MD1404Z - Method for decompression of lymphatic thoracic duct - Google Patents
Method for decompression of lymphatic thoracic duct Download PDFInfo
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- MD1404Z MD1404Z MDS20190093A MDS20190093A MD1404Z MD 1404 Z MD1404 Z MD 1404Z MD S20190093 A MDS20190093 A MD S20190093A MD S20190093 A MDS20190093 A MD S20190093A MD 1404 Z MD1404 Z MD 1404Z
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- 230000001926 lymphatic effect Effects 0.000 title claims abstract description 50
- 238000000034 method Methods 0.000 title claims description 15
- 230000006837 decompression Effects 0.000 title claims description 8
- 210000002978 thoracic duct Anatomy 0.000 title abstract description 4
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- NNJVILVZKWQKPM-UHFFFAOYSA-N Lidocaine Chemical compound CCN(CC)CC(=O)NC1=C(C)C=CC=C1C NNJVILVZKWQKPM-UHFFFAOYSA-N 0.000 claims abstract description 4
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Abstract
Description
Invenţia se referă la medicină, în special la hepatologia chirurgicală şi poate fi utilizată în corecţia chirurgicală a sindromului ascitic la pacienţii cu ciroză hepatică decompensată. The invention relates to medicine, in particular to surgical hepatology and can be used in the surgical correction of ascites syndrome in patients with decompensated liver cirrhosis.
Este cunoscut faptul că cauza principală a evoluţiei ascitei la bolnavii cu ciroză hepatică este hiperlimfogeneza hepatică, ca urmare a hipertensiunii portale şi blocajul circulaţiei limfatice aferente prin ductul toracic limfatic (DTL). In urma măririi presiunii intraductale are loc transudarea transparietală a limfei, sedimentarea proteinelor plasmatice în ţesuturile adiacente cu inflamare productivă şi formarea bridelor, care deformează şi comprimă DTL. Insuficienţa aparatului valvular al DTL, care apare în acest caz, agravează blocajul circulaţiei limfatice magistrale aferente, ceea ce duce la progresarea ascitei şi evoluţiei în stadiul refractar (terminal), cand administrarea preparatelor diuretice devine neefectivă. It is known that the main cause of the development of ascites in patients with liver cirrhosis is hepatic hyperlymphogenesis, as a result of portal hypertension and blockage of the afferent lymphatic circulation through the thoracic lymphatic duct (TLD). As a result of the increase in intraductal pressure, transparietal transudation of lymph occurs, sedimentation of plasma proteins in adjacent tissues with productive inflammation and the formation of clamps, which deform and compress the TLD. The insufficiency of the valvular apparatus of the TLD, which occurs in this case, aggravates the blockage of the afferent main lymphatic circulation, which leads to the progression of ascites and evolution to the refractory (terminal) stage, when the administration of diuretic drugs becomes ineffective.
Este cunoscută metoda de decompresie al ductului toracic limfatic, care include efectuarea operaţiei de drenaj exterior al DTL, care se aplică pentru corecţia chirurgicală al sindromului ascitic în ciroza hepatică ca metodă extracorporală de dezintoxicare în ciroza hepatică cu complicaţii de insuficienţă hepatică. Operaţia constă în introducerea în lumenul ductului a unui cateter de drenaj prin incizia peretelui vasului şi aplicarea suturii parietale de fixare. In acest caz se mobilizează doar un sector limitat al poţiunii cervicale a DTL, suficient pentru aplicarea drenajului. Limfa evacuată se supune filtrării prin limfosorbţie şi reinfuziei intravenoase [1]. The method of decompression of the thoracic lymphatic duct is known, which includes performing the operation of external drainage of the DTL, which is applied for surgical correction of ascites syndrome in liver cirrhosis as an extracorporeal method of detoxification in liver cirrhosis with complications of liver failure. The operation consists in introducing a drainage catheter into the lumen of the duct through an incision in the vessel wall and applying a parietal suture for fixation. In this case, only a limited sector of the cervical portion of the DTL is mobilized, sufficient for the application of drainage. The evacuated lymph is subjected to filtration by lymphosorption and intravenous reinfusion [1].
Dezavantajul metodei constă în efectul temporar asupra sindromului ascitic, deoarece procedura se desfăşoară o perioadă limitată de timp. Mai mult decât atât, ca rezultat al deformării DTL, dereglările circulaţiei limfatice aferente se pot chiar agrava şi după înlăturarea cateterului de drenaj, ascita se acumulează din nou. The disadvantage of the method is the temporary effect on ascites syndrome, since the procedure is performed for a limited period of time. Moreover, as a result of the deformation of the DTL, the associated lymphatic circulation disorders may even worsen and after the removal of the drainage catheter, ascites accumulates again.
Este cunoscută de asemenea, metoda de decompresie a ductului toracic limfatic prin efectuarea anastomozei limfo-venoase, care constă în exteriorizarea şi mobilizarea venei jugulare interne, separarea ductului toracic limfatic în regiunea unghiului venos stâng, mobilizarea porţiunii cervicale a DTL suficientă pentru aplicarea anastomozei (în regiunea proximală sau distală a porţiunii cervicale a DTL) şi formarea unei anastomoze între porţiunea cervicală a DTL şi vena jugulară internă pentru înlăturarea hipertensiunii limfatice în duct şi ameliorarea circulaţiei limfatice aferente [2]. The method of decompression of the thoracic lymphatic duct by performing lympho-venous anastomosis is also known, which consists of externalizing and mobilizing the internal jugular vein, separating the thoracic lymphatic duct in the region of the left venous angle, mobilizing the cervical portion of the TLD sufficient for applying the anastomosis (in the proximal or distal region of the cervical portion of the TLD) and forming an anastomosis between the cervical portion of the TLD and the internal jugular vein to remove lymphatic hypertension in the duct and improve the afferent lymphatic circulation [2].
Dezavantajul metodei constă în aceea că efectul de drenaj este limitat şi local, metoda fiind eficientă doar în cazurile blocajului segmentar al circulaţiei limfatice aferente, pe când blocajul circulaţiei limfatice aferente are un caracter difuz, înglobând toată porţiunea cervicală a DTL. În plus, operaţia poate cauza o deformare mai mare a ductului toracic şi ca rezultat al acesteia anastomozele deseori se trombează, fapt ce explică nereuşitele frecvente şi aplicarea destul de rară a lor chiar şi în clinicile hepatologice specializate. The disadvantage of the method is that the drainage effect is limited and local, the method being effective only in cases of segmental blockage of the afferent lymphatic circulation, while the blockage of the afferent lymphatic circulation has a diffuse character, encompassing the entire cervical portion of the DTL. In addition, the operation can cause a greater deformation of the thoracic duct and as a result the anastomoses often thromboze, which explains the frequent failures and their rather rare application even in specialized hepatology clinics.
Este cunoscută metoda de decompresie a ductului toracic limfatic, care constă în exteriorizarea şi mobilizarea venei jugulare interne, separarea ductului toracic limfatic în regiunea unghiului venos stâng, mobilizarea porţiunii cervicale a ductului toracic limfatic, efectuându-se mobilizarea ductului pe parcursul întregii porţiuni cervicale cu secţionarea tuturor ramurilor limfatice aferente din această porţiune. Mobilizarea largă a ductului toracic limfatic pe tot arcul segmentului cervical, de la locul de ieşire din mediastinul posterior până la confluenţa cu unghiul venos stâng şi secţionarea ramurilor limfatice aferente conduc la eliberarea colectorului principal al DTL de bride, diverse deformaţiuni, care provoacă insuficienţa aparatului valvular şi la denervarea (desimpatizarea) porţiunii cervicale a DTL, ce duce la dilatarea compensatorie al vasului, păstrând tonusul peretelui vascular. In plus, pe masura executării intervenţiei se formează un spaţiu liber în jurul unghiului venos stâng si, sub acţiunea forţelor hidrodinamice intraductale, ductul toracic eliberat ia o formă curbă optimă. Prin aceasta se creează condiţii pentru circulaţia limfatică firească prin DTL, pentru deblocajul circulaţiei limfatice aferente. Astfel, prin decompresia DTL se inlatură limfostaza hepatică şi intraabdominală ca una din principalele cauze de formare a ascitei în ciroza hepatică, ceea ce duce la regresul treptat al sindromului ascitic. Asadar, rezultatul tehnic al invenţiei constă în mărirea lumenului porţiunii cervicale a ductului toracic limfatic şi în restabilirea tonusului vascular [3]. The method of decompression of the thoracic lymphatic duct is known, which consists in externalization and mobilization of the internal jugular vein, separation of the thoracic lymphatic duct in the region of the left venous angle, mobilization of the cervical portion of the thoracic lymphatic duct, mobilization of the duct along the entire cervical portion with sectioning of all afferent lymphatic branches in this portion. Wide mobilization of the thoracic lymphatic duct along the entire arc of the cervical segment, from the place of exit from the posterior mediastinum to the confluence with the left venous angle and sectioning of the afferent lymphatic branches lead to the release of the main collector of the DTL from clamps, various deformations, which cause insufficiency of the valvular apparatus and to denervation (desympathization) of the cervical portion of the DTL, which leads to compensatory dilation of the vessel, preserving the tone of the vascular wall. In addition, as the intervention is performed, a free space is formed around the left venous angle and, under the action of intraductal hydrodynamic forces, the freed thoracic duct takes on an optimal curved shape. This creates conditions for natural lymphatic circulation through the DTL, for unblocking the afferent lymphatic circulation. Thus, by decompression of the DTL, hepatic and intra-abdominal lymphostasis is eliminated as one of the main causes of ascites formation in liver cirrhosis, which leads to the gradual regression of the ascites syndrome. Therefore, the technical result of the invention consists in increasing the lumen of the cervical portion of the thoracic lymphatic duct and in restoring vascular tone [3].
Dezavantajele metodei menţionate constau în aceea că după mobilizarea extinsă a DTL cu secţionarea ramurilor limfatice aferente ductul limfatic devine instabil în spaţiul creat şi apare riscul torsionării cu blocajul secundar al circulaţiei limfatice, ce poate provoca agravarea sindromului ascitic. The disadvantages of the mentioned method are that after extensive mobilization of the DTL with sectioning of the related lymphatic branches, the lymphatic duct becomes unstable in the created space and there is a risk of torsion with secondary blockage of lymphatic circulation, which can cause aggravation of the ascites syndrome.
Problema pe care o rezolvă invenţia constă în înlăturarea blocajului limfocirculator în porţiunea cervicală a ductului toracic limfatic, totodată constă în stabilizarea traiectului arcului cervical al DTL cu scop de profilaxie a torsiunii lui. The problem that the invention solves consists in removing the lymphocirculatory blockage in the cervical portion of the thoracic lymphatic duct, and also consists in stabilizing the trajectory of the cervical arch of the DTL with the aim of preventing its torsion.
Esenţa invenţiei constă în aceea că sub anestezie locală cu sol. Lidocaină de 1% se efectuează o incizie de 4…5 cm paralelă claviculei stângi, se secţionează pe straturi ţesuturile moi şi fasciile cervicale între picioruşele muşchiului sterno-cleido-mastoidean, se mobilizează vena jugulară internă cu unghiul venos stâng, se determină localizarea trunchiului principal al ductului toracic limfatic şi confluenţa limfo-venoasă, apoi se mobilizează extins ductul limfatic pe tot traiectul segmentului cervical de la confluenţă până la mediastinul posterior prin excizia bridelor şi a pachetului de ganglioni limfatici prescaleni, se mobilizează ramurile limfatice eferente, care se ligaturează, apoi după restabilirea limfocirculaţiei prin ductul toracic limfatic, cu aceleaşi ligaturi se fixează de fasciile cervicale adiacente cu suspendarea ductului în spaţiul creat în poziţie stabilă optimal funcţională, se efectuează hemo- şi limfostaza necesară, se suturează straturile amplasate deasupra muşchiului sterno-cleido-mastoidian ale plăgii postoperatorii şi se aplică un pansament aseptic. The essence of the invention lies in the fact that under local anesthesia with sol. 1% lidocaine, a 4…5 cm incision is made parallel to the left clavicle, the soft tissues and cervical fascia are sectioned in layers between the pedicles of the sternocleidomastoid muscle, the internal jugular vein is mobilized with the left venous angle, the location of the main trunk of the thoracic lymphatic duct and the lymph-venous confluence is determined, then the lymphatic duct is mobilized extensively along the entire path of the cervical segment from the confluence to the posterior mediastinum by excising the clamps and the bundle of prescalene lymph nodes, the efferent lymphatic branches are mobilized, which are ligated, then after restoring lymph circulation through the thoracic lymphatic duct, with the same ligatures it is fixed to the adjacent cervical fascia with the suspension of the duct in the created space in an optimally stable functional position, the necessary hemo- and lymphostasis is performed, the layers located above the sternocleidomastoid muscle are sutured of the postoperative wound and an aseptic dressing is applied.
Rezultatul invenţiei constă în mobilizarea eficientă şi stabilizarea traiectului arcului cervical al DTL cu scop de profilaxie a torsiunii lui pentru restabilirea funcţiei de drenare a DTL şi reactivarea limfocirculaţiei centrale. Astfel, prin decompresia DTL se înlătură limfostaza hepatică şi intraabdominală ca una din principalele cauze de formare a ascitei în ciroza hepatică, ceea ce duce la regresul treptat al sindromului ascitic. The result of the invention consists in the effective mobilization and stabilization of the trajectory of the cervical arch of the DTL with the aim of prophylaxis of its torsion for the restoration of the drainage function of the DTL and the reactivation of the central lymphocirculation. Thus, by decompression of the DTL, hepatic and intra-abdominal lymphostasis is removed as one of the main causes of ascites formation in liver cirrhosis, which leads to the gradual regression of the ascites syndrome.
Metoda se realizează în modul următor. The method is carried out in the following way.
Sub anestezie locală cu sol. Lidocaină de 1% se efectuează o incizie de 4…5 cm paralelă claviculei stângi, se secţionează pe straturi ţesuturile moi şi fasciile cervicale între picioruşele muşchiului sterno-cleido-mastoidean, se mobilizează vena jugulară internă cu unghiul venos stâng, se determină localizarea trunchiului principal al ductului toracic limfatic şi confluenţa limfo-venoasă, apoi se mobilizează extins ductul limfatic pe tot traiectul segmentului cervical de la confluenţă până la mediastinul posterior prin excizia bridelor şi a pachetului de ganglioni limfatici prescaleni, se mobilizează ramurile limfatice eferente, care se ligaturează, apoi după restabilirea limfocirculaţiei prin ductul toracic limfatic, cu aceleaşi ligaturi se fixează de fasciile cervicale adiacente cu suspendarea ductului în spaţiul creat în poziţie stabilă optimal funcţională, se efectuează hemo- şi limfostaza necesară, se suturează straturile amplasate deasupra muşchiului sterno-cleido-mastoidian ale plăgii postoperatorii şi se aplică un pansament aseptic. Under local anesthesia with sol. 1% lidocaine, a 4…5 cm incision is made parallel to the left clavicle, the soft tissues and cervical fascia are sectioned in layers between the pedicles of the sternocleidomastoid muscle, the internal jugular vein is mobilized with the left venous angle, the location of the main trunk of the thoracic lymphatic duct and the lymph-venous confluence is determined, then the lymphatic duct is mobilized extensively along the entire path of the cervical segment from the confluence to the posterior mediastinum by excising the clamps and the bundle of prescalene lymph nodes, the efferent lymphatic branches are mobilized, which are ligated, then after restoring lymph circulation through the thoracic lymphatic duct, with the same ligatures it is fixed to the adjacent cervical fascia with the suspension of the duct in the created space in an optimally stable functional position, the necessary hemo- and lymphostasis is performed, the layers located above the sternocleidomastoid muscle are sutured of the postoperative wound and an aseptic dressing is applied.
Exemplul 1 Example 1
Pacienta M., 59 ani, internată cu diagnosticul clinic: Ciroză hepatică HCV decompensată Child "C"(10). Hipertensiune portală. Ascită refractară. Suferă de ciroză hepatică timp de 5 ani. Antecedent pe parcursul unui an a suportat 2 episoade de hemoragii variceale, stopate endoscopic prin ligaturare şi plombare cu adeziv fibrinic. Ascita a evoluat după a doua hemoragie variceală cu 3 luni în urmă şi nu cedează terapiei diuretice, progresează în dinamică. Diureza fortaţă maximal cu 400 mg de veroşpiron şi 160 mg de furosemid nu depăşeşte 600...800 ml. In scopul înlăturării blocajului limfocirculaţiei aferente s-a aplicat metoda revendicată. Intraoperator s-a stabilit îngustarea şi deformarea segmentului cervical al DTL cu blocaj limfocirculator. După o mobilizare extinsă pe tot parcursul porţiunii cervicale diametrul DTL s-a mărit de la 0,3 până la 0,8 mm, arcul ductului s-a reexpansionat şi funcţia de drenare limfatică centrală s-a restabilit. Perioada postoperatorie a decurs fără complicaţii. Diureza s-a mărit până la 1500 ml. Administrarea dozelor moderate de preparate diuretice (furosemid 40 mg + veroşpiron 100 mg) a condiţionat un efect diuretic adecvat - până la 2500 ml. Masa corporală peste 11 zile după operaţie s-a redus cu 7 kg datorită diminuării considerabile a ascitei. Externată în stare satisfăcătoare. La examenul de control peste 2 luni ascita clinic nu se determină, diuretice se folosesc în doze minimale (veroşpiron 50...100 mg/zi), probele hepatice în limitele normei. Patient M., 59 years old, hospitalized with the clinical diagnosis: Decompensated HCV liver cirrhosis Child "C" (10). Portal hypertension. Refractory ascites. Suffers from liver cirrhosis for 5 years. Previously, during one year, she suffered 2 episodes of variceal hemorrhages, stopped endoscopically by ligation and sealing with fibrin glue. Ascites developed after the second variceal hemorrhage 3 months ago and does not respond to diuretic therapy, progresses in dynamics. Maximum forced diuresis with 400 mg of verospiron and 160 mg of furosemide does not exceed 600...800 ml. In order to remove the blockage of the afferent lymphocirculation, the claimed method was applied. Intraoperatively, narrowing and deformation of the cervical segment of the DTL with lymphocirculatory blockage was established. After extensive mobilization throughout the cervical portion, the diameter of the DTL increased from 0.3 to 0.8 mm, the arch of the duct re-expanded and the central lymphatic drainage function was restored. The postoperative period was uneventful. Diuresis increased to 1500 ml. Administration of moderate doses of diuretics (furosemide 40 mg + verospiron 100 mg) provided an adequate diuretic effect - up to 2500 ml. Body weight over 11 days after the operation decreased by 7 kg due to a significant decrease in ascites. Discharged in satisfactory condition. At the control examination over 2 months, clinical ascites was not determined, diuretics were used in minimal doses (verospiron 50...100 mg/day), liver tests were within normal limits.
Exemplul 2 Example 2
Pacientul C., 40 ani, internat cu diagnosticul clinic: Ciroză hepatică HBV+D decompensată Child "C"(11). Hipertensiune portală. Ascită refractară. Suferă de ciroză hepatică timp de 7 ani. Antecedent a suportat splenectomie şi un episod de hemoragie variceală profuză, stopată conservativ cu sonda Blakemore. Ascita a evoluat pe parcursul ultimilor 2 ani, nu cedează terapiei diuretice, progresează în dinamică. A suportat multiple laparocenteze cu evacuarea de la 5 până la 12 L de lichid ascitic. Edeme periferice marcate. Diureza forţată maximal la 400 mg de veroşpiron şi 160 mg de furosemid nu depaşeşte 750 ml. In scopul înlăturării blocajului limfocirculaţiei aferente s-a aplicat metoda revendicată. Intraoperator s-a stabilit compresia şi deformarea segmentului cervical al DTL cu blocaj limfocirculator. După o mobilizare extinsă pe tot parcursul porţiunii cervicale diametrul DTL s-a mărit de la 0,2 până la 0,7 mm, arcul ductului s-a reexpansionat şi funcţia de drenare limfatică centrală s-a restabilit. Perioada postoperatorie a decurs fără complicaţii. Diureza s-a mărit până la 1200 ml. Administrarea dozelor moderate de preparate diuretice (furosemid 40 mg şi veroşpiron 200 mg) a condiţionat un efect diuretic adecvat - până la 2000 ml. Masa corporală peste 8 zile după operaţie s-a redus cu 6,5 kg datorită diminuării ascitei. Externat în stare satisfacătoare. La examenul de control peste 3 luni s-a determinat ascită minimală, diureticele se folosesc în dozaj optimal (veroşpiron 100 mg/zi şi furosemid 40 mg de 3 ori/săptămână), probele hepatice în limitele normei. Patient C., 40 years old, hospitalized with the clinical diagnosis: Decompensated HBV+D liver cirrhosis Child "C" (11). Portal hypertension. Refractory ascites. Suffers from liver cirrhosis for 7 years. Previously, he underwent splenectomy and an episode of profuse variceal hemorrhage, stopped conservatively with the Blakemore probe. Ascites has evolved over the last 2 years, does not respond to diuretic therapy, progresses in dynamics. He underwent multiple laparocentesis with evacuation from 5 to 12 L of ascitic fluid. Marked peripheral edema. Maximum forced diuresis at 400 mg of verospiron and 160 mg of furosemide does not exceed 750 ml. In order to remove the blockage of the afferent lymph circulation, the claimed method was applied. Intraoperatively, compression and deformation of the cervical segment of the DTL with lymph circulation blockage were established. After extensive mobilization throughout the cervical portion, the diameter of the DTL increased from 0.2 to 0.7 mm, the arch of the duct re-expanded and the central lymphatic drainage function was restored. The postoperative period was uneventful. Diuresis increased to 1200 ml. Administration of moderate doses of diuretics (furosemide 40 mg and verospiron 200 mg) provided an adequate diuretic effect - up to 2000 ml. Body weight over 8 days after the operation decreased by 6.5 kg due to the decrease in ascites. Discharged in satisfactory condition. At the control examination over 3 months, minimal ascites was determined, diuretics are used in optimal dosage (verospiron 100 mg/day and furosemide 40 mg 3 times/week), liver tests within normal limits.
Metoda elaborată de decompresie a ductului toracic limfatic permite stabilizarea traiectului ductului toracic limfatic cu înlăturarea blocajului limfocirculator în porţiunea cervicală a ductului toracic limfatic şi restabilirea funcţiei de drenare limfatică pentru ameliorarea rezultatelor tratamentului ascitei refractare la pacienţii cu ciroză hepatică decompensată. The developed method of thoracic lymphatic duct decompression allows stabilizing the thoracic lymphatic duct trajectory by removing the lymphocirculatory blockage in the cervical portion of the thoracic lymphatic duct and restoring lymphatic drainage function to improve the results of refractory ascites treatment in patients with decompensated liver cirrhosis.
1. Пациора М. Д., Хирургия портальной гипертензии, Медицина, Ташкент, 1984, с. 182-184 1. Paciora M. D., Hirurgiya portalnoj hypertensii, Medicine, Tashkent, 1984, p. 182-184
2. Пациора М. Д., Цацаниди К.Н., Лебезев В.М. Лимфовенозный анастомоз при асците у больных с портальной гипертензией, Хирургия, Москва, 1985, № 8, с. 80-83 2. Paciora M. D., Tsatsanidi K.N., Lebezev V.M. Lymphovenous anastomosis in ascites in patients with portal hypertension, Hirurgiya, Moscow, 1985, № 8, p. 80-83
3. MD 1093 F1 1998.11.30 3. MD 1093 F1 1998.11.30
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