RU2396915C1 - Method of thermal mucoclasia of gallbladder and simultaneous estimation of its efficiency - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, abdominal surgery, and can be used for thermal mucoclasia of gallbladder. For this purpose during cholecystomy sanitisation of gallbladder is performed. After that into gallbladder cavity introduced is catheter with latex balloon on the end. Then under X-ray control the balloon through syringe is filled with X-ray contrastive solution 90°C until the balloon takes contours of gallbladder. After 10 minutes the solution is removed. After that under visual control of endoscope, gallbladder walls are irrigated with 1% methylene blue solution with 5 minute exposure. After that dye is washed off and degree of mucosa dying is estimated. In case if all parts of mucosa are dyed into blue colour efficiency of mucoclasia is proved. In case if undyed sections are present mucoplasia procedure is repeated.

EFFECT: method allows simultaneously without preliminary obliteration of bladder duct under visual control to carry out demucosation of gallbladder cavity aimed at its further obliteration and simultaneously estimate its efficiency, avoid complications, considerably reduce patient's stay in hospital.

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Description

The method relates to medicine, namely to abdominal surgery, and can be used to destroy the mucosa of the gallbladder with a view to its subsequent obliteration.

Gallstone disease is one of the urgent problems of modern surgery. The mere fact that more than 500,000 operations for cholelithiasis is performed annually in the United States forces surgeons to constantly improve methods for diagnosing and treating this disease (Gostishchev V.K. et al., 1996; Savelyev BC, Krieger A.G., 1999; Balalykin A.S. et al., 2004). However, despite the successes achieved in biliary surgery, the use of traditional surgical and endoscopic treatment is accompanied by a relatively high percentage of complications and deaths, especially in elderly and senile patients, as well as patients with a high degree of operational and anesthetic risk (Shapovalyants S.G. et al., 1991; Gulyaev A.A. et al., 1998). The operation of choice in this group of patients can rightfully be considered percutaneous microcholecystostomy performed under ultrasound control. It can be performed as the initial stage before cholecystectomy for the purpose of decompression of the gallbladder and relieve hypertension in the bile ducts, as well as the final manipulation (A.S. Ermolov et al., 1993; Briskin B.S. et al., 2000). However, through the fistulous opening created during microcholecystostomy, it is impossible to completely sanitize the gallbladder from calculi, moreover, such a cholecystostomy often becomes clogged, requiring constant debridement, and in some cases migrates from the gallbladder (England RE, McDermott VG, 1997; Shailendra Chopra, Gerald D. Dodd, 2000).

In this regard, surgical cholecystostomy performed from a small laparotomy access under local anesthesia remains relevant. During its implementation, it is possible to more thoroughly sanitize the cavity of the gallbladder, simultaneously removing most of the stones, including larger diameter, as well as infected bile from it (Kochnev O.S. et al., 1996). Nevertheless, the performance of traditional cholecystostomy without subsequent monitoring through cholangiography or cholecystoscopy still does not allow to achieve complete rehabilitation of the gallbladder cavity.

According to most authors, even with the complete removal of calculi, the operation of cholecystostomy cannot be considered radical in the treatment of gallstone disease, since there is a cavity in the gallbladder that contributes to re-stone formation, stagnation of bile, infection and relapse of the inflammatory process with the development of various complications (Emelyanov S. I. et al., 1996; Shurkalin B.K. et al., 1993).

To prevent these complications, many authors apply various methods of obliteration of the gallbladder cavity, i.e. mucoclasia.

Known methods of chemical mucoclasia (No. 2000121388, A61B 17/00, Suzdaltsev I.V. and others) are based on the use of various chemical agents (alcohol, phenol, etc.), which are toxic and can harm the patient due to partial absorption through the mucous membrane of the gallbladder during their use. Other physical methods, in particular thermal mucoclasia, suggest introducing into the gallbladder a liquid that is heated either by a source from outside or directly inside the gallbladder. However, the main drawback of both of them is the need for pre-obliteration of the cystic duct using electric current, which is technically difficult to accomplish, dangerous by the development of various complications, such as perforation of the gallbladder wall, damage by stray current of internal organs, requires multiple approaches, certain skills of a doctor and, most importantly, postpones the implementation of mucoclasia for a period of 2 to 7 days in order to form a post-burn scar in the mouth of the cystic duct, tr fucking in the subsequent additional x-ray control. All this, of course, delays the time spent by patients in the hospital and worsens their quality of life.

So, Neuwirth, Robert S., Bolduc, Lee R. (United States Patent 5159925, Nov.3, 1992) in his method “Cauterizing apparatus and method for laparoscopic cholecystostomy, gallbladder ablation and treatment of benign prostate hypertrophy” suggests the use of a balloon catheter with a heating element located inside the balloon for the purpose of mucoclasia of the gallbladder. However, in this method, as in the previous ones, preliminary obliteration of the cystic duct by clipping is necessary. It should be noted that the method proposed by the author for its implementation during laparoscopic cholecystostomy is equivalent to the operation of cholecystectomy, as it is performed under intravenous anesthesia with the application of intense carboxyperitoneum (20 mmHg), which can adversely affect the general condition and hemodynamics of patients, especially the elderly and senile with a high degree of operational risk. In addition, the isolation of tubular structures during the clipping process is not always possible with destructive forms of cholecystitis, pronounced hepatoduodenal ligament infiltrate. Of no small importance is the impossibility during mucoclasia to control the location of the heating element relative to the walls of the balloon, which can lead to rupture of both the balloon itself and damage to the wall of the gallbladder directly by the heating element. Bringing the fluid inside the balloon to the boiling point can also cause a dangerous expansion of the balloon due to the formation of steam and lead to its rupture and thermal damage to the gallbladder along with adjacent tissues.

The closest solution to the described method is the method proposed by domestic authors (No. 2001122352, A61B 17/00, Kartashov A.V. et al.), Proposing to use water vapor as a means to achieve mucoclasia, which directly processes the bladder cavity. However, the need for preliminary obliteration of the cystic duct by electrocoagulation, heating of the connecting tubes due to the use of high temperatures (more than 100 ° C), and most importantly, the inability to control the distribution of steam, as well as the location of the heated end of the tube inside the gallbladder, pose a great risk of damage and put it under doubt the safety of this method.

It should also be noted that none of the above methods does not allow for objective control over the obliteration of the gallbladder cavity both during and after the manipulation, which is important for deciding whether to complete the procedure or if it needs to be repeated.

The objective of the invention is to develop a method of thermal mucoclasia of the gallbladder, which allows, at the same time, without prior obliteration of the cystic duct, to democratize its cavity under visual control and at the same time evaluate its effectiveness.

The problem is solved in that a catheter with a latex balloon at the end is inserted into the gallbladder cavity, after which, under the control of fluoroscopy, the balloon is filled through a syringe with an X-ray contrast solution heated to 90 ° C until the balloon accepts the contours of the gallbladder; after 10 minutes, the solution is removed, then, under the visual control of the endoscope, the walls of the gallbladder are irrigated with a 1% methylene blue solution with an exposure of 5 minutes, after which the dye is washed off and the degree of staining of the mucosa is assessed: if all sections of the mucosa are stained blue, they are convinced of the effectiveness mucoclasia, in the presence of unpainted areas, the procedure of mucoclasia is repeated.

The method is as follows. Traditional cholecystostomy is performed under local anesthesia, during which the gallbladder cavity is sanitized. Then, through the cholecystostomy hole, a trocar sleeve is installed, through which rigid optics with a diameter of 10 mm with a biopsy channel of 5 mm (endoscope) is inserted, which allows you to check the adequacy of gallbladder debridement and, if necessary, remove remaining stones. Monitoring the state of the bile ducts is carried out using intraoperative cholangiography, for which a teflon catheter is inserted into the cystic duct through the biopsy channel of the endoscope and the bile ducts are contrasted. After making sure the ducts are passable, they proceed to mucoclasia of the gallbladder. To do this, the endoscope is removed and a catheter with a latex balloon at the end is inserted into the cavity of the gallbladder. Next, the X-ray contrast solution, previously diluted with saline in a ratio of 1: 1, is heated to 90 ° C and injected into the balloon through a syringe until the balloon accepts the contours of the gallbladder. The control over the filling of the balloon is carried out in the process of fluoroscopy, seeking close contact with all the walls of the gallbladder. After 10 minutes (time is established experimentally), the solution is evacuated through a syringe, the balloon catheter is removed.

In order to control the destruction of the mucous membrane of the gallbladder, its walls, under the visual control of the endoscope, are irrigated with a 1% methylene blue solution with an exposure of 5 minutes, after which the dye is washed off with physiological saline, which is aspirated through the endoscope channel, and the degree of staining of the mucosa is evaluated. The main criterion for the effectiveness of mucoclasia is the blue staining of damaged sections of the mucosa, while excess dye is easily washed off from the surface of an intact, normal, mucous membrane. This method is based on the ability of methylene blue to be actively absorbed by cells of the mucous membrane of the gallbladder (Filin A.V. et al., 2003). In the presence of unpainted sections of the mucosa, the mucoclasia procedure is repeated. At the end of the procedure, a drainage is installed in the cavity of the gallbladder in order to drain the wound exudate and discharge the necrotic mucosa. The process of obliteration of the gallbladder cavity is monitored sonographically.

Case Study

Patient D., 65 years old, was admitted to the MUZ GB No. 4 with complaints of pain in the right hypochondrium and epigastric region, nausea, repeated vomiting with an admixture of bile, which brought short-term relief. After a clinical and laboratory examination, the diagnosis was made: cholelithiasis. Acute cholecystitis. Diabetes mellitus, type 2, severe course. IHD, atrial fibrillation. Operational and anesthetic risk of IV art. Due to the presence of severe concomitant pathology and a high degree of operational and anesthetic risk, the patient underwent traditional cholecystostomy under local anesthesia, during which many small stones from 2 to 7 mm in diameter were removed from the gallbladder. After that, a trocar sleeve was installed through the cholecystostomy opening, an endoscope with a biopsy channel of 5 mm was inserted. During cholecystoscopy in the cervical region, 3 small calculi were found, which were evacuated. Intraoperative cholangiography was performed - no stones were found in the bile ducts, contrast medium freely enters the duodenum. Then it was decided to perform thermal mucoclasia, for which the endoscope was removed and a catheter with a latex balloon at the end was inserted into the cavity of the gallbladder. Then, under the control of fluoroscopy, the balloon is filled with a diluted radiopaque solution heated to 90 ° C until it comes into firm contact with the walls of the gallbladder. After 10 minutes, the solution is removed. In order to control the effectiveness of mucoclasia of the gallbladder wall, under the visual control of the endoscope, they were irrigated with a 1% methylene blue solution with an exposure of 5 minutes. After washing off the dye with saline, the mucosa in all departments is colored blue. No stains were found. Residues of saline are aspirated from the cavity of the gallbladder. A drainage is installed in the gallbladder cavity. On the 14th knock after obliteration, there is no discharge along the cholecystostomy, the drainage is removed. According to ultrasound, on the 21st day after obliteration, the gallbladder cavity is significantly reduced in size. The patient in satisfactory condition was discharged from the hospital. 6 months after obliteration with ultrasound, the gallbladder is a scar cord.

Thus, the task has been achieved due to the fact that the obliteration of the gallbladder cavity is carried out without preliminary coagulation of the cystic duct by introducing, under the control of fluoroscopy, a diluted X-ray contrast solution heated to 90 ° C, into a balloon catheter placed in the gallbladder, until until the balloon takes on the contours of the gallbladder, after exposure at 10 minutes, the solution is removed and the effectiveness of mucoclasia is evaluated, for which the walls of the gallbladder under visual inspection of the endoscope are irrigated with 1% growth a thief of methylene blue with an exposure of 5 minutes, after which the dye is washed off and the degree of staining of the mucosa is assessed: if all sections of the mucosa are completely stained blue, the effectiveness of mucoclasia is verified, in the presence of unpainted areas the procedure is repeated.

The application of the method of thermal mucoclasia of the gallbladder and simultaneous evaluation of its effectiveness allows us to solve a number of problems:

1. To make democotization of the gallbladder, having achieved the complete destruction of its mucous membrane without preliminary coagulation of the cystic duct, as well as to avoid formidable complications, such as perforation of the gallbladder wall, electrical injury to surrounding organs.

2. Radiologically monitor the process and completeness of filling the cavity of the gallbladder in the process of mucoclasia.

3. To evaluate the effectiveness of devitalization of the mucous membrane of the gallbladder using a simple and generally accessible method of staining.

4. Use it as the final method of treatment of gallstone disease and acute cholecystitis in patients with a high degree of operational and anesthetic risk.

5. Significantly reduce the stay of patients in the hospital and improve the quality of their life due to the fact that mucoclasia with a simultaneous assessment of its effectiveness can be performed in one stage to a cholecystostomized patient.

Claims (1)

The method of thermal mucoclasia of the gallbladder, including cholecystostomy, sanitation of the gallbladder, characterized in that a catheter with a latex balloon at the end is inserted into the gallbladder cavity, after which, under the control of fluoroscopy, the balloon is filled through a syringe with an X-ray contrast solution heated to 90 ° C until until the balloon accepts the contours of the gallbladder; after 10 minutes, the solution is removed, then, under visual inspection of the endoscope, the walls of the gallbladder are irrigated with a 1% solution of methylene blue with an exposure of 5 minutes, after which the dye is washed off and the degree of staining of the mucosa is assessed: if all sections of the mucosa are stained blue, they are convinced of the effectiveness mucoclasia, in the presence of unpainted areas, the procedure of mucoclasia is repeated.