RU2003290C1 - Method of enteral feeding after operations involving external drainage of biliary tracts - Google Patents

Abstract

The invention relates to medicine, namely to surgery, and can be used for surgery on the bile ducts. The purpose of the invention is to reduce the morbidity and physiological assimilation of food products. As the choledochoduodenostomy is applied, external drainage of the hopedoch is performed and a thin catheter is inserted through the lumen of the drainage into the duodenum and small intestine. The drainage of the hopedoch with a catheter installed in its lumen is discharged through contraception in the right hypochondrium.

Description

The invention relates to medicine, namely to surgery, and may find application in operations on the bile ducts.

A known method of biliodigestive shunting with external drainage of the biliary tract {Kuznetsov V.A. et al. Bio-digestive bypass surgery // Surgeons. - 1982 - No. 1. - P. 99-101), where, in order to prevent the development of acholia, the patient simultaneously with forced external drainage of the biliary tract or with an existing biliary fistula carries out external drainage of the duodenum through a microgastrostomy and by connecting drainage of the biliary tract and duodenum intestines with a glass tee, one of the lumens of which serves for control studies, shunting is performed, along which bile is infused.

However, the need to perform an additional gastrostomy for the installation of drainage leads to unnecessary trauma, prolongs the time of the operation, in addition, such a shunt is undesirable after performing choledoduodenostomy or transduodenal papillosphincteroplasty, since the bile is infused directly into the duodenum, t .e. in the area of the anastomosis can (. lead to the failure of the joints of the anastomosis due to increased pressure in the duodenum, and the introduction of nutrient mixtures, which are not provided in this method and which is our task, would stimulate the secretion of the pancreas with the subsequent development of acute pancreatitis and the occurrence of unwanted complications.

A known method of enteral nutrition (V.P. Spivak and others. Ways to reduce postoperative mortality in case of inconsistency of sutures after operations on the stomach // Surgeons. - 1984. - No. 3. - S. 123-125), including nasoenteric sounding with a two-channel thermoplastic probe beyond the line of the anastomosis, along the inner channel of which they provide nutrition, and along the outer channel, vacuum aspiration of the contents in the area of joint failure.

However, a long-term presence (5-7 days) of the probe in the nasopharynx causes unpleasant sensations in the patient, trzmatization of the nasopharynx and esophagus; In addition, it contributes to the occurrence of complications, such as tracheobronchitis and pneumonia, otitis media, sinusitis, and even necrosis of the wings of the nose. (Shalkov Yu.Ya. et al., 1980; Weller D.G., Nechitailo P.E., 1981.). In addition, the method is not physiological enough since no mixing process

nutrient mixture with digestive juices.

The aim of the invention is to reduce traumatic ™ and increase the physiological absorption of food products. This goal is achieved in that in the method of enteral nutrition in the postoperative period, including the introduction of a catheter for enteral nutrition beyond the line of anastomosis into the small intestine through

lumen of the choledoch drainage and along the enteral nutrition, at the same time bile is reinfused.

The novelty of the proposed method is that the authors for the first time

a method of enteral nutrition in the postoperative period by introducing nutrient mixtures rich in fats along with reinfused bile through a catheter installed in the bile duct drainage and

conducted beyond the line of the anastomosis, which significantly distinguishes the method from the prototype and helps to improve the assimilation of food and earlier restoration of bowel function due to the physiological nature of the method.

The use of choledoch drainage to guide a catheter beyond the anastomosis line for enteral nutrition and simultaneous bile reinfusion eliminates the occurrence of complications (tracheobronchitis,

pneumonia, etc.) by reducing the trauma, which also significantly distinguishes the proposed method from analogues and provides a higher positive effect.

Thus, this technical solution meets the criteria of novelty, significant differences and positive effect.

The method is carried out as follows: in the course of applying choledochoduodenoanastomosis or performing transduodenal papillosphincteroplasty, external drainage is performed

choledoch (preferably through the stump of the cystic duct), and then through the lumen of the drainage line of the anastomosis (or dissected large duodenal papilla), the duodenum is carried into the small intestine

thin catheter. The end of the catheter is set 10-15 cm distal to the Treitz ligament. Drainage of the common bile duct with a catheter coaxially installed in its lumen is withdrawn through the gur counterpoint in the right hypochondrium

Enteral nutrition begins after the introduction of nutrients into the intestines through the catheter. Prior to restoration of peristalsis, a 5% glucose solution, protein hydrolysates and Ringer's solution are introduced in a volume of 1000-2000 ml per day. With the restoration of peristalsis (usually from the 2nd day), enteral nutrition is carried out by introducing the broth, milk and creamy mixtures, as well as other liquids with a total volume of 3000-3500 ml per day, through the catheter, and parenteral nutrition is completely stopped. In order to improve the digestion and absorption of fats and fat-soluble vitamins, vein-rich nutrients are mixed with bile secreted from the bile duct drainage prior to administration. Liquid nutritional ingredients are administered continuously at a rate of 40-60 drops. per minute using a drip infusion system, and the nutritious mixture of creamy consistency with a syringe of 40 r. l every hour. Enteral nutrition is stopped when it becomes possible to take enough food naturally, the catheter is removed and the choledochus drain is pinched. The bile duct drainage is removed no earlier than 7-8 days after the operation, when, due to the formation of the canal along the drainage, the risk of getting bile into the abdominal cavity or its accumulation in the subhepatic space is eliminated. After removal of the choledoch drainage, the wound at the drainage site is covered with a crust the next day and then heals.

Example 1. Patient M., 58 years old, was admitted with complaints of periodic seizures such as hepatic colic, periodically accompanied by jaundice and dark urine. Sick for 6 months. Marks the provocation of seizures by eating fatty foods and three wheezing. During the examination, the diagnosis was established: cholelithiasis, chronic calculous cholecystitis.

02/11/91, the planned operation. Under endotracheal anesthesia, the upper middle laparotomy was performed. The gall bladder contains stones. Choledoch. up to 1.2 cm in a diamter does not contain stones. The head of the pancreas is compacted, moderately enlarged. No pathologies were detected on the part of other abdominal organs. An expansion of the common bile duct up to 1.2 cm, stenosis of a large duodenal papilla with a length of up to 1 cm, no shadows from calculi were found in the mnoperative cholangiogram. Cholecystectomy was performed. After the bladder was sutured with catgut. Transverse duodenotomy in the projection of the large duodenal papilla up to 2 cm long after mobilization of the duodenum according to Kocher. Papillosphincteroplasty 1.8 cm long was produced using a stapler 1 SPP-20. The choledoch was drained through the stump of the cystic duct with a vinyl chloride 0.4 cm diameter tube. A thin thermoplastic catheter with a diameter of 1.5 mm was inserted through the duct of the choledoch, dissected by a large duodenal papilla and duodenum into the lumen of the jejunum 10 cm distally 2-nd suture The end of the drainage tube with a catheter coaxially installed in its lumen is brought out through the contraperture in the right hypochondrium. The subhepatic space is drained according to Spasokukotsky. The check for hemostasis is dry. The surgical wound is sutured in layers tightly. Aseptic sticker.

Postoperative diagnosis of cholelithiasis, chronic calculous cholecystitis, stenosis of the large duodenal papilla.

On the first day after the operation, infusion therapy was carried out in a volume of up to 2000 ml, and within 6 hours after the operation, 400 ml of 5% glucose solution, 400 ml of casein hydrolyzate and 400 ml of Ringer's solution were dripped through the catheter into the small intestine. On the second day intestinal peristalsis appeared, 1000 ml of meat broth mixed with 400 ml of bile, allocated for drainage of choledochus, 2 eggs, 200 ml of jelly, 200 ml of sour cream with 50 ml of bile, 1000 ml of sweet tea, were introduced into the intestine through a catheter. 1200 ml of milk mixture (impression). Infusion therapy was reduced to 400 ml on the second day, and subsequently was not performed. Enteral nutrition through a catheter continued in the same volume for up to 6 days. On the first day after the operation, the catheter was removed from the intestine, the choledoch drainage was pinched and food intake through the mouth was started. During trans-drainage cholangiography performed on the 24th day, free flow of contrast into the duodenum was noted and on the 8th day the bile duct drainage was removed, the sutures were removed. The wound healed by primary intention. The patient was discharged in satisfactory condition on the 10th day after the operation .

Example 2. Patient D, 61 years old, was admitted with a clinic of acute choleculus, gtite. complicated obstructive jaundice, and cholangitis. He considers himself a patient for a year, has repeatedly noted an attack-type

hepatic colic. Last attack within 5 days. Due to the lack of effect of conservative therapy, an increase in jaundice and intoxication 24 hours after admission, the patient was operated on. 5 Under endotracheal anesthesia, Upper Mid Laparotomy was performed. In the subhepatic space, there is a whiplash infiltration consisting of an omentum and gall bladder. When the gall bladder 10 was separated from the omentum, a peravesical abscess opened - about 20 ml of thick pus was released. The gall bladder is gangrenous changed with a perforated hole at the bottom with a diameter of up to 2 cm, contains stones. Chole 15 dox up to 2 cm in diameter, does not contain stones. Paracholechoic glands are enlarged. From other organs without features. With tubular cholangiography, choledoch is up to 2 cm in diameter, there are no shadows from calculi 20, and there is an extended stenosis of the terminal part of the choledoch. Cholecystectomy, supraduodenal choledochotomil. In this case, bile with flakes of pus is secreted. During the audit of the common bile duct, there are no stones; a 25 probe with a diameter of 3 cm does not pass into the duodenum. The choledochus is superimposed - an osteoanastomosis up to 2.5 cm long and the choledochus is drained according to Pikovsky, through the lumen of the drainage it is removed into the small intestine 15-30 cm distal. Tracheal ligament catheter, mine anastomosis and duodenum, for enteral nutrition. The subcervical space is drained according to Spasokukotsky. Drainage of the common bile duct with a 35 cathexically installed catheter in its lumen was withdrawn through the contraperture in the right hypochondrium. The laparotomy wound is sutured in layers tightly. Aseptic dressing .40

Postoperative diagnosis: gallstone disease, acute gangrenous perforative cholecystitis. Terminal stenosis

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Claims (1)

The claims METHOD OF ENERGY FOOD IN THE POST-OPERATION PERIOD AFTER OPERATIONS. ACCOMPANIED BY EXTERNAL EXTERNAL DRAINAGE OF THE Biliary tract, including the insertion of a catheter for feeding beyond the choledoch anastode line. Paravesical abscess. Purulent cholangitis. On the first day after the operation, intravenous infusion therapy was carried out with a volume of up to 2500 ml; 8 hours after the operation, drip administration of 800 ml of 5% glucose solution, 400 ml of hydrolysin and 400 ml of Ringer's solution through a small intestine catheter was started. Intestinal motility recovered 24 hours after surgery. Beginning from this time, up to 6 days, enteral nutrition was administered daily through a thin catheter. Intravenous infusion was reduced to 400 ml and canceled from 4 days. 100 ml of meat broth with 200 ml of bile were injected daily into the intestines; 2 eggs, 200 ml jelly, 200 ml sour cream with 50 ml bile; 400 ml of dried apricots, 500 ml of sweet tea with honey, 1000 ml of milk mixture (impression). On the 6th day after the operation, the catheter was removed from the intestine and the choledoch drainage was pinched, food intake through the mouth was started. Drainage from the common bile duct was removed on the 8th day. Sutures were removed on the 9th day. The wound healed by primary intention. Recovery. The positive effect of the proposed method is to reduce the traumatic ™, which in the prototype is associated with transnasol administration of the enteral nutrition probe and the occurrence of complications such as tracheobronchitis, pneumonia, otitis media, sinusitis, due to the enteral nutrition through the catheter through the lumen of the drainage installed in the common bile duct behind the line of the anastomosis along with simultaneously re-infusible bile, which improves the absorption of food and allows restoration of intestinal function in the early stages ika, providing high physiologic process unlike the prototype. (56) Surgeons, 1984, No. 3, p. 123-125. mosaic, characterized in that, in order to reduce the morbidity and increase the physiological assimilation of food products, the catheter is passed through the drainage of the common bile duct to the small intestine and is fed via it with bile reinfusion.