Mirizzi chirwere: kupatsanura, nechirwere, kurapwa

The zita "Mirizzi chirwere" chokuita nezita chiremba kubva Argentina Mirizzi, ndiani munyori mabasa mazhinji chokuita physiology pakati biliary excretion, uyewo sokuora tsika mumunda intraoperative cholegraphy.

Muna 1948, basa chiremba rake kwesayenzi akatsanangura radiological semiotics hepatic urwere, zviratidzo izvo akazviratidza inopenya bile stasis uye contracture yacho bile mutsinga dzinofamba nemukaka. Uyewo, mufananidzo calculouse chirwere chaipiwa, iyo inotaurwa nezve fistula pakati gallbladder uye hepaticocholedochus.

Pane kupikisana

Havasi vose ajaira chirwere ichi sezvo Mirizzi syndrome. Chii, isu tsanangura pazasi. Asi kutanga zvinokosha kuziva kuti saka kure mushonga chaizvo pfungwa zvizere kwete kunorondedzerwa. Somuenzaniso, vanachiremba vakawanda vanodavira kuti hwaro hosha iri aienda pamusoro lumen iri ducts chiropa. Most rakawedzerwa Pfungwa chirwere hunosanganisira kuziva chiropa chirwere pamwe stenosis nzvimbo mutsinga dzinofamba nemukaka kana muhomwe Hartmann calculus, icho pamwe kuzvimba nduru dundira hworatidza pacharo mumunda cholangitis kana jaundice.

Mirizzi urwere, ane kupatsanura ari munyaya ino ndiwo maonero masayendisiti akawanda, inozivikanwa kwete chete kuderedza pamusoro lumen. The pathological kwacho kunosanganisira kodzero chisakachena uye zvakafanana bile mutsinga dzinofamba nemukaka.

Absolutely zvakasiyana kubata chirwere remasayendisiti vanodavira kuti hwaro hosha iri puzyrnoholedohealny fistula. Pane kurwisana maonero pamusoro localization ari pathological muitiro. Mune dzimwe nyaya dzesayenzi akataura nzvimbo hukama pakati gallbladder uye vanhuwo hepatic mutsinga dzinofamba nemukaka, uye mune dzimwe tsvakurudzo mapepa mienzaniso Kuwanikwa fistula pakati nduru dundira uye zvakafanana bile mutsinga dzinofamba nemukaka.

Somuenzaniso, muna kupatsanura pakati MV Corlette, H. Bismuth (1975) aimiririra bilio-biliary fistula mhando mbiri zvichienderana localization ari mhesano (pamusoro kana pazasi huru mukomboni pamusoro cystic mutsinga dzinofamba nemukaka uye nenduru).

Vamwe vatsvakurudzi vanoti nekuratidzwa chirwere kuti aienda pamusoro lumen uye paumbwe hepaticocholedochus holetsistoholedohealnogo fistula.

Yakasiyana-siyana dudziro chezvematongerwe chirwere zvinoomesa omumwe ayo chaizvo uye kwakanyanya kuwana dzinobudirira kurapa nayo.

Mumakore achangopfuura, kazhinji unogona kuwana dudziro itsva zvokurwara ichi sezvo Mirizzi chirwere? Types dzayo vanoonekwa dzakasiyana mbiri chirwere:

• chenjera chimiro, umo kujekesa lumen hepaticocholedochus;
• chisingaperi chimiro, izvo chinokurwadzai nezve fistula pakati hepaticocholedochus uye gallbladder lumen.

The tsananguro chekare

Kurondedzerwa chaiwo chirwere kwacho sezvo Mirizzi urwere, pikicha iyo chinopiwa pepa iri inoumbwa mana makuru zvokudya:

• pedyo nenzvimbo zvinofambirana mutsinga dzinofamba nemukaka pamusoro gallbladder uye chiropa huru mutsinga dzinofamba nemukaka;
• Kuvapo matombo ari gallbladder kana mutsinga dzinofamba nemukaka pamutsipa wake;
• obstructive chiropa mutoo aibuda, izvo zviri kukonzerwa mune wakaiswa concrement mutsinga dzinofamba nemukaka uye gallbladder kuzvimba akapoteredza;
• kuvapo jaundice kana pasina cholangitis naye.

Misimboti kupatsanura

Ndezvipi chirwere ichi yakakamurwa sezvo Mirizzi chirwere? The kupatsanura kunosanganisira kuparadza pamwero mukuru mutsinga dzinofamba nemukaka rusvingo chiropa puzyrnoholedohealnym fistula (Csendes):

• Nyorai I - kudzvinya vanhuwo mutsinga dzinofamba nemukaka matombo chiropa mutsipa gallbladder kana mutsinga dzinofamba nemukaka.
• Type II - kuvapo vesico-holedohealnogo fistula pokugara asingasviki 1/3 of zvachose sekamufarenzi ari mutsinga dzinofamba nemukaka chiropa;
• Type III - kuvapo vesico-holedohealnogo fistula, izvo inoremekedzwa 2/3 ari sekamufarenzi ari mutsinga dzinofamba nemukaka chiropa;
• Type IV - kuvapo vesico-holedohealnogo fistula, zvinotora zvizere sekamufarenzi hepatic mutsinga dzinofamba nemukaka, sezvamakaropafadzwa mutsinga dzinofamba nemukaka rusvingo pasi kupedza kuparadza.

Zvinokonzera kuti urwere kukura

The kukonzera chirwere ichi sezvo Mirizzi urwere vari:

• compression lumen bile mutsinga dzinofamba nemukaka externally Penina calculous rikwanise cholecystitis;
• Kuvapo bile mutsinga dzinofamba nemukaka stricture iri kunze munzvimbo chiropa;
• hepaticocholedochus inotungamirwa perforations pamberi stricture;
• Kugadzirwa vesicovaginal fistula holedohealnogo yakafanana kubviswa stricture.

Zvichienderana nemamiriro biliary ducts, kukura uye uremu matombo, uyewo nzira kurapwa kwacho kunogona chakarembera chero pamusoro nhanho, asi kushandurwa kubva zvishomanana compression pamusoro bile mutsinga dzinofamba nemukaka iri vesico-holedohealny fistula inogona kuchengetwa chete panguva gallstone chirwere.

Compression degenerates kupinda bile mutsinga dzinofamba nemukaka stricture kana vavhiyiwa iri kunonoka uye hosha anova chisingaperi chimiro, umo nguva kuregererwa anotsiviwa peaking. Apo nguva gallbladder rusvingo uye hepaticocholedochus vanotanga kuonana kuti akaparirwa ibwe guru muhomwe Hartmann. Under kumanikidzwa uremu hwake hwakaramba trophism unovapo decubitus gallbladder rusvingo uye mutsinga dzinofamba nemukaka. Zvadaro puzyrnoholedohealny fistula aumbwa.

Kuburikidza yakadaro pathological mishumo kubva gallbladder kupinda lumen hepaticocholedochus kuwa concretions. Fistula akawedzera dhayamita nokuderedza ayo zvinyama compression wongoramba. Somugumisiro, mashoko aienda pamusoro proximal chikamu hepaticocholedochus kukapfuurira, kuti gallbladder ipfupi kukura, izvozvo haazombotaurwi mutsipa, Hartmann muhomwe uye chikamu chikuru muviri. Somugumisiro, mashoko gallbladder anova akafanana divertikulopodobnoe dzidzo, ndiro shoko chete lumen pamusoro extrahepatic bile mutsinga dzinofamba nemukaka uchishandisa yakafarikana anastomosis. Kazhinji, hapana sefuro chokubuda.

symptomatology

Mirizzi chirwere sei? Zviratidzo runozivisa cholecystitis kunoitika muna chakasimba kana chirwere fomu kukura zvokuimba jaundice. The nenhamba yakakura kwazvo varwere vanachiremba manotsi mberi huripo gallstone chirwere pamwe kakawanda kurwisa, cyclical zvokuimba jaundice. About mashoko dzesayenzi, chakajeka uye kazhinji akaratidza zviratidzo zvinosanganisira kurwadziwa repamusoro zvakanaka dumbu. Marwadzo uye jaundice hanya muna 60-100% nyaya.

Jaundice anooneka kazhinji pamberi vesico-holedohealnogo fistula.
Kana cholangitis akacherechedza fivhiri. Dzimwe nguva kunokanganisa kurwadziwa hypochondrium, kudhaka, kukura pfungwa nomuviri zvemwana asati (mabasa somunhu Ufukidze pamusoro vanhuwo chirwere). In ropa zvinowedzera mwero bilirubin, alt, AST, uye alkaline phosphatase.

Ndiani anonyanya?

Mirizzi chirwere kunoitika muna 0.1% varwere pamberi gallstone chirwere. Kana kuvhiya kupindira iri kuchengetwa 0.7-2.5% wevarwere. Sick, varume navakadzi zvachose vemarudzi ose uye marudzi. Pakukwegura, chirwere kunoitika zvikuru kakawanda.

nzira nechirwere

Chii kunzwisisa pakurapa zvirwere zvakadai Mirizzi chirwere? Chirwere uye kuvhiya handicho zvakazara kunorondedzerwa.

In mushonga ano, hapana mitemo kazhinji chigamuchirwe kuitisa chirwere dzokuvhiya. Pasinei nokufambira mberi mune zvokurapa kuri zvirwere zvakasiyana-siyana, chirwere oparesheni rinoumbwa yakaoma. Izvi zvinoshanda vanenge 20% nyaya. Chete vaongorori shoma vakaona kuti Ultrasound chirwere kushanda asati zvasvika chaiyo nangananga 67,1% nyaya, MRI - muna 94,4%, intraductal Ultrasound - pa 97% uye endoscopic retrograde cholangiopancreatography - 100%.

Zvose izvi zvinoratidza kuti nzira ano paku nechirwere hapasi kuti zvibvire kuziva Mirrizi chirwere munguva yapfuura kuvhiyiwa.

Kakawanda, apo Ultrasound akawana zvinotevera zviratidzo:

• ekisitenjeni mutsinga dzinofamba nemukaka mukati chiropa uyewo yaro proximal vanoda akaererana vanhuwo mutsinga dzinofamba nemukaka unexpanded gallbladder;
• kuwana gallbladder rakawunyana mamiriro.

CT Mirizzi chirwere zviratidzi uwirirane zvinhu dzakaonekwa ne Ultrasound. Kunyange zvazvo CT haagoni kupa mashoko okuwedzera inokosha imwe nzira ultrasonic, basa rayo kuona pamberi kenza ari proximal ducts ari gallbladder riri nani yakakwirira, iyo inokosha iri Kusiyanisa Mirrizi chirwere pamwe pamberi kenza.

Magnetic resonance kuri, endoscopy uye retrograde cholangiopancreatography (ERPHG) chirwere dzinoshandiswa yakaenzana panyaya yokuziva uye stricture holetsistoholedohealnogo fistula. The mifananidzo iri nzira T1 uye T2 anogona kuva zvakarurama kusiyanisa kuzvimba kubva kenza, hazvina chakanaka CT uye Ultrasound nguva dzose. Zvisinei, nokuda mubhadharo kunzvera kubudikidza MRI nzira ichi chirwere haina kushandiswa utano nzvimbo dzose.

Magnetic resonance cholangiopancreatography ari yerudzi rutsva, asi zvishoma kudzidza mhando nechirwere. Masayendisiti akawanda somukana aizobudirira zvikuru maonero kunan'anura zvokurwara akadai Mirrizi syndrome.

Mamwe masayendisiti vanoti mune zvavainyora zvakanakira laparoscopic ultrasonography pancreatoduodenal nharaunda. Panguva kuvhiyiwa vanofungidzirwa chirwere pamusoro CM nzira iyi zvinoita kuvaka-chaicho nguva mufananidzo bile ducts akawanda ndege nezvibereko zvakasiyana pamakona. Zvisinei, pari zvino, nzira iyi inoramba dzisingambosvikiki uye unexplored kusvikira pakuguma.

Zvinofanira kucherechedzwa kuti, pasinei nokuvapo akasiyana nzira nechirwere, chigaro kuvapo CM achiri zvakaoma, izvo zvinogona kutanga chiremba zvoita kukuvara vanhuwo bile mutsinga dzinofamba nemukaka, iyo kunonzwisiswa akaguma ave nduru dundira kana yakafarikana chokubuda. Kushaya kazhinji akagamuchira nzira nechirwere asati kuvhiya riri kufurira kukudziridza yenzira.

kurapwa Guidelines

Sei yaipotsa Mirizzi chirwere? Treatment kunosanganisira nzvimbo huru mbiri: rentgenoendoskopichesky nzira uye kuvhiya kupindira.

Rentgenoendoskopichesky mhando kurapwa ingashandiswa sezvo kwokutanga danho asati kuvhiyiwa kugadzirira kuvhiyiwa. Iye anoita se yakazvimirira nzira kurapwa varwere pamberi SM panyaya kumusoro rufimbi ngozi.

Zvazvakaipira Zvak Vatsvakurudzi zhinji dzinosanganisira:

• nemwaranzi kugarotamba kuvarwere uye vanachiremba;
• mutengo mukuru nokuda endoscopy uye X-ray ongororo;
• nekusagona kurambidza aienda pamusoro lumen pakati proximal chikamu nevakariri bile mutsinga dzinofamba nemukaka.

Maererano nemabhuku nesayenzi siyana zvikuru pakati pavo nzira kushanda kupindira. Pane nzira dzakasiyana-siyana kuti zvomusejari mashandiro pa SM.
Vamwe vanachiremba vanodavira kuti Mirrizi kubatwa laparoscopy chirwere ari zvachose contraindicated.

Pakazosvika anonyanya muchimiro kushanda apo wokutanga mhando ndiyo cholecystectomy chirwere, izvo vaisanganisa nokuda zvikasabudiswa choledoch.

Sei kutorerwa nokuvapo imwe fistula biliobiliarnogo Mirizzi chirwere? Ezvinhu basa kunoda kuparadzana uye kupora hloledoha kuvimbika. Sezvo imwe nzira nokuvhara vanhuwo bile mutsinga dzinofamba nemukaka, iro rinoshandiswa nenzira dzakawanda vanovhiya ndiko kurambidza kuremara rusvingo rwaro kuburikidza akasiya chikamu nduru dundira. Zvisinei, vamwe vanachiremba vanodavira kuti kusiya zvinyama anogona kuwedzera mukana residual choledocholithiasis.

In paine fistula holetsistobiliarnogo yakarumbidza Implementation zvinowanzoitwa bile mutsinga dzinofamba nemukaka stents mapurasitiki kumbobvumira hunhu. Kudiwa ichi mhando kushanda, masayendisiti akawanda anotsanangura kuvapo refu kuchinja kuitika munzvimbo anogumbura hunhu hepatoduodenal nemarunda, kuti SM anogona kuonekwa nazvo sezvo kukuvara womuenzaniso bile mutsinga dzinofamba nemukaka masvingo. At yavo yakawanda deformation bile mutsinga dzinofamba nemukaka rusvingo dziri fistula.
Pakuvhiya, pane mukuru azvipire pangozi yematambudziko.

zvinogoneka yematambudziko

Kakawanda richiwanika pashure pokuvhiyiwa iri kuomesa sehwakajairika bile mutsinga dzinofamba nemukaka stricture. Maererano Russian mutsvakurudzi GI Dryazhenkova (2009) 46 varwere akavhiyiwa, stricture kwakaitika muna 6.5%.

Zvii remapazi pamusoro inonzi arasika abudise, iyo yakaitwa varwere mana kwokutanga chimiro CM (stenotic maonero)? Vanotsvakurudza V. S. Savelev, VI Revyakin (2003) rakati zvakanaka rinomutsa nehosha Zvisinei, tsanangura kubviswa mutsinga dzinofamba nemukaka nzvimbo abudise gadziriro zvinotevera:

• Kugadzirwa jaundice;
• abudise mhingaidzo wakatsamwisa paumbwe calculi duku;
• munyu deposition pamusoro pamasvingo abudise;
• kuunganidza detritus, zvakafanana kusachinja-chinja kusvika putty kuti chinokurwadzai idzokororo yokurwiswa cholangitis.

The soro dhigirii yakaoma hwokushanda iri varwere pamwero wakakwirira tsika bile mutsinga dzinofamba nemukaka rusvingo kuparadzwa. Kana hosha iri rechitatu kana kuti rechina Danho, izvozvo rinozivikanwa wakakwirira mwero wokufa kwevanhu pashure kuvhiyiwa. Kana hosha iri rechitatu kana kuti rechina sandara, vanachiremba vanovhiya vakawanda tsitsi holedohoeyunoanastomoza.

Kurapa pashure pokuvhiyiwa

Sezvo yacho Mirizzi chirwere? Treatment pashure pokuvhiyiwa kunosanganisira ropa count tipe mangwanazve avhiyiwa, vhiki rimwe nerimwe zuva asati zvinoerera kubva kuchipatara. Sutures vanobviswa pazuva rechi10 zuva.

Avhareji urefu chipatara kugara mazuva 10-12. The zvachose ya yavaipora nguva iri mwedzi miviri.
Kazhinji, varwere akaratidza zororo ari pachipatara pacho iri kunaya dhipatimendi.

mhedziso

To zuva Mirizzi urwere, kupatsanura, chirwere uye kurapwa iro zvinorondedzerwa munyaya ino, mushonga anoonekwa somunhu mumwe matambudziko anoitika gallstone chirwere. Zvisinei, mune nechirwere uye kuvhiyiwa kuchiri dzinoverengeka zvisingagadziriswi nyaya.

Pasinei chokwadi kuti pane zvakawanda rakasiyana-siyana kuvhiya kupindira, kurapwa zvabuda havasi kusangana inotarisirwa.
Munguva oparesheni, ikawanda intra- uye postoperative kuomesa unodiwa.

Nematambudziko pakuitisa chirwere mabasa, pangozi kuzotadzira bile mutsinga dzinofamba nemukaka, vashoma zvakawanika, uye akapfuma chakarondedzera nzira Kuvhiya ndiwo chinodiwa kuti zvimwe zvakadzama kudzidza dambudziko.

The Sumo nheyo ano nechirwere uye kukura Zvakanyanya Kunaka Panguva Yepamuviri nzira mumunda kuvhiyiwa zvichienderana pavaipfuura chirwere kunoita murwere optimize kurapa pamwe kuomesa uku cholelithiasis.