RU2760538C1 - Method for the prevention of postcholecystectomy syndrome - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to physiotherapy, and can be used to prevent the development of postcholecystectomy syndrome (PCES) after laparoscopic cholecystectomy (LCE). Infrared laser radiation is applied 1-2 days after the operation. Against the background of compliance with the appropriate diet, a complex physiotherapeutic effect is carried out. From the 1-2 day after the operation and before the removal of postoperative sutures, daily procedures of exposure to low-intensity laser radiation (LILR) are carried out using a matrix emitter on the right hypochondrium with a wavelength of 0.89 μm, a maximum radiation power of 50 W per pulse, a repetition rate pulses 80 Hz, exposure time 5 min. Then, after the removal of the postoperative sutures, daily cryomassage (CM) and ultrasound therapy (UST) procedures are performed sequentially in the course of one procedure. At the same time, CM is carried out through a cotton fabric using a cryopacket with a temperature of minus 21-23°С on the area of ​​the right hypochondrium: first, circular strokes are performed with a cryopackage for 1 min, alternating with applications in this area - 1 s each, then 1 min - a break in exposure, then for 2 minutes - again circular stroking with a cryopack, alternating with applications after 1 s. 30 minutes after the end of the CM, ultrasound is applied to the area of ​​the right hypochondrium with a frequency of 1 MHz, a pulsed mode, a pulse duration of 10 ms, a labile technique with an emitter of 5 cm2, an intensity of 0.4 W/cm2, 5 minutes per procedure, then - on the right paravertebral region at the level of Th7-Th12 vertebrae, with an intensity of 0.2 W/cm2for 3 minutes daily. 10 complex CM and UST procedures are performed.EFFECT: method provides early warning of gastrointestinal tract dysfunctions, restoration of patients' well-being and preservation of these positive effects for a long time, and with minimal use of medications up to complete refusal to take them.2 cl

Description

The invention relates to medicine, physiotherapy, medical rehabilitation, gastroenterology and concerns methods of early prevention of the development of postcholecystectomy syndrome (PCES) in patients after laparoscopic cholecystectomy (LCE).

Cholelithiasis (cholelithiasis) is one of the most common diseases of the hepatobiliary system; in recent decades, cases of its detection have been steadily increasing, which leads to a significant increase in the number of cholecystectomies (ChE). According to statistics, gallstones are diagnosed in 52.5% of the population of Russia, mainly of working age [1]. This gives this problem not only medical, but also social significance. Although at present the possibilities of treating gallstones with conservative methods have expanded, ChE remains the main method of its treatment (more than 200,000 operations per year) [2]. But, as clinical practice and literature data show, CE does not always bring relief to the patient. Many patients (up to 50%) develop a symptom complex after surgery, united by the general name "postcholecystectomy syndrome" (PCES), which was recommended by the 7th Congress of the Scientific Society of Gastroenterologists of Russia (2007) to be considered taking into account the entire complex of pathological conditions associated with long-term biliary pathology.

PCES is defined as a clinical symptom complex of functional and / or organic changes that developed after ChE, or aggravated by it, or developed independently as a result of technical errors in its implementation [1, 2].

In case of violation of the adaptive-compensatory capabilities of the hepatobiliopancreatoduodenal system (HBPDS) due to

with the absence of a gallbladder, the prerequisites for the development of PCES arise. Its early and delayed forms are distinguished. The former include residual stones in the cystic duct or common bile duct, cholangitis, the consequences of intraoperative damage to the bile ducts, bile outflow, the latter - recurrent formation of stones in the ducts, strictures, inflammation of the cystic duct stump / GB, stenosis of the large duodenal papilla, sphincter dyskinesia Oddi. Symptoms after ChE can be of the nature of biliary or pancreatic disorder. Most often, the patient is worried about pain, discomfort in the right hypochondrium or epigastrium. Of the dyspeptic phenomena, bitterness in the mouth, belching, nausea, heartburn, loss of appetite, and stool disorders are more often noted.

After ChE, the synchronization of the flow of bile acids into the intestine is disturbed, and "hologenic diarrhea" develops, which can also be caused by disturbances in innervation due to an operating injury. A significant number of patients have increased irritability, fatigue, and poor sleep.

All this requires preventive measures, postoperative rehabilitation of morphological and functional changes in the hepatobiliary-pancreatoduodenal system. Despite some success in drug therapy, these issues have not yet been resolved. Currently, more and more importance in their solution is given to physiotherapeutic methods that have various pathogenetic mechanisms of action [6].

Post-ChE diets are also essential for optimal digestive function in the absence of a gallbladder (GB). The diet after ChE differs from the usual diet. Due to the loss of the storage function of the gallbladder, food should be at least 5-6 times a day. Usually, patients are prescribed table 5-5a according to Pevzner, sharply reducing the content of cholesterol-containing foods, fatty acids (animal fats) in food. After ChE, they do not recommend offal, bacon, fatty meat, fried foods, a large amount of seasonings and spices, baked and rich dishes, carbonated drinks.

Since obesity contributes to the disruption of metabolic processes in the body, the diet after ChE involves nutrition aimed at losing weight.

To eliminate the spasm of the sphincter of Oddi, medications are used: drotaverine, papaverine, mebeverin, gimecromone. In the presence of enzyme deficiency, the appointment of enzyme preparations is required (Creon, pangrol, mezim-forte, pancreatin).

Disorders after ChE are often combined with constipation and increased pressure in the duodenal system. Therefore, with these complaints, prokinetics are prescribed (domperidone, metoclopramide, trimebutin). To prevent cholelithiasis (re-formation of stones in the ducts) after ChE, to increase the production of bile and its excretion, to lower cholesterol, ursodeoxycholic acid preparations are prescribed as prescribed by the doctor.

Also, the disturbed microbial landscape of the small and duodenum (Duodenum) is treated by prescribing intestinal antiseptics and antibiotics, followed by the use of probiotics and prebiotics.

A particularly important role is played by the use of physiotherapy in the rehabilitation of patients after ChE, in the prevention of PCES.

It is usually recommended to prevent the development of PCES with the help of physiotherapy in the early stages - 8-14 days after the operation. The most effective is complex treatment, including (in addition to physiotherapeutic methods) drinking mineral water, balneotherapy, exercise therapy, massage. Of the physiotherapeutic methods, amplipulse, microwave therapy, PMF, ultrasound in a pulsed mode to the liver region and to the right back at the ThVI-ThX level are recommended paravertebral. UHF and microwave therapy, galvanization, drug electrophoresis have anti-inflammatory and analgesic effects; procedures are performed on the liver area, collar zone. Prescribe electrosleep. Mud therapy (applications of sulfide silt, sapropel or peat mud on the right hypochondrium) are effective 2-3 weeks after CE (G.Sh. Gafiyatulina et al. Physiotherapy. Textbook. P.229. [Electronic resource]: https: // med -vvolske.ru/docs/2018_04_16/Q9y7esrh9By2e96fHzYkaGK3f.pdf ).

Our earlier clinical studies have shown the high efficiency of cryotherapy (CRT) in patients with duodenal ulcer, colitis, irritable bowel syndrome [4, 6]. Earlier, the positive effect of CRT on the correction of the state of immunity, microcirculation, regeneration, and an increase in the general resistance of the body was also revealed.

The results of experimental studies in the field of cryomedicine have shown that integrating systems are most sensitive to cold influences, for example, neurohumoral - at the level of the organism and organ, microhemocirculatory - at the level of organs and tissues, membrane complexes - at the level of cells [4].

Under the influence of cold, the functional power of modulatory stress-limiting systems increases: GABAergic, serotonergic, opioid peptide systems, antioxidant systems, and prostaglandin systems. In the cryomassage zone (CRM), a sharp narrowing of blood vessels occurs, which slows down the blood and lymph supply of tissues and increases the tone of muscles and blood vessels. When the effect of the cold stops, the vessels in the massage zone expand, lymph and blood flow accelerate, the temperature rises (becomes higher than in the surrounding tissues). Activation of blood circulation contributes to increased tissue nutrition, the production and release of anti-inflammatory substances into the blood, which relieve swelling and relieve pain: locally tense muscles relax, spasms and the effect of "pinching" are eliminated ( http://kryomed.ru/kriomassazh-v-lechenii-osteoxondroza / ). In the problem area, cell functions are restored, repair is stimulated.

It is known to use CRT in the rehabilitation of patients after CE (Filimonov R.M., Styazhkina E.M., Filimonova T.R., Olshanskaya N.M. , M., 2019, pp. 38-40). For KRM, we used a Delta-Term cryopack with a temperature of -21 ... -23 ° C. The procedure consisted of stroking and short-term applications in the abdomen and segmental-reflex zone (two approaches in each zone) for 3-5 minutes with a 2-minute break. The course includes 10-12 daily procedures. In this known method, the effect was carried out on patients with a prescription of ChE from 1 to 3 years. The leading clinical syndromes after ChE were painful and dyspeptic, especially in violation of the diet, i.e. patients had already developed PCES. Of the asthenovegetative symptoms, general weakness, sleep disturbances, and headaches were more common. After the course of KRM, all patients were less likely to be bothered by abdominal pain, heartburn, belching of air and eaten food, flatulence. Stool normalization was noted, especially in patients with diarrhea. Mood and sleep improved. These effects became apparent after 4-5 CRM procedures.

However, in this method, CRT was used with already developed PCES.

The therapeutic effect of ultrasound (US) is also known, which is determined by its mechanical, thermal and physicochemical factors [3, 6]. The mechanical action is manifested in tissue micromassage, increasing the permeability of cell membranes. A consequence of the thermal action of UST can be considered a change in diffusion processes, the rate of biochemical reactions. Its physicochemical effect is manifested in the activation of redox processes, the formation of biologically active substances [3]. The use of ultrasound in therapeutic dosages (0.2-0.4 W / cm2) leads to a combined effect: increased microcirculation, anti-inflammatory, antispastic, desensitizing, analgesic, loosening of connective tissue and stimulation of regeneration. Scar tissue formed upon exposure to ultrasound is stronger and more elastic in comparison with “normal” scar tissue [3].

At the same time, there is a known method of restorative treatment of patients who have undergone ChE (Medical rehabilitation / under the editorship of V.M. Bogolyubov, - Perm, 1998, vol. 3, p. 320) by local exposure to ultrasound (US) with a frequency of 880 kHz on the right hypochondrium with an intensity of 0.4-0.7 W / cm2 and the corresponding segmental zone (D6-D10 on the right) with an intensity of 0.2-0.4 W / cm2.

The disadvantage of this method is the use of a higher intensity and continuous mode of ultrasound, which in the early postoperative period can cause undesirable inadequate side reactions in patients, therefore, is not suitable for early prevention of PCES.

Also, it has now been established in experiments that when exposed to low-intensity laser radiation (LLLT), cell membranes change their energetic activity, the cellular-nuclear apparatus in the DNA-RNA-protein system is stimulated, redox reactions are activated, ATP synthesis increases, processes are stimulated intra- and extracellular regeneration. It is known that LLLT of the infrared range has a pronounced anti-inflammatory effect, helps to reduce the formation of LPO, restore important energy-dependent processes (synthesis of proteins and nucleic acids, hormones, transport of ions and molecular compounds through the cell membrane, reception of the cell membrane), normalizes metabolic and bioenergetic processes in tissues [3, 5]. LILI normalizes microcirculation, reduces tissue edema and accelerates reparative processes in gastroduodenal pathology [3, 5, 6]. However, there are practically no data on the use of LILI for early prevention of PCES.

It is known to simultaneously carry out complex drug and laser therapy for cholecystitis (RU 2301653 C1, 06/27/2007, GOU VPO "North Ossetian State Medical Academy" of the Federal Agency for Health and Social Development). In this case, laser therapy is prescribed in a differentiated manner. If the duration of the disease is less than 7 years and the course is mild, laser reflexotherapy is carried out daily by contact, a course of 10 procedures. Wavelength 1.3 μm, radiation power 1 mW, modulation frequency 2.4 Hz. Different modes of action are applied to different acupuncture points. If the disease lasts more than 7 years and the course is moderate or severe, ILBI is performed with a wavelength of 0.63 microns, with a radiation power at the end of the fiber of 1.5-2.0 mW. The duration of the procedure is 20 minutes. Course of 7 procedures. The method reduces the duration of treatment, increases the effectiveness of drug therapy, however, it concerns the treatment of non-calculous cholecystitis only, and therefore, its use for early prevention of PCES after ChE may be ineffective.

There is a complex method of treatment of patients with already developed PCES (Filimonov R.M., Filimonova T.R., Musaeva O.M. ), including the effect of ultrasound and LILI, as well as a comparison of the effectiveness of such an effect with CRT in patients with PCES in stationary conditions. For treatment, ultrasound (Sonopuls apparatus) with a frequency of 1 MHz, pulsed mode (pulse duration 10 ms or duty cycle 50%), labile effect of a large emitter (5 cm2) on the right hypochondrium, intensity 0.2-0.4 W / cm2, according to 2-4 minutes, and on the right paravertebral area at the level of Th7-Th12 vertebrae, with an intensity of 0.2 W / cm2 - 3 minutes, daily, for a course of 10 procedures.

Further, without a time interval, the LILI (device "Mustang 2000") was exposed to a matrix emitter on the right hypochondrium, wavelength 0.89 μm, with a maximum radiation power of 50 W per pulse, pulse repetition rate 80 Hz, exposure time 5 min. There are 10 daily procedures per course.

Patients of the other group underwent cryomassage (CRM) of the abdomen and paravertebral zone at the D4-D12 level according to the developed method. At the same time, a cryopacket of DELTA-THERM company (registration number FSR2007 / 00829) with a temperature of -21 ... -23 ° C was used for KRM. The procedure, lasting 10-15 minutes, consisted of stroking and short-term applications, in two approaches with a 2-minute break (in each zone). The course of treatment includes 10-12 daily procedures. No side effects from the therapy were observed in any patient.

Data were obtained that in the rehabilitation treatment of patients with PCES in the first months after ChE, the most promising is the combined use of UST and LILI. This complex has a more pronounced analgesic, anti-inflammatory effect and influence on dyspeptic syndrome than KrM. In the later period, with severe pain syndrome, it was shown that CRM is more effective (86.4%) than the complex of UST and LLLT (77.3%). In case of dyspeptic syndrome, accompanied by diarrhea, CRM is also more effective, and in case of constipation, a complex of UST and LLLT.

In asthenoneurotic syndrome, CRM was more effective than UST and LLLT (90.9% and 77.3%, respectively). When cold was used as a therapeutic factor, the response of the organism depended on its initial state and parameters of cold exposure. The nature of the body's reactive response to short-term and adequately dosed cold was distinguished by shifts more pronounced in quantitative and qualitative terms than to heat.

Laser therapy has a more pronounced analgesic effect in comparison with UST. In the above study, LILI had no effect on stool disorders in patients with PCES. A pronounced normalizing effect of UST on intestinal motility in cases of constipation was noted. Monotherapy with UST showed a more pronounced anti-inflammatory effect on the mucous membrane of the stomach and duodenum than with monotherapy with LLLT.

The developed methods of application of KrM, LILI of the infrared range and UST in PCES were well tolerated by patients, were highly effective and contributed to an increase in the quality of life.

The complex use of LLLT and UST in this known method contributed to a pronounced improvement in the functional state of the digestive organs: stomach, liver, pancreas, apparently due to the local, as well as reflex influence on these organs, carried out through the skin receptors of the reflexogenic zones of these organs, and also their interoreceptors, which led to the restoration of disturbed functions of the stomach, improvement of microcirculation and general trophic effect on the gastrointestinal tract, increasing the protective properties of the mucous membrane of the stomach and duodenum, as well as adjacent organs, activating local mechanisms of tissue homeostasis in them and thereby reducing inflammatory manifestations.

However, this complex method was used for more than 1 month after ChE , and the patients already had quite pronounced symptoms of PCES, requiring them to prescribe medications.

Our proposed method provides for an earlier start of rehabilitation treatment, rehabilitation, immediately after the operation (1-2 days) in order to prevent the symptoms of PCES development, improve and accelerate the healing of tissues damaged by the operation and stimulate the adaptive processes of the digestive system and the whole organism as a whole, that is, to ensure the prevention of the development of PCES.

Thus, such a technical problem was solved as the development of a more perfect and sparing algorithm for a complex physiotherapeutic effect in patients after LCE for the prevention of gastrointestinal dysfunction, restoration of patients' well-being and preservation of these positive effects for a longer time, and with minimal use of medications, up to complete refusal to accept them.

As the closest analogue (prototype) can be adopted a method of treating patients who have undergone both cavity and LCE, and aimed at secondary prevention of stone formation, for which a combined magnetic-infrared-laser effect is performed after surgical removal of stones or the affected gallbladder (RU 2136336 C1, 10.09.1999, Timofeev V.A.). For this, the very next day after the ChE operation, laser radiation is applied to the area of the surgical intervention, with a wavelength of 0.88-0.90 μm, a density of 2.5-3.0 W / cm2 and a pulse repetition rate of 5-5000 Hz. The values of the magnetic induction are 34-35 mT for 10-15 minutes. Only 12-15 sessions. Then, an electric current is applied with a frequency of 70-100 Hz at a current of 30-150 mA and a pulse duration of 5-7 ms for 15-25 minutes. 10-12 sessions per course. The method allows to eliminate the causes of stone formation and exclude relapses of the disease for at least 6 months, however, it may have a number of contraindications, due to the use of sufficiently strong effects on the body at such an early period after the operation.

The technical result of the proposed method is early prevention of PCES development - the day after LCE operation, prevention of gastrointestinal dysfunctions, restoration of patients' well-being and preservation of these positive effects for a long time, with minimal use of medications, up to complete refusal to take them.

For this, a method is proposed for preventing the development of PCES after laparoscopic cholecystectomy (LCE). Against the background of compliance with the appropriate diet, a complex physiotherapeutic effect is carried out: from the 1-2 day after the operation and until the removal of postoperative sutures, daily procedures of exposure to low-intensity laser radiation (LLLT) are carried out using a matrix emitter on the right hypochondrium region, with a wavelength of 0.89 μm, maximum radiation power 50 W per pulse, pulse repetition rate 80 Hz, exposure time 5 min.

Then, after the removal of the postoperative sutures, daily cryomassage (CRM) and ultrasound therapy (UST) procedures are performed, sequentially in the course of one procedure. In this case, KRM is carried out through a cotton fabric using a cryopacket with a temperature of minus (21-23) ° C to the area of the right hypochondrium: first, circular strokes are performed with a cryopackage for 1 minute, alternating with applications in this area - for 1 second, then 1 minute - break, then for 2 minutes - again circular stroking with a cryopack, alternating with applications after 1 second.

Then, 30 minutes after the end of KRM, during the procedure, ultrasound is applied to the area of the right hypochondrium with a frequency of 1 MHz, a pulsed mode, a pulse duration of 10 ms, a labile technique with a 5 cm2 emitter, an intensity of 0.4 W / cm2, 5 minutes per procedure, then - on the right paravertebral region at the level of Th7-Th12 vertebrae, with an intensity of 0.2 W / cm2 for 3 minutes, daily.

10 complex CRM and UST procedures are performed. According to the indications, drug therapy is used.

In our proposed method, we propose to prevent the development of PCES, using the above physiological effects in a sequential complex, and using more gentle modes of exposure with a shorter course of each of the effects to exclude the possibility of adverse effects.

The early onset of physiological effects in the proposed sequence and mode within the framework of the proposed method allows to reduce the duration of both LLLT and cryotherapy in the course of each session, in contrast to the previously known method (Filimonov R.M., Styazhkina E.M., Filimonova T.R. , Olshanskaya N.M. a minute break, and in patients with already developed PCES. According to our experience, with such a duration of cryotherapy, excessive irritation of the skin can be observed, in particular, in patients with sensitive skin, a tendency to allergic reactions, asthenoneurotics. In this case, this is extremely undesirable, since after the removal of the stitches in the area of their application, there may still be non-fallen crusts. Subsequently, we found that in order to achieve a preventive effect within the framework of the proposed method after an early exposure to LILT, and since CT is carried out in combination with UST, shorter sessions of the CT course are sufficient - in 2 approaches, respectively, 1 and 2 minutes per area of the right hypochondrium , with a one minute break.

The onset of early effects with LLLT is based on the fact that it has a normalizing physiological effect, which persists even after the termination of this effect; the duration of the preservation of the effect increases from procedure to procedure, overlapping at a certain moment the time between procedures (AA Stenko, IV Kumova, IG Zhuk. The use of low-intensity laser radiation in the treatment of surgical pathology // Journal of the GrSMU. 2006. No. 1, pp. 37-40). It is assumed that the action of laser radiation on human tissue leads to a reversible (non-damaging) change in the spatial configuration of cell membranes and enzyme molecules, which causes a change in their regulatory functions and, as a consequence, in the functional activity of cells. LLLT stimulates the metabolic activity of the cell, which can be one of the important points that determine the effect of low-intensity laser radiation on the most important functions of cells and tissues, vital processes and regeneration. LLLT stimulates the production of a universal source of energy ATP in mitochondria, accelerates the rate of its formation, increases the efficiency of the mitochondrial respiratory chain, and the amount of oxygen consumed decreases. LILI has an antioxidant effect. It leads to a decrease in spastic reactions of microvessels, especially of the arterial link, normalizes the permeability of the wall of microvessels, and improves the rheological properties of blood. Secondary effects represent a complex of adaptive and compensatory reactions resulting from the implementation of primary effects in tissues, organs and the whole organism: anti-inflammatory, analgesic, regenerative, desensitizing, immunocorrecting, improving regional blood circulation, hypocholesterolemic, bactericidal and bacteriostatic (see above: A.A. . Stenko et al., Ibid.). All this helps to prepare the tissues immediately after the operation for the subsequent complex treatment.

When removing the stitches, 7-8 days after surgery, a course of complex effects of KRM and UST is started.

In the proposed method, with a more active healing and, accordingly, an earlier start of CT, its beneficial effects help to reduce the body's energy consumption (glucose, ATP), in particular in the area of the operation, which makes it possible to more optimal recovery and increase the effectiveness of subsequent stimulating blood circulation, regeneration, preventing the formation of hypertrophic scars.

A number of earlier studies have shown that it is with the use of CT that the patient's psychoemotional state normalizes rather quickly after the operation. It is recommended that KpM in the claimed method be carried out through a clean cotton cloth in order to avoid the aforementioned undesirable effects of skin irritation.

The main effects of CRT are pain relief, reduction of inflammation and muscle spasm, antihypoxic, hemostatic and reparative action. With KRM, there are rhythmic fluctuations in the processes of constriction (during cold exposure) and vasodilation (upon termination of exposure), which contributes to the restoration of microcirculation in the microvessels of not only the blood, but also the lymphatic channel, prevents ischemic tissue damage (reactive hyperemia). With repeated exposure to low temperatures, an increase in the tone and elasticity of the vascular wall occurs. A decrease in vascularization of the surface layers of tissues during cryotherapy causes vasodilation in deeper tissues (muscles, internal organs) (Kotenko K.V. et al. Modern cryotherapy technologies in medical rehabilitation of children. // Clinical Bulletin of Kremlin Medicine. 2016, 4, p. 12-18). All these effects contribute to the most physiological recovery after surgery, without dysfunction and the formation of rough scars.

The claimed method is carried out as follows.

1. Nutrition.

First of all, patients are recommended a diet - limiting animal fats, foods high in cholesterol, easily digestible carbohydrates, spicy, sour, fried foods. Dietary restrictions begin immediately after surgery. They use mashed soups, jelly, low-fat broths. Then vegetable purees, porridge on the water, steam cutlets, meat of lean fish are added to the menu. In the future, the patient's diet should contain a normal amount of protein, a reduced amount of fats and carbohydrates. However, the main thing in the prevention of PCES is to provide fractional nutrition. Frequent small-volume meals (4-5 r / d) at the same time contribute to a better outflow of bile, thereby preventing its retention. Eating large amounts of food, especially when eating irregularly, can lead to the development of pain and other disorders. If the condition worsens, maximum sparing of the gastrointestinal tract should be ensured: in the first 2 days, you can take only warm liquid: sweet tea, fruit and berry juices diluted with water 1/2, rosehip decoction. During the day, you can drink only 2 glasses, in small sips. After 2 days, allow pureed food in a small amount. These are slimy and mashed cereal soups - oat, rice, semolina, mashed porridge from the same cereals, jelly, mousse, jelly. Then you can include in the diet low-fat non-acidic cottage cheese, lean meat, low-fat fish.

Dishes are cooked steamed or boiled in water. They take food 5-6 r / d in small volumes. Then you can switch to diet No. 5a according to Pevzner, which must be adhered to for 3-4 weeks. The diet contains proteins - 100 g, fats - 80 g, carbohydrates - 350 g, table salt - 4-6 g. Free liquid must be drunk 1.5-2 liters. Daily ration weight - no more than 3 kg. The daily calorie content is about 2800 kcal. Limit mechanical and chemical irritants in the diet. Exclude products that enhance the processes of fermentation and putrefaction in the intestines, sharply stimulating the secretory function of the stomach, pancreas, enhancing bile secretion and irritating the liver. Food is cooked in water or steamed, wiped. The temperature of cold dishes is not lower than 15 ° С, hot dishes - not higher than 62 ° С.

They recommend yesterday's wheat bread, soups are cooked in a slimy broth with grated cereals, vegetables, or in vegetable broths with finely chopped vegetables - potatoes, carrots, zucchini, pumpkin, boiled cereals - rice, semolina, oatmeal, noodles (you can add eggs to soups - dairy mixture, which is prepared by combining a raw egg with an equal volume of milk and seasoned with butter, sour cream), low-fat types of meat in the form of steam cutlets, soufflé or mashed potatoes, low-fat varieties of fish and poultry, mainly in chopped form, but soft varieties and parts allowed to be taken periodically in a piece, boiled in water or steamed. Boiled and mashed vegetables: potatoes, zucchini, pumpkin, carrots, beets, cauliflower in the form of mashed potatoes, soufflés, casseroles, porridge is cooked in water with the addition of pureed milk, puddings are allowed, eggs are added to dishes and given in the form of steamed protein omelets , milk in natural form or in dishes according to individual tolerance. Fresh non-acidic cottage cheese in its natural form or in dishes - casseroles, soufflés, puddings, mild cheese: Russian, Yaroslavl, sour cream in a small amount in a dish. Kissel, mashed compote, jelly, baked apples, pears, preserves and jams made from sweet berries and fruits, sugar, honey, fruit caramel, marmalade. With good tolerance, about 100 g of ripe strawberries, strawberries, raspberries, apple, cherry, strawberry juices in half with hot water, a small amount of parsley and dill, bechamel sauce with a small amount of sour cream (without pre-frying flour), fruit and berry juices are allowed per day gravy, tea, milk coffee surrogates, rosehip decoctions. Butter is added to the finished dish in an amount of no more than 30 g per day, and vegetable oil - with good tolerance.

Excludes fresh white and rye bread, puff pastry, fatty meats (lamb, pork), poultry (duck, goose) and fish, fried, stew, sausages, smoked meats, canned food, liver, kidneys, brains, fried and salted fish , canned fish, fatty cottage cheese with high acidity, spicy cheese, refractory fats - mutton, beef, pork, legumes, pasta, millet, pearl barley, crumbly cereals, mushrooms, sauerkraut, radish, radish, onion, garlic, sorrel, meat and fish broths, cold snacks, sour fruits rich in fiber, chocolate, ice cream, halva, creams, spices, cocoa, strong coffee, cold carbonated drinks, alcohol.

Approximate diet menu number 5a.

Breakfast : protein steam omelet from two eggs, semolina milk porridge, tea with milk.

2nd breakfast : applesauce.

Lunch : slimy oatmeal soup, steamed meat cutlet, buckwheat porridge, strained compote.

Afternoon snack : homemade pureed cottage cheese.

Dinner : steamed fish cutlets, mashed potatoes, tea.

At night : kefir, white bread (200 g), sugar (30 g), butter (20 g).

If you are intolerant to vegetable oil, you should abandon it. With severe obesity, the calorie content of foods is limited. Foods that the patient cannot tolerate should be excluded from the diet. It can be milk, fats, eggs.

For the prevention of PCES, a diet enriched with fiber (wheat bran (Rekitsen-RD), carrots, cabbage, corn, oatmeal, etc.) is also recommended 1.5-2 months after the operation. Such a diet normalizes the chemical composition of bile and, first of all, cholesterol content.

2. Pharmaceutical prophylaxis of PCES.

Prescribing drugs depends on complaints and clinical symptoms. They use antispasmodic drugs, agents that normalize the motility of the gastrointestinal tract and the function of the sphincters of the bile ducts and duodenum, adsorb deconjugated bile acids, reduce inflammation of the mucous membrane of the duodenum (duodenum), suppress the activity of pathological microbial flora, hepatoprotective agents, enzyme preparations. The increased excitability of the sphincters of the biliary tract helps to reduce psychotherapy, intake of sedative and antispasmodic drugs, as well as a number of physiotherapeutic procedures, such as those offered in this method.

3. Physiotherapy.

Against the background of patient compliance with the diet, on the 1st or 2nd day after the LCE operation (immediately after discharge from the surgical department), LLLT procedures are performed (for example, using the Mustang 2000 apparatus) with a matrix emitter on the right hypochondrium, wavelength 0.89 microns, with a maximum radiation power of 50 W in a pulse, a pulse repetition rate of 80 Hz, an exposure time of 5 minutes. LLLT procedures are continued until the day of removal of postoperative sutures.

After the removal of the postoperative sutures (7-8 days after the operation), a course of complex effects of KRM and UST is started, which is carried out for 10 days. All physiotherapy procedures can be carried out both inpatiently and on an outpatient basis or in a day hospital setting.

KRM of the abdomen (area of the right hypochondrium) is carried out according to the developed technique. During the research period, we used DELTA-THERM cryopackages (registration number FSR2007 / 00829) with a temperature of -21 ... -23 ° C. However, any suitable cryopackages can be used - made of plastic bags, or such well-known synthetic bags as "Cryoberg", "Pino", "Cryogel" and others, using standard cold fillers, standard methods of sterilizing bags. KRM is carried out by alternating circular stroking with applications on the area of the right hypochondrium - 1 second each (a second is stroking, a second is applied to this area, then again a second is stroking, etc., i.e. intermittent stroking with alternating it with short-term applications) through a cotton fabric in two approaches: first, KRM is carried out for 1 min, then a 1-minute break, then another 2 minutes of KRM is carried out in the form of circular strokes, alternating with applications for 1 second (a second - for stroking, a second - for application). When performing KRM, skin irritation in the area of the forming scar is not allowed (this is partly facilitated by the use of a cotton pad).

The alternation of short strokes and applications helps the tissues to better adapt to cold effects, does not cause stress.

30 minutes after the end of KRM, ultrasound is performed (for example, using a Sonopuls apparatus), using ultrasound with a frequency of 1 MHz, a pulsed mode (pulse duration 10 ms), a labile effect with a large emitter (5 cm2), first on the right hypochondrium, with an intensity of 0.4 W / cm2, for 5 minutes, and then - to the right paravertebral region (Th7-Th12 vertebrae) - with an intensity of 0.2 W / cm2 for 3 minutes, daily.

This complex of two physiological effects is carried out within 10 days.

As evidence of the effectiveness of prevention of PCES in the implementation of the proposed method, we present examples of its implementation .

In total, the study involved 38 people who underwent LCE for cholelithiasis (24 women and 14 men), age 35-57 years. The operations were carried out from a mini-access, taking into account the length of the disease and other individual indications. The scope of the operation in all cases included, in addition to ChE, choledochotomy, which, accordingly, contributed to the possibility of increasing the severity of PCES in the future. All patients after ChE were treated on an outpatient basis at the National Medical Research Center of the Republic of Kazakhstan or its branches, against the background of a specialized diet (table No. 5a according to Pevzner), as well as, if necessary (according to indications), appropriate medication support (enzymes, hepatoprotectors, pro- and prebiotics, etc.) ... With regard to physiotherapeutic effects, taking into account the principles of adaptive randomization and a prospective study, the patients were divided into 4 groups (the study, respectively, did not include patients with known contraindications to these methods of physiotherapy):

Group 1 (9 people, control) - during the observation period (1-3 months after LCE operation) received only a diet and adequate medication,

Group 2 (9 people) - received UST + LLLT, in the same modes as in the claimed method, however, the entire course of exposure began only after the removal of postoperative sutures, and after another month (delayed), CT was started according to the mode of the proposed method;

Group 3 (9 people) - received LLLT after the operation in the mode of the claimed method, and a month later (i.e. delayed after LLLT) - UST and KRM in the mode, according to the inventive method;

Group 4 (11 people, group of experience) - received a course of actions according to the proposed method (LILI immediately after the operation, then KRM and UST immediately after removing the sutures).

All patients underwent laboratory and instrumental studies in dynamics, allowing them to monitor their condition, including the functional activity of the gastrointestinal tract (blood tests - general, biochemical, including liver enzymes, lipid complex, coprogram, abdominal ultrasound, EGDS, psychological testing).

Before the start of the study, after LCE, all patients had complaints of pain in the epigastrium, right and left hypochondrium, discomfort in the right hypochondrium, rumbling in the abdomen, flatulence, stool disturbances in the form of diarrhea or constipation, weakness, sleep disturbances, increased irritability and anxiety (increased levels according to valid psychological diagnostic methods: anxiety scale, etc.).

At the same time, the pain syndrome was arrested without requiring the appointment of analgesics in all patients of group 4 (experimental group) already on day 2-3 of LILI exposure. At the same time, the psychoemotional state of the patients improved, sleep returned to normal, according to the data of valid psychological tests for anxiety and anxiety, these manifestations also reached normal levels by 2-3 days from the beginning of the procedures.

In patients of other groups, including even groups 2 and 3, where all three treatments were also performed, but in a different mode (delayed CRT), in the period between the end of the course of the first physiotherapeutic treatment (LLLT or UST + LLLT) and the subsequent CRT or UST + CRT , or at the end of the corresponding course of all three influences, the pain syndrome resumed after a few days and, accordingly, the psychoemotional state of the patients worsened (the indicators of anxiety and aggression increased, the patients complained of insomnia, which required the appointment of appropriate sedatives). Approximately 50% of patients in these groups required almost daily prescription of analgesic and sedative drugs.

No side effects from the conducted treatments were observed in any patient or in any of the groups.

As for the objective indicators of health, recorded using laboratory and instrumental research methods, dyspeptic syndrome (heartburn, belching, nausea) was absent by the end of the course of all influences in group 4 in more than 81% of patients (p <0.05), in other groups - from ~ 44% to ~ 55% (p <0.1).

Stool disturbances in the form of diarrhea or constipation in patients of group 4 (treated with the claimed method) were not observed by the end of the entire course of LILI + CrT + UST in ~ 72% (p <0.02).

In the rest (control) groups, relief of diarrhea was observed by the end of the full course in about 45% (of the number of patients in each group), constipation - in about 33% of patients (of their number in each group). However, the data were not always statistically reliable.

In the study of the macroscopic picture of the mucous membrane of the stomach and duodenum (EGDS) before and after treatment, more pronounced positive dynamics was observed in group 4 (experimental group): inflammation of the mucous membrane of the stomach and duodenum completely disappeared immediately after the end of the course of the proposed complex effect (p <0, 05). In groups 2 and 3, the disappearance of inflammatory phenomena in the same period was observed only in about 30% of patients (p <0.03) of the number of patients in the corresponding group; in group 1, it was practically not observed at the same time, but was achieved at a later date.

In the fourth group, after the effects of the proposed method, the most pronounced normalization of the lipid spectrum was also noted: a significant decrease in the level of triglycerides (p <0.05), low-density lipoproteins (p <0.01), an increase in the level of high-density lipoproteins (p <0.01 ), a decrease in the coefficient of atherogenicity of the CA (p <0.01). In the other groups, no such clear dynamics was observed.

Thus, the mode and sequence of application of three physiotherapeutic effects proposed in this method: LILI of the infrared range, and then the complex of CT and UST, allow the most complete arrest of the earliest manifestations of PCES in patients after LCE.

According to follow-up studies, it was found that within the next 1.5 years after the completion of the course of exposure in patients of group 4, there were no exacerbations from the hepatobiliary system. At the same time, in patients of groups 1-3, there was a different frequency of exacerbations manifested mainly in spring and autumn in the form of a return of pain syndrome, psychoemotional disorders, and stool disorders (in general, from 15 to 19%), which required the appointment of an appropriate drug treatment. This gives reason to believe that the claimed method offers an optimal sequence in terms of the physiology of the body, mechanisms of postoperative repair, the sequence of using physiotherapeutic techniques in such patients, contributing to the most pronounced improvement in the functional state of the digestive system: stomach, liver, pancreas, after LCE operation, apparently , due to the most physiological approach to the postoperative state of the living tissues of this zone, the reflex effect on the organs concerned, carried out through the skin receptors of the reflexogenic zones of these organs, as well as their interoreceptors, improving microcirculation and the general trophic effect on the gastrointestinal tract, activating the local mechanisms of its tissue homeostasis and rapidly reducing inflammatory manifestations, helping to reduce the risk of developing and subsequent possible recurrences of PCES.

BIBLIOGRAPHY

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Claims (6)

1. A method of preventing the development of postcholecystectomy syndrome (PCES) after laparoscopic cholecystectomy (LCE), including exposure to infrared laser radiation on the 1-2 day after surgery, characterized in that against the background of compliance with the appropriate diet, a complex physiotherapeutic effect is carried out: from the 1-2 day after the operation and until the removal of the postoperative sutures, daily procedures of exposure to low-intensity laser radiation (LLLT) are carried out using a matrix emitter on the right hypochondrium with a wavelength of 0.89 microns, maximum radiation power 50 W per pulse, pulse repetition rate 80 Hz, exposure time 5 min; then, after the removal of the postoperative sutures, daily cryomassage (CRM) and ultrasound therapy (UST) procedures are carried out sequentially in the course of one procedure, while CRM is carried out through cotton fabric using a cryopacket with a temperature of minus 21-23 ° C to the right hypochondrium: first in for 1 min with a cryopackage, circular strokes are performed, alternating them with applications in this area - 1 s each, then 1 min - a break in the action, then within 2 minutes - again circular stroking with a cryopack, alternating with applications after 1 s; then, 30 minutes after the end of KRM, ultrasound is applied to the region of the right hypochondrium with a frequency of 1 MHz, a pulsed mode, a pulse duration of 10 ms, a labile technique with an emitter of 5 cm ² , an intensity of 0.4 W / cm ² , 5 minutes per procedure, then - on the right paravertebral region at the level of Th7-Th12 vertebrae, with an intensity of 0.2 W / cm ² for 3 minutes, daily, they carry out 10 complex CRM and UST procedures. 2. The method according to claim 1, characterized in that drug therapy is used according to the indications.