MD880Z

MD880Z - Method for mini-invasive treatment of massive hepatic metastases

Info

Publication number: MD880Z
Application number: MDS20140074A
Authority: MD
Inventors: Георге АНГЕЛИЧ
Original assignee: Георге АНГЕЛИЧ
Priority date: 2014-05-21
Filing date: 2014-05-21
Publication date: 2015-09-30
Also published as: MD880Y

Abstract

The invention relates to medicine, particularly to hepatology and oncology, and can be used for mini-invasive treatment of massive hepatic metastases in patients with liver cirrhosis.According to the invention, the claimed method consists in that through the laparoscopic access in the infraumbilical region under video optics control is introduced an additional trocar in the subhepatic region, is removed the ascitic fluid from the abdominal cavity, is identified the hepatic tumor focus and is performed the biopsy sampling from the tumor, then using a bipolar electrode, which is introduced through the trocar port, is performed the bipolar diathermocoagulation with the frequency of 300 kHz and the power of 100…250 W of the tumor central surface with the slow movement of the electrode in its depths with the continued thermodestruction of tumor tissue without damaging the adjacent hepatic tissue, for 3…7 minutes in pulsating regimen, at the same time on the periphery of the intact hepatic tissue is infiltrated 15…30 ml of a mixture comprising per 1 ml:then in the same points is infiltrated fibrinogen sol. 15…30 mg, afterwards in the subhepatic space is introduced a checking drain for 2…5 days and is performed the peritoneal lavage with a mixture containing broad spectrum antibiotics and proteolytic enzymes.

Description

Invenţia se referă la medicină, în special la hepatologie şi oncologie, şi poate fi utilizată pentru tratamentul miniinvaziv al metastazelor masive hepatice la pacienţii cu ciroză hepatică. The invention relates to medicine, in particular to hepatology and oncology, and can be used for the minimally invasive treatment of massive liver metastases in patients with liver cirrhosis.

Este cunoscută metoda de tratament al cancerului hepatic nerezectabil şi metastatic, care include aplicarea unimomentană a termodistrucţiei cu unde de frecvenţă ultraînaltă de 120 kHz cu intensitatea de 100 W şi puterea curentului de 1 A prin intermediul unor sonde-electrozi. Timpul de acţiune fiind de 2…3 min [1]. The method of treatment of unresectable and metastatic liver cancer is known, which includes the simultaneous application of thermodestruction with ultrahigh frequency waves of 120 kHz with an intensity of 100 W and a current strength of 1 A through probe-electrodes. The action time is 2…3 min [1].

Dezavantajele metodei cunoscute constau în aceea că sondele-electrozi folosite traumează ţesuturile moi ale peretelui abdominal, ţesutul hepatic şi cel tumoral, ceea ce poate provoca hemoragii intraabdominale profuze din metastazele voluminoase bogat vascularizate, care necesită hemostază chirurgicală în cadrul unor intervenţii urgente cu riscuri majore. The disadvantages of the known method are that the probes-electrodes used traumatize the soft tissues of the abdominal wall, liver and tumor tissue, which can cause profuse intra-abdominal hemorrhages from voluminous, richly vascularized metastases, which require surgical hemostasis in urgent interventions with major risks.

Problema pe care o soluţionează invenţia constă în elaborarea unei metode de tratament miniinvaziv prin abordul laparoscopic cu scopul distrucţiei termice parţiale centrale a tumorii, fără lezarea ţesutului hepatic neafectat de procesul tumoral, cu utilizarea concomitentă a adezivului fibrinic în interiorul tumorii, care ar evita, de asemenea, complicaţiile hemoragice intraabdominale. The problem solved by the invention consists in developing a minimally invasive treatment method through a laparoscopic approach with the aim of partial central thermal destruction of the tumor, without damaging the liver tissue unaffected by the tumor process, with the concomitant use of fibrin glue inside the tumor, which would also avoid intra-abdominal hemorrhagic complications.

Conform invenţiei, metoda revendicată constă în aceea că prin accesul laparoscopic în regiunea subombilicală sub controlul opticii-video se introduce un trocar suplimentar în regiunea subhepatică, se evacuează lichidul ascitic din cavitatea abdominală, se identifică focarul tumoral hepatic şi se prelevă biopsia din tumoare, apoi cu ajutorul unui electrod bipolar, care se introduce prin portul trocarului, se efectuează diatermocoagularea bipolară cu frecvenţa de 300 kHz şi intensitatea de 100…250 W a suprafeţei centrale a tumorii cu aprofundarea lentă a electrodului şi termodistrugerea continuă a ţesutului tumoral fără lezarea ţesutului hepatic adiacent, timp de 3…7 min în regim pulsativ, totodată la periferia ţesutului hepatic intact se infiltrează 15…30 ml de un amestec care include, la 1,0 ml: According to the invention, the claimed method consists in that through laparoscopic access to the subumbilical region under the control of video optics, an additional trocar is inserted into the subhepatic region, the ascitic fluid is evacuated from the abdominal cavity, the liver tumor focus is identified and a biopsy is taken from the tumor, then with the help of a bipolar electrode, which is inserted through the trocar port, bipolar diathermocoagulation is performed with a frequency of 300 kHz and an intensity of 100…250 W of the central surface of the tumor with slow deepening of the electrode and continuous thermal destruction of the tumor tissue without damaging the adjacent liver tissue, for 3…7 min in a pulsating mode, at the same time, 15…30 ml of a mixture is infiltrated at the periphery of the intact liver tissue, which includes, per 1.0 ml:

aprotinină, UIK 250…1000 sol. trombină, UI 25…100 sol. clorură de Ca2+, µmol 15…30,aprotinin, UIK 250…1000 sol. thrombin, UI 25…100 sol. Ca2+ chloride, µmol 15…30,

ulterior în aceleaşi puncte se infiltrează sol. fibrinogen 15…30 mg, după care în spaţiul subhepatic se introduce un dren pentru control pe o perioadă de 2…5 zile şi se efectuează lavajul peritoneal cu un amestec ce conţine antibiotice cu un spectru larg de acţiune şi fermenţi proteolitici. subsequently, 15…30 mg of fibrinogen solution is infiltrated into the same points, after which a drain is inserted into the subhepatic space for control for a period of 2…5 days and peritoneal lavage is performed with a mixture containing broad-spectrum antibiotics and proteolytic enzymes.

Rezultatul invenţiei constă în elaborarea unei metode de tratament miniinvaziv prin abordul laparoscopic cu scopul distrucţiei termice parţiale centrale a tumorii masive, fără lezarea ţesutului hepatic neafectat de procesul tumoral, care evită hemoragille intraabdominale profuze din zonele de distrucţie ale tumorii. The result of the invention consists in developing a minimally invasive treatment method through a laparoscopic approach with the aim of partial central thermal destruction of the massive tumor, without damaging the liver tissue unaffected by the tumor process, which avoids profuse intra-abdominal hemorrhages from the areas of tumor destruction.

Avantajele metodei constau în: The advantages of the method consist of:

- evitarea traumatismului ţesuturilor moi şi celui hepatic, - avoiding soft tissue and liver trauma,

- profilaxia hemoragiilor intraabdominale, - prophylaxis of intra-abdominal hemorrhages,

- este miniinvazivă pentru pacient, - it is minimally invasive for the patient,

- este tehnic accesibilă, - it is technically accessible,

- ameliorarea calităţii vieţii şi supravieţuire până la 2…3 ani. - improvement of quality of life and survival up to 2…3 years.

Metoda se efectuează în modul următor. The method is performed in the following way.

Sub anestezie generală cu suport volemic şi proteic adecvat, prin accesul laparoscopic infraombilical sub controlul opticii-video printr-un trocar de lucru suplimentar, introdus în regiunea subhepatică, se evacuează lichidul ascitic din cavitatea abdominală, se identifică focarul tumoral din ficatul cirotic şi se prelevă biopsia din tumoare. Apoi, cu ajutorul unui electrod de formă sferică, care se introduce prin portul trocarului, se efectuează diatermocoagularea bipolară cu frecvenţa de 300 kHz şi intensitatea de 100…250 W а suprafeţei centrale а tumorii cu aprofundarea lentă а electrodului în adâncul tumorii şi termodistrucţia continuă а ţesutului tumoral, fără lezarea ţesutului hepatic adiacent. Timpul de acţiune fiind de 3…7 min în regim pulsativ. Totodată, la periferia tumorii ţesutul hepatic neafectat se infiltrează cu un amestec, care include la 1 ml: Under general anesthesia with adequate volume and protein support, through infraumbilical laparoscopic access under video-optical control through an additional working trocar, introduced into the subhepatic region, the ascitic fluid is evacuated from the abdominal cavity, the tumor focus in the cirrhotic liver is identified and the tumor biopsy is taken. Then, with the help of a spherical electrode, which is introduced through the trocar port, bipolar diathermocoagulation is performed with a frequency of 300 kHz and an intensity of 100…250 W on the central surface of the tumor with slow deepening of the electrode into the depth of the tumor and continuous thermal destruction of the tumor tissue, without damaging the adjacent liver tissue. The action time is 3…7 min in a pulsatile mode. At the same time, at the periphery of the tumor, the unaffected liver tissue is infiltrated with a mixture, which includes per 1 ml:

aprotinină (UIK) 250... 1000 sol.trombină (UI) 25... 100 sol. clorură de Ca+2 (µmol) 15... 30,aprotinin (UIK) 250... 1000 thrombin sol. (UI) 25... 100 Ca+2 chloride sol. (µmol) 15... 30,

apoi în aceleaşi puncte se infiltrează sol. fibrinogen 15...30 mg. then in the same points, 15...30 mg of fibrinogen solution is infiltrated.

După finalizarea distrucţiei în spaţiul subhepatic se introduce un dren pentru control pe о perioadă de 2…5 zile cu efectuarea lavajului peritoneal cu un amestec de antibiotice de spectru larg (ceftriaxon 4 g sau ceftazidim 2 g la 500 ml ser fiziologic) şi fermenţi proteolitici (lidază 640 UN sau tripsin la 500 ml ser fiziologic) introdus în get cu expoziţie de 12…24 ore, după care se evacuează, se repetă lavajul de 2…5 ori. After the destruction is completed, a drain is inserted into the subhepatic space for control for a period of 2-5 days with peritoneal lavage with a mixture of broad-spectrum antibiotics (ceftriaxone 4 g or ceftazidime 2 g per 500 ml of saline) and proteolytic enzymes (lidase 640 UN or trypsin per 500 ml of saline) introduced into the gut with exposure for 12-24 hours, after which it is evacuated, the lavage is repeated 2-5 times.

Metoda revendicată а fost utilizată pentru tratamentul а 10 pacienţi. The claimed method was used for the treatment of 10 patients.

Exemplu Example

Pacienta A., 61 ani, a fost internată în clinică cu DS: cancer hepatic metastatic masiv pe fundal de ciroză hepatică HCV decompensată. H.T.P. Child "С" (10). Ascită refractară. Pacienta а fost pregătită pentru intervenţie timp de 3 zile. Sub anestezie generală cu suport volemic şi proteic adecvat (4 unităţi de plasmă PPC, sol.Albumini 10% - 200 ml, hepatoprotectoare, reologice), prin accesul laparoscopic infraombilical sub controlul opticii-video printr-un trocar de lucru suplimentr, introdus în regiunea subhepatică, s-au evacuat 6 litri de lichid ascitic din cavitatea abdominală, s-a identificat focarul tumoral din lobul drept al ficatul cirotic de dimensiunile 8 х 10 cm în S5, s-a prelevat biopsia din tumoare. Apoi, cu ajutorul unui electrod de formă sferică, care s-a introdus prin portul trocarului, s-a efectuat diatermocoagularea monopolară cu frecventa de 300 kHz şi intensitatea de 250 W а suprafeţei centrale а tumorii cu aprofundarea lentă а electrodului în adâncul tumorii şi termodistrucţia continuă а ţesutului tumoral, fără lezarea ţesutului hepatic adiacent. Timpul de acţiune în regim pulsativ а fost de 5 min. Patient A., 61 years old, was admitted to the clinic with DS: massive metastatic liver cancer on the background of decompensated HCV liver cirrhosis. H.T.P. Child "С" (10). Refractory ascites. The patient was prepared for the intervention for 3 days. Under general anesthesia with adequate volume and protein support (4 units of PPC plasma, sol.Albumin 10% - 200 ml, hepatoprotectors, rheological), through infraumbilical laparoscopic access under video-optical control through an additional working trocar, introduced into the subhepatic region, 6 liters of ascitic fluid were evacuated from the abdominal cavity, the tumor focus was identified in the right lobe of the cirrhotic liver measuring 8 x 10 cm in S5, a biopsy of the tumor was taken. Then, using a spherical electrode, which was inserted through the trocar port, monopolar diathermocoagulation was performed with a frequency of 300 kHz and an intensity of 250 W on the central surface of the tumor with slow deepening of the electrode into the depth of the tumor and continuous thermal destruction of the tumor tissue, without damaging the adjacent liver tissue. The action time in the pulsed mode was 5 min.

Totodată la periferia tumorii ţesutul hepatic neafectat s-a infiltrat cu un amestec, care include la 1 ml: At the same time, at the periphery of the tumor, the unaffected liver tissue was infiltrated with a mixture, which includes per 1 ml:

aprotinină (UIK) 250... 1000 sol.trombină (UI) 25... 100 sol. clorură de Ca+2 (µmol) 15...30,aprotinin (UIK) 250... 1000 sol.thrombin (UI) 25... 100 sol. Ca+2 chloride (µmol) 15...30,

apoi în aceleaşi puncte s-a infiltrat sol. fibrinogen 15...30 mg. Infiltrarea s-a efectuat în 5 puncte, câte 4 ml de fiecare amestec în zonele menţionate, adică perifocal-peritumoral. then in the same points was infiltrated sol. fibrinogen 15...30 mg. The infiltration was performed in 5 points, 4 ml of each mixture in the mentioned areas, i.e. perifocal-peritumoral.

După finalizarea distrucţiei în spaţiul subhepatic s-a introdus un dren pentru control pe o perioadă de 5 zile cu efectuarea lavajului peritoneal cu un amestec de antibiotice de spectru larg (ceftriaxon 4 g la 500 ml ser fiziologic) şi fermenţi proteolitici (lidază 640 UN la 500 ml ser fiziologic) introdus în get cu expoziţie pe 24 ore, după care s-a evacuat, lavajul a fost repetat de 4 ori. S-a constatat o evoluţie clinică favorabilă cu rezolvarea ascitei şi ameliorarea rezervelor hepatice funcţionale. A fost externată în stare relativ satisfăcătoare la 10 zile după intervenţie. Examenul repetat peste 3 şi 6 luni postoperator denotă prezenţa unui focar de fibroză 3,5x4,5 cm în zona intervenţiei. After the destruction was completed, a drain was inserted into the subhepatic space for control for a period of 5 days with peritoneal lavage with a mixture of broad-spectrum antibiotics (ceftriaxone 4 g in 500 ml of saline) and proteolytic enzymes (lidase 640 UN in 500 ml of saline) introduced into the abdomen with exposure for 24 hours, after which it was evacuated, the lavage was repeated 4 times. A favorable clinical evolution was noted with the resolution of ascites and improvement of functional liver reserves. She was discharged in a relatively satisfactory condition 10 days after the intervention. The repeated examination after 3 and 6 months postoperatively showed the presence of a 3.5x4.5 cm fibrosis focus in the intervention area.

1. RU 2231991 C2 2004.02.10 1. RU 2231991 C2 2004.02.10

Claims

A minimally invasive treatment method for massive liver metastases, which consists of inserting an additional trocar into the subhepatic region through laparoscopic access to the subumbilical region under video-optical control, evacuating the ascitic fluid from the abdominal cavity, identifying the liver tumor focus and taking a biopsy from the tumor, then using a bipolar electrode, which is inserted through the trocar port, performing bipolar diathermocoagulation with a frequency of 300 kHz and an intensity of 100…250 W of the central surface of the tumor with slow deepening of the electrode and continuous thermal destruction of the tumor tissue without damaging the adjacent liver tissue, for 3…7 min in a pulsating mode, while at the same time, 15…30 ml of a mixture that includes per 1.0 ml:

aprotinin, UIK 250…1000 sol. thrombin, UI 25…100 sol. Ca2+ chloride, µmol 15…30 later in the same points is infiltrated sol. fibrinogen 15…30 mg, and in the subhepatic space is inserted a drain for control for a period of 2…5 days and peritoneal lavage is performed with a mixture containing antibiotics with a broad spectrum of action and proteolytic enzymes.