RU2549995C1 - Method of treating pancreatic leaks following pancreatic transplantation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: pancreatic leaks following pancreatic transplantation is eliminated. That is followed by X-ray and ultrasound guided drainage of the leak regions. A gastroscope with end-face optics is used to localise a greater duodenal papilla of the transplant. A pancreatic duct of the transplant is selectively catheterised on the side of a duodenal lumen. That is followed by X-ray controlled localisation of the pancreatic leak. The pancreatic duct of the pancreatic transplant is stented. A proximal end of the stent is arranged in a major pancreatic duct and blocks the stenosis from an oedema, while its distal end is found in the intestinal lumen.

EFFECT: method provides a lower risk of interduodenal anastomosis complications following the pancreatic-duodenal and donor duodenum transplantation by improving the visualisation of the donor duodenum and the arrangement of the stent in the major pancreatic duct with blocking the stenosis from the oedema.

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Description

Technical field

The invention relates to medicine, namely to transplantology, and can be used as part of complex therapy of pancreatic streaks after transplantation of the pancreas.

State of the art

Pancreatic transplantation (TPA) is the treatment of choice for patients with type 1 diabetes mellitus complicated by end-stage chronic renal failure in the outcome of diabetic nephropathy. Despite the improvement of surgical technique, the appearance of new suture material and more effective antibacterial and immunosuppressive drugs TPA is accompanied by the highest level of postoperative complications compared with transplantation of other solid organs. Despite the large pool of potential recipients, the widespread use of TPA in the clinic is difficult due to the high risk of transplant loss due to surgical complications. Pancreas transplantation can be characterized by a unique set of surgical complications caused by exocrine secretion and low organ microcirculatory blood flow. According to world literature, along with venous thrombosis and pancreatitis of a pancreatic transplant, often complicated by pancreatic necrosis, the formation of pancreatic leakage remains the third cause in the composition of surgical complications leading to organ loss. The worldwide correction technique for this surgical complication, which, as a rule, consists in the drainage of pathological fluid formations, does not allow repeated open operations to be avoided. A group of patients for whom repeated open operations had to be performed to eliminate surgical complications is characterized by a higher frequency of transplant losses. Thus, surgical complications with a high risk of repeated relaparotomy are partly a limiting factor in the widespread spread of pancreatic transplantation. In this regard, it is relevant to solve the problem of minimally invasive treatment of parapancreatic congestion.

The prior art has not identified technical solutions regarding methods of treatment (or elimination) of pancreatic stains after transplantation of the pancreas. In modern surgical practice, the drainage of pathological fluid formations, which include a parapancreatic leak, is considered as a symptomatic treatment of this surgical complication. The inventive method relates to an etiopathogenetic method of treatment (correction) of a specified surgical complication based on stenting of a pancreatic pancreatic transplant duct.

The prior art methods of treating hypertension in the main pancreatic duct (GLP) using percutaneous puncture stenting of the main pancreatic duct (GLP) under ultrasound examination and X-ray television (RTB) guidance, for example [Mathieson JR, Cooperberg PL, Murray DJ, Dashefsky S, Christensen R, Schmidt N. Pancreatic duct obstruction treated with percutaneous anterograde insertion of a metal stent: report of two cases. Radiology 1992; 185: 465-467]. However, this method is not applicable for the treatment of pancreatic stains after transplantation of the pancreas. In addition, the known method has a significant drawback, since for stenting the pancreatic duct, it is necessary to violate the integrity of the skin and injure the pancreatic tissue, which significantly increases the likelihood of complications.

There is also a method of treating chronic pancreatitis with stenosis of the main pancreatic duct using the technique of percutaneous puncture stenting of GLP under the control of ultrasound research and RTV [RF patent No. 2341203]. This technique has an advantage over the previous one: the stent is placed intrapancreatically, blocking the stenosis zone, it is not carried out through the large duodenal papilla (BDS) in the duodenum (duodenum). Thus, the physiological closure function of the sphincter of Oddi is preserved. However, it also has a number of disadvantages, which, in addition to violation of the integrity of the skin and trauma to the pancreatic tissue (as in the above method), include the inability to remove the stent from the pancreatic duct after treatment.

The objective of the invention is to develop a new method for eliminating pancreatic streaks after transplantation of the pancreas, minimally invasive and less traumatic, in the implementation of which there is no violation of the integrity of the skin, trauma to the pancreatic tissue, violation of the integrity of the sphincter apparatus of the BDS and the possibility of removing the stent after treatment. The method allows for a shorter time to eliminate a surgical complication.

The technical result is the absence of an increase in the size of the pancreatic leak or the cessation of pancreatic juice through the drainage in case of drainage.

The problem is solved in that the method for eliminating pancreatic streaks after pancreas transplantation involves drainage of the streaks under X-ray and ultrasound guidance, after which, using a gastroscope with end optics, the area of the graft BDS in the duodenum is determined, then from the side of the duodenum without violating the integrity of the BDS ( without virsungotomy) perform selective catheterization of the pancreatic duct of the transplant along the string with its contrast, after which, under x-ray control, the localization of nkreaticheskogo streaks and operate stenting pancreatic duct pancreatic transplant, wherein a proximal end of the stent in the main pancreatic duct of an overlapping area of stenosis of edema and distal - in the intestinal lumen.

Additionally, in the treatment of pancreatic sagging after pancreas transplantation, antisecretory therapy with somatostatin is used according to a standard method.

Distinctive features of the proposed method are:

1. After transplantation of the pancreatic-duodenal complex, the interodenal anastomosis is located on the lateral wall of the vertical portion of the duodenum. In this case, the BDS of the donor part of the duodenum is located on the opposite side of the recipient's BDS wall of the duodenum. Therefore, the method of classical stenting of the pancreatic duct using an endoscope with lateral optics (duodenoscope) is not possible. The inventive method involves the use of an endoscope with end optics (gastroscope), which significantly improves the visualization of the donor BDS and additionally makes possible a detailed examination of the mucous membrane of the esophagus, stomach and duodenum (which cannot be done with a duodenoscope).

2. Retrograde access to the duct of the donor pancreas using endoscopic technique is minimally invasive and non-traumatic, because:

a) stenting of the main duct of the pancreas of the transplant is performed from the lumen of the duodenum without compromising the integrity of the skin (in contrast to antegrade methods of stenting);

b) the introduction of a stent into the pancreatic duct is carried out without violating its integrity (without performing a wirsungotomy), since there is no risk of compression of the common bile duct, since during transplantation of the complex of the duodenum and pancreas, there is no need for choledoch explantation. It is ligated and cut off from the complex.

3. This method is the most "physiological", because:

a) pancreatic secretion continues to enter the intestinal lumen and participate in the digestion process;

b) the closure function of the sphincter of Oddi is not disturbed, respectively, after the treatment and removal of the stent, the physiological mechanism of the portioned intake of pancreatic juice in the intestinal lumen is preserved.

Thus, the task of eliminating pancreatic leak is solved through the use of complex therapy, which includes stenting of the main pancreatic duct of the donor pancreas, which provides decompression in the pancreatic duct system. This helps to subside the phenomena of transplant pancreatitis and accelerates the closure of external and internal pancreatic fistula.

Description of drawings (and photographs)

The invention is illustrated by drawings and photographs, where in FIG. 1 - schematically shows the transplanted pancreato-duodenal complex with the formed interdenal anastomosis, where 1 - recipient BDS, 2 - duodeno-duodenoanastomosis, 3-graft BDS (donor pancreas), 4 - stent in the pancreatic duct of the donor pancreas; in FIG. 2 - an image of a donor BDS before stenting is presented; in FIG. 3 is an x-ray image of a donor GLP (virsungografiya) during the administration of a contrast medium; in FIG. 4 - image of a donor BDS after stenting; in FIG. 5 is an image of a donor BDS after stenting after 2 months.

DETAILED DESCRIPTION OF THE INVENTION

The method is as follows.

The formation of pancreatic leak remains the third cause in the structure of surgical complications leading to transplant loss. Diagnosis of complications, as a rule, is not difficult due to daily ultrasound monitoring of transplanted pancreas. Most often, the complication develops in the first 4 weeks after transplantation. After the appearance of ultrasound signs of a parapancreatic leak, computed tomography is performed in combination with fistulography if there is an external pancreatic fistula. The study helps to assess the size and localization of the leak, its accessibility for minimally invasive procedures, which allows to determine the tactics of correction of complications. Under U3- and / or radiological guidance, percutaneous drainage of the pancreatic leak is carried out for adequate drainage and sanation of the lesion. An integral part of successful therapy is the drainage of the main pancreatic duct in order to decompress it and create favorable conditions for the resumption of the natural outflow of pancreatic secretion into the lumen of the donor duodenum. In addition, antisecretory therapy with somatostatin preparations (octreotide) is prescribed.

The patient is examined in the supine position on the left side with a Olympus GIF-IT Q160 gastrofibroscope (gastroscope) using the EXERA II video endoscopic system. Before the study, intravenous sedation and local anesthesia of the pharynx are performed with 10% lidocaine solution (spray).

A gastroscope is subsequently inserted into the esophagus, stomach, and then into the duodenum to the area of the donor large papilla (BDS) of the duodenum (duodenum). Then, with the help of a catheter, selective pancreatic duct catheterization is performed along the string with its contrast, a contrast medium is introduced - Omnipack 250 mg diluted with warm saline solution 1: 3-25.0 ml. Then, under the X-ray control, the localization of the pancreatic leak is revealed and the pancreatic duct of the donor pancreas is stented. A conductor string is drawn into the pancreatic duct without performing a wirsungotomy. After that, a plastic pancreatic stent is installed along the string so that its proximal end is located in the projection of the pancreas body, and the distal one in the lumen of the intestine. This ensures adequate drainage of the pancreatic duct through pancreaticoduodenal stenting.

Thus, stenting of the main pancreatic duct is an integral part of the successful treatment of parapancreatic ducts. The inventive method provides decompression of the pancreatic ducts of the transplant. The method allows to avoid the use of open surgery in the treatment of pancreatic leakage.

Examples of specific performance.

Patient L., born in 1970, with a diagnosis of Type 1 diabetes mellitus, severe course B, subcompensation. Diabetic nephropathy V art. with outcome in terminal chronic renal failure (chronic kidney disease 5 tbsp. according to NKF / KDOQI). Condition after combined retroperitoneal transplantation of the kidney and pancreas with the formation of the interdenal anastomosis from 09.21.2012. Satisfactory nephrotransplant and pancreatic transplant function. Secondary arterial hypertension. Secondary subcompensated nephrogenic anemia. Diabetic polyneuropathy, retinopathy, micro and macroangiopathy.

On the 47th postoperative day, a pancreatic leak was diagnosed with the formation of an external pancreatic fistula and the blind end of the second fistulous passage in the subcutaneous fatty tissue of the left iliac region with the formation of an abscess. An esophagogastroduodenoscopy, endoscopic retrograde pancreaticography, endoscopic stenting of the pancreatic duct pancreatic duct with the aim of decompression, repeated drainage of the leak under X-ray and ultrasound guidance followed by drainage and sanitation, as well as systematic anti-inflammatory therapy were performed.

During the study, the patient’s position is lying on his left side. The study was conducted under intravenous sedation and local anesthesia of the pharynx with a 10% solution of Lidocaine (spray) with an Olympus GIF-IT Q160 gastrofibroscope using an EXERA II video endoscopic system. The gastroscope was sequentially inserted into the esophagus, then into the duodenum. The area of the donor large papilla of the duodenum (BDSC) is localized in the spur area of the duodeno-duodenoanastomosis. The mouth of the BSDK up to 2 mm in diameter (see Fig. 2). Next, selective catheterization of the pancreatic duct along the string with its contrast was performed, a contrast agent was introduced (Omnipack 250 mg diluted with warm saline solution 1: 3-25.0 ml). When x-ray it was revealed that the lumen of the donor pancreatic duct is uneven: in the head region - 3 mm, in the body region - up to 1 mm, crimped. Its contours are clear, uneven. The contents of the duct are homogeneous. In the tail region there is an extravasation of the contrast medium into the parenchyma (Fig. 3 (b)). Given the clinical and radiological data, the diagnosis was established: pancreatic leak, narrowing in the region of the head of the pancreatic duct, condition after transplantation of the pancreatic-duodenal complex and kidney from 09/21/12. Further, stenting of the pancreatic duct of the donor pancreas was performed. A string of COOK company with a diameter of 0.35 inc. Was drawn into the pancreatic duct. After that, a COOK plastic stent with a diameter of 7 Fr and a length of 5 cm was installed along the string. The discharge of transparent pancreatic juice was noted on it. Proximal in the area of transition of the pancreatic head into the body (according to fluoroscopy) - FIG. 3 (a). Evacuation of contrast medium for 2 minutes completely. The distal end of the stent in the intestine is 1.0 cm (Fig. 4).

Thus, adequate drainage of the pancreatic duct through pancreaticoduodenal stenting was achieved. On the 67th day after stenting of the pancreatic duct (the 130th day after the combined kidney and pancreas transplantation was performed), the closure of the external pancreatic fistula was noted. Pancreatic stent removal was performed 115 days after stenting (179 days after combined kidney and pancreas transplantation).

Thus, the claimed method allowed to avoid open surgery in order to eliminate surgical complications.

Claims (1)

A method for eliminating pancreatic sagging after pancreas transplantation, including drainage of sagging areas under X-ray and ultrasound guidance, after which, using a gastroscope with end optics, the location of the graft BDS in the duodenum is determined, and then, from the side of the duodenum, without the integrity of the duodenum, the pancreatic pancreatic duct is selectively catheterized. along the string with its contrast, after which, under X-ray control, the localization of the pancreatic leak is revealed and stenting is performed eaticheskogo duct pancreatic transplant, wherein a proximal end of the stent in the main pancreatic duct of an overlapping area of stenosis of edema and distal - in the intestinal lumen.

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