Prevention and treatment bile ducts injuries in patients with acute cholecystitis

Aim. To develop rational surgical tactics for the treatment and prevention of bile duct lesions in patients with acute calculous cholecystitis.

Materials and methods. The results of examination and surgical treatment of 1,645 patients with acute calculous cholecystitis at the second and third levels of medical care were studied. The results of diagnostics and elimination of the bile ducts injuries in 21 patients who developed during laparoscopic cholecystectomy for acute cholecystitis in second-level medical institutions were analyzed. Integrative assessment of the examination results is based on taking into account the results of laboratory and instrumental examination. Based on the analysis, a rational treatment strategy for this category of patients was formed and tested.

Results. The main factors that influenced the occurrence of bile duct injuries were: performing the operation in an inflammatory infiltrate and within 72 hours of the onset of the disease, intrahepatic location of the gallbladder, male gender and age over 63 years (p ≤ 0.05). The provision of assistance in case of complete damage to the main bile ducts in medical organizations of the second level should be completed by performing external drainage with further evacuation of the patient, after stabilization of his condition, to medical institutions of the third level. Partial common bile ducts injury can be eliminated by performing restorative suturing of the defect of the common bile duct the T-drainage at all levels of healthcare organization. It was clarified that patients with acute cholecystitis Grade I are shown timely laparoscopic cholecystectomy within 72 hours from the onset of the disease. For patients with acute Grade II cholecystitis complicated by inflammatory infiltrate, without signs of destruction and blockage of the gallbladder at all levels of medical care it is advisable to conservative treatment, surgery after 3 months. With the progression of endogenous intoxication with destruction of the gallbladder, cholecystostomy is advisable. Patients with acute grade II cholecystitis and complicated course who are being treated in a second-level medical organization, are shown to be transferred to a third-level medical organization for endoscopic intervention on the duodenal papilla.

Conclusion. Implementation of the proposed surgical tactics for patients with acute cholecystitis allows performing timely and rational surgical intervention, increasing the effectiveness of treatment, reducing the number of postoperative complications and mortality.

1. Revishvili A.Sh., Fedorov A.V., Sazhin V.E., Olovyannyi V.E. Emergency surgery in Russian Federation (in Russian only). Pirogov Russian Journal of Surgery /Khirurgiya. Zhurnal imeni N.I. Pirogova. 2019; 3: 88-97. https://doi.org/10.17116/hirurgia201903188 (In Russian)

2. Sugrue M., Coccolini F., Bucholc M., Johnston A. Contributors from WSES. Intra-operative gallblader scoring predicts conversion of laparoscopic to open cholecystectomy: a WSES prospective collaborative study. World J. Emerg. Surg. 2019; 14: 12. https://doi.org/10.1186/s13017-019-0230-9.

3. Romashchenko P.N., Maistrenko N.A., Pryadko A.S., Aliev A.K. Features of providing surgical treatment to victims with bile duct trauma in the hospital. Voenno-medicinskij zhurnal. 2019; 340 (2): 27-35. (In Russian)

4. de Mestral C., Rotstein O.D., Laupacis A., Hoch J.S., Zagorski B., Alali A.S., Nathens A.B. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensiry score analysis. Ann. Surg. 2014; 259 (1): 10-15. https://doi.org/10.1097/SLA.0b013e3182a5cf36.

5. Navez B., Ungureanu F., Michiels M., Claeys D. Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium. Surg. Endosc. 2012; 26 (9): 2436-2445. https://doi.org/10.1007/s00464-012-2206-7.

6. Okamoto K., Suzuki K., Takada T., Strasberg S.M., Asbun H.J., Endo I., Iwashita Y., Hibi T., Pitt H.A., Umezawa A., Asai K., Han H., Hwang T., Mori Y., Yoon Y., Huang W.S., Belli G., Dervenis C., Yokoe M., Kiriyama S., Itoi T., Jagannath P., Garden O.J., Miura F., Nakamura M., Horiguchi A., Wakabayashi G., Cherqui D., de Santibanes E., Shikata S., Noguchi Y., Ukai T., Higuchi R., Wada K., Honda G., Supe A.N., Yoshida M., Mayumi T., Gouma D.J., Deziel D.J., Liau K., Chen M., Shibao K., Liu K., Su C., Chan A., Yoon D., Choi I., Jonas E., Chen X., Tat Fan S., Ker C., Gimenez M.E., Kitano S., Inomata M., Hirata K., Inui K., Sumiyama Y., Yamamoto M. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J. Hepatobiliary Pancreat. Sci. 2018; 25 (1): 55-72. https://doi.org/10.1002/jhbp.516.

7. Shulutko A.M., Beburishvili A.G., Prudkov M.I., Sovcov S.A., Sazhin A.V., Natroshvili A.G., Natroshvili I.G. Ostryj holecistit. Klinicheskie rekomendacii [Acute cholecystitis. Clinical guidelines]. 2015. Internet portal http://xn9sbdbejx7bdduahou3a5d.xn--p1ai/stranica-pravlenija/unkr/urgentnaja-abdominalnaja-hirurgija/ostryi-holecistit.html. Date of access to electronic resource 21.05.2020. (In Russian)

8. Ansaloni L., Pisano M., Coccolini F., Peitzmann A.B., Fingerhut A., Catena F., Agresta F., Allegri A., Bailey I., Balogh Z.J., Bendinelli C., Biffl W., Bonavina L., Borzellino G., Brunetti F., Burlew C.C., Camapanelli G., Campanile F.C., Ceresoli M., Chiara O., Civil I., Coimbra R., De Moya M., Di Saverio S., Fraga G.P., Gupta S., Kashuk J., Kelly M.D., Koka V., Jeekel H., Latifi R., Leppaniemi A., Maier R.V., Marzi I., Moore F., Piazzalunga D., Sakakushev B., Sartelli M., Scalea T., Stahel P.F., Taviloglu K., Tugnoli G., Uraneus S., Velmahos G.C., Wani I., Weber D.G., Viale P., Sugrue M., Ivatury R., Kluger Y., Gurusamy K.S., Moore E.E. 2016 WSES Guidelines on Acute Calculous Cholecystitis. World J. Emerg. Surg. 2016; 11: 25. https://doi.org/10.1186/s13017-016-0082-5.

9. Miura F., Takada T., Strasberg S.M., Solomkin J.S., Pitt H.A., Gouma D.J., Garden O., Buchler M.W., Yoshida M., Mayumi T, Okamoto K., Gomi H., Kusachi S., Kiriyama S., Yokoe M., Kimura Y., Higuchi R., Yamashita Y., Windsor J., Tsuyuguchi T., Gabata T., Itoi T., Hata J., Liau K. Tokyo Guidelines Revision Comittee. TG13 flowchart for the management of acute cholangitis and cholecystitis. J. Hepatobiliary Pancreat. Sci. 2013; 20 (1): 47-54. https://doi.org/10.1007/s00534-012-0563-1.

10. Sugrue M., Sahebally S.M., Ansaloni L., Zielinski M.D. Grading operative findings at laparoscopic cholecystectomy -a new scoring system. World J. Emerg. Surg. 2015; 8; 10: 14. https://doi.org/10.1186/s13017-015-0005-x.

11. Abdelrahim W.E., Elsiddig K.E., Wahab A.A., Saad M., Saeed H., Khalil E.A.G. Subtotal laparoscopic cholecystectomy influences the rate of conversion in patients with difficult laparoscopic cholecystectomy: case series. Ann. Med. Surg. 2017; 19: 19-22. https://doi.org/10.1016/j.amsu.2017.04.018.

12. Sormaz i.C., Soyta? Y., Kaan Gok A.F., Ozgur i., Avtan L. Fundus-first technique and partial cholecystectomy for difficult laparoscopic cholecystectomies. Ulus Travma Acil Cerrahi Derg. 2018; 24 (1): 66-70. https://doi.org/10.5505/tjtes.2017.26795.

13. Maehira H., Kawasaki M., Itoh A., Ogawa M., Mizumura N., Toyoda S., Okumura S., Kameyama M. Prediction of difficult laparoscopic cholecystectomy for acute cholecystitis. J. Surg. Res. 2017; 216: 143-148. https://doi.org/10.1016/j.jss.2017.05.008.

14. Ekici U., Tatli F., Kanlioz M. Preoperative and postoperative risk factors in laparoscopic cholecystectomy converted to open surgery. Adv. Clin. Exp. Med. 2019; 28 (7): 857-860. https://doi.org/10.17219/acem/81519.

15. Veerank N., Togale M.D. Validation of a scoring system to predict difficult laparoscopic cholecystectomy: a one-year crosssectional study. J. West Afr. Coll. Surg. 2018; 8 (1): 23-39. PMID: 30899702.

16. Strasberg S.M., Hertl M., Soper N.J. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J. Am. Coll. Surg. 1995; 180 (1): 101-125. PMID: 8000648.

17. Prikaz Ministerstva zdravoohraneniya RF ot 8 iyunya 2016 g. №358 “Ob utverzhdenii metodicheskih rekomendacij po razvitiyu seti medicinskih organizacij gosudarstvennoj sistemy zdravo-ohraneniya i municipal'noj sistemy zdravoohraneniya” [Order of the Ministry of Health of the Russian Federation of June 8, 2016 No. 358 “On approval of guidelines for the development of a network of medical organizations of the public health system and the municipal health system”]. http://www.consultant.ru/document/cons_doc_LAW_200171/. Date of access to electronic resource 20.05.2020. (In Russian)

18. Romashchenko P.N., Maistrenko N.A., Pryadko A.S., Aliev A.K. Bile duct injuries and systemic approach to the treatment. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2019; 24 (1): 71-82. https://doi.org/10.16931/1995-5464.2019171-82 (In Russian)

19. Fingerhut A., Dziri C., Garden O., Gouma D., Millat B., Neugebauer E., Paganini A., Targarona E. ATOM, the all-inclusive, nominal EAES classification of bile duct injuries during cholecystectomy. Surg. Endosc. 2013; 27 (12): 4608-4619. https://doi.org/10.1007/s00464-013-3081-6.

20. Dindo D., Demartines N., Clavien P.A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann. Surg. 2004; 240 (2): 205-213. https://doi.org/10.1097/01.sla.0000133083.54934.ae.

21. Aggarwal R., Crochet P., Dias A., Misra A., Ziprin P., Darzi A. Development of a virtual reality training curriculum for laparoscopic cholecystectomy. Br. J. Surg. 2009; 96 (9): 1086-1093. https://doi.org/10.1002/bjs.6679.

22. Maystrenko N.A., Romashchenko P.N., Aliev A.K., Sibirev S.A. Acute bile duct injury. Vestnik Rossijskoj voenno-medicinskoj akademii. 2016; 1 (53): 124-130. (In Russian)

23. Hariharan D., Psaltis E., Scholefield J., Lobo D.N. Quality of life and medico-legal implications following iatrogenic bile duct injuries. World J. Surg. 2017; 41 (1): 90-99. https://doi.org/10.1007/s00268-016-3677-9.

24. Rystedt J.M.L., Montgomery A.K. Quality-of-life after bile duct injury: intraoperative detection is crucial. A national casecontrol study. HPB (Oxford). 2016; 18 (12): 1010-1016. https://doi.org/10.1016/j.hpb.2016.09.003.

25. Eikermann M., Siegel R., Broeders I., Dziri C., Fingerhut A., Gutt C., Jaschinski T., Nassar A., Paganini A.M., Pieper D., Targarona E., Schrewe M., Shamiyeh A., Strik M., Neugebauer E.A.M. European association for endoscopic surgery. Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: The clinical practice guidelines of the European association for endoscopic surgery (EAES). Surg. Endosc. 2012; 26 (11): 3003-3039. https://doi.org/10.1007/s00464-012-2511-1.

26. Battal M., Yazici P., Bostanci O., Karatepe O. Early surgical repair of bile duct injuries following laparoscopic cholecystectomy: the sooner the better. Surg. J. (NY). 2019; 5 (4): e154-e158. https://doi.org/10.1055/s-0039-1697633.

27. Dibirov M.D., Rybakov G.S., Domarev V.L., Vasilyeva M.A., Brodetsky B.M., Kosachenko M.V. Algorithm of diagnostics and treatment of elderly and senile patients with acute cholecystitis, choledocholithiasis and obstructive jaundice. Russian Sklifosovsky Journal “Emergency Medical Care”. 2017; 6 (2): 145-148. https://doi.org/10.23934/2223-9022-2017-6-2-145-148 (In Russian)