Diagnosis and Staged Treatment of Patients with Obstructive Jaundice Using Minimally Invasive Technologies

The dissertation is devoted to the improvement of diagnosis and staged treatment of patients with obstructive jaundice of various origins, with the predominant use of minimally invasive technologies. It examines the informativeness of preoperative diagnostic methods (ultrasound imaging, esophagogastroduodenoscopy, magnetic resonance cholangiopancreatography, spiral computed tomography), the criteria for assessing the severity of the patients' condition, and the optimal timing of preoperative decompression of the bile ducts. Particular attention is given to a comparison of the two-stage treatment of cholecystocholedocholithiasis using endoscopic interventions on the major duodenal papilla followed by laparoscopic or minilaparotomy cholecystectomy, as well as to an evaluation of the results of surgical treatment via minilaparotomy access. A separate section addresses percutaneous transhepatic roentgeno-endobiliary methods of internal biliary diversion as a means of palliative treatment for radically inoperable tumors of the biliopancreatoduodenal zone.

The practical significance of the work is associated with the introduction of the developed diagnostic algorithm and the comprehensive program of staged treatment into the practice of the surgical departments of the S.P. Botkin City Clinical Hospital and into the educational process of the Department of General, Laser and Endoscopic Surgery of the Russian Medical Academy of Postgraduate Education (RMAPE).

Relevance of the topic:

The treatment of patients with obstructive jaundice is one of the most challenging problems in abdominal surgery. The progressive increase in the incidence of both gallstone disease (GSD) and tumors of the biliopancreatoduodenal zone (BPDZ), unsatisfactory treatment outcomes, and a large number of complications following traditional methods of treatment compel the search for new approaches in the management of patients with this pathology [42, 60, 81, 89, 95].

Despite the long-standing study of this problem, such issues as differential diagnosis and the choice of a rational treatment strategy continue to be relevant.

The severity of clinical manifestations in patients with obstructive jaundice is determined by profound disorders affecting the entire organism, especially the liver and kidneys. The significance of these alterations is so great that they constitute the defining factors in the course of the disease, the cause of postoperative complications, and mortality. The presence of purulent cholangitis significantly worsens treatment outcomes in this category of patients. The principal cause of death in patients with obstructive jaundice is the progression of hepatic failure after surgical intervention [4, 18, 74, 121, 171, 174, 200].

Despite the use of modern technologies in the diagnosis and treatment of patients with obstructive jaundice, postoperative mortality remains rather high: in non-tumor jaundice it amounts to 6.2–13.6%, while in tumor jaundice it reaches 15–40% [39, 43, 48, 61, 113].

The application of the staged method of treatment has made it possible to improve outcomes in this complex group of patients. At present, the necessity of eliminating biliary hypertension in the preoperative period is beyond doubt. However, the choice of the method of drainage and its duration, as well as the timing of the surgical intervention, remain debatable. There are no universally accepted criteria determining the degree of severity of obstructive jaundice. The considerable variability of these indices makes assessment by individual parameters difficult and renders the evaluation of outcomes of different treatment strategies on the basis of disease prognosis very complex. [43, 60, 74, 174].

The current trend in the development of approaches to the treatment of patients with obstructive jaundice consists in the broader application of minimally invasive methods, which make it possible to achieve optimal results with minimal operative trauma. They have not only assumed a leading place in the treatment of these numerous and complex patients, but are also rapidly and universally displacing traditional methods [32, 42, 43, 45, 81, 83, 142, 160, 170].

At present, the treatment strategy for complicated GSD has not been definitively established. The two-stage method of treatment has gained the widest acceptance: choledocholithiasis is eliminated before surgery by means of endoscopic interventions on the major duodenal papilla, while laparoscopic cholecystectomy is performed as the second stage [9, 46, 71, 81, 85, 194, 217]. The disadvantages of the laparoscopic approach are the complexity of laparoscopic manipulations on the common bile duct, prolonged tense capnoperitoneum, which considerably increases the risk of surgical intervention in patients with cardio-pulmonary pathology, and the high cost of the technology, which hinders its widespread dissemination.

An alternative is the method in which intervention on the choledochus and cholecystectomy are performed in a single stage via laparoscopic or minilaparotomy access. Endoscopic papillosphincterotomy (EPST) is carried out only when concomitant papillostenosis is identified, either intraoperatively or postoperatively [37, 39, 91, 123].

In the treatment of complicated gallstone disease in our country, the minilaparotomy access according to the method of M.I. Prudkov is gaining increasing acceptance. The available publications devoted to operative interventions via minilaparotomy access in complicated gallstone disease are few in number; they do not allow a clear opinion to be formed regarding the place and role of the method in the treatment of this complex pathology, and require further investigation.

The problem of treating patients with BPDZ tumors has lately been acquiring ever greater relevance, not only because of the rising incidence, but also because approximately 90% of them cannot undergo radical surgery. The definitive method of treatment in this category of patients is increasingly becoming percutaneous transhepatic biliary diversion procedures performed under ultrasonic and roentgen-television guidance [14, 33, 43, 81, 112, 161, 184, 220, 235]. They can be accomplished regardless of the level and extent of biliary obstruction. This new branch of clinical medicine has been termed "interventional radiology." However, the question of the choice of biliary diversion method in radically inoperable patients remains controversial to this day, and their social adaptation continues to be a difficult and not fully resolved problem.

Thus, the diagnosis and treatment of patients with obstructive jaundice of both tumor and non-tumor origin constitutes a relevant problem and requires investigation both with regard to determining treatment strategy and to the method of resolving the pathological process.

Aim of the study

The aim of the present investigation is to improve the results of treatment of patients with obstructive jaundice by optimizing the diagnostic algorithm, applying minimally invasive technologies, and employing the staged method of surgical treatment.

Objectives of the study

1. To study the informativeness of various preoperative diagnostic methods for obstructive jaundice and, on the basis of the results obtained, to develop the most optimal algorithm for their application.

2. To determine the most significant criteria for assessing the severity of the condition of patients with obstructive jaundice and the optimal timing of preoperative decompression of the bile ducts.

3. To analyze the results of the staged method of treatment of patients with cholecystocholedocholithiasis, combining endoscopic intervention on the major duodenal papilla with subsequent laparoscopic or minilaparotomy cholecystectomy.

4. To evaluate the results of surgical treatment of cholecystocholedocholithiasis via minilaparotomy access.

5. To assess the effectiveness of the application of percutaneous roentgeno-endobiliary methods of internal biliary diversion in patients with radically inoperable tumors of the biliopancreatoduodenal zone.

6. To substantiate the principles of staged treatment and the use of minimally invasive technologies in patients with obstructive jaundice of various origins.

Scientific novelty

1. An algorithm of preoperative diagnosis in patients with obstructive jaundice has been developed, making it possible to shorten the time required to establish the clinical diagnosis, to exclude the use of invasive diagnostic methods in the majority of cases, and to determine the most optimal treatment strategy depending on the cause of the jaundice.

2. The most significant criteria for assessing the severity of the condition of patients with obstructive jaundice have been determined.

3. The optimal timing of preoperative decompression of the bile ducts depending on the severity of obstructive jaundice has been established.

4. The advantage of surgical treatment of cholecystocholedocholithiasis via minilaparotomy access over the traditional method has been demonstrated.

5. The effectiveness of the clinical application of percutaneous roentgeno-endobiliary methods of internal biliary diversion as a definitive method of palliative treatment in patients with radically inoperable tumors of the biliopancreatoduodenal zone has been substantiated.

Practical significance

The developed diagnostic algorithm, employing modern radiological diagnostic methods, makes it possible to determine within a short time the level and character of biliary obstruction and the extent of the tumor process, and to choose the most optimal treatment strategy for patients with obstructive jaundice depending on its cause.

The basis of the developed comprehensive program for the treatment of obstructive jaundice is constituted by a differentiated approach taking into account the degree of its severity. Preoperative decompression of the bile ducts is the principal means of resolving cholestasis, hepatorenal failure, and inflammatory phenomena in the bile ducts.

The application of the staged principle of surgical treatment, the established timing of preoperative decompression of the bile ducts depending on the severity of obstructive jaundice, and the use of minimally invasive technologies make it possible to reduce mortality and the rate of postoperative complications and to shorten the duration of hospitalization.

Implementation of the results of the study

The results of the study have been introduced into the everyday practical work of the surgical departments of the S.P. Botkin City Clinical Hospital, Moscow. On the basis of the materials of the work, at the Department of General, Laser and Endoscopic Surgery of RMAPE, seminars and lectures are conducted within the framework of the advanced training program for surgeons from various regions of Russia and the CIS countries.

Approbation of the dissertation

The materials of the dissertation have been presented as reports: at the Congress of Moscow Surgeons "Emergency and Specialized Surgical Care" (Moscow, 2005); at the scientific conference (with the participation of countries of the near and far abroad) "New Technologies in Diagnosis, Interventional Radiology and Surgery of the Liver and Pancreas" (St. Petersburg, 2005); at the interregional scientific-practical conference "Minimally Invasive Technologies in Surgery" (Makhachkala, 2005); at the 6th scientific-practical conference of outpatient surgeons of Moscow and the Moscow region "Problems of Outpatient Surgery" (Moscow, 2005).

The dissertation was approbated at the joint scientific meeting of the staff of the Department of General, Laser and Endoscopic Surgery of RMAPE and the surgical departments of the S.P. Botkin City Clinical Hospital, Moscow, on 01.06.06.

Publications of the results of the study

Nine publications have been issued on the topic of the dissertation.

Main propositions of the dissertation submitted for defense:

1. The optimal combination of diagnostic methods in patients with obstructive jaundice is the sequential application of ultrasound imaging (USI), esophagogastroduodenoscopy (EGDS), magnetic resonance cholangiopancreatography (MRCPG), and spiral computed tomography (SCT). The most informative preoperative diagnostic method for identifying the level and character of biliary obstruction is MRCPG, which, when USI is non-informative, can replace invasive diagnostic methods (ERCPG and PTCG).

2. The principal criterion for determining the severity of the condition of patients with obstructive jaundice is the level of hyperbilirubinemia.

3. Decompression of the bile ducts is the main and effective component of preoperative preparation in patients with obstructive jaundice; it makes it possible to resolve cholestasis and hepatic failure and to arrest the inflammatory process in the bile ducts. The timing of preoperative drainage of the bile ducts is determined by the severity of obstructive jaundice and does not depend on its cause.

4. Surgical treatment of cholecystocholedocholithiasis via minilaparotomy access is a low-trauma and effective method that makes it possible to reduce mortality and the rate of postoperative complications and to shorten the duration of hospitalization.

5. Percutaneous transhepatic roentgeno-endobiliary methods of internal biliary diversion are minimally invasive and effective means of palliative treatment in patients with radically inoperable tumors of the BPDZ, making it possible to reduce mortality and the rate of postoperative complications and to shorten the duration of hospitalization.

Scope and structure of the dissertation. The work is set out on 167 pages of computer-typed text (Microsoft Word 2000 program, Times New Roman font, font size 14 points, 1.5 line spacing), and consists of an introduction, a literature review, a description of the materials and methods of the study, three chapters (3–5) containing the results of the author's own investigations, a conclusion, conclusions, practical recommendations, and a bibliography. The text of the dissertation