RU2376039C1 - Method for treatment of liver cirrhosis complicated with diuretic-resistant ascites - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention is related to medicine, namely to surgery, and may be used in treatment of patients with liver cirrhosis complicated with diuretic-resistant ascites. For this purpose under local anesthesia, fully implantable peritoneal port-system is installed into subcutaneous fat. Catheter of port-system is inserted into abdominal cavity with implantation to rectus muscle of abdomen by cuff, installing its working end into iliac fossa and connecting to port. System for transfusion passed through infusion pump is connected to port-system, connecting venous end of system for transfusion with subclavian vein. Prior to and after reinfusion, ascitic fluid is radiated with low-energy helium-neon laser with laser power at the outlet of 10 MW, exposure of 10-15 minutes, wave length of 0.63 mcm in continuous mode. Reinfusion of ascitic fluid is carried out with the rate of 15-20 ml per minute, fractionally by 500-700 ml with interval of 5-7 minutes, daily in volume of 1.5-2.5 l with reduction of initial volume to 1.05-0.55 l.

EFFECT: method makes it possible to reduce risk of postoperational complications development due to fractional introduction of autoascitic fluid and its radiation.

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Description

The invention relates to medicine, namely to surgery, and can be used to treat liver cirrhosis complicated by diuretic-resistant ascites in the stages of sub- and decompensation of portal hypertension.

Correction of diuretic-resistant ascites in patients with cirrhosis is an urgent problem in modern hepatology. The development of edema-ascitic syndrome in a patient means the transition of the disease to an extremely difficult phase, where the use of vascular porto decompression interventions is sharply limited by the initially severe condition of the patients. The desire to obtain a tangible and persistent effect in the treatment of ascites has led to the creation of many techniques aimed at diverting fluid from the abdominal cavity into the vascular bed.

However, peritoneovenous valve bypass grafting is not possible with a low gradient between intra-abdominal and central venous pressure (CVP), in the presence of ventral hernias of the anterior abdominal wall and chylous ascitic fluid with increased viscosity, and also there are a number of serious postoperative complications.

The prototype of the invention is a method of treating diuretic-resistant ascites in patients with decompensated liver function using peritoneovenous shunting with valve mechanism Le Veen (Peritoneovenous shunting for ascites / Le Veen H., Christodias G., Ip M. et al. Ann. Surg. - 1974. - Vol. 180. -P.580-591). This technique requires opening the abdominal cavity and access in the neck to expose the internal jugular vein, followed by ligation of its proximal end (which is also not indifferent) and the introduction of a venous catheter into the distal end of the vein up to the level of the right atrium. The Levin shunt is feasible (only!) In the presence of a significant pressure gradient between the intra-abdominal and CVP, a clear ascitic fluid with minimal viscosity and the absence of an umbilical hernia. When using the Levin shunt, ascitoreinfusion into the venous bed proceeds constantly, in large volumes, especially on the first day after installation, which causes serious complications.

EFFECT: widening of the range and correction of diuretic-resistant ascites regardless of the state of intra-abdominal pressure, central hemodynamics and rheology of ascitic contents; prevention of postoperative complications, including bleeding syndrome - as a result of the prevention of hemodilution and coagulopathy due to fractional, portioned ascitoreinfusion, and toxic-allergic reactions - by carrying out low-energy laser irradiation of ascitic fluid before and during reinfusion.

The proposed method is as follows: for a patient with cirrhosis complicated by diuretic-resistant ascites, in the stages of sub- and decompensation of portal hypertension, a fully implantable Celsite® peritoneal port system from B / Braun is installed under local anesthesia. In this case, the port catheter is inserted into the abdominal cavity through an incision on the anterior abdominal wall. The working end of the catheter is directed to the left iliac fossa with implantation to the rectus abdominis muscle by the cuff and then is passed to the port located in the subcutaneous tissue. The port is washed with saline, the catheter is cut to the required length and connected to the port. Subsequently, a system for transfusion of single use connected through the Braun FMS infusomat, the venous end of which is connected to one of the veins of the superior vena cava pool, in this case the subclavian vein, is connected to the port system. Recycling ascites fluid is carried out at a speed of 15-20 ml per minute, fractionally 500-700 ml with an interval of 5-7 minutes, to prevent overload of the cardiovascular system and redistribution of the injected fluid. Ascitorein infusion is carried out daily, in the amount of 1.5-2.5 l, fractionally, dosed, taking into account the general condition and hemodynamic parameters of patients, in order to exclude the occurrence of hemorrhagic syndrome - the initial dose is always less (1.05-0.55 l). Treatment is carried out against the background of conventional conservative treatment. After the first 1-2 ascitoreinfusion procedures, diuretic therapy is completely canceled for patients. Subsequently, conservative treatment is continued, which includes only fortifying, hepatotropic therapy and protein preparations. Ascitoreinfusion procedures are carried out until the complete regression and relief of ascites (7-10 procedures). In order to prevent toxic-allergic reactions to the administration of ascitic fluid, low-energy helium-neon laser irradiation of ascitic fluid with the LG-75 apparatus is performed before and during ascitoreinfusion, through a waveguide with an output power of 10 mW, with an exposure of 10-15 minutes, a wavelength of 0, 63 microns in continuous mode.

The application of the proposed method allows for ascitoreinfusion fractionally, portionwise, which is the main advantage, minimizes the occurrence of postoperative complications. As a result of the fractional intake (in small portions) of ascitic fluid into the venous channel, the occurrence of hemodilution and coagulopathy, which can lead to the occurrence of bleeding syndrome, is prevented. Preventive low-energy helium-neon laser irradiation of ascitic fluid prevents the development of toxic-allergic reactions during ascitoreinfusion.

The use of the port system is possible even in the presence of chylous ascites, a small pressure gradient between the intraperitoneal and CVP, as well as in the presence of ventral hernias of the anterior abdominal wall.

The proposed method does not present technical difficulties, and after the installation of the implantable device, the collection of ascites fluid and its transfusion can be performed by a nurse. Thus, during the first day in patients, ascites and stabilization of ascites and normalization of the function of the organs of the hepatorenal and cardiopulmonary systems occur.

In the available scientific, medical and patent literature, no information was found on the popularity of a method for treating liver cirrhosis, including sampling and reinfusion of ascitic fluid through a fully implantable peritoneal port system, fractional portioned ascitoreinfusion with low-energy helium-neon laser irradiation of ascitic fluid. Thus, the claimed invention meets the criterion of "novelty."

The authors' studies proved that the collection and reinfusion of ascitic fluid through a fully implantable peritoneal port system, fractional portioned ascitoreinfusion with low-energy helium-neon laser radiation of ascitic fluid prevent postoperative complications, including bleeding syndrome. Thus, the claimed invention meets the criterion of "inventive step".

Example 1. Patient D., 53 years old. Complaints upon admission for an increase in the abdomen, weakness, lack of appetite, difficulty breathing and sleep disturbance due to this, the presence of a large umbilical hernia, swelling on the legs, a sharp decrease in the amount of urine released, fatigue. Considers herself a patient for 5 years, when she began to note pain and heaviness in the right hypochondrium. From an anamnesis 12 years ago she suffered Botkin's infectious hepatitis, during the last year ascites appeared, poorly amenable to conservative therapy. It was treated stationary, laparocentesis was repeatedly performed with the evacuation of significant amounts of ascitic fluid.

Objectively: the general condition of the patient is moderate, the severity is due to intense ascites. The skin is pale, undernourished. The abdomen is sharply increased in size due to ascites. The perimeter of the abdomen at the navel was 126 cm. Due to severe ascites, it is not possible to assess the condition of the internal organs; with deep palpation, the dense edge of the enlarged spleen protruding from the edge of the hypochondrium is determined. Diuresis up to 500 ml per day without stimulation, with stimulation of 80 mg / day of furosemide - 650 ml per day. Chair with constipation. The patient underwent a clinical laboratory examination and was diagnosed with “Post-necrotic cirrhosis of the liver, portal hypertension in the stage of decompensation, splenomegaly, diuretic-resistant ascites.” Conducted conservative therapy in the clinic was ineffective. Diuresis remained negative, the perimeter of the abdomen during the period of stay in the hospital increased by 4 cm, body weight by 3 kg.

After appropriate preoperative preparation under local anesthesia, a fully implantable peritoneal Celsite® port system from B / Braun was installed. In this case, the port catheter was inserted into the abdominal cavity through an incision on the anterior abdominal wall. The working end of the catheter was directed to the left iliac fossa with implantation to the rectus abdominis muscle by the cuff and then led to the port located in the subcutaneous tissue. The port was washed with saline, the catheter was cut to the required length and connected to the port. Subsequently, a single-use transfusion system connected through Braun FMS infusomat, the venous end of which was connected to the subclavian vein, was connected to the port system.

Intra-abdominal pressure of 230 mm of water. Art., CVP - 70 mm Hg Ascitic fluid reinfusion was carried out at an average rate of 16-18 ml per minute, fractionally 595 ± 70 ml with an interval of 5 minutes, to prevent cardiovascular overload and redistribution of the injected fluid.

Ascitorein infusion was carried out daily, in the amount of 1.8 ± 0.3 l, fractionally, dosed, taking into account the general condition and hemodynamic parameters of the patient, with a decrease in the initial dose to 0.8 ± 0.25 l. In parallel, conservative therapy was performed.

However, after the first ascitoreinfusion, the patient had a toxic-allergic reaction in the form of chills with a subsequent increase in body temperature, which were stopped by conservative measures. They did not have a negative effect on the patient's condition and did not constitute a refusal from subsequent reinfusion of ascites. Subsequently, in order to prevent toxic-allergic reactions, low-energy helium-neon laser irradiation of ascitic fluid with the LG-75 apparatus was performed before and during ascitoreinfusion through a waveguide with an output power of 10 mW, with an exposure of 10-15 minutes, a wavelength of 0.63 μm in continuous mode. After 2 ascitoreinfusion procedures, the patient was completely canceled diuretic therapy.

In the postoperative period, an improvement in liver metabolism in biochemical blood tests was noted, allergic reactions to ascitoreinfusion were absent.

The perimeter of the abdomen decreased to 103 cm. Diuresis increased to 1.8 ± 0.4 l without stimulation. Ascites was completely eliminated by the end of the first week. On the 10th day, a patient with good health was discharged for outpatient monitoring.

Example 2. Patient M., 37 years old. Complaints upon receipt of a sharp increase in the size of the abdomen, shortness of breath, swelling on the legs, a sharp decrease in the amount of urine released, swelling on the legs, fatigue.

From the anamnesis: 9 years ago he twice suffered a viral hepatitis B. Subsequently, he was repeatedly treated with a diagnosis of “Exacerbation of chronic hepatitis”. Ascites appeared and began to progress steadily over the past 6 months. Recently, almost stopped responding to diuretic drugs. Repeatedly performed laparocentesis with the evacuation of large quantities of ascitic fluid. Marks the appearance of an umbilical hernia.

General condition upon receipt of moderate severity, the skin is pale, low nutrition. The abdomen is sharply increased in size due to ascites, the perimeter of the abdomen at the level of the navel 121 cm. It is not possible to palpate the state of the internal organs of the abdominal cavity due to intense ascites, with deep palpation, the dense lower pole of the enlarged spleen is determined. Diuresis up to 500 ml per day with severe stimulation (Lasix 8.0 iv, Veroshpiron 2 tablets. 2 times a day), stool with a tendency to constipation.

The patient underwent a clinical and laboratory examination and was diagnosed with “Post-necrotic cirrhosis of the liver, portal hypertension in the stage of decompensation, splenomegaly, diuretic-resistant ascites.” Conducted conservative therapy in the clinic was ineffective. Diuresis with stimulation remained negative. The perimeter of the abdomen during the time spent in the clinic increased by 3 cm, body weight by 2 kg.

After appropriate preoperative preparation under local anesthesia, a fully implantable Celsite® peritoneal port system from B / Braun was installed on the patient. In this case, the port catheter was inserted into the abdominal cavity through an incision on the anterior abdominal wall in the upper right quadrant of the abdomen. The working end of the catheter was directed to the right iliac fossa with implantation to the rectus abdominis muscle by the cuff and then led to the port located in the subcutaneous tissue. The port was washed with saline, the catheter was cut to the required length and connected to the port. Subsequently, a single-use transfusion system connected through Braun FMS infusomat, the venous end of which was connected to the subclavian vein, was connected to the port system. Intra-abdominal pressure of 220 mm of water. Art., CVP - 50 mm Hg Ascitic fluid was reinfused at an average rate of 16 ml per minute, fractionally at 570 ± 50 ml with an interval of 5 min, to prevent cardiovascular overload and redistribution of the injected fluid.

Ascitorein infusion was carried out daily, in the amount of 1.9 ± 0.4 l, fractionally, dosed, taking into account the general condition and hemodynamic parameters of the patient, with a decrease in the initial dose to 0.8 ± 0.25 l. In parallel, conservative therapy was performed.

After the first session of ascitreinfusion, the patient had a toxic-allergic reaction in the form of chills with a subsequent increase in body temperature, which were stopped by a conservative one and did not constitute a refusal from subsequent ascites reinfusion. They also did not adversely affect the patient's condition. Subsequently, in order to prevent toxic-allergic reactions before and during ascitoreinfusion, low-energy helium-neon laser irradiation of ascitic fluid with the LG-75 apparatus was carried out through a waveguide with an output power of 10 mW, with an exposure of 15 minutes, a wavelength of 0.63 μm in continuous mode. After 2 ascitoreinfusion procedures, diuretic therapy was completely canceled.

In the postoperative period, an improvement in liver metabolism in biochemical blood tests was noted, allergic reactions to ascitoreinfusion were absent.

The perimeter of the abdomen decreased to 104 cm. Diuresis increased to 1.6 ± 0.3 L without stimulation. Ascites was completely eliminated by the end of the first week. On the 10th day, a patient with good health was discharged for outpatient monitoring.

In this way, 18 patients with cirrhosis of the liver complicated by diuretic-resistant ascites were treated in the stage of sub- and decompensation of portal hypertension. In all cases, the specified technical result was achieved.

The proposed method is easily reproducible in a hospital environment. Thus, the claimed invention meets the criterion of "industrial applicability".

Claims (1)

A method for the treatment of cirrhosis of the liver complicated by diuretic-resistant ascites, including ascitic fluid withdrawal from the abdominal cavity and reinfusion of it into the venous bed until complete regression and relief of ascites on the background of conventional conservative therapy, characterized in that the sampling and reinfusion is carried out through a fully implantable peritoneal port system which is installed in the subcutaneous tissue, while the port system catheter is inserted into the abdominal cavity, the working end of the catheter is inserted into the iliac fossa, the implant is June of the catheter to the rectus muscle by the cuff, connecting it to the port, the transfusion system through the infusomat is connected to the port system, the venous end of the transfusion system is connected to the subclavian vein, and ascitic fluid is irradiated with low-energy helium-neon before and during reinfusion a laser with a laser power at the output of 10 mW, an exposure of 10-15 minutes, a wavelength of 0.63 μm in continuous mode, and ascites fluid reinfusion is carried out at a speed of 15-20 ml per minute, fractionally 500-700 ml with an interval of 5- 7 mi Daily in a volume of 1.5-2.5 L with a decrease of the initial volume to 1,05-0,55 liter.