Changes in Small Intestine Function as a Criterion for Selecting a Biliodigestive Anastomosis

The dissertation is dedicated to studying functional changes in the small intestine at different types of biliodigestive anastomoses and evaluating their impact on the choice of optimal reconstructive surgery for biliary tract diseases. The research analyzes the barrier function of the gastrointestinal tract depending on the level of bile inclusion in the digestive process, as well as the quality of life of patients after surgical interventions on the bile ducts. The obtained data form understandings of the pathogenesis of enteropathy and allow for the development of individualized rehabilitation schemes.

Relevance of the research. Since the creation of the first biliodigestive anastomoses, more than a century has passed, yet the choice of the optimal reconstructive operation, the timing of its performance, and the technical details of these interventions remain subjects of discussion [A.D. Timoshin et al., 2000; K.O. Tbach et al., 2003]. In recent years, the number of reconstructive operations on the bile ducts has increased, due to the widespread introduction and mastery of laparoscopic cholecystectomy [V.N. Filizanko et al., 2000; I.N. Grishin, 2002; V.V. Tsvirkun, I.M. Buriev, 2004].

Iatrogenic injuries of the bile ducts occur during traditional open cholecystectomy with a frequency of 0.05% to 0.2% [A.S. Segshak, M.T. Totrop et al., 1988], during laparoscopic cholecystectomy from 0.3% to 3% [Yu.I. Gallinger et al., 1996; A.G. Krieger et al., 2000; V.N. Chernyshev et al., 2004], during gastric resection with a frequency of 0.05% to 1% [E.I. Galperin et al., 1982; A.I. Nechay et al., 1991], with even lower frequency encountered during operations on the duodenum due to low duodenal ulcers. Among reoperations on the biliary ducts, patients are operated on in 13-27% due to hepatocholedochal injuries [B.V. Petrovsky et al., 1980; A.I. Krakovsky, 1988; A.A. Movchun et al., 2000], while high figures of postoperative mortality from 4 to 56% remain according to various authors [V.V. Vinogradov et al., 1972; B.S. Rozanov et al., 1973; Yu.P. Savchenko, 2000; N. Besedin et al., 2002; M.M. Mamakeev et al., 2003].

The severity of the patients' condition is due to the pronounced nature and duration of jaundice, the frequency and severity of cholangitis attacks, significant disturbances of protein and water-electrolyte metabolism, and phenomena of hepatic insufficiency [E.I. Galperin et al., 1982; R. Vasilyev et al., 2001; K. Stalev et al., 2002]. Unsatisfactory results of the operation are associated with anastomotic insufficiency, formation of external or internal fistula, bile leak, and development of cicatricial stricture [E.I. Galperin et al., 2004; A. Bashlyk et al., 2004]. At the same time, the multiplicity of repeated surgical interventions in the same patient increases the risk of complications and determines the severity of the postoperative period.

The main task of surgical interventions on the extrahepatic bile ducts is the restoration of adequate bile outflow into the lumen of the gastrointestinal tract. Depending on the nature of the process, available conditions for performing the operation, and the severity of the patient's condition, the question of the method of completing the operation is resolved individually [K.D. Toskin et al., 1991; S.I. Tretyak et al., 2003].

The evolution of the surgical approach to treating these patients passed through several stages: from the application of prolonged scaffold drainage of the biliary drainage anastomosis with removable transhepatic drains to the formation of a biliary drainage fistula using precision technologies [V.I. Tarabrin, 2003; D.N. Panchenkov et al., 2004]. The possibility of new surgical technologies sets the following task: to restore not only the lost forms, i.e., to form a biliodigestive anastomosis, but also the lost function.

Under normal conditions, bile entering the lumen of the duodenum is included in the digestive process and participates in the transition from gastric to intestinal digestion. It has a stimulating effect on the secretion of the pancreas, gastric mucosa, motor and secretory activity of the small intestine, including the activity of intestinal villi, and exerts a bacteriostatic effect on the intestinal flora [G.F. Korotko, 2003]. During the formation of a biliodigestive anastomosis, continuous bile entry occurs outside the phases of digestion due to the inactivation of the bile sphincters. Pressure in the bile ducts is regulated only by bile production in the liver and the motor function of the included intestinal loop [B.A. Korolev et al., 1990]. The absence of bile in the duodenum leads to hormonal disorders in the pancreas and of the overall digestive process. Absorption of bile acids is disrupted due to the asynchronous appearance in the duodenum of chyme, bile, and pancreatic juice [B.V. Petrovsky et al., 1980]. At the same time, various symptoms of mainly gastroenterological character appear. This reality dictates the necessity of studying adaptive-pathological mechanisms formed under new conditions of functioning depending on the level of bile inclusion into the lumen of the gastrointestinal tract.

Thus, the question of surgical tactics when it is necessary to choose a method of including the bile ducts into the digestive process remains relevant. Various pathways of bile duct inclusion, as well as the loss of autonomy of the biliary system in the digestive conveyor, are difficult to assess by subjective sensations. Solving the question of the rational inclusion of the bile ducts into any section of the digestive tube, there arises a necessity to study the functional changes that the digestive process undergoes. There are several methods for assessing the functional state of the small intestine: tests of small intestinal permeability using polyethylene glycol (PEG) and labeled EDTA, determination of fat absorption, carbohydrate absorption, vitamin absorption [A.D. Bitty, 1995], etc. From this point of view, considerable interest is aroused by the recently appeared, in terms of methodological execution, possibility of repeated investigation of the functional state of the small intestine using a macromolecular probe [I.V. Gmoishinsky, 1997].

Given the above, the goal of this work was to improve the results of surgical treatment of patients with diseases of the choledochus.

To achieve the stated goal, the following tasks were set:

1. To provide an assessment of the clinical results of biliodigestive anastomoses depending on the method of surgical construction.

2. To study the state of the barrier function of the small intestine at various biliodigestive anastomoses depending on the level of bile inclusion.

3. To study the barrier function of the small intestine during external bile drainage.

4. To study the possibility of correcting the permeability of the intestinal barrier for protein macromolecules (albumin) after surgical interventions on the extrahepatic bile ducts.

5. To conduct an analysis of the quality of life of patients who underwent biliodigestive anastomoses.

Novelty of the research results

1. For the first time, the dependence between the barrier function of the small intestine and the level of bile inclusion in the digestive process was investigated.

2. The dynamics of changes in the barrier functions of the small intestine depending on the method of construction of the biliodigestive anastomosis was revealed.

3. Schemes for correcting small intestine function disorders in the remote postoperative period were developed.

4. For the first time, an assessment of the quality of life of patients at various types of biliodigestive anastomoses for diseases of the bile ducts was provided.

Main provisions of the dissertation for defense

1. For patients who underwent operations on the extrahepatic bile ducts, a persistent violation of the barrier function of the gastrointestinal tract is characteristic in the remote postoperative period.

2. The level of bile inclusion in the digestive process affects the permeability of the small intestinal barrier for protein macromolecules. With low bile drainage, a significant violation of the barrier function of the small intestine is observed.

3. For patients who underwent operations on the bile ducts, the development of enteropathy is characteristic — a state of morphofunctional insufficiency of the small intestine, manifested in the violation of physiological barriers and the penetration into the internal environment of the organism of large quantities of intact antigens, in particular albumin. The development of enteropathy is a non-specific and time-stable process.

4. In the postoperative period, it is necessary to include enteral therapy in the complex of therapeutic measures, since replacement therapy does not lead to adequate correction of the functional state of the small intestine.

Theoretical significance of the research.

The obtained results form understandings of the functional capabilities of the gastrointestinal tract in relation to the implementation of barrier function under conditions of formation of a biliodigestive fistula, as well as form an understanding of the pathogenesis of this state, which can serve as a basis for further research in the field of postoperative rehabilitation of patients after operations on the extrahepatic bile ducts.

Practical significance of the research lies in establishing criteria for the functional state of the small intestine, which can be used for the diagnosis of enteropathies of any etiology. Along with this, the results of the research represent significant methodological interest, as new research methods, first tested in this work, were used for their obtaining. At the same time, the individual character of the dynamics of barrier function, fixed by the investigation, allows the selection of an individualized complex of necessary therapeutic measures.

Information on the practical use of the research results

Based on the obtained data, practical recommendations are proposed for use in the Krasnodar Regional Clinical Hospital named after S.V. Ochapovsky №1 (350063, Krasnodar, ul. 1 May, 167) and the bases of the Department of Surgery, Urology, Traumatology and Orthopedics of FPK and PPS Kuban State Medical University. As a result of the research, 6 printed works have been published.

Concluding the introductory part of the dissertation, I would like to express sincere gratitude to my teacher — Doctor of Medical Sciences, Professor Alexander Mikhailovich Manuylov — for providing the research topic and creating all the conditions for its execution. At the same time, I thank the collective of the Department of Surgery, Urology, Traumatology and Orthopedics of FPK and PPS KGMU for daily assistance in the work and business discussion of the obtained results.