RU2706369C1 - Method of purulent cholangitis treatment in acute biliary pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to abdominal surgery, and can be used for treating patients with acute biliary pancreatitis complicated by purulent cholangitis. Performing endoscopic papillosphincterotomy (EPST) and retrograde cholangiopancreatography (RCPG). Method comprises installing a nasobiliary drainage, the distal end of which is withdrawn through one nasal passage, is connected to an active aspiration apparatus and negative pressure of 7–14 mm Hg is created. On the first postoperative day, Chymotrypsin 10 mg + dexamethasone 8 mg, diluted in 40 ml of physiological solution NaCl 0.9 %, 2 times every 3 hours, 30 min after each administration, is administered through the nasobiliary drain tube. Patient is repeatedly connected to the active aspiration device with the previous values of negative pressure. After recovering bile efferent into duodenum and reducing intraductal pressure to 140 mm WG through nasobiliary drainage, drip introduction is 60–100 drops/minute of ozonized normal saline NaCl 0.9 % 500 ml 2 times day for 5 days.

EFFECT: method provides fast recovery of clinical and laboratory indicators, reduces complications and recurrences by performing EPST, RCPG and nasobiliary drainage.

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Description

The invention relates to medicine, namely surgery, and will find application in the treatment of patients with purulent cholangitis in acute biliary pancreatitis.

According to leading clinics, acute pancreatitis firmly took second place in the structure of urgent pathology, bypassing acute cholecystitis in recent years and second only to acute appendicitis. High mortality, reaching 40-60% with destructive forms, a large number of complications and long hospital stay are the most important medical and social problems in the treatment of acute pancreatitis [Borisov A.E., Kubachev K.G. Sergeev P.V. and others // Annals chir. hepatol. - 2009. - T. 14, No. 1. - S. 80-84 .; van Geenen E.J., van der Peel D. L. .. Bhagirath P. et al: // Nat. Rev. Gastroenterol. Hepatol. - 2010 .-- Vol. 7. N 9. - P. 495-502.].

The main etiological factor in the development of acute pancreatitis are diseases of the extrahepatic biliary tract. They account for up to 37-45% of observations. In these conditions, acute biliary pancreatitis is formed, the leading pathogenesis of which is the violation of the outflow of pancreatic secretion through the pancreatic duct system as a result of obstruction of the large papilla of the duodenum (BSDK) with calculus [Shapovalyants S.G. Mylnikov A.G., Orlov S.Yu. . and others // Annals chir. hepatol. - 2009. - T. 14, No. 1. - S. 29-33.].

Acute biliary pancreatitis is caused by many etiological factors and can subsequently cause complications from many organs and systems of the body. One of the most common complications is purulent cholangitis.

Obstruction of the bile ducts, increased intraluminal pressure and infected bile are important components in the pathogenesis of cholangitis. It is reported that the mortality rate is from 17% to 40% in the presence of concomitant diseases and advanced age. Mortality is significantly reduced with timely implementation of transpapillary interventions and conservative procedures after minimally invasive interventions [an Erpecum KJ. Complications of bile-duct stones: acute cholangitis and pancreatitis. Best Practice and Research: Clinical Gastroenterology. 2006; 20 (6): 1139-1152 .; Wada K, Takada T, Kawarada Y, et al. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. Journal of Hepato-Biliary-Pancreatic Surgery. 2007; 14 (1): 52-58.].

Despite a large number of studies, to date, all the problems associated with the diagnosis and treatment of acute beat paired pancreatitis complicated by purulent cholangitis have not yet been resolved.

At the same time, the active introduction of endoscopic surgery contributed to a more successful conservative and minimally invasive treatment of purulent cholangitis. This is due to less traumatic endoscopic interventions and the possibility of their use in severe patients. However, it should be agreed that to date, all approaches to treatment in various situations have not been developed, taking into account the characteristics of the clinical course of complicated forms of acute biliary pancreatitis.

The main trigger for purulent cholangitis developing in complicated forms of acute biliary pancreatitis is a violation of the outflow of bile, primary damage to the mucous membrane of the biliary tract due to trauma to calculi, and the activated pancreatic enzymes also have a damaging effect, and subsequently the bacterial infection will join. All of the above components of the pathogenesis of purulent cholangitis development further lead to pronounced local inflammatory changes in the mucosa of the common bile duct, edema, which, in turn, leads to the formation of narrowing of the lumen of the common bile duct and an even greater violation of the outflow of bile.

Based on the above, timely and adequate drainage of the biliary tract and the fight against the main components of pathogenesis is important in the treatment of patients with acute purulent cholangitis.

A known method of treating cholangitis, including cholecystectomy, choledochotomy, drainage of the common bile duct, bringing the drug to the area of inflammation, characterized in that the drug is used as an ozonized isotonic solution of sodium chloride, which is injected into the common bile duct during choledochoscopy during surgery and in addition, the same solution is introduced into the lumen of the common bile duct through a T-shaped drainage tube after surgery until the color and transparency of bile normalize.

The method according to claim 1, characterized in that a solution with an ozone concentration of 5 mg / L is used.

The method according to p. 1, characterized in that in the postoperative period, the solution is administered in an amount of 40 ml (RF patent No. 2157660, publ. 20.10.2000).

This method is chosen by us for the prototype.

The disadvantages of this method is that a traumatic operation is performed, this is a laparotomy with cholecystectomy, with choledochotomy with the installation of drainage in the common bile duct, for subsequent rehabilitation. Installation and prolonged use of external drainage through incisions on the anterior abdominal wall leads to infection of the postoperative wound itself. Also, volumetric surgical aids on the abdominal organs in the future lead to the formation of a powerful adhesive process, which affects the quality of life of patients. In the future, the adhesion process can be complicated by dyspeptic disorders, acute intestinal obstruction, intestinal gangrene, infertility in women.

A known method of surgical treatment of acute purulent cholangitis, including performing laparotomy under general anesthesia, revision of the abdominal organs, cholecystectomy, supraduodenal choledochotomy, revision of the biliary tract, removal of calculi from the biliary tract, drainage of the biliary tract with the installation of drainage into the common hepatic duct, fixation hepatic duct, fixation of drainage to the anterior abdominal wall, drainage of the abdominal cavity, suturing of the laparotomy wound with subsequent removal of drainage after the course and treatment, characterized in that the intraoperative length of the drainage of the common hepatic duct is measured and the edge of the proximal end is fused with flame, treatment sessions in the biliary tract are performed in the postoperative period, and 1800.0 ml of freshly prepared ozonated Ringer's solution with concentration are introduced into the biliary tract ozone 2.5-3.0 mg / l and freshly prepared ionized activated by the electrochemical method tap drinking water in the form of anolyte with a pH of 2.4-2.6 at a rate of 10.0 ml per minute, administered before the last one into the drainage cavity is a polymer monofilament fiber with a diameter of 0.5 mm and conduct it into the proximal biliary tract, using a polymer monofilament fiber, the proximal end of which is fused with flame and turn its end into a hemispherical shape with a smooth surface without increasing the width of the fiber at the end , establish the edge of the proximal end of the fiber in the biliary tract at a distance of not less than 0.3 cm from the edge of the proximal end of the drainage, irradiate through the fiber the biliary tract n with intense laser radiation with a wavelength of 0.63 microns and a power of 1.7-2.0 mW for 25-30 minutes, a fiber is removed from the biliary tract, treatment sessions are conducted daily 2 times a day for 4-12 days (patent RF №2210322, publ. 03/10/2003).

The disadvantages of this method is that a traumatic operation is performed, this is a laparotomy with cholecystectomy, with choledochotomy with the extraction of calculus from the choledochus, with further external drainage of the choledochus for subsequent rehabilitation. The use of large incisions for the patient in the early postoperative period causes the patient to have severe pain, decreased body reactivity, and a long recovery period. The long-term consequences include the formation of adhesive disease of the abdominal organs, which certainly causes the patient expressed discomfort in later life. Extraction of calculi by means of choledochotomy can lead to cicatricial stenosis at the incision site, which in turn disrupts the outflow of bile, and as a result lead to the formation of calculi, and obstructive jaundice, and subsequently to liver failure.

A known method of treating purulent cholangitis, including external controlled decompression of the bile ducts with a nasobiliary probe, removal of the gallbladder, installing drainage in the common bile duct, rinsing the bile ducts through the nasobiliary probe in the postoperative period with a drug mixture with an antibiotic, characterized in that the patient is performed recanalization after installing drainage in the bile duct. umbilical vein, an umbilical catheter is inserted into its lumen, through which every day in the postoperative period for 6-8 days simultaneously with washing using the bile ducts, intra-portal administration is carried out at a rate of 20 drops per 1 minute of a 0.9% sodium chloride solution dissolved in 250 ml and selected in accordance with the sensitivity of the microflora of bile antibiotic in a dose of 1.0 g (RF patent No. 2470600, publ. 12/27/2012).

The disadvantages of this method is that after installing the nasobiliary probe, an artificial increased pressure is created in the ducts, which can increase inflammatory changes in the common bile duct and pancreas. Also in this method, additional drainage is established after removal of the gallbladder, which forms an artificial fistula, which in the future, even after removal of the external drainage, may remain, causing discomfort in the patient. Also a drawback of this treatment technique is the implementation of sanation of the common bile duct on the 4th day after cholecystectomy and the installation of external drainage, which delays the inflammatory process in the common bile duct.

A known method of surgical treatment of cholangitis, including exposure to laser radiation, 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 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 t the treatment 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 the laser radiation with a wavelength of 760 nm is applied 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 fiber is removed from the drain Ms, the procedure is carried out in a day in an amount of at least three per course of treatment, after treatment transhepatic drainage is removed, the wound is sutured (RF patent №2491968, opub. 09/10/2013).

The disadvantages of this method is that with biliary pancreatitis complicated by purulent cholangitis with etiological causes that caused this condition most often damage the distal part of the common bile duct, for example, a wedge of calculus in the BDS, stenosing papillitis. And in this situation, it is logical to perform not antegrade decompression as indicated in the above patent, but retrograde decompression, since the cause of the development of cholangitis is distal. Therefore, this method, when the distal part of the common bile duct is affected, which most often occurs with complications of cholelithiasis, does not eliminate the main etiological factor and that is why it is symptomatic treatment in this situation.

The disadvantages of the prototype method (RF patent No. 2157660, 2000) are eliminated in the claimed technical solution.

The problem to which the invention is directed is to increase the effectiveness of treatment of patients with purulent cholangitis in acute biliary pancreatitis.

This problem is solved due to the fact that a method of treating purulent cholangitis in acute biliary pancreatitis, including drainage of the common bile duct, bringing the drug to the area of inflammation, differs in that they perform endoscopic papillosphincterotomy (EPST), retrograde cholangiopancreatography (RCHP), nasobiliary drainage the distal end of which the distal end of which is removed through one nasal passage, is connected to an active aspiration apparatus and a negative pressure of 7-14 mm Hg is created deleterious column; on the first day after surgery, through the nasobiliary drainage, chymotrypsin 10 mg + dexamethasone 8 mg diluted in 40 ml of physiological NaCl 0.9% solution is diluted 2 times with an interval of 3 hours, 30 minutes after each administration, the patient is reconnected to the active aspiration apparatus with the previous values of negative pressure; after restoration of the outflow of bile into the duodenum and decrease in intraductal pressure to 140 mm. water a column and below, through nasobiliary drainage, 60-100 drops / minute of ozonized physiological NaCl saline solution of 0.9% 500 ml are administered 2 times a day, for 5 days.

The technical result obtained by the clinical use of the claimed method consists in the rapid restoration of clinical and laboratory parameters of purulent cholangitis in acute biliary pancreatitis, reducing complications and relapses.

Causal relationship-

This result is achieved due to the fact that they perform minimally invasive intervention on the biliary tract in the amount of papillosphincterotomy, if necessary, perform choledocholithoextraction, and establish nasobiliary drainage. This intervention eliminates the etiological factor in the development of purulent cholangitis by less trauma and is more physiological. The main pathogenetic link in the development of purulent cholangitis in acute biliary pancreatitis is the formation of intraductal hypertension, which continues to persist even after dissection of the large duodenal papilla (BDS) and calculus extraction. This is due to the fact that in the distal parts of the common bile duct due to trauma to the calculus, pronounced inflammatory changes are formed with edema and deposition of fibrinous deposits. Fibrin and marked swelling are eliminated with the introduction of chymotrypsin 10 mg + dexamethasone 8 mg diluted in 40 ml of a physiological raster of NaCl 0.9%. Given the violation of the adequate outflow to the duodenum, the volume of drugs does not exceed 40 ml, so as not to cause a sharp increase in intraductal pressure and as a result not to cause more severe pancreatitis, leading to inflammatory stenosis of the lumen of the common bile duct. And precisely for this reason, the most important is the creation of negative pressure in the gall tree, which is achieved by connecting the distal end of the NBD to the active aspiration apparatus and creating negative pressure in the range of 7-14 mm. Hg. Art. The drip regimen of 60-100 drops / minute of an ozonized physiological NaCl solution of 0.9% 500 ml 2 times a day, for 5 days, is the most optimal, since it does not cause intraductal hyperemia and is most effective against infection, which is confirmed by the control chromato-mass spectrometry.

A detailed description of the method and examples of its clinical implementation

Under intravenous anesthesia using a video duodenoscope, brand "Pentax" (Japan), visualize the large duodenal papilla (BDS), perform endoscopic papillosphincterotomy (EPST). Next, retrograde cholangiopancreatography (RCHP) is performed, and if calculi are visualized, then choledocholithoectomy (CLE) is performed with further installation of nasobiliary drainage (NBD) with a diameter of 2 mm to the common hepatic duct, the distal end of which is removed through one nasal passage. After the NBD is installed, the first portion of bile is taken for biomicroscopic, chromatography-mass spectrometry and biochemical studies and the intraductal pressure is determined using the Waldman apparatus to monitor the effectiveness and dynamics of treatment.

The distal end of the BND is connected to an active aspiration apparatus (Venturi) and negative pressure is created in the minimum values of 7-14 mmHg.

On the first day after the operation, 1 hour and 4 hours after the operation, 10 mg + dexamethasone 8 mg diluted in 40 ml physiological NaCl 0.9% diluted in 40 ml of physiological NaCl (2 times with an interval of 3 hours) are injected through NBD. 30 minutes after each drug administration, the patient is reconnected to the active aspiration apparatus with the previous pressure values.

On the second day, they re-measure the intraductal pressure using the Waldman apparatus and perform fistulography. If restoration of the outflow of bile into the duodenum does not occur, conservative therapy is continued. When restoring the outflow of bile into the duodenum and lowering the intraductal pressure to 140 mm water of a column and below, sanitation of the gall tree is performed by dropping (60-100 drops per minute) through NBD of ozonized physiological solution of NaCl 0.9% 500 ml 2 times a day, for 5 days. On the sixth day, a portion of bile from NBD is re-taken to perform control biomicroscopy, biochemistry and chromatography-mass spectrometric studies to monitor the effectiveness and dynamics of treatment.

The performance of the proposed method is confirmed by the following clinical examples:

Example 1

Patient Poko V.I. 71 years old, was admitted by ambulance to the surgical department with a diagnosis of: primary: acute calculous cholecystitis complication: choledocholithiasis. Acute biliary pancreatitis. Purulent cholangitis. Upon admission, the patient’s condition is moderate, the skin is physiological in color, covered with cold, sticky sweat. There is hard breathing in the lungs on both sides, no wheezing. NPV -22 per minute. Blood pressure 110/70 mm Hg, heart rate-92 per minute. The tongue is dry, covered with a white coating, the abdomen is not swollen. The body temperature is 38.0 ° C. On palpation, the abdomen is tense in the epigastric region, the symptoms of peritoneal irritation are negative. Percussion in the sloping places of the abdomen is determined by dullness, auscultation of peristalsis is weakened. In the biochemical analysis of blood, hyperamylasemia is noted - 456.8 mmol / L. According to ultrasound scan, there are diffuse changes in the pancreatic parenchyma, an increase in the size of the pancreas, signs of acute calculous cholecystitis (stones 0.5-1.0 cm in diameter), the common bile duct is expanded to 1.1 cm in diameter, in the lumen in the distal parts, a calculus is visualized up to 0.8 cm in diameter.

The patient was treated according to the claimed method. Upon admission, an operative allowance was performed in the amount of: Endoscopic atypical papillosphincterotomy, retrograde cholangiopancreatography (RCP), choledocholithectomy (CLE), the installation of a nasobiliary drainage, the distal end of which is removed through one nasal passage. The first portion of bile was taken for biomicroscopic, chromatography-mass spectrometric and biochemical studies. Using the Waldman apparatus, the intraductal pressure was determined, which was 290 mm. water Art. After the operation, the distal end of the NDB was connected to an active aspiration apparatus (Venturi) with the formation of a negative pressure of 7 mm Hg. After 1 hour and 4 hours after the operation, 10 mg + dexamethasone 8 mg of 0.9% diluted in 40 ml physiological NaCl solution (2 times with an interval of 3 hours) was introduced through NBD via chitotrypsin. 30 minutes after drug administration, the distal end of the NDB was reconnected to the active aspiration apparatus with the previous pressure value: negative pressure of 7 mm Hg.

On the second day, the intraductal pressure was measured using the Waldman apparatus, which showed a decrease in pressure to 120 mm. water Art. A control fistulography was also performed, according to the results of which there is an active outflow of contrast into the duodenum, the shadows of calculi are not visualized. Sanitation of the gall tree was performed by dropwise administration (60-100 drops per minute) through NBD of ozonized physiological NaCl solution of 0.9% 500 ml 2 times a day, for 5 days. On the 3rd day, the distal end of the NBD is disconnected from the active aspiration apparatus and left for passive outflow.

On the sixth day, a portion of bile from the NBD was re-taken to perform control biomicroscopy, biochemistry and chromato-mass spectrometric studies.

Against the background of the treatment, the patient already had a decrease in body temperature to 37.6 ° C, a decrease in symptoms of intoxication, and an improvement in the general condition. In dynamics during a biochemical study on the 1st day and on the 6th essence, a decrease in bile amylase from 456.8 mmol / l to 75 mmol / l is noted. Similar positive dynamics in chromatography-mass spectrometry: there is a sharp decrease in the number of pathogenic bacteria, viruses and fungi.

On the seventh day the patient underwent laparoscopic cholecystectomy.

On the twelfth day in satisfactory condition was discharged.

The outcome of the disease is recovery.

Example 2

Patient Kr-i S.V., 45 years old, was admitted by ambulance to the surgical department with a diagnosis of: primary: acute calculous cholecystitis complication: choledocholithiasis. Acute biliary pancreatitis. Purulent cholangitis. On admission, the patient’s condition is of moderate severity, physiological skin integument, icteric sclera, covered with cold, sticky sweat. There is hard breathing in the lungs on both sides, no wheezing. NPV -21 per minute. Blood pressure 100/70 mm Hg, heart rate-96 per minute. The tongue is dry, covered with a white coating, the abdomen is not swollen. The body temperature is 38.4 ° C. On palpation, the abdomen is tense in the epigastric region, the symptoms of peritoneal irritation are negative. Percussion in the sloping places of the abdomen is determined by dullness, auscultation of peristalsis is weakened. In the biochemical analysis of blood, hyperamylasemia is noted - 564.4 mmol / L. According to ultrasound scan, there are diffuse changes in the pancreatic parenchyma, an increase in the size of the pancreas, signs of acute calculous cholecystitis (calculi 0.4-1.0 cm in diameter), bile duct expanded to 1.0 cm in diameter, in the lumen in the distal parts, a calculus is visualized up to 1.0 cm in diameter.

The patient was treated according to the claimed method. Upon admission, an operative allowance was performed in the amount of: Endoscopic atypical papillosphincterotomy, retrograde cholangiopancreatography (RCP), choledocholithectomy (CLE), the installation of a nasobiliary drainage, the distal end of which is removed through one nasal passage. The first portion of bile was taken for biomicroscopic, chromatography-mass spectrometric and biochemical studies and the intra-duct pressure was determined using the Waldman apparatus, which was 350 mm. water Art. After the operation, the distal end of the NDB is connected to the Active Aspiration Unit (Venturi) with the formation of a negative pressure of 14 mmHg. After 1 hour and 4 hours after the operation, 10 mg + dexamethasone 8 mg of 0.9% diluted in 40 ml physiological NaCl solution (2 times with an interval of 3 hours) was introduced through NBD via chitotrypsin. After 30 minutes of drug administration, the distal end of the NBD was reconnected to an active suction apparatus with a negative pressure of 14 mm. Hg. Art.

On the second day, the intraductal pressure was measured using the Waldman apparatus, which showed a decrease in pressure to 140 mm. water Art. A control fistulography was also performed, according to the results of which there is an active outflow of contrast into the duodenum, the shadows of calculi are not visualized. Sanitation of the gall tree was carried out by drip (60-100 drops per minute) through NBD of ozonized physiological NaCl solution of 0.9% 500 ml 2 times a day, for 5 days. On the 3rd day, the distal end of the NBD is disconnected from the active aspiration apparatus and left for passive outflow.

On the sixth day, a portion of bile from the NBD was re-taken to perform control biomicroscopy, biochemistry and chromato-mass spectrometric studies.

Against the background of the treatment, on the second day the patient showed a decrease in body temperature to 37.0 ° C, a decrease in symptoms of intoxication, and an improvement in the general condition. In dynamics during a biochemical study on the 1st day and on the 6th essence, a decrease in bile amylase from 754.5 mmol / l to 89 mmol / l is noted. Similar positive dynamics in chromatography-mass spectrometry: there is a sharp decrease in the number of pathogenic bacteria, viruses and fungi. On the seventh day the patient underwent laparoscopic cholecystectomy. On the eleventh day in a satisfactory condition he was discharged. The outcome of the disease is recovery.

Thus, the claimed method of treatment of purulent cholangitis in acute biliary pancreatitis, has allowed to achieve rapid improvement in clinical and laboratory parameters of patients, to reduce complications and relapses.

The inventive method of treatment of purulent cholangitis in acute biliary pancreatitis, we have tested on 20 patients. The results of using the technique in clinical practice showed already on the second day an improvement in the general condition of the patient: a decrease in body temperature, a decrease in symptoms of intoxication were noted. In general, a reduction in hospitalization periods, a decrease in the number of complications by 32.5% and an overall mortality rate of 4.6% was achieved.

The claimed method has the following advantages:

1. Allows you to improve the results of treatment of patients with acute biliary pancreatitis complicated by purulent cholangitis, reduce the number of complications and mortality due to timely and pathogenetic treatment tactics.

2. Retrograde drainage of the biliary tract is more physiological and less traumatic, which prevents adhesions of the abdominal cavity.

3. Active pathogenetic treatment with the formation of negative pressure in the biliary tract and the use of enzymes and ozonized saline dramatically reduces the formation of stenosis of the biliary tract in the postoperative period.

The claimed method for the treatment of purulent cholangitis in acute biliary pancreatitis, tested on sufficient clinical material, has shown efficacy and can be recommended for use in specialized surgical hospitals.

Claims (1)

A method for the treatment of purulent cholangitis in acute biliary pancreatitis, including drainage of the common bile duct, bringing the drug to the area of inflammation, characterized in that they perform endoscopic papilosphincterotomy (EPST), retrograde cholangiopancreatography (RCHP), nasobiliary drainage is established through one distal end of which stroke, attach to an active aspiration apparatus and create a negative pressure of 7-14 mm Hg, on the first day after surgery through a nasobiliary drainage the administration of chymotrypsin 10 mg + dexamethasone 8 mg diluted in 40 ml of a physiological raster of NaCl 0.9%, 2 times with an interval of 3 hours, 30 minutes after each administration, the patient is reconnected to the active aspiration apparatus with the previous values of negative pressure, after restore the outflow of bile into the duodenum and reduce intraductal pressure to 140 mm water column and below, through nasobiliary drainage, 60-100 drops / minute of ozonized physiological NaCl physiological solution of 0.9% 500 ml are administered 2 times a day, for 5 days.