RU2620756C1 - Method of surgical treatment of patients with purulent pyelonephritis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: perform video-reteretoneoscopic decapsulation of the kidney with the removal of apostematous foci, sanitation and drainage of the retroperitoneal space. In a day, the renal artery is catheterized for intra-arterial infusion. On the first day, infusion of vasaprostan in a dose of 20 mcg per 20.0 ml of 0.9% sodium chloride solution is carried out. Further for the next four days, infusions of the antibiotic from the group of cephalosporins of the 3rd generation to 50 ml of 0.9% sodium chloride solution in a continuous mode at a rate of 2 ml per hour are carried out.

EFFECT: prevention of further spread of purulent-destructive processes in the kidney due to the removal of hypertension and restoration of blood circulation along major arterial highways when the distal blood flow is opened for antibacterial therapy.

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Description

The invention relates to medicine, namely to surgery and urology, and can be used to improve the results of surgical treatment of purulent pyelonephritis.

The problem of early diagnosis and treatment of patients suffering from acute purulent pyelonephritis remains relevant. Purulent pyelonephritis is a serious disease, the untimely diagnosis of which leads to the development of septic conditions associated with fatal consequences. Despite the availability of modern diagnostic equipment, powerful antibacterial agents and wide operational capabilities, the number of patients with purulent kidney diseases continues to grow steadily. Therefore, it is currently relevant to create a new minimally invasive, less traumatic method for treating patients with purulent pyelonephritis.

A known method of surgical treatment of purulent pyelonephritis by open surgery (Ayvazyan A.V., Voino-Yasenetsky AM Acute diseases of the kidneys and urogenital tract. - M., 1985, p. 24), including lumbotomy, revision of the kidney, its drainage by nephrostomy, decapsulation, dissection or excision of carbuncles, opening and drainage of abscesses.

The disadvantage of this method is the high invasiveness because:

1. The intersection of the massive muscle layers of the lumbar region on the side of the lesion.

2. Inevitability in the early postoperative period caused by open surgery is inevitable.

3. The long duration and severity of the postoperative period, the secondary healing of the wound is determined.

4. The need in some cases of extensive kidney damage by a purulent process to resort to nephrectomy.

The closest technical result achieved (prototype) is a method of surgical treatment of purulent pyelonephritis by open surgery (Ayvazyan A.V., Voino-Yasenetsky AM Acute diseases of the kidneys and urogenital tract. - M., 1985, p. 24), including lumbotomy, revision of the kidney, its drainage by nephrostomy, decapsulation, dissection or excision of carbuncles, opening and drainage of abscesses, and intravenous antibiotic therapy in the postoperative period.

The disadvantage of this method is the high invasiveness and inefficiency, because antibiotic therapy does not eliminate the microcirculation disorders in the distal vascular bed of the kidney.

The authors proposed a minimally invasive minimally traumatic method of surgical treatment of patients with purulent pyelonephritis.

The technical result of the proposed method is to reduce the morbidity of surgical access due to minimally invasive technology for retroperitoneoscopy without losing the volume of the operation in the treatment of purulent pyelonephritis.

The technical result is achieved by preliminarily performing videoreperitoneoscopic renal decapsulation with removal of apostematous foci, rehabilitation and drainage of the retroperitoneal space, followed by catheterization of the renal artery and intra-arterial infusion in a day, moreover, vazaprostane is infused in the first day at a dose of 20 mcg to 20.0 0 9% solution of sodium chloride (NaCl) followed by an infusion of an antibiotic from the group of cephalosporins 3 pacific for the next four days pouring 50 ml of a 0.9% solution of sodium chloride (NaCl) in continuous mode at a rate of 2 ml per hour.

The method is as follows.

The essence of the method is illustrated by figures 1-2. The figure 1 presents angiography before the application of intra-arterial infusion, where the areas of ischemia in the upper pole and middle segment of the kidney are visible. The figure 2 presents angiography after a course of intra-arterial infusion, which determines the pattern of restored blood flow in all areas of the kidney.

Under aseptic conditions, after twice processing the surgical field, under endotracheal anesthesia on the affected side, in the patient’s position, three trocars are placed in the retroperitoneal space on the side. The primary operating cavity is created using retroperitoneum. In this case, a kidney is extracted from the perinephral fiber, then a fibrous capsule of the kidney is dissected with a scalpel in the lower segment of the kidney along its convex edge. Next, most of the capsules are excised. Defect the apostematous foci by electrocoagulation. A day after decapsulation of the kidney, percutaneous catheterization of the femoral artery according to Seldinger with a 1% lidocaine solution is performed, piercing the front wall of the vessel, conduct the conductor into the renal artery. Then a 4-5 F catheter (French) is inserted, which is fixed to the skin and an infusomat is attached to it and intra-arterial infusion is carried out for five days: only vazaprostan is administered on the first day, the dose of which is 20 μg 1 ampoule (per 20.0 ml 0 , 9% NaCl solution) for intra-arterial infusion in accordance with the instructions for use of this drug. Then for four days, an infusion of antibiotics in a continuous mode (cephalosporins of 3 generations) at a dose of 8.0 g of ceftazidime (2.0 g per day at a rate of 2 ml per hour per 50 ml of a 0.9% NaCl solution) is connected. The infusion is carried out by a syringe pump, for example B. Braun Perfusor Compact.

Clinical example: Patient S. 32 years old, was admitted to the hospital with complaints of pain in the left lumbar region. The patient considers himself from September 2015, when the stone of the left ureter was first discovered. Since October 2015, it has been deteriorating: the pain intensified, radiating to the left inguinal region, back. Examined by a urologist AKKP, hospitalized for surgical treatment. An objective examination: General condition of moderate severity. The consciousness is clear, the position is active. The physique is correct, moderate in nutrition. The skin is pale. Visible mucous membranes are not changed. Peripheral lymph nodes are not enlarged. No swelling. The chest is of the correct form, both halves symmetrically participate in the act of breathing. Percussion is clear pulmonary sound over all pulmonary fields, with auscultation, vesicular breathing, no wheezing. NPV 16 per minute. Heart sounds are muffled, the rhythm is correct. The pulse is rhythmic, good filling 80 per min. HELL - 120/80 mm Hg The area of the bladder and kidneys without deformation, hyperemia, no swelling. The kidneys are not palpable. The symptom of striking is negative on the right, on the left - positive.

Objective: The tongue is wet, not coated. The abdomen is symmetrical, not swollen, participates in the act of breathing. On palpation, mild, moderate soreness in the epigastrium. The liver does not protrude from the edge of the costal arch. The spleen is not palpable. There are no symptoms of peritoneal irritation. The chair is normal. The lumbar region is not swollen, symmetrical. Palpation is painless. The symptom of striking is positive on the left. Ultrasound of the kidneys: November 7, 2015 - hydronephrosis on the left, pelvis up to 46 mm, calyx up to 18 mm. Survey + I / O urography from 11/01/2015: The shape, size and location of the kidneys are normal. The shadow of the stone on the left is at the level of L ₂ , up to 2.0 cm in size. The function on the right is normal, on the left is the function.

11/07/15, after preliminary preoperative preparation, contact lithotripsy of the upper third on the left with stenting was performed under intravenous anesthesia. Further, under the ETN, retroperitoneoscopic access, according to the adopted scheme, established trocars (Fig. 1) on the left and performed decapsulation with the destruction of purulent foci (apostem) with sanitation and drainage of the retroperitoneal space. Next, the catheterization of the left renal artery was performed according to the Seldinger system, after puncture of the right femoral artery with angiographic monitoring of the position of the catheter and angiography of the left kidney (Fig. 1).

Then, during the first day, the drug vasaprostane was administered with an infusomat at a dose of 20 μg 1 ampoule (per 20.0 ml of a 0.9% NaCl solution) during the day. Over the next four days, 8.0 g of ceftazidime was administered (2.0 g per day at a rate of 2 ml per hour per 50 ml of a 0.9% NaCl solution).

When removing the catheter from the renal artery, a control angiography of the left kidney was performed (figure 2). The expressed positive dynamics of peripheral blood circulation in the area of the cortical layer and in the area of the arcade arteries over the entire surface of the kidney is determined.

Histology No. 19654: Fragments of a kidney capsule with purulent inflammation. Discharge assays: OAK: Hb128 g / l; L 8.0; ESR 4 mm / hour; P1; OAM: beats. weight 1017; protein 210 mg / ml; L 14-17 p / sp; oxalates.

Discharged in satisfactory condition.

Thus, the inventive method has a low invasiveness, minimally invasive technology of videoreperitoneoscopic renal decapsulation allows to achieve a lesser degree of trauma to the kidney and surrounding tissues, which leads to the removal of hypertension and restoration of blood circulation along large arterial arteries. Arterial infusion of vasaprostan into the renal artery allows you to open the distal vascular bed for blood flow and the delivery of immune complexes and subsequent local antibiotic therapy. The use of methods in combination is necessary to affect all levels of the vascular bed and parenchyma tissue in the area of its microabscesses and infection zones. The use of vasaprostan prevents the further spread of purulent-destructive processes in the kidney, which in some cases allows you to save it and not to perform a nephrectomy.

Claims (1)

A method for the surgical treatment of patients with purulent pyelonephritis, including antibiotic therapy in the postoperative period, characterized in that videoreperitoneoscopic decapsulation of the kidney is preliminarily performed with the removal of apostematous foci, sanitation and drainage of the retroperitoneal space, followed by intravenous artery catheterization in the arteries and an intravenous artery catheterization in a day, and the first day, infusion of vasaprostan at a dose of 20 μg per 20.0 ml of 0.9% chloride solution per dence (NaCl) followed by for the next four days infusion of an antibiotic from the group of 3rd generation cephalosporins in 50 ml 0.9% sodium chloride solution (NaCl) in a continuous mode at a rate of 2 ml per hour.

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