Surgical approach in acute cholecystitis complicated by both choledocholithiasis and obstructive jaundice
Objective: To improve the results of surgical treatment of acute cholecystitis complicated by both choledocholithiasis and obstructive jaundice. Methods: The study is based on the results of complex diagnosis and treatment of 140 patients with acute cholecystitis (AC), with complicated choledocholithiasis and mechanical jaundice. Seventy-six of patients (54.3%) had medium and severe obstructive jaundice, and 64 (45.7%) had slight mechanical jaundice. In 28 (43.75%) observations cholecystocholedocholithiasis, complicated by mechanical jaundice, was not accompanied by systemic inflammatory complications, in the remaining 36 (56.25%) observations there was cholangitis (n = 16) and biliary sepsis (n = 20). Results: Surgical approach consisted of the step-by-step approach in all 140 patients. Thus, in 64 (45.7%) observations in the presence of choledocholithiasis and mechanical jaundice, endoscopic retrograde cholangiopancreatography was performed in the first stage with an attempt of endoscopic papillosphincterotomy (EPST) and lithoextraction. In 18 cases, with phlegmonous-calculous cholecystitis and choledocholithiasis with mechanical jaundice, combined interventions were performed - percutaneous transhepatic cholecystostomy with EPST and lithoextraction. Of the 38 patients with slight mechanical jaundice, in 20 cases, the first stage was performed by percutaneous-transhepatic cholecystostomy, in 18 - by percutaneous cholecystomy through infiltration (n = 10) and drainage techniques for perivesical abscess (n = 8). In 38 cases, with gangrenous cholecystitis (n = 28), gallbladder empyema (n = 6) and local biliary peritonitis (n = 4), cholecystectomy was performed from mini-laparotomy access followed by choledocholithotomy. Conclusions: Surgical approach with AC, in complicated choledocholithiasis and in obstructive jaundice, should be differentiated and justify the implementation of phased minimally invasive surgical procedures.