Mirizzi syndrome: ngezigaba, uphethwe, ukuphathwa

Igama elithi "Mirizzi syndrome 'kuhlotshaniswa igama udokotela ohlinzayo wase-Argentina Mirizzi, ngubani umlobi imisebenzi eminingi ehlobene physiology excretion biliary, kanye umkhuba emtholampilo emkhakheni cholegraphy intraoperative.

Ngo-1948, umsebenzi udokotela wakhe yesayensi echazwe semiotics radiology hepatic syndrome, izimpawu eyabonakala elikhanyayo Bile stasis futhi contracture we imbobo Bile. Futhi, isithombe calculouse syndrome yethulwa, okuyinto lubonakaliswa ukubukeka fistula phakathi gallbladder futhi hepaticocholedochus.

Kukhona ukungqubuzana

Akuwona wonke umuntu ujwayelene nalesi sifo njengoba Mirizzi syndrome. Kuyini, thina uchaze ngezansi. Kodwa okokuqala kuyafaneleka ukuthi kuze kube manje kwezokwelapha umqondo kakhulu akachaziwe ngokugcwele. Ngokwesibonelo, odokotela abaningi bakholelwa ukuthi ngesisekelo lesi sifo singumbulali ukuvaleka mafutha anciphisa isikhala esingaphakathi ku Amapayipi kwesibindi. landiswa kakhulu ekwakhiweni syndrome kuhilela ukuhlonza isifo sesibindi ne stenosis endaweni imbobo noma ephaketheni Hartmann calculus, okuyinto kuhambisana ukuvuvukala kwesinye nenyongo futhi kubonakala cholangitis ensimini noma i-jaundice.

Mirizzi syndrome, ogama ngezigaba uvezwa kulesi sihloko umbono yososayensi abaningi, libhekene hhayi kuphela omncane mafutha anciphisa isikhala esingaphakathi. Inqubo sokugembula kuhilela kwesokudla ezivamile futhi evamile Bile imbobo.

Kasibili ehlukile aphathe lesi sifo of nososayensi abakholelwayo ukuthi ukhona ukuthi ngesisekelo lesi sifo fistula puzyrnoholedohealny. Kukhona aphikisanayo ngomhla kwasendaweni yenqubo sokugembula. Kwezinye izihloko zesayensi wawubhekisela ekwenzeni indawo phakathi gallbladder kanye ezivamile imbobo hepatic, futhi kwezinye amaphepha ocwaningo izibonelo ukutholakala fistula phakathi esinyeni nenyongo futhi ezivamile Bile imbobo.

Ngokwesibonelo, e Ukwahlukaniswa MV Corlette, uH bismuth (1975) emelelwa fistula bilio-biliary ezimbili izinhlobo kuncike kwasendaweni kwalapho (ngenhla noma ngezansi kwakwakhe eyinhloko uvule imbobo fibrosis nenyongo).

Abanye abacwaningi abathi okubonakalisa isifo ukuvaleka mafutha anciphisa isikhala esingaphakathi kanye kumiswa hepaticocholedochus fistula holetsistoholedohealnogo.

incazelo ehlukahlukene ngokuyisisekelo syndrome inkimbinkimbi bezibona essence yayo futhi usinda ukuthola izindlela eziphumelelayo yokuphatha kulo.

Eminyakeni yamuva, ngokuvamile ungathola incazelo entsha yale zokugula njengoba Mirizzi syndrome? Izinhlobo zayo ziboniswa ezimbili ezahlukeneyo lesi sifo:

• ifomu acute, lapho ayisesemikhulu inesikhala hepaticocholedochus;
• ifomu okungamahlalakhona, okuyinto kuphakamisa ukubukeka fistula phakathi hepaticocholedochus kanye gallbladder inesikhala.

Incazelo classical

Incazelo zakudala yenqubo isifo njengoba Mirizzi syndrome, isithombe okuyinto okwethulwa kulesi phepha linamakhasi ayi amalungiselelo ezine eziyinhloko:

• isikhundla eduze imbobo parallel we gallbladder nesibindi uvule imbobo main;
• Ukuba khona amatshe e-gallbladder noma imbobo e entanyeni yakhe;
• obstructive inqubo isibindi ukugeleza, okuyinto kubangelwe ezihleliwe concrement imbobo kanye gallbladder ukuvuvukala nxazonke zalo;
• khona-jaundice noma ngaphandle cholangitis kuye.

izimiso of ngezigaba

Yiziphi izinhlobo lesi sifo lihlukaniswe njengoba Mirizzi syndrome? Ukwahlukaniswa kuhilela ekubhujisweni ezingeni main imbobo odongeni isibindi puzyrnoholedohealnym fistula (Csendes):

• Thayipha mina - ecindezela okuvame imbobo amatshe entanyeni isibindi gallbladder noma imbobo.
• • Type II - khona fistula vesico-holedohealnogo bangazihluphi esingaphansi 1/3 ye-selilonke ingqikithi uvule imbobo kwesibindi;
• Uhlobo III - khona vesico-holedohealnogo fistula, okuyinto oluthatha 2/3 of obungazungeza imbobo kwesibindi;
• Uhlobo IV - khona vesico-holedohealnogo fistula, okuyinto ethatha selilonke umnyuziki imbobo hepatic, lapho odongeni imbobo is phansi ukuqedela ekubhujisweni.

Izimbangela ukuthuthukiswa syndrome

Ziyini izimbangela eziyinhloko zalokhu yalesi sifo njengoba Mirizzi syndrome:

• kokucindezelwa inesikhala Bile imbobo ngaphandle sokucasuka cholecystitis calculous acute;
• khona Bile imbobo stricture engaphandle esifundeni kwesibindi;
• hepaticocholedochus kumiswa perforations ebukhoneni stricture;
• ukuthuthukiswa fistula vesicovaginal holedohealnogo ukuqedwa okucishe kufane nalokhu stricture.

Kuye isakhiwo Amapayipi biliary, ubukhulu nesisindo zamatshe, kanye nezindlela nqubo yokwelapha kungamiswa kunoma yiziphi izinyathelo ezingenhla, kodwa ushintsho kusuka kokucindezelwa kancane uvule imbobo Bile e fistula vesico-holedohealny kungabonakala nasemkhakheni kuphela isifo gallstone.

Kokucindezela lukhumuzeka ku Bile imbobo stricture uma ukuhlinzwa imisiwe futhi lesi sifo siba ifomu okungamahlalakhona, lapho inkathi ukuthethelelwa esikhundleni NEKUKHULUMA. Lapho isikhathi odongeni gallbladder futhi hepaticocholedochus uqale ukuthintana lokho kwaqala yitshe elikhulu ephaketheni Hartmann. Ngaphansi yokucindezela isisindo sakhe eziwohlokayo trophism kuphakama decubitus gallbladder udonga futhi imbobo. Khona-ke kwamiswa fistula puzyrnoholedohealny is.

Esebenzisa imibiko enjalo sokugembula kusukela gallbladder ku mafutha anciphisa isikhala esingaphakathi hepaticocholedochus ukuwa concretions. Fistula anda ubukhulu ngokunciphisa izicubu kokucindezelwa yayo zone. Ngenxa yalokho, i-ukuvaleka ingxenye proximal ka hepaticocholedochus iqhubeka, lo gallbladder kuyehla ngobukhulu, iphele entanyeni, Hartmann ephaketheni futhi ingxenye enkulu yomzimba. Ngenxa yalokho, i-gallbladder uba njengamazwi divertikulopodobnoe imfundo, okuyinto umlayezo nge mafutha anciphisa isikhala esingaphakathi we extrahepatic Bile imbobo usebenzisa anastomosis ububanzi. Njengomthetho, akukho ukugeleza bubble.

symptomatology

Kanjani Mirizzi syndrome? Izimpawu sici cholecystitis kwenzeka ifomu oyingozi noma ezingamahlalakhona ukuthuthukiswa jaundice lokukhanda. Inombolo enkulukazi iziguli amanothi yezokwelapha eminye ekhona isifo gallstone nge ukuhlaselwa njalo, cyclical jaundice lokukhanda. Mayelana nemininingwane yezesayensi, bhá futhi izimpawu kakhulu Ngokuvamile ubonakaliswa isimo sengqondo zihlanganisa ubuhlungu esiswini elingenhla kwesokudla. Ubuhlungu jaundice othintekayo 60-100% of amacala.

Jaundice livela kaningi ku-khona fistula vesico-holedohealnogo.
Lapho cholangitis waphawula imfiva. Ngezinye izikhathi ukuphazamisa ubuhlungu hypochondrium, ukudakwa, ukuthuthukiswa pancreatitis (izenzo njengoba zinqwabelanisile isifo ovamile). Esikhathini igazi kwandisa izinga bilirubin, ALT, AST, futhi ane-alikhali phosphatase.

Ngubani izinkinga ezivamile?

Mirizzi syndrome kwenzeka 0.1% eziguli nokuba khona isifo gallstone. Uma kokungenela kuhlinzwa is ebonwe 0.7-2.5% eziguli. Abagulayo, kokubili amadoda nabesifazane ngokuphelele zonke izinhlanga nezizwe. Lapho esegugile, isifo kwenzeka kakhulu njalo.

izindlela ukuxilongwa

Uyini yinkimbinkimbi ekwelapheni izifo ezifana Mirizzi syndrome? Sifo nisondele kuhlinzwa akachaziwe ngokugcwele.

Ngo inqubo yokwelapha yesimanje, akukho imithetho owamukelwa for beqhuba izindlela zokuxilonga. Naphezu kwentuthuko emkhakheni wezokwelapha imaging izifo ezihlukahlukene, ukusebenza ukuxilongwe Ngebika nobunzima. Lokhu kusebenza mayelana 20% amacala. a abacwaningi ezimbalwa kuphela ziye zaphawula ukuthi ultrasound zesifo ngaphambi ukusebenza ifinyelela ilitshe okunembile 67,1% of amacala, i-MRI - e 94,4%, ultrasound intraductal - at 97% futhi endoscopic cholangiopancreatography retrograde - 100%.

Konke lokhu kusikisela ukuthi izindlela zesimanje ukuxilongwa wezinsimbi akusho ngaso sonke isikhathi ukwenza kube lula ukubona ukuthi Mirrizi syndrome esikhathini esingaphambili ukusebenza.

Ngokuvamile, lapho ultrasound wathola lezi zimpawu ezilandelayo:

• isandiso imbobo phakathi kwesibindi kanye ngokufanele nalokho okwenzeka proximal ovamile imbobo gallbladder unexpanded;
• ekutholeni isimo gallbladder esishwabene.

CT Mirizzi syndrome izinkomba kuhambisane izici ukutholwa ultrasound. Nakuba CT ngeke likwazi ukunikeza ulwazi ebalulekile lokuchibiyela ukuze indlela ultrasonic, indima yayo ekunqumeni khona esifweni somdlavuza Amapayipi proximal we gallbladder kunalokho okusezingeni eliphezulu, okuyinto ebalulekile kwamangqamuzana Mirrizi syndrome ne khona umdlavuza.

Magnetic resonance imaging, Endoscopy futhi cholangiopancreatography retrograde (ERPHG) izindlela zokuxilonga kukhona okulingana ngokuqondene ekuboneni kanye stricture holetsistoholedohealnogo fistula. I izithombe kule T1 mode futhi T2 kungaba ngokuqondile kakhulu ukuhlukanisa ukuvuvukala umdlavuza, it akuyona inkinga njalo CT ubuhle kanye ultrasound. Nokho, ngenxa amanani aphezulu luhlolo ngu-MRI le ndlela zokuxilonga akuyona isicelo zonke izikhungo zezempilo.

Magnetic resonance cholangiopancreatography uhlobo empeleni esasisesisha, kodwa kancane wafunda ukuxilongwa. ososayensi eziningana ukulibuka njengoba ukubukwa ethembisayo ukuqoka zokugula ezifana Mirrizi syndrome.

Abanye ososayensi bathi emibhalweni yawo izinzuzo ultrasonography laparoscopic endaweni pancreatoduodenal. Phakathi ukuhlinzwa ukuze kutholwe isifo esolwa CM le ndlela yenza kube lula ukwakha isithombe real-time of the Amapayipi Bile e izindiza eziningana isithelo-engeli lehlukene. Nokho, Okwamanje, le ndlela uhlala ezingafinyeleleki futhi nhlobo kuze kube sekupheleni.

Kufanele kuqashelwe ukuthi, naphezu khona izindlela ezahlukene uphethwe, ukusungula khona CM namanje kunzima kakhulu, okungase ukwethula udokotela ohlinzayo badukile umonakalo ezivamile Bile imbobo, okuyinto ngephutha waqonda njengendlela esinyeni nenyongo noma ukugeleza ububanzi. Ukuswelakala kokusebenza ngokuhlanganyela izindlela owamukelwa uphethwe ngaphambi kokuba sihlinzwe liyancedisana ukuthuthukisa yezindlela ezingcono kakhulu.

izinkombandlela ukwelashwa

iqedwe kanjani Mirizzi syndrome? Yokwelapha ihilela izici ezimbili eziyinhloko: indlela rentgenoendoskopichesky futhi zilekelele kuhlinzwa.

uhlobo Rentgenoendoskopichesky ukwelashwa singasetshenziswa njenge sinyathelo sokuqala ngaphambi kokuba uhlinzwe belungiselela ukuhlinzwa. Uthatha isinyathelo njengoba indlela esizimele nokwelashwa kweziguli khona SM esimweni okusezingeni eliphezulu ingozi imithi ebulala izinzwa.

I yokuntula IsAm abacwaningi abaningi zihlanganisa:

• emisebeni ukuchayeka iziguli kanye nabasebenzi bezempilo;
• inani lentengo eliphezulu Endoscopy futhi-X-ray luhlolo;
• ukungakwazi ukuqeda ukuvaleka mafutha anciphisa isikhala esingaphakathi we ingxenye proximal we ezivamile Bile imbobo.

Ngokusho nezincwadi zesayensi kuyahlukahluka bodwa izindlela ukungenela op. Zikhona ongakhetha ahlukahlukene imisebenzi kuhlinzwa at SM.
Abanye odokotela bakholelwa ukuthi Mirrizi selashwe laparoscopy sifo ngokuphelele contraindicated.

Ngu ifomu evame kakhulu yokusebenzisa ukusebenza lapho uhlobo sokuqala cholecystectomy syndrome, okuyinto kulekelelwa nkinga choledoch.

Indlela gidi ngu khona fistula biliobiliarnogo Mirizzi syndrome? umsebenzi situational kudinga ukwahlukaniswa kanye yokutakula hloledoha ubuqotho. Njengoba enye yezindlela ukuvala ezivamile Bile imbobo, okuyinto sisetshenziswa iningi lodokotela abahlinzayo ukushabalalisa isici Nogange lwawo ngokusebenzisa ingxenye kwesokunxele nenyongo sesinye. Nokho, abanye odokotela bakholelwa ukuthi kokushiya izicubu kungandisa ingozi choledocholithiasis asalile.

Ngo khona fistula holetsistobiliarnogo Kunconywa ukuqaliswa kwe-common Bile imbobo stents amapulasitiki ku bemvelo yesikhashana. Isidingo salokhu hlobo lomsebenzi, Ososayensi abaningi bathi zavelaphi khona izinguquko zesikhathi eside okwenzeka endaweni yemvelo ukuvuvukala nemisipha hepatoduodenal, lapho SM kungenziwa waqonda njengoba imodeli umonakalo Bile imbobo izindonga. Ngezinye labo elikhulu ukusonteka Bile imbobo odongeni kufakwe fistula.
Phakathi ukuhlinzwa, kukhona izinga eliphakeme lobungozi yezinkinga.

yezinkinga kungenzeka

Ngokuvamile kwenzeka emva kokuhlinzwa kuyinto inkinga njengoba ezivamile Bile imbobo stricture. Ngokusho umcwaningi Russian GI Dryazhenkova (2009) iziguli 46 ngubani Ngahlinzwa, stricture kwenzeka ngo-6.5%.

Yini imiphumela imisebenzi izincwadi zabo kulokho okubizwa ngokuthi amanzi alahlekile, owabekwa iziguli ezine nge kokuqala ifomu CM (buka stenotic)? Abacwaningi V S. grishkovec, VI Revyakin (2003) waphawula Dynamics omuhle kakhulu lesi sifo, kodwa-ke, chaza ukususwa uvule imbobo indawo isimiso sokukhuculula yezizathu ezilandelayo:

• ukuthuthukiswa jaundice;
• amanzi isimiso sokucasuka kumiswa calculi elincane;
• nosawoti sebethule ezindongeni amanzi;
• ukunqwabelana detritus, ezifanayo ukungaguquguquki kuya putty ukuthi kuphakamisa ukuhlaselwa yansukuzonke ye cholangitis.

Izinga eliphakeme sobunzima ukusebenza iziguli ngezinga eliphezulu ezivamile Bile imbobo odongeni ekubhujisweni. Uma lesi sifo ngo esigabeni lesithathu noma lesine, ziphawuleka a lokufa ephakeme ngemva kokuhlinzwa. Lapho lesi sifo itholakala ezingeni lesithathu noma lesine, odokotela abahlinzayo kunazo zithambekele holedohoeyunoanastomoza.

Ukwelashwa emva kokuhlinzwa

Njengoba iboshiwe Mirizzi syndrome? Ukwelashwa emva kokuhlinzwa kuhilela segazi sokunikela ngosuku olulandelayo emva kokuhlinzwa, omunye ngesonto futhi usuku olulodwa ngaphambi osenyameni evela esibhedlela. Sutures ziyasuswa ngosuku 10th.

Ubude obuphakathi nendawo ukuhlala esibhedlela izinsuku ezingu-10-12. Ubude obuphelele kwesikhathi wokutakula izinyanga ezimbili.
Ngokuvamile, iziguli yabonisa ukuphumula esibhedlela emnyangweni nokuvuselelwa.

isiphetho

Kuze kube manje Mirizzi syndrome, ngezigaba, ukuxilongwa kanye nokwelashwa zazo ezichazwe kulesi sihloko, imithi ibhekwa njengenye yezinkinga isifo gallstone. Nokho, emkhakheni ukuxilongwa kanye nokuhlinzwa namanje eziningi ezingaphelele.

Naphezu kweqiniso lokuthi kukhona ezahlukene izinhlobo ezahlukene kokungenela kuhlinzwa, imiphumela yokwelapha musa njalo ukuhlangabezana kulindeleke.
Phakathi ukusebenza, kukhuphuke intra- kanye nasezinkingeni ezilandela ngemva kokuhlinzwa inkinga izinga.

Ubunzima ekuqhubeni imisebenzi zokuxilonga, ingozi we imbobo Bile, inani elincane ngekucaphelisisa, futhi spectrum ocebile izindlela zokuhlinza Uyi imfuneko ngaphezulu Ukulifunda ngijule inkinga.

Ukwethulwa izimiso yesimanje ukuxilongwa kanye nokuthuthukiswa amacebo elilungile emkhakheni ukuhlinzwa kuncike nesigaba lesi sifo kwenza isiguli nokwandisa yokwelapha nale inkinga ka cholelithiasis.