Optimization of Diagnosis and Treatment of Choledocholithiasis in Geriatric Patients

The research is dedicated to the optimization of the diagnosis and treatment of choledocholithiasis in geriatric patients. The relevance of the work is due to the high prevalence of gallstone disease and the presence of life-threatening complications requiring surgical intervention. The study substantiates the advantage of minimally invasive technologies, develops improved diagnostic and treatment algorithms, and demonstrates the importance of studying central hemodynamics and nutritional status in elderly patients and long-livers during the perioperative period.

Gallstone disease is a common condition affecting people primarily over the age of 40. According to most studies, 10 to 25% of the European population suffers from gallstone disease. Approximately one quarter of the population over 60 and one third over 70 have gallstones. The problem of diagnosing and treating gallstone disease is extremely relevant due to the increase in its prevalence and the presence of life-threatening complications (V.K. Gostishchev et al., 2003; V.I. Malarchuk et al., 2004; Y. Tokunaga et al., 2003) [39, 40, 41, 90].

Concretions of the bile ducts, united by the general concept of 'choledocholithiasis', represent one of the forms of gallstone disease. According to various authors (Balalykin A.S., 1996; Nesterenko Yu.A. et al., 1993; N.A. Maistrenko et al., 2000), choledocholithiasis is found in 10-30% of patients with gallstone disease [10, 89, 99]. By the mechanism of stone formation in the bile ducts, they are divided into 'primary', formed directly in the bile duct, or entering it from the gallbladder (Tskakaya Z.A. et al., 1976). Primary stone formation in the bile duct occurs in 1-3% of patients with gallstone disease. This is usually associated with a violation of pigment metabolism or the development of scar stenosis of the distal part of the choledochus. In most patients, stones are formed in the gallbladder with subsequent migration into the choledochus, which is confirmed by the identity of the structure and chemical composition of gallbladder and bile duct concretions. The migration of stones from the gallbladder into the bile duct is facilitated by the expansion of the cystic duct or the formation of a cholecystocholedochal fistula (Mirizzi syndrome). 'Secondary' choledocholithiasis includes recurrent and residual stones.

The nature of the concretions has a fundamental value for subsequent treatment. The dreaded complications of choledocholithiasis are: cholangitis, mechanical jaundice, hepatogenic liver abscesses, liver failure (Galperin E.I. et al., 1996). Despite the successes achieved in the diagnosis and treatment of choledocholithiasis, there are many unresolved questions in this surgical problem regarding etiology, pathogenesis, classification, diagnostic methods, and rational treatment methods that could contribute to improving immediate and long-term results (B.S. Briskin et al., 2003; A.E. Borisov et al., 2004) [14, 15, 20, 22, 140, 178].

The number of emergency and planned abdominal surgeries in patients of the geriatric group with cardiac pathology (elderly - 61-75 years; old - 76-90 years; long-livers over 91 years) is increasing due to the high prevalence of choledocholithiasis. The success of surgical treatment depends on high-quality pre- and intraoperative diagnosis of the main and accompanying pathology, an adequate choice of intervention (preference is given to minimally invasive techniques) and rational management of the postoperative period. The present research is devoted to solving these issues.

Research objective

To improve the treatment outcomes of patients with choledocholithiasis through the use of minimally invasive technologies, adequate correction of hemodynamics taking into account impedance cardiography indicators, and postoperative enteral correction of homeostasis.

Research tasks

1. To study the features of the course of choledocholithiasis in patients of the geriatric group.

2. To evaluate the features of the perioperative period in patients of the geriatric group depending on the type of surgical intervention.

3. To identify changes in nutritional status in patients with complicated (cholangitis and liver abscesses) choledocholithiasis and develop principles of enteral correction of its violations.

4. To study changes in central hemodynamics in patients with uncomplicated and complicated choledocholithiasis depending on the type of surgical intervention using non-invasive bioimpedance technology — integral tetrapolar transthoracic body reography by W.G. Kubicek with computer signal processing in real-time mode.

5. To develop a rational, acceptable for practical use, clinical grouping of patients with choledocholithiasis.

6. To improve modern algorithms for the diagnosis and treatment of choledocholithiasis.

Scientific novelty

Based on clinical, laboratory, and instrumental studies, the advantage of minimally invasive technologies in the treatment of choledocholithiasis in persons of the geriatric group is substantiated, which allows improving treatment outcomes and reducing the number of postoperative complications.

The significance of studying central hemodynamics in elderly patients and long-livers using integral tetrapolar transthoracic body reography to assess its violations in the perioperative period is shown.

The nutritional status was studied and ways to correct homeostasis in geriatric group patients with complicated choledocholithiasis were developed.

The algorithms for diagnosis and treatment of choledocholithiasis and its complications in persons of the geriatric group have been improved.

Practical significance

In practical healthcare, the application of a classification of choledocholithiasis based on the temporal factor of stone formation is advisable.

Improved algorithms for the diagnosis and treatment of choledocholithiasis allow optimizing and specifying diagnostic and therapeutic measures in geriatric group patients.

The method for assessing the state of central hemodynamics using integral tetrapolar transthoracic body reography by W.G. Kubicek allows adequately and promptly determining the effectiveness of compensation of cardiovascular complications in patients with choledocholithiasis of advanced age and long-livers.

The use of enteral nutritional support using standard lactose-free isocaloric mixtures in patients with complicated choledocholithiasis allows safely conducting the postoperative period, reducing the duration of hospital treatment, and decreasing the number of infectious complications of the postoperative period.

Main provisions for defense

1. To improve the quality of diagnosis of choledocholithiasis and its complications in geriatric group patients, it is advisable to use an algorithm based on the stage-by-stage and sequential nature of examination data.

2. In the treatment of choledocholithiasis, its type, the presence of complications, and preference should be given to phased comprehensive minimally invasive treatment methods.

3. To assess the probability of cardiac risk in geriatric group patients, the use of integral transthoracic tetrapolar body reography is advisable.

4. Enteral nutritional support in patients with complicated choledocholithiasis is an integral part of complex therapy in the postoperative period.

Work validation

The main provisions of the dissertation were discussed and reported at the IV All-Russian Conference of Hepatic Surgeons (Tula, 1996), at the VI International Conference of Hepatic Surgeons of the CIS Countries (Kyiv, 1998), at a scientific session of PGMA (Perm, 2005), at the XIII International Conference of Hepatic Surgeons of Russia and the CIS Countries (Almaty, 2006). The work was discussed at a joint meeting of the departments of hospital surgery and surgical diseases of the medical-prophylactic faculty with a course in hematology and transfusion medicine, FPK and PPS of the State Educational Institution of Higher Professional Education "Perm State Medical Academy named after Academician E.A. Wagner" of the Federal Agency for Healthcare and Social Development.

Implementation of results into practice

The results of the research were implemented in the center of surgical hepatology of MUZ "Clinical Sanitary Unit No. 1" of the city of Perm. The developed methods are used in teaching the section "Gallstone Disease" at the department of surgical diseases of the medical-prophylactic faculty with a course in hematology and transfusion medicine, FPK and PPS.

Publications

10 scientific works have been published on the topic of the dissertation, including an article in the "Perm Medical Journal". The applicant is a co-author of the textbook "Nursing in Surgery" (edited by Prof. M.F. Zarivchatsky).

Structure and volume of the dissertation

The dissertation is presented on 137 pages of computer text, consists of an introduction, 5 chapters, conclusion, findings, practical recommendations, and a bibliography. It includes 19 tables, 3 figures. The bibliography contains 216 sources, of which 138 are by domestic authors and 78 are foreign.