RU2040913C1 - Method for treating the cases of purulent cholangitis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves setting drains in the ductus choledochus and two transhepatic drains in the ducts of both lobes of the liver. EFFECT: enhanced effectiveness of dialysis of bile ducts.

Description

 The invention relates to medicine and may find application in the treatment of purulent cholangitis in cases of impossibility of endoscopic decompression of the biliary tract before surgery.

 Numerous publications on the diagnosis and treatment of patients with obstructive jaundice indicate a continuing interest in leading specialists in this problem. Of particular importance, determined by high (up to 11-40%) mortality, are forms of obstructive jaundice, accompanied by acute purulent cholangitis.

 The introduction into clinical practice of methods for endoscopic decompression of the bile ducts has significantly improved the outcomes of surgical treatment of patients with obstructive jaundice by dividing the treatment aid into stages. However, in some cases, the inability for one reason or another to perform endoscopic decompression of the biliary tract, the ineffectiveness of conservative therapy dictate the need for urgent surgical correction. In this situation, the operation is performed in the general serious condition of the patient, which determines the appropriateness of the minimum intervention volume. According to various sources, mortality in this group of patients reaches 60%. Intervention at the height of obstructive jaundice, accompanied by acute purulent cholangitis, usually comes down to the option of external drainage of the common bile duct.

 Among the existing methods of external drainage of the bile ducts in practical surgery, the most widely used methods are Kera, A.V. Vishnevsky, Halsted-Pikovsky and their analogues in the form of various modifications that do not change their principle. In addition, transhepatic drainage options are used.

All these methods share common disadvantages:
passivity of drainage;
local effect of drugs introduced into the drainage;
the duration of treatment, which determines its high cost.

 The basic method is method A.V. Vishnevsky, which is taken as a prototype. It is carried out using a tube with an oblique cut of its end and with a side hole cut at a distance of 3-4 cm from this end. The drainage tube in the common bile duct is strengthened so that the side hole is located inside the duct. The choledochotomy opening is sutured hermetically around the tube, and its other end is brought out through a separate puncture of the abdominal wall.

 The main disadvantage of this method is its low efficiency in the treatment of purulent cholangitis.

 The aim of the invention is to develop a method of drainage of the bile ducts with purulent cholangitis, providing ductal dialysis.

 The method is illustrated in FIG. 1 and 2.

 After isolation of the hepatoduodenal ligament and identification of choledoch, the duodenum is mobilized according to Kocher and choledochotomy is performed as close as possible to the lateral wall of duodenum 1. This contributes to a slight increase in the lavage area. Then, after extracting stones from the ducts, etc. and its intra-operative washing, a conductor 3 with a diameter of 2-2.5 mm (with olive 4 at the end) is introduced into one of the lobar ducts 2.

 Conductor 3 is removed through the liver tissue and the anterior abdominal wall. Chlorovinyl drainage 5 is fixed to its olive by thread, which is carried out through the choledochtomic opening 6 and after separation from the conductor, drainage 5 is set high in the lobar duct 2 to the previously applied mark so that 3-3.5 cm of drainage remains in the duct (see Fig. 1). The position of the drainage is controlled radiologically. In a similar way, drainage is established in another lobe. A T-shaped drainage 7 or A.V. Vishnevsky's drainage is fixed in the choledochotomy opening (see Fig. 2). Transhepatic drainage is fixed to the skin with two ligatures. We monitor the tightness, adequacy of drainage and ductal dialysis on the operating table after suturing before draining the choledochotomy incision 6.

 After the operation is completed and the patient is transferred to the intensive care unit, we attach fluid infusion systems to both transhepatic drains, connected to vials with furatsilin solution 8. We include antibiotics, hydrocortisone and small doses of heparin in the dialysate.

 Bacteriological studies of washing water from the bile ducts showed that if, with traditional drainage methods, sanitation of discharge from the common bile duct occurs by 14-16 days, then when conducting ductal dialysis according to the described method, this period is reduced to 5-7 days.

 PRI me R. Patient R., 62 years old, medical history N 52/1752. He entered the Department of Abdominal Surgery of the Republican Clinical Hospital in Makhachkala 2.02.1990 g, about the syndrome of obstructive jaundice. Upon receipt of a complaint of pain in the right hypochondrium and in the epigastric region, fever, yellowness of the skin, skin itching, weakness, nausea. Feces are discolored, urine is dark.

 Sick for 3.5 months. Prior to admission to the surgical clinic, he was treated in the infectious ward, from where he was transferred after consulting a surgeon. In 1984, he underwent cholecystectomy for calculous cholecystitis.

 The condition at admission is severe, inhibited. Marked yellowness of the skin and mucous membranes. In the right hypochondrium there is a moderate defense, soreness, weakly positive symptom of Shchetkin. Diagnosed with PCES, choledocholithiasis, obstructive jaundice, cholangitis.

 In blood tests, the total bilirubin is 458.5 μmol / L due to direct, the total protein is 70 g / L, white blood cells 11250, HB 92, ESR 57 mm / h.

 ECG diffuse changes in the myocardium, incomplete blockade of the right leg of the bundle of His.

 Ultrasound of the liver transplant with diffuse focal changes, its size increased due to both lobes by 4.5 cm. The common bile duct is 2.5 cm in diameter, its lumen has one large calculus up to 2 cm and many small ones. Fractional and intrahepatic passages are sharply expanded.

 HCHG confirmed echotomoscopic diagnosis. With puncture of the ducts, purulent bile was obtained. The study ended with the abandonment of decompressive hepaticostomy. During the first days after drainage, 250 ml of purulent bile was released. Massive detoxification and antibacterial therapy was carried out, including intravenous forced diuresis. On the third day after receipt, the bile rate decreased to 50.0 ml. Flushing the drainage function did not improve it. Bilirubin decreased by 25 μm / mol / L. The general condition is also without significant dynamics.

 Given the low effectiveness of the therapy, it was decided that the patient should be operated on urgently.

 An operation was performed under endotracheal anesthesia, incision according to S.P. Fedorov opened the abdominal cavity. By the dissection of adhesions, the common bile duct was identified, which in diameter 3 cm thickened its walls, stones palpation in its lumen. After mobilization of the duodenum according to Kocher, a choledochotomy was performed. Bile was released from the common bile duct with a large amount of pus. From its lumen 2 large up to 2 cm stones and 6 small ones were extracted. After washing the bile duct bougie N 3 freely pass into the duodenum 12. Given the severity of the patient’s condition, the massiveness of cholangitis was performed drainage of the common bile duct according to the method described above, leaving a T-shaped drainage in the common bile duct.

After transferring the patient to the intensive care unit, drip injection of furatsillin solution into both transhepatic drains at a rate of 30 drops per minute was started. The volume of dialysis fluid on the first day was 1 liter. The next day after surgery, blood bilirubin decreased to 125.5 μm / mol / L. Body temperature dropped to 37.7 ^about C. In the next two days, ductal dialysis continued in the amount of 2-2.5 liters per day. Dialysis was stopped on the 3rd day at normal body temperature and a total bilirubin of 118 μmol / L. Transhepatic drainage was not removed. In the following days, fractional dialysis of the ducts was carried out at 200.0 twice a day. The tightness control and the adequacy of the drainage are carried out immediately after suturing of the choledochotomy incision to the drainage installed in it.

 After the operation is completed and the patient is transferred to the intensive care unit, we connect the systems for intravenous fluid infusion connected to the vials with furatsillin solution to both transhepatic drains. The composition of the dialysate includes hydrocortisone, antibiotics and heparin.

 Transhepatic drainage was removed on the 10% day after fistulography performed the day before. Drainage of the common bile duct was removed after training on the 16th day. Bacteriological examination data showed that the ducts were sanitized on the 7th day after surgery. On the 18th day, the patient in satisfactory condition was discharged from the clinic. Examined after 1.5 months. The result is regarded as good.

Claims (1)

 METHOD FOR TREATING PURULENT CHOLANGITIS, including the installation of drainage in choledach, characterized in that, in order to ensure effective rehabilitation of the bile ducts, two transhepatic drainages in the ducts of both lobes of the liver are additionally installed and ductal dialysis is performed.

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