RU2129026C1 - Method of treatment of patients with calculous cholecystitis - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: method involves percutaneous, perhepatic and intravesical fractional administration of methyl-tert.-butyl ester. Gall bladder cavity is sanitized preliminary with antiseptics, 4% sodium hydrocarbonate. After administration of ester gall bladder is perfused with 4% solution of sodium hydrocarbonate. After recovery of passability of vesical siphon vesical-duodenal perfusion is carried out with 500-1000 ml normovolenic solution. Method ensures to remove products of degradation of gall stones sufficiently and can be used for treatment of patients with acute cholecystitis. EFFECT: enhanced effectiveness of treatment. 1 tbl, 1 ex

Description

 The invention relates to medicine, namely to surgery, and can be used to treat acute calculous cholecystitis that occurs against cholesterol stones in the gallbladder.

 A known method of treating gallstone disease (AS USSR, N 1491472, M. Cl. A 61 B 17/00, A 61 M 25/00), intended for non-surgical treatment of patients with localization of calculi in the gall bladder. A laparoscopic cholecystostomy is performed with the introduction of a double-lumen drainage with an inflatable cuff at the working end into the bladder cavity. Fractional introduction of monooctanoin is carried out along one of the drainage channels. Obstruction of the cystic duct prevents the ingress of monoctanoin into the intestine, which reduces the toxic effect on the patient.

 However, this method provides the dissolution of stones for a sufficiently long time (Postolov P.M., Kovalev G.V., Nikishin G.I., Troyansky E.I., Mizintsev V.V., Bykov A.V., Nesterov S .S., Novokshchenov V.Yu., Mishin S.G. Dissolution of gallbladder stones in patients with cholecystitis with extremely high operational risk. - Surgery; 1988; (10): 29-32. Postolov P.M., Bykov A. V., Nesterov S.S., Golub V.A., Mishin S.G., Burchuladze N.Sh. Contact dissolution of gallbladder stones - Surgery; 1991; (9): 71-76), requires constant medical supervision for the patient for reasons e known toxicity of monooctanoin, as well as technically difficult and unsafe for the patient, because drainage is established laparoscopically.

 Closest to the proposed technical essence is a method of dissolving gallbladder stones using methyl tert-butyl ether as a solvent, which has the ability to dissolve cholesterol stones in a short period of time (Allen MJ, Borody TJ, Bugliosi TF, May JR, LaRusso NF , Thistle JL Rapid dissolution of gallstones in using methyl tert-butyl ether. N. Engl. J. Med; 1985; 312: 217-220). The known method is as follows. Under fluoroscopic control, a drainage is established percutaneously, transhepatically into the gallbladder cavity, through which methyl tert-butyl ether is introduced in portions of 2-5 ml, replacing it as it is saturated with cholesterol.

 The disadvantages of this method include the lack of restoration of the concentrated function of the gallbladder due to incomplete cleansing of the gallbladder wall and inadequate removal of degradation products of gallstones.

 Moreover, the authors of the method consider acute inflammation of the gallbladder as one of the contraindications to the use of methyl tert-butyl ether. Therefore, this method was not used to treat patients with acute calculous cholecystitis.

 The objective of the invention is minimally invasive, non-surgical treatment of patients with acute calculous cholecystitis.

 The technical result of the proposed method is to increase the effectiveness of treatment by eliminating inflammation and cleansing the gallbladder wall, adequately removing the degradation products of gallstones from its lumen, which are the main cause of relapse and restoration of patency of the gallbladder siphon.

 The technical result is ensured by transdermal transhepatic intravesical administration of methyl tert-butyl ether.

 New in the implementation of the technical result of the method is the preliminary sanitation of the gallbladder cavity with antiseptics and 4% sodium bicarbonate solution. Then carry out the fractional introduction of methyl tert-butyl ether, followed by perfusion of the gallbladder with 4% sodium bicarbonate solution. When restoring patency of the cystic siphon, a bubble-duodenal infusion of 500-1000 ml of normovolemic solution is performed.

 A comparative analysis of the proposed solution and the prototype shows that the proposed method differs from the known one in that methyl tert-butyl ether is used in conditions of acute inflammation of the gallbladder. In addition, unlike the prototype, the claimed method of treatment includes the phased implementation of the following manipulations: preliminary sanitation of the gallbladder; perfusion with 4% sodium bicarbonate solution after contact chemical litholysis; conducting vesicouodenal infusion.

 Thus, the proposed solution meets the criterion of "novelty."

 In the literature available to us, no information was found on the use of methyl tert-butyl ether for the treatment of acute cholecystitis and the use of sodium bicarbonate solution during chemical litholysis. In this regard, there is also no data on the use of bubble-duodenal infusion for “washing out” the products of stone degradation from the gallbladder and biliary tract into the duodenum in order to restore their patency and reduce the risk of recurrence of gallstone disease.

 Therefore, the proposed solution meets the criterion of "inventive step".

 This method can be used in patients with acute cholecystitis and with cholesterol stones of the gallbladder, which meets the criterion of "industrial applicability".

 The essence of the proposed method is as follows.

 With a confirmed diagnosis of acute calculous cholecystitis and the cholesterol nature of gallstones, ultrasonography controls the application of percutaneous transhepatic microcholecystostomy. Through the microcholecystostomy, the gallbladder cavity is sanitized, first with antiseptics, and then with a 4% sodium bicarbonate solution. The dissolution of cholesterol stones in the gallbladder is achieved by fractional introduction into the lumen of the gallbladder of methyl tert-butyl ether in a volume of from 5 to 20 ml. Then, through the microcholecystostomy, the gallbladder is perfused with 4% sodium bicarbonate solution, and when the patency of the siphon is restored, a bubble duodenal infusion of 500-1000 ml of normovolemic solution is performed. Degradation products of gallstones, elements of inflammation are evacuated through microcholecystostomy and, partly, by antegrade infusion are washed out into the lumen of the duodenum. The effectiveness of the dissolution of gallstones and the restoration of patency of the bile ducts is controlled by X-ray examination with contrasting of the bile ducts through the microcholecyst. The absence of “filling defects” in cholecystography and the free flow of contrast into the duodenum, the restoration of the normal characteristics of the gallbladder during ultrasonography (USG) are indications for the removal of microcholecystostomy.

 The inventive method is illustrated by an example of a specific implementation.

Example. Patient I., 63 years old, was admitted to the clinic on 13.1.96 with a diagnosis of acute calculous obstructive cholecystitis. The diagnosis was confirmed by USG: the gall bladder is sharply increased in size (11 x 4 cm), the wall is uneven, thickened to 0.7 cm.The contents of the gall bladder are heterogeneous, multiple reflective inclusions with an acoustic shadow totaling up to 3.2 cm ^{3 are} determined in the lumen. Some stones are fixed in the neck of the gallbladder.

 Computed tomography of the gallbladder showed no hyper-inclusive inclusions in its lumen.

 15.1.96 under the control of ultrasonography produced percutaneous, transhepatic imposition of microcholecystostomy. Evacuated 95 ml of cloudy, viscous, dark infected bile. The gallbladder cavity was sanitized with 200 ml of a 0.02% solution of furatsilina and then 200 ml of a 4% solution of sodium bicarbonate, after which contact chemical litholysis was started. Methyl-tert-butyl ether was introduced into the gallbladder over a period of 2.5–20 ml.

 After each dissolution session, the gallbladder cavity was washed from fragments of stones and products of inflammation (cell detritus, fibrin). On the 2nd day after the application of microcholecystostomy, the supply of pure hepatic bile by drainage from the gallbladder was noted. Since that time, a bubble-duodenal infusion of neutral saline solutions with a volume of up to 500 ml was carried out to restore patency and mechanical cleaning of the fluid of the cystic and common bile ducts. After 5 sessions of litholysis (14 hours), the extraction of cholesterol with the introduction of methyl tert-butyl ether stopped. When control cholecysto-cholangiography on the 4th day, filling defects were not detected, the contrast freely enters the duodenum. 20.1.96 catheter removed.

 With the control ultrasound the next day, the size of the gallbladder is 6.7 x 2.6 cm, the wall is 0.3 cm, and the lumen contains homogeneous contents without reflective inclusions.

 During the litholysis and bubble-duodenal infusion sessions, the patient did not complain, the condition is satisfactory, she feels good. A day after the removal of the microcholecystostomy, the patient was discharged from the clinic in satisfactory condition without surgical intervention.

 The proposed method of treatment was used in 14 patients with acute calculous cholecystitis with cholesterol stones, 11 of them had a serious risk of radical surgery, the remaining 3 refused to perform surgery.

 The results are presented in the table.

 Using the proposed method allows for 4 - 40 hours of litholysis to dissolve cholesterol stones in the gallbladder, normalize the bile flow and effectively act on the inflammatory process in the gallbladder without serious side effects, which makes it possible to widely introduce the method into clinical practice.

 The proposed method for the treatment of acute calculous cholecystitis in patients with cholesterol stones allows you to eliminate stones as a cause of obstruction of the gallbladder siphon in acute inflammation of the gallbladder, stop the inflammation itself without resorting to surgery, and restore normal passage of bile through the bile ducts.

Claims (1)

 A method for the treatment of calculous cholecystitis, including transdermal transhepatic intravesical fractional administration of methyl tert-butyl ether, characterized in that the gallbladder cavity is sanitized with antiseptics, a 4% sodium bicarbonate solution, then methyl tert-butyl ether is administered, followed by the gallbladder is perfused with 4% sodium bicarbonate solution and, when patency of the cystic siphon is restored, bubble-duodenal infusion of 500-1000 ml of normovolemic solution is performed.

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