RU2364367C1 - Method of endoscopic treatments fester pancreatic pseudocysts - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: endoscope is introduced into superior gastrointestinal tract. Posterior wall of stomach or duodenum is burned with a needle-knife papillotome within greatest bulging of pseudocyst into lumen thereof. After posterior wall of stomach or duodenum is burned with a needle-knife papillotome, a stent 10 or 11 Fr is brought in the formed fistula. Then, at the distance 2-3 cm from the first fistula, a needle-knife papillotome forms the second even fistula. Through the second fistula, polyvinyl chloride pig-tail probe is inserted into the cyst cavity. One end of the probe is left in the cavity of fester pseudocyst. The other end of the probe is delivered through nose. The pig-tail probe is removed after reduction of inflammation, while the stent 10 or 11 Fr is removed from the pseudocyst cavity 3 months later.

EFFECT: possibility to deliver antiseptic solutions and antibiotics directly into purulent cavity, to generate internal fistula on the stent to provide physiology of diversion of pancreatic juice in gastrointestinal lumen, to reduce risk of haemorrhage, to ensure minimal invasiveness of surgical interventions and appropriate drainage.

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Description

The invention relates to medicine, namely to surgical endoscopy, and can be used to treat suppurative pseudocysts of the pancreas.

Postnecrotic cysts, being the outcome of acute and chronic pancreatitis, make up from 79.7 to 92.6% of all cystic formations of the pancreas. Discussions about treatment methods for suppurative pseudocysts of the pancreas suggest diametrically opposite approaches to this problem - from the most conservative to the radical ones (S. V. Akulenko, V. A. Ovchinnikov, V. A. Solovyov. Percutaneous decompression technique for accelerated preparation of the wall of an unformed post-necrotic cyst of the pancreas to open application of pancreatocystodigestive anastomosis. Scientific and medical bulletin of the central Chernozem region. No. 29, III quarter, 2007, p.5-7, Danilov MV, Glabay VP, Buriev I .M. Problems of surgical diseases of the pancreas. // Surgery. - 1993. - No. 3. - p. 55-62, Surgery of the pancreas. Danilov MV, Fedorov VD - M .: Medicine. - 1995 . - 512 s.). For the treatment of pancreatic pseudocysts, it is proposed to use a wide variety of minimally invasive interventions, mainly aimed at external drainage or puncture under ultrasound control (Achkasov E.E. Treatment of false cysts of the body and tail of the pancreas communicating with its ductal system. Surgery. Journal of N . I. Pirogov. No. 9, 2007, p. 36-41).

The use of endoscopic treatment methods for pancreatic pseudocysts is an alternative to traditional surgical treatment and can improve treatment results and significantly reduce its time. It is believed that internal drainage of the cyst eliminates pain, preserves the flow of pancreatic juice into the gastrointestinal tract, and prevents a further decrease in pancreatic function, which gives a higher percentage of good results.

The closest technical solution to the claimed method is a method of applying an endoscopic cystogastro- or cystoduodenoanastomosis, which consists in introducing an endoscope into the upper gastrointestinal tract, burning a posterior wall of the stomach or duodenum with a papillotome at the site of greatest cystic bulge into the lumen of these organs, papillotoma of the onion type, with which the created anastomosis expands to 1.5-2.0 cm (Endoscopic opening of post-necrotic pancreatic jelly cysts s. Lutsenko VD et al., Surgery 2003, №9, s.10-13). The disadvantages of this method (especially in the treatment of suppurative pseudocysts) are: a high risk of bleeding from the created wide anastomosis, inadequate drainage due to gluing of the edges of the incision, the inability to sanitize the cavity with antiseptic solutions, throwing the contents of the stomach and duodenum into the cyst cavity, which helps to maintain the inflammatory process.

The objective of the invention is the elimination of these shortcomings to improve the results of endoscopic treatment of suppurative pseudocysts of the pancreas.

The solution to the problem is that after the endoscope is inserted into the upper sections of the gastrointestinal tract at the site of the greatest bulging of the cyst with a needle papillotome, an Soehendra-Tannenbaum ™ (Wilson-Cook®) stent 10 or 11 is inserted into the anastomosis created after burning the posterior wall of the stomach or duodenum Fr., which is intended for endobiliary drainage, and not for cyst drainage. Next to it, departing from the anastomosis 2-3 cm, the same anastomosis is formed with a needle papillotome, through which a polyvinyl chloride probe of the “pig tail” type is installed into the cyst cavity, one end of which is left in the cavity of the festering pseudocyst for washing with antiseptic solutions, and the other is removed through nose. After stopping the inflammatory process, the probe is removed, and the stent is left in the cyst cavity for 3 months to form an internal fistula.

The signs allowing to recognize the claimed technical solution in accordance with the criteria of "novelty" and "inventive step" are the following:

- the introduction of the stent Soehendra-Tannenbaum ™ (Wilson-Cook®) 10 or 11 Fr. into the first anastomosis for cyst drainage, which facilitates the relationship of the cyst with the Wirsung duct to ensure the physiological removal of pancreatic juice into the lumen of the gastrointestinal tract;

- the formation of the second same anastomosis with a needle papillotome departing from the first anastomosis by 2-3 cm, through which a pig tail polyvinylchloride probe is inserted into the cyst cavity for washing with antiseptic solutions, one end of which is left in the cavity of the festering pseudocyst, and the other end is discharged through nose.

Using the proposed method in the treatment of patients with festering pseudocysts of the pancreas allows:

- ensure low-invasiveness of the intervention;

- to provide external-internal drainage of the pseudocysts due to the formation of the first and second anastomosis, through which the Soehendra-Tannenbaum ™ stent and the pig tail cystasal probe, respectively, are introduced into the pseudocyst cavity, thereby preventing possible blockage of the Soehendra-Tannenbaum ™ stent with thick purulent contents the possibility of direct summing of solutions of antiseptics and antibiotics into the pseudocyst cavity from the first hours of surgery;

- reduce the risk of bleeding due to the elimination of the need to dissect the wall of the stomach or duodenum over a long period;

- to form an internal cystogastric or cystoduodenal anastomosis on the stent of Soehendra-Tannenbaum ™, which is especially important when the cyst is interconnected with the Wirsung duct to ensure the physiological abduction of pancreatic juice into the lumen of the gastrointestinal tract.

The method is presented in the drawing, where 1 is a Soehendra-Tannenbaum ™ stent, 2 is a cystasal probe, 3 is the posterior wall of the stomach with a pseudocyst pancreas that swells into its lumen.

The method is as follows.

The main guidelines for the location of the cyst to the back wall of the stomach and duodenum (duodenum) are determined. The main guidelines for the place where the cyst adjoins the posterior wall of the stomach are: smoothness of the folds, stiffness, bulging of the wall, the presence of characteristic erosions and petechial hemorrhages on the mucosa. The main guidelines for determining the location of the cyst to the posterior wall of the duodenum: deformation, smoothness of the angle of transition of the upper horizontal branch of the duodenum to the descending, flattened folds, a sharp narrowing of the intestinal lumen in the form of a gap. An endoscopic fistula between the cyst and the lumen of the stomach or duodenum is created by pin-burning the back wall of these organs with a needle papillotome. Then, a Soehendra-Tannenbaum ™ (Wilson-Cook®) 10 or 11 Fr. stent is inserted into the cyst cavity through the created pinhole through it. To install the stent into the lumen of the cyst, the OASIS ™ (Wilson-Cook®) stent delivery system is used, the latter functions as a “one-step system” in which the internal guide catheter and pusher are connected together into a single coaxial unit. After installing the guiding catheter in the cyst using a special device, a block is removed that combines the guiding catheter and the pusher into a single unit, after which the stent is installed into the cyst cavity using the pusher in the usual way. With festering pseudocysts, thick purulent contents lead to blockage of the stent, which disrupts its functioning. To prevent this, pseudocysts on the wall, departing from the stent 2-3 cm, create another point fistula with a needle papillotome, a pig tail polyvinyl chloride probe is inserted into it, which is left in the cavity of the festering pseudocyst. The endoscope is removed, leaving one end of the probe in the pseudocyst cavity, and the other is removed through the nose as follows: the nasal tube is inserted into the nasal passage, it is gripped with a clip and removed through the mouth, drainage is introduced into it, and the drainage-tube complex is removed through the nose. A control examination of the oropharynx eliminates loop formation. In this case, it is necessary to ensure that the probe does not form unnecessary loops and is not excessively taut. In the postoperative period, antiseptics and antibiotics are introduced into the drainage, which provides external-internal drainage. After stopping the inflammatory process in the pseudocyst, the cystasal probe is removed, and the stent is left in the cyst for 3 months to form a cystogastric or cystoduodenal anastomosis with subsequent extraction after recovery.

Example. Patient B., East. illness No. 529, was admitted to the surgical department No. 1 of the Belgorod Regional Clinical Hospital of St. Joasaph on 04/04/08 with complaints of constant aching pain in the left hypochondrium and epigastrium, aggravated after eating and radiating to the lower back, feeling of heaviness, nausea, repeated vomiting, general weakness, body weight loss in 3 months per 10 kg. During the examination (ultrasound), an exacerbation of chronic pancreatitis, a pseudocyst of the pancreas (10 cm × 6.5 cm) was diagnosed. 02/05/08 performed endoscopic cystogastroanastomosis on the stent with cystasal drainage. The postoperative period was uneventful - nausea, vomiting stopped, and appetite was restored. The patient was discharged in satisfactory condition under the supervision of a gastroenterologist at the place of residence.

Claims (1)

A method for endoscopic treatment of suppurative pseudocysts of the pancreas, including the introduction of an endoscope into the upper gastrointestinal tract, burning with a papillotome of the posterior wall of the stomach or duodenum at the site of greatest swelling of the pseudocysts in the lumen of these organs, characterized in that after burning with the acicular papillotome the duodenum at the site of greatest bulging of the pseudocyst into the created anastomosis, a 10 or 11 Fr stent is inserted, then, retreating 2-3 cm from the first of the anastomosis, with a needle papillotome form the second same anastomosis, through which a polyvinyl chloride probe of the pig tail type is inserted into the cyst cavity, leaving one end in the cavity of the festering pseudocyst, and the other end is brought out through the nose, the pig tail probe is removed after the inflammation has been stopped and a 10 or 11 Fr stent is removed from the cavity of the pseudocyst after 3 months.

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