RU2213521C1 - Method for evaluating effectiveness of low-invasive treatment of pancreas pseudocysts - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making cyst cavity puncture, suction and rinsing. Dynamic estimation of pseudocyst cavity is carried out directly during the intervention. Two or more hypoechogenic zones of stable ultrasonic structure and of not less than 15 mm diameter being observed, conclusion is drawn that the low-invasive treatment applied has turned to be ineffective. EFFECT: enhanced effectiveness of evaluation. 3 dwg

Description

 The invention relates to medicine and can be used in gastroenterology, departments of radiation invasive diagnostics.

 There is a method of minimally invasive treatment of pancreatic pseudocysts under ultrasound control, when a series of punctures or installation of drainage into the cyst cavity is used. The effectiveness of manipulation is evaluated in the delayed period (from 2 to 15 days) according to two main ultrasound criteria: a decrease in the volume of focal lesion and a change in the echogenicity of the internal structure of the pseudocyst due to a reduction in the cystic fraction of the lesion (A. Lotov, “Minimally invasive interventions under ultrasound control during surgical diseases of the organs of the hepatopancreatoduodenal zone Doctoral dissertation, MMA named after IM Sechenov, 1998 - 465 pp .; Manual on ultrasound diagnostics under the editorship of VV Mitkov, volume 1, M., 1996, p. 132- 161).

 The disadvantage of this method is, firstly, that the effectiveness of the manipulation is not evaluated directly during minimally invasive intervention, which leads to the inability to introduce a correction in the process of medical manipulations. Secondly, the identification of the absence of the effect of the manipulation on 2-3 days and later leads to an increase in the clinical course of the disease, since time is wasted during the evaluation period by ultrasound observation of the dynamics of the size and echogenicity of the cystic pancreatic formation. All this significantly reduces the effectiveness of the minimally invasive treatment of this pathology.

 The essence of the proposed method lies in the fact that they conduct a dynamic assessment of the pseudocyst cavity immediately during the intervention and when at least two hypoechoic zones with a stable ultrasound structure of at least 15 mm in diameter are detected, they conclude that the minimally invasive procedure is ineffective. This statement is based on the basic principles of ultrasound diagnostics and minimally invasive gastroenterology that the hypoechoic zone with a stable structure is a closed system without a clinically significant connection with the main cavity of the pseudocyst, the size of the foci is not less than 15 mm due to the resolution of the available ultrasound equipment, and the number zones of at least two is explained by the reduced possibility of subjective error with such a number of foci.

 The lack of adequate drainage of these zones during a series of punctures or through drainages allows the detritus and foci of inflammation to remain unchanged, which in turn supports the further development of the pathological process in the form of a complicated course of chronic pancreatitis. This pathogenetic justification applies only to pseudocysts who do not have a message with the main pancreatic duct. In foci that have a similar message, this mechanism also takes place, but it is not the main one.

The method is as follows:
In the initial clinical and instrumental study of a patient with a suspected complication of chronic pancreatitis, a cystic formation of any pancreas is revealed. At the consultation, as part of the attending physician, surgeon and specialist in radiation diagnostics, further therapeutic tactics are determined. If it is advisable to conduct a medical minimally invasive intervention under ultrasound control, taking into account the ultrasound semiotics of the cystic cavity, appropriate puncture needles or drains from 0.8 to 1.4 mm in diameter are selected. Then, a diagnostic and treatment (diapevic) puncture-aspiration biopsy of the pseudocyst of the pancreas is carried out with a needle or stylet catheter. During the manipulation, constant ultrasound monitoring of the echogenicity and structure of the entire cystic cavity is carried out. The figure 1 shows the relative position of the ultrasound probe 1, the pseudocysts of the pancreas 2 and the puncture needle / drainage 3 before aspiration and flushing of the contents of the pseudocyst 5. The capsule 4 and the actual cystic cavity, as a rule, are irregular in shape 5. The figure 2 shows the stage of aspiration or rinsing of the pseudocyst cavity. At the same time, intense echopositive moving, chaotic signals 7 appear on the screen of the ultrasound device, filling the entire lumen of the pseudocyst cavity. The process of active suction and washing can be carried out simultaneously in the form of a reciprocating movement of the 6 piston of the syringe connected to the cannula of the needle or stylet catheter 3. The appearance of at least two hypoechoic zones in the cavity of the pseudocyst with a stable ultrasound structure 8 of at least 15 mm in diameter against the background of aspiration and lavage of the cavity, there is a lack of drainage of these sections of the pseudocyst 2. This criterion is prognostic adverse for the efficiency of manipulation and that immediately requires correction a puncture process: the tool end under ultrasound guidance sequentially fed to the data zones 8 and then do repeated aspiration and washing zone 6 with the destruction of these inner webs pseudocyst being walled zones.

 With the disappearance of hypoechoic zones with a stable ultrasound structure, manipulation is considered effective. A catheter or several catheters are placed in the pseudocyst cavity, which will be subjected to repeated ultrasound monitoring 1-2 times a day during aspiration and washing of the residual pseudocyst cavity.

Example
Patient M., 54 years old. Hospitalized in the clinic of internal diseases with a diagnosis of chronic pancreatitis (CP).

 He complained of girdles of intense pain in the epi- and mesogastric regions, nausea, vomiting up to 6 times a day. The patient is observed for CP for 6 years. Abuses alcohol. Two years ago, a pseudocyst puncture was performed in the projection of the tail of the pancreas (pancreas). For 2 years he was not treated, did not drink alcohol. The patient did not observe the regime of work and rest, the principles of a balanced diet. This aggravation connects with elementary overloads.

 Objectively: upon palpation of the abdominal cavity, pain in the epigastrium and left hypochondrium is determined, where a dense rounded formation is palpated up to 150-200 mm in diameter. FGDS: swelling of the posterior wall of the stomach is determined, a decrease in folding in this zone, the gastric mucosa is not changed. Ultrasound: in the projection of the body and tail of the pancreas, the cystic formation of an inhomogeneous structure up to 170 mm in diameter with the presence of papillary septa is determined, there are no organic changes on the side of the liver, gall bladder and bile ducts (Fig. 3). During the CT scan, the diagnosis was confirmed.

 Biochemical analyzes are within normal limits, except for an increase in amylase level - 685 mmol / l. In the choice of treatment tactics, ultrasound semiotics of cysts was taken as a basis. Despite the discrepancy between the RCT and UST data on the localization of the OP and the internal structure, it was decided to conduct a series of diagnostic punctures with the collection of tissue material from fragments with a parietal position, the center of the cystic cavity and the capsule of OP.

 During puncture of the cavity and sections of the capsule, tissue contents were obtained. In the punctate from the center of the focus, there are elements characterizing the contents of the cystic cavity (fragments of detritus, cells of a flattened epithelium, single leukocytes). During aspiration, 3 hypoechoic zones with a stable ultrasound structure up to 20 mm in size were identified. Under ultrasound control, the walls of these zones, in the form of wall structures, were destroyed by a puncture needle, and the zones disappeared. After 10 days, the pseudocyst cavity was completely reduced.

 The patient is observed for 5 years without signs of relapse of the pseudocyst of the pancreas.

 The proposed method was used in 18 people (10 men and 8 women) aged 33 to 62 years. Cyst relapse after minimally invasive interventions under ultrasound control was observed in two patients who were subsequently operated on. In other patients, the cyst cavity was completely reduced in 20-35 days, no relapse was observed within 3-5 years. A control group of 12 people with pseudocysts of the pancreas underwent minimally invasive manipulations under ultrasound control according to standard methods. Relapse was observed in 9 patients.

 Thus, the proposed method for evaluating the effectiveness of minimally invasive interventions for pancreatic pseudocysts is a highly effective technique for immediate control of manipulation, which allows timely adjustments to the manipulation and significantly reduces the risk of relapse, as well as improves long-term treatment results.

Claims (1)

 A method for evaluating the effectiveness of minimally invasive treatment of pancreatic pseudocysts, including cystic puncture, aspiration and washing, and further monitoring under ultrasound guidance, characterized in that they perform a dynamic assessment of the pseudocyst cavity directly during the intervention and when at least two hypoechoic zones with stable ultrasound structure are detected with a size of at least 15 mm in diameter, they conclude that the minimally invasive manipulation is ineffective.

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