RU2268657C2 - Method for diagnosing and treating the cases of mechanical jaundice of non-tumor genesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out ultrasonic hepatopancreaticobiliary zone examination. Gallbladder and biliary tract dilation to confluence being found, endoscopic transpapillary interventions are done under X-ray control. Intrahepatic ducts dilation additionally taking place to the third order ducts, transcutaneous transhepatic cholangiostoma is done under ultrasonic control. 3-4 days later, mechanical jaundice cause is checked by means of antegrade cholangiography and endoscopic retrograde pancreatocholangiography. The detected pathology is corrected.

EFFECT: reduced open operations of internal draining.

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Description

The invention relates to medicine, namely to abdominal surgery, and can be used in the treatment of patients with obstructive jaundice of non-tumor origin.

The closest solution is the method for the diagnosis and treatment of obstructive jaundice, described by O.D.Lukichev, V.G. Ivshin, G.A. Starchenko and others (Surgery named after N.I. Pirogov, No. 1, M .: Medicine, 1990, p.10-14), which provides for the phased ultrasound of the abdominal organs, gastroscopy, endoscopic retrograde pancreatocholangiography (ERPC), laparoscopy and percutaneous transhepatic cholangiography (HCHG) to diagnose the cause of obstructive jaundice, and also makes it possible to carry out bilia drainage pathway. The use of a complex of instrumental methods allowed to reduce the preoperative stay of patients, to reduce the number of complications and deaths.

However, in this technique there is no clearly defined differentiated approach to the use of endoscopic or diapevic techniques in a specific clinical situation to resolve obstructive jaundice.

The objective of the invention is to improve the results of treatment of patients with obstructive jaundice of non-tumor genesis by determining indications for endoscopic and diapevic techniques, which in turn will reduce the number of open internal drainage operations, reduce the number of complications and deaths.

The problem is solved in that the ultrasound examination of the hepatopancreatobiliary zone reveals the proposed types of biliary hypertension, which determine the further surgical tactics in this group of patients. Type I biliary hypertension involves retention according to ultrasound of the biliary tract and gall bladder up to confluence; with type II biliary hypertension, expansion of the intrahepatic bile ducts up to the third order joins.

In type I, endoscopic transpapillary interventions are used under ERCP - control, which allows to eliminate the pathology of the large duodenal papilla (BDSC) in the form of stenosis, perform lithotripsy and lithoextraction from extrahepatic bile ducts and subsequently end the treatment with video laparoscopic cholecystectomy (B).

In type II biliary hypertension, they suggest the application of percutaneous transhepatic cholangiostomy (ChChS) under ultrasound guidance, and after 3-4 days against the background of leveling biliary hypertension (confirmed by control ultrasound examination), specifying the cause of obstructive jaundice using antegrade cholangiography and ERPC, or endoscopic , or open surgical correction of the revealed pathology.

The invention is illustrated in the drawing, which shows a diagram of the proposed method for the diagnosis and treatment of obstructive jaundice of non-tumor origin.

     Case Study 1.

Patient N-th, 22 years old, was admitted to the surgical department of the regional clinical hospital in Kursk on November 26, 2003 with complaints of colicky pain in the right hypochondrium, nausea, vomiting, and yellowing of the skin. The above symptoms appeared 3 days ago. I did not seek medical help. On the day of treatment, the intensity of the pain syndrome increased sharply, vomiting became repeated. After performing a clinical and biochemical laboratory study of blood and urine, performing an ultrasound of the abdominal organs, the diagnosis was made: cholelithiasis, cholecystocholedocholithiasis, distal choledoch block, type I biliary hypertension. Conducted infusion therapy, including antispasmodics, analgesics. November 27, 2003, fibrogastroduodenoscopy with examination of BSDK, ERPHG - conclusion: hepatic choledochus is contrasted up to 15 cm in diameter, filling defects are not noted, there is a conical narrowing of the distal section for 1 cm. Endoscopic papillosphincterotomy, lithoextraction were performed. The postoperative period without complications. Received infusion therapy with crystalloid solutions. November 29, 2003 - ERPHG - control: stenosis of BSDC is eliminated, a free discharge of contrast into the duodenum is noted. 12/01/2003, in a planned manner under endotracheal anesthesia performed VLHE. The postoperative period was uneventful. Sutures were removed on November 6, 2003. Healing per prima. In satisfactory condition, she was discharged under the supervision of a surgeon in the clinic.

The final clinical diagnosis: cholelithiasis. Chronic cholecystitis.

Choledocholithiasis. Stenosis of BSDK. Obstructive jaundice.

Stay in the hospital - 10 beds (according to the standard - 22 beds).

Case Study 2.

Patient Za, 47 years old, was admitted to the surgical department of the Kursk Regional Clinical Hospital on April 29, 2003 with complaints of dull aching pain in the right hypochondrium, nausea, vomiting, and yellowness of the skin for 2 weeks. I did not seek medical help. On the eve notes repeated vomiting, paroxysmal nature of pain, the appearance of skin itching. After performing a clinical and biochemical laboratory study of blood and urine, performing an ultrasound of the abdominal organs, the diagnosis was made: cholelithiasis, cholecystocholedocholithiasis, distal choledoch block, type II biliary hypertension. Appointed infusion, antispasmodic, analgesic therapy. 04/30/2003, performed CCC under ultrasonic control; Antegrade cholangiography - conclusion: hepatic choledochus is contrasted up to 2.5 cm in diameter, in the distal part there is a filling defect up to 2.5 cm in diameter, a conical narrowing of the distal part is up to 1.5 cm long, there is no discharge of contrast into the duodenum. Received infusion, antispasmodic, analgesic and antibiotic therapy. 05.05. In 2003, fibrogastroduodenoscopy was performed with an examination of BSDC, endoscopic papillosphincterotomy, lithotripsy and lithoextraction. The postoperative period without complications. 05/08/2003 - control ultrasound - conclusion: signs of biliary hypertension are not visualized; ERPC - control: stenosis of BSDC is eliminated, a free discharge of contrast into the duodenum is noted. 05/13/2003, in a planned manner under endotracheal anesthesia performed VLHE. The postoperative period was uneventful. Sutures were removed on 05/18/2003. Healing per prima. In satisfactory condition, was discharged under the supervision of a surgeon in the clinic.

The final clinical diagnosis: cholelithiasis. Chronic cholecystitis.

Choledocholithiasis. Stenosis of BSDK. Obstructive jaundice.

Stay in a hospital - 19 beds (according to the standard - 22 beds).

Thus, the task was achieved in that, through a strictly differentiated approach to the use of endoscopic and diapeutic techniques for drainage of the gall tree, it was possible to avoid, firstly, their unreasonable use and the complications accompanying these methods, respectively; secondly, highly traumatic open operations, the performance of which against the background of bilemic endotoxemia and increasing hepatic insufficiency is almost inevitably accompanied by certain complications.

The application of the proposed method ultimately leads to the fact that:

     1. The treatment time for patients with obstructive jaundice syndrome of non-tumor origin is reduced.

     2. The number of complications associated with the implementation of endoscopic, diapevic and open surgical techniques is reduced, which in turn leads to a decrease in mortality in this category of patients.

     3. Increases the cost-effectiveness of the treatment of patients with syndrome of obstructive jaundice of non-tumor origin.

Claims (1)

A method for the treatment of obstructive jaundice of non-tumor origin, characterized in that an ultrasound examination of the hepatopancreatobiliary zone is performed first, then, with the revealed expansion of the gallbladder and bile ducts to confluence, endoscopic transpapillary interventions are performed under radiological control, and with additional expansion of the intrahepatic bile ducts up to the third order ducts percutaneous transhepatic cholangiostomy under ultrasound guidance, and after 3-4 days, clarify they identify the cause of obstructive jaundice using antegrade cholangiography and endoscopic retrograde pancreatocholangiography and correct the revealed pathology.