Postcholecystectomic syndrome Tashkent Medical Academy The department of the faculty and hospital surgery

At first open cholecystectomy was performed in 1882 year by German surgeon Karl Langenbuch The first cholecystectomy in Russia – by Yu. F. Kossinskiy in 1886 year The first laparoscopik cholecystectomy was performed in 1882 year by German surgeon Erich Muhe History

The gall stone disease has every 10 person at our planet At 5-40% patients, to which was performed the cholecystectomy, appear or save dyspeptic phenomenas, needing treatment. EPIDEMIOLOGY

Indications for cholecystectomy Chronic calculous cholecystitis Acute calculous cholecystitis Cholesterosis of the gall bladder Polyposis of the gall bladder

Technique of the open cholecystectomy

Technique of the laparoscopic cholecystectomy Laparoscopic cholecystectomy is “gold standard” method of treatment of the gall stone disease

Postcholecystectomic syndrome- joined different pathological states and connected with them clinic manifestations, checked the patients, to which the cholecystectomy was performed.

Main symptoms of the PChES Pains in the abdomen (constant or attacks) with jaundice External bile fistula Pains in the abdomen (constant or attacks) without jaundice Extended bile ducts Narrow bile ducts Steadfast jaundice Periodically jaundice

-Diseases and pathological atates of the bile-pancreatic system and BDM, not liquidated at the operation (choledocholithiasis, stenosing papillitis, stenosis of the CBD, cysts of the bile ducts and other );. Classification -Diseases and pathological atates of the bile-pancreatic system and BDM, directly connected with the operation (defeat of the bile ducts, strictures and deformations of the cult of the bladder’s duct). -Diseases and pathological atates of the bile-pancreatic system and BDM, connected with the gall stone disease (chronic pancreatitis, hepatitis, gastritis and other). -Diseases of other organs and systems, not connected with the bile system and cholecystectomy (diaphragmal hernia, USD, psychosteny and other) - diseases, conducted with the functional defeats of the bile ducts and duodenum, appear as result of absence of the gall bladder: diskynesion of the bile ducts and Oddy’s sphincter.

The reasons of the postcholecystectomic syndrome functional (to 60%) organically reasons (about 40%) - changes of the bile ducts - changes of the GIP - defeats not connected with the GIP

Reasons of the residual stones 1. Cholelithiasis wasn’t identified: - Ignore the indicationts to the choledochotomy; - Hidden currency of the choledocholithiasis -Hard state of the patient; -Technical complications during the operation; - Mistakes in the diagnosis 2. Inferioity revision of the ducts Reasons of the recidive stones 1. Different pathological states, inducting the defect of bile evacuation 2. Very big cult of the bladder’s duct or staying the part of gall bladder 3. Presence of the alien objects in the ducts (ligatures, drainages, ascarides)

Indications to the ERPChG  Jaundice or cholangitis in anamnesis or at the hospitalization  Increasing of the factors of hepatic tests  Pancreatitis in anamnesis  Expansion of the common bile duct more than 8 mm or 8 mm or presence cut-in in it by the US datas  Presence of the small concrements in the gall bladder and wide bladder’s duct by US

Wide bladder’s duct (more than 5 mm) Presence of small conrements in the gall bladder and bladder’s duct Intraoperative visualisatiion of expansed bile duct at the case of divergence with the data of before operative US Impossibility of before operative performing of the ERPChG and TTChG Indications to the intraoperative cholangiography

Technique of the intraoperative cholangiography

Choledocholithotomy

Sewing of the choledotomic aperture and drainage of the choledoch

Lithextraction from the CBD

US Clinic and diagnostic of the residual choledocholithiasis Pain in the epigastria, left underrib Mechanical jaundice Bile fistulas Acute cholangitis X-ray contrasted methods -ERPChG -TTChG - Fistulography

Endoscopic retrograd pancreaticocholangiography

TREATMENT Not operable Operable Washing Instrumental deleting Solution MiniinvasiveOpen ERITTEBI

Removing the residual stones by the drainage

Removing the residual stones by the endoscopic methods

ERPChG before EPST ERPChG after EPST

Method of performing of the transcutaneus transhepatical endobiliar interventions

RED of TPCh and descending of the concrements

Reasons and clinic of the strictures of the bile ducts Mechanical jaundice Acute cholangitis Bile fistulas

Surgical reconstruction of the passibility of the bile ducts At the LChE – conversion (passing to the open operation)

Bile-digestive anastomosis

Transhepatical endobiliar interventions at the strictures of the bile ducts

The tactic of general physician: 1. Collecting the patient’s complaints and anamnesis 2. Conducting the US 3.Biochemical analysis 4.MRI-cholangiography 5. To refer in time for surgeon’s examination