Mirizzi syndrome: Ukuhlelwa, isifo, unyango

Igama "Mirizzi syndrome" ezinxulumene ne igama ugqirha evela Argentina Mirizzi, ngubani na ke umbhali imisebenzi emininzi enxulumene amalungu ka zinomgutyulo biliary, kwakunye kusenziwa kwezonyango kummandla cholegraphy intraoperative.

Ngowe-1948, umsebenzi ugqirha wakhe zenzululwazi wachaza semiotics zeradiyoloji hepatic syndrome, iimpawu zazo wabonakala duct stasis eqaqambileyo contracture we bile duct. Kwakhona, umfanekiso calculouse syndrome idlalwa, nto leyo ichazwe kwi inkangeleko fistula phakathi senyongo kunye hepaticocholedochus.

Kukho yintswela

Asingabo bonke uqhelene nesi sifo njengoko Mirizzi syndrome. Yintoni na, siya uchaze ngezantsi. Kodwa kuqala kubalulekile ukuphawula ukuba ukuza kuthi ga amayeza ingqiqo kanye akachazwanga ngokupheleleyo. Ngokomzekelo, oogqirha abaninzi bakholelwa ukuba sisiseko sifo a licuthe le mithambo kwi imibhobho kususwa kunye nezintso ezo. Kakhulu kwandiswa ekuqulunqeni syndrome kubandakanya ukuchongwa lwesifo ewasusa indawo stenosis yobisi okanye pocket Hartmann calculus, nto leyo sikhatshwa ukudumba esinyini inyongo kwaye esizibonakalisa kwi cholangitis entsimini okanye senyongo.

Mirizzi syndrome, ogama yokuhlela thaca kweli nqaku izimvo zezazinzulu ezininzi, zibandakanya nje ukuvala le mithambo. Le nkqubo yezifo ibandakanya ilungelo elifanayo kokuhlambeleyo bile duct.

Ngokuqinisekileyo ngokwahlukileyo ukunyanga esi sifo izazinzulu abakholelwa ukuba sisiseko sifo fistula puzyrnoholedohealny. Kukho ephikisanayo kwi kwasendaweni kwenkqubo yezifo. Kumanqaku lwesayensi ekubhekiswe ubudlelane indawo phakathi senyongo kunye duct eziqhelekileyo hepatic, kunye namanye amaphepha ophando yimizekelo ngokufumaneka fistula phakathi esinyini inyongo kunye bile duct eqhelekileyo.

Ngokomzekelo, xa lucalulo MV Corlette, H. Bismuth (1975) fanekisela bilio-biliary fistula iintlobo ezimbini ngokuxhomekeke zalapha ekhaya kwabo okuhlangana (ngasentla okanye ngezantsi umchiza engundoqo duct esinganyangekiyo nenyongo).

Abanye abaphandi bathi ukubonakalalisa isifo licuthe le mithambo kunye nokusekwa hepaticocholedochus fistula holetsistoholedohealnogo.

ukutolikwa ezahlukeneyo wawachitha syndrome nzima imbono kubume bayo kwaye nzima ukufumana iindlela ezisebenzayo ukuluphatha.

Kwiminyaka yakutshanje, ngokufuthi uyakwazi ukufumana ingcaciso entsha yale ngezifo njengoko Mirizzi syndrome? Iindidi awo ziboniswa lunee ezimbini sifo:

• uhlobo etsolo, apho iingqameko sayo hepaticocholedochus;
• uhlobo ezingapheliyo, nto leyo evusa inkangeleko fistula phakathi hepaticocholedochus kunye sayo senyongo.

Inkcazelo classical

Inkcazelo ezaziwa inkqubo sifo njengoko Mirizzi syndrome, ifoto yayo thaca kolu viwo lunamaphepha ali amalungiselelo ezine eziphambili:

• indawo close duct engumzekelo senyongo kunye kwesibindi duct engundoqo;
• Ukubakho yamatye senyongo okanye bile entanyeni yakhe;
• obstructive inkqubo kwesibindi flow, nto leyo ibangelwa ngendlela esisigxina duct ne gallbladder concrement ukudumba ngeenxa zonke kuso;
• ubukho senyongo kunye okanye ngaphandle cholangitis kuye.

izimiso yokuhlelwa

Ziziphi iintlobo lesisifo eyahlulwe Mirizzi syndrome? Ulwahlulo ibandakanya inqanaba ukutshatyalaliswa engundoqo duct udonga zesibindi puzyrnoholedohealnym fistula (Csendes):

• Chwetheza I - ukucudisa amatye bile entanyeni isibindi senyongo eqhelekileyo okanye duct.
• Uhlobo II - ubukho vesico-holedohealnogo fistula elifumileyo ngaphantsi kwe 1/3 la manani achazwe zizonke duct kwesibindi;
• Uhlobo III - ubukho vesico-holedohealnogo fistula, emi 2/3 we-manani achazwe we bile kwesibindi;
• Uhlobo IV - ubukho vesico-holedohealnogo fistula, nto leyo ethatha ojikeleyo ngokupheleleyo duct hepatic, kuthiwa phantsi udonga bile ukugqibezela intshabalalo.

Ezibangela ukuba uphuhliso syndrome

Iimbangi ezingundoqo esi sifo njengoko Mirizzi syndrome:

• ucinezelo mithambo bile duct ngaphandle Bamqumbisa cholecystitis calculous oyingozi;
• phambi stricture bile duct ibekwe ngaphandle kummandla kwesibindi;
• hepaticocholedochus ukubunjwa perforations phambi stricture;
• uphuhliso fistula vesicovaginal holedohealnogo ukupheliswa engumzekelo stricture.

Kuxhomekeka isakhiwo imibhobho biliary, ubukhulu kunye nobunzima namatye, ngokunjalo iindlela inkqubo unyango inganqunyanyiswa nawaphi na amanyathelo ngasentla, kodwa inguqu ukusuka ucinezelo kancinane lwe enyongweni duct kwi vesico-holedohealny fistula ibonakala kuphela xa isifo gallstone.

Ucinezelo bazale zibe inyongo obucala stricture ukuba utyando lilibaziseka kwaye sifo iba ifomu esingapheliyo, apho ixesha kuxolelwe lokutshintshwa soveliso. Xa ixesha kodonga senyongo kunye hepaticocholedochus kuqala qha ukuba zanixa- ilitye elikhulu kwipokotho Hartmann. Phantsi uxinzelelo ubunzima bakhe maxongo trophism kuvela decubitus senyongo eludongeni duct. Emva koko fistula puzyrnoholedohealny yenziwe.

Esebenzisa iingxelo zophendlo lwezifo ukusuka senyongo enjalo sayo hepaticocholedochus concretions ukuwa. Fistula landa ububanzi ngokunciphisa zone yayo inyama ucinezelo. Ngenxa yoko, licuthe inxalenye proximal ye hepaticocholedochus iqhubeka, senyongo lifinyele ubukhulu, iyalahleka intamo, Hartmann epokothweni yaye inxalenye enkulu yomzimba. Ngenxa yoko, senyongo uba ngathi divertikulopodobnoe imfundo, nto leyo umyalezo kunye mithambo of extrahepatic inyongo duct usebenzisa anastomosis ngokubanzi. Ngokuqhelekileyo, akukho flow kwiqamza.

symptomatology

wenza njani Mirizzi syndrome? Iimpawu uphawu cholecystitis kwenzeka kwifomu oyingozi okanye ezingapheliyo kunye nophuhliso senyongo ngoomatshini. Inani elikhulu lezigulane kumanqaku lwezempilo isifo gallstone kunye ekuhlaseleni, senyongo ngoomatshini nokungazinzi koqoqosho ezikhoyo. Malunga data yenzululwazi, ezikhanya yaye uninzi iimpawu ngokufuthi wabonakalaliswa ziquka iintlungu esiswini ephezulu ngasekunene. Iintlungu kunye senyongo ochaphazelekayo 60-100% yamatyala.

Senyongo livela phambi vesico-holedohealnogo fistula.
Xa cholangitis yaphawula nomkhuhlane. Ngamanye amaxesha aphazamise intlungu hypochondrium, ukunxila, uphuhliso pancreatitis (izenzo njenge ukusibeka sisifo efanayo). Egazini kwandisa izinga yibilirubin, ALT, AST, kunye obrak phosphatase.

Ngubani na kuxhaphake kakhulu?

Mirizzi syndrome kwenzeka ngo-0.1% ezigulane kunye ubukho sifo gallstone. Ukuba yokungenelela ngotyando uyaqapheleka 0.7-2.5% kwizigulane. Abagulayo, amadoda kunye nabafazi ngokupheleleyo kuzo zonke iintlanga nezizwe. Ebudaleni ikwandim, isifo kwenzeka kakhulu ngakumbi rhoqo.

iindlela isifo

Yintoni ukuntsonkotha unyango lwezifo ezifana Mirizzi syndrome? Uxilongo kunye nendlela ngotyando akachazwanga ngokupheleleyo.

Xa amayeza mihla, akukho imithetho eyamkelekileyo ukuze kwenziwe iinkqubo yoxilongo. Nangona kukho inkqubela entsimini zizifo ezahlukahlukeneyo umfanekiso zonyango, umsebenzi uxilongo Umiswe nzima. Oku kusebenza malunga ne-20% amatyala. a abaphandi ezimbalwa kuphela ukuba kuqatshelwe ukuba ultrasound esi sifo ngaphambi komsebenzi ufikelela ekujoliswe ngqo 67,1% amatyala, MRI - ngo-94,4%, ultrasound intraductal - kwi-97% kunye cholangiopancreatography endoscopic retrograde - 100%.

Konke oku kubonisa ukuba iindlela zale mihla kokuxilongwa instrumental akasoloko kwenza kube lula ukubona Mirrizi syndrome kwixesha owandulela lo msebenzi.

Amaninzi, xa ultrasound wafumana mpawu zilandelayo:

• ukwandiswa umoya ngaphakathi isibindi ngokunjalo bungqamene proximal othambekele ye bile eqhelekileyo senyongo unexpanded;
• ukufumana karhulumente senyongo ukushwabana.

Iimpawu syndrome CT Mirizzi ungqamane iimpawu ukubonwa ultrasound. Nangona CT akakwazi ukunika ulwazi olubalulekileyo zokuxabangela ukuba indlela cuke, indima yawo ekumiseleni phambi somhlaza kwi imibhobho proximal ye senyongo yi kunokuba phezulu, nto leyo ibaluleke kakhulu kumahluko Mirrizi syndrome ne phambi somhlaza.

Magnetic intlokoma umfanekiso, endoscopy kunye cholangiopancreatography retrograde (ERPHG) iindlela zokufumanisa isifo alingana ngokumalunga ekuchongeni stricture holetsistoholedohealnogo fistula. Le iifoto kwi T1 imo kunye T2 kunokuba ngokucokisekileyo ngakumbi ukwahlula ukudumba ngumhlaza, ayikho ngamaxesha CT isidima kunye ultrasound. Noko ke, ngenxa yokuba amaxabiso aphezulu iimviwo ngu MRI le ndlela diagnostic ayisetyenziswanga kuwo onke amaziko ezempilo.

Magnetic intlokoma cholangiopancreatography uhlobo olutsha noko, kodwa kancinane wafundela of kokuxilongwa. izazinzulu ezininzi ukujonga njengendlela izimvo ethembisayo ukuba ityumbe ngezifo ezifana Mirrizi syndrome.

Ezinye izazinzulu zithi kwiincwadi zabo iingenelo ultrasonography laparoscopy indawo pancreatoduodenal. Ngethuba utyando moshilongo ekucingelwa CM le ndlela yenza kube lula ukuba kwakhiwe i-time umfanekiso we bile duct kwi iinqwelomoya eziliqela iziqhamo-engile ezahlukeneyo. Okwangoku, Noko ke, le ndlela uhlala ingafikeleleki kwaye unexplored kude kube sekupheleni.

Kufuneka kuqatshelwe ukuba, nangona ubukho iindlela ezahlukeneyo sifo, ukuseka ubukho CM kusenzima kakhulu, nto leyo bangazisa ugqirha balahlekile yaye zibangela umonakalo bile duct eqhelekileyo, nto leyo ngempazamo waqonda njenge lwesinye inyongo okanye flow ububanzi. Ukunqongophala iindlela eyamkelekileyo loxilongo phambi kotyando ityhala ukuphuhlisa indlela engcono.

Izikhokelo zonyango

Njani bayiyeka Mirizzi syndrome? Unyango ibandakanya iinkalo ezimbini eziphambili: indlela rentgenoendoskopichesky kunye nongenelelo yotyando.

uhlobo Rentgenoendoskopichesky unyango nga tirhisiwaka njengenyathelo lokuqala phambi utyando ukulungiselela uqhaqho. Wenza njenge ndlela elizimeleyo zonyango kwizigulane kunye ubukho SM kwimeko komngcipheko ophezulu iintlungu.

Bobubi ISityhi abaphandi emininzi iquka:

• sesichengeni sosasazeko lwemitha kwizigulane kunye nabasebenzi bezonyango;
• ixabiso eliphezulu ukuba iimviwo endoscopy kunye X-ray;
• ekungakwazini ukuphelisa licuthe le mithambo kwenxalenye proximal we bile duct wenziwamkhulu eqhelekileyo.

Ngokutsho ezincwadini zesayensi zahlukile kakhulu phakathi kwabo iindlela zokungenelela lwentsebenziswano. Kukho iinketho ezahlukeneyo imisebenzi zoqhaqho e SM.
Abanye oogqirha bakholelwa ukuba Mirrizi ziphathwe yi laparoscopy syndrome nto contraindicated ngokupheleleyo.

Ngu uhlobo oluxhaphakileyo ngakumbi ukusebenza xa Uhlobo lokuqala cholecystectomy syndrome, nto leyo esongezelelwe ekufunxeni choledoch.

Indlela ethathelwa yi ebusweni fistula biliobiliarnogo Mirizzi syndrome? umsebenzi lobume kufuna kuqhawulo recovery hloledoha ingqibelelo. Njengoko enye iindlela yokuvala bile duct eqhelekileyo, olusetyenziswa yi uninzi oogqirha kukuba ukuphelisa le siphene udonga lwaso ngokusebenzisa ingxenye ekhohlo inyongo lwesinye. Noko ke, abanye oogqirha bakholelwa ukuba ukushiya inyama nga kwandisa ingozi choledocholithiasis intsalela.

Xa kukho fistula holetsistobiliarnogo kucetyiswa ukuphunyezwa common bile duct stents iiplastiki kwi uhlobo okwethutyana. Imfuno olu hlobo yokusebenza, izazinzulu ezininzi uchaze ubukho utshintsho ixesha elide esivulekayo kummandla wendalo yokukrala nemisipha hepatoduodenal, apho SM ubonakala ungumzekelo umonakalo iindonga inyongo duct. Xa deformation bile duct donga lwabo kakhulu ezibandakanywe fistula.
Ngexesha kotyando, kukho izinga eliphezulu ubungozi iingxaki.

iingxaki kunokwenzeka

Kaninzi kwenzeka emva kotyando yi kwingxaki njengoko akwi common bile duct stricture. Ngokutsho ngumphandi Russian GI Dryazhenkova (2009) izigulane 46 owayefumene utyando, stricture kwenzeka ngo-6.5%.

Yintoni iziphumo isebenzela ekuthiwa yokuhambisa amanzi elahlekileyo, esenziwa izigulane ezine kunye nefom initial CM (buka stenotic)? Abaphandi V. S. savelev, VI Revyakin (2003) ikuqaphele nemiba ezintle sifo, nangona kunjalo, chaza ukususwa kwindawo umoya inkqubo yemibhobho yezi zizathu zilandelayo:

• uphuhliso senyongo;
• semibhobho kokuphazamiseka nimqumbisa ukuyilwa calculi amancinci;
• iityuwa yokulahlwa kwe ezindongeni amanzi;
• Ukhuliso lwe detritus, efanayo efanayo ukuya putty ukuba Uxhokonxwa ukuhlaselwa nezolo of cholangitis.

Ngezinga eliphezulu lobunzima operation kwizigulane kunye iqondo eliphezulu akwi common bile duct udonga intshabalalo. Ukuba sifo kwinqanaba lesithathu okanye lesine, ziphawuleka izinga lokusweleka ephakamileyo emva kotyando. Xa esi sifo ibekwe kwinqanaba lesithathu okanye lesine, abaninzi oogqirha asekele holedohoeyunoanastomoza.

Treatment emva kotyando

Njengoko ebekwe Mirizzi syndrome? Unyango emva kotyando ibandakanya wegazi anikezele ngengomso emva kotyando, kwiveki enye imini enye phambi kokuba bekhululwe esibhedlele. Sutures zisuswa ngomhla we-10.

Ubude avareji lokuhlala esibhedlele ziintsuku 10-12. Ubude lilonke ixesha ekuphulukenwe nalo ke iinyanga ezimbini.
Ngokuqhelekileyo, izigulane yabonisa ukuphumla kwi sibhedlela kwisebe kwimeko yesiqhelo.

isiphelo

Ukuza kuthi ga Mirizzi syndrome, ukuhlelwa, isifo kwaye afumane unyango lwe ezo zichazwe kweli nqaku, amayeza sithathwa njengomnye iingxaki sifo gallstone. Nangona kunjalo, endle loxilongo kunye notyando nangoku inani le miba ingasonjululwanga.

Nangona isibakala sokuba kukho uluhlu olubanzi lweentlobo ezahlukeneyo yokungenelela ngotyando, iziphumo zonyango abasoloko ukuhlangabezana kulindeleke.
Ngexesha lo msebenzi, ukunyuka kweqondo ingxaki obuvakalayo postoperative.

Ubunzima ekuqhubeni imisebenzi diagnostic, umngcipheko umonakalo we bile duct wenziwamkhulu, inani elincinane leembono, kunye spectrum zizityebi ngeendlela zotyando afuneka ngaphezulu olunzulu isifundo ngxaki.

Ukuqaliswa kwe siseko mihla loxilongo kunye nophuhliso ngamaqhinga kangangoko entsimini kotyando ngokuxhomekeke kwinqanaba le sifo yenza umguli ukuphakamisa unyango nale ingxaki lwe cholelithiasis.