Tactics of surgical treatment of patients with acute destructive cholecystitis complicated by perivesical infiltrate

Abstract

Acute cholecystitis ranks second after acute appendicitis among urgent abdominal pathology. The number of patients with this disease is constantly growing, and according to various authors occurs in 10-12% of adults in the United States and Europe, which is the reason for about 2.5 million emergency and planned surgery [1]. The "gold standard" of surgical treatment of acute calculous cholecystitis is laparoscopic cholecystectomy [2,3]. Destructive forms of acute cholecystitis can be complicated by the development of dense perivesical infiltrate, which leads to technical difficulties during surgery and is often the cause of damage to the extrahepatic bile ducts, as well as the cause of laparoconversion. Despite the success of modern surgery, the rate of laparoconversion during laparoscopic cholecystectomy reaches 30% in destructive forms, and the frequency of iatrogenic damage - 1.4%, and in infiltrates, the percentage of this complication increased. [4,5]. The aim of the study was to improve the results of surgical treatment of destructive calculous cholecystitis complicated by perivesical infiltrate. Materials and methods. The results of surgical treatment of 177 patients with acute calculous cholecystitis complicated by perivesical infiltrate were analyzed, who were treated in the clinic of the Department of Surgery №2 Bogomolets national medical university during 2012-2021. Patients were divided into the main group (92 patients) and the comparison group (85 patients). The main group included patients who underwent surgery within 48 hours of infiltration, in the comparison group surgery was performed at a later date. The mean age of patients was 62.6±7.5 years, groups were representative by sex, age and comorbidity. Examination of patients and preoperative preparation was carried out in accordance with approved treatment standards. Results of the research. In patients of the main group during the operation was found loose perivesical infiltrate, which was easily separated by a blunt and / or sharp way with a clear visualization of the elements of the Kahlo triangle, which allowed to complete the operation laparoscopically. In 12 (13.04%) patients of the main group with concomitant choledocholithiasis laparoscopic cholecystectomy was preceded by endoscopic retrograde cholangiopancreatography followed by endoscopic papillosphincterotomy and lithoextraction of stones as the first stage of treatment. For 48-72 hours, patients underwent antibacterial, hemostatic and anti-enzyme therapy, followed by the second stage of laparoscopic cholecystectomy. The average duration of surgery was 58.2±5.4 minutes. Intraoperative complications in patients of the main group were not detected. All patients in the comparison group also began laparoscopic surgery. However, prolongation of conservative treatment of acute cholecystitis complicated by perivesical infiltrate as preoperative preparation for more than 72 hours led to the formation of gross inflammatory and scarring of the hepatoduodenal area, which on average doubled the time of surgery due to serious technical difficulties(110.4±6.3 minutes). Clinical signs of obstructive jaundice caused by choledocholithiasis were diagnosed in 15 (17.6%) patients of the comparison group. After performing the first stage of treatment (endoscopic retrograde cholangiopancreatography, endoscopic papillosphincterotomy with lithoextraction), the patient underwent conservative therapy according to the scheme described above for 5-7 days, the second stage - laparoscopic cholecystectomy. In 5 (5.9%) patients due to the inability to clearly identify the biliary tract and vascular structures, the operation was completed by laparoconversion. Iatrogenic damage of the common bile duct occurred in 3 patients (3.5%) of the comparison group (in one patient the complication was diagnosed intraoperatively). There were no fatalities in the main group and the comparison group. Conclusion. Performing laparoscopic cholecystectomy in patients with acute destructive cholecystitis in the early stages of perivesical infiltration allowed to halve the duration of surgery, minimize the development of intraoperative complications and avoid laparoconversion.