RU2157660C1 - Method for treating the cases of cholangitis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves introducing ozonized isotonic sodium chloride solution with ozone concentration of 5 mg/l into the common bile duct during the operation. The same kind of solution is introduced into the common bile duct through a T-shaped tube in postoperative time. EFFECT: enhanced effectiveness of treatment. 3 cl, 1 dwg, 1 tbl

Description

 The invention relates to medicine, in particular to surgery, can be used to treat patients with cholangitis, which is manifested by pain in the right hypochondrium, fever, chills, yellowness of the skin and sclera.

 There is a method of treating cholangitis with the help of sanations during fibro-choledochoscopy. In this case, physiological saline is used, which is injected directly into the common bile duct (Halperin E.I. et al. Actual issues of purulent cholangitis. Surgery, 1988, No. 6, pp. 21-29).

 As the closest analogue, a method for treating cholangitis has been adopted, including surgery - cholecystectomy, choledochotomy, choledochoscopy with the introduction of physiological saline into the common bile duct during fibrocholedoscopy (Briskin BS and other choledocholithiasis: problems and prospects. Annals of surgical hepatology. 1998, t, . 3, N 2, pp. 71-78). However, the known method has several significant disadvantages. Saline does not contribute to reducing the viscosity of bile, restoring its normal acidity and removing endotoxemia, but only contributes to the partial removal of infected bile from the bile ducts. In addition, long-term use of antibiotics is necessary, which can cause allergic reactions, especially in patients with prolonged obstructive jaundice, leading to dysbiosis and not affecting the healing of cholangitis. Therefore, such fibro-choledochoscopy essentially does not carry a therapeutic character.

 For the first time as a therapeutic agent, ozone was used to treat poorly healing wounds, fistulas and burns. The action of ozone is multidisciplinary, which allows it to be used for various diseases. So, the bactericidal effect of ozone is known. The mechanism of the bactericidal action of ozone is as follows. Plasma membranes are the main target of ozone. Under the action of ozone on the cell membrane, lipid oxidation in it proceeds predominantly by the ozonolysis of double bonds; lipid peroxidation processes play a secondary role in this. The direct cause of the death of bacteria under the action of ozone is local damage to the plasma membrane, leading to the loss of viability of the bacterial cell and (or) its ability to multiply (Idov EI Aspects of the use of ozone in medicine. Anestesiol. And resuscitation. 1997. N 1. C . 90-94).

 Another aspect of the effects of ozone is associated with its effect on the immune system. Intravascular infusion of an ozone solution leads to the mobilization of the humoral immunity - an increase in the phagocytic activity of neutrophils. Under the influence of therapeutic doses of ozone, lymphocyte proliferation increases. The effective action of ozone as an antihypoxic and detoxification drug when it is administered intravenously several times a day (Bulynin V.I. et al. Use of ozone in the treatment of surgical diseases. Sat. Teach, article "Specialized medical care". Voronezh. 1996. S. 364-368).

 The proposed method of treatment is based on the idea of using ozone as a bactericidal, detoxifying, antihypoxic drug to treat the inflammatory process in the extra- and intrahepatic bile ducts. The experimental part of the work was preliminarily performed on white Wistar rats 6-8 months old and weighing up to 120 g, which, under nembutal anesthesia at the rate of 40 mg / kg of weight, opened the anterior abdominal wall, prepared the bile duct near the place of its entry into the duodenum and using a bile duct was punctured with a hypodermic needle and 1-2 ml of an ozonized isotonic sodium chloride solution with an ozone concentration of 5 mg / L was retrogradely injected. In addition, the tissues in the liver, gall bladder and bile ducts were irrigated with the same solution through a nebulizer. In the 1st (control) group, normal saline was administered. Rats were euthanized after 1 and 3 days, the liver, bile duct and regional lymph nodes were taken and preparations were prepared for scanning electron microscopy, immunomorphological and histochemical studies.

 When studying the preparations using light electron microscopy, it was found that in the places of the needle injection through the wall of the bile duct (see drawing, a) the integrity of the epithelial layer is violated, which in turn causes the effect of a sharp proliferative activity. With the introduction of an ozonized isotonic sodium chloride solution already on the 3rd day (see drawing, b), the defects of the ductal mucosa were restored. In control animals, by 3 days from the start of the experiment, proliferation was weak and the appearance of the mucosa was the same as at the beginning of the experiment (see drawing, a). This fact indicates the high ability of ozone to influence the processes of recovery, to activate cell division, to direct the process of mitosis. In a histochemical study of enzymes in the epithelium of the mucous membrane of the bile duct and in hepatocytes 1 day after (administration of an ozonized isotonic sodium chloride solution, the amount of succinate dehydrogenase, the main enzyme of aerobic respiration of cells, almost doubled and the amount of glucose-6-phosphate dehydrogenase, which is responsible for pentose phosphate pathway for the oxidation of glucose, namely the energy activity of the cell. In case of immunohistochemical study of regional lymph nodes stained with monoclonal antibodies, proliferative activity of B-lymphocytes increased 3 times after immunohistochemical study of regional lymph nodes stained with monoclonal antibodies, which can lead to increased production of immunoglobulins.

 Thus, these data showed that the introduction of ozonized physiological solution is locally safe and appropriate, since after ozone therapy, the transport of nutrients through the endothelium of microvessels to cells and tissues improves, the possibility of their participation in redox processes, translating the respiration of cells into aerobic conditions - the most economical for the body, the energy intensity of cell structures is accumulated by enhancing the pentose phosphate pathway of glucose oxidation. Ozone stimulates the immunocompetent cells of the lymph nodes to proliferate, which creates favorable conditions for maintaining immune homeostasis under conditions of reparative regeneration. This served as one of the prerequisites for topical use of ozone in the clinical setting for cholangitis. It was experimentally established (Aleinikov S.O. et al. "Respiratory effects of ozone. Pulmonology, 1997, N 3, pp. 81-91.) That the concentration of ozone in an isotonic sodium chloride solution of up to 5 mg / l is safe for the human body with intravenous, intracavitary administration. Ozonated isotonic sodium chloride solution is used to irrigate various inflammatory foci, replacing them with normal saline. The sanitizing effect of ozone is associated with an effect on bacteria, viruses and fungi.

 With cholangitis, the leading factor is endotoxemia. Therefore, we used ozonized physiological solution in connection with the bactericidal, detoxifying properties of ozone, as well as the ability with its local administration, i.e. directly into the focus of inflammation, increase antibody production.

 The technical result of the proposed method is to reduce endotoxemia with a complete and rapid debridement of the biliary tract.

 The technical result is achieved due to the effect on the bacterial flora directly in the common bile duct by introducing an ozonized isotonic sodium chloride solution into the area of the inflammation zone, and also due to the concomitant rehabilitation of the small intestine.

 The method is as follows. A patient under anesthesia during a laparotomy after removal of the gallbladder is injected with a fibrocholedochoscope into the choledochotomy wound, the common bile duct is examined and an ozonized isotonic sodium chloride solution with an ozone concentration of 500 mg / l in an amount of 500 ml is constantly instilled into the lumen, constantly removing the resulting fluid mixed with putty and small stones from the abdominal cavity by suction. The operation ends with the installation of a T-shaped drainage tube in the common bile duct, the outer end of which is sutured to the anterior abdominal wall. The T-shaped tube serves not only for the rehabilitation of the extra- and intrahepatic bile ducts, but also for the rehabilitation of the small intestine, due to which intoxication is quickly removed. In the postoperative period, 40 ml of an ozonized isotonic sodium chloride solution with an ozone concentration of 5 mg / L is slowly injected into the lumen of the common bile duct through a drainage tube for 5 minutes. Manipulations are carried out daily, only 3 per course of treatment.

 The method has passed clinical trials at the Department of Endoscopy RMAPO based on the hospital. S.P. Botkin for 16 patients with cholangitis. Of these, between the ages of 34 and 62, there were 3 men and 13 women. The treatment period was 3 to 5 injections daily, i.e. 3 to 5 days.

 As our observations have shown, under the influence of an ozonized isotonic sodium chloride solution, bile is rapidly purified from fibrin and pus, and bile viscosity decreases due to a decrease in the amount of cholesterol. To confirm the advantages of the proposed method in comparison with the known, we give a comparative table.

 Thus, as can be seen from the table, with the proposed method of treatment, recovery occurred in 100% of patients, while with the known method of treatment, none of the patients recovered completely, and improvement was noted in 80% of patients.

Example. Patient G., 68 years old, and / b 26724, was admitted with complaints of pain in the right hypochondrium, body temperature 38 ^o C, chills, nausea, vomiting, yellowness of the skin and sclera. Ultrasound of the abdominal organs revealed the following: the liver is not enlarged, the intrahepatic bile ducts are enlarged in both lobes, the common bile duct is expanded in the terminal part to 15 mm. The gall bladder is deformed, its wall is unevenly thickened, in the lumen of the gall bladder there are multiple calculi up to 6 mm in diameter. Conclusion: obstructive jaundice, block of the terminal portion of the common bile duct, gallstone disease, chronic calculous cholecystitis, inductive pancreatitis. An esophagogastroduodenoscopy was performed with examination of a large duodenal nipple - papillitis was detected. Blood test total. - within the normal range. Urinalysis: alkaline reaction, protein - 0.06, positive bilirubin. Biochemical blood test: bilirubin commonly. 94 μmol / L, direct - 64 μmol / L, indirect - 30. ALT transferases - 246, AST - 339, alkaline phosphatase - 2252. Immunoglobulins: IgG - 18%, IgM - 1.08%, IgA - 5. Number of lymphocytes 18.7%.

 The patient underwent surgery - cholecystectomy from the neck. During the operation, the common bile duct was opened, fibro-choledochoscopy was performed with irrigation of the bile ducts with 200 ml of an ozonized isotonic sodium chloride solution with an ozone concentration of 5 mg / L. Removed several small stones and putty. A T-shaped drainage tube is installed in the common bile duct, the distal end of which is fixed on the anterior abdominal wall. In the postoperative period, a choledochoscope was performed through a drainage tube. There are no calculi in the lumen of the common bile duct, bile with flakes of fibrin. Remediation was performed with ozonized physiological saline in an amount of 40.0 ml with an ozone concentration of 5 mg / L. Subsequently, sanitation through the drainage tube was carried out daily, only 5 per treatment course. Indicators of bilirubin, transaminases Alt and ACT, white blood cells decreased to normal, jaundice disappeared. The number of lymphocytes on the 7th day after surgery is 29.4%. Peripheral blood IgG 24%, IgM 0.92%. IgA - 40. The drainage tube was removed on the 14th day from the time of surgery. The patient was discharged from the hospital on the 19th day from the time of the operation. At the control examination after 6 months, no complaints.

 Thus, the proposed method allows to achieve with purulent cholangitis a decrease in endotoxemia by 2 times in a short time and without the use of antibiotics. It was possible to achieve recovery in 100% of patients.

 The remission period is significantly extended. In all patients treated with the proposed method, relapse was not observed and the period of remission lasts 3-6 months.

 The treatment time is reduced from 1 month to 6 to 10 days.

Claims (3)

 1. A method for the treatment of cholangitis, including cholecystectomy, choledochotomy, drainage of the common bile duct, bringing the drug to the area of inflammation, characterized in that the drug used is an ozonized isotonic sodium chloride solution, which is injected into the common bile duct during choledochoscopy during surgery and additionally, the same solution is introduced into the lumen of the common bile duct through a T-shaped drainage tube after surgery until the color and transparency of bile normalize.  2. The method according to claim 1, characterized in that a solution with an ozone concentration of 5 mg / L is used.  3. The method according to claim 1, characterized in that in the postoperative period, the solution is administered in an amount of 40 ml.

Images