EA017079B1 - Method for treating pancreatic pseudocyst (variants) - Google Patents

Abstract

The invention relates to medicine, in particular to surgery and can be used for the treatment of pancreatic pseudocyst and is aimed at reducing operation traumatic injuries, decreasing a risk of complications and shortening treatment time. A method is proposed for the treatment of pancreatic pseudocyst by percutaneous transgastric cystogastrostomy with stenting under ultrasound and fibrogasroscopic control. The claimed method can be carried out in two embodiments. Principles of said method can be applied in other cases when it is necessary to create low-traumatic, percutaneous fistula between abdominal body structures.

Description

The invention relates to medicine, namely to surgery and can be used to treat pseudocyst of the pancreas.

Pancreatic pseudocysts are capsule-limited fluid accumulations in the form of cavities located both in the gland itself and in the tissues surrounding it. The disease occurs in different age groups, both in men and women, but in men it is more common.

Small pseudocysts can be asymptomatic. Symptoms of the disease appear when the cyst reaches a large size and causes compression and displacement of neighboring organs. There is a gradual, slowly progressing course of the disease, and more acute, when the cyst reaches a large size in a short time, causes severe functional impairment from other organs and is accompanied by complications.

According to studies by various authors, most pseudocysts of the pancreas need treatment, as they can be accompanied by various complications.

The most common complications of the pseudocyst of the pancreas include hemorrhage, infection, ruptures with the development of peritonitis, external and internal fistulas, the formation of internal fistula, compression of nearby structures with the development of jaundice, thrombosis of nearby vessels, development of subhepatic forms of portal hypertension, impaired evacuation from the stomach, etc. P. and only 10-50% of post-necrotic pseudocysts undergo spontaneous resolution [1, 2].

According to some studies, the number of complications directly correlates with the duration of the pseudocyst and is 20% in patients with early pseudocysts (less than 6 weeks), 46% with pseudocysts existing 7-12 weeks, 75% with periods of more than 13 weeks [3].

Several types of surgical interventions are used to treat pseudocysts: percutaneous aspiration punctures under the control of ultrasound (ultrasound), CT (X-ray computer tomography); external drainage; internal drainage and resection.

Percutaneous aspiration in most cases is ineffective due to the presence of a message of pseudocysts with the pancreatic duct system, which can occur in 40-60% of cases [4]. In most cases, repeated aspiration is required, which increases the risk of infection [5].

External drainage is the simplest method, but according to various sources it has a rather high percentage of pseudocyst relapses (up to 22%), complications (suppuration, bleeding, tears) and often (10 to 40%) leads to the formation of an external pancreatic fistula [6, 7, 8, 9] with its subsequent complications.

For the treatment of pancreatic cysts that are associated with the main pancreatic duct, percutaneous internal transgastric drainage is used [10].

Internal drainage operations are aimed at creating a message (fistula) of the cyst with the gastrointestinal tract. These operations are the main treatment for pancreatic pseudocysts [11].

Internal drainage operations are also indicated for pseudocysts existing for 6 weeks or more with increasing symptoms, as well as in the presence of symptomatic chronic pseudocysts of 6 cm or more in diameter [12, 13].

Pancreatic resections, along with a pseudocyst, are currently rarely performed and have strictly limited indications.

The most popular methods of internal drainage are cystogastrostomy and cystoejunostomy. A meta-analysis of the observation conducted in 1020 patients since 1960 showed a pseudocyst relapse in 4.5% after cystejunostomy and 2.5% after cystogastrostomy [14].

Cystogastrostomy can be performed both by open surgery and less traumatic - endoscopically (transmural drainage), laparoscopically and transdermally transgastrally.

Recently, preference has been given to minimally invasive technologies.

Compared to open operations, these technologies are accompanied by less tissue trauma, are easier for patients to carry, have a greater economic effect and fewer complications [15]. Patients have a shorter hospital stay, early postoperative recovery and a higher level of quality of life. These technologies are the gold standard in most patients with post-necrotic pancreatic pseudocysts.

A known method of treating pancreatic cysts, which is carried out by drainage of cysts under ultrasound and radiological control. In this case, a puncture is performed at a point located on the left at the level of the first lumbar vertebra in the region of the Lesgaft-Grünfeld triangle, and the drainage device is carried out towards the pancreatic cyst 0.52.0 cm outward from the lateral surface of the vertebra [16].

There is also known a method for percutaneous treatment of pancreatic cysts, involving the formation of percutaneous cystogastro- and cystoduodenoanastomosis [17], including determining the location of the formation of anastomosis in an ultrasound study, conducting appropriate preparation and performing ultrasound percutaneous transgastric drainage of the pancreatic pseudocysts.

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Drainage is fixed in the cyst by tightening the threads and folding the distal end according to the type of RF Ιαίΐ. Prolonged traction is performed for 14-18 days under repeated x-ray control to form a cystogastrodrug. Subsequently, the drainage is removed.

However, with this method of treatment, we have identified a number of disadvantages.

1. In most cases, this technique requires a long time (according to our data, from 12 to 23 days).

2. This treatment method is difficult for patients and requires constant prescription of painkillers, patient monitoring, and the quality of life is reduced.

3. The formation of a linear anastomosis occurs rarely, especially in cases of a formed wall, and most often the distal end of the drainage during traction is straightened and removed transgastrally from the cyst. A point defect in the posterior wall of the stomach closes quickly and cysts relapse.

4. There is a large number of purulent complications from the side of the cyst and at the exit of drainage through the anterior abdominal wall, which additionally intensifies the pain syndrome and requires constant dressings and antibiotics.

5. Often disrupted from the stomach.

The prototype of the proposed method in the prior art is not identified.

To eliminate the above drawbacks, we proposed a low-traumatic and highly effective method of drainage of the pseudocyst of the pancreas, which is easily tolerated by patients.

The objective of the present invention is to reduce the morbidity of the operation, reducing the risk of complications and reducing treatment time.

The problem is solved by the claimed method, which will expand the therapeutic options for minimally invasive treatment of pancreatic cysts.

Thus, a method of treating a pancreatic pseudocyst is drainage followed by temporary stenting, in which, under hardware control, visualization is introduced into the cyst cavity through the walls of the stomach using a device for percutaneous drainage of cavity formations, a flexible tube with a detachable part with side of the distal end and provided at the distal end with drainage holes made of radiopaque biocompatible material with shape memory, at the same time, before transdermal insertion, at least two separate at least half-coils are formed on the detachable part of the tube, the number of half-coils, their diameter, the shape of the winding, the distance between them, as well as the direction of the axis around which the half-coils are made, are selected in accordance with spatial localization, shape and number of cysts, the drainage is introduced in a fully straightened state and, after administration, is positioned so that at least one half-thread is in the cavity of the cyst, and at least one half-thread was in the stomach cavity with the formation of an anastomosis between the cyst cavity and the stomach cavity, after which, when the cyst wall and stomach wall fused in the area of the formed anastomosis, the external-internal transgastric drainage was transformed into a temporary internal cystogastrostomy stent by separating the detachable part.

The method is carried out by percutaneous transgastric cystogastrostomy with stenting under ultrasound and fibrogastroscopic control.

The inventive method can be carried out in two ways.

One-stage - in cases of existing fusion of pseudocysts with the posterior wall of the stomach (operation of internal drainage).

In two stages - for the formation of fusion of pseudocysts with the posterior wall of the stomach, followed by transformation of the external-internal, transgastric drainage into the internal cystogastrostomy stent (transfer of the external-internal drainage to the internal).

Access is percutaneous, transgastric in the avascular zone under the supervision of ultrasound ultrasound (Doppler ultrasound).

Each of the methods has 2 methods - retrograde and anterograde.

The method is as follows.

Before surgery, a standard examination is performed to determine pathological changes, clarify the relationship of the pseudocyst with the stomach and select the optimal path of intervention. 30 minutes before the operation, premedication (antibiotic prophylaxis, the introduction of H2 blockers) is carried out.

The patient is fed into the operating room on an empty stomach. Anesthetics are introduced, general anesthesia is not required.

One-stage method of setting the drainage

After processing the surgical field under ultrasound control, percutaneous, trans-gastric (through 2 walls of the stomach) puncture of the pancreas is performed. Partially aspirate the contents. They use the stylet-catheter principle of setting the drainage, which, in our opinion, has advantages over the trocar method.

During the puncture, the drainage is in a straightened state, located on a hard piercing fragment. Drainage exceeds the piercing fragment itself in diameter and “seals” places

- 2 017079 punctures in the stomach upon reduction.

Moreover, the drainage is made of a radiopaque biocompatible material with shape memory, more often has two turns of a spiral or other (double ρίβΐηίΐ) shape.

In a retrograde installation under the control of ultrasound, two turns of drainage are introduced into the lumen of the pseudocyst, the proximal, straightened end of the drainage is above the skin, making it easy to manipulate it. Aspirate the contents dry. Further, under the control of FGDS (fibrogastroscopic), using the proximal end of the drainage, one of the turns is moved into the lumen of the stomach (retrograde installation of the proximal turn in the lumen of the stomach), followed by separation of the proximal end of the drainage in the most favorable (for location in the stomach) location. Thus, one turn is located in the pseudocyst, and the other in the lumen of the stomach. Remove air from the stomach. Perform ultrasound control. Prescribe antiulcer therapy, bed rest, observation for 12 hours.

In an anterograde installation after percutaneous transgastric puncture, the pseudocysts under ultrasound control move only one distal turn of drainage into the lumen of the pseudocyst. Dosed traction is carried out “on oneself”, but so as not to remove the distal turn from the lumen of the pseudocysts, aspirate the contents.

The proximal, formed end of the drainage is located above the skin, its separation is carried out in the selected optimal place, on the piercing fragment. Moreover, the most proximal end of the drainage is used for releasing. The reduction is carried out under FGDS control. In the future, the management of the patient is the same as with the above method.

Under certain conditions (filling the stomach with liquid, air, the use of manipulators under the control of FGDS, etc.), the proximal drainage loop can be installed immediately or formed in the lumen of the stomach, without releasing.

Two-stage method of setting the drainage

The methods for reducing the proximal end of the drainage are the same as for the one-stage (retrograde and anterograde installation of the proximal end of the drainage into the lumen of the stomach).

But the method itself is divided into two stages:

stage. Under ultrasound control, percutaneous, trans-gastric (through 2 walls of the stomach) puncture of the pancreatic pseudocysts is performed and two turns are moved at once, or in the case of anterograde reduction of the pseudocysts into the lumen, the proximal, straightened end of the drainage is located above the skin, making it easy to manipulate and carry out a dosed traction on itself, to form a fusion.

This usually takes 2-3 days. At the same time control the amount and nature of the discharge. Antibiotics, analgesia, antiulcer therapy are prescribed prophylactically.

stage. The installation of the proximal end of the drainage into the lumen of the stomach under FGDS control is carried out in the same way as with the above-described one-stage method of setting the drainage. There is a transformation of the external-internal, transgastric drainage into the internal cystogastrostomy stent (transfer of the external-internal drainage to the internal).

The principles of this method can be applied in other cases when it is necessary less traumatic, transdermally to create an anastomosis between the cavity structures of the body.

Case Studies

Example 1. Patient L. born in 1962 Case history No. 1916. He entered the Department of Hepatology and Minimally Invasive Surgery, 9th Clinical Hospital on May 13, 2008. On admission he complained of abdominal pain, nausea, malaise, and weight loss.

From the anamnesis of the disease: the first attack of acute pancreatitis was in 2003, was hospitalized in 9-GB for 3 weeks. The pancreatic cyst (6 cm) and chronic calcifying pancreatitis were first detected in 2004. The cyst continued to increase slowly. I was on an outpatient basis and about 10 times in hospital treatment in various medical institutions (BSMP, 9-GKB, 5-GKB). Repeatedly performed aspiration sanitation of the cyst, however, the cyst continued to accumulate contents and increased in size. In 2007, percutaneous transgastric cystogastrostomy was performed according to the method of Ivshin V.G., however, after 2 months the formed anastomosis closed, and the cyst formed again, began to increase in size. Constant pain appeared, lost 7 kg. Repeated aspiration sanitation without effect. Content - pancreatic juice with a high content of amylase (more than 12,000 units), cytologically - without features. The volume of the cyst is about 1 liter.

The patient's condition at the time of receipt of moderate severity. Low power. Growth 168. Weight 55 kg. On palpation in the epigastrium, a round, soft-elastic, non-displaceable painful formation is determined about 12 cm in diameter. Ultrasound, CT scan (X-ray computed tomography) were performed, in which chronic calcifying pancreatitis and a large pseudocyst of the pancreatic tail 123x89 mm with formed walls were detected, compressing the stomach and large vessels. When FGDS revealed compression of the posterior wall of the stomach, the site of the anastomosis is not determined. Performed aspiration sanitation of pseudocysts under ultrasonic testing, dry. Removed 950 ml of clear, transparent

- 3 017079 contents (pancreatic juice with a high content of amylase (more than 15,000 units), cytologically without atypia.

The next day (after a puncture) with a control ultrasound, the cyst regained its volume again. Diagnosed with:

chronic calcifying pancreatitis. Pancreatic pseudocyst (body-tail) type 2 (E'Escby). An internal drainage operation is indicated.

05/14/08. Percutaneous transgastric cystogastrostomy of the pancreatic cyst under ultrasound. The proximal coil is set anterograde.

Postoperative course without features. At control ultrasound (05.16.08) - chronic calcifying pancreatitis. The cyst cavity slept, it determines the turn of the stent, passing into the stomach.

Control of FGDS (05.16.08). In the lower third of the stomach, from the back wall into the cavity comes a turn of the stent, through which the pancreatic contents enter.

Analyzes are within normal limits. The pain syndrome has disappeared. There are no complaints.

In satisfactory condition, was discharged under outpatient supervision at the place of residence. Control inspection 10/16/08. There are no complaints. Gained weight +6 kg.

Ultrasound (10/16/08). The pancreas is not enlarged, with calcifications, the cyst cavity is not determined, in its place is a stent passing through the back wall into the stomach.

RCT OBP (10.16.08). Calcifying pancreatitis. Pronounced positive dynamics. The stent stands still. Cysts are currently not detected.

In the control FGDS (10.16.08), a spiral-shaped stent is located in the lower third of the body of the stomach but on the posterior wall. The stent was removed - there were no complications.

Follow-up inspection in May 2009. No complaints. Gained weight +8 kg. With ultrasound, CT of the cyst is not determined. Pancreas without negative dynamics.

Follow-up inspection in September 2009. No complaints. Gained weight +9 kg.

With ultrasound, RSC of the cyst is not determined. Pancreas without negative dynamics.

Example 2. Patient D. 40 years. Case history No. 3636. He entered the Department of Hepatology and Minimally Invasive Surgery, 9th Clinical Hospital on 02/06/2009. Upon admission he complained of abdominal pain, worse after eating, malaise, weight loss.

Anamnesis of the disease: the first attack of acute pancreatitis was in 2005, was hospitalized in the 4th hospital for about 1 week, then outpatient treatment. The cyst of the pancreatic head was first detected in 2005 (November) 4x5.0 cm when he was hospitalized with another attack of acute pancreatitis for 2 weeks. In 2006 (August) he was in BSMP with another exacerbation of pancreatitis. A cyst of the same size. In 2008 (September) he was on an outpatient treatment with another exacerbation of pancreatitis. Cyst 4.7x5.9.

In 2009, he independently applied to the MGDC. Cyst about 6.0 cm.

In 2009 (January 15 - 29, 2009) he was hospitalized in organized crime groups. The cyst was aspirated three times under an ultrasound scan dry (22, 24 and 26.01.09), but the cyst quickly regains volume. A pseudocyst located in the head of the pancreas compresses the portal vein and the inferior vena cava with signs of biliary and virsungial hypertension.

The contents of the cyst are high in amylase, cytologically - without atypia.

Permanent pain syndrome, especially intensifying after eating since 2006, in 2009 increased significantly. The quality of life suffers - as it cannot eat (pain intensifies significantly). Weight loss of 12 kg.

He was treated at the Department of Hepatology and Minimally Invasive Surgery, 9th Clinical Hospital from 02/06/09 to 03/06/09.

Diagnosis: chronic calcifying pancreatitis. Pancreatic pseudocyst of type 2 head (ΌΈ ^ ίάίο). Compression of the inferior vena cava, portal vein. Biliary and virsungial hypertension. Pain syndrome.

Ultrasound OBP (02/09/09). Pseudocyst in the head of the pancreas, compresses the portal and inferior vena cava with a dense capsule (Y = 73 ml ³ ). Wirsung duct expanded to 4 mm.

RCT OBP (11.02.09). Pseudocyst of the pancreas (60x48 mm) with compression of the inferior vena cava, and portal portal vein. Signs of biliary and virsungial hypertension. Conservative treatment without effect.

02/23/09. Operation: percutaneous transgastric drainage of the pancreatic cyst.

Postoperative course without features. The pain syndrome stopped.

According to drainage, there was a daily release of pancreatic juice of about 80 ml with a high amylase content (53256 units / l, with a dilution of 1: 100. Ν = up to 380).

Ultrasound (02.20.09). ПЖ-35-14-15 mm. The cyst cavity is drained, does not contain fluid.

FGDS counter. (02/26/09). In the antrum is a drainage tube.

Conclusion: the condition after drainage of the pancreatic cyst through two walls of the stomach

- 4 017079 ka.

Due to the fact that the amount of discharge did not decrease, indications were given for percutaneous, transgastric cystogastrostomy and stenting surgery.

03/04/09. Operation (stage 2): under FGDS control, the proximal turn of the formed stent was reduced to the lumen of the stomach (anterograde method of establishing the proximal turn of the stent).

Postoperative course without features. The wound on the anterior abdominal wall has healed. Control ultrasound 03.03.09. Cysts in the pancreatic head are not detected, the stent stands still. FGDS control - in the lower third of the stomach, from the back wall into the cavity comes a turn of the stent. Analyzes are within normal limits. The pain syndrome has completely disappeared. There are no complaints.

In satisfactory condition, was discharged for outpatient monitoring at the place of residence.

Control hospitalization from 09/29/09 to 10/08/09. Case history No. 27086. I gained + 20 kg in weight, pains do not bother me, I feel good.

10/6. The stent was removed endoscopically.

During the control ultrasound: the pancreas is not enlarged, there are no cysts, the pancreatic duct is 2.5 mm. No data were found for virsungial or biliary hypertension.

According to the analyzes compensated. It is discharged without complaints, in satisfactory condition.

Assigned control of ultrasound after 6 months.

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Claims (4)

CLAIM 1. A method of treating a pseudocyst of the pancreas by drainage followed by temporary stenting, in which, under hardware control with visualization, a drainage is introduced into the cyst cavity through the walls of the stomach using a device for percutaneous drainage of cavity formations, a flexible tube with a detachable part from the distal side is used as drainage end and provided at the distal end with drainage holes made of a radiopaque biocompatible material with shape memory, while up to percutaneously of the introduction on the detachable part of the tube form at least two separate at least half-turn, and - 5 017079 the number of half-coils, their diameter, the shape of the winding, the distance between them, as well as the direction of the axis around which the half-coils are made, are selected in accordance with spatial localization, the shape and number of cysts, the drainage is introduced in a fully straightened state and, after administration, is positioned in this way so that at least one half-thread is in the cavity of the cyst and at least one half-thread is in the cavity of the stomach with the formation of an anastomosis between the cavity of the cyst and the cavity of the stomach, after which, when the cyst wall is fused and the walls of the stomach in the zone of the formed anastomosis, the external-internal transgastric drainage is transformed into a temporary internal cystogastrostomy stent by separating the detachable part. 2. A method of treating a pancreatic pseudocyst by drainage followed by temporary stenting, in which, under hardware control with visualization, a drainage is introduced into the cyst cavity through the stomach walls using a device for percutaneous drainage of cavity formations, a flexible tube with a detachable part from the distal side is used as drainage end and provided at the distal end with drainage holes made of a radiopaque biocompatible material with shape memory, while up to percutaneously at least two separate at least half-coils are formed on the detachable part of the tube, the number of half-coils, their diameter, the shape of the winding, the distance between them, as well as the direction of the axis around which the half-coils are made, are selected in accordance with spatial localization, by the shape and number of cysts, the drainage is introduced in a fully straightened state and, after administration, is positioned so that at least one half-thread is in the cavity of the cyst and at least one half-thread is in the cavity ludka to form a fistula between the cavity and the cavity of the stomach cyst, then drainage is carried out to form traction seam between the cyst wall and stomach wall in the area formed by the anastomosis, after which the outer-inner drainage transgastralny transformed into internal stent tsistogastrostomichesky by separating the separable portion. 3. The method according to claim 1 or 2, characterized in that when the drainage is introduced, initially all half-threads of the drain are placed in the cyst cavity, a portion of the detachable part of the drain is left over the skin, then part of the half-turns are moved from the cyst cavity to the stomach cavity by moving the drain, leaving them in the cavity cysts at least one half-turn and separate the detachable part of the drainage with the placement of the separated end in the stomach cavity. 4. The method according to claim 1 or 2, characterized in that when the drainage is introduced, at least at least one half-turn of drainage is placed in the cyst cavity, a section of the detachable part of the drainage, including a section for forming half-turns for placement in the stomach cavity, is left over the skin, then dosed traction is carried out, the detachable part of the drainage is separated and the separated end is lowered into the stomach cavity with the formation of at least one half-turn in the stomach cavity. 4 ^^ Eurasian Patent Organization, EAPO Russia, 109012, Moscow, Maly Cherkassky per., 2