RU2311873C2 - Method for sanitizing purulent-necrotic foci of abdominal cavity and retroperitoneal space at acute destructive pancreatitis - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should insert a gastroscope into fistular foramen in the wall of a hollow organ to fulfill sanitation followed by cavitary nasodrainage. The innovation enables to decrease traumatism and drain distant small-sized sites of congestion.

EFFECT: higher efficiency.

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Description

The present invention relates to medicine, namely to surgery and can be used in the treatment of acute destructive pancreatitis (ODP).

Pancreatic necrosis, which at the beginning of the century had the glory of one of the most unpredictable catastrophes in the abdominal cavity, today remains a formidable pathology in which mortality according to some literature data reaches 85% (Savelyev et al., 1983, 1993; M.I. Filimonov et al. ., 1997; V.A. Glushko, 1991; S.A. Shalimov et al., 1990; K. Bosscha., Et al, 1998; D. Egidito et al., 1991).

The complexity of the pathogenesis of the disease and the features of the pathomorphology of the pancreas (pancreas) and cellular spaces of retroperitoneal localization in pancreatic necrosis served as the basis for the introduction of a wide range of operations into clinical practice (V.A. Kubyshkin, 2000).

The choice of the volume, nature and time of surgery depends on the stage of the pathological process and the type of complications developed. Most of the operations (debridement and drainage of the omental bursa, abdominal cavity, plugging and drainage of the omental bursa, omentopancreatopexy, abdominal pancreas, resection of the pancreas), proposed by a number of authors (BC Saveliev et al., 1981, 1983; V.M.Buyanov et al., 1988; A.A. Shalimov, 1984; LEHollander et al., 1984), often lead to repeated surgical interventions with the goal of redevelopment of purulent-necrotic foci. Meanwhile, laparotomy itself and especially repeated interventions contribute to the deterioration of the condition of patients and the development of new complications.

The multi-stage course of the pathological process necessitates the search for such methods of treating ADP, the timely use of which would reduce the number of infectious and other complications that are the main cause of mortality without additional risk. The last decade is characterized by the widespread introduction of instrumental biophysical and automated methods into clinical practice (BC Saveliev, V. A. Kubyshkin, 1999; Yu.A. Nesterenko, S. G. Shapovalyants, 1993; BC Saveliev, E. G. Yablokov, 1995; S.N. Bogdanov, 1997). Subsequently, instrumental interventions are improved and acquire the character of therapeutic measures. The advent of optical instruments with fiber optics, in particular endovideo surgical technologies, has led to the emergence of new opportunities leading to their widespread use in the treatment of NDC.

A promising direction is the development of surgical methods for the treatment of pancreatic necrosis, which, in addition to intraoperative sanitation and treatment measures in the postoperative period, include revision and reorganization of parapancreatic cell and gland bags, necrcestrectomy with optical devices with fiber optics under X-ray control and up to the final process.

As an analogue, the study was taken Glushko V.A. "Stage endoscopic necrectomy in the complex treatment of acute destructive pancreatitis" // Abstract. Diss. for the degree of candidate of medical sciences M., 1991

After processing the surgical field in the operating room, a laparotomy is performed with a longitudinal or cruciform incision, access to the pancreas and parapancreatic tissue is performed, necrsecvestrectomy, rehabilitation of the parapancreatic space are performed. At the end of surgery, an omentobursopancreatostomy is formed. In the postoperative period for drainage, starting from 1-3 days, with an interval of 24-48 hours, stepwise endoscopic revisions of the stuffing box with sanitation of the cellular space are carried out until the destructive process is completely eliminated and the external pancreatic fistula is formed.

The disadvantages of this method are the following:

1. With laparotomy, infected contents from the retroperitoneal accumulation may enter the free abdominal cavity with the subsequent development of peritonitis.

2. Access to the pancreas and parapancreatic tissue through laparotomy is traumatic.

3. If necessary, repeated intervention in the abdominal cavity, it is necessary to perform repeated traumatic relaparotomy, aggravating the general condition of the patient.

As the closest analogue taken "Method for the treatment of retroperitoneal pancreatogenic phlegmon" (patent of the Russian Federation No. 2189949). A tight dilatation of the wound canal is carried out. Primary drainage is carried out by drains with a diameter of 10-11 mm under combined sonofluoroscopic control. Washed retroperitoneal space. In the post-manipulation period, a water-soluble contrast is introduced into the destruction zone, the distribution of which clarifies the volume and topography of the destruction zone. Transfistular visually controlled instrumental retroperitoneal necresecvestrectomy is performed.

The disadvantages of this method are the following:

1. The initial installation of thick drainage significantly increases the risk of damage to the main vessel and hollow organs.

2. It does not adequately drain distant streaks with a thickness of less than 10 mm.

Objectives of the invention:

1. Improving the results of treatment of patients with ADP, reducing mortality, reducing treatment time by using minimally invasive surgical technologies, reducing trauma and eliminating laparotomy.

2. Limiting the spread of purulent-necrotic process by creating an effective outflow of purulent-necrotic masses.

The essence of the invention lies in the fact that with the formed fistulous hole in the wall of the hollow organ, sanitation is carried out by introducing a gastroscope through the formed hole in the wall of the hollow organ, followed by the nasodrenization of the cavity. The technical result is the effectiveness of closed sanitation of purulent-necrotic foci of the abdominal cavity and retroperitoneal space in acute destructive pancreatitis due to the existing fistulous opening.

The method is as follows.

In the radiological operating room, after sedation and laying the patient, an intravenous anesthesia is performed. As premedication, the patient is injected with 2-4 ml of 0.1% methacin solution and 2 ml of Relanium solution 40-50 minutes before the study in order to relax the duodenum (duodenum) and reduce the secretion of digestive glands. Local anesthesia of the oropharynx is carried out with a 2% lidocaine solution. Manipulation is performed strictly on an empty stomach. The patient is laid on his left side, with the left arm located behind his back. The left leg is straight, the right is bent at the knee. An endoscope is inserted. After the introduction of the endoscope into the duodenum, the patient is placed on his stomach, hands along the trunk. The method is performed by Olympus endoscopes, with end and side optics. When conducting an endoscope, the nature of the contents of the stomach and duodenum, the state of the walls, the localization and the diameter of the lesion site are determined. As a rule, this is along the back wall of the stomach in the upper third of the body and antrum, as well as in the area of the posterior wall of the duodenum. A gastroscope is inserted into the fistulous opening, and it is promoted under visual (endoscopic) and radiological control. The endoscope is inserted into the purulent-necrotic cavity and sanitized by washing it with solutions (furatsilin), the existing necrotic sequestra are crushed with biopsy forceps, passed through the working channel of the endoscope and washed out of the cavity with a stream of a solution supplied under slight pressure. The main criterion for the nonviability of the pancreas or parapancreatic tissue to be removed is visual signs: the presence of gray tissue, in the form of an unstructured mass, from which pus is excreted by the instrument. After aspiration of the contents in the same volume through an installed catheter, fistulography is performed. The cavity is filled with a water-soluble X-ray contrast drug (40-50% omnipack solution) in a volume sufficient to gain an idea of the configuration of the cavity and the direction of its distribution. Further, nasodrainage is established along the working channel of the gastroscope for subsequent sanitation of the cavity.

The method was tested on 12 patients.

1. Patient A., 62 years old, No. 196, was admitted to the clinic of the RCPFHG on 03.03.2003. After a set of diagnostic measures (ultrasound, RCP, EFGDS, laboratory tests), the clinical diagnosis was established: pancreatic necrosis, parapancreatic phlegmon. Internal intestinal fistulas. Internal pancreatoduodenal fistula. Considers himself ill for about 3 weeks, was treated conservatively in the Central District Hospital at the place of residence, with negative dynamics of non-stopping febrile temperature, he was sent to the RCSCH clinic. Upon admission, a serious condition caused by sepsis was hospitalized in the intensive care unit. After the necessary preoperative preparation for the patient on March 6, 2003, the purulent necrotic cavity of the parapancreatic phlegmon was drained under ultrasound control, about 400 ml of pus was evacuated. The patient's condition has improved. Drainages were washed with antiseptic solutions. After 7 days, temperature rises to febrile figures appeared in the evening. On ultrasound, adequate drainage of retroperitoneal fiber is noted. On stage fistulography, in addition to the existing drained cavity, there is a complete discharge of contrast in the duodenum through a contrast isthmus about 1.2 cm wide. The patient was taken to an X-ray. A gastroscope was performed in the duodenum. In the lower third of the vertical branch of the duodenum along the medial wall there is a fistulous opening with a diameter of up to 1.2-1.5 cm, through the lumen of which flakes of fibrin and pus are visualized. A gastroscope is inserted through the wall of the duodenum into the purulent necrotic cavity, the cavity is washed. Pus, pieces of necrotic fiber are abundantly washed in the duodenum. A necrosecvestrectomy was performed with biopsy forceps, sequestration was removed outward by the flow of the supplied solution. Installed for sanitation and drainage drainage, which is removed nasally. In the postoperative period, washing was performed, the patient's condition improved. The end of the drainage is carried out according to indications (cavity closure).

At the control examination after 2 months: the patient recovered by 7 kg, pain is absent. On ultrasound: a decrease in the size of the pancreas, with sonological signs of chronic pancreatitis.

The developed method of sanitizing purulent-necrotic foci of the abdominal cavity in acute destructive pancreatitis allows to improve treatment results, reduce the number of postoperative complications, fatal outcomes of NDP and is recommended for practical use.

Claims (1)

A method of sanitizing purulent-necrotic foci of the abdominal cavity and retroperitoneal space in acute destructive pancreatitis, including the introduction of a gastroscope and contrast medium, characterized in that when a fistulous hole is formed in the wall of a hollow organ, sanitation is carried out by introducing a gastroscope into the fistula hole in the wall of the hollow organ, followed by nosing cavities.