RU2544362C1 - Method for kidney allotransplantation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: donor's kidney is grafted. After an uretherocystoanastomosis is formed, trocars are inserted within renal poles. Their outer ends are embedded into subcutaneous fat. Coletex AKL Hydrogel tissue 150-1,500 ml is placed into a retroperitoneal space. The wound is closed in layers. The retroperitoneal space is filled with Coletex ADL Hydrogel 100-800 ml through the trocars 8-16 hours after the surgery. The re-filling procedure is performed every 24-48 hours for 6-8 days. The trocars are removed.

EFFECT: method reduces the risk of acute and chronic allograft nephropathy, prevents the haemodynamic disorders of the donor organ.

Description

The invention relates to medicine, in particular to surgery, transplantology.

Allotransplantation of the kidney (ATP) is the only renal replacement therapy that contributes to the most complete rehabilitation of patients with end-stage chronic renal failure. However, the survival of the recipient and the renal transplant largely depends on the nature of the course of the early postoperative period, the main adverse factors of which are: on the one hand, a high risk of bleeding, and on the other, thrombosis of the arteries and veins of the renal transplant.

The risk of bleeding in the early period after ATP is due to pathological conditions of the blood coagulation system, often concomitant with chronic renal failure, exacerbated by constant heparinization of patients receiving renal replacement therapy with hemodialysis, with the formation of hematomas, which cause the formation of hemo - and urodynamic disorders in the renal transplant, leading to transplant death and an increase in the incidence of infectious complications, often fatal in the face of massive immunos ppressivnoy therapy early period after kidney allograft as well as the development of hemorrhagic shock and death of the patient.

However, the inability to fix the kidney transplant in the operative wound / retroperitoneal region causes a high risk of arterial and vein thrombosis of the renal transplant due to the displacement of the latter (up to horizontal inversion) under the influence of changes caused both by pressure in the abdominal cavity and as a result changes in muscle tone of the anterior abdominal wall.

The highest risk of the complications of kidney transplantation described above is characterized by an early postoperative period. In this regard, the most relevant is the use of a set of measures to prevent the above complications in the early period after ATP.

The known method of ATPP, including its processing, the formation of vascular anastomoses of the type "end-to-side" and restoration of blood flow in the body, followed by laying the transplant in the optimal position (Filiptsev P.Ya. Clinic, diagnosis and treatment of surgical complications in patients with hemodialysis and after kidney transplantation. Thesis for the academic degree, doctor of medical sciences - M., 1990, pp. 245-248).

However, the application of the described method of ATPP is not accompanied by the implementation of manipulations aimed at ensuring reliable prophylaxis of hemostasis, improving blood flow and preventing arterial thrombosis in the veins of the renal transplant, which increase the effectiveness of surgical intervention by reducing the time needed to restore functional usefulness and increase the survival of the kidney allograft and the quality of life of the recipient.

The closest is the method of kidney allotransplantation (RF Patent 2461360, IPC АВВ 17/00, publ. 2012), including access to the retroperitoneal space, the formation of anastomoses between the same vessels of the donor kidney and recipient of the end-to-side type, ureterocystoanastomosis, external drainage of the retroperitoneal space, suturing of the surgical wound. The formation of anastomoses between the vessels of the same name of the donor kidney and recipient is carried out in such a way that the defects of the vascular wall formed for anastomosis are located medially, which allows the renal transplant to be placed with its outer edge towards the abdominal cavity, as a result of which the risk of kidney displacement and kinking of the vessels is minimized.

The disadvantage of this method of ATPP is also the inability to fix the transplant in the retroperitoneal space, thereby creating conditions for increasing the risk of hemodynamic disturbances in the transplant with subsequent deterioration of its functional usefulness.

The objective of the proposed method is to improve the results of ATPP by eliminating a significant displacement of the donor kidney in the retroperitoneal region in the early period after ATPP in order to minimize the risk of hemodynamic disturbances caused by kinks in the blood vessels of the kidney. Achievements of the formation of the capsule around the graft, which ensures the fixation of the position of the latter, improve blood flow in the parenchyma of the donor kidney, stimulate the restoration of its function, reduce the severity of damage to the renal tissue as a result of the possibility of early differential diagnosis of rejection episodes and their relief at the preclinical stage and increase the effectiveness of prevention of intra- and postoperative bleeding due to filling the retroperitoneal space with hydrogel materials.

To accomplish the task with ATPP, the method includes access to the retroperitoneal space, the formation of anastomoses between the same vessels of the donor kidney and recipient of the end-to-side type, ureterocystoanastomosis, external drainage of the retroperitoneal space, suturing of the surgical wound. New is the fact that after the formation of ureterocystoanastomosis in the region of the poles of the kidneys, trocars are placed with the installation of their outer ends in adipose tissue directly under the skin in the area of the surgical wound. Then, a Coletex-AKL hydrogel napkin is placed in the retroperitoneal space in the amount of 150-1500 ml, and the surgical wound is sutured in layers, 8-16 hours after the operation, the retroperitoneal space is filled through the trocars with the Coletex ADL hydrogel material in the amount of 100-800 ml every 24-48 hours for 6-8 days, after which the trocars are removed.

The introduction of the Coletex ADL hydrogel napkin ensures the safety of the ports being in the postoperative wound for a long time, the introduction of the Coletex-AKL hydrogel napkin allows the kidney to be fixed for a long time due to its natural viscosity. The improvement of peripheral blood flow in the renal transplant parenchyma is achieved due to the vasodilating effect of lidocaine, while the hemostatic effect is achieved due to the introduction of Coletex-AKL hydrogel material into the retroperitoneal region.

In the department of "Transplantology, nephrology and surgical hemocorrection" using the proposed method was performed 28 ATP. The restoration of renal blood flow function occurred on average 4.3 ± 1.8 days earlier, and the degree of rejection episodes was less pronounced in comparison with transplants performed in a standard way, which, of course, had an impact on the survival of the donor kidney. None of the ATPs performed by the proposed method was complicated by the development of clinically significant bleeding and the formation of hematomas, as well as infectious inflammation of the tissues of the surgical wound.

The implementation of the method shown in specific clinical examples.

Example 1

Patient K., born in 1970, was admitted for allotransplantation of a kidney with a diagnosis of an abnormality in the development of the urinary system. Chronic pyelonephritis. Chronic renal failure, terminal stage. Anemia.

According to the proposed method, an inhalation vessel was accessed under inhalation anesthesia, a donor kidney was treated, anastomoses were formed between the vessels of the same name of the donor kidney and recipient, end-to-side, and ureterocystoanastomosis was performed. A kidney transplant was placed retroperitoneally in an optimal position. After this, Coletex-AKL hydrogel hemostatic material was placed in the retroperitoneal region in a volume of 300 ml until the retroperitoneal space was completely filled, then 2 endoscopic ports (5 mm) were placed at the poles of the renal transplant, the distal ends of the ports were fixed with a monofilament absorbable suture material to the peritoneum, and the beveled port parts are towards the kidney. The ports were filled with Coletex ADL hydrogel material (10 ml each), after which the surgical wound was sutured in layers, placing the external openings of the ports under the skin in adipose tissue in the area of the surgical wound.

In the early postoperative period, the ports performed a drainage function. Videoendoscopic monitoring of the state of the postoperative wound and graft was performed with filling the wound with 100 ml of Coletex ADL hydrogel material every 24 hours.

The restoration of transplant function was observed on the 5th day after surgery. Ports were removed on the 6th day after surgery. Normalization of the function of a paired donor kidney occurred on the 8th day after allotransplantation; both surgical interventions were performed simultaneously.

The course of the immediate postoperative period occurred without complications.

Example 2

Patient D., born in 1963, was admitted for allotransplantation of a kidney with a diagnosis of polycystic kidney disease. Chronic pyelonephritis. Chronic renal failure, terminal stage. Anemia. Arterial hypertension.

According to the proposed method, under endotracheal anesthesia, access to the iliac vessels was made, the donor kidney was treated. A native nephrectomy was performed due to the risk of developing infectious complications. Ureterocystic and vascular anastomoses were formed. The renal graft was placed retroperitoneally in the optimal position. After that, the Coletex-AKL hydrogel hemostatic material was placed in the retroperitoneal region in a volume of 1500 ml until the cavity formed after nephrectomy was completely filled (a large cavity was formed in place of the bed of the removed native kidney), then, as described in Example 1, the ports were installed.

Visual assessment of the condition of the operation area was carried out by a rigid endoscope with optics having a bevel angle of 30 ° and 70 °, placed in one of two endoscopic ports, 5 mm in diameter, installed in the region of the upper and lower poles of the kidney with filling the postoperative wound with 800 ml of Coletex hydrogel material ADL "every 48 hours for 7 days.

The course of the immediate postoperative period occurred without complications. When observed within 6 months after ATP, there were no signs of hemodynamic disturbances associated with exposure to adverse immune (rejection) and non-immune factors.

The application of the proposed method in clinical practice can increase the frequency of primary kidney function, reduce the incidence of acute and chronic transplant nephropathy, eliminate hemodynamic disturbances, which leads to increased survival of donor organs, patients and their quality of life.

Claims (1)

A method of kidney allotransplantation, including access to the retroperitoneal space, the formation of anastomoses between the same vessels of the donor kidney and the recipient of the type "end-to-side", ureterocystoanastomosis, external drainage of the retroperitoneal space, suturing of the surgical wound, characterized in that after the formation of the ureterosystic region the kidneys place trocars with the installation of their outer ends in adipose tissue directly under the skin in the area of the surgical wound, then into the retroperitoneal space along they keep the Coletex-AKL hydrogel napkin in the volume of 150-1500 ml, the surgical wound is sutured in layers, and 8-16 hours after the operation, the retroperitoneal space is filled through the trocars with the Koleteks ADL hydrogel material in the amount of 100-800 ml every 24- 48 hours for 6-8 days, after which the trocars are removed.