The idea of the dissolution of gallstonesnecessary medication captures researchers all over the world. It is attractive by the fact that when the successful use of drugs is no longer necessary in the operation, in which there is always a risk of an adverse outcome. In medical practice, the method of drug dissolution of gallstones appeared in the early 70s, when henodeoksiholovaya acid was obtained and subsequently ursodeooksiholovaya acid (UDCA). Medications that decrease the number of cholesterol in bile by inhibition of its synthesis in the liver and increase the pool of bile acids in bile. As a result, it loses lithogenicity bile stones and dissolution occurs.
The therapeutic effect in enteral applicationlitholytic drugs is achieved in patients with gallstones, consisting primarily of cholesterol. As is known, most of the stones are mixed, also containing bilirubin, proteins, and various salts. In this connection, use may litolizisa only 20% of patients suffering from GSD. Application of the method shown in seriously ill patients with high operational and anesthetic risk and patients who refuse surgery or extracorporeal lithotripsy (EKLT). litolizisa method has many contraindications to the appointment, with underestimation of which the therapeutic effect is not achieved, and possible complications.
The therapeutic effect when taking litholyticdrugs can be expected in 1.5-2 years. The daily dose of UDCA preparation is 10-15 mg / kg. The best results were observed by limiting the consumption of fatty foods, rich in cholesterol. The main drawback of the method is low efficiency litolizisa. Even with a strict selection of patients to dissolve the stones or reduce their sizes manage no more than 60% of them, and this effect is achieved with smaller pure cholesterol stones. After discontinuation of drugs marked by a high percentage of recurrence of the disease. It is not enough high efficiency limits the use litholytic therapy as an independent method of treatment of cholelithiasis. More generally it is used in combination with other methods and in particular with remote crushing stones.
non-invasive method of crushing stonesgallbladder. But not every patient can be recommended to the medical procedure and does not always achieved positive results. For therapeutic effect requires strict selection of patients. Experience has shown that the efficacy of extracorporeal lithotripsy (EKLT) depends on the properties of stones that determine the success of their fragmentation and elimination, as well as on the functional status of the gallbladder, which determines the frequency of complications and side effects of the elimination period and the early recurrence of stone formation.
The criteria for selection of patients with cholecystolithiasis (withsymptomatic and asymptomatic forms of the disease) are for EKLT: single and a few (2-4) concretions that occupy less than half the volume of the gallbladder; preserved contractile-evacuation function of the gallbladder. The success of treatment depends on the presence of calculi calcium salts and their degree of calcification. Good treatment results are achieved in patients with ehopronitsaemymi and ehoneplotnymi (not containing calcium) radiolucent calculi, increasing their ehonepronitsaemosti ehoplotnosti with signs and radiopacity crushing efficiency drops.
Contraindications EKLT are: Multiple cholecystolithiasis, covering more than 1/2 of the volume of the gallbladder; calcified stones; decrease in contractile-evacuation function of the gallbladder and the gallbladder is disabled; concretions of bile ducts and biliary obstruction; the impossibility of enteral litolizisa after crushing stones (gastroduodenal ulcer, allergy); pregnancy.
About rezultath lithotripsy judged by 3-18 months,when is released from the gallbladder stone fragments. To speed up the process of elimination and reduction of the size of the fragments to patients prescribed oral therapy litholytic. In the near and distant periods fragments elimination process can produce complications in the form of attacks of biliary colic, acute cholecystitis, obstructive jaundice and acute pancreatitis. It should be noted that these complications are rare. In a rigorous selection of patients good treatment results (full exemption from the gall bladder stones) is observed in 65-70% of patients. Unsatisfactory results EKLT when fragments do not come out of the gallbladder, or, on the contrary, increase in size, associated either with the incorrect assessment of the gallbladder function or to the qualitative composition of the stones. After a successful lithotripsy possible recurrence of stone formation, was observed in 20-23% of patients undergoing this procedure (most of them have lipid metabolism disorders). The measure of prevention of disease recurrence in these patients is to carry out corrective holesterinsnizhayuschey therapy.
Non-operative treatment methods inherent in onedrawback nepatogenetichnost therapy. Expect good results of treatment when used in the long term it is not necessary, because if you can not work on all links in the pathogenesis of the disease remains the gallbladder body, forming concretions. That is why the surgical removal of the gallbladder is seen as a radical method of treatment of gallstone disease, relieving the patient of biliary colic and dangerous complications. At present, hospitals use three ways to remove the gall bladder: laparoscopic, surgery of minimal surgical approach and the standard laparotomy.
The appearance in the medical practice of the methodLaparoscopic cholecystectomy (LCE) was a milestone in the development of gallstone surgery. For a little more than 10-year existence, it has gained wide recognition and received a further improvement. Endoscopic techniques have been producing up to 70-80% of cholecystectomies.
By the indications for LCE includeuncomplicated symptomatic cholelithiasis, asymptomatic form of the disease and cholesterosis gallbladder. Improving the technology of endoscopic surgery has allowed to expand the indication for intervention with combined lesions of the bile ducts. Among the contraindications for this operation, emit a dense inflammatory infiltrate in the neck of the gallbladder and hepatoduodenal ligament, pregnancy, transferred to laparotomy, obesity, liver cirrhosis, intrahepatic location of the gallbladder, obstructive jaundice and acute pancreatitis.
Partly trauma surgery at LCE,gentle instrumental technique provides easy postoperative period, short-term presence of the patient in the hospital (3-5 days) and shorter vocational rehabilitation (2,5-3 weeks). These factors determined by the low rate of postoperative complications in the surgical wound, abdominal and cardio-pulmonary system.
Along with the undeniable advantages LCE operationcarries the risk of serious complications: bleeding into the abdominal cavity, the intersection of the common bile duct, internal injuries, bile leakage into the abdominal cavity, purulent processes in the areas of intervention. Their causes are most often adhesions and inflammation in hepatoduodenal zone.
Cholecystectomy from the mini-laparotomy
This method consists of cholecystectomy surgeryOpen a small quick access to elements endosurgery. The operation is carried out using a set of tools, including a ring retractor, retractor hinged mirror (change their geometry), lighting apparatus and electrocoagulators.
The use of mini-laparotomy withCholecystectomy is expedient in cases where there are contraindications to the laparoscopic procedures. The technology to make this operation allows removal of the gallbladder in the presence of inflammatory infiltration and adhesions in the area hepatoduodenal ligament; when previously transferred laparotomy, when can we expect spayaniya abdominal organs from the abdominal wall; obesity and intrahepatic location of the gallbladder. Mini-access is preferable in patients with concomitant diseases of the heart and pulmonary systems.
Cholecystectomy from the open laparotomy
Removal of the gallbladder from the standard widelaparotomy is classified as traumatic interventions with an increased risk of developing complications. Despite this lack of general laparotomy, the need for its application remains in complicated gallstone disease, when intervention is required in the extrahepatic bile ducts, and in acute cholecystitis. Forced to move to wide laparotomy occurs in operations of laparoscopic and mini-access, if in the course of surgery there are technical difficulties or iatrogenic complications.
Thus, the existing methods of treatment of cholelithiasisthe most effective is surgical removal of the gallbladder. It is important to quickly identify the indications for surgery, without waiting for the development of complicated forms of the disease.