RU2699537C1 - Ultrasonic fistulography method in patients with an external fistula of the parenchymal organ - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for ultrasonic fistulography in patients with an external fistula of the parenchymal organ. External fistula is first washed three times with an ozonized physiological solution with bubbling concentration of ozone of 40–60 mg/l and at constant overpressure of 100 mm Hg. Solution is aspirated with a syringe and volume of the entered solution is measured. Then, drainage is introduced at constant overpressure 100 mm Hg with the same volume of ozonized preparation "Ultravist" with initial bubbling ozone concentration of 60 mg/l. Drainage tube is clamped to perform multiplanar ultrasonic scanning in 3D reconstruction mode.

EFFECT: method provides higher effectiveness and accuracy of diagnostics ensured by introduction of necessary and sufficient volume of ozonized solution of contrast substance.

1 cl, 1 ex

Description

The invention relates to medicine, namely to surgery and radiation diagnostics, and can be used to diagnose the external fistula of parenchymal organs.

Known methods of fistulography [1,2], which consist in the slow introduction through the drainage tube of the gallbladder or common bile duct, under the control of fluoroscopy, 20-60 ml of 15-30% triiodinated radiopaque solution (triombrast, urographin, etc.), followed by dynamic radiography in 2 projections. Changing the position of the patient, they achieve filling of the studied biliary tract. Some authors [3] used complex contrasts with bactericidal and detoxification properties. According to the literature [4], it is known about the bactericidal and detoxification properties of ozonated solutions, which are successfully used to treat infected fistula [5].

The main disadvantages of these methods: dynamic x-ray fistulography leads to an increased dose of radiation; it is impossible to determine the necessary and sufficient amount of contrast introduced; differentiate this pathology with other diseases; it is not always possible to detect a message of the fistulous cavity with the ducts or vessels of the parenchymal organ, abdominal or chest cavity due to the increased viscosity of the contents of the fistula; insufficient sanitation of the fistulous course and residual cavity of the fistula.

In abdominal surgery, the known method of ultrasonic fistulography [6], taken as a prototype, including the introduction of contrast - antiseptic solution into the fistulous passage through the drainage, followed by ultrasound scanning.

The disadvantages of the prototype are: the inability to determine the necessary and sufficient volume of the injected contrast medium; it is not always possible to detect the message of the fistulous cavity with the ducts of the parenchymal organ due to the increased viscosity of the contents of the fistula; insufficient sanitation of the fistulous course and residual cavity of the fistula.

The basis of the invention is the task of improving the method of ultrasonic fistulography in patients with an external fistula of the parenchymal organ, which would eliminate the indicated drawbacks and increase the diagnostic accuracy by introducing into the fistula the necessary and sufficient volume of an ozonized solution of a contrast agent with subsequent ultrasound examination in 3D reconstruction mode.

The problem is solved in that before performing ultrasonic fistulography in patients with an external fistula of the parenchymal organ, the fistula is pre-washed three times with ozonized physiological saline (bubble concentration of ozone 40-60 mg / l). The remainder of the solution is carefully aspirated. Then, a solution of the same composition is introduced into the same drainage tube under a constant overpressure of 100 mm. Hg. Art., then aspirate it with a syringe and measure the volume of the entered solution with an accuracy of 1-2%. Then, the same volume of the Ultravist ozonized preparation (iodine concentration of 240 mg / ml) is introduced into the same drainage (constant overpressure of 100 mm Hg), with a bubble concentration of ozone of 40-60 mg / l. After that, the drainage tube is clamped by a clamp and polyposition ultrasound scanning is performed in 3D reconstruction mode.

The method is as follows. After a clinical examination (complaints, medical history, objective examination), the external fistula is drained using a drainage tube. Securely fix it to the skin with a nodal suture. Then the canal, cavity and branches of the fistula are washed three times with ozonized (bubble concentration of ozone 40-60 mg / l) with physiological saline. This procedure provides sanitation of the canal and cavity of the fistula. The antiseptic and detoxification properties of ozonized physiological saline with a bubble concentration of ozone of 40-60 mg / l have been described previously [4]. In addition, according to our data, a 3-fold washing with ozonized (bubble concentration of ozone 40-60 mg / l) with physiological solution of the external bile fistula leads to a change in the viscosity of bile (viscosity decreased from 4.7 - 6.68 MPa s to 2, 8 - 4.0 MPa s). The cellular composition of bile is noticeably changing. Under bile microscopy, the number of leukocytes decreased from 32 - 38 to 3 - 4, and epithelial cells - from 22 - 27 to 2 - 3. Therefore, the implementation of fistulography is greatly facilitated. The viscosity of bile and the contents of the fistula decreases, this leads to a decrease in hydrodynamic resistance and the ozonized physiological saline much more easily and more completely fills the fistulous passage and its branches. After washing, 100 mm are introduced under constant overpressure. Hg. Art., ozonized physiological solution in the fistulous passage and its branches through the same drainage tube. Then it is aspirated with a syringe and the volume of the entered solution is measured accurately (1-2% error). Our studies have shown that 3-fold washing makes the canal, cavity and branches of the fistula more accessible for research and penetration of contrast. This allows you to determine the necessary and sufficient amount of contrast. After aspiration and volume determination, the same volume (which was determined) of the Ultravist ozonized contrast solution (iodine concentration 240 mg / ml, is introduced into the drainage tube (without removing it from the fistula channel) (overpressure 100 mm Hg). temperature 36-36 ° С) with a bubble concentration of ozone 40 - 60 mg / l. Then the tube is pinched with a clamp and polyposition ultrasound scanning is performed in 3D reconstruction mode.

The necessary and sufficient volume of contrast medium corresponds to the volume of ozonized physiological solution, which is aspirated with a syringe from the fistulous course of the parenchymatous organ and its branches. Overpressure 100 mm. Hg. Art. corresponds to the average arterial physiological pressure and is not able to inflict additional damage.

The claimed bubbling ozone concentration of 40-60 mg / l was recognized as optimal for action on aerobic, anaerobic microflora, Pseudomonas aeruginosa. According to our data, at a lower concentration, the pathogenic flora was sown from the drains in 37% of cases; at a higher concentration, a cytolytic effect on the cells of the parenchymatous organ was observed.

An "ultravist" with an iodine content of 240 mg / ml has: osmolarity at 37 ° C - 0.48 osm / kg H ₂ O; viscosity at 20 ° С - 4.9 MPa / s; at 37 ° С - 2.8 MPa / s; density at 20 ° С - 1.263 g / ml, at 37 ° С - 1.255 g / ml; pH 6.5-8.0 [7.8]. According to our data, a contrast medium with the indicated physicochemical characteristics is best ozonized and maintains a bubble concentration of ozone of 40-60 mg / l for 6 hours. "Ultravist", warmed to body temperature before being introduced through the drainage, is better tolerated and easier to administer due to lower viscosity of the solution.

An example of using the method. Patient H., 30 years old, was admitted to the I surgical department of the Donetsk Clinical Territorial Medical Association (83003, Donetsk, pr. T. Ilyicha, 14) with a diagnosis of incomplete external intrahepatic biliary fistula. Condition after laparotomic echinococcectomy, omentocystohepatopexy April 8, 2015 due to echinococcal cyst of the right lobe of the liver. 04/21/2015, under the control of ultrasound, additional drainage of the residual cavity was performed. He was discharged with an external incomplete biliary fistula to continue treatment at the place of residence. He re-entered the clinic on 08/15/2015 to resolve the issue of further treatment tactics and drainage removal. The general condition of the patient was satisfactory. HELL - 130/90 mm RT. Art. The abdomen is soft, moderately painful to palpation in the right hypochondrium. The liver is not enlarged. Physiological administration is normal. Blood tests - without pathological changes. When computed tomography of the abdominal organs 08/15/2015: the liver is moderately increased in size, the contours are smooth, heterogeneous structure due to the presence in S7 of a reduced density site, 4.1 x 2.8 cm in size, with a drainage tube. Single small calcifications up to 0.2 cm in diameter are visualized in the parenchyma of the left lobe. 08/17/2015, performed ultrasonic fistulography in 3D reconstruction mode according to the proposed method. The connection between a small residual cavity in the liver and intrahepatic bile ducts was revealed. The gall bladder, extrahepatic bile ducts, and duodenum were performed with the contrast agent Ultravist. Ultrasound of the liver revealed no additional formations. In the area of surgical intervention - areas of fibrosis. After conservative treatment and sanitation of the fistula with antiseptic solutions, the drainage was removed on 08/22/2015. Recovery. 08/26/2015, Discharged from the hospital in satisfactory condition. Saturation of solutions with ozone was carried out using the apparatus "OZONE UM-80" (Kharkov). The use of ozone is due to both its direct bactericidal effect on the microbial cell by damaging its membrane during ozonolysis, and dysfunction of organelles during the action of induced oxidizing agents [4,5].

The effectiveness of the proposed method was proven in 11 patients with a non-parasitic liver cyst having communication with the intrahepatic bile ducts in clinical conditions on the basis of the 1st surgical department of the Donetsk Clinical Territorial Medical Association (83003, Donetsk, pr. Ilyicha 14). These patients previously underwent percutaneous transhepatic drainage of the cyst. When performing fistulography according to the standard method [6], there were no messages between the liver cyst and intrahepatic bile ducts. And with fistulography according to the claimed method, a message was found between the liver cyst and the intrahepatic bile ducts. The identification of such a message, in our opinion, relates to increasing the accuracy of diagnosis, which is important for predicting the volume of operation.

The proposed method is highly effective, reliable, simple and affordable to perform in practical medicine.

Information sources:

1. Beresneva EA, Comprehensive X-ray examination of patients with external fistulas / EA Beresneva N.Yu. Pautkina L.V. Shramko // Vestn. radiology and radiology. - 1990. - No. 2. - S. 11 - 18.

2. Halperin E.I., Manual on biliary tract surgery / E.I. Halperin, P.S. Vetsheva // M .: Vidar, 2009 .-- 568 p.

3. Hydrogen peroxcide enhanced ultrasound fistulography in the assessment of entero-cutaneous fistulas complicating Crohnʼs disease / G. Maconi [et all.] // Gut.- 1999.- No. 45 (6) .- 874-878 p.

4. Ozone therapy. Internal diseases [Text]: textbook / O.V. Maslennikov, K.N. Kontorshchikova.- N.Novgorod, 2003.-258s.

5. Ozone, reactive oxygen species and intensive care methods in medicine. VIII All-Russian scientific-practical conference with international participation. Nizhny Novgorod September 23-25, 2009.- Revista Ozonoterapia.- 2009.- No. 1 (3) Suppl. - 222 p.

6. Andreeva I.V. Ultrasonic fistulography in abdominal surgery / I.V. Andreeva, A.A. Vinogradov, S.V. Levenets // http: // ultrasound.net.ua / materiali-konferencii-t _a -zjizdiv / III - kongres - odesa - 2008.

7. Ultravist, solution. Instruction [electronic resource] .- Source: https://health.mail.ru/drug/ultravist/

8. Ultravist ^® (iopromide) injection [electronic resource] .- Source: https://www.radiologysolutions.bayer.com/products/ct/contrast/ultravist/

Claims (1)

The method of ultrasonic fistulography in patients with an external fistula of the parenchymal organ, which includes the introduction of an antiseptic solution into the fistula through the drainage with further ultrasound scanning, characterized in that the external fistula is pre-washed three times with ozonized saline solution with a bubble concentration of ozone of 40-60 mg / l and at a constant overpressure of 100 mm Hg, the solution is aspirated with a syringe and the volume of the entered solution is measured, then it is introduced into the drainage at a constant design pressure 100 mmHg the same volume of the Ultravist ozonized preparation with an initial bubble concentration of ozone of 60 mg / l, after which the drainage tube is clamped and a polypositional ultrasound scan is performed in 3D reconstruction mode.