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INVENTION
Russian Federation Patent RU2086186
METHOD OF TREATMENT acute cholecystitis
Name of the inventor: SY Nikulenko
The name of the patentee: Smolensk State Medical Institute
Address for correspondence:
Starting date of the patent: 1993.02.26
The invention relates to medicine, namely to surgery, and can be used in the treatment of acute cholecystitis. Essence: patients underwent laparoscopy and produce external drainage of the gallbladder. After calming down of acute cholecystitis from the cavity of the gall bladder calculi removed, and the cavity of the gallbladder obliterans. At the same time introduced into the submucosal layer of the mouth of the cystic proton obliterator followed by electrocoagulation infiltrated tissues, further obliterator injected into the wall of the gall bladder with intact mucosa, followed by electrocoagulation wall from the neck to the bottom for 5-7 days washed cavity gallbladder Pervomura solution.
DESCRIPTION OF THE INVENTION
The invention relates to medicine, namely to the surgery of the biliary tract, and can be used in the treatment of acute cholecystitis in patients with high risk surgery and inefficiency of conservative therapy.
A method of treating acute calculous cholecystitis, including laparoscopic gall bladder drainage catheter. After the relief of inflammation of the gall bladder and the formation of fistulous (as a result of a finding of a catheter into the gallbladder for 5-8 days), the catheter was removed and carried fistulokoletsistoskopiyu (holedhoskopom company "Olympus"). For the introduction of the endoscope into the gallbladder fistula probing expanded to the desired diameter. Inspection fistulous cavity and gall bladder was performed at a constant filling them through the working channel of the endoscope with a solution of NaCl, which provided optimal conditions for observation. Discovered concretions using baskets Dormia removed if they are not greater than the diameter of the fistulous. Removal of small stones, if they are less than 3 mm was carried out by forced laundering cavity of the gallbladder, using fluid outflow with calculi directly through the fistula. Sinev Y. Volkov SV et al. "Endoscopic removal of stones from the gallbladder with acute cholecystitis, Surgery, 1989, 1, p.60.
Disadvantages of this method are: the possibility of recurrence of acute cholecystitis, gall-forming outer or mucous fistula, because gallbladder retained cavity in which after removal of bile drainage accumulates and mucus.
The purpose of the invention, improving the treatment of acute cholecystitis results in patients with high-risk surgery, namely the prevention of recurrence of acute cholecystitis in patients undergoing leparoskopicheskoe drainage of the gallbladder.
The essence of the proposed method for the treatment of acute cholecystitis is that it is performed by means of chemo-obliteration and electrocoagulation wall after laparoscopic gallbladder drainage and sanitation gallbladder stages.
Method is as follows
Patients underwent laparoscopy, in which produce external drainage of the gall bladder with a tube diameter of 8-10 mm, fixing it to the bottom of the anterior abdominal wall sutures. Such laparoscopic cholecystostomy (LHS) leads to subsiding of acute cholecystitis. After three days to inspect the cavity and removal of the gallbladder stones. For this purpose, a children's proctoscope, which after removal of the drainage of the gall bladder is introduced into its cavity through the outer opening of LHS.
After complete removal of stones and products of inflammation of the bladder cavity determine the patency of the biliary ducts. To this end, through the drain tube into the gall bladder and injected contrast agent for X-ray control watching it enters the duodenum. The absence of pathology of the bile duct dictates indications for gallbladder sclerosis with obliteration of its cavity.
The initial stage of endoscopic obliteration of the gall bladder (EOZHP) provides for "off" from the gallbladder bile duct. To do this in the area of the neck of the gallbladder and the mouth of the cystic duct under the control of the full endoscope (children proctoscope) a special needle with a stop at a distance of 5 mm from the end in the wall of the gall bladder was injected 3-4 ml of alcohol (96%) with novocaine (2%) in a ratio of 2: 1 to infiltration tight. Then bellied electrode coagulated infiltrated alcohol-novocaine tissue area mouth of the cystic duct. The effect of "off," the gall bladder is determined by the receipt or absence of bile. If through the outer tube drainage LHS bile is not received within 2 days, it is considered that there was obliteration of the cystic duct, and you can start obliteration of the cavity of the gall bladder. Three days after the obliteration of the cystic duct reintroduced hollow endoscope and into the wall of the gallbladder to the area with preserved mucosal perform injection alcohol solution, then immediately produce electrocoagulation wall from the neck to the bottom of the gallbladder. Upon completion of this stage, op-electro-mukoklazii the gallbladder drainage tube set with a plastic foam on her sleeve, which corresponds to the size of the cavity of the gall bladder. Within 5-7 days after a specified drainage gall bladder was washed with a solution of Pervomura. This leads to a productive aseptic inflammation of the gallbladder wall, his scar shrinkage and obliteration. In accordance with the decrease of the gallbladder cavity draining tube used with cuffs smaller.
Example. Patient P. 84 years, was admitted to the surgical department of the medical history of 07.06.94 N 6600.
The clinical picture of the disease consistent with acute cholecystitis. Conducted during the first days of conservative treatment was not effective. Signs of acute inflammation of the gall bladder and intoxication grew. Due to the high risk of surgery, due to age and severe concomitant diseases for the relief of acute cholecystitis abscess complicated by empyema and inflammatory infiltration of the gallbladder, 09.06. Laparoscopic cholecystostomy (LHS) has been performed. LHS made with fixing the bottom of the gall bladder to the anterior abdominal wall sutures, and the introduction into its cavity decompressive tube diameter of 10 mm.
In the next two days of the gallbladder was allocated to 150 ml of bile with fibrin and small stones. Symptoms of acute cholecystitis were stopped. The general condition improved.
On day 5, after LHS made holetsistoskopiya. For children holetsistoskopii used hollow proctoscope with fiber optics, which is injected through the outer opening of the fistulous LHS. From the neck of the gallbladder using fortsepa removed calculus diameter of 7 mm. When holetsistoskopii been found that the cystic duct and the open mouth thereof enters lumen bladder bile. Mucous in the cervix swollen area and flushed, her contact is observed bleeding. In the area of the body and the bottom of the visible mucosal necrosis with fibrin raids. The cavity of the gallbladder furatsilina washed with a solution and re-drained rubber tube diameter of 10 mm.
In order to identify lesions of the bile ducts 20.06. fistuloholetsistoholangiografiya performed. It was found that no signs of pathology hepaticocholedochus and free contrast agent enters the 12th intestine.
Given the likelihood of recurrence of acute cholecystitis and cholecystectomy impossibility because of the high operational risk, it decided to produce a cavity obliteration of the gall bladder.
22.06. made repeated holetsistoskopiya at which performed obliteration of the mouth of the cystic duct with an alcohol solution is injected into the submucosal layer of the mouth of the cystic duct and electrocoagulation of the infiltrated tissues. After that, the flow of bile in the gallbladder lumen ceased. The bladder wall portion stored on the mucosa and the injection solution of alcohol produced, after which the coagulated places. Step mukoplazii completed drainage installation in the cavity of the gall bladder to remove the products of inflammation. During the procedure and after the deterioration of health complications were observed.
Over the next 5 days through the drain tube gall bladder was washed with a solution of Pervomura. To monitor the process of obliteration 28.06. Dynamic holetsistoskopiya was performed. In its conduct of the endoscope with an outer diameter of 10 mm with difficulty held in the cavity of the gall bladder, because Clearance last decreased significantly due to his scar shrinkage. The width of the gallbladder lumen corresponds to the diameter of the tube installed in it. Visually, the gallbladder wall were whitish-pink color. Due to reduction in size of the gallbladder drainage tube diameter was reduced to 5 mm, and its continued washing solution Pervomura cavity for the next 5 days.
07.07. to determine the status of the gallbladder ultrasonography performed. The gallbladder is visualized in the form of a dense ehostruktury 40 x 11 mm, without clearance in the neck and middle third of the body. Only in the area of the gall bladder lumen were detected, which corresponded to the width of 5 mm.
08.07. fistuloholetsistografiya made through the external opening of the fistula LHS introduced 5 ml of 76% solution Urografin This revealed a narrow fistula residual cavity of the gall bladder the size of 40 x 2 mm. Drainage of the gallbladder is no longer produced. The patient was discharged home in satisfactory condition. When monitoring the patient for a year relapse and complaints related to the conduct of operations is not revealed.
Total proposed method were treated 8 patients with acute calculous cholecystitis in age from 70 to 84 years. Obliteration of the gallbladder occurs within 4 weeks. No complications were observed. Long-term results were followed up in 3 patients. No evidence of recurrence of inflammation of the gallbladder was observed.
Control of the obliteration of the gall bladder is carried out using dynamic ultrasound and X-ray contrast fistuloholetsistografiey once a week. Draining tube is removed when the bladder lumen is reduced to 1 cm. Timing obliteration of the cavity of the gallbladder 3-4 weeks.
CLAIM
A method of treating acute cholecystitis, including laparoscopic drainage, sanitation gallbladder removal konrementov, characterized in that a visual inspection make obliteration of the gall bladder by introducing a submucosal layer mouth of the cystic duct obliteratora followed by electrocoagulation infiltrated tissues, then after the obliteration of the cystic duct introduced obliterator in gallbladder wall in areas with preserved mucosa, followed by electrocoagulation wall from the neck to the bottom of the gallbladder, for 5 7 days washed through the cavity left by the drainage of the gall bladder solution Pervomura.
print version
Publication date 28.01.2007gg
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