HOLEDOHOSTOMYYa [lat. (ductus) of choledochus a bilious channel + Greek stoma of companies, an opening, pass] — imposing of outside bilious fistula on the general bilious canal with use of various drainages; one end of a drainage is entered through a holedokhotomichesky opening into a gleam of a channel, and another is brought to a front abdominal wall through an operational wound or through a separate opening.
Indications to a choledochostomy are: a cholangitis (see), existence of stones in the general bilious channel (see Cholelithiasis), need of a decompression of bilious ways after a faterovy nipple operations (a big nipple of a duodenum, T.) and terminal department of the general bilious channel, impassability or damage of the general hepatic or the general bilious channels if it is impossible to execute other operations. Through holedokhosty it is possible to remove the infected bile at a purulent cholangitis, to wash out bilious channels, to enter into them antibiotics, to carry out contrast rentge-nol. a research of bilious channels to take residual (residual) concrements, etc.
The greatest distribution for a choledochostomy was gained by the T-shaped rubber tubes offered by E. Duayen and implemented in broad surgical practice of H. Kehr by name to-rogo them and began to call in the subsequent (see Drainage). After a choledochotomy (see) the ends of a horizontal part of the T-shaped tube shortened to 2 — 3 cm enter into the general bilious canal in the direction, a cut, distal and proximal from a ho-ledokhotomichesky opening, then carefully take in to a vertical part of the tube removed outside of (fig., a). T-shaped drainages with the extended horizontal part of the tube intended for carrying out through fater of pacifiers in a duodenum use seldom in connection with danger of development of pancreatitis and a pancreatonecrosis. The T-shaped drainage well keeps in a gleam of a channel, passes bile and outside, and in the distal direction. Nedostatkokhm of these drainages is damage of a wall of a channel at their extraction (the ends of a horizontal tube develop, increasing its general diameter), and also a possibility of a separation of a horizontal part of a tube in the place of its connection with vertical. The elastic cast T-shaped drainages of different diameters made of latex are more convenient. For reduction of an injury of a channel an upper part of a horizontal tube is cut off.
A. V. Vishnevsky suggested to use for a choledochostomy a direct rubber tube with the side opening located at distance of 3 — 4 cm from its end, to-ry enter into the canal towards a liver (fig., b). The drainage is fixed to a wall of the general bilious channel, the wound to-rogo is taken in around the removed tube. The second end of a drainage as well as a vertical part of the T-shaped drainage, remove through an operational wound outside, extend and lower in a glass jar with antiseptic solution, to-ruyu put at a bed of the patient. The created siphon promotes outflow of bile from bilious channels. Lifting bank with the tube lowered in it on different height, it is possible to regulate pressure of bile in a channel (a drainage — a siphon — the manometer). A lack of this method is danger of premature loss of a drainage tube from the general bilious channel, intake of bile in an abdominal cavity and development of bilious peritonitis (see).
The drainage is deleted usually in 12 — 14 days. Before it he within 2 — 3 days is «trained», pressing at first for 2 — 3 hours, and then on more long term. Absence of pains, temperature increase demonstrates elimination of inflammatory changes and free passability of bile in a duodenum. Before removal of a drainage make rents-genol. a research of extrahepatic bilious channels with administration of radiopaque substance through a tube: at a normal passage of bile in a duodenum and lack of concrements the drainage is deleted. After removal of a drainage biliation outside quickly stops (on condition of its normal outflow in a gut), the fistular course quickly begins to live.
Allocation outside of a significant amount
of Fig. The diagrammatic representation of a choledochostomy by means of the T-shaped tube (a) and by Vishnevsky's method: 1 — the general bilious channel; 2 — a duodenum; 3 — a drainage tube; 4 — a stump of a vesical channel; the parts of drainage tubes which are in a gleam of the general bilious channel are designated by dashed lines.
bile (to 800 ml a day) within 12 — 14 days usually is not followed by serious violations in an organism of the patient. However, if loss of bile continues longer time, then there occur changes in electrolytic balance and fermental systems of an organism. Therefore in case of a nonremovable obstacle for outflow of bile in distal department of the general bilious channel (a concrement, a stricture, a tumor) it is necessary to resort to imposing of a biliodi-gestivny anastomosis: holedokhogast-rostomiya (see Holetsist, an ogastrosto-miya), choledochoduodenostomies (see) or choledochoenterostomies.
See also Bilious channels.
Bibliography: Smirnov E. V. Hirur
gichesky operations on the bilious ways, JI., 1974; Fedorov S. P. Gallstones and surgery of bilious ways, M. — L., 1934; Shalimov A. A., etc. Surgery of a liver and bilious channels, Kiev, 1975; To e h of H. Chirurgie der Gallen-wege, Stuttgart, 1913.
O. B. Milonov.