RU2136215C1 - Method of preoperative determination of permeability of cystic duct in patients ill with mechanical jaundice - Google Patents

Abstract

FIELD: medicine; ultrasonic methods of preoperative diagnosis of permeability of cystic duct in patients ill with mechanical jaundice. SUBSTANCE: registration of bile admission to common bile duct is effected under control of echography at moment of building up dosed compression on region of gallbladder, and appearance of flow of bile contents in common bile duct is indicative of permeability of cystic duct. EFFECT: reduced number of recurrences. 2 dwg

Description

 The invention relates to medicine and relates to ultrasonic methods for preoperative diagnosis of cystic duct patency in patients with obstructive jaundice.

 Closest to the proposed is the preoperative method for determining the patency of the cystic duct by percutaneous cholecystocholangiography, which consists in the fact that the gallbladder is punctured through the anterior abdominal wall. After aspiration of bile, a contrast agent is introduced into the gallbladder and an x-ray is taken. When contrast is detected in the common bile duct, the patency of the cystic duct is judged (K.V. Lapkin, Yu. F. Pautkin "Special methods for the study of the biliary tract", M., Publishing House of the University of Friendship of Peoples, 1989, p. 36- 37).

 However, this method has the following disadvantages: the method is invasive, accompanied by a certain radiation dose, is contraindicated in case of intolerance to iodine preparations, hemorrhagic diathesis, acute kidney diseases. Perhaps the development of complications in the form of bleeding or bile flow into the abdominal cavity.

 A new technical result - reducing the number of complications - is achieved by a new preoperative method for diagnosing the patency of the cystic duct, including registration of bile flow into the common bile duct, and registration is carried out under the control of ultrasound at the time of creating metered compression on the gallbladder and the appearance of the flow of bile contents in the common bile duct duct judge the patency of the cystic duct.

The method is as follows:
In the position of the patient lying on his back, a conventional ultrasound examination of the gallbladder from the right hypochondrium is performed, placing the sensor parallel to the costal arch. During the examination, the localization, size and nature of the contents of the gallbladder are evaluated. The left hand is placed on the area of the gallbladder, while the right hand sets the sensor perpendicular to the costal arch, along the common bile duct. Under the control of ultrasound, a dosed compression of the gallbladder is performed with the left hand and when the common bile duct appears in the lumen at the time of compression of the stained fluid flow (when using ultrasound devices with color Doppler mapping, such as "Toshiba SSA-270 A", "Ultramark -9") or jets of fluid with echogenic flakes similar to the contents of the gallbladder (on middle-class devices with a gray scale such as "Aloka SSD-630", "Combison 320-5"), judge the patency of the cystic duct (Fig. 1 and 2).

 Example 1

 Patient K., 67 years old, IB No. 5289, was admitted to the surgical clinic of the Tomsk Regional Hepatology Center on September 11, 1998 with complaints of dull pain in the right hypochondrium, yellowing of the skin and sclera. dark urine, discoloration of feces, weakness, malaise. From the anamnesis: sick on 08/26/98, when, after moderate pain syndromes, yellowness of the skin appeared, which progressively increased. Previously, there was no jaundice. Since 1994, suffers from gallstone disease. Upon admission, a state of moderate severity, low nutrition (weight deficit 12 kg). The skin and mucous membranes are intensely icteric. Pulse 74 beats / min, blood pressure 110/70 mm Hg The vesicular breathing, no wheezing. The borders of the heart are extended to the left by 1.5 cm, tones are arrhythmic, amplification of 1 tone at the apex, gross systolic murmur. The tongue is wet, coated with a white coating. The abdomen is soft, with deep palpation, slightly painful in the right hypochondrium. The liver protrudes from under the costal arch by 10 cm, the edge is even. The bottom of the enlarged gallbladder is palpated.

Red blood cells - 4.1 • 10 ¹² / l, Hb - 117 g / l, white blood cells - 11.3 • 10 ⁹ / l, eosin - 5%, l - 27%, s / I - 64%, m - 4% , ESR - 47 mm / hour. Total protein -75.0 g / l, total bilirubin - 163.3, direct - 115.9, indirect - 47.4 micromol / l. ALT - 5.21; ACT - 2.73 mmol. Urinalysis: yellow, transparent, UV - 1023, protein - 0.033% of urate.

 Echocardiography: a complex mitral defect with a predominance of stenosis. Relative tricuspid insufficiency. Severe pulmonary atrerial hypertension.

 Fibrogastroscopy: superficial gastritis, cicatricial deformity of the duodenal bulb, duodenitis. There is no bile in the duodenum.

 Ultrasound examination: the liver is significantly lowered, moderately enlarged, protrudes from the costal arch by 9-10 cm, the surface is smooth, the lower edge is sharp. The structure of the parenchyma is homogeneous, of medium echogenicity. Intrahepatic bile ducts are significantly expanded, pronounced periductal fibrosis. Fractional hepatic ducts expanded to 10-11 mm, the common bile duct expanded all the way to the pancreatic department, diameter 20 mm. Gall bladder enlarged to 112 • 37 mm, deformed. The walls are thin, sealed. In the cavity - stagnant contents in the form of suspended matter and flakes. Against this background, a group of small calculi (2-3 mm) with an acoustic shadow is determined along the back wall. During compression of the gallbladder, congestive bile with flakes enters the lumen of the common bile duct, which indicates the patency of the cystic duct. The pancreas is enlarged in the head to 31 mm, its contours are tuberous, the structure is heterogeneous, of increased echogenicity, with fibrous inclusions. The body and tail of the gland are of normal size and structure. The Wirsung duct is unevenly expanded throughout up to 8 mm. Conclusion: a pancreatic head tumor, dilatation of the biliary tract (low block), signs of chronic cholangiocholecystitis, gallbladder stones.

 Due to the pronounced concomitant pathology (rheumatism, continuously recurring course, complex mitral defect, atrial fibrillation, NK IIB), radical surgery for a pancreatic tumor is impossible. Given the patency of the cystic duct, established by ultrasound, it is possible to perform palliative bile duct surgery by applying cholecystoenteroanastomosis.

 On September 16, 1998, under anesthesia, an operation of cholecystoenteroanastomosis with Braunovsky anastomosis was performed from the upper-middle access. During the audit, the liver is large, stagnant, green. On the lower edge of the left lobe of the liver is a site suspicious of metastasis (up to 1 cm). The gall bladder is enlarged, deformed by adhesions, tense. The common bile duct is expanded, tense. The head of the pancreas is enlarged, compacted, regional lymph nodes are not enlarged by palpation. A more detailed audit is not possible without extending access below the navel. During puncture of the gallbladder, thick, stagnant bile was removed. A choledochoduodenostomy with Brownian anastomosis 2.0 - 2.5 cm wide was laid. When opening the gallbladder, a mass of small stones (up to 2-3 mm in diameter) was removed from it.

 Postoperative diagnosis: a tumor of the head of the pancreas IV Art. Obstructive jaundice. ZhKB. Metastasis to the liver.

 Ultrasound examination in the postoperative period - the intrahepatic bile ducts are not dilated, the air in the lumen. Common bile duct 1 1 mm. The gall bladder is medium in size, a loop of the small intestine is fixed to the bottom. The walls of the bladder are moderately thickened, in the lumen - putty-like bile. Conclusion: Condition after application of cholecystoenteroanastomosis. Pneumobilia.

 The postoperative period was uneventful. Discharged 09/29/98 in satisfactory condition under the supervision of an oncologist.

 Thus, the proposed diagnostic method allows, in the preoperative period, using a non-invasive method, without the use of contrast agents and radiation exposure, to determine the patency of the cystic duct in patients with obstructive jaundice when planning a biliary surgery and recommend appropriate surgical tactics in order to choose the least traumatic method of surgical treatment, which in turn is a warning of postoperative complications. Of particular relevance is this study in patients with chronic opisthorchiasis, which in 57% of cases is complicated by the development of stricture of the cystic duct.

Claims (1)

 A method for preoperatively determining the patency of the cystic duct in patients with obstructive jaundice, including recording the flow of bile into the common bile duct, characterized in that the registration is carried out under the control of ultrasound at the time of creating a metered compression on the gallbladder, and by the appearance of the flow of bile contents in the common bile duct judge the patency of the cystic duct.

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