RU2768192C1 - Method for open isolated normothermic chemoperfusion of head and neck - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to oncology. Cardiac and aortic vessels are approached by means of a median sternotomy; a Finochetto rack retractor is placed with the vascular covering of the brachiocephalic trunk, the left common carotid artery and the left subclavian artery. After opening the pericardial cavity, the superior vena cava is fixed with a vascular covering. Then, a purse-string suture is applied on the brachiocephalic trunk and the left common carotid artery at 2–3 cm from orifice with 3/0 prolene suture; the suture is fixed with a Rummel tourniquet. In parallel, total systemic heparinisation is performed until an activated clotting time of 400–500 seconds is achieved. Brachiocephalic trunk, left common carotid artery, left subclavian artery are cannulated; after access to all necessary vessels, isolated head perfusion circuit is closed, pneumatic cuffs preliminarily put on the upper one-third of the upper extremities are inflated to pressure of 300 mm Hg., venous blood is sampled from the head, neck, upper extremities, blood from the superior vena cava is directed into the reservoir. Then isolated blood circulation circuit is started by blood flow along brachiocephalic trunk and left common carotid artery. Brachiocephalic trunk, the left common carotid artery, the left subclavian artery are clamped immediately at the mouth, the superior vena cava is clamped in place before the inflow into the right atrium. Performing isolated head perfusion with volumetric rate of 800 ml per minute along formed time contour, duration of isolated head perfusion is 30–60 minutes; blood gas analysis is performed every 15 minutes, acid-base state is controlled.

EFFECT: method allows to provide treatment of unresectable new growths of head and neck due to targeted action of higher doses of cytostatic, while minimizing its entry into systemic circulation, which will significantly facilitate the process of treating oncological patients and, as a result, the quality of life after the combined treatment.

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Description

The invention relates to medicine, namely to oncology, and can be used to treat patients with unresectable head and neck formations (or their transient metastases), or as part of their combined treatment.

At the moment, in the practice of treating head tumors, there is a method of chemotherapy by intracarotid sequential administration of ozonized saline (OSS) and a chemosensitizer, followed by the administration of a chemotherapy drug. When implementing this method, there is an increase in the effectiveness of treatment due to the synergistic effect of OFR, which increases the oxygenation of the tumor with the excitation of radical chain reactions of oxidation (the Haber-Weiss reaction) and, at the same time, potentiates the action of the chemosensitizer in relation to the susceptibility of the tumor tissue to the chemotherapeutic agent under conditions of increased stress oxygen (Medyanik I.A., Mukhina I.V., Dvornikov A.V. patent for invention RU2418587C1 2010-01-21). A significant disadvantage of this method is the “openness” of the system, which implies the entry of the administered OFR, chemosensitizer and chemotherapy drug into the systemic circulation, followed by a depressing effect of these drugs on the liver and other organs. These phenomena entail a decrease in the possibility of implementing this method due to both toxic effects on organs and an increase in the volume of contraindications to the implementation of this method.

When developing the proposed method, we considered the idea of a method of hyperthermic chemoperfusion of the pleural cavity, the essence of which is to create an isolated blood circulation circuit in the pleural cavity, which allows chemotherapy of the pleural cavity with minimal entry of cytostatics into the systemic circulation. This technique has successfully proven itself in the implementation of the treatment of neoplasms of the pleural cavity. For this purpose, an apparatus for hyperthermic perfusion is used, consisting of a reservoir based on a pleural jar, a set of sterile lines, a heat exchanger with a thermostat, a roller pump, a gravitational leukocyte filter, monitoring equipment and a thermostat. Its essence lies in the shutdown of the lung from the blood circulation and its isolated perfusion with a cytostatic, while minimizing the flow of the chemotherapy drug into the general circulation (Levchenko Evgeny Vladimirovich, Senchik Konstantin Yurievich, Barchuk Alexei Stepanovich, Lemekhov Vladimir Grigorievich, Gelfond Vladislav Markovich, Timofeeva Ekaterina Sergeevna; patent for invention 2358775, date 09/28/2009).

However, even "soft" hyperthermia (38-41°C), as a component of chemoperfusion treatment of neoplasms, can have a negative effect on the nervous tissue. In this regard, the exclusion of the hyperthermic component allows the use of this method in the treatment of neoplasms of the head and neck, subject to its significant modernization while maintaining the fundamental component - isolated chemoperfusion.

Isolated "open" normothermic chemoperfusion has not previously been used. The complexity of the procedure was the lack of modern techniques and tools. For CNS tumors, only systemic chemotherapy was used. The proposed method for the treatment of head and neck tumors is used for the first time.

The purpose of our proposed method is to provide treatment of unresectable neoplasms of the head and neck due to the targeted action of higher doses of cytostatic, while minimizing its entry into the systemic circulation, which will greatly facilitate the treatment of cancer patients and, as a result, the quality of life after combined treatment.

The solution of this problem is achieved by open access to the vessels of the heart by the method of median sternotomy, mobilization and taking on vascular covers of the brachiocephalic trunk (BCS), the left common carotid artery (LOCA), the left subclavian artery (LSA) (preliminary formation of a carotid-subclavian anastomosis on the left is possible for perfusion of the left carotid artery from the basin of the subclavian artery). The superior vena cava (SVC) is then mobilized transpericardially. BCS, VOC and SVC are cannulated. Due to the cannula in the SVC, the cardiotomy reservoir is filled. Preliminary systemic heparinization of the patient is carried out. To clamp the arteries and veins of the upper extremities, pneumatic cuffs are used, which are inflated by the time the cardiotomy reservoir is filled. Isolation of blood circulation is achieved by clamping the BCS, VOC, LPA immediately at the point of origin from the aortic arch. The SVC is clamped at the confluence of the brachiocephalic veins. Clamping of large vessels is carried out in order to minimize the release of cytostatics into the systemic circulation. According to the created closed isolated circuit, isolated normothermic chemoperfusion of the head is started, which reduces the likelihood of an inflammatory process and edema in the perfused tissues. The duration of the procedure is 30-60 minutes, which is enough for the cytostatic to enter the vessels that feed the tumor. The use of a membrane oxygenator makes it possible to achieve a state of hyperoxia, which potentiates the antitumor effect of the complex therapy of malignant neoplasms. During perfusion, blood gas composition and its acid-base indicators are constantly monitored. The procedure ends with the washing out of the cytostatic agent from the formed circulatory circuit by perfusion with a special solution consisting of 1500 ml of 0.9% sodium chloride solution, 500 ml of gelofusin and 300 ml of erythrocyte suspension. The washing out of the cytostatic agent is carried out so that the chemotherapy drug does not enter the general circulation after the implementation of the proposed method.

The proposed method allows us to solve a number of problems of modern oncology of the head and neck region, namely the risk of complications resulting from systemic chemotherapy. In addition, it becomes possible to use higher doses of cytostatics, which will enhance the therapeutic effect, reduce the manifestation of systemic intoxication of the body after systemic chemotherapy and increase the median survival of this category of patients.

The invention is illustrated in FIG. 1, which shows the connection diagram of the circuits of the apparatus for isolated chemoperfusion

The method is based on the creation of a closed circuit by cannulating the brachiocephalic trunk (1), the left common carotid artery (2), the left subclavian artery (3), the superior vena cava (4) and the use of pneumatic cuffs (5) on the upper limbs (upper third level) .

The method of "open" normothermic isolated chemoperfusion of the head and neck is implemented through the following actions: median sternotomy is performed, a lath retractor (Finochetto dilator) is installed. They are mobilized and fixed with vascular tourniquets-covers: BCS (1), VOC (2), LPA (3). The pericardium is opened with a T-shaped incision, which is fixed with 4 separate interrupted sutures to the skin. It is mobilized and taken for vascular closure of the SVC (4). A purse-string suture with a 3/0 prolene thread is applied to the BCS and VOC at a distance of 1-3 cm from the mouth, the thread is taken on the Rummel tourniquet. Total systemic heparinization is performed until an activated clotting time of 400-500 seconds is reached (heparin is administered intravenously at the rate of 100 U/kg of the patient's body weight). BCS and LOSA are cannulated with 1/4-3/8 inch cannulas, in the direction “toward the head”. The SVC is cannulated with a cannula with a diameter of 1/4-3/8 inches, in the direction "towards the head". The isolated circuit of the isolated perfusion of the head is closed: venous blood sampling from the head, neck, upper limbs: blood from the SVC to the cardiotomy reservoir, and return from the latter to the BCS and VOC. Parallel blood circulation is started along this circuit. Vascular isolation of the head is carried out: a) air is pumped into the cuffs (5) installed on the right and left shoulder to a pressure of 300 mm Hg; b) pinch BCS, VOC, LPA immediately at the mouth; d) clamp the SVC immediately in place before flowing into the right atrium. Isolated perfusion of the head begins. Perfusion is performed at a volumetric rate of 800 ml per minute along the formed time contour with a solution consisting of 300 ml of an erythrocyte suspension, 700 ml of a 0.9% sodium chloride solution, high doses of a cytostatic agent (melphalan 1.5 mg per 1 kg of body weight) under conditions of hyperoxia and normothermia (37.5 degrees Celsius), which is achieved by connecting a membrane oxygenator with a heat exchanger. The duration of isolated perfusion of the head is 30-60 minutes. Every 15 minutes, a blood gas analysis is performed, the acid-base state is monitored. At the end of the procedure, the head is perfused with a solution consisting of 1500 ml of 0.9% sodium chloride solution, 500 ml of gelofusin and 300 ml of erythrocyte suspension. The cannulas are removed and the cannulated vessels are sutured. Neutralize heparin with a solution of protamine sulfate at the rate of 1.5 mg of protamine sulfate for every 100 IU of heparin. Layered suture of the sternotomy wound.

Claims (1)

The method of isolated normothermic chemoperfusion of the head, characterized in that it provides access to the vessels of the heart and aorta through a median sternotomy, the Finochetto rack retractor is installed, followed by taking the brachiocephalic trunk, the left common carotid artery, the left subclavian artery onto the vascular covers; after opening the pericardial cavity, the superior vena cava is fixed with a vascular cover; then, a purse-string suture is applied to the brachiocephalic trunk and the left common carotid artery 2-3 cm from the mouth with a 3/0 prolene thread, while the thread is fixed with a Rummel tourniquet; in parallel, total systemic heparinization is performed until an activated clotting time of 400-500 seconds is reached; while cannulating the brachiocephalic trunk, the left common carotid artery, the left subclavian artery; after access to all the necessary vessels, the isolated head perfusion circuit is closed, the pneumatic cuffs previously put on the upper third of the upper limbs are inflated to a pressure of 300 mm Hg. Art., venous blood is taken from the head, neck, upper limbs, blood from the superior vena cava is sent to the reservoir; then an isolated circulatory circuit is started with blood flow through the brachiocephalic trunk and the left common carotid artery; clamp the brachiocephalic trunk, the left common carotid artery, the left subclavian artery immediately at the mouth, clamp the superior vena cava in place before flowing into the right atrium; isolated perfusion of the head is performed at a volume rate of 800 ml per minute along the formed time contour, the duration of the isolated perfusion of the head is 30-60 minutes, while every 15 minutes a blood gas analysis is performed, the acid-base state is controlled.

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