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CNAA / Theses / 2009 / June /

Evolutional particularities of the biliary lithiasis in patients with hepatic cirrhosis


Author: Pisarenco Sergiu
Degree:doctor of medicine
Speciality: 14.00.27 - Surgery
Year:2009
Scientific adviser: Vladimir Hotineanu
doctor habilitat, professor, State University of Medicine and Pharmacy "Nicolae Testemitanu"
Institution:
Scientific council:

Status

The thesis was presented on the 10 June, 2009
Approved by NCAA on the 1 October, 2009

Abstract

Adobe PDF document1.49 Mb / in romanian

Keywords

bile, biliary lithiasis, liver cirrhosis, fibrin adhesive, laparoscopic cholecystectomy, hemostasis of the gallbladder fossa.

Summary

The dissertation was completed within the Department of Surgery No. 2 of the State University of Medicine and Pharmacy “Nicolae Testemiţanu”. In the period 2003-2007 there were hospitalized 5423 patients with various surgical pathology in the clinic. The patients were divided into 3 groups: the study basic group (group – I) comprised 132 (28.9%) patients with liver cirrhosis displaying clinical and laboratory signs of biliary lithiasis. Group II (control) was formed of 324 (71.1%) cases of liver cirrhosis without biliary lithiasis. Group III (control) consisted of 1010 (18.6%) cases of biliary lithiasis in the absence of the hepatopathy.

There were identified the primary factors for lithogenesis in patients with liver cirrhosis compared to biliary lithiasis in the absence of hepatopathy. Thus, the biochemical changes of bile with an increased concentration of precipitating components (calcium bilirubinate) and decrease of stabilizing factors (cholic acid and phospholipids), conditioned by the alteration of hepatic functions, associated with decreased motility of the extrahepatic biliary pathways and gallbladder, associated with chronic and latent infection, determine the higher incidence of biliary lithiasis in cirrhosis patients compared to general population. The diagnosis of biliary lithiasis in cirrhosis patients was ruled based on clinical data, both subjective and objective, the results of laboratory investigations, and non-invasive and mini-invasive instrumental methods. Clinical evolution of biliary lithiasis in patients with cirrhosis was frequently characterized by an asymptomatic clinical picture, with relatively more rare obstructive inflammatory complications, but severe destructive processes, associated with rapid decompensation of the hepatic functions.

A comparative experimental study of the hemostatic properties of the noncommercial fibrin adhesive and “TachoComb” preparation was performed, and it showed similar results. This study allowed for the implementation in the clinical practice of laparoscopic cholecystectomy with application of fibrin adhesive hemostasis of the gallbladder fossa (invention patent MD 3093). The given method presumes thorough infiltration of the retrovesicular area with fibrin adhesive leading to the decollation of gallbladder in the circumstances of a secure hemostasis of the gallbladder fossa, improving the outcomes of the miniinvasive surgical treatment in biliary lithiasis of the patients with liver cirrhosis. The performed research has shown the reasonability of an individualized strategy in the medical-surgical and endoscopic treatment in patients with liver cirrhosis and biliary lithiasis, surgery being indicated in acute destructive cholecystitis with calculus, the cholecystectomy in asymptomatic biliary lithiasis, as a rule, causing worsening of changes in liver functions with the progression of the cirrhotic process.