The Role and Place of Minimally Invasive Echo-Controlled Decompression Interventions in the Treatment of Acute Cholecystitis in Elderly Patients

The dissertation addresses the problem of treating acute cholecystitis in elderly and senile patients, in whom conventional surgical interventions are accompanied by high overall and postoperative mortality. The work analyzes the possibilities of using minimally invasive echo-controlled decompression interventions (gallbladder puncture and microcholecystostomy under ultrasound guidance) as an element of active surgical tactics. On the basis of clinical material, observation groups were formed, the severity of the patients' condition was objectively assessed using the APACHE II and POSSUM scales, and an algorithm for choosing therapeutic tactics was developed that takes into account the operative-anesthesiological risk. Indications for echo-controlled gallbladder decompression were formulated, the immediate and long-term results of its application were evaluated, and a reduction in postoperative and overall mortality was demonstrated.

INTRODUCTION

Relevance of the problem. Acute cholecystitis (AC) is a widespread pathology, ranking third after acute appendicitis and acute pancreatitis in the structure of urgent abdominal pathology. Patients with acute cholecystitis constitute no less than 13–15% of hospitalized surgical patients [13, 107]. By the present time, considerable experience has been accumulated in the surgical treatment of patients with AC. The wide introduction of endoscopic treatment methods has led to a qualitative improvement in the level of medical care for this pathology [8].

Nevertheless, over the decades, the overall and postoperative mortality rates in elderly patients with AC have shown no tendency to decrease and amount to 8 to 40% [3, 6, 14, 25, 128, 148, 168, 170], which is ten times higher than that in young patients [4, 8]. Urgent interventions in the group of persons over 80 years of age are accompanied by a postoperative mortality of 40–50%, causing a high risk of an unfavorable outcome [26, 34, 65, 108]. On the basis of these data, a number of authors consider such interventions unjustified and unpromising for surgical treatment in elderly age groups in patients with a high operative-anesthesiological risk.

In the domestic and foreign medical literature, a large number of works are devoted to the problem of treating patients with AC, reflecting mainly the use of modern endosurgical technologies [2, 67, 100]. At the same time, studies addressing this problem specifically in elderly and senile patients are relatively few in number.

At the present stage of the development of surgery, scientific and technological progress has made it possible to reconsider some concepts regarding the surgical treatment of AC. The appearance of ultrasound scanning apparatus in the medical arsenal made it possible to fundamentally change not only the diagnosis of diseases of the biliary tract, but also served as an impetus for the development of a new therapeutic direction — ultrasound diapeutics or navigational surgery, i.e., the performance of therapeutic manipulations under sonographic guidance. This technique, developed as early as the 1970s, is being used increasingly both in foreign [190, 194, 201] and in domestic surgical clinics [32, 43, 48, 109, 117, 130, 131]. Such interventions primarily include the modern minimally invasive variant of cholecystostomy — gallbladder puncture and microcholecystostomy under ultrasound navigation. This technique proved to be devoid of one of the main drawbacks of a surgical operation — the traumatic nature of the intervention [37, 40, 165, 171, 211]. This circumstance is extremely attractive for the treatment of AC in elderly patients with severe concomitant diseases.

It is very difficult to objectively determine the true tolerance to the upcoming operation in elderly and senile patients based only on the results of clinical examination with the use of a limited arsenal of instrumental methods [81]. Therefore, precisely in elderly and senile patients, it is necessary to use methods that allow safely postponing the radical operation and to use the time obtained in order to maximally safeguard the upcoming surgical intervention or reasonably refrain from it in cases of a high degree of operative-anesthesiological risk.

In recent years, a number of reports have appeared in the medical literature on the effectiveness of the use of diapeutic techniques in AC [21, 47, 111, 202, 203]. However, even at present the questions of choosing indications for these procedures in groups of surgical patients remain debatable. The long-term results of the use of such treatment methods remain practically unstudied. Thus, in the geriatric surgery of acute cholecystitis there remain unresolved questions, and the unsatisfactory results of treatment of these patients explain the relevance of further research.

Aim of the study: to improve the results of treatment of elderly patients with acute cholecystitis by using minimally invasive echo-controlled decompression interventions.

Objectives of the study

1. To study the effectiveness of surgical treatment of acute cholecystitis in elderly and senile patients.

2. To determine the indications for the use of echo-controlled gallbladder decompression methods in elderly patients with acute cholecystitis.

3. To study the effectiveness of the introduction of echo-controlled gallbladder decompression methods in elderly and senile patients with acute cholecystitis. To analyze the long-term results of the use of minimally invasive echo-controlled decompression interventions in elderly patients with acute cholecystitis.

4. To formulate an algorithm of active surgical tactics for the treatment of elderly patients with acute cholecystitis using minimally invasive echo-controlled decompression interventions.

Scientific novelty

By means of objective methods it has been established that when assessing the severity of the patient's condition according to the APACHE II scale above 18 points and the risk of lethal outcome exceeding 50% according to the POSSUM scale in patients with acute cholecystitis without peritonitis in elderly age groups, the operative risk exceeds the indications for surgery.

It has been substantiated that active surgical tactics, supplemented by the performance, according to the formulated indications, of minimally invasive echo-controlled decompression interventions, makes it possible to significantly improve the immediate results of treatment of elderly patients with acute cholecystitis.

It has been proven that the long-term results of treatment of non-operated elderly patients with acute cholecystitis are reliably better when using minimally invasive echo-controlled decompression interventions.

Theoretical and practical significance of the work

In the course of the work, the variants of the clinical course of acute cholecystitis in elderly and senile patients were studied when using various approaches to surgical and conservative treatment.

An algorithm for choosing surgical tactics has been developed, which includes, along with the surgical method of treatment and conservative measures, the use of minimally invasive echo-controlled decompression interventions, which makes it possible to improve both the immediate and the long-term results of treatment of elderly patients with acute cholecystitis.

Main provisions submitted for defense

1. The use of minimally invasive echo-controlled decompression interventions is an effective and safe method of treating acute cholecystitis in elderly patients with a high operative-anesthesiological risk.

2. Active surgical tactics in acute cholecystitis, supplemented by the use of minimally invasive echo-controlled decompression interventions, makes it possible to significantly improve both the immediate and the long-term results of treatment in elderly patients with acute cholecystitis and to reduce postoperative mortality from 13.5% to 3.7% and overall mortality from 10.2% to 1.6%.

Introduction of the results of the work into practice

The results of the dissertation research have been introduced into clinical practice and are used in the work of the Emergency Surgical Department of the Municipal Healthcare Institution "City Clinical Hospital No. 6 named after Academician V.N. Koshelev" in Saratov, the Surgical Department of the State Healthcare Institution "City Clinical Hospital No. 8" in Saratov, and the Emergency Surgical Department of the State Healthcare Institution "City Clinical Hospital No. 2 named after V.I. Razumovsky" in Saratov.

The materials of the work are also used in the educational process (in lectures, seminars, and practical classes) in the training of 3rd–6th year students, clinical residents, clinical interns, and listeners of the Faculty of Advanced Training and Professional Retraining of Specialists at the Department of Surgical Diseases of the Private Educational Institution of Higher Professional Education Medical Institute "REAVIZ".

Approval of the work

The main provisions of the dissertation work were reported and discussed at the interregional conference "Modern Medical Technologies in the Examination of the Spine and Other Organs in the 21st Century" (Saratov, 2009); the interregional scientific conference with international participation "New Technologies in Experimental and Clinical Surgery" (Saratov, 2011); the interregional scientific-practical conference dedicated to the 10th anniversary of Clinical Hospital No. 2 in Nalchik "Topical Issues of Modern Surgery" (Nalchik, 2010); the 12th International Slav-Baltic Scientific Forum "Saint Petersburg — Gastro-2010" (Saint Petersburg, 2010); the III All-Russian Week of Medical Science with international participation (Saratov, 2014); the "Summer Medical Internet Forum" (Saratov, 2014).

The provisions of the dissertation were discussed at meetings of the Saratov Society of Surgeons named after S.I. Spasokukotsky (2010, 2014).

Publications on the topic of the dissertation

On the topic of the dissertation research, 6 scientific works have been published, including 4 in journals included in the list of periodic scientific and scientific-practical publications recommended by the Higher Attestation Commission of the Ministry of Education and Science of the Russian Federation for the publication of the main results of dissertation research for the degree of Candidate of Medical Sciences.

Relation to the plan of scientific research

The work was carried out in accordance with the plan of research work of the private educational institution of higher education "Medical University "Reaviz".

Personal contribution of the author to the conducted research

The author personally and independently carried out an analysis of the fundamental modern literature on the topic of the dissertation, formed the groups of the clinical study in a volume sufficient to obtain statistically reliable results; determined the design of the study. All methods of surgical treatment of patients with acute cholecystitis were mastered by the author. The author independently performed analytical and variation-statistical processing of the obtained data, on the basis of which reliable and well-grounded generalizations and conclusions were made; the manuscripts of the author's abstract and the dissertation were prepared. The formulation of the aim and objectives of the dissertation research and the discussion of the obtained results were carried out jointly with the academic supervisors.

The microbiological component of the research was carried out by the author in the licensed laboratory of the Federal State Budgetary Educational Institution of Higher Professional Education "Saratov State University named after N.G. Chernyshevsky" together with the head of the laboratory, Doctor of Biological Sciences O.V. Ulyanova.

Structure and scope of the dissertation

The dissertation is set out on 119 pages of typewritten text and consists of an introduction, a review of the literature, 2 chapters of the author's own research, a discussion of the obtained results, conclusions, practical recommendations, and a bibliography comprising 135 domestic and 88 foreign literary sources. The dissertation is illustrated with 14 tables and 21 figures (photographs, schemes, diagrams, graphs).

Chapter 1. REVIEW OF THE LITERATURE

1.1. Issues of modern surgical tactics in acute cholecystitis in elderly patients

The term "cholecystitis" is understood, in practice, to cover virtually all inflammatory diseases of the gallbladder and the biliary ducts, proceeding from the fundamental postulate of the primacy of gallbladder pathology and the secondary nature of the lesion of the biliary ducts [27, 60, 143]. The occurrence of acute cholecystitis is associated with the action of several etiological factors. The leading role belongs to gallstone disease, which promotes the development of bacterial infection [49, 66, 71, 74, 139, 153].

Many authors recognize acute obstructive cholecystitis as the most frequent variant of the development of acute cholecystitis [34, 36, 46, 142, 164]. The main cause of its development is obstruction of the cystic duct by a calculus, a mucous plug, or increasing edema [31, 36]. As a consequence, hypertension rapidly develops, leading to destructive inflammation in the wall of the gallbladder. Only from the moment of obstruction of the cystic duct is there a danger of infection and destruction of the gallbladder [147, 175]. [19]

Theoretical and clinical studies by E.I. Galperin, Yu.M. Dederer, their students and followers have shown that, in essence, the concept of biliary hypertension encompasses the pathogenesis of all forms of complicated cholecystitis [16, 23, 29, 115]. The main difficulty lies in the impossibility of predicting the disease: hypertension can quickly reach large values [8, 70]; the infection may become clearly evident not from the very beginning, but somewhat later, when it has already become generalized [6, 10, 35, 64, 155]; these complicating moments are often accompanied by decompensation of concomitant diseases. With the development of the theory of biliary hypertension, the approaches to and attitude toward acute cholecystitis have changed significantly. Yu.M. Dederer and co-authors [29] established a direct dependence between the level of pressure in the gallbladder and the degree of destruction of its wall: the higher the pressure, the more pronounced the destruction. Disturbance of microcirculation contributes to a decrease in tissue resistance, to the penetration of infection into deeper layers of the wall and beyond its limits [61, 148].

An important role in the progression of pathological processes in destructive cholecystitis is played by the intravesical bacterial flora [45, 93]. Disturbance of bile outflow in obstruction or vascular ischemia leads to the rapid development of not only pathogenic but also conditionally pathogenic microbes [197]. As a consequence, the pressure in the gallbladder increases even more, creating prerequisites for the extravesical spread of infection.

The bacterial contamination of cystic bile, according to data from different authors, ranges from 40 to 90%, with bacterocholia increasing with longer durations of obstruction [38, 39, 82, 131, 159]. It is not excluded that abacterial cultures are a consequence of the imperfection of research methods under standard conditions, and that anaerobic infection is present in these observations [12, 30, 54, 114, 116, 160].

In widely discussed experimental studies, it was established that microbial contamination of bile alone does not yet lead to the development of inflammation in the gallbladder wall [81, 166]. This is due to the fact that under physiological conditions the sterility of bile is largely ensured by the antibacterial effect of bile acids [81, 139, 151, 152, 154, 169, 219]. Microbial colonization of the gallbladder, the initiating moment of which is bacterial adhesion, is one of the factors contributing to the development of acute cholecystitis [141, 177]. The reasons for this are a decrease in the bactericidal properties of bile due to a disturbance of the excretory function of Kupffer cells of the liver [143], and a disturbance of bile outflow occurring as a result of obstruction of the cystic duct [81, 159, 178]. In addition, under conditions of disturbed biliary hydrodynamics, the barrier function of the intestinal mucosa is disturbed, which leads to increased translocation of bacteria from the intestinal lumen into the bloodstream [208]. This explains the routes of penetration of bacteria into the biliary system by hematogenous and lymphogenous routes. There is also the opinion that microorganisms constantly enter the bile as a result of duodenobiliary reflux [149, 156, 158, 182].

The prescription of antibiotics is included in the standard of treatment of acute cholecystitis [72, 89, 181], and the conduct of rational antibacterial therapy is considered an important component in the complex treatment of this disease. For rational antibacterial therapy, a bacteriological study is required to determine the type of pathogen and its sensitivity to drugs. With the traditional treatment tactics, a bacteriological study can be performed only perioperatively. Thus, the physician can receive the information of interest for substantiating antibiotic therapy only 5–6 days after the operation. By this time, the patient is most often already being prepared for discharge and the result of the bacterial culture in no way affects the therapeutic tactics.

1.1.1. Variants of surgical tactics in acute cholecystitis

The modern history of the surgical treatment of cholecystitis spans more than 120 years from the moment when in 1882 Langenbuch performed the first cholecystectomy. [35] To this day, his phrase: "The gallbladder must be removed not because it contains stones, but because it produces them" is considered a dogma, and the main method of treating calculous cholecystitis remains surgical [22].

There is no section of surgery in which the opinions of surgeons differ as significantly as in determining the surgical tactics in acute cholecystitis. As early as the 1930s, opposite points of view were expressed, when M. Weber said: "A surgeon operating immediately because of the onset of symptoms of gallbladder empyema is only playing with death." C. Heyd retorted: "Those who advise waiting are playing a game of chance" [7].

The study of the problem of surgical tactics in acute cholecystitis has generated many works proving the effectiveness of one or another, frequently diametrically opposed, approach to the timing of surgical intervention [60, 162, 182, 188]. The paradoxical nature of the situation was aggravated by the fact that "… both surgeons who replaced the 'expectant' tactics with the 'active' one, and those who replaced the 'active' with the 'expectant' one, achieved a reduction in mortality" [1]. E.I. Galperin gave an explanation of this paradox: "This reduction was apparently related not to a change in tactics, but to the accumulation of experience and the improvement of diagnostic methods."

When analyzing the medical literature devoted to the problems of treating patients with AC, there is no doubt about the necessity of surgical intervention. There is only a choice of its timing and character. All tactical variants of AC treatment can be classified as active, expectant, and staged therapeutic tactics.

1.1.2. Expectant tactics in the treatment of patients with acute cholecystitis

In the years when operations for AC were a rare event, the opinion of S.P. Fedorov remained unshakable, who stated: "I avoided, whenever possible, and continue to avoid operations during an attack of cholecystitis, and I think that is why I have separate hundreds of operations with almost no mortality." In the 1960s–1980s, the main type of interventions were operations performed after preoperative examination and conservative treatment requiring no less than 5–7 days. Such tactics were accompanied by a mortality rate reaching 7.2–11.6% [24, 28, 64, 173].

The positive aspects of the "expectant" tactics are considered to be:

The possibility of arresting the attack by conservative measures within 1–2 days without the development of any complications in no less than half of the patients.

During an operation undertaken at early stages, in the acute period of the disease, the inflammatory infiltrate makes it difficult to isolate the elements of the hepatoduodenal ligament, and the destruction of the "infiltrate" may be complicated by microbial contamination of the abdominal cavity.

In "emergency" operations, the danger of iatrogenic injuries to the vessels and the common bile duct increases as a result of changes in the topography of the subhepatic space. In addition, elderly patients require prolonged preoperative preparation because of the high frequency and severity of concomitant diseases.

The most consistent opponents of active tactics and "early" operations were V.V. Vinogradov [17], as well as a number of other Soviet surgeons.

According to data of B.N. Esperov and co-authors [135]: "… when in the 1950s the tactics of treating AC were applied as in acute appendicitis, mortality reached 40%." The question of tactics and timing of operation for AC was discussed at the conference of surgeons in Saratov (1967), the plenum of the All-Russian Society of Surgeons in Kaliningrad (1968), the conference of hepatologists in Kemerovo (1969), and at the XXIV Congress of the International Society of Surgeons in Moscow (1971). At these symposia, an active appeal was made to abandon active tactics and "early" operations. At the height of an AC attack it was recommended to operate only on patients with peritonitis, while all other patients were recommended to undergo conservative treatment, with the operation to be performed after the subsidence of acute inflammatory phenomena [42; 52; 79].

Proponents of the expectant tactics believe that the main advantage of operations performed in the "cold interval" is the fact that they are performed under conditions when the inflammatory changes in the hepatoduodenal zone have subsided. It is generally accepted that this occurs approximately 2–3 weeks after the elimination of the acute attack. These time frames are quite relative. It has been shown that against the background of clinical well-being, severe inflammatory-destructive changes may persist in the region of the biliary tract and adjacent organs and tissues [88, 140]. Perivesicular abscesses and a dense infiltrate involving the hepatoduodenal ligament, the duodenum, and the colon complicate the operation and sharply hamper the performance of tissue dissection [23]. Analyzing the causes of this phenomenon, many authors point out that the powerful antibiotics used in the conservative treatment of acute cholecystitis create conditions for the appearance of atypically proceeding variants of the disease, which are accompanied by asymptomatic formation of purulent extravesical complications [8, 9]. It has been established that in those cases when severe destructive changes were discovered in the zone of surgical intervention during an operation in the "cold" period, the gallbladder was, as a rule, blocked, that is, the obstruction had not resolved by the time of the operation [8].

To date, in determining the treatment tactics, the majority of surgeons are guided by the patient's age and the duration of the disease as simple and objective criteria [106, 133]. The duration of the disease undoubtedly plays an important role in the development of perivesicular inflammatory changes and in the difficulties of performing the operation. Every surgeon in practice has to note that there is no direct temporal pattern in the staging of the course of acute cholecystitis [135]. Quite often, no technical difficulties arise when performing cholecystectomy 7–10 days from the onset of the disease [23, 221]. At the same time, findings of a dense perivesicular infiltrate, or even a perivesicular abscess, several weeks after a "relieved" attack of acute cholecystitis are not uncommon [81, 103]. There is also no direct relationship between the patient's age and the severity of his physical condition [94]. At present, a proposition has been formulated according to which the severity of the patient's condition determines only the intensity of conservative therapy, which simultaneously serves as preoperative preparation, and the choice of the method of surgical treatment [119, 134].

1.1.3. Active tactics in the treatment of patients with acute cholecystitis

According to V.N. Klimov [58]: "Throughout the history of surgery, operations at the height of an AC attack were not popular, but were always necessary. Their unpopularity is explained by the high mortality, and the necessity of their performance is dictated by vital indications." Interest in the intensification of therapeutic measures with the performance of "early" operations in patients with AC (within 24–48 hours from the moment of manifestation of the attack) increased after four randomized clinical studies carried out in the 1970s [162, 180, 182, 188]. As a result of these studies, it was established that in the vast majority of patients it is possible to perform the operation within 48 hours of the onset of the attack. It was convincingly proven that the active tactics are safe and lead to a reliably lower mortality and a lower frequency of complications associated with the development of AC complications. In our country, despite the fact that practically all researchers named the "delayed" performance of the operation as the main cause of lethal outcomes in the surgical treatment of patients with AC, the "expectant" tactics prevailed [76]. The majority of patients after the relief of acute phenomena were simply discharged from the hospital without operation. In a number of hospitals, this situation persists even now [8, 134].

The positive elements of the "active" tactics, according to its proponents, are:

Conservative therapy leads to a subsidence of the clinical manifestations of AC only in half of the patients with acute cholecystitis.

In elderly patients, asymptomatic variants of the course of destructive forms of AC quite often occur.

Active surgical tactics in AC make it possible to shorten the length of hospital stay of patients.

An early operation performed before bacterial infection of the bile prevents cholecystogenic changes in the liver and the development of decompensation of concomitant diseases.

Postoperative mortality in early operations differs little from that in planned operations [5] [1, 11, 105, 118, 176]. The expediency of active surgical tactics in patients with AC, according to its proponents, is due to: first, to the fact that the morphological changes in the gallbladder arising against the background of hypertension and caused by the inflammatory process never disappear without a trace, but lead to the development of extravesical complications; second, to the fact that the improvement in the patient's condition occurring with infusion therapy is often only apparent, since it does not always objectively reflect the reversibility of the inflammatory process [121, 140, 216]. In the clinical practice of any surgeon, there are regularly encountered observations in which, with prolonged conservative therapy, including antibiotics, against the background of clinical signs of improvement in the patient's condition, gangrene of the gallbladder, its perforation, or the formation