The method of treatment of purulent cholangitis

 

(57) Abstract:

The invention relates to medicine, namely to surgery, and can be used for treatment of suppurative cholangitis. Patients before operation set nasobiliary the drainage tube in the common bile duct through the major duodenal papilla. The outer end of the tube bend in the knee and have a height of 16-18 cm from the level of the choledochus. For dosage reduction intraductal pressure bending the outer end of the tube daily lowered by 1-2 cm After 3-8 days perform surgery for extrahepatic bile passages. In the common bile duct enter the second drainage tube towards the duodenum. To the outer end of nasobiliary tubes connect the infusion system and apparatus Waldman. Under the control of the intraductal pressure washed extrahepatic moves warm (37,0°C) medicinal mixture of the following composition: 0.9% common salt solution to 100.0 ml 0.25% solution of novocaine to 100.0 ml, metrogel 50,0 ml, platifillina hydrotartrate 0,2% 1,0 ml, prednisolone 30 mg, a solution of heparin 5000 IU, antibiotic 1.0 g, depending on the sensitivity of microflora. Wash the bile ducts within 7-10 days. The method allows the ü treatment. 1 Il.

The invention relates to medicine, mainly to abdominal surgery and can be used for the treatment of patients with gall-stone disease.

Suppurative cholangitis is one of the most dangerous complications of diseases of the biliary system. The reason for its occurrence is the violation of the passage of bile in the result of choledocholithiasis, stricture of the bile duct, stenosis of major duodenal papilla, patterns Galeotti anastomoses, tumors of the bile duct and the pancreatic head, cystic formations in the bile ducts. Prolonged stagnation of bile in the mechanical obstacles to its outflow leads not only to jaundice and hypertension in them, hyperextension bile ducts and capillaries, activate and spread of infection, the formation of microabscesses in the liver and sepsis. In bile capillaries are formed separate clusters of pus that are inadequately or not at all drained in the bile ducts and occurs dissecting suppurative cholangitis /E. I. Halperin, N. In. Volkova "Diseases of the biliary tract after cholecystectomy" - M. : Medicine. - 1988. - 244-246 C./. The mortality of these patients is high and reaches 70% or more. Therefore, when purulent cholangitis shown How. This reorganization of the biliary tract are not only passive external decompression of the bile ducts, but also active washing with antiseptic solutions through the drainage tube.

There are installazione-rehabilitation decompression of the bile ducts at their major and minor extensions, as well as intraductal sorption detoxification /A. A. Shalimov, S. A. Shalimov, M. E. Nechitailo, B. D. Domansky "Surgery of the liver and zhelchevyvodjashchih ways" - K.: Health. - 1993. - S. 376-377/. Both of these receive protected by author's certificates of the USSR: first. C. N 1155250 "Method of treatment of purulent cholangitis" /MKI A 61 B 17/00, bull. N 18. - 1985/ second.with. N 1599022 "Method of treatment of acute suppurative cholangitis" /MKI A 61 M 1/00, bull. N 38. - 1988/. A common disadvantage of both methods is uncontrolled passive external decompression of the extrahepatic biliary ducts in the postoperative period. As a result of this rapid discharge of intraductal pressure leads to acute liver failure, since there is a swelling of the walls and the obstruction of the small bile ducts, terminates the message with small and larger abscesses, broken their drainage formation of isolated micro - and microabscesses circulation in her shock, when the portal blood, bypassing the sine wave passes into the inferior Vena cava /B. A. Petrov, E. I. Galperin, surgery of the extrahepatic bile ducts" - M.: Medicine. - 1971. - S. 167/.

Also known "the Way of gradual decompression of the biliary tract with mechanical jaundice" /USSR, and. C. N 1395296, MKI A 61 K 17/00, bull. N 18. - 1988/, in order to prevent postoperative liver failure by excluding instant negazirovannoy decompression of the biliary tract and reduce the injury of the common bile duct /choledochus/ during surgery before choledochotomy perform the obturation of the isolated section of the choledochus bystrootverdevayuschey mixture of fibrinogen and thrombin above choledochotomy and below obturated plot choledochus impose choledochoduodenostomy. According to experimental data in the postoperative period seal of a mixture of fibrinogen and thrombin resolved within 20 hours and, thus, prevents instantaneous decompression of the biliary tract, this method has the following disadvantages: - the process of resorption fillings and repair of bile passage is not controlled by any means, but because it is not possible to prove how decompr the duct categorically cannot be after operation causes the failure of the seams imposed anastomosis with the development of peritonitis or duodenal fistula; in - patients with suppurative cholangitis you as soon as possible to perform decompression of the biliary tract and begin rehabilitation of the biliary tree, and this method forces the user to specify another 12-20 hours after surgery to restore the lumen of the common bile duct and eliminates the possibility of washing with antiseptic solutions; g - accommodation in purulent contents of the choledochus seal of fibrinogen with thrombin contradicts the basic rule of purulent surgery: removing foreign bodies and sequesters of purulent cavity, and put the seal may not fully dissolve, become a foreign body, obtenerse the common bile duct, and break, thus, the passage of infected bile.

In addition, external drainage of the bile ducts with suppurative cholangitis should be continued after surgery 2-3 weeks and requires dosed mode decompression in the first 3-5 days, so at this time the most commonly develop acute liver failure. In the beginning of the decompression should hold the hydrostatic intraductal pressure equal to the maximum resistance resistance is 100-180 mm column of water /A. A. Shalimov, S. A. Shalimov, M. E. Nechitailo, B. D. Domansky "Surgery of the liver and biliary tract".- K.: dorofee. - 1993. - S. 344 - 345/. Intraductal hydrostatic pressure must be reduced gradually to 100-120 mm water column pressure equal to the passage of bile or of contrast into the duodenum normal /O. B. Filonov, A. P. Timoshin "a Comprehensive study during surgery on the biliary tract" - M.: Medicine. - 1981. - S. 86-87/. During washing of the bile ducts also need to ensure that intraductal pressure did not exceed 180-200 mm water column, thus further increasing the possible reflux washing solutions in the pancreatic duct with the development of pancreatitis /pancreatic necrosis/ or reflux in venous system /cholangiography reflux/.

Known method of decompression of the biliary tract on the principle of "communicating vessels", which is dosed discharge of bile from the choledochus out through one catheter, and then reverse its introduction into the duodenum through another catheter /A. with. N 1572642, MKI A 61 M 1/00, "a Method for the treatment of obstructive jaundice", bull. N 29, - 1990/ the Disadvantage of this method is the lack of ability to flow promyshlyennogo bladder and biliary tract" /A. with. N 1338858, MKI A 61 K 31/00, bull. N 35. - 1987/ providing suction the contents of the duodenum, liver and gallbladder bile with subsequent introduction into the duodenum medicinal mixtures containing anticholinergic, antibiotics, analgesics, and hydrocortisone and Dimexidum. This drug mixture is injected into the duodenum, which significantly reduces the rinsing effect of the biliary tract since it is only due to the expiration of bile. In addition, the medicinal composition of the mixture does not contain substances acting on the anaerobic microflora, and heparin, a solvent "putty-like" masses and small gallstones in most cases of suppurative cholangitis /A. A. Shalimov, S. A. Shalimov, M. E. Nechitailo, B. D. Domansky "Surgery of the liver and biliary tract". - K.: dorofee. - 1993. - S. 336-337/.

As a prototype of the claimed invention taken as "a Method of treatment of purulent cholangitis".with. N 1155250, MCI And 61 In 17/00, published in bull. N 18 1985, the essence of the method, taken as a prototype, is that patients with suppurative cholangitis to prevent biliary peritonitis and ensure the active washing extrahepatic biliary ducts used drainages on the working end and placed inside the two tubes of smaller diameter. While the working end of the drainage tube is installed in choledocho, and the ends of tubes of smaller diameter injected into the left and right hepatic ducts. Through the tubes of smaller diameter located inside the drainage tube impose an antiseptic solution which is flowing out through the drain tube installed in choledocho.

This method has the following disadvantages: 1 - external drainage of the common bile duct is dosed without decompression of the biliary tract with the creation of the initial hydrostatic pressure equal to the maximum resistance of the sphincter of major duodenal papilla /160-180 mm water column/ that is fraught with the development of postoperative acute liver failure; 2) the introduction of antiseptic solutions in the bile ducts when washing is not controlled by the measurement of intraductal pressure, which may be accompanied by a pressure increase and lead to reflux of bile into the pancreatic duct with the development of acute pancreatitis or reflux through the wall of the bile duct into the venous system of the liver; 3 - location of the two small diameter tubes to summarize the solution of antiseptics in the bile ducts in one drainage tube according to the flakes of fibrin, SamAccountName masses, washed out of the choledochus that requires constant attention and regular washing of the drainage tube.

These disadvantages can be eliminated in the proposed solution. The aim of the present invention is the prevention of postoperative complications associated with fast reset intraductal pressure in the biliary passages and the process of washing with antiseptic solutions. This objective is achieved in that before the operation using fibrobronchoscopy patient set nasobiliary the drainage tube through the major duodenal papilla in the common bile duct to the level of the confluence of the right and left hepatic ducts. The outer end of this drainage tube in nasal passage stack so that bending a knee was on 16-18 cm above the level of the common bile duct and created, thus, the hydrostatic pressure 160-160 mm of a water column in the bile passages. Daily height of the bend of the drainage tube is reduced by 1-2 cm, reducing the hydrostatic pressure in the bile ducts gradually up to 100-120 mm of a water column. Then after 3-6 days to improve the condition of patients, perform surgery for cholelithiasis, during which in the common bile is -6 mm towards the duodenum. The outer part of the tube output on the anterior abdominal wall through montepertuso. In the postoperative period through nasobiliary the drainage tube is injected drug mixture that enters the bile ducts at the confluence of the right and left hepatic moves, irrigates common hepatic and common bile ducts and flows outside through the drainage tube that is inserted into choledocho during surgery. To prevent increased intraductal pressure during washing infusion drug mixture is performed under the constant control apparatus Waldman, United with the infusion system. For irrigation of the bile ducts using medicinal mixture consisting of warm /37,0oC/ novocaine solution, physiological saline, platifillina hydrotartrate, prednisolone, heparin, antibiotics according to the sensitivity of microflora of the choledochus and metrogel /derived intorimidazole/.

Detailed description of the invention and examples of its application-specific

The patient with suppurative cholangitis with duodenoscope, for example, firms Olympus GF-1 T-30, perform duodenoscope, find a hole large duodenal papilla and not through the Yu drain tube /2/ with a diameter of 2 mm and promote it to the confluence of the right and left hepatic ducts /3/, based on the results of retrograde papillomaviridae. Thus at the outer nasal passage bend /4/ nasobiliary drainage tube /2/ must be at a height of 16-18 cm above the level of the choledochus /1/ to create intraductal hydrostatic pressure equal to 160-180 mm water column. /On the body level choledochus corresponds to the mid-axillary line on the right/. Daily height of bend /4/ outdoor Department nasobiliary drainage tube /2/ reduce to 1-2 cm, bringing intraductal hydrostatic pressure up to 100-120 mm of a water column.

Within 3-8 days carry out such drainage of the common bile duct through nasobiliary tube. As a result, significantly improves the condition of patients: decreased jaundice, intoxication, decreased body temperature. In this more favorable background perform surgery cholecystectomy. During the operation in the common bile duct /1/ through the stump of the cystic duct /5/ or by choledochotomy hold the drain tube /6/ with a diameter of 4-6 mm in the direction of the duodenum /7/. The drain tube /6/ fix seams and checked for leaks finding it choledocho by insertion through her 30 ml of warm /37,0oC/ 0.25% of p is.

For irrigation of the bile duct drug mixture injected through drip nasobiliary drain tube /2/. Irrigating common hepatic and common bile duct /1/ drug mixture flows out through the drain tube /6/ mounted in choledocho /1/ during the operation. To prevent increased intraductal pressure during washing infusion system /8/, for example, "Device for infusion of blood and infusion solutions single use" type PR-12-06, connected in parallel with the device Waldman /9/ and during the whole time of introduction of the drug mixture is measured intraductal pressure and by its level regulate the speed of infusion /from 20 to 40 drops in 1 minute/. This intraductal pressure during the infusion should be in the range of 100-120 mm of a water column.

Medicinal mixture to wash the bile duct has the following composition: warm /37,0oC/ 0.9% sodium chloride solution to 100.0 ml; warm /37,0oC/ 0.25% solution of novocaine to 100.0 ml; warm /37,0oC/ solution metrogyl 50,0 ml; hydrotartrate platifillina 0,2% 1,0 ml; prednisolone 30 mg; solution of heparin 5000 UNITS; an antibiotic to which sensitive microflora, for example, afatoxin of 1.0. General about the. the 6-th and 8-th day perform bacterial culture test of bile from the choledochus. As soon as you get the result of bakposev bile, showing the absence of microflora, nasobiliary drain tube /2/ is removed from the digestive tract. The drain tube /6/ mounted in choledocho /1/ during the operation, keep another 4-6 days. Usually, by this time it comes out 50-100 ml of bile, which indicates the subsidence of the inflammation in the walls of the bile ducts and the restoration of the passage of bile into the duodenum. Against this background, perform the control fistulography through the drain tube /6/ and in the absence of pathological obstruction to flow of bile into the duodenum /7/, the drain tube /6/ extracted from the choledochus /1/. In its place of standing in the anterior abdominal wall is injected rubber latex strip for 1-2 nights. In the absence of the expiration of bile out during this period rubber latex strip is removed from the wound and place dry gauze bandage. The wound heals itself.

In cases of suppurative cholangitis only during the operation about cholelithiasis drainage tube for washing biliary tract install in the reverse order. First /in lying to the wall and placed on the platen, to bend her was on 16-18 cm above the level of the choledochus /1/. 3-4 days after the operation using duodenoscope carried out in the common bile duct /1/ nasobiliary drain tube /2/ and immediately begin washing the bile ducts by the method described above (see example 3/.

Example 1. B-e-VA, 63 years /I. B. N 200/ enrolled in the surgical Department of BSMI N 1, Rostov-on-don the transfer of infectious diseases Department with the diagnosis: cholelithiasis, chronic cholecystitis, choledocholithiasis, suppurative cholangitis. She noted the pain in the right hypochondrium, chills, fever to 38.0oC and above, icteric staining of the skin and mucous membranes. In General, the analysis of blood: leukocytes 10,3109/l, WBC - natriello Palocco-nuclear - 14,0%, segmented - 69,0%; lymphocytes - 11,0%; monocytes was 2.0%. ESR 25 mm/hour, leukocyte index of intoxication - 6,7 /normal 1,0/. Total bilirubin blood - 216 µmol/l, direct bilirubin - 192 μmol/L.

The patient performed duodenoscope apparatus company "Olympus" brand GT-1 T-30, found a large duodenal papilla. Produced endoscopic papillotomy. The resulting secretion of bile with white flakes of fibrin. Bile taken on basicsliderui /allocated Gras the duodenal papilla in the common bile duct entered nasobiliary drain pipe with a diameter of 2 mm Outside, the nasal passage, the drain pipe is bent in the knee at the level of 16 mm from the mid-axillary line on the right. Through this tube was made turbid outflow of bile from the common bile duct. Daily level of bending of the tube was reduced to 2 cm, bringing the intraductal pressure to 100 mm of a water column.

As a result of outflow of bile after 4 days the patient's condition improved significantly decreased jaundice (total bilirubin decreased to 52,0 umol/l/ and intoxication /leukocyte index of intoxication decreased to 1.4/. On this background, the operation was performed laparotomy, cholecystectomy, choledocholithotomy. Through choledochotomy hole in the common bile duct in the direction of the duodenum conducted drain pipe with a diameter of 5 mm, It is fixed in the common bile duct ligatures. Controlled leak location drainage tube in choledocho by insertion through her 30 ml of warm /37,0oC/ a 0.25% solution of novocaine. The outer end of the drainage tube placed on the anterior abdominal wall through contraparte hole. The next day after the operation started washing extrahepatic bile ducts medicinal mixture consisting of warm /37,0oC/ 0.9 percent erstwhile 50,0 ml, hydrotartrate platifillina 0,2% 1,0 ml, prednisolone 30 mg, solution of heparin 5000 IU, antibiotic oxacillin - 1,0, Medicinal mixture was introduced drip /up to 30 drops in 1 minute/. To prevent increased intraductal pressure during washing and constant monitoring to infusion system at the outer holes nasobiliary drainage tube connected apparatus Waldman. The pressure in the ducts during washing their medicinal mixture did not rise above 120 mm water column. Once in the common bile duct, this drug mixture washed it and common hepatic duct, passed down towards dvenadcatiperstnoy intestine, where through the drainage tube that is inserted into choledocho during surgery, flowed out into the tank. In this mode, the washing of the bile duct was continued for 7 days. Made on the eve of the bacterial culture test of bile from the choledochus microflora found. Therefore, the washing extrahepatic biliary ducts terminated and nasobiliary drain pipe is extracted from the digestive tract. Continued external drainage of the common bile duct through a tube inserted in it during the operation. To 16-th day after surgery, out for this drainage tube flowed 5 is ia/ through this drain tube: received good contractarian intrahepatic bile ducts and common bile duct, shadows suspicious concretions were found, the contrast agent was freely admitted into the duodenum. In this regard, the drainage tube is removed from the common bile duct. Along its course in the wound put rubber latex strip. Within 2 days of the expiration of bile out not marked. Rubber strip extracted from the wound, applied a dry gauze bandage. The next day the patient in a satisfactory condition and was discharged for outpatient treatment.

Example 2. B-e C-I, 66 years /I. B. N 1897/ enrolled in the surgical Department of the Rostov BSMP N 1 about cholelithiasis, acute exacerbation of chronic cholecystitis, choledocholithiasis, mechanical jaundice, purulent cholangitis, inner gallbladder-duodenal fistula. At admission her condition is severe: marked yellowness of the skin and mucous membranes, nausea, vomiting, increased body temperature to 38.7oC. In the General analysis of blood leukocyte count of 14.2-109/l, WBC - natriello stab - 11,0%, segmented - 80,0%; lymphocytes 5,0%; monocytes to 4.0%. Leukocyte index of intoxication equal to 10.1. Total bilirubin blood - 194,0 µmol/l, direct - 95,0 µmol/L.

The patient performed duodenoscope apparatus is as nasobiliary drain pipe. The outer end of her nasal passage bent at the knee, which is installed at a height of 18 cm from the level of the mid-axillary line on the right. On the installed drainage tube was allocated bile mixed with pus. Bacterial culture test bile revealed the presence of E. Coli, sensitive to chloramphenicol, erythromycin, oxacillin, remission and gentamicin. Daily bending tube in nasal passage was reduced to 2 cm in relation to the level of the choledochus. Intraductal hydrostatic pressure increased to 120 mm water column. During the week the patient's condition has improved: decreased body temperature, decreased jaundice, total bilirubin blood reached values of 35.0 mmol/l, direct - 17,0 µmol/L. In General, the analysis of blood: leukocytes 8,0109/l, WBC - natriello stab - 6,0%, segmented - 76,0%; lymphocytes - 13,0%; monocytes -3,0%. leukocyte index of intoxication became 2,3. Against this background, the patient performed the surgery cholecystectomy with the elimination of the gallbladder-duodenal fistula, instrumental revision of the choledochus and operating cholangiography. Through the stump of the cystic duct into the common bile duct in the direction of the duodenum conducted drain pipe with a diameter of 5 mm, It is fixed by the ligature and check the ora of novocaine. The outer part of the drainage tube removed on the anterior abdominal wall through contraportada. After the surgery the next day started washing extrahepatic bile ducts medicinal mixture of the following composition: warm /37,0oC/ 0.25% solution of novocaine to 100.0 ml warm /37,0oC/ 0.9% sodium chloride solution to 100.0 ml warm /37,0oC/ solution metrogyl 50,0 ml, hydrotartrate platifina 0,2% 1,0 ml, prednisolone 30 mg, a solution of heparin 5000 IU, antibiotic erythromycin 1.0 g in the total number of 255 ml. of Medicinal mixture was injected through nasobiliary the drainage tube at a rate of 25 drops in 1 minute. At the outer holes nasobiliary tube parallel to the infusion system was connected apparatus Waldman for the continuous measurement intraductal pressure during infusion of drug compound. It was equal to 120 mm water column. Washing bile duct stopped after 12 days, when the bacterial culture test bile revealed the absence of microflora. Nasobiliary drainage tube was removed from the digestive tract. External drainage of the common bile duct is continued on the tube installed in it during the operation. To 18 days after the operation, the amount of bile, the waste in the drainage tube is lnyh on the concrements are not identified, the contrast agent was freely admitted into the duodenum. Therefore, the drainage tube was removed from the common bile duct. On the box it standing held rubber latex strip. When observed within 1 day of geleistete on the anterior abdominal wall was not. Rubber strip removed and the wound superimposed dry gauze bandage. The patient in a satisfactory condition was discharged for outpatient treatment.

Example 3. B-e P-K, 64, /I. B. N 1612/ enrolled in the surgical Department of the emergency hospital N 1, Rostov-on-don with a diagnosis of cholelithiasis, obstructive cholecystitis, choledocholithiasis, the major duodenal papilla stenosis, obstructive jaundice, acute suppurative cholangitis. The patient's condition severe: severe pain, nausea, vomiting, body temperature of 38.7oC, yellowness of the skin and mucous membranes. In this regard, the patient on the same day were operated urgently. During the operation completed cholecystectomy, choledocholithotomy, instrumental revision of the common bile duct. From choledochus did turbid bile with flakes of fibrin. It is taken for bacterial culture test /analysis revealed pr. vulgaris sensitive to neoplasene/. Through the stump of the cystic duct towards Donatz the BKA fixed a ligature and tested for tightness finding it choledocho, as well as the tightness of the suturing choledocholithiasis holes by insertion through the drain tube warm /37,0oC/ a 0.25% solution of novocaine. The outer end of the drainage tube placed on the anterior abdominal wall through contraparte hole and laid on the platen with the height of the tube bends, equal to 18 cm above the mid-axillary line on the right. Drainage from the choledochus was allocated muddy bile. Every day the height of the bend of the drainage tube was cut to 2 cm Intraductal pressure reduced to 120 mm water column. 3 days after surgery, the patient's condition has improved. Against this background made duodenoscope with endoscopic papillotomy and retrograde in the common bile duct held nasobiliary drain pipe with a diameter of 2 mm on the same day started washing extrahepatic bile ducts warm /37,0oC/ drug mixture consisting of 0.9% solution of sodium chloride Sol 100,0 ml; 0.25% solution of novocaine to 100.0 ml; solution metrogyl 50,0 ml; hydrotartrate platifillina 0,2% 1,0 ml; prednisolone 30 mg; solution of heparin 5000 IU; antibiotic neoplasia 1.0 g in the total number of 255 ml using infusional systems /Devices for infusion of blood and infusion solutions of a single application is in. Parallel to the infusion system was connected apparatus Waldman for measuring intraductal pressure during washing of the biliary tract. It was equal to 120 mm water column. Irrigation of the bile ducts was carried out for 9 days. After receiving bachanalia bile, which indicates the absence of microflora in it, nasobiliary the tube was removed from the digestive tract. External drainage of the choledochus continued through the tube installed in it during the operation. This drainage tube was removed from the choledochus after it was released about 100 ml of bile per day and perform the audit fistulography, showed the absence of stones in the common bile duct and the free flow of contrast into the duodenum. While standing in this drainage tube in the wound of the anterior abdominal wall put rubber latex strip for 1 day. The expiration of bile output was not. The rubber strip is removed, the wound superimposed dry gauze bandage and the patient is in satisfactory condition has been discharged from hospital.

Thus, compared with the prototype of the proposed method has the following advantages: - prevents nekontroliruemoe is possible as acute liver failure; b - allows you to measure intraductal pressure during a session flush extrahepatic biliary ducts, which eliminates the increase in pressure and development in connection with these complications; it is possible to avoid clogging of drainage pipes during washing of the biliary tract; g - drug mixture contains a substance dissolve small gallstones /heparin/ as well as the drug intorimidazole /metrogel/ acting on clostridial microflora, antibiotic, according to the sensitivity of microflora.

This method is applied in 28 patients with gallstone disease and strictures of major duodenal papilla, complicated by the development of acute suppurative cholangitis. Negative consequences in connection with its use are not observed, the phenomenon of acute liver failure did not develop in the postoperative period in any patient.

The method of treatment of purulent cholangitis, involving surgery and washing extrahepatic bile ducts medicinal mixture in the postoperative period, characterized in that patients previously conducted nasobiliary the drainage tube in the common bile duct through the major duodenal then, by improving the condition of the patients, perform surgery for extrahepatic biliary tract, can be installed in the common bile duct of the second drainage tube and under the control of the intraductal pressure hold postoperative lavage extrahepatic bile ducts by drip through nasobiliary the drainage tube warm (37,0oC) drug mixture containing a salt solution, novocaine, metrogel, hydrotartrate platifillina, prednisolone, heparin and antibiotics in the following ratio: 0.9% common salt solution to 100.0 ml 0.25% solution of novocaine to 100.0 ml solution of metrogel 50,0 ml, hydrotartrate platifillina 0,2% 1,0 ml, prednisolone 30 mg, a solution of heparin 5000 IU, antibiotic 1.0 g, respectively, the sensitivity of microflora of bile.

 

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