Prediction and prevention of postoperative bile leaks in patients with pathology of the biliary tract

The article discusses the results of a retrospective analysis of the 168 medical history of patient with pathology of bile ducts. According to our research, the frequency of postoperative bile leaks after cholecystectomy develops in of 0,8-1,0%. The method of choice in diagnosis of early postoperative bile leaks after cholecystectomy is hepatobilioscintigraphy, endoscopic retrograde cholangiopancreatography 

Cholelithiasis is one of the most common surgical disease in the worldwide. Currently, more than 1.2 million cholecystectomies are performed per year in the world. The frequency of complications after cholecystectomy is 1.5-16.8%. In the structure of postoperative complications leading place occupies leaks of bile duct. This complications observed after an open cholecystectomy in 5-15%, after cholecystectomy from miniaccess 3, 6%, and after laparoscopic cholecystectomy in 2-5% (W.P. Rusanov., 2003; A.D. Shestakov with co-authors., 2005; Lau J.Y. et al., 2006; VermaG.R. etal., 2002; YamanerS. etal., 2002). The main causes of postoperative bile leaks can be the failure of the stump of the cystic duct, aberrant hepatic and cystic ducts, the gallbladder bed - duct of Luschka, iatrogenic damage to the main bile duct. According to (E. I. Galperin Y. M. Dederer) bile leaks from the duct of Lyuchka representing about 0.2 - 0.4% of all cholecystectomy. Unsatisfactory results of treatment of biliary complications after cholecystectomy is mostly due to delayed diagnosis. (А.S., Ermolov 1998; W.N., Budaryn 2000; А.Y. Lobakov with co-authors ., 2000; G.А. Baranov with co-authors., 2007; А.А., Ylshenko 2007).

Conducting the analysis of the literature data, we concluded that the main factor of postoperative bile leaks is hypertension in the ductal system.

Purpose of research.

Elaboration and clinical approbation of an optimal algorithm that should significantly reduce postoperative complications.

Materials and methods of research: We conducted a retrospective analysis of the results surgical treatment of 168 patients with pathology of bile ducts in the department of emergency surgery Almaty city clinic hospital №7 between January 2014 and September 2014.

The mean age of patients was 52±6,4. Of these, 102 women (60,7%) and 66 men (39.3%). The current study shows that this pathology most common in the age group of 31 to 50 years old and 51 to 70 years old.

Cholecystectomy an open access by the Kocher was performed in 62 patients (36.9%), laparoscopy cholecystectomy- in 106 patients (63.1 %). Before the operation all the patients was performed a complex of diagnostic measures, physical and clinical examination, Oesophago-Gastric-Duodeno-Scopy OGDS, ultrasound of abdominal organs, according to testimony - ERCP, dynamic hepatobilioscintigraphy (GBSG) or computed tomography.

Bile leaks after cholecystectomy occurred in 6 patients (3.5 percent). Of these 4 women, 2 men. The frequency of bile leaks depending on the form of inflammation of the gallbladder- acute calculouscholecystitis: phlegmonous-1, gangrenous-3, mechanical jaundice-2.

Among patients with bile leaks after cholecystectomy, the majority were patients with acute gangrenous calculouscholecystitis.

According to the amount of free bile and intensity of postoperative bile leaks we divided into 3 grades by criteria of Morgenstern L. I grade bile leakage (to 100 ml/day from the abdominal cavity drainage or circumscribed accumulation of fluid in the bed of the gall bladder with a volume less than 100 ml with ultrasound) was identified in 2 patients. II grade bile leakage (100-500 ml/day on drainage or free fluid above and below the liver during ultrasound) was diagnosed in 3 patients. III grade bile leakage (more than 500 ml/day. on drainage or free fluid in 3 or more areas of the abdomen) — at 1 patients. All the patients was performed a ultrasound examination and Oesophago-Gastric-Duodeno-scopy (OGDS), hepatobilioscintigraphy (GBSG), percutaneous transhepatic cholangiography.

At 2 patients with I grade bile leakage was revealed leaks from duct of Luschka. The analysis of the protocol of operations showed intrahepatic location of the gallbladder, that leading to failure coagulation of small bile ducts. Postoperative antiinflammatory and infusion therapy for 7-8 days, and stimulation of motility of the gastrointestinal tract has led to stop bile leaks on 12 day.

As well as the causes of bile leaks were as follows: at 3 patients the failure of the stump of the cystic duct, characteristically, that

1. According to our research, the frequency of postoperative bile leaks after cholecystectomy develops in of 0,8-1,0%;
2. The main cause for the development of postoperative bile leaks after cholecystectomy is inadequate examination of patients before or during surgery, and incorrect assessment of anamnestic, laboratory and instrumental data obtained at the preoperative stage;

in these patients occurred biliary hypertension due to choledocholithiasis (2), stenosis of major duodenal papilla (1) is not resolved before and during surgery. In one patient bile leaks from the abdominal cavity drainage were observed for 3 days after surgery in a volume of 500 ml or more after laparoscopic cholecystectomy. Performed endoscopic retrograde cholangiopancreatography, where it was established the stenosis of major duodenal papilla. Endoscopic papillosphincterotomy eliminates the hypertension in the bile ducts, leading to stopping bile leaks from the stump of the cystic duct and recovery.

The method of choice in diagnosis of early postoperative bile leaks after cholecystectomy is hepatobilioscintigraphy, endoscopic retrograde cholangiopancreatography, which allow to determine not only the causes of complications, but also to perform necessary therapeutic interventions aimed at their elimination.

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