RU2786644C1 - Method for drainage of retroperitoneal space in purulent-necrotic parapancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to minimally invasive abdominal surgery. Under ultrasound control, 2-3 percutaneous punctures of the omental sac and the paracolon are performed sequentially on the right and/or left by extraperitoneal access. Rigid conductors are carried through the channels of the needle into the omental sac and retroperitoneal space. The needles are removed and puncture channels are treated with a bougie along the conductors, through which the omental sac and the paracolon on the left and/or right, with the condition of covering the purulent cavity and bringing the ends of the drains to necrosis, are sequentially inserted and the drains are blocked with clamps, excluding spontaneous ejection of exudate. Then, alternately, the clamps are removed and the exudate is evacuated, closed with removable drainage bags. Then, after 2-3 days, the drainage bags are removed and the area of purulent-necrotic parapancreatitis is washed with aqueous solutions of antiseptics. From days 7-10, the condition of the omental sac and retroperitoneal space is monitored once a week using omentobursoscopy and retroperitoneoscopy.

EFFECT: method provides simultaneous drainage of the omental sac and paracolons on the right and left; provides effective relief of the purulent-necrotic process in the omental sac and paracolic tissue, expands the possibilities of surgical techniques for drainage of cavities of varying degrees of complexity and configuration and makes it possible to reduce mortality.

1 cl, 2 ex

Description

The present invention relates to medicine, namely to minimally invasive surgery, and can be used in the treatment of patients with pancreatic necrosis in the phase of purulent complications.

Surgical treatment of pancreatic necrosis remains an urgent problem of abdominal surgery due to disappointing results of treatment and high mortality (B.C. Saveliev et al., 2009; P.R. Rakhimov et al., 2017; E.A. Gallyamov et al., 2020; E.R. Dellinger et al., 2012). Modern approaches to the surgical treatment of pancreatic necrosis are aimed at the most radical sanitation of the purulent-necrotic focus, subject to the reduction of surgical trauma and the use of minimally invasive treatment methods (Yu.V. Kulezneva et al., 2015; E.A. Gallyamov et al., 2020; M.W. Buchler et al., 2000). The main tasks of surgical treatment of infected pancreatic necrosis using minimally invasive treatment technologies are to remove pathological exudate and areas of necrosis (Goltsov V.R., 2015, Shabunin A.V. 2018). There are publications in which the use of minimally invasive techniques (puncture-drainage interventions) can achieve a decrease in mortality even in patients with a severe course of the disease (F.V. Galimzyanov et al., 2016).

An analogue of the proposed method for drainage of the retroperitoneal space is an access method for operations in the retroperitoneal space with complications of pancreatitis, proposed by V.N. Pozdeev, D.V. Mizgirev, A.A. Kuznetsov et al. (RU 2340288 IPC A61V 17/94; A61V 17). With this method, the localization, size, structure of purulent-necrotic formation is assessed using computed tomography. Under the control of computed tomography, a purulent-necrotic formation is punctured extraperitoneally with a needle no more than 20 cm long and no more than 1.66 mm in diameter, with a mandrin. After puncture, the mandrin is removed from the needle. A superrigid conductor with a flexible end is inserted into the formation cavity. The patient is removed from the aperture of the tomograph. The needle is removed from the formation, rigidly fixing the conductor. On the display screen of the tomograph, the distance from the puncture point on the surface of the patient's body to the purulent-necrotic formation is measured. Rigidly fixing the conductor, a pointed drainage or an angiographic bougie with a diameter of 5 mm is introduced along it under ultrasound control into the projection of a purulent-necrotic formation. The conductor is removed. The inserted device is fixed to the skin with a suture. The patient is transferred to the operating room. A trocar is inserted along the inserted device to a measured depth, focusing on the inserted device when a purulent-necrotic formation is reached, then the drainage (bougie) is removed, a laparoscope is inserted and retroperitoneoscopy is performed.

The disadvantages of the method:

- the use of computed tomography at the stage of diagnosis and drainage increases the radiation load on the patient;

- lack of visual control at the stage of drainage increases the risk of damage to vascular structures and retroperitoneal organs;

- the creation of one access to the retroperitoneal space does not provide full drainage and makes sanitation difficult, especially in the case of large cavities and cavities of irregular shape;

- the method does not provide for the possibility of creating multiple accesses to the retroperitoneal space;

- the method does not provide for the possibility of draining the stuffing bag with omentobursitis.

As the closest analogue, a method for the treatment of retroperitoneal pancreatogenic phlegmon, proposed by O.I. Okhotnikov, S.V. Ivanov (RU 2 128 949 IPC A61M 27/00; A61B 17/00). The method of treatment is as follows: according to the results of a sonographic study, signs of an exudative lesion of the retroperitoneal space in pancreatic necrosis are revealed. After that, under sonographic control, a targeted puncture of the retroperitoneal space is carried out with a needle of large diameter, for example, 17.5 G, with verification of the pathological discharge. Further manipulations are carried out under combined sono-fluoroscopic control. A water-soluble contrast is introduced along the needle into the destruction zone, the distribution of which specifies the volume and topography of the destruction zone. Then, through the lumen of the needle, a safe j-guide is inserted into the affected area and sequential hermetic dilatation of the wound channel is carried out through it with telescopic bougies, for example, from K Storz, to a caliber of 30-32 Fr, followed by the installation of a double-lumen drainage of large diameter (10-11 mm) and flow-through rinsing. Similarly, additional drains (1-2) are installed, depending on the prevalence of the destructive process.

In the post-manipulation period, not earlier than 5 days later, according to clinical, radiological and sonographic indications, according to the established drainage, an amplatz is inserted telescopically into the retroperitoneal space - a thin-walled casing with a beveled working end, through which, after temporary removal of the drainage, an optical instrument is inserted, for example, a rigid nephroscope firm K. Storz, through which they carry out visual control over the state of the destruction zone, and also carry out necrosequestrectomy.

The disadvantages of the method:

- the method does not provide for the possibility of draining the stuffing bag with omentobursitis with large-diameter drains;

- the introduction of a water-soluble contrast impairs visualization and makes it difficult to carry out an intervention under ultrasound control, bougienage of the wound channel under X-ray control increases the risk of damage to vascular structures and organs of the retroperitoneal space due to the lack of their visualization;

- the use of a soft conductor at the stage of bougienage of the wound channel does not provide sufficient rigidity of the structure, as a result of which it breaks and changes the direction of the bougie in the tissues;

- there is no possibility to drain the retroperitoneal space along a pre-planned trajectory, due to the emptying and subsidence of the cavity after the installation of the first drainage.

Tasks:

- creation of full-fledged accesses, by simultaneous, sequential drainage of the stuffing bag and paracolon on the right and left with double-lumen drainages of large diameter, taking into account their subsequent washing;

- expanding the capabilities of the surgical technique for draining cavities of varying degrees of complexity and configuration along a pre-planned trajectory;

- increasing the efficiency of the rehabilitation of the purulent-necrotic process of the retroperitoneal space, for a set of drains leading directly to the necrosis (sequestration) zone, which allows not only the evacuation of liquid exudate, but also the removal of necrotic tissue through double-lumen drainage tubes when they are washed with antiseptic solutions;

- relief of the purulent-necrotic process of the omental sac and retroperitoneal space (paracolon on the right and left);

- decrease in mortality due to increased efficiency of sanitation of purulent-necrotic focus.

The essence of the method is that, under ultrasound control, sequentially 2-3 percutaneous punctures of the cavity of the omental sac and paracolon on the right and / or left are carried out with extraperitoneal access, rigid conductors are passed through the channels of the needle into the cavity of the omental sac and retroperitoneal space, the needles are removed and bougie along the conductors puncture canals, through which the omental bag and paracolon on the left and / or on the right, with the condition of covering the purulent cavity and bringing the ends of the drains to necrosis, are sequentially introduced and the drains are closed with clamps, excluding spontaneous release of exudate, immediately after that, the clamps are alternately removed and the exudate is evacuated, closed removable drainage bags, then after 2-3 days the drainage bags are removed and the area of purulent-necrotic parapancreatitis is washed with aqueous solutions of antiseptics, after which, from 7-10 days, the state of the omental sac and retroperitoneal space is monitored once a week using omentobursoscopy and retroperitoneoscopy.

The method has been tested for 15 years in 256 patients with purulent-necrotic parapancreatitis.

EFFECT: one-stage, sequential drainage of the stuffing box and paracolon on the right and left by double-lumen drainages of large diameter 30-32 Fr, their sequential introduction and overlap during drainage, prevents the emptying of the liquid and the closure of the cavity and allows the tubular drainages to be arranged in such a way that during drainage tubes covered the purulent cavity, and the ends were brought to necrosis; the location of the drains in the cavities along a pre-planned trajectory, the supply of drains directly to the zone of necrosis (sequestration), allows not only the removal of the exudative component, but also the sanitation of necrotic tissue through double-lumen drainage tubes when they are washed with antiseptic solutions, which makes it possible to effectively stop purulent-necrotic The process in the omental sac and paracolic tissue expands the possibilities of the surgical technique for draining cavities of varying degrees of complexity and configuration and makes it possible to achieve a decrease in mortality.

Approbation of the method allowed to reduce mortality from 45 to 14.3%. The method is carried out as follows.

At the diagnostic stage, computed tomography of the abdominal organs and retroperitoneal space is performed, the location of necrosis zones in the pancreas and parapancreatic tissue is determined, and the configuration and distribution of fluid accumulations adjacent to the area of necrosis are specified. Puncture trajectory planning and subsequent drainage are performed in such a way that the drainage tubes cover the purulent cavity throughout, and the ends of the tubes are brought to the necrosis zone. Using a needle with a mandrel under constant Y3 control, percutaneous sequential punctures of the cavity of the omental sac are performed through the gastrocolic ligament and paracolon on the right and left with extraperitoneal access, followed by passing through the needle 2-3 rigid conductors into the cavity of the omental sac and 1-2 -x into the retroperitoneal space, through the conductors, the puncture canal is sequentially bougienage, the introduction of drainage and its overlap, which prevents the emptying of the liquid and the closure of the cavity and allows the location of the drains so that the drains cover the purulent cavity throughout, and the ends are brought to necrosis followed by sanitation.

Subsequently, on the 2-3rd day after drainage, the cavities are washed with aqueous solutions of antiseptics 4 times a day until visually clean rinsing water appears each time. With an interval of 7-8 days, a programmed replacement of double-lumen drains along the guidewire under R-control with contrasting is performed, in case of their obturation with sequesters, a replacement is made.

In order to visually control the course of the purulent-inflammatory process, starting from 7-10 days after the formation of channels at the site of percutaneous drainage tubes, using a flexible endoscope, it is possible to perform omentobursoscopy or retroperitoneoscopy.

Example 1. Patient D., 46 years old, was transferred to the clinic from the central regional hospital on 06/20/2014, on the 16th day from the onset of the disease, with a diagnosis: “Common infected pancreatic necrosis, purulent-necrotic parapancreatitis. Retroperitoneal pancreatogenic phlegmon paracolon on the right and left. Purulent omentobursitis. On June 20, 2014, computed tomography of the abdominal organs and retroperitoneal space was performed, zones of necrosis in the region of the body of the pancreas, acute necrotic accumulation in the omental sac and parapancreatic tissue on the right and left were identified. The trajectory of punctures and subsequent drainage were planned in such a way that the drains covered the purulent cavity in the omental bag throughout, and the ends were brought to necrosis in the region of the body of the pancreas, it was decided to drain the paracolic tissue with two drains on the right and left, in the cranial direction to the tail of the pancreas gland and head and two drains in the caudal direction. Operation 06/20/2014: "Drainage of the omental sac and retroperitoneal tissue from both sides under ultrasound control." In the conditions of the operating room under ultrasound control, using a primary access needle, successive percutaneous punctures of an acute necrotic accumulation of the omental sac were made through the gastrocolic ligament, three rigid conductors were successively installed; further, a puncture was performed in the left lateral region with an extraperitoneal paracolon access on the left in the cranial direction, a rigid conductor was inserted through the needle to the tail of the pancreas and in the caudal direction to the small pelvis, in the same way, paracolic fiber was punctured on the right with the introduction of two rigid conductors. Then sequentially bougienage was performed along the rigid conductors of the wound channels using K Storz bougies, the introduction of drainage and its overlap, which prevented the emptying of the liquid and the closure of the cavity and allowed its location along a given trajectory in the cavity, the puncture channel was expanded to a diameter of 32 Fr. Three double-lumen drains with a diameter of 32 Fr were installed in the omental bag, two double-lumen drains with a diameter of 32 Fr were installed in the paracolic tissue on the right and left according to the above method.

In the postoperative period, a positive clinical and laboratory dynamics of the condition was observed, the cavity was washed through the drains with an aqueous solution of chlorhexidine every six hours until visually clean washing water appeared.

On 06/27/2014, 07/04/2014, 07/11/2014, 07/18/2014, programmed replacements of the drains of the omental sac and paracolic space on the right and left under X-ray control with contrast were carried out. On June 27, 2014, omentobursoscopy and retroperitoneoscopy were performed; purulent discharge and necrotic tissue were not detected. Due to the positive dynamics, normalization of indicators, on July 30, 2014, the patient was discharged with drainages in a satisfactory condition for further treatment at the place of residence.

08/20/2018 Patient D. was hospitalized for a follow-up examination. There is no discharge through the drains; produced fistulography, which shows obliteration of the pathological cavity; drains removed.

Example 2. Patient V., aged 54, was admitted to the clinic on May 3, 2016. He considers himself ill for about 3 weeks, was treated conservatively in the NRB at the place of residence, with negative dynamics and intractable febrile temperature, he was sent to the Clinical Clinical Hospital No. 2. Upon admission, the patient was in a serious condition due to sepsis, in connection with which he was hospitalized in the intensive care unit. Performed computed tomography of the abdominal cavity and retroperitoneal space, identified areas of necrosis in the head of the pancreas, acute necrotic accumulation in the omental bag and parapancreatic tissue on the right. The trajectory of punctures and subsequent drainage was planned so that the drains covered the purulent cavity in the omental bag throughout, and the ends were brought to necrosis in the region of the pancreatic head, it was decided to drain the paracolic tissue with two drains on the right, in the cranial direction to the head of the pancreas and in the caudal direction. A clinical diagnosis was made: “Common infected pancreatic necrosis, purulent-necrotic parapancreatitis. Retroperitoneal phlegmon on the right. Purulent omentobursitis. After the necessary preoperative preparation, on May 4, 2016, the patient underwent the operation: “Drainage of the omental sac and retroperitoneal space on the right under U3-control” according to the method described in example 1. two double-lumen drains with a diameter of 30 Fr, two double-lumen drains with a diameter of 30 Fr into the paracolon on the right. In the postoperative period, the stuffing bag and paracolon on the right were washed with an aqueous solution of chlorhexidine every six hours until visually clean lavage water appeared through the installed drains.

The patient's condition improved. On May 14, 2016, May 21, 2016, and May 28, 2016, programmed replacements of the omental sac and retroperitoneal drains were performed under X-ray control with contrast enhancement. On May 11, 2016, omentobursoscopy and retroperitoneoscopy were performed; purulent discharge and necrotic tissue were not detected. Due to the positive dynamics, normalization of indicators, on 06/07/2016 the patient was discharged with drains for further treatment at the place of residence in a satisfactory condition.

07/02/2016 Patient A. was hospitalized for a follow-up examination. There is no discharge through the drains; produced fistulography, which shows obliteration of the pathological cavity; drains removed.

Claims (1)

A method for draining the retroperitoneal space in case of purulent-necrotic parapancreatitis, including methods of control, characterized in that, under ultrasound control, 2-3 percutaneous punctures of the cavity of the omental sac and paracolon are performed sequentially on the right and / or on the left with extraperitoneal access, through the channels of the needle, rigid conductors are passed into the cavity omental sac and retroperitoneal space, the needles are removed and the puncture channels are bougie along the conductors, through which the omental sac and paracolon on the left and / or on the right, with the condition of covering the purulent cavity and bringing the ends of the drains to necrosis, are sequentially inserted and the drains are blocked with clamps, excluding spontaneous ejection exudate, immediately after that, the clamps are alternately removed and the exudate is evacuated, covered with removable drainage bags, then after 2-3 days the drainage bags are removed and the area of purulent-necrotic parapancreatitis is washed with aqueous solutions of antiseptics, after which, from 7-10 days, the condition of the saliva is monitored once a week nic bag and retroperitoneal space using omentobursoscopy and retroperitoneoscopy.