1. Postcholecystectomic syndrome
Tashkent Medical Academy
Postcholecystectomic syndrome
The cathedra of the faculty and hospital surgery

4. Classification of the PChES by Bismuth – Corlett
Bismuth I
Bismuth II
Bismuth III a
Bismuth III b
Bismuth IV

5. Indications to the cholecystectomy
Chronic calculous cholecystitis
Acute cholecystitis
Cholesterosis of the gall bladder
Polyposis of the gall bladder

6. Technique of the open cholecystectomy
At first was performed in 1882 year by German surgeon
Karl Langenbuch
The first cholecystectomy in Russia – Yu. F. Kossinskiy in year

7. Technique of the laparoscopic cholecystectomy
Laparoscopic cholecystectomy is checked and reliable (“gold standard”) method of treatment of the gall stone disease

8. The gall stone disease has every 10 man at our planet
Postcholecystectomic syndrome is collective notion, joined different pathological states and connected with them clinic manifestations, checked at the patients, to which the cholecystectomy was performed .
At 5-40% patients, to which was performed the cholecystectomy, appear or save dyspeptic phenomenas, needing treatment.
The gall stone disease has every 10 man at our planet

9. 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

10. Classification
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); .
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.

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

12. Reasons of the residual stones Reasons of the recidive 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)

13. 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

14. Indications to the intraoperative cholangiography
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

15. Technique of the intraoperative cholangiography

16. Technique of the intraoperative cholangiography

17. MSCT

18. Choledocholithotomy

19. Sewing of the choledotomic aperture and drainage of the choledoch

20. Lithextraction from the bladder’s duct

21. 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 US

22. Types of the retrograd papillosphincterotomy
Boarded papillosphincterotomy
Papillotomy
Subtotal or total papillosphincterotomy

23. Endoscopic retrograd pancreaticocholangiography

24. TREATMENT
Not operable
Operable
Washing
Instrumental deleting
Solution
Miniinvasive
Open
ERI
TTEBI

25. Deleting the residual stones from the drainage

26. Deleting the residual stones by the endoscopic methods

27. ERPChG after EPST
ERPChG before EPST

28. Method of performing of the transcutaneus transhepatical endobiliar interventions

29. RED TDCh and descending of the concrements

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

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

32. Pass-by bile-digestive anastomosis

33. Transhepatical endobiliar interventions at the strictures of the bile ducts

34. Installation of the nitinol stents

35. Installation of the plastic stents

36. External-internal drainage

37. One stage stenting of the hepaticocholedoch

38. Endoprosthesing of the occlused stent

39. U-form stenting

40. Stenting of the left lobe of the liver through the epigastral access