RU132997U1 - DRAINAGE FOR DECOMPRESSION OF INTRAHEPENIC FLOWS IN MECHANICAL JAUNDICE CAUSED BY CENTRAL LIVER CANCER - Google Patents

Abstract

1. Drainage for decompression of the intrahepatic ducts with obstructive jaundice caused by central liver cancer, containing a hollow tube with holes on the distal end and winding fishing line with fixation of its ends, the distal end of the tube is made conical with x-ray contrast marks, and removable mandrin, characterized in that on the tube made of siliconized latex, there are two cylinders, the first of which is located closer to the distal part, providing dilatation of the pat the logical formation of the bile ducts during their “blocking”, and the second balloon, eliminating the leakage of blood and bile into the free abdominal cavity and the possibility of loss and dislocation of drainage in the biliary tract, is located closer to the proximal end, with drainage holes made before and after the first balloon, and the fishing line is wound before and after the second cylinder. 2. Drainage according to claim 1, characterized in that the winding is made with a force of (2.15-2.25) N fishing line with a diameter of 0.2 mm for 15 cm after the first balloon and 5 cm after the second balloon.

Description

The utility model relates to medicine, in particular to the treatment of obstructive jaundice caused by central liver cancer.

Central liver cancer accounts for 10-20% of the total number of patients with mechanical jaundice of tumor origin, the mortality rate at which reaches high percent.

The main cause of death: hepatic-renal failure, a violation in the blood coagulation system, a decrease in the immunological status of the patient. Prolonged obstructive jaundice leads to inhibition of hepatocyte function, cholestasis creates the prerequisites for the development of infection in the biliary tract. Any surgical procedures under general anesthesia against a background of high bilirubin significantly increase the number of postoperative complications and mortality, which reaches 50% (A.V. Kukushkin et al. Medical imaging No. 1 of 2003) - [1], while patients undergoing radical surgery after relief of jaundice, complications are observed much less frequently.

One of the most effective ways to stop obstructive jaundice is to drain the intrahepatic ducts under ultrasound guidance. In particular, with central liver cancer, this option for removing obstructive jaundice remains the most preferred at the present stage.

However, in the early postoperative period, complications very often arise (according to various literature data from 5.4 to 74% of cases) in the form of dislocation of drainage, its loss from the liver into the free abdominal cavity with bile and bleeding into the abdominal cavity with the development of peritonitis. Although this complication can occur in the absence of dislocation in the form of leakage of blood and bile in addition to drainage.

A known method of transhepatic cholangiostomy with obstructive jaundice due to high strictures of the common bile duct (Dagestan State Medical Institute, application 93019508/14, 01/14/1993, authors Girev G.I., Guseinov A.G., Dzhalalov Yu.V., Adziev A.A. .) - [2]. The invention eliminates the complications of transhepatic cholangiostomy with obstructive jaundice in the form of bleeding and bile duct into the abdominal cavity past the drainage or when it falls out of the intrahepatic duct, as well as the possibility of accidental damage to neighboring organs during liver puncture. The essence of the invention lies in the fact that to puncture the liver under the control of vision and to exclude the possibility of damage to neighboring organs under local anesthesia, an incision in the right hypochondrium 3-4 cm long is opened. The abdominal cavity is opened, the edge of the liver around the proposed puncture site is stitched with thread. In the center of the site, limited by a suture, puncture and drainage of the hepatic duct is carried out by a known method, after which the thread is tied. That allows you to tightly close the edges of the wound of the liver around the catheter, a leg is formed from the remaining edges of the thread, on which the catheter is fixed in the installed position. The disadvantage of this method is the high risk of eruption of sutures on the liver due to its flabbiness against the background of obstructive jaundice and the inability to drain both ducts with their separate block.

A known method of transparietal retro-antegrade cholangiostomy. The method relates to medicine, namely to surgery of the organs of the pancreatobiliary zone, and can be used in the treatment of patients with obstructive jaundice. (Application 98118886/14, 10/15/1998, author Okhotnikov) - [3]. The method of cholangiostomy consists in the fact that under ultrasound control, transparietal puncture of the central departments of the separated intrahepatic gall tree is performed. A safe J-shaped conductor is inserted into the gall tree visualized by contrast cholangiography, which is retrogradely displaced into the distal parts of the gall tree, along the bile ducts of 2-4 orders of the anterolateral segments of the liver. Then, a proportional catheter with an end opening is inserted through the conductor. After this, the conductor is removed, a commensurate conductor needle with a sharpened end and a flexible opposite is inserted through the catheter, and the catheterized bile duct is punctured from the inside and removed outside until its opposite flexible end is in the gall tree. After that, the catheter is pulled out of the gall tree and left in the hepatic parenchyma for 2-3 days for auto-sealing of the puncture canal. The conductor needle is displaced antegrade, as close as possible to the zone of obstruction of the gall tree, and cholangiostomy drainage with shape memory is established according to the Seldinger technique. In this case, the drainage repeats the course of the initially punctured canal from the distal sections up to the obstruction zone. As a result, the efficiency of external transparietal drainage of the biliary tract increases with their obstruction at the level of the portal of the liver, as well as with the intrahepatic block.

Unfortunately, this drainage does not solve the problem of blood and bile leakage into the free abdominal cavity, but it solves the issue of drainage dislocation due to braiding.

To address the issue of eliminating leakage of blood, bile into the free abdominal cavity, a high percentage of loss, and also dislocation of the drainage, preliminary glue application of Sulfacrylate glue on the diaphragmatic surface of the liver and parietal peritoneum at the site of drainage into the hepatic ducts was proposed (Vasiliev R.Kh. Combined laparoscopy. "Medicine" Tashkent, 1976, pp. 74-77. Marchenko VT, Guidelines for the use of medical glue "Sulfacrylate". Novosibirsk, 2005, pp. 7-12) - [4]. The disadvantage of this method is the appearance of a possible allergic reaction in a patient to glue "Sulfacrylate", and in addition, the glue gets into other tissues of the body.

To conduct a comparative analysis with the claimed device, an Amplatz Extra / Ultra Stiff 3 mm elastic braided conductor (THSCF-35-90-3-AES / AUS1 / AUS2) for percutaneous biliary drainage (http://www.chole-ray.com) was taken - [5]. Percutaneous biliary drainage is indicated for patients with obstructive jaundice, who have ineffective endoscopic drainage or have a complex lesion of the liver gate. The most common indication is malignant neoplasms of the bile ducts and pancreas.

The drainage is made in the form of an elastic hollow tube, on the distal end of which there are openings, and fishing line is wound on the surface with fixation of its ends, the distal end of the tube is made conical with X-ray contrast marks, and contains a removable mandrin.

The drainage selected for the comparative analysis is not effective enough, since the problem of blood and bile leakage into the free abdominal cavity is not solved, and in addition, a high percentage of loss and dislocation of the drainage associated with the patient's breathing excursion, displacement of the liver relative to the parietal peritoneum during breathing, and also the impossibility of using it with a separate block of the right and left parts of the liver.

The technical result, which is achieved by the claimed utility model, is to increase the efficiency of the drainage used in the treatment of obstructive jaundice caused by central liver cancer at any time of the disease.

The technical result is achieved by the fact that in the drainage for decompression of the intrahepatic ducts with obstructive jaundice caused by central cancer of the liver containing an elastic hollow tube, there are holes on the distal end and the line is wound with fixation of its ends, the distal end of the tube is conical with X-ray contrasting marks, and a removable mandrin, the new thing is that on the tube, there are two cylinders, the first of which is located closer to the distal part, providing a dilat july pathological formation of the bile ducts with their "block", and the second balloon, eliminating leakage of blood and bile into the free abdominal cavity and the possibility of loss and dislocation of drainage in the biliary tract, is located closer to the proximal end, with drainage holes made before and after the first balloon , and the fishing line is wound before and after the second cylinder.

In the drainage on the tube, the winding is made with a force of (2.15-2.25) N with a line of 0.2 mm diameter for 15 cm after the first balloon and 5 cm after the second balloon.

The essence of the utility model is presented in figure 1, 2, 3, where:

Figure 1 - drainage with a mandrin.

Figure 2 - the position of the drainage after removing the mandrel from the tube - flows bile.

Figure 3 - method of attaching fishing line.

Here: 1 - elastic hollow tube;

2 - proximal balloon;

3 - distal balloon;

4 - valves of the cylinder sealing unit with gas supply tubes in the cavity of the cylinders;

5 - fishing line wound on the drainage pipe;

6 - holes on the surface of the drainage tube;

7 - abdominal wall;

8 - the liver;

9 - aperture;

10 - pathological formation (tumor);

11 - gall bladder;

12 - common bile duct;

13 - lobar ducts (bile ducts);

14 - mandrin (metal stylet);

15 - echo contrast marks;

16 - bile:

Drainage is set as follows: the position of the patient on the back. Using an ultrasonic sensor on the skin in the projection of the drained duct 13 choose a place for optimal manipulation. Local tissue anesthesia is performed along the proposed puncture channel at the site of the proposed subsequent drainage 1 with mandrin (metal stylet) 14 and a small skin incision is made. Through a skin incision under the control of an ultrasonic probe, drainage 1 with a mandrin 14 is carried out through a pathological formation (tumor) 10 of the bile ducts (lobar ducts) 13 with their “block” at the level of the liver gate. The echo-contrast marks 15 make it possible to accurately control the course of the drainage with the mandrin 14 in the scanning plane by the ultrasonic sensor. Then, mandrin 14 is removed, which does not allow associated tissues to obstruct the lumen of the drainage, after which bile 16 begins to leak, which is one of the factors confirming [the correctness of the location of the drainage. Then the balloons are inflated - first, the proximal balloon 2, after - the distal balloon 3, controlling their location in the liver tissues, followed by fixation of the drainage to the skin to prevent its loss.

Drainage for decompression of the intrahepatic ducts with obstructive jaundice caused by central liver cancer is an elastic hollow tube 1, on the distal end of which there are holes 6, and on the surface there is winding fishing line 5 with fixation of its ends, the distal end of tube 1 is conical, the surface of the tube 1 is marked with X-ray contrast marks 15, in addition, the drainage contains a removable mandrin 14. On the elastic tube 1, made of siliconized latex, there are two cylinders, the first 3 of which are laid closer to the distal part, which ensures dilatation of the pathological formation of the bile ducts during their “blocking”, and the second balloon 2, which excludes blood and bile leakage into the free abdominal cavity and the possibility of loss and dislocation of drainage in the biliary tract, is located closer to the proximal end, while drainage holes 6 are made before and after the first balloon 3, and the fishing line 5 is wound before and after the second balloon 2 with a diameter of 0.2 mm with a force of (2.15-2.25) N for 15 cm after the first balloon and 5 cm after the second balloon.

External drainage of the biliary tract is carried out under ultrasound guidance, by installing drainage into the biliary tract of any segment of the liver, depending on the height of the tumor lesion. Using an ultrasound transducer on the skin in the projection of the drained duct, a site is selected for optimal manipulation. Local tissue anesthesia is performed along the proposed puncture channel and a small skin incision. Through a skin incision, under the control of an ultrasound probe, drainage is performed through a pathological formation (tumor) of the bile ducts with their “blocking” at the level of the liver gate. The distal end of the drainage tube 1 has a conical shape for easy passage of the drainage through a pathological formation in the lumen of the biliary tract, and the echo-contrast marks 15 allow precise control of the device’s progress in the scanning plane by an ultrasonic sensor. Then, mandrin 14 (metal stylet) is removed, which does not allow associated tissues to obstruct the drainage lumen, and bile 16 begins to flow out of the hole on the holder, which is one of the factors confirming the correct location of the device. Next, balloons 2 and 3 are inflated in order, controlling their location in the tissues of the liver, with subsequent stitching of tube 1 to the skin to prevent its loss. A balloon located closer to the distal part is necessary for dilating the pathological formation (tumor) of the bile ducts during their “blocking”, the second balloon 2 prevents blood and bile from flowing into the free abdominal cavity and the possibility of prolapse and dislocation of tube 1 in the biliary tract. Cylinders 2 and 3 are made of siliconized latex. A drainage tube with a diameter of up to 5 mm is made of polyamide with x-ray contrast marks 15, the distal end is made conical with a diameter of 3 to 5 mm from reinforced x-ray contrast polyurethane. Length 80 cm with marks 5 cm across a length of 30 cm. Additionally, to give the same elasticity and density over the entire surface of the drainage, the fishing line is wound closely to each other, the winding is made with a force of (2.15-2.25) N fishing line with a diameter of 0, 2 mm for 15 cm after the first balloon and 5 cm after the second balloon.

The drainage is equipped with two valves of the cylinder sealing unit 2 and 3 with gas supply tubes in their cavity and a mandrel (metal stylet) 14. In addition, on the distal part of the tube 1, there are side holes 6 for leakage of the contents of the hepatic ducts and x-ray contrast marks 15 for establishing the depth finding drainage inside the liver and hepatic ducts.

The proposed utility model allows effective treatment of obstructive jaundice caused by central liver cancer, eliminates the urgent state of the patient without radical intervention and blood and bile leakage into the free abdominal cavity and a high percentage of loss and dislocation of drainage, which significantly reduces the percentage of complications and lethality in the performance of the department emergency surgery.

Thus, the proposed drainage solves the problem of treatment of obstructive jaundice caused by central cancer of the liver, eliminates the urgent state of the patient without radical intervention, eliminates leakage of blood and bile into the free abdominal cavity and a high percentage of loss and dislocation of drainage, which significantly reduces the number of postoperative complications and mortality in rates work of the emergency department, the number of bed days, economical, simple in technical execution, applicable in any surgical th hospital equipped with ultrasound equipment.

Clinical case: Patient T., 82 years old, and.b. N 7839, was admitted to the Republican Clinical Hospital No. 2 of Kazan, 28 / XI-12, with complaints of pain in the right hypochondrium, nausea, chills, a rise in body temperature to 39.0 ° C. Case history: considers herself a patient since 21 / XI-12, when the above abdominal pains appeared, nausea. Caused vomiting on her own, after which she noted temporary relief. Over the next seven days, the pain did not stop, and therefore caused an SMP, was sent to the Republican Clinical Hospital No. 2 of Kazan with suspected gallstone disease (a history of laparoscopic cholecystectomy in 1998). The present condition of the patient: the condition of the patient of moderate severity, the skin of the jaundice. Harsh breathing in the lungs, no wheezing. Heart sounds are muffled, pulse is 86 beats. in minutes, arrhythmic. Blood pressure 130/80 mm Hg The tongue is dried. The abdomen is swollen, participates in the act of breathing, is painful on palpation and is somewhat tense in the right half. Symptom Shchetkina-Blumberg negative. The liver is enlarged to 12 cm from under the edge of the costal arch, dense, painful. The gall bladder is not palpable. Symptom of Kera, Ortner positive. Noises of intestinal peristalsis are heard, not amplified. There is no splash noise. Gases depart. Urination is frequent, painless. Pasternatsky’s symptom is negative on both sides. Per rectum: no features. Laboratory data: blood leukocytes of 20.8 thousand / ml; ESR 33 mm / min; about. blood bilirubin 111.4 mmol / L. Diastasis of urine 64 units. Survey radiography of the abdominal cavity: free gas, fluid levels are not determined. On an ultrasound of the hepatobiliary system from 28 / XI-12 g.: Liver - enlarged, intrahepatic ducts: right expanded to 8 mm., Left 6 mm., Gall bladder - removed, common bile duct - 3 mm., Pancreas - size in head area 28 mm. In the gates of the liver, a heterogeneous isohyperechoic formation with fuzzy, uneven contours is determined - 5 × 8 mm in diameter. The periportal lymph nodes are enlarged in the form of a drainage focus - 20 mm in diameter. Diagnosed with Klatskin tumor, obstructive jaundice. Therapeutic diagnosis: IHD, atherosclerotic cardiosclerosis with impaired conduction and rhythm; chronic pyelonephritis, latent course.

The started conservative infusion, antispasmodic, antibacterial therapy did not produce a noticeable effect. Considering the ineffectiveness of the conservative measures taken, the presence of obstructive jaundice, the severity of the patient’s condition, the patient’s age, as well as severe concomitant pathology, decompression cholangiostomy was superimposed under ultrasound control using the original drainage, up to 180.0 ml of dark bile. Subsequently, detoxification, antibacterial, antispasmodic, hepatotropic therapy was carried out, the patient's condition after which was gradually normalized. According to the cholangiostomy, up to 350.0-400.0 ml of light, cloudy greenish discharge was received during the observation period. Jaundice was asleep. On fistulography from 12 / XII-12 g: the contrast medium fills the intrahepatic ducts, the latter are somewhat enlarged due to the tight filling with contrast. The common bile duct is not visualized, contrast does not enter the duodenum 12. Subsequently, the patient has a nasogastric tube installed to return bile. 15 / XII-12, the patient was discharged in satisfactory condition for outpatient monitoring and decisions on further planned surgical treatment in the oncology department.

Claims (2)

1. Drainage for decompression of the intrahepatic ducts with obstructive jaundice caused by central liver cancer, containing a hollow tube with holes on the distal end and winding fishing line with fixation of its ends, the distal end of the tube is made conical with x-ray contrast marks, and removable mandrin, characterized in that on the tube made of siliconized latex, there are two cylinders, the first of which is located closer to the distal part, providing dilatation of the pat the logical formation of the bile ducts during their “blocking”, and the second balloon, eliminating the leakage of blood and bile into the free abdominal cavity and the possibility of loss and dislocation of drainage in the biliary tract, is located closer to the proximal end, with drainage holes made before and after the first balloon, and the fishing line is wound before and after the second tank. 2. Drainage according to claim 1, characterized in that the winding is made with a force of (2.15-2.25) N fishing line with a diameter of 0.2 mm for 15 cm after the first balloon and 5 cm after the second balloon.

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