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APPLICATION OF MINIMALLY INVASIVE METHOD OF TREATMENT OF
PATIENTS WITH CHOLEDOCHOLITHIASIS
Radjabov Anvar Islomovich
Ochilov Ulmas Barotovich
https://doi.org/10.5281/zenodo.13638234
Summary
The article highlights the problems of diagnostics and treatment of gallstone disease
(GCD) in persons of different age groups. The data of morbidity statistics for different countries
and regions are given. Modern methods of choledocholithiasis treatment, which are currently
applied in our country in surgical clinics, are considered. When studying the methods of
treatment of LCB and choledocholithiasis, as well as complications arising from these
pathologies, it can be concluded that the ideal method of treatment of the pathology in question
has not yet been found. To date, for the majority of physicians, the main method of treatment
of GIC remains surgical removal of stones.
Keywords:
cholelithiasis, choledocholithiasis, laparoscopic cholecystectomy, retrograde
papillosphincterocholidochotomy
Relevance.
Concretions in bile ducts at cholecystolithiasis according to different authors
are detected approximately in 10-25% of cases [3]. Therefore, the problem of
cholecystocholedocholithiasis treatment is actual for any general surgical hospital. Retrograde
papillosphincterocholedochotomy (ERPST) and laparoscopic cholecystectomy (LCE) is
historically the first and most common scheme of minimally invasive treatment of
choledocholithiasis [1]. In subsequent years, ERPST became more frequently used due to the
widespread introduction of laparoscopic surgery. The method is highly effective, complete
stone extraction can be achieved in 80-98% of patients [2,3]. The indisputable advantage of the
two-stage method of treatment is the possibility of rapid performance of low-traumatic
decompression of bile ducts with decreased duration of anesthesia, which is actual in elderly
patients with serious concomitant pathology [3,4]. Some authors insist on application of two-
stage minimally invasive treatment method with ERPST in all patients in order to reduce
lethality and complications [5]. In the last decade, as a result of intensive development of
laparoscopic
surgery,
publications
about
one-stage
laparoscopic
method
of
cholecystocholedocholithiasis treatment have appeared [3,5].
Purpose of the study:
to improve the results of treatment of patients with acute calculous
cholecystitis complicated by choledocholithiasis by using minimally invasive methods of
treatment with nitroglycerin and EAP.
Material, methods of research.
Patients with acute calculous cholecystitis complicated
by choledocholithiasis, to whom retrograde papillosphincterotomy was applied in the
treatment complex, in order to accelerate the terms of cholangitis process recovery, were
supplemented with retrograde lavage of choledochal lumen with electroactivated solution
EAR-A, possessing anti-inflammatory property.
For preparation of electroactivated aqueous solution we used Apparatus NPF "Espero-1",
developed in 1998 by the employee of Tashkent Institute of SANII S.A.A.Alyokhin. Espero type
bioelectroactivator is authorized by the Pharmcomittee of RUz for obtaining preparations used
in medical and clinical practice and was widely used by the staff of V.V.Vakhidov Research
Institute and clinics of TMA. Electroactivated solution - anolyte (EVR-A) is formed in the anode
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zone (Graphite), pH of which is from 7 - to 1; ORP 0 +1200 mV. EBP-A (anolyte) has a
pronounced antimicrobial activity, anti-inflammatory, antipruritic, anti-allergic action,
bactericidal, drying, inhibitory properties, slowing down biological processes.
Results and their discussion.
From 46 examined patients of the third group in
41(89,1%) the first stage of the operation was successfully performed, which ended with
complete removal of concrements from the choledochus. The duration of the first stage of
surgery in the third group of patients with successful completion averaged 22±1,8 minutes. In
all these patients after the acute inflammatory process in the lesion and normalization of
intoxication indices, as well as blood bilirubin by 5-6 days the second stage of surgical
intervention - cholecystectomy - was performed. In 4 (8.6%) patients of the third group, due to
dense occlusion and high location of the concrement on the background of strong spasm of the
choledochal muscular structures, the first stage of surgery was unsuccessful - by means of
ERPST it was not possible to remove the concrements. In 1 (2.1%) cases in the first operation
during manipulation due to technical difficulties there were intraoperative bleedings from
choledochal vessels. In 5 (10,8%) patients antegrade removal of stones from the choledochus
with drainage of the choledochal lumen with one-stage cholecystectomy on the background of
acute cholecystitis with high intoxication of the organism was forcedly performed. Out of 41
(89,1%) patients, who at the first stage with the help of ERPST were successfully removed the
concrements, after general detoxication and anti-inflammatory conservative therapy by 5-6
days 40 (97,5%) patients underwent delayed cholecystectomy with laparoscopic method. In 1
(2,1%)-patient because of contraindication to laparoscopic operation the second stage was
applied by open laparotomy method. Thus, only 6 (13.0%) patients underwent open method of
surgery with median laparatomic access.
Analysis of the results of intoxication parameters of the patients' organism revealed the
following changes: on the first day of treatment the div temperature varied in the range of
38,8±0.06. In the general blood analysis the content of leukocytes averaged 8,7±0,17. The
volume of middle molecules ranged between 0,192±0,011. An increase in COE and LII was also
observed.
At ultrasound examination of liver, gallbladder and bile ducts of all this group of patients
as well as in the previous group of patients stasis of intrahepatic bile ducts and common bile
duct and dilatation of lumen of intrahepatic bile ducts and upper part of common bile duct were
revealed. In the majority of cases in 44 (95,6%) patients there were revealed signs of cholangitis
and hyperbilurubinimia on the background of mechanical jaundice.
From 4 patients of the third group, in whom it was not possible to remove the
concrements at RPSCT, in 2 (50%) the concrement of the common bile duct was localized in the
upper third part, in 1 (25%) patient the localization of the concrement in the middle parts of
the bile duct was revealed, in 1 (25%) patient the obturation concrement was located in the
lower parts of the common bile duct.
In all these patients as well as in the previous patients from the moment of admission in
parallel with complex diagnostic investigation general detoxication and symptomatic therapy
were carried out. From laboratory data, first of all, we studied indices of general intoxication
and blood bilirubin, ALT, AST.
In all cases the size of the stones was at least 7-8 mm, which was the main reason for the
failure of RPSCT within 30-40 min. Because of this, it was decided to suspend the procedure of
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retrograde papillosphincterotomy and to switch to emergency-delayed laparotomy after
appropriate preoperative preparation.
The mean duration of open surgery was 65±3,1.
Drainage tubes from the abdominal cavity were removed on the 5th-6th day. Pikovsky
drainage from common bile duct was removed on the 8th-9th day of treatment.
Conclusion.
Thus, our conducted study revealed the following peculiarities, which have
an important practical value: when using nitroglycerin 0,5 mg under the tongue during ERPST,
the % of not successful removal of stones from the choledochus decreases from 48,3% of cases
to 10,8%.
When using nitroglycerin 0,5 mg under the tongue before performing ERPST contributes
to the increase in the number of successful removal of the nodule from 38,7% to 89,1%.
Performance of RPSCT against the background of common bile duct wall spasm control
with application of nitroglycerin 0,5 mg under the tongue decreases technical difficulties of
stone removal thus decreases bleeding complications from 14% to 2,1%, duration of RPSCT
time from 60,2±2,8 min to 25,4±1,9 min.
After stone removal from the choledochus and within 3-4 days after ERPST application of
retrograde sanation and lavage of the common bile duct with the use of EAR-A, decreases
complications of prolonged cholangitis by 17,7%, accelerates the terms of normalization of
total bilirubin and intoxication from 8 to 3-4 days. In the treatment of patients with cholecystitis
complicated by choledocholithiasis application of nitroglycerin and retrograde sanation and
lavage of choledochus with electroactivated solution EAR-A, improves the results of treatment
and reduces the period of hospital treatment of this category of patients from 12,6 to 8,4 days.
All this allows us to widely recommend the proposed method of treatment in clinical practice
and has economic efficiency.
References:
1.
Bautkin, A. V. The problem of intra- and postoperative complications in the treatment of
acute calculous cholecystitis and ways of their prevention / A. V. Bautkin, M. F. Cherkasov, A. A.
Eleyev // Medical Bulletin of the South of Russia.- 2012. - № 3. - С. 4-6.
2.
Bystrov, S. A. Mini-invasive interventions in acute cholecystitis complicated by
mechanical jaundice / S. A. Bystrov, B. N. Zhukov // Medical Almanac. - 2011. - № 2. - С. 87-89.
3.
Lugovoi A.L. et al. Significance of laparoscopic choledocholithotomy in the treatment of
cholecystocholedocholithiasis // Herald of St. Petersburg Medical Academy of Postgraduate
Education - Vol. 3, No. 3 2011 - pp. 31-35.
4.
Boltaev T.SH., Safoev B.B. The use of chemical preparation of dimethyl sulfoxide in
combination with the physical method in treatment of purious soft tissues // Tibbiyotda yangi
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Safoev B.B., Razhabov A.I., Yarikulov Sh.Sh., Comparative evaluation of the results of
treatment of patients with acute calculous cholecystitis complicated by choledocholithiasis //
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