RU2123806C1 - Surgical method for treating destructive forms of pancreatitis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves dissecting pancreas parenchyma by applying 2-3 parallel incisions using high pressure hypothermic novocaine solution jet containing also enzyme inhibitors and antibiotics. The jet is applied in known operation mode. The gland is subjected to infiltration with this solution. Outlet pressure of the jet is equal to 80 atm and emitted from 5-6 cm distance. Injections are made under outlet pressure of 80 atm. The nozzle is brought tightly close to the organ surface. The solution is injected in radial direction relative to the pancreatic duct. EFFECT: reduced intensity of destructive processes; effective way of gland drainage.

Description

 The invention relates to medicine, namely to surgery.

 Despite significant successes in the treatment of acute pancreatitis, the high mortality rate in this disease (according to some authors, mortality in destructive forms of acute pancreatitis remains at the level of 30 - 50%) forces us to continue the search for new methods of treatment. Among modern ways to solve this problem are known: fillings of the excretory ducts of the gland, cryodestruction, exposure to laser, plasma, ultrasound devices, various schemes of drug therapy, etc. (Shalimov S.A., Litvinenko A.A., Ishankulov A.M. Cryosurgical treatment of pancreatitis. // Clinical surgery. - 1991. - N 1. - P. 54, Alperovich A.I. Actual issues of diagnosis and surgery liver and pancreas: Collection of scientific papers - Tomsk, 1987, Litvin GD, Brekhov EI, Yakimenko AP The use of lasers in operations on the pancreas and spleen in clinical practice // Application of lasers in medicine. - Kiev .: Naukova Dumka, 1985. - S. 22 - 24 .;). At the same time, many of the above methods, along with their advantages, have serious disadvantages, namely either low efficiency, high cost and complexity of use, which is important for medical institutions of the general medical network.

 A known method of treating destructive forms of pancreatitis, which is universally recognized and most common, which consists in wide drainage of the omental bursa (Savelyev V.S., Buyanov V.M., Ognev Yu.P. Acute pancreatitis. - M .: 1983, Filin V.I. Acute diseases and damage to the pancreas. - L., 1982). In some cases, this method is supplemented by the infiltration of parapancreatic fiber with solutions of enzyme inhibitors, dissection of the pancreas with a scalpel, or using ultrasound, laser systems.

The disadvantages of this method are:
1. Drainage of the stuffing bag allows you to remove only that part of pancreatic exudate that enters it by diffusion through the capsule of the pancreas. Thus, this intervention prevents the active pancreatic secretion from entering the abdominal cavity and, reducing the effects of enzyme toxemia, does not have a pathogenetic orientation towards eliminating the pathological process in the gland itself.

 2. Infiltration of parapancreatic fiber with solutions of protease inhibitors only slightly inactivates the active elements outside the pancreas.

 3. Dissection of the pancreas in order to improve the outflow of pancreatic secretion with a conventional scalpel can lead to massive unstoppable bleeding from crossed vessels; when cutting it with a laser beam, the effect of "brewing" not only vessels, but also the excretory ducts occurs, which further disturbs the drainage of the parenchyma; ultrasound dissection of the gland has advantages over the above methods, since it leaves the majority of blood vessels, including small ones, uncrushed, which prevents the risk of bleeding, but this method is difficult to use and is very expensive, which makes it inaccessible to medical institutions of the general medical network; there are some other disadvantages.

 The combination of the above disadvantages of the methods forced us to approach this problem from a different perspective.

 The aim of the invention is to improve the results of treatment of patients with destructive forms of pancreatitis, namely reducing the degree of operational risk, mortality, reducing the length of hospital stay of patients.

 This goal is achieved by the fact that to ensure adequate drainage of the pancreas itself, it is longitudinally differentially dissected by a high-pressure jet of a hypotonic solution of novocaine, which also contains proteolytic enzyme inhibitors and broad-spectrum antibiotics. Differentiated dissection of the gland, leaving the blood vessels and excretory ducts uncrossed, prevents the possibility of bleeding and secretion from damaged duct systems and provides the most optimal conditions for draining the parenchyma and removing necrotic areas without unnecessary organ trauma. The use of a cooled solution with the indicated ingredients makes it possible to reduce the activity of destructive processes directly in the gland itself, since diffuse deep infiltration of it with the indicated preparations occurs.

 The liquid jet is obtained using any medical device that allows you to create a pressure jet with an outlet pressure (in front of the nozzle system) of at least 120 atm, which meets the following parameters: jet diameter of not more than 0.15 mm, spraying at a distance of 5 cm from the nozzle end not more than 0.7 mm; the correctness of the selection of the jet is determined as follows: from a distance of 3 cm it must penetrate at least 3 and not more than 4 sheets of dry newsprint, tightly pressed against each other. In this mode, it is traumatic for the hands of surgeons. An example of such a device is a needleless injector ("Jet-1"), which also has a relatively low cost.

 The method is as follows: after the revision of the pancreas, a necrotic tissue is removed by a jet technique. To do this, a stream of physiological solution (saline solution is used to prevent unnecessary waste of expensive drugs) affect the foci of necrosis from a distance of 7 - 8 cm from the end of the nozzle to the surface of the gland in circular motions. After necrectomy, two to three parallel longitudinal sections are made on the upper surface of the pancreas, taking into account the zone and the nature of the changes in the gland. Accordingly, the depth of dissection of the parenchyma, which can be 1/2 of the thickness of the organ, is also adjusted. The more pronounced the destructive process, the greater should be the depth of dissection. For the purpose of directed separation of tissues, a stream of liquid is slowly conducted along a visually outlined trajectory perpendicular to the surface of the gland from a distance of 1.5 - 2.0 cm from the nozzle to the surface of the organ. Pressure indicators, jet configurations, and parameters of its conducting were worked out in the experiment and are optimal. An increase in pressure, jet diameter, and a decrease in distance will contribute to a decrease in the degree of differentiation of the dissection, an increase in tissue trauma, and, conversely, a decrease in pressure below 120 atm and a corresponding change in other indicators will lead to a decrease in the efficiency of tissue separation. After applying the incisions (using the above solution containing novocaine, enzyme inhibitors and antibiotics, cooled to 5 degrees. To prevent the occurrence of side effects, 0.25 - 0.5% novocaine solution is used. The content of the remaining drugs should correspond to the maximum therapeutic dose) pancreas additionally infiltrated by the described solution. For this purpose, it is processed by a jet with an outlet pressure of 80 atm. from a distance of 5 - 6 cm in translational movements over the entire available surface. The final step is the batch introduction of only enzyme inhibitors into the thickness of the parenchyma. The nozzle is brought close to the surface of the organ and a batch (2–3 ml) injection of the same solution is made in the direction radial with respect to the Wirsung duct. At least 5 injections are evenly distributed, evenly distributed along the length of the organ. The operation ends with wide drainage of the stuffing bag according to the accepted method.

 After conducting experimental studies on 18 outbred dogs and establishing the effectiveness of the method using macro-, micro- and laboratory research methods, it was used in a clinic in 5 patients.

Clinical example: Patient K., 54 years old, N 21345/2, was admitted to the blade on 06/06/93 as an ambulance with complaints of pain in the right hypochondrium of paroxysmal nature and radiating to the lumbar region, nausea, vomiting. Pallor of the skin, tachycardia up to 88 beats were noted. min, temperature increase to 37.8 degrees; palpation positive symptoms of pancreatitis, cholecystitis, muscle stiffness in the epigastric region. Blood test: white blood cells 9.6 • 10 ⁹ , ESR 15 mm / hour, amylase 340 (g.h.) / l (normal from 7 to 28), urine diastasis 1030 (g.h.) / l, normal 28 - 64. Diagnosis: acute destructive pancreatitis, acute cholecystitis. Operated on an emergency basis. On the operation: acute phlegmonous cholecystitis, acute destructive pancreatitis with extensive foci of hemorrhagic and fat necrosis. If possible, the necrotic masses were removed according to the method described above, two parallel incisions were made, with a depth of 1.5 cm and a length of 8.0 cm. The gland was infiltrated and injected with a solution containing 0.25% novocaine, the enzyme inhibitor was contrical and the antibiotic was claforen. The solution is cooled to 5 degrees. The operation is supplemented with cholecystectomy. In the postoperative period - standard conservative therapy. Discharged home in satisfactory condition 3 weeks after surgery. The total solution flow rate was 120 ml. The device "Jet-1" was used.

 The positive effect of the application of the method is as follows: optimal conditions are provided for decompression and drainage of the pancreas, destructive processes immediately after processing are reduced, and necrotic tissues are removed with high quality and less traumatic. Accordingly, mortality is reduced, the length of hospital stay of patients is reduced. In the experimental group of patients there were no fatal outcomes. Patients were discharged from the clinic within a period of 2.5 to 7 weeks after surgery.

 The results obtained, as well as the simplicity and relatively low cost of using the proposed method make it possible to consider its use in destructive forms of pancreatitis.

Claims (1)

 A method of treating destructive forms of acute pancreatitis, which consists in providing an outflow of pancreatic secretion, characterized in that the pancreas parenchyma is cut with 2 to 3 parallel longitudinal sections of a high-pressure jet of a hypothermic novocaine solution containing enzyme inhibitors and antibiotics, with an outlet pressure of at least 120 atm, with a jet diameter of not more than 0.7 mm at a distance of 5 cm from the end of the nozzle from a distance of 7 - 8 cm from the end of the nozzle to the surface of the gland, additionally infiltrate the gland at with the indicated solution, using a jet with an outlet pressure of 80 atm from a distance of 5 - 6 cm and injecting it into the gland at an outlet pressure of 80 atm, bringing the nozzle close to the surface of the organ and introducing the solution in a direction radial to the Wirsung duct.