RU2562135C1 - Method of treating acute post-manipulation pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine. After the manifestation of a clinical picture of acute pancreatitis a guide is introduced into MPD orifice. A stent is installed by the guide into the papilla region in such a way that its one end is in MPD lumen 20-25 mm from its orifice, and the other one projects to 10-15 mm into the duodenum lumen. The stent is removed after 2-3 days after the relief of pain syndrome and disappearance of enzymatic toxaemia.

EFFECT: method provides the treatment of acute post-manipulation pancreatitis due to the drainage of the main pancreatic duct under conditions of oedema in the papilla region.

4 cl, 5 dwg, 1 ex

Description

The invention relates to surgery, and more specifically to surgical endoscopy, and can be used in the treatment of acute pancreatitis that occurs after retrograde transpapillary interventions.

It is known that one of the most formidable and common complications of endoscopic retrograde interventions is acute post-manipulative pancreatitis. There are a large number of publications in the literature, including multicenter and randomized trials reflecting the use of pancreatic stents in the treatment of chronic pancreatitis in the presence of ductal pathology of the pancreas (pancreas) (strictures, pancreatic hypertension, pancreatic fistula and cysts).

In addition, the installation of pancreatic stents has been widely used for a long time for acute pancreatitis of biliary genesis, which occurred on the background of the insertion of calculus into the terminal part of the choledochus or into the ampoule of the large duodenal papilla (BDS), which causes the stone to block the mouth of the main pancreatic duct (GLP) and prevents outflow of pancreatic juice from GLP to the duodenum 12. The scope of the operation in this case consists in performing endoscopic papillosphincterotomy, lithoextraction and pancreatic stenting in order to resolve pancreatic hypertension and, as a consequence, the clinic of acute pancreatitis.

In addition, in the last decade, pancreatic stenting has been widely used as a prophylaxis for the development of acute post-manipulative pancreatitis, especially in patients with a high risk of developing such a complication.

In the patent (RU 2263517 C2, Mikhailova S.A. 10.11.2005), the Wirsung duct is decompressed using a silicone stent or catheter for pancreatogastrostomy with pancreatoduodenal resection. A stent or catheter is fixed in the anastomosis by one of the sutures of the inner row. The free end of the stent or catheter is freely positioned in the stomach and tied to a nylon thread discharged through the nose. After 7-10 days, the stent or catheter is removed.

The proposed method is a stage of traditional surgical intervention and is aimed directly at the decompression of the Wirsung duct, resulting from mechanical stress and trauma during the operation. The method is preventive, and pancreatoduodenal resection, in the vast majority of cases, is performed for a tumor lesion of the pancreatobiliary zone or chronic pancreatitis.

Patent RU 2364367 C1, Sedov et al., 08/20/2009, describes a drainage method for treating suppurative pancreatic pseudocysts. Its main stages are holding an endoscope in the upper sections of the gastrointestinal tract, followed by burning with a papillotome of the posterior wall of the stomach or duodenum at the site of greatest bulging of the pseudocyst into the lumen of these organs. After the creation of the anastomosis, a stent is placed in it, departing 2-3 cm from the first anastomosis, and the second same hole is formed with a needle papillotome. Through it, polyvinyl chloride drainage of the pig tail type is installed in the cyst cavity. In this case, one end of the drainage is left in the cavity of the suppurating pseudocyst, and the second is removed through the nasal passage. Cystonasal drainage is removed after 5-7 days, and the stent is removed from the cavity of the pseudocyst after 3 months.

This method is intended for the treatment of one of the main complications of chronic pancreatitis - pancreatic pseudocyst.

A method for the prevention of bleeding from a papillosphincterotomy wound during multi-stage endoscopic surgery for choledocholithiasis is described in patent RU 2458636 C1, Tolstokorov, 08.20.2012. Catheterization of the ampoule of the large duodenal papilla, endoscopic retrograde pancreatocholangiography. Then, using an arc papillotome, a papillosphincterotomy is performed, followed by partial extraction of calculi. After this, a temporary stent with rounded curved perforated ends is installed so that one end is placed in the common bile duct and the other in the duodenum. After 2-4 days, the stent is removed and the remaining stones are removed. The method according to the authors allows to increase the reliability of the prevention of postpapillotomy bleeding.

Although this method is minimally invasive, it is aimed at preventing another possible complication of retrograde interventions - postpapillotomy bleeding, and not at treating post-manipulative pancreatitis as proposed in the patented method, which generally has a different purpose and specificity.

The closest in essence is a method for the prevention of acute post-manipulative pancreatitis (Manzerov E.V., Moroz M.P. Reactive pancreatitis after endoscopic manipulations on the large duodenal papilla / RZHGKK, No. 3, 2007, pp. 14-23 - prototype). The method includes the implementation of complex conservative therapy aimed at suppressing the secretion of the pancreas, stomach and duodenum, reducing enzyme toxinemia, eliminating hypovolemia, water-electrolyte and metabolic disorders, improving the rheological properties of blood and minimizing microcirculatory disorders, combating hypoxemia, treating gastric paresis intestinal tract, pain relief and stenting.

The applicant is not aware of the use of plastic pancreatic stents in the treatment of acute pancreatitis that has already arisen in the short term after performing endoscopic manipulations on the BDS. Moreover, most domestic and foreign experts are afraid of performing any transpapillary interventions in the conditions of an existing edema of the BDS region. This is due to the potential risk of exacerbating the clinical picture, as well as significant technical difficulties in performing this manipulation.

We set the task - to develop a method for effective rapid relief of the clinical picture of acute post-manipulative pancreatitis that has already arisen.

A patented method for the treatment of acute post-manipulative pancreatitis includes complex conservative therapy aimed at suppressing the secretion of the pancreas, stomach and duodenum, reducing enzyme toxinemia, eliminating hypovolemia, water-electrolyte and metabolic disorders, improving blood rheological properties and minimizing microcirculatory disorders, , treatment of paresis of the gastrointestinal tract, relief of pain.

Stenting of the main pancreatic duct (GLP) is performed using an endoscopic technique, for which a flexible conductor string is inserted into its mouth, then a plastic stent is placed on it so that one of its ends is in the GLP lumen at a distance of 20-25 mm from its mouth and the other protruded 10-15 mm into the lumen of the duodenum. The stent is removed 2-3 days after the relief of pain and the disappearance of enzyme toxemia.

The method can be characterized by the use of radiopaque plastic stents with lateral perforations and retaining wings at both ends, as well as the fact that the flexible conductor string has a diameter of 0.64-0.9 mm, and the plastic stent has a length of 3 up to 5 cm and a diameter of 1.7-2.3 mm.

The method can be characterized by the fact that the position of the stent is monitored endoscopically upon receipt of pancreatic juice through its lumen.

The technical result consists in minimally invasive effective and rapid treatment of acute post-manipulative pancreatitis, reducing the time of regression of the clinical and laboratory picture of acute post-manipulative pancreatitis due to reliable drainage of GLP in conditions of existing edema of the papilla region.

The essence of the method is illustrated in the drawings, where

in FIG. 1 shows a view of the pancreatic stents used: a) a curved plastic stent with lateral perforations and bilateral wings-retainers; b) a straight plastic stent with lateral perforations and bilateral wings-retainers;

in FIG. 2 - edema of the area of endoscopic papillosphincterotomy;

in FIG. 3 - retrograde cholangiopancreaticography; dilatation of the main pancreatic duct;

in FIG. 4 - RG-picture of pancreatic stenting;

in FIG. 5 - the same as in figure 4 - endoscopic photograph.

Patients for endoscopic intervention were selected according to the following criteria: the clinical picture of acute post-manipulative pancreatitis in the near future after the initial procedure, accompanied by an increase in blood and / or urine amylase, characteristic changes according to the ultrasound examination (ultrasound) of the abdominal cavity and in some patients with changes characteristic for acute pancreatitis according to the results of endoscopic ultrasonography (ESM) and computed tomography (CT).

After revealing in patients the clinical picture of acute pancreatitis that arose on the background of an intervention on the BDS (usually from 12 hours to 1.5 days after the initial procedure) and a comprehensive diagnostic program, including laboratory research methods, ultrasound of the abdominal cavity and a number of cases of ESD and CT, an emergency re-endoscopic intervention was performed in the volume of stenting of GLP.

Endoscopic transpapillary interventions were performed using duodenoscopes: JF-1T140, TJF-100, EVIS TJF-160Q, manufactured by Olympus and the ED-250-XT5 from Fujinon with an instrument channel of 3.2 and 3.8 mm, using the EVIS EXERA video unit. The x-ray stage of the intervention was performed using a Siremobil Compact electron-optical transducer from Siemens, Germany, or the General Electric Advantix angiographic apparatus, USA.

Interventions were carried out using various endoscopic instruments: single and double-lumen catheters, radiopaque plastic strings with a diameter of 0.6 to 0.9 mm, papillotomes with the possibility of strings and pushers along them, Olympus, Japan, Boston Scientific, USA, and Wilson-Cook, USA. For pancreatic stenting, we used radiopaque plastic stents with lateral perforations and wings with retainers from Olimpus (Japan), Wilson-Cook (Germany) and Boston Scientific (USA) with a diameter of 1.5-2.5 mm and a length of 30 to 50 mm.

Surgery itself is as follows.

After performing duodenoscopy and assessing the state of the EPST or BDS zone (Fig. 2), they sought to selectively catheter the mouth of the GLP, which was usually complicated by the presence of pronounced edema of this zone. The reference point was the typical location of the mouth of the Wirsung duct in the projection of the postpapillotomy site. As a rule, the mouth of the GLP is localized below and to the right of the mouth of the common bile duct, which, after previously performed EPST, is usually not difficult to determine. In all cases, cannulation was carried out along a plastic conductor string.

With successful catheterization of the mouth of the GLP, in some cases, in order to avoid contrast of the GLP against the background of the already developed OPMP, the orientation of the instruments was carried out by means of X-ray navigation, depending on the characteristic direction of the guide wire. However, in most observations, retrograde pancreatography was performed to accurately determine the location of the conductor string by introducing 1.5-2 ml of a contrast medium solution diluted with a dioxidine solution in a ratio of 3: 1 at the mouth of the GLP. At the same time, the presence of a moderately pronounced dilatation of the GLP, which developed against the background of edema of the mouth of the GLP, was usually determined on the pancreatogram (Fig. 3).

After that, a plastic stent was installed along the string using a pusher in order to resume an adequate outflow of pancreatic juice into the lumen of the gastrointestinal tract so that the proximal end of the stent was 20–25 mm above the mouth of the GLP and the distal end protruded by 10–15 mm into the lumen 12 duodenal ulcer (Fig. 4, 5). An indicator of the adequate performance of therapeutic pancreatic stenting was the beginning of copious flow of viscous pancreatic juice through its lumen.

The results of a retrospective study conducted at the Department of Hospital Surgery No. 2 RNIMU them. N.I. Pirogov on the basis of City Clinical Hospital №31 in 2008-2013, gave the following results. Performing pancreatic stenting as early as possible from the clinic of acute post-manipulative pancreatitis was technically feasible in 90.5% of cases (19 out of 21). At the same time, in all the observations after performing stenting of GLP, there was a pronounced positive clinical effect that led to the recovery of patients, in addition, the hospitalization period was significantly reduced (6-21 days). At the same time, the mortality rate of patients in the group where pancreatic stenting was not performed or failed was 28.9%, and the length of stay in the hospital was significantly delayed (15-33 days).

The obtained results convincingly demonstrate the effectiveness of this method of treating APS, and the implementation of internal pancreaticoduodenal drainage does not cause additional discomfort to the patient.

The criteria by which the effectiveness of this treatment method was evaluated were: a positive clinical picture (pain management and well-being of patients), the absence of amylazuria according to laboratory research methods and instrumental data for OP according to the results of control abdominal ultrasound.

CLINICAL EXAMPLE. Patient Sh., 66 years old, was admitted to the clinic as planned to perform retrograde intervention for PCES, papillostenosis and biliary hypertension.

Earlier, in 2006, the patient underwent a laparoscopic cholecystectomy for chronic calculous cholecystitis. After 4 years, she began to notice periodically occurring pains, a feeling of heaviness in the right hypochondrium. An ambulatory ultrasound revealed signs of biliary hypertension.

In connection with the above complaints and findings, she was admitted to the hospital for endoscopic intervention.

An examination in the clinic confirmed the presence of dilation of the common bile duct (up to 10.1 mm) and suggested the presence of stenosis of the BDS. 05.24.10 planned atypical (non-cannulation) papillosphincterotomy, retrograde cholangiography, revision of the common bile duct, biopsy was taken. The operational diagnosis is formulated as PCES. Papillostenosis of the 3rd degree, which served as the cause of biliary hypertension.

In the immediate postoperative period, the patient developed a clinical picture of acute pancreatitis (an increase in amylazuria to 4502 units / l and leukocytosis to 13.4). According to ultrasound: acute pancreatitis (pancreatic edema), signs of biliary and pancreatic hypertension (up to 4 mm).

In this regard, after 20 hours from the initial intervention an urgent repeated retrograde intervention was performed. It was found that the mouth of the GLP is located 3 mm lower and to the right of the edge of the mouth of the common bile duct, the tissues in this zone are swollen, hyperemic, the lumen of the mouth of the GLP is less than 1 mm, and no pancreatic juice is present.

A plastic conductor string with a diameter of 0.6 mm was carried out at the GPP and pancreatic stenting was performed along it. A plastic stent 40 mm long and 2.3 mm in diameter was installed. After this, an abundant flow of turbid pancreatic secretion was noted. Additionally, for the purpose of enteral nutrition, an endoscopic installation of the probe for the Trades ligament was performed.

In the postoperative period, against the background of complex conservative therapy, positive dynamics were noted: the pain syndrome was stopped, normalization of laboratory parameters was noted 2-3 days after repeated intervention (leukocytes - 9.1, amylazuria - no). According to the results of the control ultrasound of the abdominal cavity, as well as CT scan of the abdominal cavity, pathological changes were not detected. The pancreatic stent was removed on the 5th day. The patient was discharged under the supervision of a doctor at the clinic on the 7th day after repeated intervention.

Claims (4)

1. A method of treating acute post-manipulative pancreatitis, including complex conservative therapy aimed at suppressing the secretion of the pancreas, stomach and duodenum, reducing enzyme toxinemia, eliminating hypovolemia, water-electrolyte and metabolic disorders, improving blood rheological properties and minimizing microcirculatory disorders with hypoxemia, treatment of paresis of the gastrointestinal tract, relief of pain, stenting of the main pancreatic duct (GLP) using an endoscopic technique, for which a flexible conductor string is inserted into its mouth, then a plastic stent is installed along it so that one of its ends is in the GLP lumen at a distance of 20-25 mm from its mouth and the other - protruded 10-15 mm into the lumen of the duodenum, and the stent is removed 2-3 days after the relief of pain and the disappearance of enzymatic toxemia. 2. The method according to p. 1, characterized in that use radiopaque plastic stents with lateral perforations and wings-retainers at both ends. 3. The method according to p. 1, characterized in that the flexible conductor string has a diameter of 0.64-0.9 mm, and a plastic stent has a length of 3 to 5 cm and a diameter of 1.7-2.3 mm. 4. The method according to p. 1, characterized in that the position of the stent is controlled endoscopically upon receipt of pancreatic juice through its lumen.

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