RU2535150C2 - Method of treating cholelithiasis in experiment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and deals with the treatment of cholelithiasis. A stone-dissolving mixture, consisting of a solution of octanic acid in glycerol in a ratio of 1:1 is introduced through cholecystoma, the introduction is performed by stream introduction in a volume of 0.2 ml/kg, one time per day for 3-5 days.

EFFECT: invention provides fast dissolution of concrements, irrespective of their composition, with low general and local impact pathogenicity.

3 tbl, 3 ex

Description

The invention relates to medicine, namely to surgery, and for the treatment of gallstone disease.

The incidence of cholelithiasis in recent decades continues to increase. The prevalence of this disease in the Russian Federation is approximately 1 million people per year [1]. If in cases of isolated cholecystolithiasis the invasiveness of the intervention is significantly reduced using laparoscopic techniques, then in the presence of choledocholithiasis, an extensive laparotomy with an audit of the biliary tract is most often required. Available techniques for laparoscopic revision of the common bile duct are rather laborious and not always successful. The use of endoscopic papillosphincterotomy subsequently leads to a violation of the closure function of the sphincter and the development of insufficiency of the large duodenal papilla, and does not guarantee the removal of large calculi [2]. Most patients with cholelithiasis belong to the category of the elderly and senile, with pathology of the cardiovascular and respiratory systems, which significantly increases the risk of surgery. Consequently, the need and relevance of finding solutions for less traumatic removal of stones from the gallbladder and common bile duct in people at high risk of surgery is obvious.

There is a method of treating cholelithiasis by administering through a cholecystostomy or through a T-shaped drainage inserted into a choledochus a solution of diethyl ether in sterile olive oil in a 1: 1 ratio. In this case, 120 ml of the drug mixture are administered per day in the regimen of 10 drops per 1 minute, performing from 5 to 16 daily sessions [3]. In this case, the stones are reduced in size, but complete dissolution does not occur. The disadvantages of the method is its lack of effectiveness (not complete dissolution of the stones), as well as the toxicity of the solution in vivo [4].

There is a method of treating cholelithiasis by introducing methyl tert-butyl ether through a cholecystostomy catheter [5]. The drug is administered continuously for 3-5 days., In a volume of 125 ml / day. However, the use of ether can lead to biliary hypertension due to the fact that the ether evaporates at a temperature below body temperature and the injected liquid, passing into a gaseous state, can occupy a volume 220 times the original [6]. In addition, methyl tert-butyl ether is toxic and, in use, causes various local complications in some cases: acute chemical cholecystitis, pain in the injection area, duodenitis, duodenal erosion. In some cases, general complications: acute hepatic-renal failure, nausea, vomiting, narcotic sleep. In addition, the dissolution time of calculi (cholesterol) is, according to various authors, from 4 hours to several days. Such a long exposure exacerbates the pathogenic effect of the solvent [6].

A known method of treating cholelithiasis by introducing into the gallbladder and bile ducts monoctanoin (Sarggs1-8210), we have chosen as a prototype [7]. The method is carried out by continuous infusion of monooctanoin through a T-shaped drainage into the common bile duct at a rate of 3-10 ml / hour, with single stones from 1 to 11 days (average 4 days), with multiple stones 2-26 days (average 9 days ) This method allows you to effectively dissolve cholesterol calculi. However, the effectiveness of the method is manifested in relation to only cholesterol stones, not dissolving pigment stones. In addition, mono-octanoin, when used in patients, causes side effects: nausea, vomiting, anorexia, diarrhea, discomfort in the abdomen, lower chest or back; possible occurrence of postbulbar duodenal ulcer, a change in the barrier of permeability of the gastric mucosa [6].

To increase the effectiveness of the method of treating cholelithiasis by reducing the time and the possibility of using both cholesterol and pigment calculi, a solution of octanoic acid in glycerol in a ratio of 1: 1, at a dose of 0.2 ml / kg, is injected into the gallbladder through a cholecystostoma every once in day for 3-5 days.

Octanoic acid (n-Octanoic acid, caprylic acid) C ₇ H ₁₅ COOH is a monobasic saturated carboxylic acid (saturated fatty acid), a colorless oily liquid with an unpleasant odor. Contained in the form of glyceride in cow oil and especially in coconut fat, found in Limburg cheese, fusel oil (in the form of isoamyl ether) and beet molasses. Found in Tahitian noni juice.

It is formed during the dry distillation of oleic acid and during the oxidation of normal octyl alcohol. It crystallizes in the cold, t _pl = 16.5 °, t _bale = 237.5 ° C. Density (at 15 ° C), kg / m ³ , 706.0-710.0, dens. 0.91 (20 ° / 4 °), n ^D ₂₀ = 1.4285. Dielectric constant: 2.45 at 20 ° C. Refractive Index: 1.4279 at 20 ° C. It is soluble in alcohol, ether and in hot water [8]. The viscosity of octanoic acid at 20 ° is 5.83 centipoise (MPa · s) [9].

Octanoic acid is metabolized in the liver to CO ₂ and water.

Octanoic acid finds its application in medicine: a complex with caprylic acid normalizes microbiocenosis and the digestive system, is involved in the prevention of inflammatory diseases, and strengthens the immune system. Octanoic (caprylic) acid is also used in the food industry and as a raw material for ethyl caprylate, a synthetic aromatic substance used to create food essences for flavoring confectionery.

It is a product for the synthesis of a-lipoic acid in mitochondria. Included in the plasma-replacing drug "human albumin" as an auxiliary substance. Also used for the manufacture of anti-inflammatory creams and ointments.

It acts as the main component of the dietary supplement “complex with caprylic acid” used to normalize intestinal microbiocenosis, inhibit the growth of yeast in the gastrointestinal and genitourinary tract, normalize the digestive system as a whole, strengthen the immune system and prevent the development of inflammatory diseases.

The toxic effect of octanoic acid on internal organs is noted only when using large doses (7-25 g / kg) [10].

Glycerin C ₃ H ₅ (OH) ₃ is a colorless, viscous liquid, the simplest trihydric alcohol. Non-toxic, odorless, sweet in taste, which is why it got its name (glycos - sweet). It is soluble in all proportions in water and alcohol, almost insoluble in ether, carbon disulfide, chloroform, fatty and essential oils and gasoline, and is highly hygroscopic. Glycerol readily reacts with many organic and inorganic compounds, forming esters, aliphatic and aromatic ethers and glycerides (glycerates) of metals. When used, per os is adsorbed in the intestine.

The density of 1.261 g / cm ³ . Melting point - 20 ° C, boiling point - 290 ° C. The specific gravity of glycerol = 1.2637 (Mendeleev, 1861), = 1.2590 (Bruhl et al.). Glycerol is optically inactive; the refractive index for line 3 of hydrogen is 1.488 (Bruhl) [8].

The viscosity of glycerol at 20 ° - 1480 centipoise (MPa · s) [11].

To justify and verify the effectiveness of the proposed method in an in vitro experiment, 147 calculi were extracted from the gall bladder of patients operated on for gallstone disease laparoscopically. Using the atomic emission method, the mineral composition of the stones was determined. According to the predominant content of Ca ^{2+, the} selected stones were conditionally divided into 3 groups: low-mineralized, medium-mineralized and highly mineralized. Low-mineralized are mainly represented by cholesterol calculi. Medium and highly mineralized calculi were mixed and pigmented stones in composition. Starting with calculi of low mineralization and pre-weighing each stone, we placed them in test tubes and poured a solution of octanoic acid in glycerol in a ratio of 1: 1. At the same time, a constant temperature equal to the temperature of the human body was maintained for several hours. For a more convenient assessment of the results, we introduced a conditional coefficient (K '), which reflects the time of dissolution of the calculus in minutes in terms of 1 mg of stone mass.

It turned out that on average K '= 5.565 (n = 56). It was noted that K 'in the group of calculi with a low degree of mineralization when using octanoic acid is 4.395' (n = 19), in the group with an average degree of mineralization K '= 5.866' (n = 17), in the group with a high degree of mineralization K ' = 6.703 '(n = 20).

In order to increase the viscosity of the solution (for a longer maintenance of the concentration of the solvent in the gallbladder) and reduce the possible toxicity of octanoic acid, its solution in glycerol was used in a ratio of 1: 1. The viscosity of the solution increases due to the fact that the viscosity of glycerol is 254 times higher than the viscosity of octanoic acid. The decrease in the toxicity of octanoic acid when mixed with glycerin is due to the formation of a significant amount of hydrogen bonds arising between the OH group of the acid and the oxygen of one of the glycerol hydroxyls, as well as between the OH group of glycerol and the oxygen of the carboxylic acid group. These interactions reduce the reactivity of octanoate and, therefore, its toxicity [5].

When using a solution of octanoic acid in glycerol in the ratio 1: 1, the dissolution time of the calculi remained the same K '= 5.757 (n = 51), and accordingly, with a low degree of mineralization K' = 4.256 (n = 15), with an average K '= 6.044 ( n = 17), with high K '= 6.971 (n = 17). The optimal ratio of octanoic acid: glycerol - 1: 1 was derived experimentally, this is the maximum possible fraction of glycerin, at which the rate of dissolution of calculi remains the same. With an increase in the proportion of glycerol, the litholytic effect does not occur.

Table 1 The dissolution time of calculi depending on the composition of the solvent Solvent Coefficient (K '), the time of dissolution of the calculus in minutes in terms of 1 mg of stone mass Octanoic acid 5, 565 (n = 56) Octanoic acid: glycerol 1: 0.5 5,498 (n = 10) Octanoic acid: 1: 1 glycerin 5, 757 (n = 51) Octanoic acid: glycerol 1: 1.2 No effect (n = 10) Octanoic acid: glycerol 1: 1.5 No effect (n = 10) Octanoic acid: glycerol 1: 2 No effect (n = 10)

The method is as follows: after implantation of a calculus extracted from the patient’s gall bladder operated on for gallstone disease, a cholecystostomy is placed in the rabbit’s gall bladder. On the third day of the postoperative period, when the condition of the rabbit is stabilized, a solution consisting of octanoic acid and glycerol in a ratio of 1: 1 in a volume of 0.2 ml / kg is injected through the cholecystostomy, after which the drainage is pinched. The introduction is continued for 3-5 days 1 time per day.

Case Studies

Example 1

A sexually mature male outbred rabbit weighing 2.95 kg under anesthesia (zolet 1.5 mg / kg intramuscularly in combination with 0.05 ml / kg xylazine intramuscularly) with the addition of local anesthesia 0.25% -40.0 novocaine was performed minilaparotomy in the projection of the gall bladder oblique access parallel to the costal arch about 3 cm. On examination, the gall bladder without features, pear-shaped. The bubble is opened; contains about 1.0 ml of olive-colored bile; its mucous membrane is velvety, yellow-green. A highly mineralized calculus, d-4 mm, dark gray in color, weighing 56 mg, was planted, an external cholecystostomy was applied.

During the operation, blood was taken from the jugular vein; baseline biochemical parameters: total bilirubin - 10.8 μmol / l, Ast -135 U / l, Alt - 125 U / l, α-amylase - 392 U / l, urea - 4.7 mmol / l, creatinine - 81 μmol / l

In the postoperative period, infusion therapy was carried out once with saline in a volume of 120.0 ml, antibiotic prophylaxis and the administration of pain medications.

On the third day after the operation, when the condition of the rabbit was stabilized, a solution of octanoic acid in glycerol in the ratio of 1: 1 in the amount of 0.6 ml 1 time per day for 3 days was injected through the cholecystostoma. On the sixth day after surgery, the rabbit is slaughtered.

On examination, in the subhepatic space, a moderately pronounced loose adhesion process, in the area of the imposed stoma, a piece of the omentum is soldered. Most adhesions manage to disconnect stupidly. The gall bladder is slightly deformed. When opening the lumen of the organ, yellow-green bile was detected in a volume of about 1.5 ml. The relief of the mucous membrane was somewhat smoothed. No calculus was found.

Biochemical parameters after the experiment: total bilirubin 11.5 - mcmol / l, Ast - 205 U / l, Alt - 52 U / l, α-amylase - 216 U / l, urea - 4.9 mmol / l, creatinine - 68 μmol / l.

Histological data:

In all parts of the gallbladder (neck, body and bottom), signs of moderately severe acute exudative inflammation and degenerative changes in the integumentary epithelium (diffuse non-uniform lymphocytic-neutrophilic infiltration and moderate swelling of the stroma of the mucosa) were noted. In the zone of standing of the cholestoma, sections of desquamation of the mucosa were noted. Muscular and serous membranes without features. The histoarchitectonics of all examined organs (stomach, small intestine, heart, kidneys, brain, liver) was preserved, their tissues and cells did not have significant pathological changes.

Example 2

In the control group, without introducing a stone-dissolving mixture, a sexually mature male outbred rabbit weighing 2.72 kg under anesthesia (zolet 1.5 mg / kg intramuscularly in combination with 0.05 ml / kg xylazine intramuscularly) with the addition of local anesthesia 0.25% - 40.0 novocaine, minilaparotomy was performed in the projection of the gallbladder by oblique access parallel to the costal arch of about 3 cm.The gallbladder was opened, a highly mineralized calculus weighing 60 mg in the form of an irregular polyhedron of dark gray color, 1-3.8 mm, was planted. The tightness of the bubble is restored.

During the operation, blood was taken from the jugular vein; initial biochemical parameters: total bilirubin - 8.1 μmol / l, Ast - 105 U / l, Alt - 84 U / l, α-amylase - 343 U / l, urea - 2.9 mmol / l, creatinine - 67 μmol / l

In the postoperative period, infusion therapy was carried out once with saline in a volume of 120.0 ml, antibiotic prophylaxis and the administration of pain medications.

On the sixth day after the operation, the animal was withdrawn from the experiment sharply.

With a macroscopic examination in the subhepatic space, a moderate adhesion process; the gall bladder is slightly deformed. In the perivesical space, the presence of serous exudate was noted. In the subhepatic region, tissue edema and an accumulation of a cloudy yellowish liquid were noted. When the bladder was opened, up to 0.5 ml of olive bile, cloudy with small flakes, was found in the lumen, and the calculus was irregular in shape (closer to the ovoid), black and green. The mass of calculus is 64 mg. The calculus is heterogeneous in structure - it is represented by an irregular yellow-gray polyhedron, of rocky density, coated from the surface with a layer up to 0.1 cm thick of a black-green homogeneous mass, separated without significant effort. Mucous gallbladder for a considerable extent with a smooth relief, swollen, yellow-green color. At the location of the calculus is a trace-imprint with an area of about 0.5 cm ² , gray-green.

Biochemical parameters of blood taken on the 6th day of the experiment: total bilirubin 45.0 - µmol / l, Ast - 303 U / l, Alt - 119 U / l, α-amylase - 301 U / l, urea - 5.9 mmol / l, creatinine - 78 μmol / l.

Histological examination of the gallbladder and liver parenchyma in the bed area: a flattened epithelial lining with dystrophic and atrophic changes was detected. Own plate of the mucous membrane and submucosa were diffusely infiltrated by lymphohistiocytic elements mixed with plasma cells. In the standing zone of the calculus, the mucous membrane was absent for a considerable length (epithelial elements were found in the form of separate fragments among the masses of detritus); and in the muscle layer of the organ, zones of dissociation of muscle and connective tissue elements and diffuse leukocyte infiltration were noted. Stasis was detected in the microvasculature, and thrombus formation in vessels of medium caliber; focal fresh hemorrhages were noted. The serous membrane is thickened due to edema, inflammatory infiltration and the presence of fibrinous deposits (pericholecystitis phenomena). The liver parenchyma was characterized by hepatocytes in a state of granular dystrophy, depleted in glycogen, with scanty focal infiltration of the stroma in the triad zone.

Example 3

3.12 kg adult mongrel male rabbit under general anesthesia (flying 1.5 mg / kg intramuscularly in combination with 0.05 ml / kg xylazine intramuscularly) with the addition of local anesthesia 0.25% - 40.0 novocaine minilaparotomy was performed in the bile projection bladder oblique access parallel to the costal arch about 3.5 cm. On examination, the gall bladder without features, pear-shaped. Cholecystostomy was performed, mid-mineralized calculus was implanted, d-4.2 mm, yellow-gray in color, weighing 54 mg, external cholecystostomy was applied.

During the operation, blood was taken from the jugular vein; baseline biochemical parameters: total bilirubin - 12.4 μmol / L, Ast - 98 U / L, Alt - 112 U / L, α-amylase - 372 U / L, urea - 4.9 mmol / L, creatinine 86 μmol / l

In the postoperative period, infusion therapy was carried out once with saline in a volume of 120.0 ml, antibiotic prophylaxis and the administration of pain medications.

On the third day after the operation, when the condition of the rabbit was stabilized, a solution of octanoic acid in glycerol in the ratio of 1: 1 in the amount of 0.6 ml 1 time per day for 3 days was injected through the cholecystostoma. On the sixth day after surgery, the rabbit is slaughtered.

On examination, in the subhepatic space, a moderately pronounced loose adhesion process. Most adhesions manage to disconnect stupidly. The gall bladder is slightly deformed. When opening the lumen of the organ, yellow-green bile was detected in a volume of about 1.0 ml. The relief of the mucous membrane was somewhat smoothed. No calculus was found.

Biochemical parameters after the experiment: total bilirubin 14.5 - mcmol / L, Ast - 155 U / L, Alt - 96 U / L, α-amylase - 320 U / L, urea - 5.6 mmol / L, creatinine - 78 μmol / l.

Histological data:

In all parts of the gallbladder (neck, body and bottom), there are signs of moderate acute exudative inflammation and diffuse non-uniform lymphocytic-neutrophilic infiltration and moderate swelling of the stroma of the mucosa. Muscular and serous membranes without features. Only serosis showed changes reflecting the postoperative adhesive process. Liver parenchyma with preserved histoarchitectonics, minor effects of protein dystrophy of part of hepatocytes. The histoarchitectonics of all examined organs (stomach, small intestine, heart, kidneys, brain) were preserved, their tissues and cells did not have significant pathological changes.

This method is used to treat gallstone disease in 30 sexually mature outbred rabbits - males, weighing 2.8-3.4 kg. For control, 5 rabbits were used with the addition of calculi in the lumen of the gallbladder, without the application of cholecystostomy and, accordingly, without the introduction of a solvent. The results of the experiment are shown in tables 2, 3.

Low-mineralized calculi were dissolved in all cases of administration of a solution of octanoic acid in glycerol, medium-mineralized when administered for 3 days or more, highly mineralized on the 4th day of treatment. Biochemical parameters reflecting the general toxic reaction did not significantly change.

table 2 The effectiveness of the method depending on the number of days of administration of a solution of octanoic acid in glycerol and the degree of mineralization of calculi Number of days of administration Low salinity n = 9 Mineralized n = 10 Highly mineralized n = 16 2, n = 6 + ± ± 3, n = 8 + + ± 4, n = 8 + + + 5, n = 8 + + + Control (without solvent) n = 5 Note: + - no calculus after treatment was found
- - calculus without significant changes
± - incomplete dissolution of calculus

During a morphological study of the gallbladder, stereotypical changes were noted in the form of a slight and moderate acute exudative inflammation and moderate dystrophic changes in the integumentary epithelium. There were no significant features in the muscle membrane. Only serosis showed changes reflecting the postoperative adhesive process. The histoarchitectonics of all examined organs (stomach, small intestine, heart, kidneys, brain) were preserved, their tissues and cells did not have significant pathological changes. Only in the liver parenchyma were the phenomena of moderate protein dystrophy of some hepatocytes observed.

Thus, the claimed method of treating cholelithiasis in comparison with the prototype has the following advantages: reduced treatment time due to the speed of the dissolving effect, low general and local toxicity of the solution used and the effectiveness of the method with calculi of various compositions (cholesterol and pigment).

Bibliography

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Claims (1)

A method of treating cholelithiasis in an experiment, which includes administering a drug substance to the gallbladder through a cholecystostoma, characterized in that a solution of octanoic acid in glycerol in a ratio of 1: 1 is used as a drug substance, the injection is carried out jet in a volume of 0.2 ml / kg mass, once a day for 3-5 days.