RU2113175C1 - Method to treat purulent cholangitis and cholangiogenous hepatic abscesses - Google Patents

Abstract

FIELD: medicine, surgical hepatology. SUBSTANCE: method deals with dosed decompression and perfusion of bile ducts by medicinal preparations via a two-channel drainage. Simultaneously it is necessary to create a residual pressure in bile ducts. Then constant perfusion of a bile arbor is conducted for 7-10 days. EFFECT: higher efficiency to conduct an adequate draining and a full-value sanitation of a bile arbor in case of purulent process in a liver. 3 dwg

Description

 The invention relates to medicine, in particular to surgical hepatology, and can be used to treat purulent cholangitis and cholangiogenic liver abscesses.

 Against the background of purulent cholangitis, multiple cholangiogenic abscesses occur due to the fact that with the usual, traditional method of drainage of the biliary tract, a rapid and uncontrolled decrease in intraductal pressure occurs. As a result, the hydrostatic backwater disappears, the ducts subside, the outflow of purulent bile is disrupted, and therefore there is a closure of micro- and macroabscesses of the liver.

A known method of treating purulent cholangitis and cholangiogenic abscesses of the liver by draining the bile ducts with a two-channel probe, followed by their fractional perfusion with antiseptics [1],
The technique allows you to perform dosed decompression of the biliary tract and reduce the likelihood of hepatic-renal failure. However, this method does not allow to maintain residual intraductal pressure and, therefore, does not exclude the formation of cholangiogenic liver abscesses.

 The aim of the invention is adequate drainage and full rehabilitation of the gall tree with a purulent process in the liver.

 This goal is achieved by the fact that according to the method of treating purulent cholangitis and cholangiogenic liver abscesses by dosed decompression of the biliary tract and fractional perfusion of them, residual pressure in the ducts is created, equal to or slightly lower than the originally measured, by raising the drainage in the form of a "knee" by 15- 20 cm above the level of the middle axillary line of the patient and continuous therapeutic perfusion of the ducts.

 The method is illustrated in FIG. 1-3.

 The method is as follows. After a laparotomy, the cause of obstructive jaundice, purulent cholangitis is eliminated and the bile ducts through the hepatikostoma are sanitized (Fig. 2). Inside the perforated catheter 1 with a diameter of 4.0-5.0 mm, a thinner and more flexible catheter 2 with a diameter of 1.3-2.3 mm is inserted, which is installed inside the hepatic bile ducts and the intraductal pressure is measured by Waldman's apparatus. Drainages are fixed to the hepatic choledoch wall with catgut thread and are brought out through a puncture in the right hypochondrium. After surgery, an internal antiseptic solution (furatsillin) is infused through an internal drainage using a rack and a system for transfusion of drugs 3. External drainage ensures the outflow of bile and perfusate, and most importantly, by lifting its end in the form of a “knee” 15-20 cm higher the middle axillary line creates an intraductal pressure equal to 150-200 mm of water. Art. Given that with an intrabiliary pressure of 200-250 mm of water. Art. if cholangiovenous and cholangiolymphatic reflux occurs, then the perfusion of the biliary system is performed under pressure not exceeding these figures. Maintaining a residual pressure equal to or slightly lower than originally measured by raising external drainage above the patient’s liver level by 15-20 cm and constant perfusion, eliminates the closure of micro- and macroabscesses, their autonomous development and ensures adequate drainage of the gall tree (Fig. 3 a, b)

 The criterion for the duration of bile duct drainage according to the described method is the positive dynamics during the course of the disease, improvement of the functional parameters of the liver and data from the control fistulocholangiography. This period is from 7 to 10 days. We give a clinical observation.

Patient 3-in, 68 years old (source. Bol. N 12872) was admitted to the clinic on 07.06.90 with complaints of high body temperature (up to 39-40 ^o C), chills, jaundice, weakness and poor appetite. A month ago (May 11, 1990), one of the hospitals in the city was operated on for destructive cholecystitis, and cholecystectomy was performed. In the postoperative period, jaundice and purulent processes in the bile ducts increased. In this regard, on 05/14/90, relaparotomy, drainage of the bile ducts and subhepatic abscess were performed. However, the condition remained serious and diagnosed: the patient's liver abscess was transferred to the hepatosurgery clinic. Objectively: the condition is serious, the skin is icteric. In the lungs, vesicular breathing, no wheezing. Pulse 88 in 1 min of satisfactory qualities. HELL 130/70 mm Hg The abdomen is of the correct form, participates in the act of breathing, soft, painful in the right hypochondrium. The liver is enlarged 2-3 cm below the costal arch, painful. Blood test: HB 94 g / l, Er. -3.1 • 10 ¹² / l. , ESR-60 mm / h. Total bilirubin is 123.4 μmol / L. Ultrasound of the liver: intrahepatic bile ducts are dilated, in the projection of the portal of the liver and 5-6 segments, cavity formations measuring 2.0x3.0x3.0 cm are determined.

With HCHG, moderate dilated intrahepatic ducts are determined, in the area of subsegmental ducts there are multiple, irregularly shaped cavities, unevenly filled with contrast. At the C / 3 level of hepaticoholedoch there is a structure. In the subhepatic space visible drainage. With a diagnosis of multiple cholangiogenic abscesses of the liver, obstructive jaundice, the operation was performed on 09.06.90. During the audit, it was found that in the region of 5-6-7 segments of the liver, densification areas of 4.0x4.0 cm were determined. Abscesses were hidden. Hepatic choledoch drainage removed and choledochotomy opening widened. Purulent bile with fibrin flakes stood out from the common bile duct. The intraductal pressure was measured; it amounted to 150 mm of water. Art. The gall tree is sanitized and installed in the hepaticoholedoch T-shaped drainage with a thinner lumen in the intrahepatic bile ducts. Drainages are removed through a puncture in the right hypochondrium. In the postoperative period, the patient, along with the traditional basic detoxification and antibacterial therapy, underwent continuous perfusion of the bile ducts with furacilin solution under a pressure of 150 mm of water. Art. On the 3rd day after the operation, the patient's condition improved, the body temperature decreased to 37.5 ^o C, the discharge from the external drainage became lighter with single fibrin flakes. On day 7, a control fistulocholangiography was performed. Intrahepatic bile ducts are moderately dilated, purulent cavities are not determined. The T-shaped drainage of hepaticoholedrach is visible and more thin - intraductal. On day 14, the drains were removed. Given the presence of a cicatricial structure of hepaticoholedoch, the patient underwent percutaneous transhepatic endoprosthetics. He was discharged from the clinic in satisfactory condition on July 28, 1990. At the follow-up examination, he feels satisfactory a year later, the endoprosthesis has migrated.

 Thus, the proposed method for the treatment of purulent cholangitis and cholangiogenic liver abscesses, in contrast to the known one, allows not only dosed decompression of the bile ducts in the postoperative period, but the main thing is to create residual intraductal pressure, eliminating the closure of abscesses, and therefore contributes to their adequate rehabilitation. The bile duct drainage technique was used in 15 patients with cholangiogenic liver abscesses and, in combination with well-known, traditional methods of treatment, reduced postoperative mortality by half in this extremely difficult category of patients.

Claims (1)

 A method of treating purulent cholangitis and cholangiogenic liver abscesses by dosed decompression and perfusion of the bile ducts with drugs through a two-channel drainage, characterized in that "residual" pressure is created in the bile ducts and the perfusion of the "gall tree" is carried out for 7-10 days.

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