the early postoperative period in case of its acute clinical course) were performed in 46 (14,4%) cases. Complications after one-stage operative interventions were observed in 6 (8,8%) patients, after two-stage interventions – in 3 (6,5%) patients. There were no lethal outcomes after two-stage interventions. 1 patient died after one-stage operative intervention, the death was caused by extensive myocardial infarction.Conclusions1. Two-stage surgical approach to treatment of complicated forms of gallstone disease in elderly and senile patients is preferred as it allows to reduce the frequency of postoperative complications by half.2. Two-stage operative interventions include: LCE with further EPSE during the early postoperative period in case of acute cholecystitis and EPSE with further LCE in case of its chronic clinical course.3. One-stage interventions (LCE with further biliary duct interventions) are possible in case of acute cholecystitis complicated with non-dense paravesical infiltrate, absence of sclerotic gallbladder and excessive adhesive process in case of chronic cholecystitis.