RU2491968C1 - Method of surgical treatment of cholangitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery of bile ducts and can be applied for treatment of patients with different forms of cholangitis. Under control of ultrasonic examination and X-ray television transcutaneous and transhepatic introduction of drainage with diameter 9 Fr and its placement into one of common ducts of liver in such way, that working end of drainage is at the level of general hepatic duct, are performed. On the following day under control of ultrasonic examination and X-ray television laser light conductor is introduced into transhepatic drainage. Laser irradiation impact with wavelength 760 nm in pulse-periodical mode with duration of impulse 50 msec and interval 100 msec with irradiation power 0.25 W and time of impact 5 min is performed. Procedures are carried out every second day in quantity at least three for treatment course.

EFFECT: method makes it possible to reduce intoxication, improve general condition of patient by fast subsidence of inflammatory process, bactericidal, detoxification impact on endothelium of bile ducts and infected bile, which makes it possible to avoid open surgical operations on bile ducts.

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Description

The invention relates to medicine, namely to surgery of the bile ducts, and can be used to treat patients with various forms of cholangitis - chronic recurrent, protracted and complicated gallstone disease.

Despite significant successes in the diagnosis and treatment of patients with cholangitis, including forms complicated by gallstone disease, treatment of cholangitis remains an urgent problem. Most often, the cholangitis clinic develops against the background of obstructive jaundice, the cause of which is choledocholithiasis in 62% of cases, cicatricial stricture of the extrahepatic bile ducts in 24.5%, and stricture of the large duodenal papilla in 13.2% of cases.

One of the reasons for the lack of noticeable improvement in the treatment of cholangitis is an increase in the number of patients with protracted and chronic forms that are not amenable to standard antibiotic therapy due to the multivalent resistance of microorganisms to the antimicrobial agents used.

In this regard, the development of new technologies for the treatment of patients with various forms of cholangitis is currently an urgent task.

A known method of treating cholangitis (Vasiliev I.T., Mumladze RB, Seltsovsky A.P., Kolesova O.E., Yakushin V.I. “Ozone therapy in emergency surgery”, Moscow, 2003, p.55 -59), in which, after the choledocholithotomy is established after choledocholithotomy, the choledoch drainage is injected with ozonized physiological saline, at a concentration of up to 5 mg / l, which has a bactericidal and antioxidant effect on the mucosa of the bile ducts. The introduction of the solution is performed daily for 3-7 days.

The disadvantage of this method is the rarely occurring allergic reactions to ozone in the form of urticaria and chills. In addition, with the introduction of the ozonated solution, it can leak through the choledochotomy opening into the subhepatic space with the subsequent development of a subhepatic abscess or peritonitis, which requires dynamic ultrasound monitoring and can cause repeated surgery.

A method for surgical treatment of cholangitis was adopted as the closest analogue (Togonidze N. A., Geynits A. V., Atayan M. S. “Third Congress of the Association of Surgeons named after N. I. Pirogov, Moscow, 2008).

The method consists in the fact that after performing the standard intervention on the bile ducts from the laparotomic access - choledocholithotomy, the choledochus is drained using a special device, which is a Holsted-Pikovsky drainage or Kerr drainage with a laser waveguide mounted in its lumen.

Drainage is installed in the common bile duct through the choledochtomic opening and is removed to the anterior abdominal wall through contraperture in the right hypochondrium. Laser therapy is performed using the Atoll apparatus with helium-neon radiation generated in the visible red part of the spectrum with a wavelength of 632.8 nm. The radiation power at the end of the fiber is 20 mW, the exposure time is 20 minutes. Endoholedheal laser irradiation (ECLO) begins on the second day of the postoperative period. Spend from 5 to 8 sessions with a frequency of 1 time per day. Drainage removal is carried out after its training (overlapping drainage for a certain period of time with a gradual increase in this time) after 12-14 days.

However, the known method has significant disadvantages. For the installation of drainage in the bile duct and treatment of cholangitis, it provides for an open surgical intervention, which is fraught with the development of complications - both intraoperative (bleeding, damage to the hollow organs and bile ducts), and complications in the postoperative period (purulent-inflammatory complications, cardiac complications -vascular, respiratory system, paresis of the gastrointestinal tract). Especially often, these complications occur in elderly patients with the presence of concomitant somatic diseases. Complications may develop that are directly related to interventions on the bile ducts, the most dangerous of which is leakage of bile into the subhepatic space, which can lead to the development of an abscess or peritonitis if the process leaves the subhepatic space. In this case, there is a need for repeated surgical intervention.

In addition, provided for the implementation of the method of the device are not available on the medical equipment market.

The objective of the invention is to provide a more effective method of surgical treatment of cholangitis, which allows to obtain a pronounced and persistent clinical effect.

The essence of the invention lies in the fact that in the method of surgical treatment of cholangitis, including exposure to laser radiation, previously on the eve of the treatment procedure in the right hypochondrium along the midclavicular line, a skin incision of 3 mm is performed, under the supervision of ultrasound and X-ray imaging, transdermal and transhepatic injection of drainage with a diameter of 9 Fr and its installation in one of the lobar ducts of the liver so that the working end of the drainage is at the level of the common hepatic duct, the next day they perform the treatment procedure under the control of ultrasound and X-ray television, a laser light guide is inserted into the pre-installed transhepatic drainage, the working part of which is brought into the choledoch cavity and is advanced to its terminal part, after which it is exposed to laser radiation with a wavelength of 760 nm in a pulse-periodic mode with a pulse duration of 50 ms and an interval of 100 ms with a radiation power of 0.25 W and an exposure time of 5 minutes, after the procedure, the laser light removed from the drainage procedure performed in a day in an amount of at least three per treatment, after treatment transhepatic drainage is removed, the wound sutured.

Using the invention allows to obtain the following technical result.

The proposed method is highly effective. It allows you to get a pronounced clinical effect in a short time with minimal tissue trauma, consisting in a quick subsidence of the inflammatory process in the bile ducts - in 3 - 5 days, reducing intoxication of the whole organism and improving the general condition of the patient.

The pronounced anti-inflammatory, bactericidal and detoxifying effect allows in some cases to remove the need for additional administration of antibacterial drugs or significantly reduce their doses, to eliminate detoxification therapy, which minimizes side effects.

The clinical result obtained is more persistent in comparison with the known methods of treating cholangitis. However, complications and side effects characteristic of them do not develop.

The method is minimally invasive and is easily tolerated by patients.

The use of this method in patients of the elderly and senile age, as well as in patients with the presence of a pronounced concomitant somatic pathology, is especially relevant, since it allows avoiding the performance of traditional open surgical interventions on the bile ducts.

The duration of one procedure is up to 5 minutes, which is repeated every other day. The total number of procedures for a patient is at least three, on average, from three to five, the length of hospital stay is reduced to 5-7 days. In some cases, the procedure can be performed on an outpatient basis.

The method has wide functionality, because can be used to treat various forms of cholangitis, both chronic relapsing and complicated by gallstone disease.

The technical result is achieved due to the new technology developed by the authors, which includes the non-surgical passage of the laser fiber into the choledoch through the hepatic drainage, which is pre-installed - on the eve of the procedure under the supervision of ultrasound (ultrasound) and radio television in one of the lobar ducts of the liver so that the working end of the drainage is at the level of the common hepatic duct, which allows during the procedure to remove the fiber from the drainage lumen into the choledoch cavity and implement exposure laser beam directly on the endothelium and the duct itself infected bile. This allows you to increase its antibacterial and anti-inflammatory effect, activate drainage function, detoxification processes and increase local and general immunity, which provides a pronounced and persistent clinical effect.

A high clinical effect is also achieved due to the complex systemic exposure to laser radiation simultaneously - directly on the endothelium of the common bile duct and bile and indirectly - on liver cells through the walls of a drainage tube installed in the lobar duct through which the fiber passes.

The parameters of laser radiation, including the spectrum of its effects worked out by the authors in the course of clinical trials, make it possible to launch a cascade of intracellular processes aimed at activating the antioxidant system and stimulating the link of non-specific humoral protection. Against the background of minimal tissue trauma, maximum mobilization of all pathogenetic links, including self-regulation processes, is achieved.

The method is as follows.

On the eve of the procedure, transhepatic drainage of the patient's bile ducts is performed. In the right hypochondrium along the midclavicular line, a skin incision of 3 mm is performed.

Under the control of ultrasound and X-ray television, percutaneous and transhepatic injection of 9 Fr diameter drainage is performed using the “free hand” method and it is installed in one of the lobar ducts of the liver so that the working end of the drainage is at the level of the common hepatic duct, which allows the fiber to be removed during the procedure from the lumen of the drainage into the cavity of the common bile duct.

The next day, the treatment procedure is performed under the supervision of ultrasound and X-ray television. Use the domestic laser system "LAMI".

The patient is laid horizontally on his back. A laser fiber is introduced into a pre-installed transhepatic drainage, the working part of which is brought into the choledochus cavity and is advanced to its terminal part. The depth of introduction of the optical fiber into the choledochus is controlled by the image on the screen of the electron-optical converter and commensurate with the length of the previously installed drainage.

Carry out the action of laser radiation with a wavelength of 760 nm in a pulse-periodic mode, a pulse duration of 50 ms and an interval of 100 ms. The power of laser radiation is 0.25 watts. The exposure time is 5 minutes. After the procedure, the laser fiber is removed from the drainage.

The procedure is carried out every other day in an amount of at least three per treatment course. After the course of treatment, the transhepatic drainage is removed, the wound is sutured.

The proposed method was used at the Department of General Surgery with a course of hepatopancreatobiliary surgery RMAPO based on the surgical departments of the City Clinical Hospital named after S.P. Botkin in the treatment of 36 patients (volunteers) with inflammatory diseases of the bile ducts - 29 women and 7 men aged 56 to 83 years.

In all cases, the application of the method for the treatment of cholangitis made it possible to obtain a pronounced clinical effect in a short time, consisting in a quick regression of the inflammatory process in the bile ducts, normalization of their function without complications and undesirable side effects, improvement of the general condition of patients with a more stable effect.

The follow-up period for patients ranged from 1 to 6 months, no relapses were noted.

Example. Patient Pyanova T.A. 81 years old. Received in the Department of Surgery Hospital. S.P. Botkin diagnosed with cholangitis. From the anamnesis it is known that a patient with choledocholithiasis in 1984 performed choledochoduodenostomy. In the last two weeks, the patient had complaints of chills with fever up to 39 degrees, heaviness in the right hypochondrium, general malaise. Upon admission to the general analysis of blood leukocytes 13 thousand, the shift of the leukoformula to the left. Ultrasound revealed dilatation of the common bile duct up to 8 mm with the presence of gas in the lumen, a heterogeneity zone in the parenchyma of segment VIII.

The patient was treated according to the proposed method. Previously, on the eve of the procedure, a 3 mm skin incision was made in the right hypochondrium along the midclavicular line. Under the control of ultrasound and X-ray television, percutaneous and transhepatic injection of 9 Fr diameter drainage was performed and it was installed in the lobar duct of the liver so that the working end of the drainage was at the level of the common hepatic duct.

The next day, the treatment procedure was performed under the supervision of ultrasound and X-ray television. A laser fiber has been introduced into the pre-installed transhepatic drainage, the working part of which is brought into the choledoch cavity to its terminal part. Laser irradiation with a wavelength of 760 nm was performed in a pulse-periodic mode with a pulse duration of 50 ms and an interval of 100 ms at a radiation power of 0.25 W. The exposure time was 5 minutes After the procedure, the laser fiber is removed from the drainage. Three procedures were performed every other day. After the course of treatment, the transhepatic drainage was removed, the wound was sutured.

The patient was discharged.

Against the background of the treatment, the patient's condition improved, chills and temperature reaction passed. During the control ultrasound, the previously noted area of heterogeneity in the parenchyma is not visualized. In a general blood test, a decrease in the level of white blood cells to 9.5 and the normalization of blood leukoformula were noted. The patient in satisfactory condition was discharged home. The observation period is 3 months. No relapse.

Claims (1)

A method of surgical treatment of cholangitis, including laser irradiation, characterized in that previously, on the eve of the treatment procedure, a 3 mm long skin incision is made in the right hypochondrium along the midclavicular line, and transdermal and transhepatic injection of 9 Fr diameter drainage is performed under ultrasound and X-ray imaging and placed in one of the lobar ducts of the liver so that the working end of the drainage is at the level of the common hepatic duct, the next day a procedure under the control of ultrasound and X-ray television, a laser fiber is inserted into a pre-installed transhepatic drainage, the working part of which is brought into the choledoch cavity and advanced to its terminal part, after which it is exposed to laser radiation with a wavelength of 760 nm in a pulse-periodic mode with a duration of a pulse of 50 ms and an interval of 100 ms with a radiation power of 0.25 W and an exposure time of 5 min, after the procedure, the laser fiber is removed from the drain, fools spend every other day in an amount of at least three per treatment course, after the end of the treatment course, the transhepatic drainage is removed, the wound is sutured.