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The postcholecystectomy syndrome (PHES) includes group of the diseases of generally gepatobiliarnopankreatichesky system arising or amplifying after carrying out a cholecystectomia or other expanded operation on the bilious ways which were made mainly concerning cholelithiasis.
Definition of a syndrome as if emphasizes its convention as the main characteristic of a syndrome — communication with the postponed cholecystectomia can be various. The postcholecystectomy syndrome includes diseases at which communication with a cholecystectomia is obvious (for example, a syndrome of a long stump of a vesical channel), but there are diseases where communication directly with operation is not so explicit (holepankreatit, etc.).
There are opponents of this term, however, them a little. At most of doctors practical expediency of the term does not raise doubts, however is conventional that the term without additional indication of character of a disease loses clinical meaning.
Definitions of the individual diseases included in PHES:
The true new growth of stones in the damaged general bilious channel proceeds quite often with disturbance of circulation of bile and development of infectious and inflammatory process.
False recurrence of a lithogenesis, or the "forgotten" stones of a bilious channel — the stones existing at the time of operation and for various reasons not removed from the general bilious channel at the time of operational treatment.
The stenosing duodenal papillitis — the cicatricial and inflammatory narrowing of a big duodenal nipple leading often to development bilious, and sometimes and to pancreatic hypertensia, and also disturbance of alkalization of a duodenum.
Active commissural process in subhepatic space (limited chronic nonspecific peritonitis of subhepatic space) — a chronic inflammatory disease of a peritoneum and adjacent cellulose of area of a remote gall bladder and the damaged general bilious channel.
Chronic biliary pancreatitis (chronic holepankreatit) — the chronic pancreatitis connected with dysfunction of biliary system is more often — with bilious hypertensia.
Hepatogenous gastroduodenal ulcers — the ulcers, apparently, connected with an abnormal liver function and biliary system, in particular observed at bilious hypertensia.
Cicatricial narrowings of the general bilious channel — the postoperative (posttraumatic) narrowings of the general bilious channel of different degree leading to disturbance of circulation of bile and development of infectious and inflammatory processes in bilious ways.
Syndrome of a long stump of a vesical channel — the stump of a vesical channel increasing in sizes under the influence of bilious hypertensia causing quite often expressed painful symptom complex and appearing the place of a new growth of stones.
The postcholecystectomy syndrome tends to growth generally because of increase in number of cholecystectomias and other operative measures on the bilious ways. However the frequency of development of PHES () decreases by 100 operated patients at the expense of the best the preoperative and conducted during operation examination a little in recent years. The percent of development of PHES in operated fluctuates from 5 to 25.
Among patients the stenosing duodenal papillitis (30 — 50%) meets with PHES more often (especially at it is long not operated). Quite often the papillitis is combined with stones of the general bilious channel (true and false recurrence of a lithogenesis), biliary pancreatitis, etc. Stones of the general bilious channel (true and false recurrence) occur at 10 — 20%, active commissural process in subhepatic space — at 10 — 15% of patients.
To surgical failures a reflux cholangitis after an operational papillotomiya, biliodigestivny fistulas, insufficiency of a stump of a vesical channel treat with development of abscess, different types (and degrees) narrowings of the general bilious channel, etc.
Etiology and pathogeny
The reasons promoting development of PHES:
— late carrying out operation. Here cases when after the confirmed ZhKB active form developed migration of a stone in the general bilious canal and (or) acute cholecystitis belong first of all;
— defective inspection to and during operation. Here non-performance of ultrasonography and an operational holangiografiya in this connection do not find out stones and narrowings of the general bilious channel" a stenosis of a big duodenal nipple and other pathology that leads to the incomplete volume of the surgical help belong;
— actually surgical failures during operation: damage of channels, the wrong introduction of drainages, leaving of a long stump of a vesical channel, imposing of excessively narrow holedokhoduodenoanastomoz, not extraction of the found stones, etc.
In development of PHES special value has a condition of a big duodenal nipple at the time of performance of operation on a gall bladder. Its damage is often connected with migration of a stone on the general bilious channel. The stenosing duodenal papillitis plays an important role in development of disturbances of circulation of bile and developing of bilious hypertensia. The foreground in a pathogeny of the majority of the diseases carried to PHES, first of all such as true recurrence of a lithogenesis of the general bilious channel, biliary pancreatitis, a syndrome of a long stump of a vesical channel, a hepatogenous gastroduodenal ulcer, etc. is allocated for the stenosing duodenal papillitis.
If the big duodenal nipple at the time of operation was intakten, then excellent results of a cholecystectomia are observed at 90 — 95% operated. Absolutely other results are yielded by cholecystectomias at nekorrigirovanny narrowing of a big duodenal nipple. Therefore in a similar situation even more often the cholecystectomia is combined with a papillosfinkterotomiya which is quite often carried out by means of the endoscope. If leave the Stenosing duodenal papillitis without correction, then development of PHES is probable at 50 — 60% of the patients subjected only to a cholecystectomia.
Of course, in development of PHES play a role and other mechanisms. In particular, the increasing significance is attached to duodenal hypertensia.
The majority of the diseases carried to PHES break normal circulation of bile that is followed by a cholestasia, favorable conditions for development of a biliary infection. Except local processes, long even the insignificant cholestasia promotes deep disturbances of a cholesteric exchange and at these patients (first of all at suffering from the expressed stenosing duodenal papillitis and stones of the general bilious channel) the forced progressing of atherosclerosis with the subsequent development of a myocardial infarction or brain stroke is quite often observed.
There is no conventional classification of a postcholecystectomy syndrome. More often in daily practice the following systematization is used:
1. Recurrence of a lithogenesis of the general bilious channel (false and true).
2. Strictures of the general bilious channel.
3. The stenosing duodenal papillitis.
4. Active commissural process (limited chronic peritonitis) in subhepatic space.
5. Biliary pancreatitis (holepankreatit).
6. Secondary (biliary or hepatogenous) gastroduodenal ulcers.
Approximate formulation of the diagnosis:
1. A postcholecystectomy syndrome — false recurrence of a lithogenesis — a stone of the general bilious channel.
2. A postcholecystectomy syndrome — the stenosing duodenal papillitis with a resistant pain syndrome and disturbance of circulation of bile.
3. A postcholecystectomy syndrome — active commissural process (limited chronic nonspecific peritonitis) of subhepatic space.