Endoscopic Treatment of Cholelithiasis in a Short-Stay Hospital

The research is dedicated to the development and rationale for the application of endoscopic surgery for the treatment of cholelithiasis in short-stay hospital conditions. The relevance of the study is due to the necessity of rational use of financial resources in healthcare and the implementation of resource-saving technologies. The work analyzes the history of the development of inpatient-replacing forms of medical care in Russia and the place of endoscopic surgery therein. The principles of organization and tactics for performing endoscopic operations, including transcystic and laparoscopic interventions, in ambulatory-polyclinic practice conditions are studied. Based on clinical material, the high efficiency and safety of the proposed approach are proven, and an algorithm for patient treatment and rehabilitation is developed.

The work has great practical significance, as the created new direction in the treatment of cholelithiasis and the principles of early rehabilitation ensure high economic efficiency of treatment and have great social significance. The developed principles have been introduced into clinical practice and are widely used in the work with a short-stay hospital.

The literature on the topic of the problem has been reviewed.

In the metrics of the development of surgery and this specialty, it is necessary to see the trends of the realization of its achievements, which have a social orientation.

The advantages of the Soviet system of healthcare (high level and free of charge) over the foreign ones were demonstrated over almost a whole century. In the 90s of the XX century, the socio-economic crisis that developed in the USSR negatively affected the sphere of healthcare, led to its reforming, which is carried out in conditions of an extreme deficit (30-60%) of financial resources (Starodubov V.I. et al., 2001),

Rational use of financial costs is one of the main tasks of practical healthcare, for which even at present the following disadvantages are characteristic: the bed-capacious bed fund is used inefficiently: the duration of examination and treatment of patients is great, outdated technologies of the diagnostic and treatment process are applied, patient treatment standards do not contribute to the implementation of new effective forms of treatment, doctors lack interest in increasing the efficiency of patient treatment.

Practically in all regions of the Russian Federation, patients in surgical hospitals resort to the use of personally purchased medicinal preparations, medicinal materials, expensive instruments, etc.

Within the framework of the implementation of the main directions of the Concept of Healthcare Development of the Russian Federation, the current tasks of improving the level of healthcare of the Russian Federation are maximum permissibility of inpatient care for the population, intensification of the use of expensive bed funds, search for means of increasing the efficiency of patient treatment, scientific substantiation of the introduction of resource-saving technologies into practice.

One of the multiple problems of healthcare reform and preserving its viability is the rational use of financial costs in the inpatient sector, namely — the efficient use of the bed fund through the development of inpatient-replacing forms (IRF) of providing surgical care to the population.

At present, certain successes have been achieved in creating a model of a day hospital (DH) for the treatment of surgical infections, vascular diseases of the lower extremities, diseases of the musculoskeletal system, etc. In recent years, ambulatory surgery and other types of surgical activity have begun to develop. However, it is easy to notice that ambulatory surgery includes the simplest extra-surgical operations.

At present, organizational issues of the activity of inpatient-replacing forms of medical care for the population are not resolved, their types and forms are not determined, the workload norms of doctors are not defined, the economic efficiency of DH activity is not calculated. Existing forms of reporting regarding the organization of medical care of IRF are imperfect, an economic mechanism of financing stimulating the development of these forms of activity has not been developed.

The relevance of the problem is even more clearly outlined in light of the achievements accomplished in the last 20 years. We are talking about the development of new equipment and instruments for endoscopic research and operations. The creation of a new direction in surgery — endoscopic surgery, its wide application in hospitals for acute and chronic diseases, the accumulation of a huge positive experience (Eralykin A.S. et al., 1993, 1996; Gallinger Yu.I. et al., 1993; Beburnshvil A. et al., 2000; Yemelyanov S.I., et al., 2000; Borisov A.E. et al., 2003; Prudkov M.N. et al., 2004) attracted the attention of pioneer surgeons and allowed them to evaluate the capabilities of the method in ambulatory-polyclinic practice. Rare publications (Eralykin V.D. et al., 1999; Sazhin V.P. et al., 2004; Kulchiev A.A. et al., 2004) testified to the great prospects of endoscopic surgery in this direction and to the necessity of solving this problem, which has social significance.

Cholelithiasis is one of the most common diseases of the digestive system, affecting all age groups of the population. Its frequency is growing, the number of surgical operations, including emergency ones due to complications, is increasing, and along with them the number of unsuccessful interventions is growing. Hundreds of thousands of people are dropping out of active life and labor activity, and some lose their ability to work and become disabled.

Cholelithiasis affects the entire duodeno-pancreatobiliary system and therefore requires the performance of complex diagnostic and therapeutic interventions. In the last 20 years, a rapid technical progress has been noted and a new minimally invasive endoscopic direction has been introduced into clinical practice for its treatment. Laparoscopic and transcystic operations have become an alternative to traditional surgical treatment in many institutions. The low trauma of endoscopic surgery has ensured an increase in the efficiency of treatment of cholelithiasis, a reduction in the duration of hospital stay, and the period of vocational and labor rehabilitation. Endoscopic surgery has acquired enormous social significance (Gallinger YuN, 1993; Eralykin A.C., 1996; Onoprienko A.B., 1999; Prudkov M.I., 2000; Yemelyanov S.I., 2004). On various problems of endoscopic surgery of the extrahepatic biliary system, dozens of doctoral dissertations have been defended. However, unresolved and controversial questions of this section of modern surgery remain. 1. Endoscopic surgery is applied only in conditions of surgical hospitals, which significantly limits its great potential capabilities. Moreover, even in large hospitals, labor-intensive endoscopic techniques (ERCP, laparoscopic cholecystectomy, mechanical stone extraction) are not sufficiently widespread, and a significant frequency of conversion during laparoscopic operations is noted. 2. Ambulatory-polyclinic (short-stay hospitals) endoscopic surgery in Russia is practically not developed, the concept of its application has not been formed. Moreover, in many cities and large medical institutions, its performance is prohibited. 3. The principles of rehabilitation of patients after endoscopic operations, the duration of disability of patients, and the features of postoperative management of patients remain controversial and unresolved.

The goal of the work is to develop ways to improve the quality of treatment of cholelithiasis by implementing methods of endoscopic surgery in a short-stay hospital.

Research tasks: 1. To study the history of the development of inpatient-replacing forms of medical care in Russia and the place of endoscopic surgery of cholelithiasis therein.

2. To develop the principles of endoscopic surgery of cholelithiasis in a short-stay hospital.

3. To analyze the direct results of endoscopic surgery of cholelithiasis and to develop ways to increase the efficiency and safety of performing endoscopic operations in a short-stay hospital.

4. To evaluate the economic efficiency and significance of endoscopic surgery of cholelithiasis in a short-stay hospital.

Scientific novelty.

The historical aspects of endoscopic surgery of cholelithiasis have been studied, and the unused in clinical practice wide capabilities of a new direction in surgery — mini-invasive surgery in ambulatory-polyclinic practice have been demonstrated. For the first time, the principles of endoscopic surgery of cholelithiasis in short-stay hospitals based on a city clinical hospital have been developed and applied: ethical, organizational, tactical-technical, and rehabilitative.

Based on a large clinical material, the possibility and high efficiency of the application of modern laparoscopic and endoscopic transcystic methods of diagnosis and treatment of cholelithiasis in a short-stay hospital have been proven.

An algorithm for the treatment of cholelithiasis has been developed.

Practical significance,

Under the new conditions of application, a system for selecting patients for surgery in ambulatory-polyclinic conditions has been formulated, the features of their examination and diagnosis of diseases of the pancreatobiliary system, the principles of increasing the frequency of successful operations, the safe performance of operations, and the management of patients at various stages of treatment, including the period of early rehabilitation.

The created new direction in the treatment of cholelithiasis and the principles of early rehabilitation and restoration of the normal lifestyle and work capacity ensure high economic efficiency of treatment and have great social significance.

Basic provisions brought to the defense;

1. Endoscopic surgery, including transcystic and laparoscopic operations, as a minimally invasive method, can be used for the treatment of cholelithiasis in ambulatory-polyclinic conditions in a short-stay hospital at a city clinical hospital.

2. The necessary conditions for the effective and safe treatment of cholelithiasis in a short-stay hospital are the presence of highly qualified personnel, equipped with modern high-quality equipment, adherence to the diagnostic algorithm, treatment, and rehabilitation of patients.

3. Endoscopic surgery of cholelithiasis in a short-stay hospital is a new form of medical care and has great economic and social significance.

Work testing.

The results of the work are used in the educational and pedagogical process of the departments of surgery and endoscopy of the Kuban State Medical Academy and have been reported at congresses of the Society of Endoscopic Surgeons of Russia in 1999-2004.

Implementation into practice and publications.

The developed principles of endoscopic treatment of cholelithiasis have been introduced into clinical practice and are widely used in the work with a short-stay hospital (SSH) within the structure of the Ambulatory Surgery Center based on City Hospital No. 3.

14 scientific works have been published on the topic of the dissertation.