Method of dissolving stones in common bile duct

FIELD: medical procedures.

SUBSTANCE: patients preliminarily undergo endoscopic papillo-sphincterotomy, whereupon stone in common bile duct is dissolved and removed by way of supplying stone-dissolving therapeutic mixture, in particular 1:1 solution of diethyl ether in olive oil, directly to bile stone. Therapeutic mixture creates, in the lumen of bile duct, hydrostatic pressure 200 mm water head. More specifically, 120 ml of therapeutic mixture is supplied during one day at a rate of 10 drops/min, while performing 5 to 16 daily sessions of stone-dissolving therapy.

EFFECT: increased efficiency in removal of sparingly soluble stones in common bile duct.

2 ex

 

The invention relates to medicine, mainly to abdominal surgery, and can be used for minimally invasive removal of stones from the common bile duct.

Dissolution of gallstones in the biliary tract refers to a bloodless method of restoring the patency of the common bile duct (choledochus). In recent times it is used in the most debilitated patients and in elderly and senile age, when you need non-traumatic removal of larger stones from the choledochus, because they were not able to retrieve using video endoscopy equipment. Conducted a search of the scientific and patent literature showed that for deciding on the solvent used different methods. In particular, the introduction of the solvent through the drain tube located at one end in choledocho (Rahvusele. “Bloodless methods of removing gallstones”. - M.: Higher school. - 1989. - S, 232). The disadvantage of this method is that in the cases of the complete obturation of the choledochus a large stone, this method is not applicable, because it closes the outflow of bile. Also entered in the choledoch dissolving substance is mixed with bile, which reduces its concentration and thus reduces the impact on the stone. It is possible to introduce camerastore substances through nasobiliary on ena, established in the common bile duct by endoscopic retrograde catheterization through the major duodenal papilla (Vagasil, ibid, s, 232). This method is complex, requires special expensive equipment and trained personnel. There is a way of introducing camerastore substances through the external biliary fistula (Vagasil, ibid, s.226). For this purpose in its outer hole impose appropriate diameter pipe and seal around the hole in order kartnerstrasse substance is not leaking out. To achieve this it is extremely difficult, and in cases of complete obstruction of the choledochus stone this method is not applicable, because it stops the flow of bile. With the goal of creating a higher concentration of the solvent near the stone a method of deciding a medicinal mixture through a thin tube that held the stone in choledocho through the lumen of the outer drainage installed in choledocho during surgery (Pamporov et al. “The dissolution of residual bile duct stones in the early stages after surgery”. - Surgery. - 1989. No. 12. - P.67-71). The disadvantage of this method is that choledocho not created hydrostatic pressure to push the soluble fragments of stone in the duodenum, thus decreasing the effectiveness of therapy. Most b is izkuyu analog is the Way of the dissolution of residual stones choledochus” (patent RF № 2189178, IPC And 61 In 17/00, And 61 To 31/08, 35/78, And 61 R 1/16, publ. bull. No. 26, 2002), which is taken as a prototype. The essence of this method lies in the fact that in order to accelerate the removal of a stone from the extrahepatic bile ducts to him directly fed medicinal mixture through a thin catheter is held on the vent tube, and create hydrostatic pressure in the lumen of the choledochus by raising the outer end of the drainage tube 16 cm from the level of the mid-axillary line, which saves up to full discharge residues gall stone in the duodenum.

This method has the disadvantage that the discharge of residues gall stones through the major duodenal papilla must dissolve it to small fragments, which requires a longer time to apply camerastore therapy. This is especially inhibits the process of removal of stone fragments in cases bad its solubility, the large size of the stone, and in the presence of diseases of major duodenal papilla, which according to the literature found in 25.0% of the observations (Vchost.exe et al. The choice of tactics of surgical treatment of patients with calculous cholecystitis complicated by the diseases of the distal choledochus, depending on the extent of surgery and anesthetic risk. - In the.: Uspensky reading. - Issue 3. - Tver. - 2003. - P.142-144). In addition, created in choledocho hydrostatic pressure equal to 160 mm of water column, low enough to push the stone fragments in cases of poor solubility, because they are usually very difficult to dissolve to small sizes, especially when they contain calcium salts (Vagasil. Bloodless methods of removing gallstones. - M.: Higher school. - 1989. - S). However, clinical experience shows that cholangiography reflux occurs when the pressure in choledocho more than 200-250 mm of water column (Aeolian et al. Modern methods of treatment of purulent cholangitis and colagiovanni abscesses. Method recommendations. - Maykop. - 1993. - C.11).

These drawbacks are eliminated in the proposed technical solution.

The aim of the invention is to accelerate the discharge of fragments dissolve gall stones from the choledochus. This objective is achieved in that before camerastore therapy, the patient perform papillosphincterotomy endoscopic method, which gives an opportunity to make a wider hole in the distal choledochus (in the field of large duodenal papilla) for the separation of fragments of gall stones. In addition, to enhance the impact camerastore drug mixture on stone scoreupdate her into the lumen of the choledochus, and to increase the pushing action of hydrostatic pressure in choledocho his raise to 200 mm of water column.

Detailed description of the method and examples of its practical implementation.

In the cases when due to the severity of the patient, it is impossible to extend or to continue the operation to remove stones from the extrahepatic bile ducts, especially in elderly and senile patients with choledocholithiasis, surgical intervention finish external drainage of the choledochus tube with internal diameter not less than 4 mm In the postoperative period after 8-12 days (depending on the General condition of the patient, perform a control fistulography and determining the location of the stone in 1-2 days perform endoscopic papillosphincterotomy length of 1.5 cm, for example papillotomes firm “PENTAX”. During this manipulation of the choledochus yourself away small stones or delete them with baskets of Dormia. However, larger gall stones (diameter of 2.0-3.5 cm, especially irregular polygonal shape or subulate), commensurate with the diameter of the lumen of the distal choledochus to remove or break up can't. In these cases apply camerastore therapy. For this purpose, the outer end of the drainage tube make a hole diameter of 2 mm and through him by whom roveto drainage tube in the choledoch conduct a thin tube so that to the inner end it was located directly next to the stone. To the outer end of the thin tube connected infusion system with camerastore drug mixture and begin to enter the choledoch drip (10 drops in 1 minute) in the amount of 120 ml per session. Entered in the choledoch camerastore drug mixture affects the stone and flows outside the lumen of the drainage tube. To create hydrostatic pressure of the outer end of the drainage tube choledochus is lifted to a height of 20 cm above the level of the right mid-axillary line on the pad and fix to the body of the patient. In this position the outer end of the drainage tube retain during each session camerastore therapy. Throughout the course of treatment do 5-16 sessions (depending on the solubility of stones), one session daily. The passage of fragments of a gall stone in the duodenum determine clinically: the cessation of bile flow through the drainage tube out, a break with the introduction of choledoch warm (37,0° (C) solution of novocaine (he must act freely, without causing pain), the absence of abdominal pain after clamping the drainage tube for 4-12 hours, and by measuring the hydrostatic pressure in choledocho or fistulography.

Example 1. B-Noi, Mr C. D., 70 years (IB. No. 40925/1433) deal is in the Department of surgery № 2 BSMP - 2, Rostov-on-don in the emergency admission with a diagnosis of acute gangrenous calculous cholecystitis, obstructive jaundice. In General, the analysis of blood leukocytes 8,3·109/l, leukocyte formula blood: Palocco-nuclear natriello - 15%, segmented - 65%; the level of total bilirubin blood - 58,14 µmol/L. due To increasing signs of obstructive jaundice on the 2nd day of inpatient treatment, the patient was urgently operated. During surgery cholecystectomy revealed dilatation of the common bile duct to 1.6 cm because Of the severity of the patient operating cholangiography was not performed. The operation ended with the formulation of the choledoch drainage by Pikovsky with an inner diameter of 4 mm and drainage of the subhepatic space. To improve the condition of the patient on the 10th day after the operation was fistulography, in which the distal choledochus revealed a filling defect with a diameter of 1.4 cm, testified to the presence of the stone. In this regard, the next day papillotomes firm “PENTAX” performed endoscopic papillosphincterotomy length of 1.5 see Attempts to extract the stone from the choledochus basket of Dormia did not succeed. After 2 days, ensuring reliable hemostasis in the area of papillosphincterotomy, through the outer drainage choledochus to the stone in the common bile duct summed thin Proc. of the BKA, it is connected infusion system with camerastore a mixture containing a solution of diethyl ether in sterile olive oil in the ratio 1:1, and started therapy for dissolving the stone. The outer end of the drainage tube choledochus during the session camerastore therapy is elevated to 200 mm above the right mid-axillary line to create a hydrostatic pressure in the common bile duct. Conducted 7 sessions camerastore therapy. On the 8th day marked the cessation of bile flow out the drainage of the choledochus. The drainage tube was parijata: abdominal pain in a patient within 12 hours has not appeared. When the control fistulography identified the free flow of contrast material choledocho into the duodenum. The shadow stone choledocho was not determined.

Example 2. B-Naya-on Z.N., 70 years (IB. No. 5167/575) enrolled in the Department of surgery № 2 BSMP-2, Rostov-on-don for acute calculous cholecystitis, choledocholithiasis, mechanical jaundice. Concomitant diseases were: chronic ischemic heart disease, angina, atrial tachyarrhythmia, circulatory insufficiency of the 2nd degree. Peptic ulcer of the duodenum.

When applying the General condition, in the General analysis of blood leukocytes 6,2·109/l leukocyte the th formula blood: stab natriello - 17%, segmented natriello - 51%; the level of total bilirubin - 50,88 µmol/L. due To increasing signs of obstructive jaundice sick on the 3rd day after admission was operated. Performed laparoscopic cholecystectomy. During the operating cholangiography detected extended up to 2 cm choledoch and stone with a diameter of 1.8 cm in its distal. Because of signs of heart failure, complete drainage of the choledochus by Pikovsky and drainage subhepatic space. After surgery the patient was first in the hospital, and then in the cardiology Department because there was a growing signs of disorders of the heart. Then, the patient developed gastric ulcer bleeding. She was transferred to the intensive care unit, and then into surgery. Executed on the 12th day after surgery, fistulography confirmed the presence of a stone in the distal choledochus. The next day the patient produced endoscopic papillosphincterotomy length of 1.5 cm was Exposed the lumen of the choledochus. Attempts to remove the stone using baskets of Dormia have failed. He was appointed camerastore treatment by the method described above. Held 11 of its sessions. On day 12 after beginning the patient noted an instant insignificant the Yu abdominal pain with sharp relief. After the expiration of bile out through the drainage choledochus was not followed. Clamping of the drainage tube 12 hours abdominal pain is not caused. Enter the warm of 0.25%solution of novocaine freely received in the choledoch. When the control fistulography stone choledocho is not detected, the contrast agent was freely admitted into the lumen of the duodenum.

The proposed method of treatment 6 patients. Complications were not observed. The passage of stone fragments were observed on 6-16 days after execution 5-16 sessions camerastore therapy, on average, 8, 4 day. In the prototype the discharge of stones noted at an average of 11.8 days (from 6 to 22 days).

Thus, compared with the prototype of the proposed method has the following advantages: 1 - the earlier passage of fragments of gallstones in the duodenum, due to the increased diameter of the hole in the distal choledochus to promote them through the major duodenal papilla, as well as enhanced feed mode camerastore drug mixture into the lumen of the choledochus and increases the hydrostatic pressure in choledocho up to 200 mm of water column; 2 - reduced the time and number of sessions conduct camerastore therapy.

The method of treatment of choledocholithiasis, including the dissolution and destruction of stone common gelong the duct by summing camerastore medicinal mixture, which is a solution of diethyl ether in olive oil in the ratio 1:1, directly to the gall stone, while creating a hydrostatic pressure of this drug mixture into the lumen of the common bile duct, characterized in that patients perform pre-endoscopic papillosphincterotomy, then, creating a hydrostatic pressure of 200 mm of water column, enter 120 ml of the medicinal mixture in night mode 10 drops in 1 min, carrying from 5 to 16 daily sessions camerastore therapy.



 

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